John Harper would sit on his verandah all day, doing nothing. A wheat and sheep farmer in his mid-40s, he had just retired from shearing. He was lethargic. He was moody. He had no idea what was wrong.
"I'm as fit as a Mallee bull," he thought. "Why do I feel like I'm dying?"
As his family relationships suffered, he wondered if his wife might be the problem. Instead, she proved to be his lifeline.
At his wife Michelle's urging, Mr Harper went to see his GP, a mate, who diagnosed him with depression.
Mr Harper said he had felt "like half a man" after giving up shearing. "My brain had this image that I was a big, tough farming bastard and I should be able to shear all day and drive a tractor all night."
He saw a counsellor, and his experience encouraged him to reach out to others in his community of Stockinbingal, 400 kilometres south of Sydney. "The best thing you can do to help is show people you care," he said.
What began with blokes' outings on the school mini-bus for "drinks and a bit of a chat" grew into the lauded grassroots initiative Mate Helping Mate, which raises awareness of mental health issues in rural Australia and features in the ABC TV documentary series Man Up, airing from October 11.
Mr Harper, 61, said when he started talking about what he was going through, people gradually opened up about their own problems. Once you get them talking "you can't shut blokes up", he said. "It reinforced to me that I wasn't the only one."
While women are more likely to verbalise their problems and seek help, men often bottle up their emotions and isolate themselves when depressed.
"Isolation is basic animal instinct," Mr Harper said. "If we see a beast on its own at the farm, we know it's crook. So we bring it in, we get the best person we can to make it right and we put it back with the flock.
"But we don't do that with mental health. We've got people who go home, pull the blinds down, and what do we do? We leave the poor bastards there. If we do that with a beast, a few days later its legs are up."
Mr Harper said the first step to recovering from depression or anxiety was to let someone know – your partner, a mate, your GP – you needed help.
"You've got to have trust and confidence to open up," he said. "Blokes are wired not to talk about it, but it has to change."
Men who consider themselves "self-reliant" 34 per cent more likely to have suicidal thoughts
Self-reliance was once intrinsic to the self-image of the Australian male, who valued his independence and ability to overcome obstacles alone.
But a new study has linked it to the disproportionate number of men taking their own lives.
Research based on the world's largest all-male cohort study found those who identified as self-reliant were significantly more likely to experience suicidal thoughts, while in the preceding two weeks nearly one in 10 had been disturbed by thoughts they would be better off dead.
A University of Melbourne examination of 13,884 men in the Australian Longitudinal Study on Male Health (Ten to Men) explored whether particular factors related to being male might increase the likelihood of suicide. It found those who considered themselves "self-reliant" were 34 per cent more likely to have experienced suicidal thoughts.
The unpublished study was presented at the European Symposium on Suicide and Suicidal Behaviour in Spain last month and is under peer review.
Centre for Mental Health director and the study's lead author, Jane Pirkis, said the findings had implications for suicide prevention, because those people were less likely to seek help.
"It's plausible because if you're extremely self-reliant you're used to solving problems for yourself," Professor Pirkis said. "You're not used to reaching out to others for help, either your mates or professionals."
Suicides as a proportion of total deaths in Australia hit a 10-year high in 2015, new data from the Australian Bureau of Statistics shows. Last year 3027 Australians took their own lives – an average of eight a day – and suicide remains the leading cause of death for Australians aged 15 to 44.
Men were three times more likely than women to take their own lives, with suicide accounting for 19.3 deaths per 100,000 men compared to 6.1 deaths among women.
Talking to men who "learned the hard way"
Research by the Black Dog Institute has also highlighted the unhelpful role played by an overemphasis on stoicism and traditional masculine beliefs.
Interviews with men who had recently attempted suicide revealed those traits were among four factors – alongside acute stress, depressed mood and ineffective coping strategies – that combined to increase the risk of suicidal behaviour.
Dr Andrea Fogarty, a research fellow at the Black Dog Institute. Photo: Black Dog
"That expectation of being able to solve problems alone and figure things out was a huge contributing factor," Andrea Fogarty, a Research Fellow at the Black Dog Institute, said. "A lot of them would talk about the cultural impact of living in a society where they're told you're a man if you can solve your problems independently."
Dr Fogarty said women were more likely to talk to their friends, recognise that they needed help and seek it. Men, however, were more likely to isolate themselves, not wanting to burden others, let them down or have anyone see them differently.
"A lot of men who adhered to these traditional ideas of masculinity and what it means to be a man reported that it wasn't helpful in the long run," she said. "There was a lot of reflecting back and wishing they hadn't learned the hard way. While they may have made it through an attempt and reported a lot more openness to talking about their problems now, a lot wish they had done it sooner, because maybe they wouldn't have lost their friendships or their partner or their job."
NSW chief psychiatrist Murray Wright said one of the problems in addressing men's mental health was their "real reluctance to engage, because it doesn't go with your stereotypical view of masculinity to talk about feelings".
He said one challenge was in co-ordinating existing services, so that people who were identified as depressed were referred for help before it got worse.
One successful initiative, the Rural Adversity Mental Health Program, was set up during the 1990s drought when it was recognised that farmers would not go to the doctor for any reason, let alone to discuss their emotions.
"We worked out there was no point in sending a mental health worker to see them but what we did was give mental health literacy training to people such as financial advisers who had a legitimate reason to be involved with farmers," Dr Wright said.
Dr Fogarty said it was important to provide alternative services – such as easily-accessed online tools like the My Compass program – for men who may be reluctant to use existing ones.
Professor Pirkis said men needed better geared interventions such as Men's Sheds, where they can talk while engaged in other activities.
'One of the great public health challenges of the 21st century'
More than twice as many Australians die by suicide each year than in car accidents. It is the main cause of death for people aged 15 to 44 and the leading cause of premature death in Australia.
As well as the devastating impact on family and friends, suicide costs the community an estimated $17.5 billion annually, according to the Australian Institute of Health and Welfare.
Sebastian Rosenberg, senior lecturer at the University of Sydney's Brain and Mind Centre. Photo: Supplied
Yet suicide prevention activities and research are drastically underfunded, data collection is inadequate and the approach to the issue is disparate and disorganised, said Sebastian Rosenberg, senior lecturer at the University of Sydney's Brain and Mind Centre.
"How can a public health problem of this magnitude gone neglected for so long?" he asked.
Mr Rosenberg said there was "still a great deal of shame" surrounding suicide, something "that underpins a colossal inaction on the part of public health".
"There is not a national branding or program or set of messages which could be tested and deployed," he said. "We spend almost nothing on evaluating programs, which means it's impossible for the system to learn and for the quality of suicide prevention activities to improve. And we lack statistics – about attempts, about demographics, about whether people are alive or dead within six months of visiting a mental health service. We are poorly placed to determine what to do."
Mr Rosenberg said suicide is "one of the great public health challenges of the 21st century". Addressing it required cooperation between health, community and social services, as well as educational, vocational and employment services. Collection of detailed data could help better understand who is at risk and how to design appropriate responses.
And he said more needed to be done to counter beliefs that suicide was somehow natural or inevitable.
"This sort of attitude, which comes off the back of a lack of funding and a lack of programs, permits people to look the other way and it permits stigma to be perpetuated," Mr Rosenberg said.
"There's an attitude of 'Oh, there's really nothing we could have done about that anyway' which in my mind is, frankly, bullshit - particularly when you look at the evidence about suicidality and the link between previous attempts and future attempts."
The people at greatest risk of taking their own lives are those who have previously attempted suicide. An estimated 65,000 Australians attempt suicide annually – an average of 178 each day.
"If we did nothing more than focus our attention on [those survivors] ... we would make a huge dint in our overall suicide statistics," Mr Rosenberg said.
Spending money to save lives
Mr Rosenberg said "it would be very generous to suggest that Australia spends $100 million on suicide prevention annually. This is a tiny amount of money on what is a very complex, multi-faceted public health issue that affects hundreds of thousands of people every year."
He called for more funding and support for programs like LifeSpan, an evidence-based suicide prevention program developed by Black Dog Institute researchers.
LifeSpan involves nine proven strategies being implemented together and tailored to local community needs. The program is being rolled out in NSW and in its first few years is expected to prevent 21 per cent of suicide deaths and 30 per cent of attempts.
The program is supported by the NSW government, whose $1.8 billion investment in mental health services for 2016-17 includes $8 million for a new suicide prevention fund, $3 million for crisis support organisation Lifeline and $5 million for specialist mental health services for older people.
NSW Mental Health Minister Pru Goward said she was particularly concerned about the suicide rate among older men, with those over 85 recording the highest rate of any age group. These men were often unused to organising social activities for themselves and could slip into depression after losing their wives.
"With older men I have known who have had depression, a lot of it is about masculinity," Ms Goward said. "Everyone thinks men don't cry and because they've always had a job and supported their family, that they don't have this problem.
"Well, nobody can cope with everything and I think that's the message we need to get to men: that everybody is vulnerable and there are things you can do."