A Clarion Call to Action: An interview with Dr. Roger McIntyre to discuss COVID-19, unemployment, and suicide. by Stephen Douglas

A Clarion Call to Action: An interview with Dr. Roger McIntyre to discuss COVID-19, unemployment, and suicide.

in interview with our Editor

We sat down over the safe distance of video conferencing recently with Dr. Roger McIntyre, M.D., FRCPC, Professor of Psychiatry and Pharmacology, University of Toronto and Head of the Mood Disorders Psychopharmacology Unit at University Health Network to discuss his assessment of the state of mental health in amidst the current COVID-19 pandemic. Here are some thoughts he shared with us:

PSY Hello, Dr. McIntyre. Thank you for joining us today. You recently co-authored a letter to World Psychiatry highlighting the correlation between employment and suicide (McIntyre & Lee, 2020). Could you highlight for us the concern you addressed?

RM It begins with this current situation we’re in with respect to the global threat to mental health. I’ve often referred to it as a “triple threat”: anxiety about the virus, insecurity concerning finances, and the (impact of) quarantine and physical distancing. When we began to see this unfold in the early months of this year, it appeared to me that this was not only a viral pandemic, this was going to be a mental health pandemic. The reason why is that I began to think of lessons (we can take) from history. I specifically wanted to focus on the relationship between (mental health and) the economic shock, which is a consequence of unemployment. We’ve seen about 15 years of job creation eliminated in about six weeks in Canada, which is an unthinkable statistic, and the Statistics Canada unemployment rate is now approaching 14 percent. When we look at mental health broadly, the most robust association between macro-economics and mental illness is the link with suicide. If we go back to the Great Recession (2007–09), the Asian financial crisis (1997-99), and, of course, the Great Depression (1929-33), what we’ve observed is a fairly consistent relationship.

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I call it the “one percent rule”; for every one percent increase in unemployment during these times that I mentioned, around the world in disparate economies there is a commensurate increase in suicide of one percent. Again, association, not causation, but highly replicated.

PSY It’s that consistent, is it?

RM It’s really consistent. And to add further merit to the association, interventions that governments put in place in some economies of Europe and also in Asia, like Japan, to mitigate some of the broader health risks of the economic shock during the Great Recession showed that government expenditures in specific areas reduced mental illness and suicide. So that provides further strength to the association.

Going back over 100 years, the father of sociology Émile Durkheim was a leader in trying to understand, from a social perspective, what contributes to suicide. He had a classic observation in the late 1800’s that people who identified themselves as of Protestant faith had a higher suicide rate than those who identified as of Catholic faith. His hypothesis was that it had something to do with social integration, that Catholics (at the time) were a more integrated group. The notion can be extended to work. When we are working, we not only have more economic security, but we have the framework, we have social connectedness, we have a sense of who we are, a sense of identity around us.

So our analysis, which you made reference to that was based in the United Stated and replicated for Canadian data, effectively replicated the one percent rule. We took into consideration projected unemployment statistics. This included the previous trajectory. Canada has had a fairly stable suicide rate for 20 years or longer, there was an uptick during the Great Recession, as projected by the one percent rule, and then it came back down again. In the United States during the last 15 to 20 years the CDC (Centers for Disease Control and Prevention) reported a steady increase — in fact, about a 30% increase — in suicide rates. The opioid epidemic contributed to this. We needed to take into consideration what the trajectory was before the (COVID-19) shock and build that into the model, along with a few other assumptions. We were able to calculate on both sides of the CanadaUS border a (projected) increase in excess deaths due to suicide, based on a number of assumptions, one of which being where unemployment is going to go. Taken together, it really is a call to action.

We all were concerned, of course, about our physical health during this time, but the World Health Organization identifies health as physical health, mental health, and social health. During the height of the time of the virus we had no choice but to have emergency measures, that’s very clear. I always say, when there is a tornado coming, you better run for cover. But we now have evidence, and the ability to make data-driven decisions. The projection we did on suicide was not just a call to action but also an opportunity to inform policy briefs. What can we do as a society to make sure this (increase in suicides) doesn’t happen? This should not be a fait accompli. There are things that we can do. We learned from the Great Recession that there are things that were done that we can do to get ahead of this.

PSY Suicide rates are highly verifiable, that’s what makes them a really good measure. With our investment, with the Canada Emergency Response Benefit program, it’s not perfect of course, but significantly better than the financial support available in the US, would your model suggest that we will see lower increases in suicide rates?

RM Yes, it’s a great point. The answer is yes. In the United States, when you lose your job you also lose your health insurance. That is a distinct difference between the Canadian employee and the American employee. And that only adds to the insecurity and concern. On the Canadian side, when you look at the federal government’s response with respect to wage subsidies, income support, forbearance on obligation not just for small business but also for tenants, these types of interventions have been shown to not just benefit mental health but possibly also (reduce) suicide.

In fact, during the Great Recession, the Japanese government reported that for every 1% increase in GDP spending that they directed toward health care resources, they were able to reduce (rates of) suicide 0.2% in Japan. So I think what you are hearing from the Canadian federal government is in many ways a ‘playbook’ as to how to do this with respect to the economic provisions, the forbearance on obligation.

Also, what we need to be thinking about is that this event is actually affecting some groups very differently. The face-to-face economy is differentially affected here. And who works in the face-to-face economy? Typically women, as well as people who have less skilled jobs. When you look at the Oxfam survey that came out two weeks ago, in addition to women you have racial (minority) groups being disproportionately affected by this. Moreover, because of the economics, they may not have the advantage of having home support and people to help them out. So women are taking a disproportionate burden here, and people who are less economically advantaged, and minority groups.

So I think there has been a textbook play on this. As we really try to be granular and precise, we really want to make sure we are divesting our activities, not just resources but activities, toward these more vulnerable groups.

The Trudeau government has also allocated significant funding towards more virtual mental health care.

That’s essential, it’s sine qua non, because the mental health care system in this country, let’s call it what it is, it’s been pretty lousy for a long time. It’s really difficult if you have a son or daughter, or you yourself, if you have a mental illness, to get timely access to good care from a mental health perspective. There are pockets that are great, but as a general statement, we haven’t had a very accessible mental health care system and so my hope is that a positive externality of this will be what now appears to be (possible). We’re all digitalized now. This is the opportunity to provide more accessible, high quality coordinated care and psychiatric first aid for people who have mental illness in this country. If you actually break your leg or your bleeding profusely you run to your emergency room, as you should, and many emergency rooms across the country offer psychiatric first aid, but that’s not readily available in a lot of places. So I think that’s possibly a positive externality of this.

PSY So it sounds like you’re hoping to see an injection of some infrastructure to support mental health beyond what we had prior to COVID-19?

RM Absolutely. Said differently, we’re talking about suicide, which is not a mental illness, it’s a tragic behavioural outcome. 80% of people who commit suicide have depression. But depression’s not the only illness linked to suicide. There are others, like post-traumatic stress, drug and alcohol misuse, and others. The mental health care system — before (COVID19) — had not sufficiently addressed in a timely and high-quality way our health needs from a mental health perspective. Now what you have is a threat to mental health and an increase in the rates of mental illness. For example, in the United States there has been a 20% increase in the prescription of antidepressants in the last three months and a 30% increase in prescriptions for anxiety. We did a study in China showing about a 20% increase in depression. The list goes on and on and on. So we already have the early dark clouds of mental illness that are appearing. We have proxies of that. And those illnesses have not, prior to COVID-19 been addressed sufficiently with brick-and-mortar systems. So, yes, I hope that this does result in a reconfiguration of what we’re doing.

It begins with the political will and the prioritization, because the needs weren’t met before and now the needs are greater. So it would seem to me that this is the time to act. And since the world has been forced to go digital, I think we’re there now. I think it can be a game changer for the provision of mental health in this country.

PSY That’s a great vision and aspiration. Hopefully that’s something we can rally all mental health professionals around. You also touched upon mental health indicators that would be less verifiable or less measurable. What are you seeing in the Mood Disorder Clinic that would be correlated to suicide but perhaps might go under the radar?

RM One of the issues that we’re hearing from lots of patients here in the Toronto area is the difficulty in accessing primary care. About 70% of depression care in Canada is actually delivered by family physicians and nurse practitioners, people in the primary care system. And for a variety of reasons, whether people have shut their clinics down or they’re partially shut down as they’ve gone virtual — part of this is people don’t know what’s happening, people are very fearful of going to their local clinic — what many people have been observing is that there has been a reduction in referrals coming from primary care to depression centres. That’s a very concerning paradox here. That’s a health systems issue.

The second part is that among people who do have access, of course (that includes) people who see us (at the Mood Disorder Clinic), what we’re hearing is an intensification of depression. We did another study in China where we looked at the effect of COVID-19 broadly in the general population, and then we began to look at sub-populations.

When we looked at people who had preexisting depression, what we’ve observed is something that probably won’t surprise you; people who have pre-existing depression report a much greater degree of symptom intensification during this time when compared with people in the general population who do not have a pre-existing mental illness. The levels of symptom intensification reported that we capture with various rating instruments in our study are reaching and exceeding the threshold for what we would call clinically significant. One of the features about depression for people who have it is that amongst other things it really interferes with your ability to be more resilient to stressors. In fact, one of the ways that we try to treat depression is that we try to boost people’s resiliency. And people are more susceptible to these types of stressors. Now (COVID-19) is a terrible stressor for everybody, but especially for people who had difficulty adapting to some of the stressors, so this population is a bit more vulnerable.

PSY It sounds like that also suggests there may be a long term tail that we need to be careful about, that after conditions change, after people return to work, we could still be dealing with the aftermath for quite some time.

RM To quote Yogi Berra, “It’s hard to make predictions, especially about the future.” When it comes to predicting the pandemic of mental illness and suicide, many factors can help moderate here. As you can guess, I agree with the thesis that economics is the foundation, the bedrock of all health, not just mental health. If you wanted to predict the future with respect to suicide and mental illness, probably best not to talk to a doctor or a public health official. I would talk to an economist.

The debates go on, is it going to be a V-shaped recovery, is it going to be a W, is it going to be a U, is it going to be all these letters, and who knows. But certainly it’s concerning.

It’s not only the unemployment rate, it’s how long you’re unemployed for. If you’re unemployed for a week, that’s obviously different than if you’re unemployed for two years. In keeping with what anyone would expect, that would be more hazardous.

And we’re seeing some of the predictions coming from the Fed in the US and the Bank of Canada here, we’re hearing measured at best, probably somewhat dour recovery to the economy in the short term. Again, who knows? Let’s hope it bounces back. But that is a clarion call for mental illness priority, because again, economics of unemployment is tightly yoked to suicide and mental illness. So economics as they change positively or negatively, you see the commensurate change in suicide and mental illness.

I think that we’re looking at a tsunami of mental health concerns. Unfortunately, I don’t think that it’s going to be a blip on the curve. This is going to go on for a little while. These aren’t meant to be dour projections, these are meant to say, ‘Let’s be prepared. Let’s modify this.” Patients are saying they’re having difficulty accessing their care provider, having difficulty getting their medications, supply chain hiccups, some provinces enacted 30 days maximum supplies of medications, a lot of patients are reporting feeling very isolated, reporting intensification of symptoms, so all of that is happening right now. But what I’m also hearing from a lot of patients that is a concern is that they’re not working, and not only that but they’ve now been reorg’d out of a job. Their job is gone. And so, in addition to having the difficulties that we’re all faced with, now they have this terrible uncertainty with respect to their economics. So I think we need to get ahead of this, and the evidence has shown that if we do, we can seriously prevent a lot of this. And so, it’s more of a call to action than it is a dour, apocalyptic kind of statement. PSY I hear, within all the negative stories concerning the economic condition, that there is a lot that we can do. Is there anything, before we close, that you would say enheartens you?

RM At this point, what’s really given me a hopeful thought around this is what we learned from the Great Recession. There were social measures put in place, and a variety of other individual measures put in place, that significantly mitigated the risk. So I don’t think we even need to get that creative. Let’s just learn from history and recapitulate what was done, and let’s just make it a priority. I’m starting to see some of this discussion taking place globally. I’m heartened by the fact that mental health appears to be enjoying, for the first time in my lifetime, an international priority of conversation, which I think is a great thing.

PSY Well, I’m glad to hear that, and grateful for your time to share that message with us. As a profession, we can join in the effort to make that happen by being involved in the discussion, and perhaps a little political. Thank you very much for your time.

Reference:

McIntyre, R.S. and Lee, Y. (2020), Preventing suicide in the context of the COVID‐19 pandemic. World Psychiatry, 19: 250-251. doi:10.1002/ wps.20767