Drop in Suicides Won't Result in Complacency in Psychiatry

A recent JAMA study shows a decrease in suicide deaths between 2019-2020, despite a 17% overall increase in mortality.

Shockwaves were sent through both the public and the psychiatric community when a March 2021 JAMA report showed suicides were actually down during the duration of the COVID-19 pandemic.

Conventional wisdom from both laypersons and psychiatrists is that the pandemic and the mitigation measures put in place like social distancing and shelter-in-place orders, while effective in combatting the virus, would have a negative impact on the collective mental health of the country.

As the deadly virus ravages communities throughout the country with some estimates having a 20% overall increase in deaths year over year and political and economic strife took hold, it would be hard to believe suicides could decrease.

And while it is undoubtedly true that there will be mental health problems on a wide-scale in the years to come, why did suicides actually decline during such a divisive and difficult time?

From a psychiatric standpoint, the most reasonable explanation is that people, even those with mental health concerns, can really focus during the course of a disaster or traumatic event, but eventually the disaster only exacerbates those types of problems and there is concern that suicides could rise in the subsequent years.

Dealing with a Disaster

“In a state of acute stress, people are somehow dealing with it like in war, there are less suicides because you're just trying to make ends meet,” Christoph Correll, MD, professor of Psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, said in an interview with HCPLive®. “But also, people are not using the help that they should. So, we're basically creating a mental health crisis, every day.”

Ultimately, suicides can be a lagging indicator of a mental health crisis.

And Correll said clinicians are already starting to see some evidence that the mental health crisis might be difficult to manage in years to come.

The JAMA Study

On March 31, Farida B. Ahmad, MPH, National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), and Robert N. Anderson, PhD, National Center for Health Statistics, Mortality Statistics Branch, Division of Vital Statistics, published new data in JAMA showing the totality of US deaths in 2020.

Provisional estimates indicate a 17.7% increase in the number of deaths in 2020 (the increase in the age-adjusted rate was 15.9%) compared with 2019.

Obviously, the biggest difference between 2019 and 2020 was COVID-19 deaths, which went from 0-345,323, but there was also an increase in mortality from heart disease, unintentional injuries, stroke, Alzheimer disease, and diabetes in 2020.

The researchers identified 44,834 suicides in 2020, a reduction from the 47,511 suicides in 2019.

Initial Reports

Certain conditions that are easier to quantify are already showing the impact of the pandemic.

An example of this can be seen in patients with eating disorders, patients who came back to psychiatric services weighing much less than they were before the pandemic.

One explanation for this is people generally have checks in place in friends, family, and co-workers.

But during the pandemic, most of these checks weren’t in place, leading many patients to engage in reckless or dangerous behaviors that are associated with their disorder.

“We see that in the UK, whether it's physical or mental disorders, the use of care is going down,” Correll said. “But that doesn't mean people are healthier. It just means there, they're even doing less than during normal times and that's really problematic, because they should have more attention and get more help, but they get less.”

Psychiatry is Individualized

“Resilience is one of the major factors that come into play regarding suicide risk, and really just mental health and I think this past year has really tested all of us and our resilience,” Anum Iqbal Baig, MD, Charles R. Drew University of Medicine & Science said in an interview with HCPLive. “I think it's challenging. I think some people do have the potential to thrive and maybe can get ahead, but I think during this time, social support and feeling of connection and having access to multiple resources are some of the things that determine that.”

It is challenging to attribute 1 prevailing factor in suicide trends since each patient with suicide ideation suffers from different circumstances and characteristics, including history of past suicide attempts, developmental history, social support, and access to lethal means.

“It's a difficult one to answer because there are just so many factors involved,” Baig said. “Especially, you know, there are multiple factors that determine a patient's risk for suicide, which we always evaluate.”

Baig also said while she was completing her residency in the early part of the pandemic, when was part of a substance abuse rotation.

“I noticed that the patients were really not doing well,” she said. “During that time in July, we were extremely busy. We were doing a lot of telepsychiatry at the time, and I really noticed that a lot of patients were relapsing. A lot of patients were very depressed and with the pandemic going on a lot of them lost loved ones.”

What Can Be Done

While suicides could rise in future years, there are some ways to mitigate the damage.

For one, education can be a key factor moving forward, both for patients and clinicians to help identify early warning signs of suicide ideation. In addition, there should be a public push in instilling hope that the pandemic and other problems are only temporary and there is reason to believe once the threat of COVID-19 has decreased substantially.

Also, an increase in funding to mental health services can help limit some of the damage that may occur.

“At the moment, the resources are going a lot into physical health and, and vaccination and, and we're turning a little bit of a blind eye to the growing mental health pandemic that will basically come,” Correll said.

But the pandemic might offer a chance in psychiatry to destigmatize mental illness, which in part could lead to more patients seeking help earlier.

“We're now not talking just about a subgroup that is depressed or anxious, we’re talking about mental well-being or lack thereof, and stress and depression and sadness is my much more common place. And it's a unifying feature for all of us,” Correll said.