by Dr. Renae Norton
Our lives have changed in many ways recently.
The mental health toll of the coronavirus pandemic is just becoming apparent. It is too early to predict how much of an impact it will have, but there are a number of indicators that can help us anticipate what to expect and how best to manage our own mental health needs, the needs of our patients and the needs of those we love. When it comes to measuring the impact on the mental health of Americans that COVID-19 is having, suicide is probably our best marker.
The coronavirus pandemic is unique as catastrophic events go. It is like floods, earth quakes and hurricanes in that we are helpless to stop it and it kills many people in it’s wake. But it is different from other catastrophic events because we cannot see it coming, we cannot predict who or where it will strike or even if it will strike. It is unpredictable and that causes most of us to feel anxious.
We also do not know how long we will be under attack or what life after COVID-19 will be like. It has the potential to change our status in the world marketplace, our local and national economy’s, and our life expectancy, all in one fell swoop. This makes the future seem very uncertain and we also tend to get emotional when we cannot predict the future on so many different levels.
We do not have many other experiences to which we can compare this pandemic. We have had one other pandemic in the US, the Spanish flu pandemic of 1918. It was the deadliest in the history of the world up to now, infecting an estimated 500 million people worldwide—about one-third of the planet’s population—and killing an estimated 20 million to 50 million victims, including some 675,000 Americans. Obviously we survived that pandemic, and I believe that we will survive this one as well.
That said, so far the US has had the highest infection and death rate worldwide.
New Corona Virus
COVID -19 has infected 5,614,458 worldwide with 1,717,077 of those cases being in the US. It has killed 350,958 worldwide of which 100,800 were US citizens. So despite representing only 5% of the world population, we have had 30% of all the deaths worldwide. Likewise, we have roughly 20% of the cases of infection in the world. The projections for the US are that the rate of infection for the virus will continue to go up for the foreseeable future, while many other nations have been able to flatten the curve of the virus.
Since we aren’t testing enough and we do not have enough protective gear, our best and only real way to combat the pandemic is to do social distancing. In the places where people are doing this, they are flattening the curve, so it is working. In places where they are not doing social distancing, not so much. While social distancing is our best and apparently only hope presently, it does not come without costs.
Isolation, which used to be a sign of emotional instability or depression, is the new normal. “Social distancing” once a symptom, is now a mandate. The problem is that isolating has always been a risk factor for suicide.
Translation? We should worry about the rate of suicide going up over the next 12 or so months.
Mental Health Takes a Hit
The actual toll COVID-19 takes on mental health will not be known for months or perhaps even years. For one thing, COVID-19 may be the gift that just keeps on giving. We really do not know yet if we can contain it and for how long so we also do not know what it is going to cost us in lives lost and economic loss.
Since suicides get reported, and emotional disturbances typically do not, they will probably be our best way of assessing the damage to the mental health of Americans. But tracking only suicides has the obvious limitation of missing the number of cases of emotional pain that do not result in a suicide attempt. The way to think about this is that many people will suffer greatly from what is happening, while only the least healthy, or the most emotionally at risk will invoke a solution as desperate as suicide.
Even using suicide as the marker, we still won’t know for months if suicide is spiking in 2020. In the meantime, there are a number of things that we do know about suicide that could help us predict and possibly limit the damage.
History of Social Isolation
First we can generally assume that those who have a history of social isolation will be more at risk for suicide, so they will need more support during this time. That said, I think it is also important to be aware of how this pandemic is affecting different groups. For example, I treat a population (eating disorders) that tends to isolate normally. Among this group of patients, I have several who have adjusted well to “sheltering in place” because that was the way they were living their lives already. In some cases, it took some of the pressure to be “normal” off of them, effectively making life easier.
One patient even commented “Now that everyone else is ‘isolating’ like me, I don’t feel like such a weirdo. Also, the fact that I can’t go out kind of makes me want to go out. Go figure.” This is called “reactance” which means resisting the pressure to do a thing (stay home) by feeling the need to do the opposite instead (go out).
Suicide Risk May be Different With COVID-19
When it comes to suicide rates most of the researchers looking at communities hit by an earthquake, flood or hurricane, do not find that the rates of suicide go up, or even spike in the years following such events. This came as a surprise to the researchers.
Regarding COVID -19 Dr. Marianne Goodman, a psychiatrist at the Department of Veterans Affairs, in the Bronx said “I think during the actual crisis, suicide will be lower. And once the longer-term economic impact is felt, I suspect, suicide will be rising again.” 
I see her point. Many of my patients are presently feeling as if the emotions that they have been struggling with for years, are now being “shared” by a large portion of our society. They feel a kinship for people they have never even met. A sort of “We are all in this together.” mentality. Instead of being the only terrified person, they are one among many terrified persons. In addition, in many cases, those who suffer from depression and have suicidal thoughts, have already developed coping skills for dealing with them so they are ahead of the game in some ways. So much so, that they have become resources for friends and family who have never had to deal with the debilitating fear or anxiety that can lead to suicidal thinking.
For other suicidal individuals, the threat of dying from a plague relieves some of the pressure to commit suicide. When you are suicidal, the experience is one of having a huge decision hanging over your head all the time. I am not saying that suicidal urges are decreasing, because the little bit of research that has been done since Coronavirus started, tells us that suicidal thoughts are increasing for adults.  To be clear, suicidal thoughts do not usually translate into suicides, as the vast majority of people with suicidal thoughts do not act on the impulse.
Current Health Problems
There are two groups that I think could be more at risk of acting on the suicidal ideation and that is the individual who is more at risk for the virus medically, and the individual who has not developed the coping skills to deal with the added stress of sheltering in place. Medically, men are more at risk, especially older men who are obese, and/or who have one of the co-morbid conditions such as diabetes, high cholesterol or vascular disease. Another group with suicidal ideation who may be more at risk for acting on the impulse are individuals, such as a distraught teenager, who cannot self-sooth and tends to panic easily.
Other groups who may be more at risk are the poor and underemployed.
A definite driver of suicide is economic hardship. Suicide rates in the United States have been rising steadily since 2000 — by 35 percent overall, across most age groups — but the rate of increase roughly doubled in the wake of the 2008 downturn in the economy. Historically, the job losses, evictions, and displacements caused by recessions tend to lead to an increased number of suicides.
According to Psychology Today, the U.S. suicide rate has already increased every year for the past two decades. In 2018, the U.S. suicide rate was at 14.8 per 100,000. This isn’t too far from the suicide rate that we saw during the Great Depression. After the stock market crash of 1929, the suicide rate skyrocketed 50% from 12.1 during the Roaring Twenties to 18.1 per 100,000 beginning in the 1930s.
Fast forward to recent years and the average suicide rate for the years from 2008 to 2018, was about 13.1 per 100,000. Currently, we appear to be heading for the worst economic downturn since the Great Depression. Although no one can really predict what is going to happen or how this will all pan out economically, we can predict that the rate of suicide may go up if the economy suffers huge losses over an extended period of time.
Suicide is Preventable
There are several variables that increase the likelihood of suicide. Knowing what they are can help prevent the act itself. They include:
Unemployment – Unemployment is a well-established risk factor for suicide. In fact, 1 in 3 people who die by suicide are unemployed at the time of their deaths. The unusually high unemployment resulting from the pandemic could therefore increase the likelihood of suicide. I believe it will depend primarily upon how long the rise in unemployment lasts. If it is a short term situation many people will be able to hang on and be OK. The longer it lasts the more damage it will do to our mental health. Currently our government is taking steps to mitigate the damage. That said, the hardest hit are the ones least able to weather the storm financially.
Hopelessness – Suicide often stems from a deep feeling of hopelessness. The inability to see solutions to problems or to cope with challenges life throws at us. Suicide can seem like the only solution. Most of the time the problem is temporary. Most survivors of suicide attempts go on to live full, rewarding lives.
Key Risk Factors – Depression, psychiatric disorders, substance use, chronic pain, a family history of suicide and a prior suicide attempt are all risk factors for suicide. If a person deemed at risk due to any of the above exhibits sudden mood changes—even a suddenly upbeat mood—or completely new behaviors, they may be actively suicidal.
Themes that are common are: Those who speak about being a burden to others, having no reason to live or no one to live for, feeling trapped, or in unbearable pain may be suicidal.
Age – Statistically, suicide occurs most frequently among people ages 45 to 54. Women are more likely than men to attempt suicide; men are more likely than women to complete the act.
You CAN Help
Some people believe that bringing up suicide will trigger it. That simply is not true. Indeed, if you do not bring it up, it is more likely that the individual will make an attempt. It is helpful to have researched the resources available (therapist or prevention hotline) and to conclude the conversation with a plan to follow up with the person on progress being made to find help.
A suicide assessment consists of the following types of questions:
- How are you doing?
- Are you thinking about hurting yourself?
- Are you thinking about dying?
- Are you thinking about suicide?
- Have you come up with a specific plan
- Things a Suicidal Person May Say:
- “I’m just tired.”
This is usually in response to the fact that they sleep all day long. But the translation is I’m just tired of life.
- “I just want to be done.”
Translation: “I can’t do this (life) anymore, it is too hard.
- “I just want to sleep.”
Translation: So I can avoid all contact with other people. It can also mean “sleep forever”.
- “I can’t keep doing this.”
Translation: Most people interpret this to mean work or school or boyfriends, but it can also mean “I can’t keep doing this whole living thing.”
- “I just want to be alone.”
Translation: Most suicidal individuals hate being alone, but they isolate to eliminate reasons for living.
- ” I don’t care.”
Translation: It may sound callous and apathetic, but what it means is I am so consumed with suicidal thoughts, I do not have the mental energy for other things.
- “I can’t imagine living the rest of my life like this.”
Translation – Take this literally.
- “I feel so much better.”
Translation – If all of a sudden, they feel better, even though it looks like a good sign, it can be the end of the road because they have made their decision to take their life and are no longer tormented about making the decision.
Things to Do:
If possible, try to get the individual into a treatment setting voluntarily.
Communicate that you believe them, and that you do not think they are crazy.
Share your love/concern/sadness for them.
Remind them of the people who need and love them.
Help them make a plan to address an issue that is hanging them up
Watching someone you love struggle with suicidal thoughts is very hard…. do not try to do it all alone. A therapist or trusted mental health professional can assist and support in many ways. If you are struggling with thoughts of suicide DON’T WAIT, call the National Suicide Prevention Lifeline at 1-800-273-8255 or contact a mental health professional TODAY!
Dr. Renae Norton
 The New England Journal of Medicine, January 14, 1999, Retraction: Suicide after Natural Disasters
 The New York Times, May 19, 2020, Is the Pandemic Sparking Suicide?
 The New York Times, May 19, 2020, Is the Pandemic Sparking Suicide?
 National Library of Medicine, February 2020, Effect of Economic Crisis on Suicide Cases: An ARDL Bounds Testing Approach
 Psychology Today, Suicide
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Materials contained on this site are made available solely for educational purposes and as part of an effort to raise general awareness of the psychological treatments available to individuals with health issues. These materials are not intended to be, and are not a substitute for, direct professional medical or psychological care based on your individual condition and circumstances. Dr. J. Renae Norton does not diagnose or treat medical conditions. While this site may contain descriptions of pharmacological, psychiatric and psychological treatments, such descriptions and any related materials should not be used to diagnose or treat a mental health problem without consulting a qualified mental health care provider. You are advised to consult your medical health provider about your personal questions or concerns.