Experts push against linking suicide, pandemic
Suicide is so much more complex than a straight connection, doctor says
In England, a 19-year-old died in hospital in late March, following a suicide attempt. She was “deeply affected by the pandemic” and felt she “could no longer cope,” according to media reports.
Afew days later, in Germany, a state finance minister took his own life. The economic fallout from the coronavirus crisis and the “population’s huge expectations, particularly of financial help,” had “overwhelmed him,” the state’s governor said.
And last Sunday, a top emergency room doctor who treated COVID-19 patients in hard-hit Manhattan, and contracted the virus herself, died by suicide. Her father told the New York Times, “She tried to do her job, and it killed her.”
In this extraordinary time of loss, sickness, social isolation and economic insecurity, there has been a string of media reports linking the pandemic to suicide. These tragic stories, along with a surge in calls to crisis lines and recent articles in scientific journals arguing that the conditions are rife for a spike, are fuelling perceptions that COVID-19 will trigger a rise in suicides.
But some mental health experts are pushing back against these dire prognostications, which they say are not rooted in solid evidence, with past pandemics providing few clues about how the complex set of factors at play during COVID-19 will influence suicide rates. Rhetoric about the inevitability of suicide carries risks, they say, including reinforcing a sense of hopelessness, and diverting resources away from marginalized groups who have lost access to basic mental health services in the crisis.
They caution against connecting the pandemic to the act of taking one’s own life.
“I really understand why people want to make a direct line to cause when they know something about someone,” said Dr. Tyler Black, a psychiatrist and suicide expert at B.C. Children’s Hospital in Vancouver. “But suicide is so much more complex than that.”
“The rough answer, and this is the tough answer for people who are trying to understand why people they care about died,” Black said, “is that most of the time in suicide, we don’t know why.”
It is right to be concerned about the economic toll of the crisis on communities, said Nova Scotia Sen. Stan Kutcher, professor emeritus of psychiatry at Dalhousie University. However, when it comes to suicide risk, “large blanket statements are unlikely to be correct because there’s just too much individual variability,” he said.
Kutcher is calling for a more measured approach to suicide prevention in the pandemic — one that focuses on providing supports to those he says are most at-risk, including the severely mentally ill, those without access to virtual care and some Indigenous communities, where there were high suicide rates before COVID-19.
“Instead of making stuff up, and saying, ‘Oh my God, the sky is falling,’ we can say, ‘We know what the factors are that put people at increased risk — not just for suicide, but for poor outcomes,’ ” he said. “We can do something about it.”
In Canada, roughly 4,000 people take their own lives each year, according to a 2018 report by the Mental Health Commission of Canada and the Public Health Agency of Canada, making suicide the ninth leading cause of death in this country and a significant public health concern.
There are known risk factors, such as depression, addiction, family history, incarceration, economic hardship, loneliness, time of year (spring and summer) and occupation (physicians, police officer and first responders), the report states.
There is a constantly evolving and improving range of evidence-based treatments for those experiencing suicidal thoughts, including medications, therapy and followup care. In Indigenous communities, traditional healing practices and other community-led interventions can counter the legacies of colonialism that have driven up suicide rates, according to the Centre for Suicide Prevention.
Yet there is still a lot we don’t know about suicide, which is relatively rare and is oftentimes an impulsive act, occurring within a few minutes of the decision, Kutcher said.
As a clinician, he participated in “psychological autopsies,” interviewing friends and relatives to try to figure out what led to deaths by suicide.
“Sometimes you can get a glimmer, and other times you just have no idea,” he said.
In a broad sense, COVID-19, which has triggered lockdowns and upended the economy, has heightened some of the known risk factors for suicide, but “if it is a factor it may only be a factor in a particular person in a particular circumstance, and not for everybody else,” Kutcher said.
At the same time, the pandemic has also introduced protective factors, such as “social cohesion” — the sense we are all in this together — which has historically coincided with a reduction in suicides, said Dr. Juveria Zaheer, a clinician scientist at the Institute for Mental Health Policy Research and a psychiatrist in the emergency department at CAMH, citing the Second World War as an example.
Zaheer said her patients are experiencing the pandemic in different ways.
“I’ve had people who have major mental illness say to me, ‘This is really scary, but this isn’t what I’m most worried about right now,’ ” she said.
Another patient with a history of trauma is sharing coping strategies with friends, she said.
“What’s happening right now is a situation we have never experienced in our lifetimes. It is very difficult to know what the collective impact will be for a while,” she said. “We just don’t have the data.”
(In Canada, it will be a long wait for nationwide numbers of suicides in the pandemic, with Statistics Canada having yet to release cause of death information for 2019. This was scheduled for November 2020, but this date has been pushed back because of limited capacity in the pandemic, with no new date confirmed, a spokesperson said.)
A literature review published last month in the Lancet Psychiatry, which probes the question of whether suicide rates will rise in the pandemic, is one of several recent journal articles to note an apparent link between the 1918 Spanish flu pandemic in the U.S. and an increase in suicides.
However, the connection is hardly conclusive: In the abstract of the paper cited in the Lancet article, the author acknowledges, “Further individual-level aggregate studies are needed to confirm the findings of the study.”
James Coyne, an emeritus professor of psychology in psychiatry at the University of Pennsylvania, who spent a decade in Europe consulting on multi-level suicide prevention programs, said we “should be careful about the relevance of the Spanish flu to COVID-19.”
A century ago, “there were no drugs to treat mental disorder except opium and the ‘rest cure’ to treat nervousness,” Coyne said.
Black, who delved into the historical U.S. suicide data and did not identify a link, said it is not possible to extrapolate from this study and others on suicides during past epidemics, in part because they are so context-specific.
Several crisis lines report a surge in calls during the COVID-19 pandemic. Kids Help Phone is seeing an increase in conversations about suicide in Quebec and Atlantic Canada, said Alisa Simon, senior-vice president of innovation and chief youth officer.
Stephanie MacKendrick, CEO of Crisis Services Canada, which runs a national network of distress lines, said there has been an uptick in “active rescues” by first responders — triggered when a caller is “at imminent risk of harm” or when there is a suicide in progress.
However, Black said crisis lines are not necessarily a bellwether for suicide rates, in part, because research has shown “by far and away, the majority of calls to ‘lifelines’ or ‘suicide distress lines’ … are non-suicidal.”
“We don’t know what’s going to happen to suicide risk,” Black said. “But we do know that people who are underserviced, underprivileged and disadvantaged are going to have tremendous problems in the next few months, and we need to support those people.”
These struggles are top-ofmind for Max FineDay, the executive director of Canadian Roots Exchange, which advocates for the advancement of reconciliation and the well-being of Indigenous youth.
“Indigenous young people are often underserved in almost every way imaginable. Because of that, we suffer. We are often at the bottom of every negative statistical index,” said FineDay, who is from Sweetgrass First Nation in Saskatchewan.
“There’s going to be such a great and dire need for investment in mental health support.”