Medical Ethics

COVID-19 and suicide: Trading one pandemic for another

By Sarah Kathryn Chambley, MS-4, with input from J. David Baxter, M.D., FACP, Interim Associate Dean Savannah Campus and Associate Professor of Medicine, Mercer University School of Medicine

Sarah Kathryn Chambley

In times of crisis, communities historically come together to support one another, a phenomenon called the “pulling-together effect.”1 A sense of belongingness, such as being one community member of many experiencing a crisis, is protective against adverse mental health.2 The nation pulled together on September 11, 2001, and suicide rates decreased after the terrorist attacks.1 However, the coronavirus pandemic is a new and unprecedented kind of crisis. In the midst of a time when human instinct is to come together in support of one another, humans are faced with the fear that the community is the very real threat to health.

Efforts to remain socially distant (i.e., the six-foot rule) to contain COVID-19 and protect our physical health have been implemented. Large gatherings have been prohibited. Visitation has been limited in hospitals, even when death is imminent. And at least early on, all non-essential businesses had to close their doors to the public. All these efforts, while valid, raise concerns that in attempt to contain the virus the government has incidentally put the nation at risk for another kind of pandemic; a suicide pandemic. Mental health may be put at risk while intending to protect physical health. The coronavirus pandemic has affected more than the nation’s physical health. The direct and indirect effects of the shutdown have increased the risk of suicide – keeping in mind that school and childcare closings have forced parents to take time off from work or to work from home, businesses have shut their doors or laid off employees in order to follow social distancing protocols, and more than 22 million Americans applied for unemployment insurance in April 2020.3

Times of economic hardships are associated with higher suicide rates. For every one percent increase in unemployment, there is a one percent increase in suicide deaths and a greater than three percent increase in deaths related to opioids.4 Additionally, the shutdown itself and the media’s portrayal of it has built up barriers to mental health care services. The media has implied that mental health services are not a priority by exaggerating the fact that health care systems are overwhelmed with critically ill COVID-19 patients. Many Americans falsely believe that mental health services fall into the category of non-essential medical care.1 Additionally, news coverage regarding the knowns and unknowns about coronavirus can cause great worry, stress, and anxiety for a consumer – especially the ones who are at greatest risk of contracting the virus. Physical and mental health problems alone can trigger suicidal behavior, compounding the anxiety of being at greater risk of coronavirus infection. Prevention efforts, such as social distancing, have inadvertently put our nation at greater risk of suicidal thoughts and behaviors. Social connectivity, which typically increases during times of crisis, decreases suicide risk. Weekly attendance at religions services is associated with a five-fold lower suicide risk.5 However, these gatherings have been prohibited under the social distancing guidelines. Restrictions to visitation in health care facilities, such as hospitals and nursing homes, have remained in place during the pandemic. Stay-at-home orders have increased social isolation and loneliness, both which are associated with suicidal thoughts and behaviors. There is an additional factor that makes this situation all the more concerning. In March 2020, more than 2.5 million firearms were sold in the U.S. This is an 85 percent increase in sales compared to March 2019, and it marks the highest sales in U.S. history.3 Ownership, access, and unsafe storage increase the risk of suicidal behaviors for not only the owner, but for all members of the household. Handgun ownership puts the owner at a 22-fold greater risk. The presence of a gun in the home is associated with a two- to 10-times greater risk for every member of the household.3 Firearms are the most common method of suicide. The reason for the increase in sales remains unclear, but the increase is relevant and frightening regardless of the reason.

Concerns about continuing the social distancing and stay-athome orders are growing throughout the medical community. Economic instability, lack of access to mental health services, heightened stress and anxiety, social isolation, and a rise in firearm purchases create the perfect scenario for negative health outcomes. More than 600 physicians signed a “A doctor a day” letter that was sent to President Donald Trump in May that urged him to end the national shutdown. They said that they are concerned about the already apparent negative effects of the

shutdown on our country’s wellbeing, including missed health checks, financial instability, and an increase in substance abuse and mental health problems.6 The letter highlighted several patients who had experienced negative health effects as a result of the government shutdown. The first example was a man and woman with two children. His job was furloughed and hers was reduced to part-time. The man began drinking heavily and the woman was diagnosed with depression, worsening her preexisting diabetes mellitus type two. Another patient, unable to see her therapist, relapsed into depression and died of a fentanyl overdose several weeks into the pandemic. The letter stated that, “The millions of casualties of a continued shutdown will be hiding in plain sight, but they will be called alcoholism, homelessness, suicide, heart attack, stroke, or kidney failure.”6

Concerns regarding potential negative outcomes of the government’s COVID-19 prevention efforts are not suggesting that no action should be taken to control the spread of disease. My assessment is that they are underscoring the need for individualized precautions and patient care. Social connectivity is essential for the patient who is at high risk of mental illness, while an immunocompromised patient might benefit more in isolation. A dilemma arises because those with heightened risk of experiencing a trauma, such as an immunocompromised patient, are the ones most likely to experience adverse mental health – like anxiety, depression and suicide – during and after the trauma.7 When this dilemma does arise, health care providers should educate the patient on the virus while attempting to understand what the patient values most, whether that’s their mental or physical health. Are health care providers practicing beneficence and non-maleficence when counseling a patient with pre-existing depression and anxiety to follow stay-at-home orders? Are hospital facilities really respecting patient autonomy by denying visitors, especially at during end-of-life care? Social distancing does not have to equal social isolation. During this time of crisis, social support can be maintained via telephone and video chat, such as Zoom or FaceTime. Virtual religious services can still take place, with both live stream and pre-recorded options. The media can help by distributing suicide hotline information and showing advertisements that prompt viewers to check in on their own mental health. Physicians should utilize the already established resources to combat negative health outcomes during the pandemic, such as telehealth services. Every patient encounter, not just one’s with a psychiatrist, can serve as an opportunity to monitor a patient’s mental health status. Online resources that are designed to detect and provide care for basic mental health conditions are available. Now is the time for primary care physicians to ensure that a referral pathway to mental health specialists is in place at their practice. It is undoubtedly difficult to tell whether the benefits of self-isolation to physical health outweigh the harm to mental health, but the medical community has and must continue to raise red flags that the fight against one pandemic might be creating several others. MAG members are encouraged to submit their ethics articles and comments and questions to David Baxter, M.D., FACP, at baxter_jd@mercer.edu.

References

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7. Reger, M.A., Stanley, I.H., & Joiner, T.E. (2020). Suicide mortality and coronavirus disease 2019 – a perfect storm? JAMA Psychiatry. https://doi:10.1001/jamapsychiatry.2020.1060 Joiner, T.E., Van Order, K.A., Witte, T.K., Selby, E.A., Ribeiro, J.D., Lewis, R., Rudd, M.D. (2009, July 31). Main predictions of the interpersonal-psychological theory of suicidal behavior: empirical tests in two samples of young adults. Europe PMC. 118(3):634-646 . doi:10.1037/a0016500. Mannix, R., Lee, L.K., & Fleegler, E.W. (2020). Coronavirus disease 2019 (COVID-19) and firearms in the united states: will an epidemic of suicide follow? Annals of Internal Medicine. https://doi.org/10.7326/M20-1678 Azar, A.M. (2020, May 21). We have to reopen – for our health. The Washington Post. https://www.washingtonpost.com/opinions/reopening-isnt-a-question-ofhealth-vs-economy-when-a-bad-economy-kills-too/2020/05/21/c126deb6-9b7d11ea-ad09-8da7ec214672_story.html?fbclid=IwAR3WXJ14eeKqzOPeRddGmN_ jOlqZTAP9DqoBWoIfKJIfbEhkSONhgEU4HlM VanderWeele, T.J., Li, S., Tsai, A.C., & Kawachi, I. Association between religious service attendance and lower suicide rates among US women. JAMA Psychiatry. 2016;73(8):845851. doi:10.1001/jamapsychiatry.2016.1243 Olsen, T. (2020, May 20). Doctors raise alarm about health effects of continued coronavirus shutdown: ‘Mass casualty incident’. Fox News. https://www.foxnews.com/politics/doctors-raisealarm-about-health-effects-of-continued-coronavirus-shutdown?fbclid=IwAR0rEvY3eEMlqZ HE2KcZVgPrw1YMLq4oQLq_yByDvLk1EV8sVqApGWXad3w Centers for Disease Control and Prevention. (2020, May 14). If you are immunocompromised, protect yourself from COVID-19. CDC. https://www.cdc.gov/ coronavirus/2019-ncov/need-extra-precautions/immunocompromised.html

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