Association Between Andropause Symptoms and Suicidal Ideation in Japanese Men: A Rural Community-Based Study

Abstract

Objective:

This study aimed to investigate the association between andropause symptoms and suicidal ideation among Japanese men using community-based data.

Methods:

We conducted a survey anonymously in Akita, Japan, in July 2024. In total, 577 men aged ≥19 years completed the questionnaire, including demographic data, and items, such as andropause symptoms, health habits, and suicidal ideation. Andropause symptoms as an exposure variable were measured. The outcome variable was suicidal ideation in the previous month. We estimated the odds ratio (OR) and 95% confidence interval to examine the association between andropause symptoms and suicidal ideation.

Results:

Severe andropause symptoms according to the Aging Male’s Symptoms scale and suicidal ideation were noted in 63 men (10.9%) and 18 men (3.1%), respectively. Multivariate logistic regression analysis revealed a significant positive association between severe andropause symptoms and suicidal ideation. This association remained unchanged even when andropause symptoms were divided into the somatic, psychological, and sexual scales. Additionally, even among participants aged ≥40 years, the OR for the severe group was significantly higher at 8.72.

Conclusions:

Severe andropause symptoms are associated with suicidal ideation among Japanese men. These findings suggest the importance of focusing on andropause as a new perspective for suicide prevention in men.

Introduction

Although the global suicide mortality rate has been declining, >700,000 people die from suicide annually. ¹ Although the suicide rate in Japan has been declining since 2000, it remains among the highest of the Organization for Economic Co-operation and Development countries.^2,3 Among them, middle-aged men aged 40–59 years consistently show a high suicide rate. ⁴ Middle-aged individuals bear significant responsibilities, such as holding managerial positions at work and taking care of children or elderly family members, while also playing a socially important role. Therefore, suicide prevention is important in this population. Suicide does not occur suddenly; it typically develops through suicidal ideation and suicide attempts. ⁵ To prevent suicide at an early stage, it is essential to identify and address the risk factors associated with suicidal ideation.

The leading causes of suicide in Japan are health issues, including depression, ³ and this trend has also been observed in middle-aged men. ⁶ Notably, psychiatric disorders are strong risk factors for suicide.^7,8 Such a background in middle-aged men may be influenced by a decline in testosterone levels. Testosterone decline play a role in the onset of depression. ⁹ In recent years, andropause has garnered attention as a condition that is difficult to differentiate from depression in middle-aged men. ¹⁰ Andropause, also referred to as late-onset hypogonadism (LOH), is a syndrome associated with aging and a decline in serum testosterone levels. ¹¹ The symptoms of andropause encompass a wide range, including physical symptoms (e.g., general fatigue, insomnia, stiff shoulders, urinary problems, heavy headedness, tinnitus), psychological symptoms (e.g., depression, decreased motivation, decreased concentration, irritability), and sexual dysfunction (decreased libido, erectile dysfunction, decreased morning erections). ¹¹ The most common age of onset of andropause is after the age of 40 years, ¹² although it can occur in younger adults. Excessive physical and psychological stress can lead to decreased testosterone levels. ¹³ Middle-aged men are more likely to be exposed to physical and psychological stress because of their heavy responsibilities and interpersonal relationships in both work and family life, suggesting that they may have a higher risk of developing andropause. Andropause symptoms have been reported to affect the quality of life and presenteeism in middle-aged and older men, significantly influencing their daily lives, including work.^14,15 Moreover, compared to women, men tend to be less likely to seek social support or visit medical institutions even when experiencing mental health issues. ¹⁶ Therefore, addressing andropause is an important component of mental health strategies for employed men.

To the best of our knowledge, no study has directly investigated the association among andropause, LOH, and suicide. However, studies have reported an association between decreased serum testosterone levels and suicide behavior.^{17 -19} This association can be explained by the fact that a decline in testosterone levels affects mood and cognitive function, leading to the emergence of depressive symptoms. ²⁰ However, andropause involves a range of symptoms. Additionally, andropause symptoms can occur even when testosterone levels are within the normal range.^21,22 This suggests the necessity of investigating the association between suicidal behavior and andropause symptoms based not only on biological indicators but also on comprehensive assessments of andropause symptoms.

This community-based study aimed to examine the association between andropause symptoms and suicidal ideation among Japanese men. By clarifying this association, these findings may contribute to the development of new suicide prevention strategies for Japanese men.

Participants and Methods

Participants and Data Collection

We conducted a cross-sectional, self-administered questionnaire survey anonymously in a rural area of Akita Prefecture, Japan. The anonymous questionnaire survey was originally designed to develop suicide countermeasures for both men and women living in the area based on a suicide prevention plan. The questionnaire inquired about demographic data and items such as andropause symptoms, health habits, and suicidal ideation. To ascertain the prevalence of suicidal ideation with an accuracy of 4.0% and 1.0% margin of error, ²³ the required sample size was 1476. The predicted response rate in the rural area was approximately 30.0%. ²⁴ Based on this, we set the sample size to 5000. We calculated the population proportions by sex and 10-year age groups from the total population of approximately 44,000 residents, and randomly sampled 5000 individuals aged ≥19 years in accordance with these proportions. The questionnaire was delivered to 5000 residents (2397 men and 2603 women) aged ≥19 years on July 1, 2024, with response deadline set for July 31, 2024. Responses were received from 1574 participants (641 men and 933 women), yielding a response rate of 31.5%. In total, 641 men were included to examine the impact of andropause symptoms on suicidal ideation in this study. We excluded individuals with no data on andropause symptoms (n = 63) or age (n = 1). Responses from 577 individuals were included in the analysis. This study was approved by the Institutional Review Board of Akita University Medical School (approval number: 3162). Informed consent was obtained from the participants.

Variables and Measurements

Covariates

We collected demographic data on age class (in 10-year age groups), living arrangement (living alone; living apart due to job transfer; others; living with someone: 2-generation household, 3-generation household, or others), employment status (employed or not employed), subjective economic status (good: very good or good; poor: very poor or poor), and data on self-reported andropause symptoms, sleep duration (continuous value), and psychological distress. Living arrangements were categorized into 3 groups: living with someone, living alone (living alone or living apart due to job transfer), others. Based on a previous study, sleep duration was categorized into short sleep (<6 h/day) and ≥6 h/day. ²⁵ Psychological distress was measured using the Kessler Psychological Distress Scale (K6).^26,27 The K6 consists of 6 questions with a total score ranging from 0 to 24. The results were classified into 2 groups: “not severe” (0–12 points) and “severe” (≥13 points), in order to distinguish individuals experiencing severe psychological distress, such as depression. ²⁸ Age class (19–39, 40–69, ≥70 years), living arrangement (living with someone, living alone, others, missing data), employment status (employed, not employed, missing data), subjective economic status (good, poor, missing data), and sleep duration (≥6 h/day, <6 h/day, missing data) were included as covariates in the main analysis.

Exposure Variables

Andropause symptoms were set as exposure variables. They were measured using the Japanese version of the Aging Male’s Symptoms (AMS) scale.^29,30 The Japanese version of the questionnaire has been validated. ³⁰ The AMS consists of 17 questions evaluated on a 5-point scale (1 = none, 5 = extremely severe). The 17 questions are distributed over 3 subscales: somatic (7 questions), psychological (5 questions), and sexual (5 questions). The severity levels of andropause symptoms (total score of AMS scale) were classified as follows: “not severe” (<50 points) and “severe” (≥50 points). ³¹ Each severity of 3 subscales was defined as the following: somatic symptoms, “not severe” (<19 points) and “severe” (≥19 points); psychological symptoms, “not severe” (<13 points), and “severe” (≥13 points); and sexual symptoms, “no” (<11 points) and “severe” (≥11 points). ²⁹ The AMS scale has high sensitivity but low specificity for LOH diagnosis. ³² However, the sexual symptoms subscale of the AMS was correlated with total and free testosterone levels in the blood and was used to diagnose LOH.^33,34 In Japan, a total score of ≥10 on the following 4 items of the AMS rating scale predicts suspected blood testosterone deficiency status: a decrease in muscular strength (No. 10), a decrease in the ability to perform sexually or its frequency (No. 15), a decrease in the number of morning erections (No. 16), and a decrease in sexual desire/libido (No. 17). ³⁵ Based on the 4 AMS items described above, the severity of andropause symptoms was assessed using the “testosterone deficiency score” (TD score), which was defined as follows: “not severe” (<10 points) and “severe” (≥10 points). ³⁵ Additionally, to investigate the risk of suicidal ideation in individuals suspected of having testosterone deficiency and experiencing severe andropause symptoms, we defined a combined group that met the following criteria: an AMS total score of ≥50 and a TD score of ≥10.

Outcome

The outcome variable was suicidal ideation in the past month. The participants were asked, “Did you think about committing suicide in the past month?” The response options were “yes,” “no,” or “unsure.” If one answered “yes,” the participant was considered to have suicidal ideation. Suicidal ideation is used to predict suicide risk because it occurs before a suicide attempt or completion of suicide.^36,37

Data Analysis

Regarding the characteristics of the study participants, we determined the distribution of respondents based on demographic data, sleep duration, and psychological distress, grouped by the AMS total score.

To examine the association between andropause symptoms and suicidal ideation, we performed a multivariate logistic regression analysis and estimated odds ratios (ORs) and 95% confidence intervals (CIs). First, we performed univariate and multivariate logistic regression analyses to examine the association between each exposure variable (AMS total score, somatic subscale, psychological subscale, and sexual subscale) and suicidal ideation after adjusting for covariates (age class, living arrangement, employment status, subjective economic status, and sleep duration). Second, we performed a multivariate logistic regression analysis of the associations between the TD score, combined group, and suicidal ideation (Model 1). As the TD score did not include psychological factors, in Model 2, we performed the analysis by adding psychological distress to the covariates in Model 1. Third, as the onset of andropause is common in men aged ≥40 years, we performed a sensitivity analysis by restricting participants to those aged ≥40 years to examine the association between andropause symptoms and suicidal ideation.

All statistical analyses were performed using the IBM SPSS Statistics version 28 (IBM SPSS Software Group, Chicago, IL, USA). All statistical tests were 2-sided analyses, and differences were considered significant at P < .05.

Results

Table 1 presents the baseline characteristics of the study participants. More than half of the participants were aged 40–69 years, living with someone, employed, had good subjective economic status, slept ≥6 h per day, and did not experience severe psychological distress. Participants with an AMS total score of ≥50 (severe andropause symptoms) tended to be more likely to be aged 40–69 years, live with someone, be unemployed, have a poor subjective economic status, have shorter sleep duration, and have more severe psychological distress than those with a score of <50.

Table 1.

Characteristics of the Study Participants.

	Total (n = 577)	Aging Male’s Symptoms Scale (score)
		<50 (n = 514)	≥50 (n = 63)
Characteristic	n (%)	n (%)	n (%)
Age class (years)
19-39	64 (11.1)	58 (11.3)	6 (9.5)
40-69	310 (53.7)	273 (53.1)	37 (58.7)
≥70	203 (35.2)	183 (35.6)	20 (31.8)
Living arrangement
Living with someone	373 (64.7)	329 (64.0)	44 (69.8)
Living alone	179 (31.0)	161 (31.3)	18 (28.6)
Others	18 (3.1)	17 (3.3)	1 (1.6)
Missing	7 (1.2)	7 (1.4)	0 (0.0)
Employment status
Employed	356 (61.7)	319 (62.1)	37 (58.7)
Not employed	220 (38.1)	194 (37.7)	26 (41.3)
Missing	1 (0.2)	1 (0.2)	0 (0.0)
Subjective economic status
Good	299 (51.8)	284 (55.2)	15 (23.8)
Poor	272 (47.2)	225 (43.8)	47 (74.6)
Missing	6 (1.0)	5 (1.0)	1 (1.6)
Sleep duration
≥6 h/day	450 (78.0)	417 (81.1)	33 (52.4)
<6 h/day	107 (18.5)	83 (16.2)	24 (38.1)
Missing	20 (3.5)	14 (2.7)	6 (9.5)
Psychological distress (K6 score)
<13	500 (86.6)	477 (93.8)	23 (36.5)
≥13	53 (9.2)	20 (3.9)	33 (52.4)
Missing	24 (4.2)	17 (3.3)	7 (11.1)

Table 2 shows the association between andropause symptoms (AMS total score and somatic, psychological, and sexual subscales) and suicidal ideation. For all scores, even after adjusting for all covariates, the ORs (95% CIs) for the severe group were significantly higher compared with those of the “not severe” group: total score, 10.32 (3.39-31.42); somatic scale, 8.12 (2.72-24.18); psychological scale, 11.32 (3.71-34.60); and sexual scale, 8.70 (1.76-43.08).

Table 2.

Association Between Andropause Symptoms and Suicidal Ideation (n = 577).

Variable	Participants of each category	Suicidal ideation	Univariate		Multivariate a
	n	n	OR	95% CI	OR	95% CI
AMS total score
<50	514	8	1.00 (Reference)		1.00 (Reference)
≥50	63	10	11.93	(4.52-31.54)	10.32	(3.39-31.42)
AMS subscales score
Physical
<19	475	7	1.00 (Reference)		1.00 (Reference)
≥19	102	11	8.08	(3.05-21.40)	8.12	(2.72-24.18)
Psychological
<13	483	6	1.00 (Reference)		1.00 (Reference)
≥13	94	12	11.63	(4.25-31.87)	11.32	(3.71-34.60)
Sexual
<11	252	2	1.00 (Reference)		1.00 (Reference)
≥11	325	16	6.47	(1.47-28.42)	8.70	(1.76-43.08)

Abbreviations: AMS, Aging Male Symptoms; CI, confidence interval; OR, odds ratio.

^aAdjusted variables: age class, living arrangement, employment status, subjective economic status, and sleep duration.

Table 3 shows the results of the associations between the TD score, the combined group (AMS total score ≥50 points and TD score ≥10 points), and suicidal ideation. In Model 1 for the TD score, the OR (95% CI) was significantly higher for the severe group compared with the “not severe” group (OR, 11.64; 95% CI, 2.36-57.48). In Model 2, after adjusting for psychological distress, the association remained significant (OR, 6.41; 95% CI, 1.24-33.19). For the combined group, the OR (95% CI) was significantly higher for the severe group compared with the “not severe” group (OR, 8.42; 95% CI, 2.81-25.23).

Table 3.

Associations Among the TD Score, Combined Group, and Suicidal Ideation (n = 577).

Variable	Participants of each category	Suicidal ideation	Model 1 a		Model 2 b
	n	n	OR	95% CI	OR	95% CI
AMS TD score
<10	282	2	1.00 (Reference)		1.00 (Reference)
≥10	295	16	11.64	(2.36-57.48)	6.41	(1.24–33.19)
Combined group c
Not severe	519	9	1.00 (Reference)		N.A.
Severe	58	9	8.42	(2.81-25.23)	N.A.

Abbreviations: AMS, Aging Male Symptoms; CI, confidence interval; N.A., not applicable; OR, odds ratio; TD, testosterone deficiency.

^aAdjusted variables: age class, living arrangement, employment status, subjective economic status, and sleep duration.

^bAdjusted variables: psychological distress in addition to Model 1.

^cThe severe group in the combined group was defined as having an AMS score of ≥50 and a TD score of ≥10.

Table 4 shows the proportion of participants with suicidal ideation, categorized by the severity of andropause symptoms, among participants aged ≥40 years (n = 513). Participants in the severe AMS total score and severe TD score groups tended to experience suicidal ideation. In Table 4, no participants with suicidal ideation were observed in the “not severe” group of the TD score. Therefore, Table 5 shows the results of a sensitivity analysis on the association between only the AMS total score and suicidal ideation among participants aged ≥40 years. Even among participants aged ≥40 years, the OR (95% CI) was significantly higher for the severe group compared with the “not severe” group (OR, 8.72; 95% CI, 2.50-30.35).

Table 4.

Proportion of Participants With Suicidal Ideation Among Those Aged ≥40 years.

	All	Participants with suicidal ideation
Variable	n	n (%)
AMS total score
<50	456	7 (1.5)
≥50	57	8 (14.0)
AMS TD score
<10	230	0 (0.0)
≥10	283	15 (5.3)

Abbreviations: AMS, aging male symptoms; TD, testosterone deficiency.

Table 5.

Association Between Andropause Symptoms and Suicidal Ideation Among Participants Aged ≥40 years (n = 513).

Variable	Participants of each category	Suicidal ideation	Univariate		Multivariate a
	n	N	OR	95% CI	OR	95% CI
AMS total score
<50	456	7	1.00 (Reference)		1.00 (Reference)
≥50	57	8	10.47	(3.64-30.12)	8.72	(2.50-30.35)

Abbreviations: AMS, aging male symptoms; CI, confidence interval; OR, odds ratio.

^aAdjusted variables: age class, living arrangement, employment status, subjective economic status, and sleep duration.

Discussion

Our results revealed that andropause symptoms were significantly associated with suicidal ideation. This association remained significant in a sensitivity analysis using the TD score, which predicts suspected blood testosterone deficiency status. To the best of our knowledge, this is the first community-based study to examine the association between andropause symptoms and suicidal ideation.

Previous studies have reported an association between blood testosterone levels and suicidal behavior. Lower testosterone levels reflect a state of andropause or LOH. Notably, findings regarding this issue are inconsistent, possibly due to differences in study populations or methodologies.^{18,20,38 -41} Some studies have reported that higher testosterone levels are associated with suicidal behaviors.^{20,39 -41} This may be due to the characteristics of testosterone, such as aggressiveness and impulsivity, that may contribute to suicidal behaviors. ³⁹ In contrast, other studies have found an association between lower testosterone levels and suicidal behaviors.^18,20,40,41 Decreased testosterone levels can affect mood and cognitive functions, making individuals more susceptible to depression. ²⁰ Although our study did not measure testosterone levels, a sensitivity analysis using the TD score showed a positive association with suicidal ideation, which is consistent with these findings. One possible explanation for the inconsistency in these results is the hypothesis that both high and low testosterone levels contribute to suicidal behaviors.^20,40 In the past, it was hypothesized that high testosterone levels in young adults were associated with suicidal behaviors, whereas low testosterone levels in middle-aged and older individuals were thought to contribute to suicidal behaviors. ⁴⁰ However, both high and low testosterone levels can contribute to suicidal behaviors across all age groups. ²⁰ In this study, a positive association was observed between severe andropause symptoms and suicidal ideation, both in the overall group of participants aged ≥19 years and when limited to those aged ≥40 years. As andropause symptoms can occur regardless of testosterone levels, it may be necessary to interpret the results of testosterone levels and andropause symptoms separately. Additionally, the effects of testosterone levels, LOH, and andropause symptoms may differ among suicidal ideation, suicide attempts, and completed suicide. In the future, it will be necessary to examine the association among testosterone levels, andropause symptoms, and suicidal behaviors.

In studies such as ours, which focused on andropause symptoms not based on testosterone levels, distinguishing these symptoms from depression can be challenging. ¹⁰ Therefore, the results of this study may also reflect an association between depressive symptoms and suicidal ideation. However, in the analysis of the AMS subscale in this study, not only the psychological subscale but also the somatic and sexual subscales showed a positive association with suicidal ideation. Additionally, there was a significant association between the TD scores and suicidal ideation in the sensitivity analysis, even after adjusting for severe psychological distress. These results suggest that the association between andropause symptoms and suicidal ideation may be explained by factors other than psychological ones.

For example, physical conditions such as cardiovascular disease and diabetes mellitus, which are associated with LOH and become more prevalent in middle age and later,^11,42 may also have an impact on suicidal ideation. A previous study showed that the OR for suicidal ideation was significantly higher in individuals with multimorbidity, which included both mental and physical health conditions, than in those with mental health conditions alone. ⁴³ Individuals with both mental and physical health conditions may find it difficult to resolve their concerns and anxiety even with social support, which may make them more prone to suicidal ideation. However, as this study did not obtain information on the participants’ physical conditions, future studies should consider this factor.

Andropause most commonly develops in working-age men in their 40s and beyond, ¹² a stage of life when they are more likely to undergo changes in social roles and the accompanying physical and psychological stress. ³⁹ Additionally, testosterone plays an important role as a social hormone that influences motivation to take on challenges, sense of adventure, and competitiveness.^44,45 Testosterone levels increase when individuals receive recognition from those around them.^44,45 In this study, the results remained unaffected, even after considering employment status, subjective economic status, and cohabitation with family members. However, we were unable to account for presenteeism and work environment, leaving the possibility that these factors may help explain our findings.

These findings have important implications for both public health and clinical practice. In community settings, andropause symptoms may go unrecognized, as men are often less likely to seek help for psychological or sexual health concerns. Therefore, routine screening for andropause symptoms in middle-aged and older men, especially employed men, may help identify individuals at risk of suicidal ideation. In clinical settings, it may be helpful for healthcare providers to consider assessing andropause symptoms when treating male patients with psychological distress, especially when typical signs of depression are accompanied by somatic or sexual complaints. Recognizing andropause as a potential contributor to suicidal ideation may support earlier interventions and tailored care strategies for men’s mental health.

This study has some methodological limitations. First, it employed a cross-sectional design, making it difficult to establish causal associations. In other words, the physical and psychological stress that triggered suicidal ideation may have also led to the onset of andropause symptoms. Future longitudinal studies will be necessary to examine whether andropause is a risk factor for suicidal behavior. Second, because this study was conducted in a single region, it may be difficult to discuss its generalizability. However, the prevalence of severe andropause symptoms (10.9%) and suicidal ideation (3.1%) in the present study were similar to those reported in other studies.^23,46 Therefore, the findings of this study are significant. Third, we evaluated only the symptoms of andropause and examined their association with suicidal ideation. Combining the assessment of andropause symptoms and LOH (i.e., blood testosterone levels) may allow for a more accurate evaluation of the risk of suicidal ideation. To address this limitation, we performed a sensitivity analysis using the TD score and found results similar to those of the main analysis.

Conclusion

Andropause symptoms are positively associated with suicidal ideation among Japanese men. Middle-aged and older men account for a large proportion of the total number of suicides. In suicide prevention strategies for men, focusing on andropause or LOH may contribute to reducing the suicide rate in this population. Future research should include screening that incorporates testosterone levels in addition to the AMS scale, as well as longitudinal and intervention studies based on such assessments.