Summations
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Adolescent men die by suicide at higher rates than adolescent women. Factors associated with the COVID-19 pandemic suggest that this trend may intensify during the current worldwide crisis.
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Social distancing, virtual education, and substance use patterns associated with the COVID-19 pandemic may impact adolescent suicide risk. Adolescent men relative to adolescent women may be more vulnerable to associated developmental setbacks and impairments associated with these practices and community trends that raise suicide risk.
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Clinical recommendations can be advanced at this time to reduce the impact of these practices and community trends on adolescent suicide risk.
Perspectives
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While we await anticipated high-quality impact data from the pending community, national, and international epidemiological studies, these evidence-supported proposals remain tentative.
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Further delineation and development of these proposals are needed, which future data will support.
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A men’s mental health focus is one amongst many of importance in reducing suicide risk in adolescence. Nonetheless, as adolescent men remain much more likely than adolescent women to suffer a loss of life from suicide, a focus on this group is warranted.
Introduction
Data from across the developed world within the last decade continue to show an established trend that though female adolescents are much more likely than male adolescents to experience suicidal ideation and suicide attempts, male adolescents die by suicide at significantly higher rates (Roh et al., Reference Roh, Jung and Hong2018). In the USA, only accidental injuries surpass suicide as the leading cause of male adolescent death (Centers for Disease Control and Prevention, 2020).
The COVID-19 pandemic has drastically changed society, however, and some (Hoekstra, Reference Hoekstra2020; Szlyk et al., Reference Szlyk, Berk, Peralta and Miranda2020) have already noted a pressing need for a renewed consideration of adolescent suicide in this new era. Though a recent Japanese study (Isumi et al., Reference Isumi, Doi, Yamaoka, Takahashi and Fujiwara2020) has preliminarily found that youth suicide rates did not change during the acute effects of the first wave of the pandemic, the authors note that the ramifications of the pandemic are likely to be complex and long-lasting.
One complexity that warrants consideration is the male-specific impacts of the pandemic within adolescence. We have observed that matters of male development, social relationships, and substance use trends may place male adolescents within a specific vulnerability to the pandemic’s effects. This may not only further raise suicide amongst adolescent men relative to women, but also call for renewed assessment and intervention approaches tailored to men. The real loss of adolescent life to suicide within these emerging worldwide developments makes these observations important to consider now.
While we await anticipated studies concerning adolescent suicide in this new era, we present the following perspective of the World Federation of Societies of Biological Psychiatry’s Task Force on Men’s Mental Health in order to call attention to these considerations and to guide practitioners in adolescent suicide risk assessment and prevention within our new world landscape.
Observations
Social distancing
Social distancing practices, important to control the spread of infectious disease, may impart significant consequences on adolescent mental health (Clemens et al., Reference Clemens, Deschamps, Fegert, Anagnostopoulos, Bailey, Doyle, Eliez, Hansen, Hebebrand, Hillegers, Jacobs, Karwautz, Kiss, Kotsis, Kumperscak, Pejovic-Milovancevic, Christensen, Raynaud, Westerinen and Visnapuu-Bernadt2020; Orben et al., Reference Orben, Tomova and Blakemore2020). Consequences may include an increased risk of adolescent suicide, particularly for men.
Adolescent development entails a mobilisation of social relationships with peers to promote entry into adulthood (Gilmore & Meersand, Reference Gilmore and Meersand2014). The processes of normalisation (Shapiro, Reference Shapiro2008) and of the second individuation (Blos, Reference Blos1967) depend upon peer connections to shift from private inner life and the family towards the adult socialised world. Though virtual outlets may help to maintain peer connections in a pandemic world, friendships amongst men relative to women are traditionally based upon shared physical activities, competitive games and sports, and group processes (Rubin, Reference Rubin1986). The traditional focus in female friendships upon on emotional intimacy, relatedness, self-disclosure, and verbal expressivity may be more adaptable to the transition to virtual connectedness, while male adolescents’ friendships may be more impacted by societal closures and lockdowns. This may have significant consequences: in a recent pooled analysis of adolescents from 90 countries, the absence of close friends is a unique risk factor for suicidal behaviour for male, but not female early adolescents (Campisi et al., Reference Campisi, Carducci, Akseer, Zasowski, Szatmari and Bhutta2020).
Simultaneously, female adolescents are normatively emotionally and functionally more connected to their families than male adolescents (Dwairy & Achoui, Reference Dwairy and Achoui2010). Adolescent men may experience greater difficulty than adolescent women with restriction to the family home as traditional cultural ideals of masculinity across many cultures entail valuations on strength, independence, and autonomous competency (Kågesten et al., Reference Kågesten, Gibbs, Blum, Moreau, Chandra-Mouli, Herbert and Amin2016). The regressive experience of home restriction may be challenged, potentially leading to parent–child conflict and punishments, which are a common antecedent to adolescent suicide (Holland et al., Reference Holland, Vivolo-Kantor, Logan and Leemis2017). Alternatively, the adolescent may submit to the experience and potentially suffer an attendant loss of esteem surrounding masculine autonomy. As suicide in young men can function as an effort to hide self-perceived masculine weakness and as a compensatory action against dependency (Rasmussen et al., Reference Rasmussen, Haavind and Dieserud2018), these responses also carry risk.
Virtual schooling
The transition from on-site to virtual schooling carries both educational and social implications specific to adolescent men. The challenges of virtual schooling in the COVID-19 era (Black et al., 2020) may most directly impact students with the least supports and pre-existing higher suicide risk.
Transitioning from brick and mortar to virtual schooling is associated with persisting negative academic effects (Fitzpatrick et al., Reference Fitzpatrick, Berends, Ferrare and Waddington2020). Poor academic performance is a robust predictor of future suicide, with greater strength as a predictor amongst males than females (Bjorkenstam et al., Reference Bjorkenstam, Weitoft, Hjern, Nordstrom, Hallqvist and Ljung2011). As many cultures worldwide traditionally place a higher emphasis on male career achievement relative to non-financial family obligations, diminishing prospects upon graduation may affect adolescent men disproportionately. Hopelessness about the future wrought by academic setbacks may onset, a notable concern in that a recent study found hopelessness to be a male-specific risk factor for suicide attempts across adolescence and young adulthood (Miranda-Mendizabal et al., Reference Miranda-Mendizabal, Castellví, Parés-Badell, Alayo, Almenara, Alonso, Blasco, Cebrià, Gabilondo, Gili, Lagares, Piqueras, Rodríguez-Jiménez, Rodríguez-Marín, Roca, Soto-Sanz, Vilagut and Alonso2019).
The social setbacks of on-site education closure also carry implications. In addition to the challenges of losing access to peers for friendships through the cancellation of organised team sports, closure yields reduced exposure to male role models in schools including male teachers, coaches, and other mentor figures. Mentorship moderates the relationship between stress and depression (Hurd & Zimmerman, Reference Hurd and Zimmerman2010), the latter of which is the largest risk factor for male adolescent suicidal ideation (Coleman, Reference Coleman2015). Mentorship as a protective factor may be particularly important amongst male adolescents with absent fathers, who have poorer interpersonal relationships and more fragile masculine self-identities (Beaty, Reference Beaty1995). The increased ease of truancy with virtual schooling contributes to additional unstructured time, a known risk factor for adolescent substance abuse (Dumas et al., Reference Dumas, Ellis and Litt2020) that is highly correlated with adolescent suicidal behaviour through multiple pathways (Wang & Yen, Reference Wang and Yen2017). Unstructured socialising is a risk factor for adolescent delinquency (Hoeben & Weerman, Reference Hoeben and Weerman2016), and delinquency is a risk factor for suicidal behaviours (Thompson et al., Reference Thompson, Ho and Kingree2007). With access to competitive sports and other structured group activities limited, male adolescents may instead turn to gang involvement for socialisation.
Substance use
Adolescent substance use in the COVID-19 era has increased (Dumas et al., Reference Dumas, Ellis and Litt2020). Adolescent men are significantly more likely than adolescent women to use substances both alone and with peers in the COVID-19 era (Dumas et al., Reference Dumas, Ellis and Litt2020). Both behaviours are dangerous: ignoring social distancing practices in order to use with peers makes adolescent men vulnerable to contracting COVID-19, while solitary drinking is known to be associated amongst late adolescents with increased depressive symptoms and suicidal ideation (Ju et al., Reference Ju, Kim, Oh and Park2019). Male adolescent substance use in the home or rule breaking to escape the home to use with peers may yield increased parent–child conflict and punishments, which again are a common antecedent to adolescent suicide (Holland et al., Reference Holland, Vivolo-Kantor, Logan and Leemis2017). An increase in adult alcohol use during COVID-19 (Pollard et al., Reference Pollard, Tucker and Green2020) suggests that parents may also be using more heavily. Male adolescent exposure to parental use may lead to an increase in substance use amongst their adolescent offspring (Sigman, Reference Sigman2020), as well as impact the family supportive functions to male adolescents through direct intoxication, domestic violence (Campbell, Reference Campbell2020), and other functional impairments.
Recommendations
Male adolescents require special consideration on account of unique socioemotional developmental vulnerabilities to pandemic stressors coupled with pre-existing high suicide rates. As male adolescents have fewer suicide attempts relative to female adolescents prior to completed suicide (Miranda-Mendizabal et al., Reference Miranda-Mendizabal, Castellví, Parés-Badell, Alayo, Almenara, Alonso, Blasco, Cebrià, Gabilondo, Gili, Lagares, Piqueras, Rodríguez-Jiménez, Rodríguez-Marín, Roca, Soto-Sanz, Vilagut and Alonso2019), clinicians must be attentive to often subtle risk factors. In one large American study, over two-thirds of adolescents with suicidal ideation (67.3%) and over half of those with a suicidal plan (54.4%) or suicide attempt (56.9%) did not have any contact with a mental health specialist in the past year (Husky et al., Reference Husky, Olfson, He, Nock, Swanson and Merikangas2012), and as such all clinicians play a crucial role. While responsible media reporting guidelines as suggested by the World Health Organization (World Health Organization, 2017) and pre-existing best practices in screening and prevention remain the core of any recommendations (Shain, Reference Shain2016), this perspective proposes that best practices today may be informed by these preliminary observations while awaiting higher quality evidence. As society is rapidly changing in ways that may increase adolescent suicide, these preliminary observations warrant attention to reduce adolescent suicide.
Summary
Address social distancing challenges
Social distancing practices, while essential to reduce COVID-19 transmission rates, may have negative effects upon important processes in male adolescent development. Screening and referral practices should tend to male adolescents’ capability to sustain friendships in spite of societal lockdowns as well as to deficits in male adolescent resiliency around healthy masculine self-regard to the regressive experience of restriction to the family home. Heightened parent–child conflict in the home should be assessed and addressed.
Address virtual schooling challenges
Educational achievements and access to the supportive functions of the school community, including male mentorship, decline with in-person school closure. Screening and assessing for adolescent reactions to academic decline and loss of educational supports are indicated. System coordination with school guidance counsellors, coaches, mentor figures, tutors, and other educational supports should be considered to preserve the positive function of role models for adolescent males.
Address substance abuse
Heightened attention to screening and monitoring of substance use disorders is crucial. Interventions to reduce means of access to alcohol and other drugs in the family home are important. Counselling and education to increase appropriate family authoritative structure that balances warmth with firmness is indicated, while parents should be assessed for increasing alcohol or substance use with subsequent support or referral provided where indicated.
Further research observations and studies are needed during these turbulent times to better understand the impact of the COVID-19 crisis on suicidal behaviour in adolescents, and male adolescents in particular. Updated policies and clinical practices in general and select populations will be needed based on further research to prevent a major international crisis of adolescent suicide.
Acknowledgements
The authors would like to acknowledge the World Federation of Societies of Biological Psychiatry (WFSBP), where Dr. Timothy Rice is Co-Chair and Dr. Leo Sher is Chair of the WFSBP Task Force on Men’s Mental Health.
Authors contributions
The authors meet the criteria of authorship described by The International Committee of Medical Journal Editors (ICMJE).
Financial support
This work received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
The authors declare no conflict of interest.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees.
