"I'm talking about where people suffer massive depression, where people commit suicide, where tremendous death happens… I mean, definitely would be in far greater numbers than the numbers that we're talking about with regard to the virus." (Monday March 23, 2020)
"You're going to lose a number of people to the flu, but you're going to lose more people by putting a country into a massive recession or depression…You're gonna lose people. You're gonna have suicides by the thousands." (Tuesday March 24, 2020)
President Trump brought suicide to the forefront of national discussion in defending the decision to move toward re-opening the economy to stave off a recession. While coronavirus is estimated to kill thousands of Americans, suicide is a perennial public health problem. For that reason alone, continuing to talk about the issue is critically important.
However, the way we talk about suicide matters. Use of phrases such as “commit suicide” have fallen out of favor because they convey stigma about mental health and suicide. That stigma may actually worsen things for people experiencing suicidal thinking by sending messages of blame, and lessening efforts by persons in need to seek help. Guidelines exist to promote responsible reporting and public discussion about suicide.
National leadership’s tone about the topic is not sensible and the narrative is not evidence-based. Sensationalizing suicide, and irresponsibly trying to predict “tremendous” suicide death “in the thousands”, only serves to stoke fear and anxiety, potentially worsening the problem of suicide risk.
The fact of the matter is that assessing the veracity of these basic claims is difficult. Will suicidal thinking, attempt, and death rise during or immediately after the pandemic or a recession? Trump’s statements and relying on recession-based data also presume we will end up with a lingering recession.
What do we know about pandemics, economic strain, and suicide rates?
We could only locate one study addressing the direct matter of pandemic and suicide, which has considerable limitations. Two other recent events we may be able to draw on for insight reach conflicting conclusions. There is modest evidence that suicide rates may drop or remain steady after major events like 9/11. On the other hand, there is some evidence of an increase in recession-related suicide rates. All of these studies are tempered by recent evidence suggesting the field of suicide prevention does little better than a 50/50 coin flip in predicting suicide.
So where do we go from here?
The best approach is a public health prevention model. We need to implement safeguards, from communities, organizations and all the way down to individuals to prevent the worsening of suicide-related behavior in times of unique pandemic and economic stress. A few considerations and strategies during the pandemic are (discussion of suicide prevention post-pandemic is a worthy future discussion):
Theories of suicide and the Centers for Disease Control and Prevention approach to suicide prevention repeatedly highlight the importance of social connection. Social isolation, on the other hand, can worsen suicide risk. Fortunately, technology-based and old-fashioned ways of staying connected exist. Suicide prevention literature also shows that sending caring contacts can help us feel connected. We may send letters or postcards, even electronically, especially to persons we know to be quarantined or otherwise isolated. Those in need of connection can always reach out via the National Lifeline (1-800-273-Talk) or CrisisText (Text “Home” to 741741). We also acknowledge these suggestions may not be possible where challenges exist for vulnerable populations.
Crisis call center funding and support
A public health approach relies on crisis call centers. Interestingly, evidence supports persons reaching out to call centers are often seeking social support or connection. Federal, state and county governments should act swiftly to ensure staffing and funding support as part of any comprehensive pandemic or economic recession planning. More practical guidance on crisis call centers has also been offered.
Firearms represent the most common lethal method of suicide deaths. Since the pandemic hit the United States, gun sales have spiked considerably. Research has shown firearm owners often believe gun ownership is not associated with suicide, and that policies such as safe gun storage may help reduce suicide risk. These studies point to important strategies for suicide prevention such as developing public awareness and education materials through social media and radio platforms, as well as implementing safe storage of firearms. Partnering with firearm sellers in storage and suicide prevention efforts seems to be a promising avenue.
A team of United Kingdom researchers provided a roadmap of factors that may impact suicide during times of economic crisis. They highlighted pathways to suicide beginning with perceived threat of job loss and actual loss (of job, home, etc.) leading to relationship conflict and worsening debt. The financial stresses contribute to poor mental health and coping. In our time of pandemic and economic loss, policy makers should invest in funding of welfare, unemployment insurance and other policies to stem the impacts of job and financial loss. As the U.S. government has just passed an economic stimulus package, it remains clear that strong financial supports to individuals, families, and small businesses is vital when placed in suicide prevention terms.
Enhancing resources for stress coping in the home
Current shelter-in-place orders can certainly hinder our stress coping strategies. We can take a few practical de-stressing steps to limit fear and anxiety. First, in creating a personal schedule, news consumption should be limited to one time per day and from reliable, accurate sources. Healthy eating, regular sleep and other back-to-basics are vital to managing stress at home. A wide variety of enjoyable activities are still possible such as spending time in nature, walking with friends at appropriate social distance, movies, music, and so forth (see here for pleasurable events ideas). Mindfulness shows solid evidence in helping treat conditions such as depression and anxiety. A few free online resources include mindfulness for health care professionals and Mindful.org for easy to implement techniques.
Many insurance companies recently expanded coverage for telehealth, including teletherapy. Publicly available resources exist to help find affordable therapists via telephone or web access. For health service providers treating patients via distance, crisis response planning for persons experiencing suicidal ideation or other high risk problems should include removal of lethal suicide methods like guns. Further valuable telehealth crisis response planning information has been offered.
The coronavirus poses economic, health and other challenges for us all. Suicide is certainly a pressing matter within the discussion. We are all in the suicide prevention effort together. Stay connected, support others, share helpful resources and advocate for smart public discourse and policy.
Rob Cramer, Ph.D. is an associate professor and Belk Distinguished Scholar in the Department of Public Health Sciences at UNC Charlotte.
Jagdish Khubchandani, Ph.D., MPH, MBBS is a professor in the Department of Nutrition and Health Science at Ball State University.