Suicide Prevention in the Context of COVID-19

Among the innumerable negative effects linked to the coronavirus 2019 (COVID-19) crisis, various risk factors for mental illness, including social isolation, unemployment, and financial difficulty, have increased drastically. People with pre-existing psychiatric illness are especially vulnerable to these circumstances, potentially compounding the impact of reported interruptions to mental health care due to the pandemic.^1-3

A wide range of public survey results have shown substantial increases in symptoms of anxiety and depression associated with COVID-19, and a poll conducted by the Kaiser Family Foundation revealed that 53% of adults have experienced worsening mental health that they attribute to worry and stress regarding the pandemic. Respondents also reported a greater frequency of maladaptive behaviors and other impairments, such as disruptions in sleep and eating as well as increased alcohol and substance use.⁴

Due to these trends and other factors, many experts have noted the heightened potential for an increasing risk of suicide in the context of the COVID-19 crisis.^5,6 However, rising suicide rates should not be viewed as inevitable, according to Christine Moutier, MD, psychiatrist and chief medical officer of the American Foundation for Suicide Prevention. In a paper published online in October 2020 in JAMA Psychiatry, she proposed that the current circumstances present opportunities to improve suicide prevention efforts on multiple levels.⁵

We recently interviewed Dr Moutier to explore these points, including implications for clinicians.

What are some ways in which the COVID-19 pandemic may influence suicide risk, and which populations may be most at risk?

There are several ways in which the COVID-19 pandemic may influence suicide risk. Since risk factors for suicide are fairly well-established, we can think about the ways the pandemic exerts an effect on some of these. The most obvious is the pandemic’s potential to lead to deterioration in mental and/or physical health and the way the social distancing public health measure can lead to social disconnectedness for some.

Loneliness was already an increasing problem in American society pre-pandemic, and it could worsen related to the impact of the pandemic on school, work, and the usual social supports in place for elderly or marginalized populations. Another area relates to finances and/or employment and fears about or realized job or financial losses. Grief is another experience many are having, either directly related to COVID-19 or the pandemic’s impact on anticipated milestones or events. There have been documented increases in alcohol consumption in some regions of the world, which could exacerbate depression or addiction or other facets of mental health and coping.

Also, the increased availability of lethal means such as firearms, opioids, and other toxic substances, especially with more time spent at home sheltering in place, could increase suicide risk since we know that accessibility of lethal means increases individual and population risk of suicide. Of particular concern in the United States, the purchase of firearms increased by 85% during March 2020 at the start of COVID-19, compared with previous years during March.⁵

In terms of higher risk populations, particular groups are more likely to have elevated suicide risk during COVID-19. This relates to pre-pandemic suicide risk vulnerabilities, inequitable impacts of the pandemic, people with lower access to mental health care, especially for those with mental health conditions at baseline or other suicide risk factors. We worry a lot about people in unsafe homes related to domestic violence or abuse with the increased amount of time we are spending in the home and the potential to be disconnected from safeguarding influences like neighbors, friends, and family.

People with socioeconomic disadvantage, people who live in rural areas, or BIPOC (Black, Indigenous, and People of Color), and sexual minorities — all of these populations could have greater risk since economic, educational, and health disparities are being accentuated by the pandemic. Other potentially higher risk groups include frontline health and essential workers, youth and elderly populations, parents with school age children, and males since men have higher rates of suicide in general and may be less likely to find creative ways to connect to supports or treatment during the pandemic. People who represent intersectionality across these risk areas are of particular concern.

What interventions and other suicide prevention measures should be employed or adapted in this context?

It is encouraging that a recent American Foundation for Suicide Prevention (AFSP) sponsored Harris poll of American adults found that 26% of people say they have accessed mental health treatment or support using technology like teletherapy.⁷ Research has found that psychiatric or other forms of mental health treatment can reduce suicide risk.

There are a broad range of interventions and prevention measures that research has shown to have a risk-reducing impact on the population. These include policy initiatives at the federal, state, and local levels, which could accomplish wide-sweeping implemented changes that would effectively reduce suicide risk. Policy, for example, can increase access to effective mental health care by passing state mental health parity laws currently being advocated for in a number of states. These would enforce the federal Mental Health Parity and Addiction Equity Act passed in 2008, which largely lay dormant until recent years since it’s up to states to monitor and enforce insurance coverage for mental health on par with physical health conditions.

Legislation could require reform of our nation’s crisis response system, which we have a great head start on now that the 988 Suicide Prevention Hotline Designation Act has been passed into law just last month. Such a reform would build a mental health informed response (instead of the current way that leans heavily on law enforcement to respond) to mental health crises into communities across the United States. Legislation can also mandate suicide prevention training for key roles such as health professionals, teachers, and first responders. It could mandate that medical and nursing licensing boards not ask intrusive questions about mental health that don’t get at impairment.

Legislation can also focus and fund suicide prevention programs for key populations such as youth, veterans, and other important groups. During COVID-19, such legislation is being considered for some of the high-risk groups mentioned earlier — for example, the Dr Lorna Breen Healthcare Provider Protection Act which would fund support prevention programs for physicians and other HCPs on the frontline during COVID-19.⁸

In my paper I outline strategies across several areas of risk that could involve various industry leaders from health care to alcohol distributors to media and entertainment. Additionally, workplace or corporate leaders can implement mental health and suicide prevention initiatives for their workforces.

What are other relevant recommendations for clinicians?

As clinicians, we all need to pay special attention to our own resilience, sleep, and mental health right now during COVID-19, and provide extra support to our colleagues. We shouldn’t be afraid to have a brave conversation if we notice that a colleague might be struggling. You can learn more about how to have these conversations at #RealConvo and our AFSP RealConvoguides.

Clinicians across all specialties have a key role to play in preventing patient suicide by following fairly recent standards of care that can been implemented in almost any health setting. They include steps such as screening, risk assessment, safety planning, and lethal means counseling, as well as systematically providing caring communication with higher-risk patients over time. These steps can be found in the National Action Alliance for Suicide Prevention consensus document here.  I have a clinical handbook on suicide prevention co-authored by Drs Stephen Stahl and Anthony Pisani releasing soon, which provides guidance for clinicians in any specialty area for caring for patients at risk for suicide.

What are remaining needs in this area in terms of research, policy development, or otherwise?

We must increase the federal research investment in COVID-specific risks and prevention strategies for mental health, substance abuse, and suicide.

We need to ensure telemedicine services remain available for providing psychiatric and mental health care, since this has allowed many more at-risk Americans to access care.

We need to expand the access of rural population and others to evidence-based suicide risk-reducing treatments such as cognitive behavioral therapy (CBT), Dialectical (DBT), Collective Assessment and Management of Suicidality (CAMS), Attachment-Based Family Therapy (ABFT), and Safety Planning.

Health care organizations and other workplace organizational leadership should provide essential and frontline health care workers access to mental health care without negative career repercussions.

During and post-COVID, policy makers should incentivize expansion of evidence-based workplace and school mental health and suicide prevention programs.

Anti-stigma education and pro-help seeking messaging could build on the COVID-related increased dialogue about coping and mental health, using creative strategies such as mental health experts partnering with media and entertainment platforms and content creators.

Media also needs to be extra thoughtful about the messages that could create suicide contagion during COVID-19 by painting a hopeless picture or sensationalizing or exaggerating incidence of suicide.

All of these activities should include the input of people with lived experience — now including COVID-related lived experience and other diverse backgrounds in decision-making related to policy, clinical, and research. We could benefit from an expansion of peer specialists and peer educators who have lived experience to mitigate the healthcare workforce shortages especially in mental health.

Lastly, we can all make an extra effort to connect in meaningful ways with the people in our lives, offer extra kind outreach to elderly neighbors, and take extra care of our own mental health during this pandemic. We will get through this time, and our sense of being in it together can make a big difference.

References

1. Johnson HR. Position paper: The impact of COVID-19 on mental health. Psychiatry Advisor. https://www.psychiatryadvisor.com/home/topics/general-psychiatry/position-paper-the-impact-of-covid-19-on-mental-health/ Published online September 3, 2020. Accessed November 18, 2020

2. Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 2020;7(9):813-824. doi:10.1016/S2215-0366(20)30307-2

3. Panchal N, Kamal R, Orgera K, et al. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issuebrief/the-implications-of-covid-19-for-mentalhealth-and-substance-use Published online August 21, 2020. Accessed November 18, 2020.

4.     COVID-19 disrupting mental health services in most countries, WHO survey. World Health Organization. https:/www.who.int/news/item/05-10-2020-covid-19-disrupting-mental-health-services-in-most-countries-who-survey Published online October 5, 2020. Accessed online November 18, 2020.

5.     Moutier C. Suicide prevention in the COVID-19 era: Transforming threat into opportunity. JAMA Psychiatry. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772135 Published online October 16, 2020. Accessed November 18, 2021

6. Wasserman D, Iosue M, Wuestefeld A, Carli V. Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World Psychiatry. 2020;19(3):294-306. doi:10.1002/wps.20801

7. National Action Alliance for Suicide Prevention. Public perception of mental health and suicide prevention survey results. Published online August 2020. Accessed January 13, 2021.

8. Dr. Lorna Breen Health Care Provider Protection Act introduced in Senate. American College of Emergency Physicians. https://www.acep.org/corona/COVID-19-alert/covid-19-articles/dr.-lorna-breen-health-care-provider-protection-act-introduced-in-senate/ Published online July 29, 2020. Accessed online November 18, 2020.