Earlier this month Psychiatry Advisor spoke with Christine Moutier, MD, psychiatrist and chief medical officer of the American Foundation for Suicide Prevention, in the article entitled: Suicide Prevention in the Context of COVID-19. We also interviewed Pamela Anne Nelson, DNP, PMHNP-BC, FNP-BC, a psychiatric mental health nurse practitioner affiliated with Vanderbilt University School of Nursing and Centennial Psychiatric Associates in Nashville, Tennessee. She recently co-authored a paper regarding the role of primary care providers in suicide prevention during the pandemic, along with Susie M. Adams, PhD, PMHNP-BC, a professor at the Vanderbilt University School of Nursing.1
What are some ways in which the COVID-19 pandemic may influence suicide risk, and which populations may be most at risk?
Mandated self-isolation can have a substantial impact on mental health. Symptoms of pre-existing mental health diagnoses, especially major depressive disorder and schizophrenia, can worsen under isolative conditions, and this may lead to suicidal ideation. However, social isolation can also affect individuals without pre-existing mental health diagnoses, as it can lead to loneliness and decrease the ability to cope. Ultimately, these individuals may also be at a higher risk for hopelessness, despair, and suicide.
Vulnerable populations who have the greatest risk for suicide during a pandemic like COVID-19 are not only those living alone or facing increased isolation. There may be an increased risk of suicide among older individuals, people with lower immunity status, and those who are suddenly unemployed. Likewise, workers on the “front lines” of a pandemic may have a greater risk for suicidal ideation. In addition to health care workers and first responders, this category also includes other workers who are in high demand during the pandemic, such as those employed in grocery stores, the media, or government or financial sectors.
What interventions and other suicide prevention measures should be employed or adapted in this context, and what is the role of the primary care provider as discussed in your recent paper?
PCPs have a critical role in suicide prevention, given that 83% of people who die by suicide have visited a PCP in the prior year, and 50% have visited the PCP within 30 days of their death.2 In other words, the PCP is the provider who will be able to intervene and provide help to the suicidal patient in most instances.
During COVID-19 or in routine practice, efficient, validated tools to use for suicide screening include the Patient Health Questionnaire-2 (PHQ-2) and the Patient Health Questionnaire-9 (PHQ-9). Likewise, the American Psychiatric Association Practice Guidelines3 recommend that a suicide assessment include the following:
- Inquiry regarding suicidal ideation, plan, and intent
- History of prior suicidal ideation, plan, and past attempts
- History of non-suicidal self-injury
- Assessment of current mood, symptoms of anxiety, feelings of hopelessness, and presence of impulsivity
- History of psychiatric hospitalizations and emergency department visits for psychiatric complaints
- History of substance use disorder (SUD) or change in use of substances
- Screening for stressors, including the current pandemic
Additionally, my colleague Dr. Adams and I developed probing questions that could also be utilized during a pandemic like COVID-19 to determine the extent that stressors have impacted the patient’s depressive symptoms.1 Examples of probing questions might include:
- Do you feel that the pandemic has affected you emotionally or mentally?
- Have you or your family been impacted financially by the pandemic?
- Have you lost your job or have your hours been cut back?
- Are you worried about your finances?
- Do you have to work more because of the pandemic?
- Have you or your family been exposed to the virus?
- Are you worried about getting sick?
- Do you live alone or have you been more isolated because of the pandemic?
- How have you been spending your free time?
- Has your alcohol or drug use increased?
- Have you lost anyone close to you?
- Have you or your support system been otherwise affected by the pandemic?
What are other relevant recommendations for clinicians in general?
The United States Preventative Services Task Force (USPSTF) recommends screening for depression in all adults in the general population setting regardless of risk factors.4 All positive screening results should lead to an additional assessment that considers the severity of depression and comorbid psychological problems (such as anxiety, panic attacks, and substance abuse), alternate diagnoses, and medical conditions.
The assessment for depression can begin with the simple 2-question PHQ-2. A positive assessment on the PHQ-2 would then indicate the need for follow-up assessment with the PHQ-9. Every patient that is screened for depression with the PHQ-9 is automatically screened with a suicide assessment, given the nature of the questions that are included in this tool.
What are remaining needs in this area in terms of research, policy development, or otherwise?
SUD is an area that requires great attention in terms of both research and policy development. The rate of hospitalizations for SUD during the COVID-19 pandemic is climbing in the United States.5 Traumatic events like a pandemic often lead to anxiety, depression, and posttraumatic stress disorder. Individuals may use alcohol or other substances as a means of “coping,” but this will ultimately exacerbate symptoms and can lead to worsening mental and physical health over time. Likewise, it has been shown that having a SUD was linked to a higher risk of COVID-19 infection.6
1. Nelson PA, Adams SM. Role of primary care in suicide prevention during the COVID-19 pandemic. J Nurse Pract. 2020;16(9):654-659. doi:10.1016/j.nurpra.2020.07.015
2. Ahmedani, BK, Simon, GE, Stewart, C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6):870-877. doi:10.1007/s11606-014-2767-3
3. American Psychiatric Association. The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults. 3rd ed. American Psychiatric Association. 2020. doi:10.1176/appi/books.9780890426760
4. Depression in Adults: Screening. US Preventative Services Task Force. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-adults-screening. Published January 26, 2016. Accessed November 23, 2020.
5. Davis C. The trauma of the coronavirus pandemic could cause a nationwide spike in alcohol and drug use, experts say. Business Insider. Published March 23, 2020. Accessed November 23, 2020.
6. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry. 2020:1–10. doi:10.1038/s41380-020-00880-7