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Suicide From the Perspectives of Older Men Who Experience Depression: A Gender Analysis
John L. Oliffe, Christina S.E. Han, John S. Ogrodniczuk, J. Craig Phillips and Philippe Roy Am J Mens Health published online 3 August 2011 DOI: 10.1177/1557988311408410 The online version of this article can be found at: http://jmh.sagepub.com/content/early/2011/05/14/1557988311408410

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408410
Oliffe et al.American Journal of Mens Health

JMHXXX10.1177/1557988311408410

Suicide From the Perspectives of Older Men Who Experience Depression: A Gender Analysis
John L. Oliffe, PhD1, Christina S. E. Han, BA1, John S. Ogrodniczuk, PhD1, J.Craig Phillips, PhD, LLM1, and Philippe Roy, MA2

American Journal of Mens Health XX(X) 111 The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988311408410 http://jmh.sagepub.com

Abstract Depression can be a pathway to older mens suicide, yet the mechanisms by which this can occur are poorly understood. A qualitative study of 22 older men who self-identified or were formally diagnosed with depression was conducted to describe the connections between masculinity, depression, and suicide. Analyses of individual interviews revealed that cumulative losses around social bonds were central to older mens depression, apathy for living, and thoughts about suicide. Prominent were mens self-assessments of failing to fulfill breadwinner roles, judgments that led participants to ruminate on their shortcomings amid recognizing their older age as limiting opportunities for redemption. Stigma featured as a barrier for men acting on their suicidal thoughts, and guilt about the pain their suicide would evoke on family and friends was a strong deterrent for mens self-harm. Overall, participants alignment to masculine ideals influenced both the connectedness and detachment between older mens depression and suicide. Keywords older men, depression, suicide, masculinity

Introduction
Suicide is one of the leading causes of death in North American men and particularly high is the incidence of suicide among men 75 years and older (Statistics Canada, 2010; U.S. Census Bureau, 2010; U.S. National Center for Health Statistics, 2007; please see Tables 1 and 2). Numerous social and psychological factors are implicated, and though the pathways to suicide vary, there is consensus that severe depression can be a trigger for older mens self-harm and suicide (Gunnell, Middleton, Whitley, Dorling, & Frankel, 2003). In terms of cause, mens depression is reported to emerge from diverse sources, including grief and loss around conjugal bereavement or divorce, which in turn are significant risk factors for suicide (Elwert & Christakis, 2008; Payne, Swami, & Stanistreet, 2008; Schmutte, OConnell, Weiland, Lawless, & Davidson, 2009). Lost social bonds can also isolate men, partly because women play a critical role in connecting men socially and providing them with emotional support (Bennett, 1998; Swami, Stanistreet, & Payne, 2008). Implicated also as rendering older men who experience depression vulnerable to suicide are comorbid physical illnesses, functional limitations, and financial stresses (Beautrais, 2002; Conwell et al., 2000).

Of the many social factors underpinning mens depression and/or suicide, masculinity has attracted recent attention both in commentaries and empirical accounts. Work, including the current qualitative study, has drawn on social constructions of gender using Connells (1995) masculinities framework to advance Courtenays (2000) adaptation to mens health research by inductively deriving insights about dominant ideals of masculinity, and how they influence boys and mens gender roles, identities, and relations and their health and illness practices. Social constructionist gender studies have revealed connections between masculinities and mens depression-related experiences. Emslie, Ridge, Ziebland, and Hunts (2006) secondary analysis of mens interviews derived from a study that focused on depression-related issues found that longstanding feelings of isolation and differencein addition to sadness, guilt, detachment, anger, and fearwere central
1 2

University of British Columbia,Vancouver, British Columbia, Canada Laval University, Quebec City, Quebec, Canada

Corresponding Author: John L. Oliffe, School of Nursing, University of British Columbia, 3026190 Agronomy Road,Vancouver, British Columbia, Canada,V6T 1Z3 Email: john.oliffe@nursing.ubc.ca. Web: www.menshealthresearch.ubc.ca

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2
Table 1. U.S. Mens Suicide Rates by Age Group (2000-2006) Age (years) 2000 2001 2002 1-4 5-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85 n/a 1.2 13.0 21.4 19.6 22.8 22.4 19.4 22.7 38.6 57.5 n/a 1.0 12.9 20.5 21.0 23.1 23.4 21.1 24.6 27.8 51.1 n/a 0.9 12.2 20.8 20.5 23.7 24.4 22.2 24.7 38.1 50.7 2003 2004 n/a 0.9 11.6 20.2 20.6 23.2 24.4 22.3 23.4 35.1 47.8 n/a 0.9 12.6 20.8 20.4 23.0 24.8 22.1 22.6 34.8 45.0 2005 2006 n/a 1.0 12.1 20.2 19.9 23.1 25.2 22.2 22.7 35.8 45.0 n/a 0.7 11.5 20.8 19.7 23.2 26.2 22.7 22.7 33.3 43.2

American Journal of Mens Health XX(X) crime, behaviors that ultimately increased their risk for self-harm and suicide. The authors concluded that traditional notions of masculinity informed and influenced mens actions within and across the big build processes they described (Brownhill et al., 2005). Clearys (2005) study of young Irishmen highlighted the constraining influences of hegemonic masculinity in mens silences around distress, reluctance to disclose emotional matters, and elaborate secret-keeping in concealing plans for suicide. Oliffe, Ogrodniczuk, Bottorff, Johnson, and Hoyaks (2010) study of middle-age men who experienced depression found how aligning with masculine ideals could prompt participants to counter suicidal thoughts or draw them closer to self-harm and suicide. Although linkages between masculinity and mens depression and/or suicide have been described, much of this literature has focused on young and/or middle-age men (Schmutte et al., 2009). Yet, implicitly, much of the literature addressing older mens depression reveals causeeffect relations that are intricately connected to masculinity. For example, advancing age can be accompanied by reduced physical, mental, and emotional strength (Gunnell, Platt, & Hawton, 2009) and masculine protector and provider roles can be lost through unemployment, retirement, and illness (Gilchrist, Howarth, & Sullivan, 2007; Schmutte et al., 2009). A study of elderly widowers by Bennett (2007) found that emotional suppression, especially in public, amid embodying masculine ideals of control, rationality, responsibility, and successful action were key to mens efforts for preventing depression. Despite often experiencing significant suffering, men tend to internalize, suppress and/or deny emotional distress (Cantor & Slater, 1995; Thompson, 2008), a practice that reflects traditional Western masculinity, which avows the display of emotion as decidedly feminine and transgressing masculine ideals (Byrne & Raphael, 1997). It follows that mens suicide rates may, at least in part, reflect the stress of self- and social expectations about embodying traditional breadwinner and family man masculine roles (Chuick et al., 2009). Such interpretations are supported by a study examining older mens suicide notes which revealed guilt, regret, and blame as key themes (Salib, Cawley, & Healy, 2002). Idealized masculinities also prescribe characteristics of autonomy and self-reliance, which can influence mens risky self-management strategies and discursively shape their reluctance to engage professional mental health care services (Real, 1997; Rochlen et al., 2010; Rutz & Rihmer, 2007). Health-related stigma whereby a person can be negatively identified and disapproved of because of a mental or physical health issue (Goffman, 1963) can be particularly critical and pervasive for men who are deemed to be personally and morally responsible for their own health and illness (Greaves, Oliffe, Ponic, Kelly, & Bottorff, 2010), and in the specific context of suicide, their own

Note. n/a = not applicable. Source. Adapted from U.S. Census Bureau (2010).

Table 2. Canadian Mens Suicide Rates by Age Group (20032007) Age (years) 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90 2003 1.7 14.8 22.1 18.3 20.3 27.4 26.1 26.4 26.5 25.3 22.5 19.7 17.9 19.2 19.8 22.6 40.6 2004 1.6 14.7 19.2 19.9 23.0 23.2 23.1 25.4 25.7 21.6 17.6 14.5 17.0 19.3 20.6 26.8 19.2 2005 1.7 13.4 20.1 17.5 19.6 24.9 27.2 28.8 25.7 22.2 17.5 18.3 17.0 22.7 19.4 21.4 20.1 2006 1.2 10.1 18.9 15.5 16.6 21.7 24.2 26.1 22.8 24.5 22.3 17.4 14.0 23.4 18.4 29.2 35.7 2007 1.7 11.4 19.6 19.9 16.5 21.8 21.9 27.0 25.3 21.5 17.9 14.2 15.5 20.9 23.5 23.8 18.3

Source. Adapted from Statistics Canada (2010).

to participants accounts of their depression. Also highlighted have been recursive relationships between college mens masculinities and depression (Oliffe, Kelly, et al., 2010) and how varying configurations of masculinity connect to mens depression triggers, early symptoms, external overflow, and maladaptive coping (Chuick et al., 2009). Social constructionist gender studies have also been used to describe linkages between masculinity and mens depression and suicide. Brownhill, Wilhelm, Barclay, and Schmied (2005) detailed the potential for a cascade of events in which mens internalizing and avoidance of problems and/or self-medicating with alcohol and other drugs was linked to risk-taking, violence, aggression, and

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Oliffe et al. death. Reluctance to seek help and maladaptive self-management strategies such as self-medicating depression and suicidal ideation with alcohol and other drugs (Riska, 2009) may also be a by-product of stigma, and contribute to the discordant relationship between mens high suicide rates and low rates of clinically diagnosed depression (Mkinen & Wasserman, 2000; Rihmer, Belso, & Kiss, 2002; Rutz & Rihmer, 2007).
Table 3. Participants Demographic Information (N = 22) Demographic Age (years)a 55-59 60-64 65-69 70-74 7579 Employment status Employed full time/part time Unemployed Retired Marital status Married Common-law Separated Divorced Widowed Ethnic background Caucasian Asian Sexual orientation Heterosexual Homosexual n 3 5 5 4 5 9 6 7 3 12 1 4 2 20 2 20 2

Percentage 13 23 23 18 23 41 27 32 13 55 5 18 9 91 9 91 9

The Current Study

The goal of the current study and article is to describe linkages between masculinity, depression and suicide among older men, as a means to directing men-centered mental health care services. Interpretive descriptive methodology, in which an in-depth understanding of the participants experiences is sought, was used (Thorne, 2008). Influenced by grounded theory, naturalistic inquiry, and ethnography, interpretive description affords selection from a variety of data collection methods to present a conceptual description discussing thematic patterns and commonalities characterizing a clinical phenomenon (Thorne, 2008). In addressing the overarching research question, How does masculinity shape older mens perspectives and practices around depression and suicide?, qualitative traditions central to interpretive description, including the researchers co-construction in collecting and interpreting the data, and their commitment to inductively deriving the findings, were followed (Morse & Field, 1995).

a. Age range = 55-79 years; mean SD = 67.81 6.92 years.

Methods Participants
A total of 22 English-speaking men ranging in age from 55 to 79 years (M = 67.8 years; SD = 6.92) who selfidentified (n = 8; 37%) or self-reported that they had previously been clinically diagnosed by a health care professional (n = 14; 63%) with depression participated in the study (see Table 3). In all, 19 of the 22 participants were Anglo-Canadian and 3 participants were of Asian ancestry. Participants lived in Vancouver (n = 12; 55%), a city of 550,000 in Western Canada, and Kelowna (n = 10; 45%), a regional city in the interior of British Columbia with a population of 165,000. Postcards, brochures, flyers, and newspaper advertisements described the study and invited potential participants to contact the project manager.

Procedure
Following ethics approval and completion of a written consent form, individual in-depth, semistructured interviews lasting 60 to 90 minutes were conducted at a location

and time of the participants choice. Researchers explained to participants that the interview was not intended as a form of therapy but rather as an opportunity for us to better understand older mens depression-related experiences. Baccalaureate- and masters-prepared researchers, trained in qualitative interview methods conducted the interviews, and participants received a nominal honorarium of Canadian $30 to acknowledge the time spent and their contribution to the study. Participants provided demographic data and completed the 21-item Beck Depression InventorySecond Edition (BDI-II; Beck, Steer, & Brown, 1996; see Table 4). BDI-II has been assessed for its reliability and validity (with the specific inclusion of an alpha coefficient) in numerous studies including research with a group of young incarcerated men (Palmer & Binks, 2008), and its inclusion in the current study was based on a desire to use broad categories to describe the severity of participants depression at interview. Although an interview guide was used, participants were encouraged to share details about what was most relevant to them in an effort to foster conversation, rather than formally trade questions and answers. Although the interviews were not specifically focused on issues pertaining to suicide, the participants volunteered information about suicide and openly shared their experiences and perceptions. The content and severity of participants

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4
Table 4. Participants Depression Characteristics (N = 22) Characteristic Clinically diagnosed with depression Yes No Year(s) with clinical diagnosis of depression (of 14 participants) Diagnosed (of 14 participants) with depression by a Doctor Psychologist Psychiatrist Currently on treatment (n = 14) Group counseling Medication(s) Beck Depression Inventory score <15 (mild depression) 15-30 (moderate depression) >30 (severe depression) Not available (did not complete) Range

American Journal of Mens Health XX(X)

SD

n 14 8

Percentage 64 36

1-40

17.28

14.09 4 2 8 4 10 29 14 57 29 71 46 36 13 5

2-46

18.19

11.33 10 8 3 1

thoughts about suicide, and the specific linkages to depression revealed all the men as having direct experiences with suicidal thoughts. Within this context specific interview questions were included such as, what are your thoughts around self-harm and suicide?, along with prompts including, can you tell me more about that? and, what was that like for you? Interviewers provided a printed list of mental health service resources to the participants, and followed guidelines for ceasing interviews and referring interviewees to professional care services if they observed any participant distress. Digitally recorded interviews were transcribed verbatim excluding identifying information, reviewed for accuracy, and labeled with an identifier code.

Data Analysis
Within qualitative studies, in addition to the study findings, research questions can be inductively derived based on what is shared by the participants. The interview data were mined for instances whereby participants detailed their perspectives about suicide, and experiences around suicidal thoughts and the connections to their depression. From this parent code, labeled Suicide, a data subset was derived, abstracted and independently read by the authors. Entire interviews and the coded suicide data were discussed by the authors with the overarching research question in mind: How does masculinity shape older mens perspectives and practices around depression and suicide? In line with some components of consensual qualitative research (CQR; Hill et al., 2005), the authors worked to consensus around core ideas before moving to cross-analysis.

Specifically, through repeated readings of the interview data with the research question in mind, ideas and interpretations about recurring and converging patterns were discussed and developed by the research team. In the cross-analysis phase the team met to generate key concepts, and preliminary themes were inductively derived and labeled, along with illustrative examples drawn from the core idea data. Descriptive notes were used to define emergent themes so that relationships between them could be developed. Themes defined as coherent patternsboth within and across the datawere identified and developed through these iterative processes (Hammersley & Atkinson, 1995). The relevant empirical and masculinities literature was also revisited to prompt questions about the data and to further develop the analyses (Spradley, 1980). Cohesive sampling, the collection of rich data, and analyses engaging all the participant data and commitment to reaching author consensus were key to claiming saturation (Morse, 1995).

Results
As per Hill, Thompson, and Williams (1997) and Hill et al.s (2005) approach to classifying qualitative findings the first two themes, cumulative loss and failed providers are general (i.e., all the participants are represented) and the third theme, stigma and suicide, was typical in that it applied to more than half the participants. Though the findings are detailed in three discrete themes, the overlap between the themes reflects their connectedness in the mens lives, and distilled in what follows are the issues consistently discussed by the participants.

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Oliffe et al.

5 I start each day wondering what the point is continuing. In the words of I think it was Marc Twain thousands of years before I was born, I knew nothing and I wasnt greatly inconvenienced. Yet, rather than positioning suicide as the solution to this quandary, participants described their profound disinterest in living, for which they hoped death might emerge naturally as a by-product of older age or accident. A 75-yearold man harbored irreconcilable regrets and profound melancholy in suggesting: If I was confronted with a serious life and death situation, I wouldnt fight all that hard to stay on the alive side. I would say well my time has come and thats that. I dont want to fight this. I might not win anyway. A 66-year-old man assured us that he didnt have the nerve or whatever it takes to kill myself recalling how, even as a younger man choosing a military tour of Vietnam as the perfect place to die did not come to fruition. Similarly, a 62-year-old salesman declared that he didnt want to do anything like blow my head off . . . but on the other hand I dont want to be alive. In sum, amid significant unresolved grief mens apathy and disquiet prevailed, and real, imagined, and anticipated loss fuelled profound sadness and anxiety about being unable to stem or accept what had been lost. Although resilient in assuring us that suicide was not an option the participants indicated they had thought about, and for the most part, welcomed death as providing the ultimate respite from lifelong challenges and the hopelessness they endured. As Havens (1965) suggests, suicide most often emerges from multiple factorsa knot of circumstances tightening around a single time and place, and in this regard, participants seemed vulnerable to self-harm in giving up their fight against depression.

Cumulative Loss
In locating their depression and contextualizing perspectives about suicide, the participants detailed numerous and cumulative losses across their lives. Permeating the mens interviews was an insistence that many issues, rather than one particular incident, had fuelled their depression. For example, a 62-year-old man described a series of challenges, including job loss, financial hardship, the death of close friends, and his daughters chronic illness as strong contributors to his depression and emergent thoughts about suicide. Moreover, the grief that emerged from each of these events lay unresolved which, retrospectively, he suggested had led him to self-isolate, I guess it was anger and frustration . . . I just tuned the world out. Extreme lows punctuated the mens lives and ultimately prevailed as losses accrued to overshadow and outweigh their life accomplishments. A 66-year-old man explained that his whole life had been like a rollercoaster ride as a result of his poorly controlled depression: When Ive gone into something like in university or my flying or my locksmithing, I do very well, but then all of a sudden I crash. Everything seems to go wrong and I lose interest and I start hating the world. In this example, the pattern of loss eventually limited the mans energy and interest for taking up recreational activities and pursuing work interests. Amid these restrictions, his intimate relationship fractured and many social bonds were severed, leading to a cascade of losses: Even with my second wife, I cant hug her, weve never had a close relationship Ive always pushed her away. My older son wont talk to me now because he just doesnt like the way that Ive treated my wife. As men grew older, reversing these trends and finding opportunities for redemption faltered. Instead, lifelong struggles and depression-induced fatigue spread, and recognition of their older age and mortality grew. The mens life quality was eroded to a point where their efforts for fighting depression were questioned because the number and quality of years that they were presumably fighting for were negligible. A combination of loss, unresolved grief and fatigue underpinned mens depression, manifesting as nihilism. A 75-year-old electrician made reference to the many sites of failure in suggesting their cumulative toll had quelled his interest for living:

Failed Providers
Participants depression and suicidal thoughts were most often linked to perceptions that their lives had been of little consequence, especially in terms of failing to build a career and wealth as a means to fulfilling breadwinner roles. A 62-year-old participant explained that he had fallen short of his and societys expectations that he be the primary provider for his family, and in particular he had failed to meet the needs of his daughter, who was disabled and confined to a wheelchair: You havent accomplished what you set out to do and set your family up, so as they say, I never did figure out a way to do it.

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6 Typically, a lifetime of work was detailed by participants during the interview, demonstrating how mens masculine identities were strongly linked to what they do or did for a living. A 55-year-old bus driver revealed the centrality of his working man identity: I dont know whats going to happen if I have to retire. I really like being somebody . . . whatever that somebody is, environmental tech or a safety guy or a bus driver, and when I wasnt working, I didnt have the identity of you know whats your job and I find that really difficult. A 64-year-old participant confirmed that many older men relied heavily on work, and that retirement, redundancy, and/or retrenchment were significant threats: A lot of men who have been working for one company for a lot of years, when suddenly that stops, their whole life has been revolving around the job . . . they find themselves at a loose end with nothing to do. No purpose in life anymore. As younger men, participants had goals, made plans, and had high hopes for what they might achieve in their working lives. However, as older men, paid work had ceased or fewer work years remained and the potential for job advancement or a flourishing career were diminished. Competing with younger and relatively cheaper workers was also stressful, as a 62-year-old administrator explained, Id hired all the other staff so they could then bring in a person that was half my age at two thirds my salary and he basically just ran the systems I had set up . . . Im getting pretty old and Im not that employable or people perceive you as being old. Despite these challenges, men were dedicated to work as long as they could to ensure that they and/or their families had enough money to live comfortably. A 79-year-old participant, who worked in a clothing factory, said I manage to keep the family going . . . the only pleasure I get is to give them (his children and grandchildren) something. I just gave my two granddaughters a car. Similarly, a 58-year-old participant who worked in sales assured us that despite his discontent, Ill just keep on working, Ive got to feed the wife and kids, Ill go to work anyway even though life sucks. The fragility of the mens employment and the modest jobs they had or had previously done were ever present. Although depression invoked barriers to establishing a career, the ability to sustain or tolerate a job was also challenging. A torrent of negative outcomes accompanied mens unemployment and some participants positioned

American Journal of Mens Health XX(X) suicide as an antidote to such failings, as a 55-year-old bus driver revealed, Job losses are a big deal for me . . . a really, really big deal . . . really caused some life-changing events . . . It was probably in the middle of looking for work and beating myself up for not being a good parent and not being a good person. I couldnt even keep a job. It would be easier to just kill myself and get on with it. Let the rest of the world manage however they would. Illustrated here are connections between mens masculine identities and the roles that are contingent on their capacity to work. Participants often self-assigned failed provider labels based on their income or lack thereof, while suicide offered an end to those shortcomings, and closure to what had frequently been a lifelong battle to sustain a fundamental manly enterpriseto work and provide for family. These findings support Shiner, Scourfield, Fincham, and Langer (2009) who suggest that work-related problems and financial difficulties can strike a profound blow to mens sense of purpose and belonging. In addition, as Robertson (2007) predicts, while work and personal attachments can be protective, under strain (as is often the case with older mens depression), they can also be a source of stress.

Stigma and Suicide

Noteworthy is that many participants positioned stigma around suicide as a highly influential barrier to self-harm or acting on thoughts about suicide. However, rather than self-interest, participants consistently pointed to their desire to protect family and friends from the distress, shame, and/or guilt that would likely accompany their suicide. A 58-year-old salesman told us a story about the suicide of a close friend in explaining why he would never take his own life, regardless of the emotional, physical, and mental pain he experienced, He got depressed, he had his young son down, went home and hung himself . . . and the first person in the door was his son, why did he do that? Why did he, you know, why leave that last memory of his dad to his son? Because he knew his son would find him but maybe he didnt care. Most men agreed that family was their primary reason for living, and significant others directly and indirectly influenced participants resistance to self-harm and suicide. A 62-year-old administrators efforts for self-health were taken up for his family. Within this context, he was dedicated to protecting his family from the stigma that would accompany his suicide:

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Oliffe et al. If I hadnt have had family around, well whats to stop me from committing suicide. I, it wouldnt have mattered. It was just the fact that there were people that were important to me that I didnt want to disappoint. I guess thats what it was; I wasnt prepared to disappoint them. For a few men, the stigma associated with transgressing particular spiritual and/or moral beliefs was also a strong deterrent. A 78-year-old man explained, I dont contemplate suicide. I absolutely dont. Im a Christian and I have religious convictions that I kind of live by. Common across the participants narratives was a desire to remain true to their beliefs and family man values, and avoid the stigma that would inevitably flow toward others from taking ones life. Some men explained that they had thoughtfully considered how they might be able to take their own life without attracting the stigma that typically accompanies suicide. In this context, participants pondered a self-induced death that was not obviously suicide, as a means to leaving a financial legacy for their family. A 62-year-old administrator who was an avid kayaker described the complexities of achieving what would pass as an accidental recreational death through suicide: She (his wife) knows Im a shore hugger. Ive drilled that into kids that Ive taught. You never paddle further away from shore than you care to swim. So having someone have an accident 5 km off shore would raise red flags. So um, as I say it I couldnt do it anonymously so to speak. Underpinning these thoughts, he explained, were careful calculations about the dual benefits that his death would bring. Specifically, the burden of his depression on his family would be waylaid, and they would also be better off financially if he were dead: Its funny, you look at your life and you think ah theyd (family) be better off without me. As a matter of fact with the insurance I carry, financially they would be a hell of a lot better off without me. Likewise, the 66-year-old locksmith who had struggled financially throughout his life suggested that If I do it (suicide) properly I can arrange it so that my wife and children will get my insurance money, which they wont get if I commit suicide. So my thoughts, I continually think how can I do it? How can I kill myself without the insurance company knowing that I killed myself? You know, make it look like an accident.

7 Whereas Roeloffs et al. (2003) and Sirey et al. (2001) suggest that stigma around mens depression can fuel mens reluctance to seek professional medical help and/or comply with treatments, our findings reveal how suiciderelated stigma can also inhibit older men from acting on their suicidal thoughts.

Discussion
The current study supports many findings drawn from previous work connecting masculinities and depression (Addis, 2008; Chuick et al., 2009; Emslie et al., 2006; Oliffe, Kelly, et al., 2010), and suicide (Cleary, 2005) while further mapping the pathways between mens depression and suicide (Brownhill et al., 2005; Oliffe, Ogrodniczuk, et al., 2010). In sum, although the influences of masculine ideals on mens depression and suicide are ever present, fine-grained analyses afforded insights to how discrete aspects of masculinity can emerge as risk or potential remedy. This is important because made available are opportunities for transitioning descriptive research toward interventions. Also afforded by our novel study are rarely described insights about how older mens masculinities intersect with suicidal thoughts among participants who are clinically diagnosed or selfidentify as depressed. In connecting these emergent but somewhat estranged bodies of knowledge, we are better equipped to begin to consider the ingredients for older mens suicide prevention programs. By soliciting the views of participants who experience depression, we have also responded to Schmutte et al.s (2009) call for qualitative studies to better understand the complexities in and around older mens suicide. Some empirical weight and important contextual information is also provided to interrogate Synnotts (2009) assertion that the greatest risk factor for mens suicide is masculinity. Permeating the three thematic findings are poignant examples of how mens depression and thoughts about suicide are mediated by their alignments to masculine ideals around work and family. Visible are intricate connections between work and family man identities and masculine provider and protector roles, and their potential to bolster or block mens efforts for managing suicidal thoughts. In this regard, aligning to masculine ideals emerges as neither entirely risky nor health promoting in nature. For example, as Kilmartin (2007) poignantly articulated, discourses of masculinity preserved and perpetuated on stage and screen in stories such as Its a Wonderful Life (Capra & Capra, 1945) and Death of a Salesman (Miller, 1949) can posit mens undetected suicide as rational and selfless in making good on the patriarchal promise of providing financial security to their family. Yet also evident in our study were mens efforts to protect their family and provide for them through continuing their fight against depression. In this regard work and family-centered

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8 masculine ideals can bolster mens resilience and afford purpose to counter the thoughts about self-harm and suicide that can flow from depression. The findings from this study support Rochlen et al.s (2010) recommendations for depression self-management strategies that draw on mens alignment to work and physical activity. That said, as older men encounter reductions in physical and mental strength, and work opportunities, depressive episodes can be especially difficult to manage. Perhaps this explains, at least in part, why the study participants who worked were reluctant to retire despite their self-reported fatigue and lethargy amid advancing age. In addition, noteworthy is how the ideals of Freedom 55, a retirement plan for leaving the workforce at 55 years of age, have buckled within the current economic downturn while life expectancy in many Western countries continues to rise. Having to work longer is a trend likely to continue for the baby boomers (born 1946-1964) rendering more men susceptible to the challenges that arise from the nexus of working in older age (in many cases to offset escalating costs of living) despite deteriorating physical and mental health. Many recommendations focus on making adjustments to professional mental health care services as the lynchpin to advancing the well-being of older men who experience depression (see Klap, Unroe, & Unutzer, 2003; Luoma, Martin, & Pearson, 2002; Rutz, 2001; Strike, Rhodes, Bergmans, & Links, 2006). As symptoms of mens depression may differ from those of women to an extent that they are inadequately captured by some generic diagnostic criteria and screening tools (Pollack, 1998; Rochlen et al., 2010), it may be beneficial for clinicians to include questions about work and family, as well as directly asking about older mens thoughts toward self-harm and suicide. In addition, bringing targeted virtual and communitybased programs to the attention of older men, as Kravitz et al. (2011), Schmutte et al. (2009) and Williamson (2010) suggest, can effectively message and connect men with others and familiar activities. Especially promising are men-centered mental health promotion and suicide prevention programs that recognize how some idealized masculine identities, roles, and relations can effectively work for rather than against mens health (Wade, 2009). For example, the National Institute of Mental Healths Real men. Real depression campaign incorporates masculine ideals of courage, strength, and physical fitness to garner mens help-seeking and self-management (i.e., it is brave to ask for help). Community-based initiatives, including the Australian mens sheds (Golding, Brown, Foley, Harvey, & Gleeson, 2007) and the U.K.s men in sheds programs (Williamson, 2010) have successfully attracted older men to workshop-type spaces in community settings to provide opportunities for regular hands-on

American Journal of Mens Health XX(X) activity by groups deliberately and mainly comprising men. Many of the attendees are older men facing issues associated with a series of significant life change, such as aging, retirement, isolation, unemployment, disability, and separation, and report camaraderie and a sense of belonging as key benefits of their participation in the groups (Golding et al., 2007).

Limitations
Although generalizability was not the aim or claim of this study, it is important to acknowledge four significant limitations. First, whereas descriptive studies are the feedstock for developing targeted health interventions, the current study clearly resides within the former and is limited in what can be reasonably claimed as valid for guiding programs, policy and practice. Related to this, it is also important to acknowledge that nearly half the participants reported mild depression (via the BDI-II) and this significantly limits the findings from the current study. Second, related to the first limitation, services similar to the aforementioned U.S., U.K., and Australian community-based programs might remedy some of the suffering experienced by depressed older men who reside in Canada; however, the appeal and acceptability of these options was not formally assessed in this study. Third, the cross-sectional study design does not afford insights about changes (or the processes that underpin change) across boys and mens lives, which in turn influence their practices around depression and suicide. Implicit to this limitation is the acknowledgement that depressive symptoms and suicidal thoughts reported by participants may very well reflect long-standing mental health difficulties that predate their entry into later adulthood. Fourth, although the current study focused on older men and masculinities, there may be gender similarities as well as differences between older men and women in regard to depression and suicidal thoughts. These four limitations, however, offer direction for future research that might usefully include testing the findings drawn from this study in larger studies among diverse subgroups of older men with Gender Role Conflict Scale (Good & Wood, 1995) and/or Conformity to Masculine Norms Inventory (Mahalik & Rochlen, 2006) research to more fully apprehend prevailing patterns in how masculinities connect to mens depression and suicide. In addition, conducting life course and longitudinal studies to distil and address how particular transitions (e.g., fatherhood, middle-age, disability, retirement) affect mens depression and thoughts about suicide would provide further evidence on which to contextualize the findings drawn from larger Gender Role Conflict Scale and/or Conformity to Masculine Norms Inventory studies. Mixed sex samples and gender comparisons might

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Oliffe et al. also afford important insights to the specific interplays between femininities, masculinities, depression, and suicide.

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Beautrais, A. L. (2002). A case control study of suicide and attempted suicide in older adults. Suicide and Life-Threatening Behavior, 32, 1-9. Brownhill, S., Wilhelm, K., Barclay, L., & Schmied, V. (2005). Big build: Hidden depression in men. Australian and New Zealand Journal of Psychiatry, 39, 921-931. Byrne, G. J., & Raphael, B. (1997). The psychological symptoms of conjugal bereavement in elderly men over the first 13 months. International Journal of Geriatric Psychiatry, 12, 241-251. Cantor, C. H., & Slater, P. J. (1995). Marital breakdown, parenthood and suicide. Journal of Child and Family Studies, 1, 91-102. Capra, F. (Producer), & Capra, F. (Director). (1945). Its a wonderful life [Motion picture]. United States: Liberty Films. Chuick, C. D., Greenfeld, J. M., Greenberg, S. T., Shepard, S. J., Cochran, S. V., & Haley, J. T. (2009). A qualitative investigation of depression in men. Psychology of Men & Masculinities, 10, 302-313. Cleary, A. (2005). Death rather than disclosure: Struggling to be a real man. Irish Journal of Sociology, 14, 155-176. Connell, R. W. (1995). Masculinities. Berkeley: University of California Press. Conwell, Y., Lyness, J. M., Duberstein, P., Cox, C., Seidlitz. L., DiGiorgio, A., & Caine, E. D. (2000). Completed suicide among older patients in primary care practices: A controlled study. Journal of the American Geriatrics Society, 48, 23-29. Courtenay, W. (2000). Constructions of masculinity and their influence on mens well-being: A theory of gender and health. Social Science & Medicine, 50, 1385-1401. Elwert, F., & Christakis, N. A. (2008). The effect of widowhood on mortality by the causes of death of both spouses. American Journal of Public Health, 98, 2092-2098. Emslie, C., Ridge, D., Ziebland, S., & Hunt, K. (2006). Mens accounts of depression: Reconstructing or resisting hegemonic masculinity? Social Science & Medicine, 62, 2246-2257. Gilchrist, H., Howarth, G., & Sullivan, G. (2007). The cultural context of youth suicide in Australia: Unemployment, identity and gender. Sociology & Social Policy, 6, 151-163. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York, NY: Simon & Schuster. Golding, B., Brown, M., Foley, A., Harvey, J., & Gleeson, L. (2007). Mens sheds in Australia: Learning through community contexts. Retrieved from http://www.ncver.edu.au/publications/1780.html Good, G. E., & Wood, P. K. (1995). Male gender role conflict, depression, and help seeking: Do college men face double jeopardy? Journal of Counseling and Development, 74, 70-75. Greaves, L., Oliffe, J. L., Ponic, P., Kelly, M., & Bottorff, J. L. (2010). Unclean fathers, responsible men: Smoking, stigma and fatherhood. Health Sociology Review,19, 522-531. Gunnell, D., Middleton, N., Whitley, E., Dorling, D., & Frankel, S. (2003). Why are suicide rates rising in young men but falling

Conclusion
In further realizing the potential benefits (while also recognizing the threats) of masculine ideals across mens lives, strength-based approaches that highlight emotional fitness and skill development to broaden mens selfmonitoring and management (e.g., ways to ask for help, recognizing emotions, and mechanisms for emotional management) may be especially useful for advancing the mental health of older men who experience depression and/or suicidal thoughts. In paying attention to what is known about, as well as ensuring an ongoing commitment to better understanding emergent linkages between masculinity, depression, and suicide, the predominant positioning of particular masculine norms or scripts as artifact or outcome might be reconsidered to leverage specific masculine ideals as mediating and ideally disconnecting mens depression from self-harm and suicide. Acknowledgments
Thanks to Melanie Phillips and Kristy Hoyak for their project management and to Tina Thornton for her editorial assistance in finalizing this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research and article was made possible by the Social Science Humanities Research Council (SSHRC; Grant No. 11R28234). Career support for the first author is provided by a Canadian Institutes of Health Research new investigator and a Michael Smith Foundation for Health Research scholar award.

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