More Than Just Depression: The Need to Screen for Anger As Suicide Risk Among Working-Aged Men

BACKGROUND AND PURPOSE

Over 47,000 people in the U.S. die each year by suicide; 77% are men (Murphy et al., 2018; Curtin et al., 2016). The largest increase in suicide over the past 20 years has been among working-age men (25-64) (Curtin et al., 2016). Working-age men are sometimes considered a “double jeopardy” risk group due to elevated suicide risk and difficulty engaging in help-seeking behavior (Addis & Mahalik, 2003; Good & Wood, 1995).

Suicide remains under-detected and under-treated by health and mental health professionals. Many professionals only screen for suicide specifically after identifying depressive symptoms. Depression, though significant, is not the only risk factor for suicide and may not always be present in individuals who die by suicide. Traditional depression screening measures do not include questions about anger/irritability, potentially missing this alternative manifestation of depression in men displayed (Giegling et al., 2009; Ammerman, Kleiman, Uyeji, Knorr, McCloskey 2015; Oliffe & Phillips 2008). This study examined the prediction of suicide risk among working-age men using a traditional depression screener and a single item screener for anger/irritability. Additionally, the researchers assessed the predictive ability of anger/irritability for suicidal risk among men without depression.

METHODS

A statewide men’s mental health and suicide prevention campaign, Healthy Men Michigan, encouraged men to take an online depression and suicide screening. This study included 2,153 men in Michigan. Depression was assessed using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS; Baer et al., 2000). The researchers assessed anger/irritability with the DSM-5 Cross Cutting Measure (American Psychiatric Association, 2013). Suicide risk was assessed using the Columbia Suicide Severity Rating Scale (Posner et al., 2011) and the ninth item of the HANDS, which asks about suicidal ideation. Logistic regression prediction models assessed relationships among suicide risk, depression, and anger/irritability.

RESULTS

This was a high-risk sample. More than 50% of the men screened positive for suicide risk, and more than 75% screened positive for moderate to high levels of depression. One-fourth of men screened positive for moderate or severe anger/irritability. The logistic regression model indicated that irritability/anger was associated with past month suicide risk (OR=1.52;95%CI,1.21-1.89;p<.001]) after controlling for depression (OR=11.29; 95%CI:8.49,15.02;p<.001). A sub-group logistic regression analysis was conducted using only men who did not screen positive for depression (N=535). Men screening positive for anger/irritability (n=63) were 3.15 times more likely to endorse suicide risk (95%CI:1.26,7.88,p=.01) than men who did not score positive for anger.

CONCLUSIONS AND IMPLICATIONS

Anger/irritability are critical in screening for suicide risk with working-age men. Reliance on positive screens for depression as a pre-curser for suicide screening is potentially life threatening as 12% of men who screen for suicide report no or low risk for depression. Masculinity theory suggests that anger/irritability are important in assessing depression and this study demonstrates a strong link between anger/irritability and suicide, absent from traditional measures of depression.