Governments need to give ‘urgent consideration’ to their public health response to prevent any possible impact of the coronavirus pandemic on the number of suicides, experts warn.
There is growing concern about the far-reaching impact COVID-19 may have on people’s mental health across the globe, with the consequences likely to be present for longer and peak later than the actual pandemic.
Forty-two researchers from around the world, including Professor David Gunnell from the University of Bristol, have formed the International COVID-19 Suicide Prevention Research Collaboration.
Writing in The Lancet Psychiatry, they say an increase in suicides is not inevitable—provided preventive action is taken imminently.
Examples of interventions include developing clear care pathways for people who are suicidal, remote or digital assessments for people under mental health care, staff training to support new ways of working, support for helplines, providing easily accessible help for those who have lost a loved one to the virus, the provision of financial safety nets and labor market programs, and dissemination of evidence-based online interventions.
In their comment for The Lancet Psychiatry, the authors write: “Suicide is likely to become a more pressing concern as the pandemic spreads and has longer-term effects on the general population, the economy and vulnerable groups.
“Preventing suicide therefore needs urgent consideration. The response must capitalize on, but extend beyond, general mental health policies and practices.”
Those with psychiatric disorders might experience worsening symptoms and others might develop new mental health problems, especially depression, anxiety and post-traumatic stress.
Loss of employment and financial worries may contribute to feelings of hopelessness. In addition to providing financial safety nets in the short-term, researchers highlight that active labor market programs will be ‘crucial’ in the long-term.
As domestic violence cases increase, academics recommend public health responses must ensure that those facing domestic violence are supported and that safe drinking messages are communicated.
The global group of experts conclude in The Lancet Psychiatry: “These are unprecedented times.
The pandemic will cause distress and leave many vulnerable.
Mental health consequences are likely to be present for longer and peak later than the actual pandemic.
“However, research evidence and the experience of national strategies provide a strong basis for suicide prevention. We should be prepared to take the actions highlighted here, backed by vigilance and international collaboration.”
Additional efforts may be required in some lower income countries with fewer public health resources and inadequate welfare support.
Other concerns in these countries include the social effects of banning religious gatherings and funerals, domestic violence, and vulnerable migrant workers.
The International COVID-19 Suicide Prevention Research Collaboration also reiterate how irresponsible media reporting of suicide can encourage further suicides. Journalists should ensure that reporting follows existing and COVID-19-specific guidelines [PDF].
Professor David Gunnell, from the University of Bristol, established the International COVID-19 Suicide Prevention Research Collaboration. He said: “It is hard to predict what impact the pandemic will have on suicide rates, but given the range of concerns, it is important to be prepared and take steps to mitigate risk as far as possible.”
COVID-19 Public Health Interventions and Suicide Risk
Secondary consequences of social distancing may increase the risk of suicide. It is important to consider changes in a variety of economic, psychosocial, and health-associated risk factors.
Economic Stress
There are fears that the combination of canceled public events, closed businesses, and shelter-in-place strategies will lead to a recession. Economic downturns are usually associated with higher suicide rates compared with periods of relative prosperity.2
Since the COVID-19 crisis, businesses have faced adversity and laying off employees.
Schools have been closed for indeterminable periods, forcing some parents and guardians to take time off work. The stock market has experienced historic drops, resulting in significant changes in retirement funds. Existing research suggests that sustained economic stress could be associated with higher US suicide rates in the future.
Social Isolation
Leading theories of suicide emphasize the key role that social connections play in suicide prevention. Individuals experiencing suicidal ideation may lack connections to other people and often disconnect from others as suicide risk rises.3
Suicidal thoughts and behaviors are associated with social isolation and loneliness.3 Therefore, from a suicide prevention perspective, it is concerning that the most critical public health strategy for the COVID-19 crisis is social distancing.
Furthermore, family and friends remain isolated from individuals who are hospitalized, even when their deaths are imminent. To the extent that these strategies increase social isolation and loneliness, they may increase suicide risk.
Decreased Access to Community and Religious Support
Many Americans attend various community or religious activities. Weekly attendance at religious services has been associated with a 5-fold lower suicide rate compared with those who do not attend.4
The effects of closing churches and community centers may further contribute to social isolation and hence suicide.
Barriers to Mental Health Treatment
Health care facilities are adding COVID-19 screening questions at entry points. At some facilities, children and other family members (without an appointment) are not permitted entry.
Such actions may create barriers to mental health treatment (eg, canceled appointments associated with child restrictions while school is canceled).
Information in the media may also imply that mental health services are not prioritized at this time (eg, portrayals of overwhelmed health care settings, canceled elective surgeries).
Moreover, overcrowded emergency departments may negatively affect services for survivors of suicide attempts. Reduced access to mental health care could negatively affect patients with suicidal ideation.
Illness and Medical Problems
Exacerbated physical health problems could increase risk for some patients, especially among older adults, in whom health problems are associated with suicide.
One patient illustrated the psychological toll of COVID-19 symptoms when he told his clinician, “’I feel like (you) sent me home to die.”5
Outcomes of National Anxiety
It is possible that the 24/7 news coverage of these unprecedented events could serve as an additional stressor, especially for individuals with preexisting mental health problems. The outcomes of national anxiety on an individual’s depression, anxiety, and substance use deserve additional study.
Health Care Professional Suicide Rates
Many studies document elevated suicide rates among medical professionals.6 This at-risk group is now serving in the front lines of the battle against COVID-19. A national discussion is emerging about health care workers’ concerns about infection, exposure of family members, sick colleagues, shortages of necessary personal protective equipment, overwhelmed facilities, and work stress. This special population deserves support and prevention services.
Firearm Sales
Many news outlets have reported a surge in US gun sales as COVID-19 advances. Firearms are the most common method of suicide in the US, and firearm ownership or access and unsafe storage are associated with elevated suicide risk.7 In this context, issues of firearm safety for suicide prevention are increasingly relevant.
Seasonal Variation in Rates
In the northern hemisphere, suicide rates tend to peak in the late spring and early summer. The fact that this will probably coincide with peak COVID-19 prevention efforts is concerning and deserves additional study.
Suicide Prevention Opportunities
Despite challenges, there are opportunities to improve suicide prevention efforts in this unique time. Maintenance of some existing efforts is also possible.
Physical Distance, Not Social Distance
Despite its name, social distancing requires physical space between people, not social distance. Efforts can be made to stay connected and maintain meaningful relationships by telephone or video, especially among individuals with substantial risk factors for suicide. Social media solutions can be explored to facilitate these goals.
Tele–Mental Health
There is national momentum to increase the use of telehealth in response to COVID-19. Unfortunately, tele–mental health treatments for individuals with suicidal ideation have lagged far behind the telehealth field.
Opportunities to increase the use of evidence-based treatments for individuals with suicidal thoughts have been noted for years, especially in rural settings, but fear of adverse events and lawsuits have paralyzed the field.
Disparities in computer and high-speed internet access must also be addressed. Research, culture change, and potentially even legislative protections are needed to facilitate delivery of suicide prevention treatments to individuals who will otherwise receive nothing.
Increase Access to Mental Health Care
As COVID-19 precautions develop in health care settings, it is essential to consider the management of individuals with mental health crises. Screening and prevention procedures for COVID-19 that might reduce access to care (eg, canceled appointments, sending patients home) could include screening for mental health crises; clinical staff would be needed to some degree in settings that may currently relegate COVID-19 symptom screening to administrative staff.
Also, rather than sending a patient with a child home, alternative treatment settings could be considered (eg, a private space outside).
Distance-Based Suicide Prevention
There are evidence-based suicide prevention interventions that were designed to be delivered remotely. For example, some brief contact interventions (telephone-based outreach)8 and the Caring Letters intervention (in which letters are sent through the mail)9 have reduced suicide rates in randomized clinical trials.
Follow-up contact may be especially important for individuals who are positive for COVID-19 and have suicide risk factors.
References
1. Drapeau CW , McIntosh JL . U.S.A. suicide: 2018 official final data. Published 2020. Accessed April 1, 2020. https://suicidology.org/wp-content/uploads/2020/02/2018datapgsv2_Final.pdf
2. Oyesanya M , Lopez-Morinigo J , Dutta R . Systematic review of suicide in economic recession. World J Psychiatry. 2015;5(2):243-254. doi:10.5498/wjp.v5.i2.243
3. Van Orden KA , Witte TK , Cukrowicz KC , Braithwaite SR , Selby EA , Joiner TE Jr . The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575-600. doi:10.1037/a0018697
4. VanderWeele TJ , Li S , Tsai AC , Kawachi I . Association between religious service attendance and lower suicide rates among US women. JAMA Psychiatry. 2016;73(8):845-851. doi:10.1001/jamapsychiatry.2016.1243
5. CBS News. Coronavirus patients describe symptoms. Published 2020. Accessed March 19, 2020. https://www.cbsnews.com/news/coronavirus-symptoms-fever-dry-cough-shortness-of-breath/
6. Dutheil F , Aubert C , Pereira B , et al. Suicide among physicians and health-care workers. PLoS One. 2019;14(12):e0226361. doi:10.1371/journal.pone.0226361
7. Mann JJ , Michel CA . Prevention of firearm suicide in the United States. Am J Psychiatry. 2016;173(10):969-979. doi:10.1176/appi.ajp.2016.16010069
8. Fleischmann A , Bertolote JM , Wasserman D , et al. Effectiveness of brief intervention and contact for suicide attempters. Bull World Health Organ. 2008;86(9):703-709. doi:10.2471/BLT.07.046995
9. Motto JA , Bostrom AG . A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv. 2001;52(6):828-833. doi:10.1176/appi.ps.52.6.828
More information: David Gunnell et al. Suicide risk and prevention during the COVID-19 pandemic, The Lancet Psychiatry (2020). DOI: 10.1016/S2215-0366(20)30171-1
