The gender paradox in suicidal behavior and its impact on the suicidal process

Journal of Affective Disorders 138 (2012) 19–26

Contents lists available at ScienceDirect

Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Review

The gender paradox in suicidal behavior and its impact on the suicidal process Didier L. Schrijvers a,b,⁎, Jos Bollen c, Bernard G.C. Sabbe a,b a b c

Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Faculty of Medicine, Universiteitsplein 1, 2610 Antwerp, Belgium Psychiatric Hospital Sint-Norbertushuis, Stationsstraat 22c, 2570 Duffel, Belgium Psychiatric Hospital Sancta Maria, Melveren-Centrum 111, 3800 Sint-Truiden, Belgium

a r t i c l e

i n f o

Article history: Received 28 February 2011 Received in revised form 31 March 2011 Accepted 31 March 2011 Available online 6 May 2011 Keywords: Gender paradox Gender differences Suicidal behavior Suicidal process

a b s t r a c t Background: An important gender difference has been reported regarding suicidal behavior with an overrepresentation of females in nonfatal suicidal behavior and a preponderance of males in completed suicide, also known as the ‘gender paradox of suicidal behavior’. The concept of a ‘suicidal process’ classifies suicidal behavior chronologically; this process starts with suicidal ideation and then implies a progression of suicidality ranging from suicidal ideation over plans to suicide attempts and finally fatal suicide. Aims/methods: The current paper aims to deepen the knowledge on the gender paradox by collecting and discussing the recent literature on this topic: the most relevant, impacting gender-related factors will be discussed within the suicidal process concept. Results: Several factors had a gender-dependent impact on suicidal behavior: psychosocial life stressors such as stressful life events but also sociodemographical or socio-economical factors, and sexual abuse. The gender differences in psychiatric (co)morbidity and in response to or attitude towards antidepressant treatment also appear to have an impact. Furthermore, not only suicide methods but also the gender-dependent variation in reporting suicide has an influence. Finally, the gender differences in help seeking behavior as well as region-dependent cultural beliefs and societal attitudes are discussed. Conclusions: Especially life-events seem to exert an important influence at the beginning of a suicidal process, whereas the other factors occur at a further stage in the process, however without a fixed chronology. Also, the duration of the suicidal process is much shorter in male than in females. Finally, some implications with regard to clinical practice and suicide prevention are suggested. © 2011 Elsevier B.V. All rights reserved.

Contents 1. 2. 3.

Introduction . . . . . . . . . Method . . . . . . . . . . . Results . . . . . . . . . . . . 3.1. Psychosocial life stressors 3.2. Sexual abuse . . . . . . 3.3. Psychiatric (co)morbidity

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⁎ Corresponding author at: University of Antwerp, Faculty of Medicine, Collaborative Antwerp Psychiatric Research Institute (CAPRI), Universiteitsplein 1, 2610 Antwerp, Belgium. Tel.: + 32 3 2652415; fax: + 32 3 2652923. E-mail address: [email protected] (D.L. Schrijvers). 0165-0327/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2011.03.050

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3.4. Antidepressant treatment . . . . . . . . . . . 3.5. Suicide methods and reports of suicide . . . . 3.6. Cognitive processes and help seeking behavior of 3.7. Cultural beliefs and societal attitudes . . . . . 4. Discussion . . . . . . . . . . . . . . . . . . . . . 4.1. Impacting factors . . . . . . . . . . . . . . . 4.2. Duration of suicidal process . . . . . . . . . . 4.3. Implications . . . . . . . . . . . . . . . . . Role of funding source . . . . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction Suicide is responsible for an estimated global burden of one million deaths per year and an estimated annual mortality of 14.5 deaths per 100,000 people. Moreover, being the tenth leading cause of death worldwide, suicide accounts for 1–5% of all deaths (WHO, 1989; WHO, 2002; Hawton and Van Heeringen, 2009). Suicidal behavior not only encompasses completed suicide, but extends from ideas and thoughts about suicide that are never acted on, to suicide attempts of varying degrees of medical severity, to fatal suicide. With regard to the suicidal behavior, an important difference in male to female ratio has repeatedly been reported for both (nonfatal) suicidal attempts as well as for fatal suicide acts: females have higher rates of suicidal ideation and behavior than males, while mortality from suicide is typically higher for males than for females (Canetto and Sakinofsky, 1998; Murphy, 1998; Beautrais, 2002; Henderson et al., 2005). More specifically, in developed countries the male-to-female ratio for suicide is between two (Western Europe) and four (USA) to one (Hawton and Van Heeringen, 2009), while suicidal ideation as well as nonfatal suicidal behavior is more common in females than in males (Beautrais, 2002; Canetto and Sakinofsky, 1998; Murphy, 1998; Van Rijsselberghe et al., 2009). This striking gender gap in suicidal behavior, i.e. the overrepresentation of females in nonfatal suicidal behavior and the preponderance of males in completed suicide, previously has been described as the “gender paradox of suicidal behavior” (Canetto and Sakinofsky, 1998). Obviously, the ‘gender’ concept not only refers to the biological differences between both sexes, but also to the social norms and cultural expectations that differ between sexes (Möller-Leimkühler, 2003). As already mentioned, suicidal behavior encompasses suicidal ideation as well as fatal and nonfatal suicide acts. Several authors make a chronological link between suicidal ideation and suicide acts by applying the concept of a ‘suicidal process’: this process starts with suicidal ideation and then implies a progression of suicidality going through ideation, plans about taking one's life and communication regarding suicidal ideation, and growing through often recurrent suicide attempts with increasing lethality and suicide intent, and ends with fatal suicide (Van Heeringen, 2001; Runeson et al., 1996). Such a concept also implicates that once a person has entered the suicidal process, i.e. experienced suicidality, he or she will become more vulnerable to future suicidal behavior. Depending on which stage of the suicidal process is achieved, the

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impact of factors such as life stress, socio-economic circumstances or mental illness on the risk of suicidal behavior might differ (Arensman and Kerkhof, 1996; Neeleman et al., 2004). In a previous paper, Canetto and Sakinofsky (1998) described the gender paradox in suicidal behavior and demonstrated that this paradox is a real phenomenon and not a mere artifact of data collection. Moreover, they tried to explain the gender paradox by proposing several theories. Accordingly, the current paper aims to deepen the knowledge on this intriguing paradox by collecting and reviewing the recent literature on this topic. It is our goal to attract attention to this paradox and search for the most relevant gender-related factors that influence this phenomenon. Moreover, we aimed to find out whether these factors have a different genderdependent suicide-risk. These factors will be discussed by using the suicidal process as a conceptual framework. As can be seen below, for some factors a lot of evidence is available whereas the knowledge of other factors is rather limited, thus allowing only hypothetical and preliminary formulations. Notwithstanding, we preferred to also include these hypothetical suggestions in order to obtain a broad sight on this paradox. Extending the knowledge on the gender paradox could lead to the development of more appropriate clinical tools to assess suicide risk in both males and females separately. 2. Method A MEDLINE survey of the relevant literature was conducted, using the following search terms, in various combinations: ‘gender paradox’, ‘suicidal behavior’, ‘suicidal process’, ‘(fatal) suicide’, ‘suicide attempt’, ‘suicide rate’, ‘gender differences’, ‘male’, and ‘female’. All abstracts were screened and potentially relevant papers and all relevant cross-references were examined in full. 3. Results In this chapter, the factors that have been reported to influence the suicidal process will be listed, with a focus on a possible gender-load of each factor. 3.1. Psychosocial life stressors Psychosocial stressful life events that have been related to an increased suicide risk are separation from the partner, relationship conflicts, economic stressors (financial problems,

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unemployment), immigration, gender identity and somatic illness. The first two factors have been reported as the most common life events that lead to suicidal presentation, however irrespective of gender (Cupina, 2009). Sociodemographical and socio-economical factors related to these life events have also been reported as possible explanations for the gender differences in suicidal behavior. With regard to the age, it has been reported that male youths (i.e. younger than 25) with Major Depressive Disorder (MDD) have an even greater risk of suicide than the already dramatically increased risk for their adult counterparts (BlairWest et al., 1999), mainly attributed to life stressors such as separation, unemployment, and financial problems in the younger male group (Cupina, 2009). Furthermore, separated males were at an increased risk for suicide compared to separated females, irrespective of age, with factors such as mental health problems, previous suicide attempts, lower education and financial problems heightening this risk (Kõlves et al., 2010). In addition, the suicide rate of white men increases once older than 65, whereas in women the reverse happens once 55 or older (Murphy, 1998). These observations were linked to the socio-professional evolutions at that life stage: most men go on retirement at 65, and thereby not only lose a major source of interpersonal contact and friendships of the workplace, but also lose a lot of self-esteem as the primary provider of the family. Retirement does not have such an impact on women, as their jobs were typically in addition to the major domestic role (Murphy, 1998; Qin et al., 2000). Furthermore, marriage is considered to be a protective factor against suicide, which also implicates that widowhood further increases the risk of suicide, especially in males (Qin et al., 2000; Hawton, 2000; Murphy, 1998). Also, being a parent of a child younger than 2 years was more protective against suicide behavior for females than for males (Qin et al., 2000; Hawton, 2000; Murphy, 1998; Beautrais, 2002). 3.2. Sexual abuse Sexual childhood abuse is considered to be an important impacting factor. Sexual abuse appears to be more common in women than in men, but the smaller rates of reported abuse among men could also be due to a relative reluctance to report the experience in this population (Bebbington et al., 2009). With regard to the impact of childhood sexual abuse on later suicidal behavior, a direct association between suicidality and sexual abuse in boys has been reported with a 4 to 15 fold increased suicide risk relative to non-abused boys (Molnar et al., 2001; Martin et al., 2004; Olshen et al., 2007). In abused girls, such an association also has been reported but appears to be mediated by other factors such as depressive symptoms, hopelessness and family functioning, resulting in a threefold increased risk relative to non-abused girls (Molnar et al., 2001; Martin et al., 2004). Accordingly, Martin et al. (2004) did observe a clear trend that substantially more sexually abused boys (55%) than girls (29%) reported suicide attempts, indicating that boys' responses to sexual abuse may be more severe than girls (Martin et al., 2004). In addition, Bebbington et al. (2009) observed in a population of 8580 British volunteers that the population attributable risk fraction of sexual abuse to a history of suicide attempts was substantially greater in female respondents

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(28%) than in male respondents (7%). Obviously, the more prevalent exposure to sexual abuse among women should be taken into account when interpreting their results. Again, a mediation by affective symptoms was demonstrated (Bebbington et al., 2009). 3.3. Psychiatric (co)morbidity In an extensive meta-analysis investigating data on 3275 suicides, a clear association has been reported between suicide and psychopathology: of the 3275 suicides that had been studied, 87.3% had been diagnosed with a mental disorder prior to death (Arsenault-Lapierre et al., 2004). Affective (unipolar as well as bipolar), substance-related, personality (especially borderline and antisocial) and psychotic disorders (schizophrenia) account for most of the diagnoses among suicides, with any affective disorder or any substance disorder being the two single most common diagnostic categories among suicide completers (Arsenault-Lapierre et al., 2004; Hawton and Van Heeringen, 2009). In addition, a history of hospitalized mental illness has been reported to be the strongest risk factor for suicide, for both males and females (Qin et al., 2000). Given this strong link between suicidal behavior and various psychiatric disorders, it is highly possible that explanations for gender differences in rates of suicidal behavior may arise from gender differences in psychopathology (Beautrais, 2002). More specifically, strong associations have been reported between MDD or borderline personality disorder (BPD) on the one hand, and suicidal behavior on the other. Available evidence indicates that substantially more female than male patients are diagnosed with MDD and/or BPD (Kessler et al., 1993; Weissman et al., 1993; Kessler et al., 1994; APA, 2000; Skodol and Bender, 2003; Paris, 2004). It should be mentioned that no consistent gender differences are known with regard to the prevalence of bipolar disorder (types I and II), but that indications in favor of a higher history of suicide attempts for women with bipolar disorder have been reported (Baldassano, 2006; Diflorio and Jones, 2010). Moreover, lifetime suicide prevalences of hospitalized patients and mixed inpatient/outpatient populations with an affective disorder were 4% and 2.2% respectively (Bostwick and Pankratz, 2000) and clinical samples of BPD patients were demonstrated to have suicide rates of 5 to 10% (Oumaya et al., 2008). Taking into account the female preponderance in MDD and BPD as well as the high suicide rates in both disorders, a strong association between gender differences in psychopathology and gender differences in suicidal behavior can be expected. Also for other psychiatric disorders, gender differences in suicidal behavior have been reported. Substance-related disorders, personality disorders, but also attention deficit hyperactivity disorder substantially increase the risk of suicide in males (Arsenault-Lapierre et al., 2004; Hawton and Van Heeringen, 2009; Hawton, 2000; Murphy, 1998; Oquendo et al., 2007). In this context, it needs to be mentioned that impulsivity/hostile/aggressive personality features, known to be involved in various psychiatric disorders, are much more prevalent in the male sex and substantially heighten the risk of suicidal behavior and especially completed suicides (Brezo et al., 2006; Strüber et al., 2008). Furthermore, most of the patients with schizophrenia that commit suicide are male (De Hert et al., 2001). Whereas mood disorders include an increased

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suicide risk in males when concomitant with any anxiety disorder and in relationship with increased depression severity, the occurrence of mood disorders solely is linked with a higher female suicide risk (Arsenault-Lapierre et al., 2004; Bjerkeset et al., 2008; Brådvik et al., 2008). Anorexia nervosa carries a high risk of suicide in female sufferers (Hawton, 2000; Harris and Barraclough, 1997). It has also been demonstrated that affective disorders predominate in suicides of both genders with comorbidity of personality disorders in 40–50% and other comorbid psychiatric disorders in even more cases (Hawton, 2000; Henriksson et al., 1993; Foster et al., 1997). Finally, the association between minor psychopathology and long-term suicidal risk appears to be much stronger in males than in females (Gunnell et al., 2002). In contrast with all this, some authors have demonstrated that the gender gap in suicide rates is mainly driven by gender's effect in the population with no psychiatric history: the presence of psychiatric disorders could moderate the effect of gender and bring closer the male and female differentials in suicide rates. Therefore, it has been speculated that it is because severe psychiatric disorders have a strong impact on male and female patients alike and pose a strong risk of suicide regardless of gender (Liu et al., 2009). However, it could be questioned then whether the high male:female suicide ratio in the nonclinical populations could be due to a higher prevalence of undiagnosed psychiatric disorders among men (Liu et al., 2009). Indeed, it already has been suggested that population studies and diagnostic systems are overdiagnosing major depression in women and/or underdiagnosing it in men due to a so-called ‘machisimo-factor’ (Blair-West et al., 1999; Chang et al., 2009). Relative to female patients, men who commit suicide are certainly under-represented in clinical psychiatric populations and over-represented in their contact with government services because of substance abuse and antisocial behavior (Rutz et al., 1995; Blair-West et al., 1999). 3.4. Antidepressant treatment As stated, mental disorders are often underdiagnosed in male patients. These low rates of diagnosis of psychopathology amongst males also could lead to a lower rate of optimal treatment in this group. Logically, the lack of a sufficient treatment results in an existing or even worsening psychiatric symptom profile, often including suicidal ideation (Rutz et al., 1995). However, not only underdiagnosis might lead to insufficient treatment but also a poor compliance, characteristic for the male sex: men often have less confidence in and patience with long-lasting pharmacological treatment schemes. Also several psychotherapeutical interventions often ask too much efforts for males. Hence, male patients mostly expect to be helped immediately and directly, with concrete and practical advices (Thase et al., 1994). Accordingly, male patients are often less willing to ask for help to friends, family or professional caregivers (Bjerkeset et al., 2008; Murphy, 1998). Logically, male-related comorbid disorders such as substance abuse or antisocial personality disorders also might have a negative influence on the treatment outcome. Besides that, possible gender differences in antidepressant response have also been studied. In general, most of the conducted studies could not find a difference between both genders regarding the clinical response to antidepressant

agents (Hildebrandt et al., 2003; Grigoriadis and Robinson, 2007). However, a few exceptions have been published: Kornstein et al. (2000) observed a better response to sertraline than to imipramine for females, whereas the reverse happened for their male patients (Kornstein et al., 2000). Additionally, females tend to react better on treatment with a MAO-I (Quitkin et al., 2002). A recent meta-analysis has confirmed and extended the latter findings: the largest gender difference has been found in response to SSRI's with a better response for females, who also tended to respond better on venlafaxine (Khan et al., 2005). 3.5. Suicide methods and reports of suicide Males tend to use methods for suicide attempts that are more immediately lethal than those chosen by females, since men use more violent methods or quicker acting agents; whereas men often die by suicide due to hanging, carbon monoxide poisoning and fire-arms, females often try to poison themselves which is a method that might have a high toxicity but is associated with a low lethality and a slow rate of action (Bjerkeset et al., 2008; Canetto and Sakinofsky, 1998; Beautrais, 2002; Henderson et al., 2005). Several reports also have demonstrated that, while females attempt suicide more often than males, as suicide attempts become medically more serious, then the percentage of males involved in such attempts increases, and the gender differences diminish (Beautrais, 2002). This also implicates that the total duration of the suicidal process is often shorter in males than in females because only few suicide attempts already can result in a fatal suicide in males. It should also be noted that the applied methods of committing suicide not only depend on availability and accessibility of the method, but also on the cultural, religious and social values in the concerned regions (Kanchan and Menezes, 2008a,b; Kanchan et al., 2009). Importantly, the type of method applied also could influence or even bias suicide reports and classifications, depending on the gender. This could lead to a substantial under-reporting of female suicides as compared with the male rate on the one hand and an underreporting of nonfatal suicidal behavior in males on the other (Canetto and Sakinofsky, 1998; Blair-West et al., 1999; Cooper and Milroy, 1995; Beautrais, 2002). Other factors could also lead to an underreporting of female suicides. Suicide is culturally less accepted for females than males, implicating that not all female suicide will be reported as such (Beautrais, 2002). Also, as drug deaths are often not identified as suicides and females mostly tend to use self-poisoning methods or other less obvious means, a lot of female suicides also might not have been recorded as suicide. Conversely, the more violent methods of men rarely can be classified as accidental deaths. With regard to nonfatal suicidal behavior in males, data on such non-fatal behavior in specific male-dominated institutions such as jails could have been excluded (Canetto and Sakinofsky, 1998). In addition, males are supposed to be more concerned about social disapproval concerning their suicidal thoughts and behavior, making nonfatal suicidal behavior unmasculine. The widely accepted association between nonfatal suicidal behavior and feminity could even help to create this gender gap in rates of nonsuicidal behavior.

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Without any doubt, such cultural attitudes will affect researchers, making them less accustomed to and less skilled at recognizing suicidal inclinations in males (Canetto and Sakinofsky, 1998). 3.6. Cognitive processes and help seeking behavior of men and women Social and social-psychological factors have also been suggested to account for the gender difference in suicide. Ancient literature linked the lower suicide rates in females to discriminating aspects of the female gender: it was stated that ‘a woman's mental life is less developed’, ‘women are intellectually not able to plan a successful suicide’, ‘are physically incompetent to commit a suicidal act like firing a gun or plunging a knife and therefore use more methods that require less physical exertion and strength…’. Some authors used a less pejorative tone and proposed the basic biological or psycho-biological differences between both sexes as a possible explanatory factor (Murphy, 1998). Fortunately, later authors saw abovementioned statements as a gross misperception and even named it an “androcentric deficiency model” (Kaplan and Klein, 1989). Notwithstanding, cognitive operations appear to be considerably more complex in women than in men, with possible implications for their suicidal behavior. Whereas men are socialized to take straight decisions and simplify complex situations in order to reach certain goals as quick as possible, women show a more inclusive thinking that may protect them from so easily reaching the ultimate decision (Murphy, 1998). This also implicates that males, once they have taken the decision to commit suicide, will not reconsider it while women dear to doubt about their taken conclusions. In addition, most women are embedded in a social network, whereas the males environment is characterized by isolation and competition. In this competitive world of men, displaying doubt is considered as weakness, implicating that they have much difficulties to talk about their suffering, hopelessness and suicide plans with near persons or professional caregivers (Murphy, 1998; Beautrais, 2002; Möller-Leimkühler and Yücel, 2010). Accordingly, males tend to resolve their problems on their own and consider seeking for help as an admission of incompetence, resulting in fewer contacts with the mental health services (Murphy, 1998; Cupina, 2009). Women, in contrast, do not consider the need for help as negative and have a greater capacity to ask for help (Murphy, 1998; Bjerkeset et al., 2008; Hawton, 2000; Beautrais, 2002; Möller-Leimkühler and Yücel, 2010). 3.7. Cultural beliefs and societal attitudes Cultural meanings also appear to influence the perception of suicidal behavior for males and females. Studies suggest that suicide, alcohol- and drug-abuse are perceived as more “male”, and that nonfatal suicidal or automutilative behavior is considered as typically “feminine” (Canetto and Sakinofsky, 1998; Möller-Leimkühler and Yücel, 2010). This difference in social acceptability of suicide and attempted suicide for males versus females might have an impact on suicidal behavior in both genders: it is proposed that these cultural values may constrain females against suicide and males against suicide attempts (Murphy, 1998; Canetto, 1997). As previously

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mentioned, such cultural beliefs could also contribute to the underreporting of female suicides (Beautrais, 2002). However, note that abovementioned perceptions occur mainly in Europe and the USA but that in certain Asian countries (China, rural areas of India, Sri Lanka), totally different cultural attitudes towards suicidal behavior exist. Remarkably, in these regions, a substantially smaller male:female suicide ratio has been reported than the ratio for USA and Europe. As already mentioned, the difference in availability of the suicide method but also in cultural and social values towards the applied method could also influence in part the reported different male/female suicide ratios in several Asian countries (Kanchan and Menezes, 2008a,b; Kanchan et al., 2009). This confirms and stresses the importance and the impact of these area-bounded cultural beliefs on the suicide rate in males and females (Beautrais, 2002; Canetto and Sakinofsky, 1998; Canetto, 1997; Möller-Leimkühler and Yücel, 2010; Bhoomikumar and Kullgren, 2011). 4. Discussion The current paper aimed to further investigate the gender paradox of suicidal behavior, i.e. the discrepancy between the overrepresentation of females in nonfatal suicidal behavior and the preponderance of males in fatal suicide. In the present overview, those factors that contributed to and impacted this gender paradox, were systematically listed and discussed. In the discussion section, we will situate these factors within the ‘suicidal process’ concept, i.e. the process in which an accumulation of several factors leads to a progression of suicidal ideas into plans and finally into (fatal) attempts. 4.1. Impacting factors As demonstrated in the results section, the suicidal process is influenced by risk as well as protective factors with the load of some factors depending on the gender. Given its chronological evolution, these factors can influence the process on different time points. However, it is very difficult to situate these factors in an exact chronological sequence on the timeline of the suicidal process. Notwithstanding, available evidence suggests that a lot of risk factors take place in the middle of the suicidal process especially for females, as the female process takes longer and often results in suicidal ideation. In contrast, for males, most factors occur at the end of a process of – sometimes much – shorter duration, and often lead to a fatal suicide. Age-related socio-demographical factors such as having young children, retirement, widowhood, separation,… exert an important influence on the suicidal process over the total time span of the suicidal process (Cupina, 2009; Kõlves et al., 2010; Murphy, 1998). Serious life events or psychosocial stressors often give the onset to a suicidal process (Neeleman et al., 2004). The type of events but also the vulnerability for such events is gender dependent (Martin et al., 2004). More specifically, childhood sexual abuse appears to be a very impacting factor, directly heightening the suicide risk in boys, and indirectly in girls (Bebbington et al., 2009; Martin et al., 2004; Molnar et al., 2001). At a further stage in the suicidal process, these life events seem to play a less important role; at that moment, psychopathology, sociodemographical, cultural and

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psychological factors appear to exert a more important influence, however without a fixed chronology or sequence. A clear association has been reported between suicide and psychopathology. For some cases, the development of a psychiatric disorder could be the onset of the suicidal process. However, in most cases, several other factors already preceded the psychiatric disorder and most often also were implicated in the etiology and/or pathogenesis of psychiatric illness. Hence, psychopathology as an impacting factor will rarely been situated at the beginning of a suicidal process. MDD and BPD have been reported as the most impacting diagnoses leading to a progression of the suicidal process, especially in females (Arsenault-Lapierre et al., 2004; Bjerkeset et al., 2008). However, these higher female prevalences of MDD and BPD do not lead to a higher female suicide rate: fatal suicide rates are larger for depressed males than for depressed females. Diagnoses such as substance abuse, personality disorders, ADHD and schizophrenia are often linked to male suicides. More in general, it has been suggested that gender differences in rates of internalizing disorders such as depression and anxiety disorders account for much of the male:female differences in suicidal behavior. The higher rates of internalizing disorders in females appear to be reflected in higher rates of suicidal attempts and ideation in this gender, whereas the higher rates of externalizing behavior (antisocial, violence, behavioral problems, and substance abuse) in males could lead to a higher rate of deaths in male suicides due to the commission of more impulsive, lethal, and determined suicidal behavior than their female counterparts (Beautrais, 2002; Spirito et al., 1993; Gasquet and Choquet, 1993). Within this context, another possible impacting factor is the poor compliance in antidepressant treatment for men. Some authors have suggested that this link between psychopathology and suicide is much stronger in females than in males (Liu et al., 2009). This may be doubted as the underdiagnosing of psychopathology in males could also be a biasing factor. As already mentioned, one should be aware of considering MDD as the only psychiatric disorder leading to a substantial suicide risk, and thus mainly focusing on female patients when assessing suicide risks. Some authors have suggested the occurrence of different types of depression, according to the gender, or at least a symptom profile that is associated with the sex. In order to stress the high suicide risk in male depressed patients, some authors even have argued to apply the concept of a ‘male depressive syndrome’, characterized by more externalizing symptom profiles such as anger, aggression, irritation, and hostility (Blair-West et al., 1999; Rutz et al., 1995; Cochran and Rabinowitz, 2002). This type of depression would then often be associated with comorbid disorders such as substance abuse and antisocial personality disorder. However, this concept has not (yet) widely been applied in the domain of affective disorders. Maybe, lowering the threshold to diagnose MDD in males should be considered, as this might lead to a faster treatment (Blair-West et al., 1999). From an epidemiological perspective, a possible underreporting of suicide in females should also be taken into account when discussing the gender paradox, probably because in Western societies suicide is culturally less accepted in females than in males. Conversely, nonfatal suicidal or automutilative behavior is traditionally considered as typically feminine. This

means that non fatal suicides are socially more accepted for females than for males (Canetto and Sakinofsky, 1998) and could therefore have a double effect: on the one hand, a suicide attempt is a very important risk factor for fatal suicide later on, but on the other hand such an attempt could often be the start of (a search for) professional help. Note that these cultural beliefs are an important factor, as gender differences in suicide rates for certain Asian countries with opposite cultural beliefs totally differ, showing an opposite male–female rate. 4.2. Duration of suicidal process A suicidal process can take long up to many years but can also be very short, even just a few minutes, during which the intensity of the suicidal ideation also can vary strongly. The duration of the suicidal process is much shorter in male than in female patients: once the process has started, males commit suicide much quicker and much more successful than females (Neeleman et al., 2004; Van Heeringen, 2001). Indeed, males often use more lethal suicide methods. Therefore, in the ‘male suicidal process’, these methods often are situated at the end of the timeline. In this context, it should be noted that the applied method is often linked to the intent of the suicidal act: gender differences in suicidal intention could contribute to the gender differences in fatal suicides (Spirito et al., 1993; Beautrais, 2002). Women, who sometimes only want to draw attention to their suffering, may intentionally use methods which are associated with a high suicide risk but are less likely to be fatal (Beautrais, 2002; Canetto and Sakinofsky, 1998). This suggestion seems to be supported by the evolution of frequently used psychotropics over decades: forty years ago, ‘toxic’ agents such as barbiturates and tricyclic antidepressants were widely prescribed, whereas nowadays safer products such as low dose benzodiazepines and selective-serotonine-reuptake-inhibitors are mostly used (Beautrais, 2002). Due to the disappearance of these possibly toxic psychotropics, it was expected that the suicide methods in females would shift from intoxications with rather safe products to the more fatal ‘male’ methods. However, no substantial increase in suicide or change in suicide methods has been reported for females. Hence, the lower suicide ratio in females is not just a consequence of the application of less lethal methods, but this could – at least in part – also be a reflection of the suicidal intention (Beautrais, 2002; Canetto and Sakinofsky, 1998; Murphy, 1998). The longer duration of the ‘female suicidal process’ also offers the possibility to apply a wider range of therapeutical interventions in this patient group. Conversely, given the shorter duration of the suicidal process in males, the threshold for searching help is higher and the time for intervention is relatively limited; this also implicates that the longer the therapy needs, the lower is the chance for success (Neeleman et al., 2004; Cupina, 2009). Other psychosocial factors also contribute to the difference in duration of the suicidal process between both genders: men often have difficulties to take back a decision, while women do dear to reconsider their taken decisions. Additionally, women do not have a negative view on seeking for help, whereas for men it often could be seen and interpreted as a

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sign of weakness. That is one of the reasons why women more frequently seek for help than men (Murphy, 1998; MöllerLeimkühler, 2003). The lack of knowledge on the impact of gender-specific factors on the duration of the suicidal process stresses the need for further prospective and retrospective research into this topic. 4.3. Implications First of all, as the majority of the MDD and BPD patients are female, it could be misleading to dedicate a higher suicidal risk only to female patients. Moreover, the current results clearly indicate that a wide range of psychiatric disorders (and not only MDD or BPD) demonstrate complex interactions with gender regarding suicide risk assessment. Hence, suicide prevention campaigns should be alert for this issue and not only concentrate on female patients or on MDD and BPD patients alone. The present data also underline that, in suicide prevention, especially the male patients remain a difficult to identify and difficult to reach population. Moreover, given the abovementioned area-bounded cultural beliefs on suicidal behavior, future prevention campaigns should also deal with the cultural beliefs and climate around suicide and mental health care (Canetto and Sakinofsky, 1998; Möller-Leimkühler and Yücel, 2010; Bhoomikumar and Kullgren, 2011). This implicates that not only mental health care providers but also primary care providers, and a range of other agencies involved in education, employment and social service should participate actively in such programs. Prevention strategies should already start at a younger age, as gender-specific factors for suicidality have also been demonstrated in e.g. a large group of high school students (Epstein and Spirito, 2010). In other words, suicide prevention should be concentrated on the development and evaluation of better ways of delivering care to both males and females, at all ages. Accordingly, for those (male) risk patients who do access mental health care, more aggressive and long term pharmacotherapy and follow-up has to be started (Blair-West et al., 1999). Such an intensive treatment and follow-up is necessary, especially in those males (but also females) with just a limited seek for help. The health care system should try to lower its threshold and should be aware of not only offering ‘crisis’ care but also long-term help and assistance. Possibly, different stages should be differentiated with not only a highly intensive follow-up immediately after a suicide attempt, but also an intensive guidance when events have occurred with a possibly high impact on the suicidal process. Moreover, for young males, the detection and biopsychosocial treatment of comorbid conditions should even more become a core intervention in suicide prevention. Eventually, it could be considered to lower the threshold for diagnosing and treating MDD in males (Blair-West et al., 1999). Of course, all these efforts that try to better reach the ‘male suicidal patient’ should be implemented in the existing action plans, without losing sight on the ‘easy-to-reach’ female suicidal patient. Second, as already mentioned, the suicidal process should be followed intensively not only in those ‘common’ psychiatric disorders that are known as suicide susceptible disorders, but also in those disorders that have not really been associated with a higher suicide risk (Neeleman et al., 2004). Again, the

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complex interactions between specific psychiatric diagnoses and gender should also be taken into account. For that reason, the development of gender-specific life charts could be an appropriate method to follow the suicidal process across the life span (Fortune et al., 2007). Such a chart can aid understanding the suicidal process by visually representing the life traject of each individual patient with a higher risk, through the collection of all abovementioned factors with their genderspecific load. In this way, an accumulation of severe and less severe risk factors across the life span can be noticed systematically. Note that protective or positive prognostic factors also should be collected in such a chart. The application of such charts could contribute to a better assessment of the suicidal risk of each individual male or female patient and thus help to avoid a (fatal) escalation of the suicidal process. Moreover, the current findings should also be taken into account when adapting existing and/or developing new suicidality rating scales. Finally, we would like to stress that a prototypical ‘male’ and ‘female’ suicidal process does not exist. However, the current knowledge does point to some gender-specific trends that could contribute to the development of more specific prevention strategies and more optimal risk assessments in the everlasting battle against suicide. Role of funding source There is no funding source to be reported. Conflict of interest There are no conflicts of interest to be reported for any of the authors.

Acknowledgments The authors would like to thank prof. C. Van Heeringen for his useful comments on earlier versions of this manuscript.

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