Psychiatric Annals

CME Article 

The Increase in Suicide During the COVID-19 Pandemic

Hai Le, MD; Burhan Ahmed Khan, MD; Syed Murtaza, MD; Asim A. Shah, MD

Abstract

The unfolding of the current coronavirus 2019 (COVID-19) pandemic, the worst global public health crisis in recent history, has caused unprecedented medical, social, and economic upheaval across the globe, and inflicted profound psychological pain on many people. The rapid spread of this highly contagious disease resulted in a host of mental health consequences: feelings of uncertainty, sleep disturbances, anxiety, distress, and depression. The wide adoption of restrictive measures, although helpful in controlling the spread of the virus, inevitably resulted in psychological and financial costs that may have long-term psychological sequelae. Previous epidemiological studies of similar outbreaks supported evidence of mental toll and increased suicide risks that should be monitored, and adequate resources should be made available to address the mental health challenges and related long-term ramifications. This work comprehensively reviews the current literature about the impact of the COVID-19 pandemic on suicide risk factors and the related vulnerable populations. [Psychiatr Ann. 2020;50(12):526–530.]

Abstract

The unfolding of the current coronavirus 2019 (COVID-19) pandemic, the worst global public health crisis in recent history, has caused unprecedented medical, social, and economic upheaval across the globe, and inflicted profound psychological pain on many people. The rapid spread of this highly contagious disease resulted in a host of mental health consequences: feelings of uncertainty, sleep disturbances, anxiety, distress, and depression. The wide adoption of restrictive measures, although helpful in controlling the spread of the virus, inevitably resulted in psychological and financial costs that may have long-term psychological sequelae. Previous epidemiological studies of similar outbreaks supported evidence of mental toll and increased suicide risks that should be monitored, and adequate resources should be made available to address the mental health challenges and related long-term ramifications. This work comprehensively reviews the current literature about the impact of the COVID-19 pandemic on suicide risk factors and the related vulnerable populations. [Psychiatr Ann. 2020;50(12):526–530.]

Coronavirus 2019 (COVID-19) has not only caused an infectious disease pandemic, but also a global psychological pandemic that may exacerbate suicide risk factors. During this ongoing public health crisis, the number of people affected socially and psychologically by COVID-19 likely exceeds the number of people contracting the virus by a huge margin. Hence, it is important to not just focus on the infectious aspect of the pandemic but also its mental heath impact.

Suicide

Suicide is a global public health issue. According to the World Health Organization (WHO), nearly every 40 seconds, one person dies from suicide, resulting in almost 800,000 deaths every year.1 Suicide attempts are estimated to be 20 times more prevalent than suicide.2 In 2018, according to the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics data, suicide was the 10th leading cause of death in the United States; in the same year, 48,344 people died by suicide, and 1.4 million attempted suicide.3 It has been observed that despite all efforts to reduce this number, there was a 2% annual increase in the rate from 2006 to 2014. The adjusted rate from 1999 to 2017 was approximately a 33% total increase in suicide. Psychological autopsies of these suicide victims showed that 90% of these suicides were related to mental health issues.4

Suicide rates had already reached a significantly high level before the COVID-19 pandemic, and during the pandemic, there has been a drastic increase in all the risk factors for suicide. A recent survey conducted by the CDC in June 2020 found that suicidal ideations were reported to as 2 times higher in the previous 30 days than in the US in 2018.5

To predict our upcoming mental health crisis, it is imperative to understand previous pandemics or epidemics. Different studies show that there was a significant increase in suicide after the 1918–1919 influenza pandemic. In 1920, an organization named Save-a-Life reported a 23% increase in suicide from 1920 to 1921 after the 1918–1919 influenza pandemic.6 Another study conducted after the 2003 severe acute respiratory syndrome (SARS) outbreak in Hong Kong showed that there was a significant increase in suicide deaths among people age 65 years and older.7

COVID-19

COVID-19 is caused by a novel coronavirus with single positive-stranded RNA. This virus has the potential to jump from animals to humans.8 Previously, two epidemics caused by this virus family have resulted in thousands of deaths, the SARS pandemic and the Middle East respiratory syndrome outbreak. This new coronavirus, also called the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can rapidly spread via respiratory droplets. COVID-19 was first identified in China in late December 2019 but was assumed to have started at the beginning of December or even earlier when it was treated as pneumonia of an unknown origin. On February 26, 2020, the first case was identified in the US, and on March 11, 2020, the WHO declared the COVID-19 disease a pandemic, which is still currently the case globally. By early November 2020, the WHO has already reported 1.2 million deaths, and around 49 million confirmed cases globally.9

Psychological Impact of the COVID-19 Pandemic

The COVID-19 pandemic presented an unprecedented global public health crisis along with its social and economic upheaval. Apart from physical suffering, the pandemic also directly and indirectly inflicted psychological suffering on many people. Like past outbreaks, in the early stage of the pandemic, the news of this largely unknown infection created fear and anxiety that swiftly crossed all borders. Anxiety and distress further intensified when the virus spread globally in just a few months. Although restrictive measures such as social distancing, social isolation, and quarantine helped flatten the curve within a few months after the initial outbreak, they were linked to feelings of uncertainty, sensorial deprivation, pervasive loneliness, anger, frustration, and boredom. Disabling loneliness and sleep disturbances are significantly associated with depression and suicidal behavior.10

“Excessive health anxiety,” a term used to describe extreme fear of contracting the disease and misinterpretation of unrelated bodily symptoms, further exacerbated the feeling of distress and anxiety that consequently resulted in sleep disturbance.11 Past epidemiological studies showed that people with distress and anxiety disorders were at a much higher risk for sleep disturbances, the second most common symptom of mental distress.12 Sleep disturbances have long been linked to a host of mental health disorders and suicidal ideation. In a survey conducted during the first few weeks of the COVID-19 lockdown, Killgore at al.13 showed that 56% reported at least some evidence of insomnia, with 30.9% in the subthreshold range, 19.8% in the moderate range, and 5.2% in the severe range, levels much higher than historically seen in the general population. The study also suggested that anxiety related to COVID-19 is a significant contributor to the increased incidence of suicidal ideation.13 Incidence of depression has also escalated during the pandemic because a large part of the population has faced multiple medical, social, and economic stressors, including job loss, social isolation, disruption of routine, fear of unknowns, and loss of loved ones due to COVID-19.

A meta-analysis by Salari et al.14 examined 17 cross-sectional studies of the general population in Europe and Asia that showed “the prevalence of stress, anxiety, and depression, as a result of the pandemic in the general population, are 29.6%, 31.9%, and 33.7%, respectively.” Furthermore, people are also suffering with signs and symptoms of psychosis, anxiety, panic attacks, posttraumatic stress symptoms, and suicidal thought.14

Risks for Suicide During COVID-19 Pandemic

Unemployment and financial loss. Financial loss and employment are considered pertinent factors for suicide.15 Owing to the pandemic, the introduction of lockdown resulted in a spike in the unemployment rate globally. With the US unemployment rate skyrocketing to 14.4% in April 2020, tens of millions of people either lost their jobs or were forced to take a pay cut.16

It has been proven historically that economic turndowns result in increases in mental health disorders and suicidal tendencies. A previous study demonstrated that unemployment from 2000 to 2011 increased suicide risk by 20% to 30%.17 People who do not feel secure in their employment tend to be at greater risk for depression, and unemployment increases their risk of alcohol use and suicide.18

Reeves et al.19 reported that most European and North American countries experienced increasing suicide rates during the 2008 to 2010 recession. The authors of the study calculated approximately 10,000 “economic suicides” during the recession in the European Union, Canada, and the US.19 It is reasonable to expect further economic decline during and after the COVID-19 pandemic to have a detrimental effect on mental health and suicidal behavior.

Social isolation. The stringent lockdown guidelines meant severe social isolation for most people. Loneliness and isolation are also considered important risk factors for several mental health disorders including depression, anxiety, chronic stress, insomnia, and late-life dementia.20 Loneliness, commonly seen among older adults, is responsible for increasing depression rates and suicidality. Damaging effects on mental well-being due to prolonged periods of isolation in nursing homes or quarantine have been well studied and reported.21 The lockdown measures also worsened rates of depression, anxiety, posttraumatic stress disorder (PTSD), and insomnia in the general population and contributed to fatigue and reduced performance in health care workers. Before the pandemic, loneliness and isolation were already quite prevalent across Europe, China, and the US (10%–40%), labeled as the “behavioral epidemic,” and essential lockdown measures to help curve the virus had the effect of worsening the already bad state of affairs.22 Furthermore, the isolation may also cause worsening of depressive symptoms, a deterioration in the perception of one's health, decreased functionality, impaired vision, and negative perception of one's own life. Systematic reviews of suicide risk have already demonstrated that loneliness is correlated with suicide attempts as well as its completion among the vulnerable populations.23

Alcohol. Social isolation and stress because of the pandemic may serve as a trigger for alcohol use, which in turn may cause a spike in alcohol use disorder and alcohol-related harms. The 2003 SARS outbreak caused a spike in alcohol abuse dependence symptoms in hospital employees who were exposed to the outbreak. Alcohol and its increased consumption correlate with a rise in domestic violence during the pandemic, increased risk of harm to children, and increased risk of suicide, not to mention worsening other mental health issues.24 Although confinement and its effect on prevalence of alcohol consumption are widely debated, the increasing use of alcohol is likely probable and can favor the passage to the suicidal act.25

Firearms. Any increase in gun ownership among the general population tends to correlate with an increase in risk for suicide with firearms. In February 2020, when lockdown measures were imposed, firearm sales rocketed in the US, with 2.5 million firearms being sold within March 2020 alone, 1.5 million of which were handguns.26 The presence of firearms and their greater availability put people at a higher risk for suicide or its completion. It is important to note that the presence of a firearm in a home poses a 2- to 10-fold increased risk compared with the absence of firearms.27

Whenever a person purchases a gun, within the first year of the purchase, the owner has a 22-fold increase in the rate of firearm-related suicide compared to those who do not purchase a handgun.28 With almost every 10% increase in household ownership, we see a rise in the firearm suicide rate of about 3.1 per 100,000 persons.28

It is necessary to mention that, with most mechanisms of suicide, completion is not commonly achieved; however, one exception is firearm-related suicide whose fatality is 40 times greater than that of drug poisoning, which is the most common method of suicide.29

Contracting COVID-19

There is a considerable amount of anxiety that is experienced by people who are infected with COVID-19. With quarantine measures in effect, patients suffering from COVID-19 must abide by stringent isolation policies at home or in office facilities. Such conditions can be burdensome and cause severe loneliness, which as mentioned previously, is a well-established risk factor for suicide. The patient's state of mind could have also worsened with guilt about potential exposure to family members and close associates, which could force isolation as well. In certain cases, the psychological impact on one person can be transferred to surrounding friends and family, especially if they have preexisting PTSD or depression.30

Vulnerable Groups

The COVID-19 pandemic has affected everyone psychologically, especially people with preexisting mental health disorders, older adults with prolonged isolation, frontline health care workers, and people on the fringes of society. Unemployment and financial stressors are well-established risk factors for suicide.17 When the unemployment rate spiked in April 2020, people with lower socioeconomic status suffered disproportionately. During this period, close to 19% of workers without a high school diploma were unemployed compared with just 7.2% of workers with a bachelor's degree or higher.14 Although younger people are more likely affected during the pandemic in financial terms, older adults are more affected medically and socially. Besides age itself being a risk factor for suicide, older adults face a particularly high risk of suicide during the pandemic due to social isolation, social distancing, quarantine, and high infection and death rate compared to other populations of people. People older than age 70 years disproportionately accounted for approximately 80% of all deaths related to COVID-19.31 Older adults at nursing homes probably fare the worst due to inadequate social distancing and other protective measures.32 Suicide, if viewed through the interpersonal theory lens, may result from perceived burdensome and thwarted belongingness.33 The pandemic is a perfect storm for all of these elements: loneliness, anxiety, and depression.

Health care workers, who are already at a higher burnout rate compared to other professions, faced a pandemic within a pandemic. The health care delivery systems witnessed one of the worst crises from March 2020 to April 2020 when emergency departments and hospitals were overwhelmed with patients suffering from COVID-19.34 Unfortunately, our health care system was unprepared for the current pandemic.35 The shortage of personal protective equipment resulted in unnecessary exposure of frontline health care workers to the virus. Coupled with work overload, the pandemic created further distress and trauma. News stories of health workers taking their lives during the height of the COVID-19 pandemic once again reminded us of the occupational hazard of practicing medicine that is not often talked about.36

Conclusion

The ongoing COVID-19 pandemic is arguably the worst global public health crisis that required the implementation of drastic safety measures, which undoubtedly helped slow down and prevent the virus spread. Unfortunately, those safety measures also resulted in prolonged social isolation and other undesired consequences, among them disruption of routine, feelings of uncertainty, job loss, financial loss, and excessive health anxiety. The pandemic is directly and indirectly linked to an increase in suicide risk factors such as anxiety, distress, depression, sleep disturbances, unemployment, financial loss, loneliness, firearm availability, and alcohol consumption. The risk of suicide is particularly challenging in identified vulnerable populations: older adults, people with existing mental health conditions, frontline health care workers, and people with lower socioeconomic status.

References

  1. World Health Organization. Suicide data. Accessed November 12, 2020. https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/.
  2. Hegerl U. Prevention of suicidal behavior. Dialogues Clin Neurosci. 2016;18(2):183–190. doi:10.31887/DCNS.2016.18.2/uhegerl [CrossRef] PMID:27489458
  3. Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health. 2018;15(7):E1425. doi:10.3390/ijerph15071425 [CrossRef] PMID:29986446
  4. Brådvik L. Suicide risk and mental disorders. Int J Environ Res Public Health. 2018;15(9):2028. doi:10.3390/ijerph15092028 [CrossRef] PMID:30227658
  5. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049–1057. doi:10.15585/mmwr.mm6932a1 [CrossRef] PMID:32790653
  6. Berger K. Seattle struggled with suicide in late stages of the 1918 flu. Here and beyond, reports of deaths by suicide indicate the mental health toll likely caused by the influenza pandemic. Accessed November 5, 2020. https://crosscut.com/2020/05/seattle-struggled-suicide-late-stages-1918-flu
  7. Yip PS, Cheung YT, Chau PH, Law YW. The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong. Crisis. 2010;31(2):86–92. doi:10.1027/0227-5910/a000015 [CrossRef] PMID:20418214
  8. Dhama K, Patel SK, Sharun K, et al. SARS-CoV-2 jumping the species barrier: zoonotic lessons from SARS, MERS and recent advances to combat this pandemic virus. Travel Med Infect Dis. 2020;37:101830. doi:10.1016/j.tmaid.2020.101830 [CrossRef] PMID:32755673
  9. World Health Organization. WHO coronavirus disease (COVID-19) dashboard. Accessed November 5, 2020. https://covid19.who.int/.
  10. Serafini G, Parmigiani B, Amerio A, Aguglia A, Sher L, Amore M. The psychological impact of COVID-19 on the mental health in the general population [published online ahead of print June 22, 2020]. QJM. 2020;113(8):531–537. doi:10.1093/qjmed/hcaa201 [CrossRef] PMID:32569360
  11. Asmundson GJG, Taylor S. How health anxiety influences responses to viral outbreaks like COVID-19: what all decision-makers, health authorities, and health care professionals need to know. J Anxiety Disord. 2020;71:102211. doi:10.1016/j.janxdis.2020.102211 [CrossRef] PMID:32179380
  12. Staner L. Sleep and anxiety disorders. Dialogues Clin Neurosci. 2003;5(3):249–258. PMID:22033804
  13. Killgore WDS, Cloonan SA, Taylor EC, Fernandez F, Grandner MA, Dailey NS. Suicidal ideation during the COVID-19 pandemic: the role of insomnia. Psychiatry Res. 2020;290:113134. doi:10.1016/j.psychres.2020.113134 [CrossRef] PMID:32505030
  14. Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health. 2020;16(1):57. doi:10.1186/s12992-020-00589-w [CrossRef]
  15. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009;374(9686):315–323. doi:10.1016/S0140-6736(09)61124-7 [CrossRef] PMID:19589588
  16. International Monetary Fund. Policy responses to COVID-19. Accessed November 5, 2020. https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19#U
  17. Nordt C, Warnke I, Seifritz E, Kawohl W. Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000–11. Lancet Psychiatry. 2015;2(3):239–245. doi:10.1016/S2215-0366(14)00118-7 [CrossRef] PMID:26359902
  18. Tapia Granados JA, Diez Roux AV. Life and death during the Great Depression. Proc Natl Acad Sci USA. 2009;106(41):17290–17295. doi:10.1073/pnas.0904491106 [CrossRef] PMID:19805076
  19. Reeves A, McKee M, Stuckler D. Economic suicides in the Great Recession in Europe and North America. Br J Psychiatry. 2014;205(3):246–247. doi:10.1192/bjp.bp.114.144766 [CrossRef] PMID:24925987
  20. Wilson RS, Krueger KR, Arnold SE, et al. Loneliness and risk of Alzheimer disease. Arch Gen Psychiatry. 2007;64(2):234–240. doi:10.1001/archpsyc.64.2.234 [CrossRef] PMID:17283291
  21. Stickley A, Koyanagi A. Loneliness, common mental disorders and suicidal behavior: findings from a general population survey. J Affect Disord. 2016;197:81–87. doi:10.1016/j.jad.2016.02.054 [CrossRef] PMID:26971125
  22. Jeste DV, Lee EE, Cacioppo S. Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions. JAMA Psychiatry. 2020;77(6):553–554. doi:10.1001/jamapsychiatry.2020.0027 [CrossRef] PMID:32129811
  23. Kobayashi LC, Steptoe A. Social isolation, loneliness, and health behaviors at older ages: longitudinal cohort study. Ann Behav Med. 2018;52(7):582–593. doi:10.1093/abm/kax033 [CrossRef] PMID:29860361
  24. Chodkiewicz J, Talarowska M, Miniszewska J, Nawrocka N, Bilinski P. Alcohol consumption reported during the COVID-19 pandemic: the initial stage. Int J Environ Res Public Health. 2020;17(13):4677. doi:10.3390/ijerph17134677 [CrossRef] PMID:32610613
  25. Ahmed MZ, Ahmed O, Aibao Z, Hanbin S, Siyu L, Ahmad A. Epidemic of COVID-19 in China and associated psychological problems. Asian J Psychiatr. 2020;51:102092. doi:10.1016/j.ajp.2020.102092 [CrossRef] PMID:32315963
  26. Small Arms Analytics. US firearms sales: March 2020 unit sales show anticipated COVID-19-related boom. Accessed November 5, 2020. https://smallarmsanalytics.com/v1/pr/2020-04-01.pdf
  27. Dahlberg LL, Ikeda RM, Kresnow MJ. Guns in the home and risk of a violent death in the home: findings from a national study. Am J Epidemiol. 2004;160(10):929–936. doi:10.1093/aje/kwh309 [CrossRef] PMID:15522849
  28. Grassel KM, Wintemute GJ, Wright MA, Romero MP. Association between handgun purchase and mortality from firearm injury. Inj Prev. 2003;9(1):48–52. doi:10.1136/ip.9.1.48 [CrossRef] PMID:12642559
  29. Conner A, Azrael D, Miller M. Suicide case-fatality rates in the United States, 2007 to 2014: a nationwide population-based study. Ann Intern Med. 2019;171(12):885–895. doi:10.7326/M19-1324 [CrossRef] PMID:31791066
  30. Kar SK, Yasir Arafat SM, Kabir R, Sharma P, Saxena SK. Coping with mental health challenges during COVID-19. Coronavirus Disease 2019 (COVID-19). 2020;199–213. doi:10.1007/978-981-15-4814-7_16 [CrossRef]
  31. Bulut C, Kato Y. Epidemiology of COVID-19. Turk J Med Sci. 2020;50(SI-1):563–570. doi:10.3906/sag-2004-172 [CrossRef] PMID:32299206
  32. Pitkälä KH. COVID-19 has hit nursing homes hard [published online ahead of print October 3, 2020]. Eur Geriatr Med. doi:10.1007/s41999-020-00411-1 [CrossRef] PMID:33011911
  33. Wand APF, Zhong BL, Chiu HFK, Draper B, De Leo D. COVID-19: the implications for suicide in older adults [published online ahead of print April 30, 2020]. Int Psychogeriatr. 2020;32(10):1–6. doi:10.1017/S1041610220000770 [CrossRef] PMID:32349837
  34. Ornstein C. How America's hospitals survived the first wave of the coronavirus. ProPublica. Accessed November 12, 2020. https://www.propublica.org/article/how-americas-hospitals-survived-the-first-wave-of-the-coronavirus
  35. Bearman G, Pryor R, Vokes R, et al. Reflections on the COVID-19 pandemic in the USA: will we be better prepared next time?. Int J Infect Dis. 2020;96:610–613. doi:10.1016/j.ijid.2020.05.059 [CrossRef] PMID:32445697
  36. Dean W. Health care worker suicides hint at Covid-19 mental health crisis to come. STAT. Accessed November12, 2020. https://www.statnews.com/2020/04/30/suicides-two-health-care-workers-hint-at-covid-19-mental-health-crisis-to-come/
Authors

Hai Le, MD, is an Assistant Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Burhan Ahmed Khan, MD, is a Graduate, Aga Khan University. Syed Murtaza, MD, is a Research Coordinator, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Asim A. Shah, MD, is the Barbara & Corbin J. Robertson Jr. Chair in Psychiatry, the Executive Vice Chair, and the Professor of Psychiatry, Family and Community Medicine, Baylor College of Medicine; the Chief of Psychiatry, Ben Taub Hospital/Harris Health System; and the Chief, Division of Community Psychiatry & Director of Mood Disorder Research Program, Ben Taub Hospital.

Address correspondence to Asim A. Shah, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Room 2.125, Neuropsychiatric Center, 1502 Taub Loop, Houston, TX 77030; email: aashah@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20201105-01

Sign up to receive

Journal E-contents