There has been a great deal of speculation on what’s to come in mental health and what the suicide rate will be when 2020 is all said and done. Suicidologist Daniel S. DeBrule, Ph.D., Assistant Professor of Medicine and Psychiatry at Baylor College of Medicine, is cautiously optimistic. He says the abrupt shifts in human behavior necessary to halt the COVID-19 pandemic—physical distancing, school cancellations, and working remotely—could result in a number of outcomes. Yes, there are, and will continue to be, adverse effects, but there have also been some benefits, which will likely be reflected in the 2020 suicide rates. He points to Japan, where the number of suicides in April was 20% lower than last year (1,455 compared to 1,814 in April 2019). Japan’s Prime Minister, Shinzō Abe, declared a state of emergency on April 7, which continued in some prefectures until May 25. Kitakyūshū, a city in Fukuoka Prefecture, is experiencing a second wave and has reinstated some of the recently lifted restrictions. A similar decrease occurred in Colorado, USA, where there was a 40% decrease in suicides for March and April. Simultaneously, though, the number of calls to Colorado Crisis Services spiked nearly 48% in March and April compared to the same months last year, with most callers seeking assistance for anxiety, depression, and suicidal ideation.
Dr. DeBrule says both the decrease in suicides and the increase in need in Colorado make sense. People’s lives have been disrupted—they are living with an ongoing fear of an invisible threat and the apprehension or reality of unemployment, which can exacerbate or activate people’s symptoms. Yet, for many people, certain aspects of life have improved. In Japan, in examining why the number of suicides has lessened, experts point to decreases in stress: people spending more time at home with their families and less time commuting to work. Teens in Japan, whose suicide rates have been on the rise in recent years, with bullying and school pressures often a contributing factor, are also experiencing less stress because the start to the academic year has been delayed. Some Americans are experiencing these same benefits. Like in Japan, people in the United States face considerable work-life balance challenges, and bullying and school difficulties present similar hurdles for young people. That said, Nikki Kontz, LMSW, clinical director at Teen Lifeline (800-248-TEEN), shared with us last week that the peer-to-peer crisis hotline in Arizona has experienced an increase in both calls and texts from teens during the pandemic, pointing to the absence of school as part of why.
Because of the coexisting benefits and adverse impacts, what we might see in the data from 2020, says Dr. DeBrule, is an increase in the number of Americans that experience crisis and utilize services but not necessarily an unprecedented surge in deaths by suicide.
What We Can Learn From SARS
Generally speaking, after a disaster, notes Dr. DeBrule, there is a delayed behavioral healthcare demand. The natural phases of recovery often include periods of communities coming together and a sense of abandonment when people’s needs aren’t met. The COVID-19 pandemic has looked quite different from other disasters; it has been ongoing and has been paired with physical distancing, bringing unique features to the disaster landscape. What might give us clues about what’s next for behavioral health is looking at communities impacted by the 2003 SAR pandemic. Just like during the COVID-19 pandemic, people feared contracting the virus, feeling helpless or worried that they or their family members would become ill. Some had trouble sleeping or increased their substance use. People also reported financial stress and feeling isolated.
Healthcare workers and people who experienced SARS faced what was called by some researchers a mental health catastrophe. In one study, researchers examined 90 subjects—all survivors of the virus—and found that the cumulative incidence of psychiatric disorders after the SARS-CoV outbreak was 58.9% (53/90): 25% of the participants experienced PTSD, and 15.6% experienced a depressive disorder. Similar to what Dr. DeBrule has pointed out about the negative and positive impacts of the COVID-19 pandemic, researchers found the same to be true during SARS. Interviewing 818 Hong Kong residents at the end of June 2003, which was toward the end of the pandemic, researchers found that people experienced increased mental health awareness, improved social and family support, and positive lifestyle changes.
While Dr. DeBrule notes that there are lessons to be learned from SARS, the novel coronavirus has been much more widespread: 188 countries or regions compared to 26. Also, the SARS pandemic lasted eight months, while we are already five months into the COVID-19 pandemic, with no end in sight. That said, some places like Hong Kong were similarly impacted. The special administrative region experienced 1,755 SARS cases with 298 deaths compared to 1,113 COVID-19 cases and far fewer deaths, with four people identified as having died from the virus. The comparison highlights most of all, says Dr. DeBrule, that people are surprisingly adaptive in the face of pandemics, even if they are experiencing mental health challenges. He shares the notion that many civilians and veterans he has worked with in the past seem to be adept at responding to the pandemic in some adaptive ways: connecting with others, giving to their communities, and in some cases, simply keeping to themselves. “Some of the clients and patients I’ve worked with and know personally seem to be familiar with and comfortable in relative isolation, particularly men. Even for myself, going back to my high school years, if you can immerse yourself in music, books, and other solitary pursuits, you think to yourself, ‘I’ve been training for times like these for years.’”
Estimated 2020 Suicide Rates: Proportionate Increases Are Likely
In the same year as the SARS pandemic in Hong Kong, there were increases in suicide: 18.6 per 100,000. The age group most affected were older adults, 65 and up. Researchers of the study pointed out that loneliness and disconnectedness among older adults were likely contributing factors. They went on to say:
Maintaining and enhancing mental wellbeing of the public over the period of an epidemic is as important as curbing the spread of the epidemic.
Dr. DeBrule says he has been perplexed by reports that predict an incredible, unprecedented increase in U.S. suicides for the 2020 calendar year. In 2017, there were 47,173 deaths by suicide; the following year, in 2018, the number rose by 1.4 percent to 48,344. That’s an increase of 1,171 additional deaths. Yet estimates for 2020 are forecasted to surpass this. For example, the foundation Well Being Trust and the Robert Graham Center estimate leaps in deaths of despair—the aggregate of suicide together with drug and alcohol-related deaths—in correlation with unemployment rates. For 2020, they predict somewhere between 9,859 to 13,349 additional deaths, depending on the increase in unemployment. “I’ve studied these patterns for well over a decade, and while we’ve seen a troubling increase over the past 10 years of 1.5% to 2% each year, there has been no indication thus far that the final numbers will resemble these recent predictions.” He is hopeful that the actual increase will not be quite as striking and also predicts that it’s possible suicide will not be a top 10 cause of death for the United States for the year 2020.
Many of the high estimates are based on predicting what will happen to the U.S. economy, but foretelling the economic impact of COVID-19 is challenging because it’s still unclear whether the virus will hit in waves, where it will do so, and whether there will be substantial enough breaks in between waves to help mitigate economic downturn. In Hong Kong, the SARS pandemic in 2003 did adversely impact the GDP, but by the end of the year, the GDP returned to pre-SARS numbers, and in 2004, there was slight growth compared to previous years. We also know, points out Dr. DeBrule, that the 1918 flu, which experts often compare the current pandemic to in order to predict what happens next in the U.S., shuttered businesses throughout the nation but did not destroy the economy. The country was already experiencing an economic downturn when the 1918 flu hit, but the stock market recovered during the pandemic. In fact, the Dow index increased by 10.5% in 1918 and then by 30.5% in 1919. The “Great Lockdown” might end up being the shortest recession in history. Again, it’s hard to predict. “Similar market increases to the 1918 flu have been occurring the first week of June, and, during the pandemic of the early 1900s, stimulus checks and governmental assistance did not occur for most Americans.”
Dr. DeBrule says that funding and mental health advocacy is essential during the pandemic, which is what he suspects is behind many of the skyrocketing estimates but notes that doom-and-gloom messaging could potentially have a harmful impact. It also, he points out, fails to factor in the benefits, and corresponding mitigating effects, that have come out of the disaster. Before the pandemic, people who were unhappy often felt isolated and alienated. This trend partially explains why, historically, spring months tend to yield the highest rates of suicide, as some may feel depression or a lack of spring fever amidst the fun and excitement their peers and others seem to experience. Now many Americans feel isolated, he points out, which creates a sense of camaraderie. “When you are isolating and unhappy, and you know that virtually every other person on the planet is too, it’s like, ‘Okay, well, I’m not alone, and many of my friends can really relate.’”