Suicide prevention targeting middle-aged males: the role of primary care

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Wetherall and O’Connor¹ consider the Mughal et al national case study series² looking at antecedents to suicide in middle-aged men, and in particular the role of primary care:

‘Mughal and colleagues conducted a national case series study to establish antecedents to suicide in middle-aged males who had consulted a GP before dying by suicide … they found that two-fifths (43%) had consulted a GP in the previous 3 months, with more than half reporting a mental health problem. Further, males who had recently consulted their GP were more likely to report a physical illness, recent history of self-harm, a mental health problem, and have experience of a work-related problem …’¹

The authors suggest that GPs should be vigilant to the potential for suicide risk when these factors present themselves in middle-aged male patients.¹

Wetherall and O’Connor offer two models to better conceptualise how various factors operate to increase suicide risk. Figure 1 is of particular interest, with its 3-stage model of ‘suicidal behaviour’.¹

Surely there is an urgent need to focus on the ‘pre-motivational phase’ in order to ensure that fewer people ever proceed to the higher-risk ‘motivational’ phase?

People are routinely being prescribed drugs such as antidepressants when they are experiencing stressful life events and/or adverse environmental conditions (that is, ‘pre-motivational background factors and triggering events’) — and serious ‘side effects’ and withdrawal effects of antidepressants have been seriously overlooked. The common antidepressant ‘side effects’ (sexual dysfunction, emotional numbing, excess introspection, fatigue, gastrointestinal problems, etc.) surely contribute to the ‘motivational’ factors clearly shown in the model. Adverse effects such as medication-induced akathisia can also occur — and are too often misdiagnosed, with tragic consequences (https://missd.co, the Medication-Induced Suicide Prevention and Education Foundation in Memory of Stewart Dolin [MISSD] — akathisia support).

The recent BBC Panorama programme ‘The Antidepressant Story’^3,4 explored this and raised awareness of previously underplayed and sometimes lasting sexual effects of commonly GP-prescribed antidepressants. These included post-selective serotonin reuptake inhibitor (SSRI) sexual dysfunction and post-SSRI sexual dysfunction (PSSD) (underreported due to its embarrassing and personal nature).⁵ These prescribed drug effects have huge consequences for people and their relationships — and especially middle-aged men who may well find themselves experiencing the full range of ‘motivational factors’ identified in the O’Connor and Kirtley model in Figure 1.¹

• © British Journal of General Practice 2023