Suicide rates have increased in the US over the past 2 decades. The latest available data (2018) shows the highest age-adjusted suicide rate in the US since 1941. In this context, coronavirus disease 2019 (COVID-19) hit the US with respect to disease models, have led to historic and unprecedented public health actions to slow the spread of the virus.
Notable social distancing interventions have been implemented to fundamentally reduce human contact. While these steps are expected to reduce the rate of new infections, the potential for adverse outcomes on suicide risk is high. Steps could be taken to mitigate potential unintended consequences in suicide prevention efforts, which also represent a national public health priority.
COVID-19 Public Health Interventions and Suicide Risk
Secondary consequences of social distancing may increase suicide risk
It is important to consider changes in a variety of economic, psychosocial, and health-related risk factors.
economic stress
The combination of canceled public events, closed businesses and shelter-in-place strategies is feared to lead to a recession. Economic recessions are generally associated with higher suicide rates compared to periods of relative prosperity. Since the COVID-19 crisis, companies have faced adversity and laid off employees. Schools have been closed for undetermined periods of time, forcing some parents and guardians to take time off from work. The stock market has experienced historic declines, resulting in significant changes in retirement funds.
Existing research suggests that sustained economic stress could be associated with higher rates of suicide in the United States in the future.
Social isolation
Major theories of suicide emphasize the key role that social connections play in suicide prevention. People who experience suicidal ideation may lack connections with other people and often become disconnected from others as their risk of suicide increases. Suicidal thoughts and behaviors are associated with social isolation and loneliness.
Therefore, from a suicide prevention perspective, it is concerning that the most critical public health strategy for the COVID-19 crisis is social distancing. Additionally, family and friends remain isolated from hospitalized people, even when their deaths are imminent. To the extent that these strategies increase social isolation and loneliness, they may increase the risk of suicide.
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 times lower suicide rate compared to those who do not attend. The effects of closing churches and community centers can further contribute to social isolation and therefore suicide.
Barriers to mental health treatment
Healthcare facilities are adding COVID-19 screening questions at entry points. In some facilities, children and other family members are not allowed (without an appointment). Such actions may create barriers to mental health treatment (e.g., canceled appointments associated with child restraints while school is canceled).
Media information may also imply that mental health services are not prioritized at this time (e.g., depictions of overwhelmed healthcare environments, elective surgeries canceled). Additionally, overcrowded emergency departments can negatively impact services for survivors of suicide attempts. Reduced access to mental health care could negatively impact patients with suicidal ideation.
Diseases and medical problems
Exacerbated physical health problems may 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 doctor: "’I feel like (you) sent me home to die . "
Results of national anxiety
It is possible that 24/7 news coverage of these unprecedented events serves as an additional stressor, especially for people with pre-existing mental health issues. National Anxiety’s findings on an individual’s depression, anxiety, and substance use merit further study.
Suicide rates of health professionals
Many studies document high rates of suicide among medical professionals. This at-risk group is now serving on the front lines of the battle against COVID-19. A national discussion is emerging about healthcare workers’ concerns about infection, exposure of family members, sick colleagues, shortages of needed personal protective equipment, overwhelmed facilities, and workplace stress. This special population deserves supportive and preventive services.
Sale of firearms
Many news outlets have reported an increase in gun sales in the United States as COVID-19 progresses. Firearms are the most common method of suicide in the US, and firearm possession or access and unsafe storage are associated with an elevated risk of suicide. In this context, firearm safety issues for suicide prevention are increasingly relevant.
Seasonal variation in rates
In the Northern Hemisphere, suicide rates tend to peak in late spring and early summer. The fact that this is likely to coincide with maximum COVID-19 prevention efforts is concerning and warrants further study.
Suicide Prevention Opportunities
Despite the challenges, there are opportunities to improve suicide prevention efforts at this unique time. Maintaining 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 phone or video, especially among individuals with substantial risk factors for suicide. Social media solutions can be explored to facilitate these goals.
Tel-Mental health
There is a national push to increase the use of telehealth in response to COVID-19. Unfortunately, mental health treatments for people with suicidal ideation have lagged far behind the field of telehealth. Opportunities to increase the use of evidence-based treatments for people 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 use and high-speed Internet access must also be addressed. Research, cultural changes, and potentially even legislative protections are needed to facilitate the delivery of suicide prevention treatments to people who would otherwise receive nothing.
Increase access to mental health care
As COVID-19 precautions develop in healthcare settings, it is essential to consider the management of people with mental health crises. COVID-19 screening and prevention procedures that could reduce access to care (e.g., canceled appointments, sending patients home) could include screening for mental health crises; Clinical staff would be needed to some extent in settings that may currently relegate screening for COVID-19 symptoms to administrative staff. Additionally, instead of sending a patient with a child home, alternative treatment settings (e.g., a private space outside) could be considered.
Remote suicide prevention
There are evidence-based suicide prevention interventions that were designed to be administered remotely . For example, some brief contact interventions (telephone outreach) 8 and the Letters of Care intervention (in which letters are sent by mail) have reduced suicide rates in randomized clinical trials. Follow-up contact may be especially important for people who are positive for COVID-19 and have risk factors for suicide.
Media reports
Due to the contagion of suicide , media reports on this topic should follow reporting guidelines and include the National Suicide Prevention Lifeline (1-800-273-TALK). The hotline remains open.
Optimistic considerations
There may be a positive side to the current situation. Suicide rates have decreased in the period following previous national disasters (e.g., the terrorist attacks of September 11, 2001). One hypothesis is the so-called bonding effect , whereby individuals experiencing a shared experience can support each other, thus strengthening the social connection. Recent advances in technology (e.g., video conferencing) could make integration easier.
Epidemics and pandemics can also alter views about health and mortality, making life more precious, death more fearsome, and suicide less likely.
Conclusions Concerns about negative secondary outcomes of COVID-19 prevention efforts should not be taken to imply that these public health actions should not be taken. However, implementation must include a comprehensive approach that considers multiple U.S. public health priorities, including suicide prevention. There are opportunities to improve suicide prevention services during this crisis. |
