COVID-19 proves that suicide is much more than a personal struggle

As the United States settles into fall, fears that the coronavirus pandemic will worsen are coming true. Infection rates have spiked in the midwest and Great Plains. There's a resurgence of COVID-19 in several neighborhoods in New York City, where restrictions tamed the virus' spread after a tragic spring.

Yet mental health experts are also deeply concerned about another worrisome trend. An article published this week in the Journal of the American Medical Association described a "second wave" of mental health and substance use disorders that threaten to inundate and overwhelm the healthcare system. Its authors, who are psychiatrists at the New York University Grossman School of Medicine, expect the surge to bring increased deaths from drug overdoses and suicides.

Deaths of despair and suicides have risen in recent years, and the pandemic has only intensified risk factors for substance use and suicide, which include social isolation, loss, and limited access to mental healthcare.

At the same time, the pandemic is revealing something critical about the nature of suicide, in particular. People, who may or may not experience mental illness or a mental health condition, can feel hopeless enough to take their own lives partly because they see no escape from circumstances that may deprive them of basic needs like food, shelter, and healthcare.

This complicates the widespread notion of suicide as the product of experiencing a mental illness or mental health condition. Through this lens, suicide is often considered a personal battle, and many people look to psychotherapy as a solution, minimizing the effect of external factors. The pandemic, however, has drawn attention to the role of policy choices like temporary protections against eviction, the linking of employment to health insurance, and the arbitrary suspension of federal pandemic unemployment payments in July, all of which have arguably intensified people's despair.

For many Americans, the future is bleak. The number of people living in poverty increased by 8 million since May, according to new research. Suddenly, people are trying to navigate long-term or permanent unemployment, housing instability, and hunger, in addition to feeling angry, isolated, anxious. Countless people are also grieving the loss of loved ones to COVID-19.

Signs of deteriorating well-being are evident in recent surveys and polls. When researchers from Johns Hopkins Bloomberg of Public Health analyzed data collected in March by the Pew Research Center, they found that more than one in four adults in the U.S. with no previous history of a mental health condition experienced psychological distress early in the pandemic.

In June, 11 percent of people who participated in a Centers for Disease Control and Prevention survey said they'd seriously considered suicide in the last month, a sharp increase compared to 2018 data. Essential workers and respondents who were young, or Black, or Hispanic, or unpaid caregivers were significantly more likely to report suicidal thinking.

While suicide is caused by multiple factors, efforts to explain a person's risk often begin and end with a discussion of whether they'd been diagnosed with a mental health condition like depression, anxiety, or post-traumatic stress disorder.

Historically, people haven't taken seriously how factors like income, food insecurity, housing, employment, and racism might influence suicide risk as both chronic and acute sources of stress, says Dr. Ashwin Vasan, a primary care physician and CEO of Fountain House, a national nonprofit that developed a community-based approach to mental health recovery known as the clubhouse model. The pandemic is making that connection.

"If you don't know how you're going to make rent next month, that's a pretty big stressor on your mental health," says Dr. Vasan, who is also a professor at Columbia University's Mailman School of Public Health.

"Clearly there's an effect on people's hope for the future...," says Dr. Vasan. "[T]here's an idea that there isn't a better tomorrow out there, and there's no hope of making it better."

Dr. Vasan says suicide prevention in the midst of the pandemic should prioritize early identification and intervention for those at risk, including seniors, people of color, and those with pre-existing mental or physical health conditions. This would mean widespread screening, permanent access to telehealth treatment, and billions of dollars from Congress to, in part, rebuild a mental healthcare system that's fragmented, underfunded, and cannot provide consistent care to more than 100 million people who live in areas with a shortage of professionals.

Dr. Christine Moutier, a psychiatrist and chief medical officer of the American Foundation for Suicide Prevention, detailed a comprehensive public health plan for reducing suicide risk during the pandemic in a new article for JAMA Psychiatry.

The recommendations reflect the CDC's prevention approach, which includes strengthening economic supports to improve financial and housing security. This broader holistic framework also counts employment and food insecurity as critical aspects of economic stability.

Dr. Moutier noted in her article, however, that increases in suicide rates aren't inevitable and that while financial strain is a risk factor, it's not predictive of suicide on its own.

In an email to Mashable, Dr. Moutier wrote this moment can help teach the average person that "suicidal struggles and behavior are not matters of personal weakness but relate to health, genetics and stressors going on [in] their lives and in the larger culture."

While it'll take years of research to determine the relationship between the pandemic and suicide rate, there's some evidence that policy matters. A handful of studies suggest that increases to the minimum wage may reduce the suicide rate. Studies also found an association between the foreclosure crisis of 2008 and increased suicide, making clear the importance of prevention strategies that keep people in their homes and support them after an eviction.

Other types of policy appear to affect suicide risk as well. The Trevor Project, a suicide prevention organization focused on lesbian, gay, bisexual, transgender, and queer youth, recently found that Latinx LGBTQ youth were 30 percent more likely to report a suicide attempt in the past year compared to their non-Latinx LGBTQ peers. Dr. Amy Green, a clinical psychologist and director of research for The Trevor Project, says the increased risk was linked to the young respondents' fears of deportation or detainment for themselves or family members, due to immigration policies. She sees a similarity in past research that observed a drop in the youth suicide rate following the passage of state marriage equality laws.

Dr. Green says such findings should prompt us to rethink suicide risk.

"There's often an idea that something can be done to change the person, to put the onus on the person to deal with the thoughts and feelings of suicide," she says. "In this case, when we have something like immigration policy...part of it is acknowledging it, not saying your fears are unfounded."

Since the pandemic has disproportionately affected Black and Latino families, Dr. Green argues that suicide prevention measures targeting LGBTQ youth of color should reflect the need for housing, food, and unemployment benefits. She says it's critical that those youth can access culturally competent mental health providers who can help them find joy and develop new strengths without insisting they become more resilient and less sensitive in the face of forces they cannot change, which is a common tactic for some therapists.

Dese'Rae L. Stage, a suicide attempt survivor, loss survivor, and creator of Live Through This, an initiative that documents the portraits and stories of attempt survivors, has long resisted the argument that suicide and mental illness are irrevocably tied to each other. She believes it creates the impression that people who aren't affected by mental illness aren't vulnerable to suicidal thinking and behavior.

Stage, who is currently pursuing a masters degree in social work, points to CDC data from 2018 that found more than half of people who died by suicide had no known mental health condition at the time. Though that doesn't preclude the possibility of an undiagnosed condition, the same report noted that many of the people who'd died by suicide also had experienced physical health challenges, a recent crisis, a financial or employment problem, loss of housing, or relationship issue.

"I feel like trauma and despair are reasonable reactions in the world and environments we're [living] in," she says.

Stage believes the pandemic is a chance to advocate for policies that improve people's economic security and well-being while supporting those who are struggling. Helping someone pay their rent, safely providing care for a child, and making dinner for a neighbor who lost their job aren't just kind things to do, says Stage. They could also prevent someone who may be feeling suicidal from losing hope, even momentarily.

"I think we are being given clear opportunities here...to reach out to the people around us and say, 'Are you OK?'" Stage says. "We have that capacity until we can start changing the systems."

If you want to talk to someone or are experiencing suicidal thoughts, Crisis Text Line provides free, confidential support 24/7. Text CRISIS to 741741 to be connected to a crisis counselor. Contact the NAMI HelpLine at 1-800-950-NAMI, Monday through Friday from 10:00 a.m. – 6:00 p.m. ET, or email [email protected]. Here is a list of international resources.