www.thelancet.com Vol 379 June 23, 2012 2383
Lancet 2012; 379: 2383–92
See Editorial page 2314
See Comment page 2316
This is the second in a Series
of three papers about suicide
University College London
Mental Health Sciences
Unit, London, UK
(A Pitman MSc[Econ],
D Osborn PhD, Prof M King PhD);
and Clinical Psychology, Faculty
of Psychology and Educational
Sciences, KU Leuven, University
of Leuven, Belgium
(K Krysinska PhD)
Dr Alexandra Pitman, University
College London Mental Health
Sciences Unit, Charles Bell House,
67–73 Riding House Street,
London W1W 7EJ, UK
Suicide in young men
Alexandra Pitman, Karolina Krysinska, David Osborn, Michael King
Suicide is second to only accidental death as the leading cause of mortality in young men across the world. Although
suicide rates for young men have fallen in some high-income and middle-income countries since the 1990s, wider
mortality measures indicate that rates remain high in specifi c regions, ethnic groups, and socioeconomic groups
within those nations where rates have fallen, and that young men account for a substantial proportion of the economic
cost of suicide. High-lethality methods of suicide are preferred by young men: hanging and fi rearms in high-income
countries, pesticide poisoning in the Indian subcontinent, and charcoal-burning in east Asia. Risk factors for young
men include psychiatric illness, substance misuse, lower socioeconomic status, rural residence, and single marital
status. Population-level factors include unemployment, social deprivation, and media reporting of suicide. Few
interventions to reduce suicides in young men have been assessed. Eff orts to change help-seeking behaviour and to
restrict access to frequently used methods hold the most promise.
Suicide risk has historically been described to increase
with age, with older men being identifi ed as the group at
highest risk. However, in the 1970s in some high-income
countries, suicide became increasingly common in young
adults, especially in young men.1 Although the focus of
concerns is now shifting to middle-aged men, who are
the group at highest risk in many countries, the lower
life expectancy of working-age men remains a major
problem.2 In the context of the global fi nancial crisis and
the propagation of new suicide methods, such as charcoal
burning, policy responses are needed. In this review, we
aim to provide an updated perspective on the burden of
suicide in young men, specifi c risk factors, and evidence-
based interventions, using published international
evidence from 2000–11. We chose to focus on data for
men aged 19–30 years, which is the most common age
group used for young men in population research.
Historical patterns of suicide in young men
50 years ago suicide accounted for 10% of deaths of people
aged 10–24 years in countries in the Organisation for
Economic Co-operation and Development (OECD) coun-
tries, against a backdrop of 2% or fewer globally.3 By the
mid-1980s suicide had become a leading cause of death
in men aged 25–34 years in high-income countries,
accounting for up to a third of mortality in young men.1
Until this point elderly men had been regarded as the
group at highest risk of death by suicide. However,
between 1950 and 1999 the highest suicide rates shifted
from elderly people towards middle-aged people (those
aged 35–45 years), and in some countries to younger age
groups (those aged 15–25 years).4 Concerns about suicide
at the turn of the 21st century related not only to WHO’s
report of a 60% global increase in recorded suicide
mortality during the previous 45 years,4 but specifi cally a
7% global increase in death by suicide in men from 1960 to
1999.5 This increase was attributed to an increase in
suicide in young men accompanied by a decrease in
suicide in older men.5 Also, suicide became increasingly
more common in men than in women in people aged
15–29 years in Europe, the USA, Asia, Australasia, and
some Latin American countries.1 Comparison of 1970 and
1985–86 WHO data show that although the highest rates
were seen in men older than 60 years, suicide rates in
men aged 15–29 years in Australia, New Zealand, Mexico,
Canada, the USA, and Ireland had reached parity with (or
in some cases surpassed) those in men aged 30–59 years.1
These international patterns seemed to suggest that
suicide, although a rare event, had become a serious
problem in young men in some parts of the world.
Search strategy and selection criteria
We searched Medline using the MeSH term “suicide” and the
subheading “epidemiology”, and publication date restrictions
of January, 2000, to August, 2011; we restricted our search to
studies written in English and including data for men. Age
group limitations were defi ned with Medline age groups
“Young Adult 19 to 24 years” or “Adult 19 to 44 years”. We
repeated the search with minor variations on Embase (using
“Human Age Groups Adult 18 to 64 years”) and CINAHL (using
“Age Groups Adult~ 19–44 years”). We chose these age ranges
to identify articles relevant to the age-range 19–30 years,
taking into account WHO defi nitions of youth as individuals
aged 15–24 years, teenagers as those aged 15–19 years, and
young adult men as those aged 20–24 years, as well as WHO
publications describing young adults as aged 15–34 years,4 and
previous Lancet studies defi ning young adolescence,10–14 late
adolescence,15–19 and young adulthood.8,20–24 For inclusion of
additional, more up-to-date papers, we did a key word search
on PubMed for the year 2011. Key references from the last
10 years were sought from international experts in the fi eld of
suicidology. We also did secondary searching of references
cited in identifi ed articles and key textbooks. Papers were
restricted to those reporting fatal outcomes. Additional
references were suggested by the peer reviewers.
www.thelancet.com Vol 379 June 23, 2012
Global patterns in suicide in young men
The number of suicide deaths in young men is probably
substantially underestimated. Wide inter national varia-
tions in the quality of suicide data are explained by under-
reporting and misclassifi cation of suicide (partly related
to legal and cultural factors), inconsistent conventions
and discontinuities in the coding of deaths, and diff ering
categories of death included in suicide analyses.6 WHO
has little suicide mortality data for many low-income and
middle-income countries (LMICs), and a proportion of
accidental death and undetermined death registrations
inter nationally should be assumed to be suicide deaths.
This potential is increased in young men, in view of their
high rates of accidental death.2,7
Findings from studies done since 2000 show that
suicide is among the top three to fi ve causes of mortality
in young men in most high-income and middle-income
countries sampled,2 and that accidental death remains
the leading cause of death in young men for countries
at all levels of economic development.8 Analysis of
mortality patterns in 44 countries across all continents
(with data for 1997–2003) shows that suicide was among
the top three causes of death for young men (aged
15–44 years) in 25 of those countries, and accidents
were the leading cause of death in 38 countries.2 Suicide
accounts for a much greater proportion of total deaths
in young men in high-income countries than it does for
those in LMICs (fi gure 1), but absolute rates of suicide
in young men are about the same in high-income
countries and LMICs, because of the greater contri-
bution of violence and traffi c accidents in LMICs.8
Temporal trends since the 1990s show that suicide
rates in young men have decreased in countries
such as Australia,9 New Zealand,10 China,11 Thailand,12
the USA,13,14 Italy,15 Austria,16 the Czech Republic,17,18
Scotland,19 England and Wales,20 and other western
European countries.17,21,22 Meanwhile, rates have risen in
countries such as Brazil,23 Singapore,24 South Korea,25
Lithuania,26 Ireland,27 and Northern Ireland.28,29 How ever,
this division is a potentially misleading over simplifi cation
of a complex public health problem, involving a very
diff erent evolution of risk and protective factors in each
country. The dichotomy also erroneously implies that
suicide in young men is no longer a problem in countries
where rates have fallen. Apparent decreases in suicide
rates in young men at a national level mask rising suicide
rates in young men at the sub-national level. This diff er-
ence is apparent by region30 and by remote residence in
the UK,30 by socioeconomic status in Australia,30,31 and by
ethnic origin in South Africa.32,33 Additionally, decreases
in the number of suicides in young men in New Zealand
are only moderate progress towards the low rates seen in
The economic and social cost of suicide in younger
age-groups is rarely reported, despite the greater
contribution deaths in young people make to life-years
lost. The cost of each young man dying by suicide in
England has been valued as £1·67 million (2009 prices),34
but has not yet been calculated in any LMICs. Despite
their ageist bias, measures such as potential years of life
lost (PYLL) are sensitive to changes in the demographic
structure, revealing the wider eff ect of suicide even when
the youth suicide rate is low or falling. In south India,
local surveillance data show that suicides of men aged
15–29 years account for the greatest proportion of PYLL
when compared with men in all other age groups,
exceeded by only women aged 15–29 years.35 Taiwanese
national mortality statistics show that the greatest
proportion of PYLL due to suicide is seen in men and
women aged 25–39 years (fi gure 2), although the greatest
number of suicide deaths occur between the ages of
40 years and 59 years.36
Economic data also show that although media reports
have tended to focus on suicides in young men, the
burden of suicide in young women and middle-aged
men are serious public health problems. In Taiwan,
during the period 1997–2007 the greatest increases in
PYLL were seen in men aged 40–59 years.36 Other
epidemiological studies show that although Sri Lanka
and Russia rank highest internationally for suicide rates
in young men,37 the greatest total numbers of suicides in
Sri Lanka are seen in men aged 41–55 years and women
Figure 1: Causes of death by injury, by sex, age-group, and region
Adapted with permission from Patton and colleagues.8 Violence refers to deaths from violence in and outside of war.
Deaths per 100 000 population
Low-income and middle-income countries
10–14 15–19 20–24 10–14 15–19 20–2410–14 15–19 20–24 10–14 15–19 20–2410–14 15–19 20–24 10–14 15–19 20–24
www.thelancet.com Vol 379 June 23, 2012 2385
aged 21–45 years,38 and in Russia are seen in men aged
The historical pattern of suicide risk increasing with
age (but representing a decreasing proportion of total
deaths) still applies in many LMICs and high-income
countries in Europe, the Americas, Israel, India, and the
far east.7,10,11,24,35,40–52 International comparisons of the most
up-to-date data from 44 high-income and middle-income
countries show median suicide rates rising through
successive age-groups: 14·4 per 100 000 men aged
15–24 years, 21·9 per 100 000 men aged 25–34 years, and
24·7 per 100 000 men aged 35–44 years.2 Similarly,
although an excess of suicide deaths in men holds true in
young people globally,2,50 the ratio is reversed for young
women in two of the most populous countries:
China37,40,44,53–56 and India.35,57,58 This occurrence is likely to
be a consequence of high rates of suicide in women in
rural areas,54 but does draw attention to the importance of
exploring sub-national trends and of comparing mortality
indicators across all age groups in both sexes. Indeed, one
of the most striking characteristics of the studies reviewed
was the restricted range of mortality indicators presented
and the substantial variability in the comparison groups
used. Such restriction hampered an assessment of the
suicide burden in young men compared with other
groups. Future epidemiological studies will have greater
use for policy makers if they present national suicide
rates in the context of other mortality indicators, to
identify groups at highest risk of suicide.
Suicide methods used by young men
International variations in the frequency of suicide
methods relate generally to local data availability. The
WHO databank does not specify method-specifi c
suicides, which means that global patterns in suicide
methods have to be derived from individual countries’
data.21 Unfortunately, few studies disaggregate data by
age group and sex. Hanging is the leading method in
young men in Europe and Australasia, and patterns of its
use are closely associated with changes in suicide rates
for this group,9,19–21,59–62 Exceptions are New Zealand, where
the proportion of men aged 15–24 years using hanging
has been rising (despite concurrent falls in this group’s
suicide rate),10 and Italy, where suicide rates for men aged
15–24 years and 25–44 years decreased from the mid-
1990s despite a rise in hanging and jumping from a
height in young men.15 Japanese data for 1999 show that
hanging accounted for 63% of suicides in men aged
20–39 years, and jumping from height accounted for
14%.47 In the USA, however, fi rearms (followed by
hanging or suff ocation) is the most common method of
suicide in men aged 15–24 years,14 accounting for 55% of
suicides in men aged 20–39 years; hanging accounts for
26%.47 Patterns at the sub-national level show that young
men in specifi c indigenous groups prefer specifi c suicide
methods: fi rearms in the USA, hanging or asphyxiation
in Canada, and hanging in Australia.63
In South Africa, hanging and fi rearms are the most-
used methods in men aged 15–34 years.33 High case-
fatality ratios for intentional self-harm are seen in many
Asian countries. For example, in China an estimated 82%
of suicide deaths are due to poisoning, although data are
not specifi c to young men.64 In India pesticide poisoning
is the leading method of suicide for young men,
accounting for 58% of suicides in men (and 25% in
women) aged 21–30 years.65 In Sri Lanka, acute poisoning
(including pesticides) is the leading method used by men
(and women) in all age groups.38 New and highly lethal
suicide methods have emerged in east Asia, including
home-manufactured hydrogen sulphide66 and other
chemical suicide methods. Charcoal-burning has rapidly
increased as a new method in Taiwan and Hong Kong,
especially in men (and women) aged 24–39 years, with
Figure 2: Eff ect of suicide inTaiwan, 1997–2007
(A) Sex-specifi c suicide rate and potential years of life lost. (B) Suicide rate and potential years of life lost due to
suicide for both sexes. Reproduced from reference 36 with permission of Hogrefe Publishing.
1997 199819992000 200120022003 2004200520062007
Potential years of life lost
Suicide deaths per 100 000
1997 1998 1999200020012002
Potential years of life lost
Suicide deaths per 100 000
Male suicide rate
Female suicide rate
www.thelancet.com Vol 379 June 23, 2012
little evidence for substitution of older methods.67
In Taiwan, charcoal-burning suicide rates during
2001–06 rose most sharply in the age group 25–44 years,
with an odds ratio of 1·3 (95% CI 1·2–1·4) for men dying
by this method compared with women.68 Overall it
accounted for 34% of suicide deaths in Taiwan during
2006.68 There are concerns about the proliferation of new
media driving the popularity of new methods,66 especially
in young people.66,69
Individual-level risk factors for suicide in
Several suicide risk factors that are well established
in the wider population have not been investigated
specifi cally in relation to young men. The absence of
such investigation is because large sample sizes of
young men are needed to achieve adequate statistical
power, and risk factors cannot necessarily be inferred
from wider studies that treat age group and sex as
separate variables. A meta-analysis of international
psychological autopsy studies, in which men had a mean
age of 28·5 years (SD 12·8), showed higher odds of
childhood disorders (odds ratio=4·95 [95% CI 2·7–9·3),
substance-related problems (3·58 [2·8–4·6]), and
personality disorders (2·01 [1·4–3·0]) for suicides in
men, but lower odds of any aff ective disorders (0·66
[0·5–0·8]).70 A case-control study of Canadian men (with
a mean age of 28·9 years [SD 8·4]) identifi ed the
psychiatric comorbidities with the highest odds ratios
for suicide as drug dependence (13·51 [odds ratio
3·11–58·82]), major depression (10·75 [3·69–31·25]),
borderline personality disorder (9·71 [2·86–33·33]), and
depression not otherwise specifi ed (9·43 [1·20–76·92]).71
A Chinese psychological autopsy study of individuals
aged 15–24 years showed that mental illness at time of
death was an important predictor of suicide in men
(odds ratio 14·0 [2·6–76·5]) but not in women.64
The relative risk of suicide in men younger than
35 years with a psychiatric disorder has been estimated
from meta-analysis of studies in high-income and middle-
income countries, and ranked as follows: schizo phrenia
(relative risk=13·66 [95% CI 5·18–36·04]), aff ective
disorders (9·26 [4·99–17·19]), substance use disorders
(5·09 [2·81–9·25]), personality disorders (4·14 [2·81–
9·25]), and anxiety disorders (3·31 [1·53–7·18]).72
Population attrib utable risk (PAR) of suicide for each
psychiatric disorder (but for men of all ages) show slightly
diff erent rankings: 26% for aff ective disorder, 19% for
substance abuse, 15% for personality dis order, 7% for
schizophrenia, and 5% for anxiety disorder.72 This conveys
the public health importance of address ing untreated
depression, al though psychiatric illness, par ticularly
depression, has been suggested to make a greater
contribution to suicide risk with increasing age, especially
in individuals older than 45 years.73 Inter national studies
of help-seeking patterns suggest that male sex and age
below 45 years predict lower help-seeking in depres sion.74
Only one study has investigated risk of suicide following
self-harm, fi nding that in England men aged 10–24 years
are at lower risk of suicide following self-harm than are
older men after self-harm.75 Ecological data describe the
eff ect of population-level alcohol consumption on suicide
rates in men aged 15–29 years, fi nding that (after
controlling for macro-socioeconomic variables) national
alcohol consumption was not related to suicide rates in
young men.22 However, an association absent at an
aggregate level might exist at the individual level.
Evidence that homosexuality is a risk factor for suicide
in men derives from Danish data showing that men in
same-sex, legalised partnerships had a suicide risk nearly
eight times greater than men in heterosexual marriages,
and double that of men who had never married.76 Studies
specifi c to young men who have sex with men are
needed, notwithstanding diffi culties in establishing
sexual orientation. In the wider population, specifi c
occupational groups (doctors, farmers) and unemployed
individuals are cited as higher-risk groups for suicide. A
study of doctors in England and Wales recorded suicide
rates for male doctors in all age groups to be two-thirds
that of men in the general population, but showed
increased rates in their female counterparts.77 Although
suicide risk in young male farmers is often mentioned in
newspaper reports from the Indian subcontinent and
West Africa, no quantitative epidemiological studies have
addressed this group. Australian studies, however, show
high rates of suicide in young male agricultural
workers.78,79 In the USA, Britain, and France, there are
confl icting fi ndings in relation to the risk of suicide in
young men in the army depending on which age
groupings are assessed.80–82 Data from the USA show an
increased risk in male army veterans aged 18–34 years,
with suicide rates twice that of the general population,80
whereas data from the UK show a reduced suicide risk
for men in the armed forces in all age groups older than
20 years.81 In France, men in the army have a reduced
risk of suicide compared with the general population, but
the suicide incidence rate ratio for those younger than
25 years is twice that for men aged 25–29 years.82
Ethnic origin and indigenous group also predict suicide
risk in young men. Worldwide, the highest suicide rates in
young men are seen in white men in South Africa;32,33 fi rst-
generation Eastern European and Caribbean immigrants
to England and Wales,83 indi genous Sami in Arctic
Norway,84 Māori men aged 15–24 years in New Zealand,10
indigenous men aged 15–34 years in Australia,63,85,86 Inuit
men aged 15–24 years in Canada,87 and Native American
men aged 15–24 years88 and 20–39 years47 in the USA.
There is also evidence suggesting that young Aboriginal
men in Canada89 and Ethiopian immigrants to Israel90
might be high-risk groups although more data specifi c to
this sex and age group are needed. Interpretation of all
studies of ethnic minority groups should take into account
the possible under-estimation of youth suicide owing to
diff erential misclassi fi cation.63,88,91 Although suicide rates
www.thelancet.com Vol 379 June 23, 2012 2387
might be higher in some minority ethnic groups, this
minority status could actually be protective in neighbour-
hoods with large minority populations. This so-called
relative misery hypothesis has been used to explain higher
suicide rates in young Aborigines and Torres Strait
Islanders compared to their white peers in mainstream
Rural or remote residence is shown to increase the
risk of suicide in young men in Australia,92–95 China,92
Denmark,96 Austria,97 and England and Wales.30,98 The
overall decline in suicide rates for Australian men aged
20–34 years (from 40 per 100 000 in 1997–98 to 20 per
100 000 in 20039) masks the continued rise in suicide
rates in young men in remote areas93 as well as in lower
socioeconomic groups.31 Explanations relate to the
migration of healthy workers to cities, and the increasing
economic disparity between men in rural and urban
areas. In relation to marital status, evidence from high-
income countries shows that marital status in men
interacts with age, such that being separated increases
suicide risk in young men to a greater extent than in
older men.99 In high-income countries, young men who
are divorced,99 have never married100 or are widowed101–103
are at higher risk of suicide than if married. Good
academic performance in school has been shown to
protect against suicide in young men (but not young
women) in Swedish record linkage studies.104
Population-level eff ects on suicide in young men
Cultural and socioeconomic variables, such as rising
unemployment, are suggested as area-level eff ects on
suicide in young men, and are likely to mediate
individual-level risk factors. A pan-European study has
shown a non-signifi cant negative association between a
1% rise in unemployment and suicide in men aged
15–29 years, but a signifi cant positive association for
women of the same age.105 At the national level, a positive
association between unemployment and suicide applies
to young men in England and Wales,106 Ireland,107 and
Asia.108 In Australia, this positive association seems to be
more pro nounced in younger men than it is in older
men,109 as does the association between lower
socioeconomic status and suicide risk.110 In England,
social deprivation is positively associated with suicide
risk for men aged 10–29 years.111 Evidence from England
and Wales suggests that suicide risk for men aged
15–44 years is highest in the most socially fragmented
areas,112,113 but this eff ect might be more pronounced in
men aged 45–64 years.114 Such studies might not be
generalisable to low-income countries.
Period eff ects in the past three decades likely to have
aff ected suicide rates in young men internationally
include war, natural disasters, the intro duction of new
means of suicide,67,68 and new substances of misuse,
policies restricting specifi c means of suicide, specifi c
youth suicide prevention policies, the expansion of new
media (and its eff ect on suicide contagion), and economic
downturn. Cohort eff ects aff ecting suicide rates in young
men will derive from the relative size of that birth cohort
in each country; exposure to childhood trauma (eg, civil
war); psychotropic prescribing patterns; and the eff ect of
the media (on young people’s attitudes to the social
acceptability of suicide, in raising their expectations
unrealistically, and aff ecting preference for specifi c
suicide methods). The media has been implicated in the
social modelling of suicidal behaviour in young people
and the spread of new means of suicide. In Taiwan, for
example, extensive news reporting of a 59-year-old male
celebrity’s suicide was associated with an increase in
suicides in men younger than 35 years.115
Interventions to reduce suicides in young men
As with risk factor studies, research specifi cally assessing
the eff ect of interventions on young men is restricted.
Population-based strategies with the potential to reduce
suicides in young men are those that reduce the pro-
portion of young men with suicide risk factors, and those
that reduce the availability of methods often used by this
group. Unfortunately, the methods common in high-
income countries (especially hanging) are also the
hardest to restrict.73 Nonetheless, a decrease in poisoning
deaths, predominantly in men and younger age groups,
followed the withdrawal of co-proxamol in Scotland.116
Legislation to restrict fi rearms has not been associated
with a reduction in fi rearm suicides in young men in the
USA,117 but is associated with statistically signifi cant
declines in Canadian men aged 15–34 years.118 Falls in
fi rearm suicides in young Australian men, and
concurrent increases in suicides by hanging in this age
group, preceded fi rearm legislation, suggesting cultural
explanations for method substitution rather than solely
the eff ects of the intervention.119 Controls on pesticide
imports to Sri Lanka have been followed by substantial
declines in suicide in men aged 17–35 years.120
Untreated depression is another target for inter-
vention, especially in view of the high PAR associated
with aff ective disorder.72 However, the evidence for anti-
depressant treat ment remains mixed as to the appro-
priate balance of risks in young people. A Swedish
ecological study covering 1977–87 detected an association
between increased sales of selective serotonin reuptake
inhibitors (SSRIs) and a decrease in suicide rates in
both men and women, with the largest reduction in
15–44 year-old individuals of both sexes.121 A US cohort
study measuring non-fatal suicide attempts in a veterans
sample (where only 8% were women) recorded a pro-
tective eff ect of SSRI monotherapy com pared with
no antidepressant, with the caveat that these results
might not hold for completed suicides.122 The US Food
and Drug Administration (FDA) has published a
meta-analysis of antidepressant trials showing a non-
signifi cantly increased risk of suicide in adults under
25 years prescribed antidepressants for any indication.123
Labelling of antidepressants in the USA has been
www.thelancet.com Vol 379 June 23, 2012
amended to draw attention to the strong age-related risk
in individuals younger than 25 years, which seems to be
neutralised between the ages of 25 years and 64 years.123
Young men feature as a high-risk group in many
nations’ suicide prevention strategies, but evidence is
scarce as to which interventions reduce this risk. The
1995–97 Australian National Youth Suicide Prevention
Strategy (NYSPS) sought to reduce risk factors in young
men through a comprehensive set of targeted and
population-level interventions, but a controlled study
showed no eff ect on suicide rates in men (or women)
aged 20–34 years.124 Novel targeted approaches are based
on the theoretical eff ect of eff orts to change young men’s
help-seeking behaviour, often involving sporting role
models and outreach to sports clubs, pubs, and
workplaces (panel 1). Their eff ect on suicides in the target
group has not yet been assessed. There is also potential
for media guidelines on suicide reporting and supportive
internet sites to reduce suicides in young men, but these
again will need specifi c investigation.
Improving responsiveness to emerging
An improved understanding of how the burden of
suicide compares between age groups for each sex can be
provided by studies that defi ne narrower and more
consistent age ranges than has previously been done,
especially in view of the diff erent suicide patterns seen in
adolescents and young adults.10 WHO might consider
establishing minimum standards on the range of
descriptive statistics presented in published studies for
every group investigated: suicide rates (both crude and
Panel 1: International programmes to address suicide risk in young men (eff ect on suicide in young men not assessed)
It’s a Goal! (England and Scotland)
An 11-week self-development programme for men aged 16–35 years, which originated in Macclesfi eld Town Football Club. It now
operates as a social franchise, with programmes emphasising teamwork, communication, motivation, and assertiveness. These
programmes are based in local football clubs across England and Scotland.
PAPYRUS Ambassador scheme (England)
Appointment of a young male television actor as an Ambassador for PAPYRUS, a national suicide prevention charity, on the basis
that young people are more likely to listen to their peers. The message he publicises is for those in distress to seek help using
PAPYRUS’ free national helpline HOPELineUK, and to encourage young people to look out for each other.
Samaritans: We’re In Your Corner (Northern Ireland)
A campaign that uses the theme of sport, and involves local sporting personalities, to raise awareness of the Samaritans helpline,
specifi cally targeting men and aiming to prevent suicides on the local rail network. It also provides support and training for
employees of Translink Northern Ireland who at times encounter people in distress at railway sites.
Breathing Space (Scotland)
A national telephone helpline service targeting men aged 16–40 years who experience low mood, depression, or anxiety. It forms
part of the Choose Life national suicide prevention strategy, and has been publicised via television adverts emphasising the value
for young men in talking through their problems.
Talk, Listen, Change (Ireland)
A campaign launched by the charity Suicide or Survive via advertising at national football and hurling league matches. By raising
awareness through sport it aims to encourage young people to talk about their diffi culties and seek support.
Life is a Team Eff ort! The Iron Dog Suicide Prevention Campaign (Alaska, USA)
A campaign that uses professional snowmobilers and the image of teamwork to encourage people to use an Alaskan telephone
helpline, as part of an Alaskan suicide prevention campaign.
Read the Signs (Australia)
A suicide prevention and mental health promotion programme for members of the retail motor trades and allied industries, most
of whom are young men, developed in collaboration with the charity Lifeline. Its website provides information about sources of
help, including how to help a friend in distress.
Mensline Australia (Australia)
A 24-h crisis support line for men with relationship and family problems. This service is promoted as part of the Australian National
Suicide Prevention Strategy, in which men are designated an at-risk group.
MATES in Construction (eastern Australia)
A programme set up to address the high rates of suicide in the Queensland construction industry, the majority of which are in men.
It uses a helpline and on-site individuals called Connectors, who have received gatekeeper training to provide support to
construction workers in distress.
For more on It’s a Goal see
For more on PAPYRUS see
For more on Samaritans We’re
In Your Corner see http://www.
For more on Breathing Space
For more on Talk, Listen,
Change see http://www.
For more on The Iron Dog
Suicide Prevention Campaign
For more on Read the Signs see
For more on Mensline Australia
For more on MATES in
Construction see http://www.
www.thelancet.com Vol 379 June 23, 2012 2389
age-adjusted), absolute numbers of suicides, proportional
mortality ratios (PMRs), the ranking of suicide as a cause
of death, and PYLL. This multi dimensional picture
would improve research cost-eff ectiveness and allow a
more responsive approach to suicide prevention, in view
of the fact that high-risk groups are constantly evolving.
Other areas for improving future research on the
burden of suicide in any group include the avoidance of
presenting confounded associations and group-level
associations. Studies investigating risk factors would be
more useful if they explored associations in specifi c
groups, where suffi cient power permitted this. Case-
control studies are probably the best means of inves-
tigating rare outcomes such as suicide but they will
always be subject to residual confounding. Cohort studies
that quantify the PAR of specifi c risk factors for completed
suicide in diff erent age groups and sexes in local settings
are likely to be most helpful in planning interventions.
WHO might also consider com missioning rapid analysis
of its datasets to reduce the substantial time lag between
suicide data collection and its translation into evidence-
based preventive interventions.
The striking variations seen in suicide rates in young
men, both within and between countries, refl ect the
heterogeneity of young male populations and the
complexity of contributing factors to each completed
suicide. These fi ndings indicate the need for a tailored
policy response in each country, taking into account the
population structure and the diff erential interaction
between socioeconomic and religious variables in each
culture. The improvements we suggest above in relation
to descriptive epidemiology would assist each country to
achieve the fi rst policy priority of identifying the highest
sub-groups at risk at a national and regional level. These
improvements would also help inform strategies to
tackle accidental death, the leading cause of mortality in
young men. Accidental death in itself shows much
international variation in mortality rates and specifi c
causes,2 shares common risk factors with suicide, and
might be easier to prevent. A second policy priority
would be to identify suicide risk factors specifi c to
young men in each cultural setting, in view of the
inappropriateness of extrapolating suicide risk factors
established for other age groups or for young men in
other cultural settings. This valuable investment in the
research evidence would inform the development of
interventions, which could then be assessed for their
contribution to each nation’s suicide prevention strategy.
In this review, we have drawn attention to wide socio-
geographic variations in the epidemiology of suicide, and
a rapidly changing picture in relation to the direction of
temporal trends. In countries where decreases in suicides
in young men have been seen, studies investigating
suicide risk at a sub-national level have shown rates to be
rising in specifi c sub-groups defi ned by geography,
ethnic origin, and socioeconomic status.30–33 Comparisons
of suicide rates in young men at the national level might
therefore be misleading, conveying little of the variations
apparent at a local level. Several studies suggest that in
some parts of the world suicides in middle-aged men or
young women could outnumber those in young men.37
Suicide risk factors specifi c to young men (panel 2)
include psychiatric illness, sub stance misuse, ethnic
origin, lower socio economic status, rural residence, and
single marital status. Population-level factors shown to
aff ect rates of suicide in young men in specifi ed parts of
the world include unemployment, social deprivation, and
the media’s reporting of suicide. This review underlines
the importance of the development of regionally and
nationally tailored approaches to reducing suicide, and
remaining abreast of key mortality indicators to identify
the groups at highest risk of premature death.
AP did the search of available studies. AP and KK retrieved and reviewed
all and wrote the fi rst draft of this paper, which was reviewed by DO and
MK. All authors contributed to the revision of drafts.
Confl icts of interest
We declare that we have no confl icts of interest.
We thank Ruth Muscat, Knowledge Resources Librarian, Royal Free
Hospital Medical Library (UCL Medical School) for help undertaking the
database searches. AP is supported by a Medical Research Council
Population Health Scientist Fellowship. The views expressed in this
review are those of the authors.
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• Psychiatric disorder
• Substance misuse
• Occupational group (agricultural workers in Australia; army veterans in the USA)
• Ethnicity and indigenous group
• Rural or remote residence (in Australia, China, Denmark, Austria, England, and Wales)
• Lower socioeconomic status (Australia)
• Single marital status: separated, divorced, never married, or widowed
• Unemployment (England and Wales, Ireland, Asia, Australia)
• Social deprivation and social fragmentation (England and Wales)
• Media infl uences—eg, reporting of suicides (Taiwan)
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