Recently the Centers for Disease Control and Prevention released a Morbidity and Mortality Weekly Report (MMWR) of survey data obtained from a large sample (n=5,412) of American adults conducted in June of 2020. The goal of this survey was to investigate the possible impact of COVID-19 on the mental health of this sample.
Since the start of the global pandemic, there has been much speculation in the suicide prevention community and among politicians about the prospect of the impact of COVID-19 on mental health in general and suicide in particular. We will not know anything for sure about the 2020 rate for a couple of years as there is a lag in obtaining mortality data from the National Center for Health Statistics. However, this recent CDC survey is cause for some concern.
One does not need to be an expert suicidologist to have sensible speculations about the possible impact of the worldwide pandemic on mental health. We know across sociological theory, economics research, and general suicide risk factor research that there are many things that could play into the potential impact of COVID-19 on suicidal ideation and rates of completions. Indeed, Durkheim’s notion of social integration would suggest that physical distancing will breed suicidal risk as he believed that our connectedness to each other—or lack thereof—plays a key role in suicidal behavior. There are extensive correlational data about the potential impact of unemployment and economic crises on suicide. Finally, from a suicide risk factor approach, potential increases in anxiety (e.g., fear of getting COVID-19) increases alcohol and drug use, and increases in depression from loss of work or through social isolation could feasibly play into a potential increase of suicidal thoughts and behaviors.
For my part, I was in the camp of those who thought there would actually be an initial resilience response, perhaps even a suppression of death by suicide. Back in February, March, and April there was to varying degrees (and some notable exceptions) some sense of shared commitment to following the recommendations of public health officials to maintain physical distance, wear masks, wash our hands, and not touch our faces. And while reliance on these practices around the world have shown a generally positive impact on flattening the curve, the U.S. has struggled (to say the least). We quickly reached our saturation point of living by the public health rules, and these simple scientifically-based recommendations became politicized – and, well, we have frankly struggled with our inability to flatten the curve of infection and the scourge of 180,000 deaths (at the time of this writing).
Without question, suicide as a cause of death will be bumped from the 10th leading cause of death as COVID-19 is quickly closing in on heart disease as our #1 killer (200,000+ deaths in 2018). But being bumped to the 11th leading cause of death because of COVID-19 is nothing we ever could have imagined back at the start of this year.
So, the question is: will we have a double tragedy? Will we have a massive death count due to the novel Coronavirus PLUS a spike in suicide deaths secondary to the brutal pandemic?
Well, I am sorry to say that the data from the MMWR are worrisome. According to the survey, 40% of the sample reported struggling with their mental health or substance abuse—40%! In comparison to previous control years of survey data obtained at the same time, in June of 2020 we see that symptoms of anxiety and depression have increased 31%. The report notes that trauma/stress-related symptoms are up 26%, and starting or increased use of substances is up 13%. Moreover, 11% of the sample seriously considered suicide in the 30 days that preceded completing the survey.
It is particularly alarming that young adults (18-24) were markedly higher in their suicidal ideation, with 25.5% reporting serious thoughts. Also worrisome are the suicide ideation results for other subgroups: Hispanic rates of ideation were 18.6%, rates for black respondents was 15.1%, for essential workers the rate is 21.7%, and for unpaid caregivers of adults the percentage with serious considerations of suicide is a staggering 30.7%! For young people in the June 2020 survey we see a stunning doubling in their consideration of suicide vs. similar survey data obtained in 2018 (10.7% vs. 4.3%).
As I fully absorb the implications of these survey findings, I feel dumbstruck. How bad is it ultimately going to be for those who struggle until we have effective vaccines and develop herd immunity? I shudder at the thought.
At this juncture many cautions should be noted about such survey research. Everything I just described from the MMWR are correlational data based on self-reports. One is taught early in statistics that correlation does not equal causation. Moreover, self-report data are also problematic for various reasons—demand characteristics and people have been known to exaggerate or minimize what is really going on, which is a central issue of internal validity. And just because psychopathology and the contemplation of suicide is markedly up in comparison to previous years, it does not mean that this will all translate into increased deaths by suicide. Nevertheless, these data should give us serious pause.
We shall see what the ultimate impact of COVID-19 is as the years pass. No one has a crystal ball. Being in the camp of thinkers that anticipated an early suppression with resilience response, many of us further believed that after an initial suppression effect that other suicide-related “shoes might drop” some months out as the cumulative effect of public health fatigue, social disconnection, and a struggling job market and economy have their inevitable impact on the rate of suicide.
All of us may wonder after some years how we will reflect back on these pandemic-wrought days. I will no doubt think back to my long-awaited spring break ski trip to Colorado with my sons the first week of March. With growing COVID-19-driven anxiety after only one day on the slopes, we decided to cancel the balance of the trip and head home to be on the safe side. Upon my return, I learned that we would not be going back to campus following our spring break week as the semester would be finished online. I could never have imagined that a mere 6 months later hundreds of thousands of my fellow citizens and people around the world would be lost to the virus. Mind you, we still are months (perhaps years) away before life returns to “normal” after vaccines have their impact and the curve is flat.
One of the things I know I will reflect on with gratitude and some measure of pride was our immediate response in early March to be a part of the pandemic solution, at least as it relates to clinical suicide prevention. Within CAMS-care we quickly made all of training entirely accessible online. We promptly hosted a series of free Zoom presentations on how to provide CAMS via telehealth (here and here) along with additional free resources for providers. We published a “fast track” journal article and three ongoing randomized controlled trials of CAMS had to be reconfigured to deal with the impact of the pandemic.
Given the recent CDC data, I am glad that we moved quickly to be ready to help make a difference in hopefully averting the potential double tragedy of lives lost to COVID-19 and to any pandemically-related suicides that might respond to suicide-focused evidence-based care.