It is a concerning fact that suicide has been among the leading causes of death in the U.S. for decades. Many warned that the pandemic could lead to the “perfect storm” of factors that would prompt a further, sharper increase in the steadily rising suicide rates.
The economic stressors that come with closed businesses and lost jobs during lockdowns, an increase in social isolation and alienation; reduced access to support services and treatment, during a period of rising demand; more physical illness, not least of all COVID-19 itself; heightened fear and health anxiety, combined with restricted access to healthy coping strategies, such as exercise, and numerous other pressures caused by the pandemic, led many to fear a COVID-19 suicide epidemic.
Contrary to widely held expectations, recent data from the U.S. National Center for Health Statistics revealed that the suicide rate in the U.S. actually decreased by 5.6% in 2020. This was a continuation of the marginal decrease which began in 2018.
Historical data shows that suicide has been an increasing problem since 2001. While the trend has been heading in the wrong direction for two decades, the new data collated by the U.S. Center For Disease Control (CDC) shows this more recent decline.
The apparent reduction in suicide rates in 2020 is certainly a welcome statistical sight. However, many experts have warned that this data needs to be seen in the context of some important caveats.
COVID-19 Suicide Rates Don’t Reveal The Whole Picture
The CDC state that the present data is preliminary. It can often take months or even years to adjudicate a possible suicide.
A similar study conducted by the Harvard Medical School in Boston, Massachusetts, which, like the CDC, used publicly available data, noted this problem: “Data for 2019 and 2020 are preliminary, a sensitivity analysis including all deaths still pending final cause adjudication as of November 14, 2020.”
Nonetheless, the Harvard researchers also found death due to suicide per 100 000 person-months apparently fell from 0.8 to 0.6. These figures are surprising given the clear increase in mental healthcare service demand during the pandemic.
The American Psychological Association (APA) surveyed their members and found that more than a third of psychologists reported increased referrals with nearly half noting a reduction in non-attendance and cancelled appointments. They experienced an overall 30% increase in patient numbers.
This included a 74% increase in patients with anxiety disorders and a 60% increase among those suffering from depression.
A combined meta-analysis published in General Hospital Psychiatry found increased rates of psychiatric morbidity, PTSD and depression linked to the COVID-19 pandemic. They concluded that “pandemics are associated with multiple mental disorders in several impacted populations.”
Most telling, the researchers found that up to 20% of U.S. adults developed mental health disorders as a direct result of the COVID-19 pandemic. This is clearly a concerning finding and somewhat contradicts the suicide statistics.
The CDC figures are not broken down by demographic profile. It is known that COVID-19 disproportionately impacts poorer communities.
In particular, research has shown that Black Americans saw the health inequalities, that already existed in their communities prior to the pandemic, exacerbate as a result of COVID-19. Dr Clyde Yancy noted that up to 50% of cases and a staggering 70% of Covid-19 deaths were among Black Americans in Chicago, despite them comprising only 30% of the population.
Sadly, this disparity is also evident in the suicide statistics revealed by other studies. A study by researchers at Johns Hopkins School of Medicine discovered that the pandemic had seen suicide rates among Black Maryland residents almost double, between March and May 2020, while rates among White residents more than halved.
It is clear that the overall suicide rates alone do not provide a true reflection of the impact of COVID-19 on the nation’s mental health. The tempered optimism they might suggest is apparently misplaced.
Sad to say, the pandemic appears to have taken a heavy mental health toll. Therefore, it is essential that all health care professionals and family members familiarise themselves with the warning signs of suicide.
Looking Beyond COVID-19 Suicide Statistics
The CDC found that nearly all other indicators of mental health stressors increased markedly in 2020. They discovered an almost 300% increase in anxiety disorders.
Perhaps, even more concerning, from the perspective of suicide risk, was the almost 400% increase in the prevalence of depressive disorders. Only a small minority received treatment.
The indicated population incident rate made sombre reading. More than 40% of respondents reported one or more mental or behavioural health problems, with more than 30% having anxiety-related or depressive symptoms.
Of particular note was that 26% stated that the symptoms indicative of these health problems arose as trauma and stressor-related disorders (TSRD) linked to their lived experience of the pandemic.
As we have discussed, the recorded suicide rates are not able to provide a full picture of the current national suicide risk. Typically they can take up to two years to complete, due to the unavoidable lag caused by adjudication.
Perhaps a better indicator of the suicide risk is suicidal ideation, meaning serious contemplation of suicide. Again the CDC research suggests the impact of COVID-19 on suicide rates has been significantly more pronounced than the raw numbers suggest.
Suicidal ideation rose to an alarming 25.5% among those aged between 18 – 25 years. Again, the disproportionate effect upon different racial and ethnic groups was evident. The overall rate was 10.7% of all respondents.
However, among the Hispanic minority it was 18.6% and among the Black minority 15.1%.
Underlining the impact of COVID-19 itself on the suicide risk was the stark finding that, among self-reported unpaid caregivers the suicidal-ideation rate was 30.7%. More than three times the overall level of risk.
Elevated risk was also notable among essential workers, with 21.7% expressing thoughts of suicide.
These additional risks, faced by Black and Hispanic communities, the young, caregivers and essential workers are not recorded in the basic suicide statistics reported elsewhere by the CDC. Clearly, prevention efforts and treatments should be tailored to serve these communities as appropriate.
The CDC observed:
“Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.”
Other Signs of the Impact of COVID-19 on Suicide Rates
It is relatively common for people suffering from mental health problems to “self medicate” with substances. Similarly, it is apparent that a substance use health problem often corresponds to an increased likelihood of mental health disorder.
This is frequently referred to as comorbidity. Where both substance misuse and mental health disorders are found together the term dual-diagnosis or dual-disorder (DD) is used.
The National Institute of Health (NIH) have recognised the difficulty in ascertaining precisely which disorder was the possible antecedent for the other. For example, Australian researchers found that self-medication for anxiety increased the likelihood of developing a generalised anxiety disorder (GAD.)
In turn, people with bipolar disorder were found to have higher rates of substance use and subsequent, related disorders.
The NIH reported that about half of people diagnosed with a mental illness will also experience a substance use disorder. High rates of substance use among people living with depression is so common that the relationship between depression and substance disorders is often referred to as bi-directional.
The CDC researchers found that a total of 13.3% of those who reported suicidal ideation has “started or increased substance use” during their study period. The U.S. Department of Health and Human Services noted the link between alcohol and substance abuse disorder and suicide risk.
This was most prevalent among the young with increasing age diminishing the risk progressively. Of all alcohol-related deaths, which were not traffic incidents, 20% were suicides.
Dual-disorder (DD), in particular, appears to be a significant suicide risk factor. French researchers found a clear correlation between DD and suicide among the prison population.
The Mount Sinai Department of Psychiatry noted that “patients with dually diagnosed mental illness and substance use disorder are at high risk for suicidal behaviour.”
They also cited numerous studies that showed how COVID-19 had increased the drivers for DD. The CDC’s findings of increased substance use further supported this research and adds credibility to the concern that the basic suicide figures are hiding a more complex and, unfortunately, far more concerning picture.
It is also clear why we might expect to see these research results. There are numerous aspects of the COVID-19 pandemic that have contributed to the worrying escalation of suicide risks.
Below is an example of such aspects.
Social isolation itself isn’t necessarily harmful. People often need some “me time.” It can provide an opportunity to relax, both physically and mentally, giving us a moment to reflect on priorities or reward ourselves.
However, where that “social isolation” is enforced and unwanted, research by Tulane University in New Orleans shows the significant detrimentally effect it can have on our physical and mental health.
COVID-19 necessitated that forced self-isolation, often combined with physical distancing, happened on a societal scale which has never been seen before. This reduced human to human contact for millions. Numerous studies have identified the problems this can bring.
Social isolation is associated with increased mortality. In particular, the socially isolated are more likely to suffer from cardiovascular disease and cancers.
The physical health impacts of enforced isolation become acute when we experience loneliness. The deficiency in social relationships leads to a marked increase in coronary heart disease and stroke.
The available literature indicates that social isolation is also linked to an increased risk of suicide. A 2019 international review of of existing studies found such a clear correlation between social isolation and increased suicide risk that the researchers urgently recommended that “objective social isolation and the subjective feeling of loneliness should be incorporated in the risk assessment of suicide.”
This concern appears well-founded. Having endured the widespread application of policies needed to tackle COVID-19, which required mass social isolation, it was predicted that suicide risks would increase.
While these have yet to emerge in the raw suicide statistics, every other indicator reveales that this increased risk did occur as a result of COVID-19.
It is important that public health education provides U.S. families with the information they need to mitigate the risks. Understanding how to protect yourself and loved ones during periods of social isolation is key.
COVID-19 caused the worst U.S. economic contraction since the Great Depression of the 1930’s. The U.S. based human rights charity, Human Rights Watch (HRW,) found that nearly 75 million Americans lost work.
These jobs were overwhelmingly in low paid service industries and the unskilled labour markets. Once again, COVID-19 disproportionately impacted the already poor and socially disadvantaged.
By January 2021 HRW reported that 24 million Americans reported food shortages and 6 million poorer households faced an imminent housing crisis, as they were no longer able to keep up with rent payments or mortgage arrears. The U.S. Census Bureau found that 47% of households with an income below $35,000 were struggling with housing payments and 25% were falling into food poverty.
Consequently, 32% of householders in the below $35,000 income percentile, expressed feelings of depression. The stimulus payment and COVID-19 related increases in unemployment payments were helpful in covering some day to day living costs, but 37% stated they had gone into debt or their debts had increased.
However many people on low incomes did not qualify for this government support. The Centre on Budget and Policy Responsibility conducted research revealing that during 2020, one in eight U.S. citizens under 65, who did not have children and were not disabled, were living in poverty.
The link between poverty and suicide rates is well established. A 2016 systematic literature review reported:
“These findings show a consistent trend at the individual level indicating that poverty, particularly in the form of worse economic status, diminished wealth, and unemployment is associated with suicidal ideations and behaviours.”
Prior to COVID-19, a dramatic rise in the suicide risk among children and young people had already been observed. The link between increasing poverty and wealth inequality was demonstrated.
With the subsequent financial impact of COVID-19 on U.S. families, the fear is this situation will have deteriorated further. The evidence supports this contention and further research is needed.
Restricted Access To Services
The Centers for Medicare and Medicaid Services (CMS) announced that the pandemic health emergency had seen a decline in service uptake. Between March and October 2020, access to primary, preventative and mental health care had reduced by millions of visits compared to the same period in 2019.
There was a 34% drop in mental health service attendance among young people under 19. The decline is service uptake among adults, under 64, was 22%.
This equated to 14 million fewer potential interventions for young people and 12 million for adults. Clearly, with the increased demand for services noted by the APA and others, this drop-in access to treatment suggests worrying systemic failures.
While similar reductions were seen across all health care services, most had recovered to pre-pandemic levels. However, this had not been the case with mental health services which were slow to bounce back and remained below 2019 averages.
Given that all other markers show a worsening mental health landscape in the U.S. this is a major concern for health care providers and wider society. The CMS expressed fears that this could have a “substantial impact on long-term health outcomes.”
Access to effective mental health care is known to be an important factor in reducing suicidal ideation and risks. Again, studies revealed disparities in the distribution of services.
Amid an overall decline in access, young people in rural areas were found to have less opportunity to engage with mental health services. Suicide rates among this demographic were notably higher.
One of the groups most prone to suicide is veterans. A 2017 study clearly identified that a lack of mental health support and interventions was a significant contributor to veterans’ high suicide rate.
Therefore the CMS have a clear basis for their concerns. The notable decrease in service uptake caused by the response to COVID-19 is extremely likely to impact suicide rates.
COVID-19 presented almost an unprecedented threat to the nation’s health. Beyond the disease itself, the measures necessary to stop the spread of infection impacted nearly every aspect of American life.
From lost employment and increased poverty to restricted access to services and social isolation, it may be years before the full extent of the damage to public health can be properly assessed.
Seldom has the American public experienced the broad level of heightened anxiety it has felt over the last 18 months. Not only were people understandably anxious about COVID-19, but the measures needed to combat it all tended towards a further increase in anxiety levels.
Even for people who were otherwise well, this added anxiety presented health challenges.
Research from the UK indicates that the young, women and the most vulnerable were most susceptible to psychological morbidity during the pandemic. Specific interventions targeting COVID-19 related anxieties among these demographic groups appear warranted.
Anxiety is a known risk factor for suicidal ideation. Canadian scientists found that anxiety disorder was a common precursor to 70% of recorded suicide attempts.
For people already suffering from, for example, GAD or PTSD, COVID-19 presented an elevated risk.
Despite the preliminary figures, which have prompted some politicians to express a view that COVID-19 did not present the mental health threat many feared, it seems those who warned of the “perfect storm” were right.
We need to recognise that COVID-19 has led to a marked increase in the nation’s suicide risk. More importantly, as a society, we must provide access to essential mental health support and interventions to those groups most at risk.
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