DEFINITION

• The annual suicide rate in the U.S. is 14.5 per 100,000 as of 2019.[1]
  • This rate has increased steadily since 2000, when it was 10.4 per 100,000.
  • Suicide is the 10th leading cause of death in the U.S. across all ages.
  • 78% of completed suicides are by males and 89% are by whites.
  • 51% of suicides are via firearm, 26% via suffocation, and 15% via poisoning.
• Previous pandemics have been associated with increases in suicide rate.
  • The U.S. reported an increase in suicides during the Spanish Flu of 1918-19.[2]
  • Hong Kong observed an increase in elderly suicides during the 2003 SARS outbreak.[3]
  • Africa experienced an increase in suicides during the Ebola epidemic.[4]
  • Possible risk factors for suicide during pandemics include isolation, fear, marginalization, psychological disorders, economic fallout, and increased domestic abuse.[5]
• The COVID-19 pandemic exacerbates multiple factors that may increase suicides.[6]
  • SARS-CoV-2 infected 76 million people worldwide in 2020.[7]
  • Economic stress is associated with higher suicide rates.[8] The pandemic has forced many businesses to close or scale back as a result of lockdown measures.
  • Social isolation is associated with increased suicidal thoughts.[9] The main U.S. public health strategy to mitigate the spread of COVID-19 has been social distancing.
  • Participation in religious communities is associated with lower suicide rates.[10] Churches and community centers have also been forced to close, contributing to social isolation and possible higher suicide rates.
  • Continuous media coverage of the pandemic may intensify anxiety and fear for individuals with preexisting mental health conditions.
  • Barriers to mental health treatment that have arisen due to the pandemic include increased restrictions at healthcare facilities.
  • In the U.S., firearm sales have surged, with a 41% increase in March 2020 and >50% increase in August and October 2020, relative to 2019 rates.[11]

APPROACH

• Multiple reports based on the early months of the pandemic have not found significant changes in the overall rates of suicide.
  • In Massachusetts, U.S., the rate of suicides during the stay-at-home period from March to May 2020 was similar to that of the same period in 2019.[12]
  • In Victoria, Australia, the number of suicides through September of 2020 was comparable to that through September of 2019 and other years prior.[13]
  • In England, the average number of suicides per month pre-lockdown (January-March 2020) was 84.0 and post-lockdown (April-August 2020) was 85.4.[14]
  • In Norway, the rate of suicides from March to May 2020 was 2.8 per 100,000, which is not significantly different from the rate for the five previous years.[15]
• However, certain groups may be more vulnerable to the effects of the pandemic and experience increased suicide rates.
  • Elderly: In older Americans, social disconnectedness is associated with higher perceived isolation, depression, and anxiety. Self-isolation further disproportionately affects elderly individuals who do not have close family and friends, or who have decreased literacy in or access to digital resources.[16]
  • Youth: Preliminary data from England suggest that child suicide deaths may have increased during the first phase of lockdown, possibly due to disruptions to education, extracurricular activities, and support services.[17]
  • Racial minorities: In Maryland, U.S., progressive closure of businesses from March to May 2020 was associated with decreased daily suicide mortality among white residents but increased daily suicide mortality among Black residents.[18]
  • Unemployed: The pandemic is predicted to cost 25 million jobs worldwide.[19] Global studies of the Great Recession in the early 2000s found that suicide risk was elevated by 20-30% between 2000 and 2011 with a peak during 2008.[20]
  • Mentally ill: Individuals with preexisting mental health issues are likely to be affected by illness relapse, interruption in psychiatric services, increased isolation, and possible exacerbation by anxiety due to the pandemic.[21]
  • Healthcare workers: Medical staff have reported increased hopelessness, guilt, and insomnia, all of which can increase the risk for suicide.[22]
• Based on studies of previous epidemics, there may also be a short-term decrease in suicide initially but an increase later.
  • Studies of natural disasters have suggested a short-term decrease in suicide in the immediate aftermath of a disaster but an increase later. Referred to as "the honeymoon period" or the "pulling together" phenomenon, this has been attributed to increased social connectedness, community cohesion, and mutual support in the acute phase of a pandemic.[23]
  • In the early phase of the pandemic, the number of suicide deaths in Japan was lower than that of prior years, but the number started to exceed historical trends in July 2020.[24]

APPLICATION

• Adequate and equitable access to mental health care should be ensured, for example through increased tele-psychiatry and mental health help lines.
• Sale of common mechanisms of suicide, particularly firearms, should be restricted.
• Digital connectedness should be encouraged to prevent social isolation.
• Economic supports, such as government stimulus, unemployment income, and rent and loan forgiveness, should be considered.
• The mental health of frontline workers should be fostered, for example by allowing for flexible shifts and adequate rest, and offering mental health care and peer support.

COMMENTS

• It is encouraging that data thus far do not reflect an overall increase in suicide deaths since the onset of the pandemic.
• However, it is imperative to remain vigilant and prevent mental health crises, as the pandemic may have long-term impacts on mental health if not immediate ones. The pandemic has generated much anxiety and stress for many, and has exacerbated numerous known suicide factors.
• It is particularly important to support at-risk populations, such as the elderly, youth, racial minorities, unemployed, and frontline workers. Methods include ensuring equitable access to mental health care, fostering digital community support, and providing economic relief.

References