The Article by Amy J Morgan and colleagues1 in The Lancet Healthy Longevity is a key advance in universal suicide prevention interventions for older men aged 65 and over in Australia, with implications for several other countries also. The authors assert that the study is, to their knowledge, the first randomized controlled trial of a gatekeeper training course with older men, worldwide. The study randomized Australian Men’s Sheds to receive Mental Health First Aid’s Conversations about Suicide course (ten clusters, n=92) or to a waitlist control group (nine clusters after withdrawals, n=169). The course teaches community members to recognize when someone is experiencing suicidal thoughts and how to provide them appropriate support. The primary outcome, intended actions to help someone at risk of suicide, showed a larger improvement in the intervention than the control group on recommended actions at 7-month follow-up (mean difference 3·31, 95% CI 2·06–4·57, p<0·0001). Suicide among older men is a crucial public health issue, with men aged 70 years and older having the highest suicide mortality rate of all age groups and genders, as reported in the 2021 Global Burden of Disease estimates.2
The study approached two important issues. First, gatekeeper training is a frequently studied and reviewed intervention in suicide prevention, but men and older age groups are seldom recipients of these interventions. In a 2024 review, men were under-represented (averaging 26·2% of the sample in 21 of 43 studies), and adults older than 45 years were omitted from 28 of the 43 studies reporting age.3 In a review of six systematic reviews,4 only one of the 61 included studies appeared to have had a majority of male participants. Second, despite the high rate of suicide among older men globally, little is known about effective suicide prevention initiatives for older people, with even less known for older men specifically.5 However, populations are ageing globally, and global time trend estimates of mean age of death due to suicide from 1990 to 2021 indicate that men are dying by suicide later in life.2 For both of these reasons, we will likely see increasing numbers and rates of suicide among older men unless effective interventions are implemented and scaled up.
#James Donaldson notes: Welcome to the “next chapter” of my life… being a voice and an advocate for #mentalhealthawarenessandsuicideprevention, especially pertaining to our younger generation of students and student-athletes. Getting men to speak up and reach out for help and assistance is one of my passions. Us men need to not suffer in silence or drown our sorrows in alcohol, hang out at bars and strip joints, or get involved with drug use. Having gone through a recent bout of #depression and #suicidalthoughts myself, I realize now, that I can make a huge difference in the lives of so many by sharing my story, and by sharing various resources I come across as I work in this space.#http://bit.ly/JamesMentalHealthArticle Find out more about the work I do on my 501c3 non-profit foundation website www.yourgiftoflife.org Order your copy of James Donaldson’s latest book, #CelebratingYourGiftofLife: From The Verge of Suicide to a Life of Purpose and Joy
The study by Morgan and colleagues1 contributes to the literature by including men exclusively, having an older sample, evaluating an intervention hitherto untested in this population, and implementing a cluster randomised controlled trial in a novel setting that could be replicated in other countries with Men’s Sheds (ie, places where men of all ages and backgrounds meet to undertake various mutually agreed activities). Therefore, the findings from the study fill a key knowledge gap in the prevention of suicide among older men.
Further work must be done to assess whether these findings generalise to the other states and territories of Australia and the several countries where Men’s Sheds operate internationally. Furthermore, it is crucial to consider selection bias, which the authors discuss, at the level of individuals and sheds. What are the characteristics of older men who do not attend Men’s Sheds, and are there other spaces that these men might frequently attend? Implementation science frameworks used with other Men’s Sheds internationally6 can identify the best way to scale up this intervention for further evaluation and implementation.
The study by Morgan and colleagues1 fits within the context of current research and practice by adapting a frequently used suicide prevention intervention, which attracts substantial research interest, to a population and setting in which the intervention appears to have never been used. Morgan and colleagues1 also continue the progression of previous gatekeeper training interventions and respond to multiple methodological requests in the literature. The study addresses the call for randomised controlled trials of gatekeeper interventions for suicide prevention by using a cluster randomised controlled trial design with implications for future group-level interventions with older men.
The study aligns with several research priorities for investigating suicide risk and recovery in men,7 including the need to explore effective interventions (priority 16) and community interventions (priority 19) as part of the Support and Recovery theme. The study is relevant to the broader context of social norms related to masculinity. As the authors consider, masculine norms of self-reliance, stoicism, and restrictive emotionality can negatively influence suicidal thinking and behaviour and related factors among men. Other research with older men has highlighted the nuanced effect of these norms on older men.8 Some changes of less magnitude evident in the study (eg, reductions in non-recommended actions) might have been influenced by opposing pressures from these norms.
Norms related to suicide also are likely to differ in older age, as compared with other age groups. For example, previous research described positive attitudes towards suicide among older men related to values regarding autonomy in choices around death.9 Future interventions could benefit from modelling the influence of norms concerning masculinity and death among older men, which can be done in theory-based interventions using the social health psychology theories that the authors mention.
With masculine norms exerting pressure on men that discourages them from talking about personal problems and help seeking,10 the study by Morgan and colleagues1 showed that meeting men where they are, in places such as Men’s Sheds, provides a valuable opportunity for intervention. The large number of men who participated in the study, during the COVID-19 pandemic, which disproportionately affected them, attests to the willingness of these men to contribute to suicide prevention. Morgan and colleagues1 should be commended on the implementation of this study during challenging global circumstances. Their study highlights the value of universal efforts such as these to empower older men in efforts to reduce the rates of suicide in their age group.
