Journal of Psychiatry and Cognitive Behaviour (ISSN: 2574-7762)

review article

Is COVID - 19 Pandemic Creating a Perfect Storm for Suicide in Vulnerable Population? Possible Ways for Patients to Cope and Measures to Mitigate Risk

Monica Halappanavar* and Ruchita Agrawal

Seven counties services, Louisville, KY, USA

*Corresponding author: Monica Halappanavar, Seven counties services, Louisville, KY, USA

Received Date: 19 September, 2020; Accepted Date: 24 September, 2020; Published Date: 30 September, 2020

Abstract

The COVID 19 pandemic has taken the world by storm and is on an unabated path of destruction. Its manifestations are farfetched. From disruption of normalcy to an economic slowdown, it has impacted people from all walks of life. There is increasing evidence regarding a spike in depression and anxiety in the general public due to the Pandemic and its negative impact on the daily lives. Handling stress related to the Pandemic, and its repercussions, is in no means an easy task for a common man, let alone for those with mental health disorders. The anecdotal evidence has been pointing towards an increase in Suicide in highrisk populations. The crisis is real, and efforts should be focused on alleviating the risk in vulnerable populations. Educating and training patients to cope with the rapidly evolving situation, restructuring their thought processes, and utilizing healthy coping skills, could keep them from slipping through the cracks. Communities/agencies need to work on strategies and policies that have been proven effective in preventing Suicide. There is increasing need for new measures to keep up with the emerging demands and challenges due to evolving situation.

Keywords

Coping Skills; COVID-19; Means Restriction; Measures and Policies; Risk Prevention; Suicide

Introduction

We are currently going through stressful and confusing times, and there is no denying that. The COVID -19 pandemic has rattled the entire globe. Who would have expected that the outbreak that took its roots in Wuhan, China, would travel all the way and knock on our doors? The entire world is grappling with an unprecedented crisis. This crisis has exploded exponentially. We are currently battling an invisible enemy that continues its relentless devastation. The repercussions the COVID -19 pandemic has had on behavioral health is profound. With the progressive surge in the number of COVI-19 cases, it appears that the situation is here to stay. Along with the increased rate of depression and anxiety over the ongoing Pandemic and uncertainties, there is an increased vulnerability for Suicide in those with mental health disorders. According to the CDC data, Suicide is the 10th leading cause of death in the United States and has been on the constant rise in the past decades. Although there are no updated 2020 statistics on suicide rates, the evidence suggests a surge in the number of suicides during the current Pandemic, and there is data supporting increased suicides in previous pandemics [1]. The risk for suicide increases 5-15-fold in patients with mental health disorders than individuals without mental health disorders [2]. The presence of a life stressor is a precipitant for Suicide, and the current Pandemic appears to have created the perfect storm.

The Deleterious Impact of Pandemic

The magnitude of the impact of COVID -19 is enormous and farfetched. The COVID -19 restrictions imposed to mitigate the spread of infection have caused several disruptions in our daily lives. There has been an economic downturn, job layoffs, furloughs, closing of schools, mandates for working from home, travel restrictions and bans, limitations on social gatherings, shutting down the entertainment industry, and restricted freedom of movement. Each of us has different levels of tolerability to handle stress. Feelings of helplessness, anxiety, and frustration are completely normal in situations such as these. However, for those with pre-existing mental health disorders, who tend to buckle under pressure, the uncertainty has been causing an overwhelming sense of fear and exasperation. These individuals are like a ticking time bomb ready to explode. The quarantine and social distancing has created isolation and lack of opportunities to stay active.

Unemployment has taken a massive toll on the financial stability of the families who live paycheck to paycheck. Paying rent, falling behind on bills, not being able to afford the basic needs have created a state of distress on individuals who are already struggling. Those that are having to work from home are having to make several adjustments, creating further stress. Working from home may not be feasible for everyone. Handling these transitions can take a toll on those with mental health disorders. There is a need to balance work and home life when managing an online school for kids and work from home. Disruption of routine, and transitioning to a new norm, could be overwhelming, making patients with mental health disorders succumb to pressure. There has been data suggesting an upward tick in domestic violence and alcohol consumption, exacerbating the risk for suicide [1].

Individuals with mental health disorders, who are Medical professionals, and front-line health care workers, are fearful of possible exposure to the virus and succumbing to the illness. Working in a high-stress environment for hours and going back to their families, with the fear of contracting COVID-19 and stressing about passing it on to their family members, takes a toll on individuals’ emotional stability. Those living in remote places with already limited access to mental health services, are being deprived of opportunity for continuity of care, due to lack of technology such as telemedicine services. Patients needing help with their suicidal tendencies may not visit the emergency room due to the worry about contracting the virus. All-encompassing, there is restricted access to services and places they priorly had. For some patients, meeting family members or going out are the only means of entertainment, which the COVID-19 Pandemic seems to have severed. Are there changes patients can adapt, so they don’t get overwhelmed to the point of giving up?

Restructuring one’s thought process to making lifestyle changes and adjustments in routine, there are several changes one can make. These changes could potentially ease stress, anxiety, and provide comfort and purpose to move on rather than letting oneself drift into the slippery slope of negativity.

Possible Ways to Cope

Acceptance and Mindfulness

Acknowledging, and developing a positive attitude towards a situation, provides a sense of ownership. The current Pandemic is indeed a stressful situation; however, thinking on whether one has control over the current situation could help accept the experience nonjudgmentally. Focusing on things that we have control over, rather than worrying about problems that we have no control over, is crucial. “Perception is a key component to gratitude, and gratitude is a key component to joy.” Being thankful for what we have and keeping a positive attitude are healthy ways to cope. It is easy to get carried away and lose ourselves in negative thoughts, which could exacerbate anxiety. Staying grounded and being mindful helps gain back the stability and equilibrium of mind. Acceptance is proven to be effective in ameliorating the causes leading to suicidal behaviors [3].

Thought Restructuring

Instead of considering the current situation as a burden, those not employed can invest time on improving their lifestyle. One can make time for exercising, take up small projects, and could focus on them. It is essential to channel energy the right way. Making positive affirmations such as telling oneself that this is not going to last forever and will get through this, it is just a matter of time, are just some ways to be assertive.

Making Healthy Lifestyle Changes

Establishing a routine and having a structure to the day is essential. Although we don’t have control over the outside world, we can establish a schedule for ourselves. Knowing what’s going to happen next gives a sense of control and keeps us from feeling helpless. Setting a sleep-wake routine, taking a shower in the morning, dressing up like you are going to the office, rather than just staying in pajamas, can make a significant positive impact on your life [4]. We need vitamin D. Research has proven the importance of sunlight. Opening blinds, pulling up curtains, and letting fresh air in are healthy practices. Exposure to sunlight increases Serotonin release, a neurotransmitter in our brain [4]. Serotonin is implicated in boosting mood and keeping us calm. Focusing on eating healthy and getting enough rest is paramount. Healthy eating will not only keep our mental balance but also boost immunity. It is essential to keep the media exposure to minimal and credible sources [5]. Several messages keep circulating on social media, which can be misleading and anxiety-provoking [5]. For someone who is already anxious, constant exposure to media about the Pandemic may be nerve-wracking. It is the fear of being out of control and uncertainty that triggers anxiety. Instead of watching news about the deaths, how bad the spread is, watching something that could lighten up the mood, and divert attention from Pandemic could be a much-needed diversion.

Taking time out for yourself is crucial

Having “me time” helps refresh and recharge. Listening to music, walking on a treadmill, taking walks in parks are some healthy ways to destress. Little things go a long way. The practice of deep breathing, yoga, and meditation have proven benefits. Because exercise, yoga, and meditation release endorphins, which are feel-good hormones. Talking to friends and other family members on the phone, planning a virtual meeting on weekends could keep one connected with friends and family. Ensuring a healthy diet and plenty of rest to keep up with the daily challenges are crucial. When it comes to the division of chores at home, communication with spouse or partner is critical. Avoid unnecessary tensions and arguments by chalking out a plan as to who does what. Taking time out for kids amidst working from home could be challenging, as it requires striking a balance between work life and family life. Along with working from home, there is an additional responsibility of taking care of kids’ schoolwork, online learning, and other activities. Having to deal with the stress of work and home life overlap seems like a herculean task. To keep up with this dual role, one requires flexibility and compromises. Discuss and divide your time to spend with kids. Helping kids with their schoolwork and spending time with them is vital. In challenging times prioritizing goes a long way. It is okay to lower expectations of oneself. There is only so much one could do; There is no need for perfectionism all the time. The higher the bar one sets for themselves, the more overwhelming it could get. Setting realistic goals, make it more achievable. If practiced and followed diligently, the above suggestions could alleviate stress and keep one from slipping into despair. Transitions are hard but bringing positive changes to routine and lifestyle can be life-changing and is warranted for the current situation.

Measures and Policies by Communities and Agencies to Curb Suicide

According to the Suicide Prevention Resource Center guidelines, suicide prevention is a multidisciplinary approach and requires strategic planning [6]. Many organizations have adopted zero suicide initiative. The key to preventing Suicide is identifying individuals at high risk for Suicide and getting them connected to the resources promptly. Possible measures that could be taken by an agency or by a service provider during the COVID situation to prevent the vulnerable population from slipping through the cracks. Telehealth services for behavioral health have been in demand. Research from the University of Zurich has demonstrated equal improvement in depression for patients receiving face-to-face services and online therapy [7]. What makes telehealth popular is its ease of access. With the internet availability and either a phone or a laptop, a provider can deliver services to patients in any remote corner of the world. This typically, benefits patients who have poor access to health care and needs to travel for distances or have transportation issues.

Increasing telehealth services can facilitate contact between providers and the patients needing assistance, especially in the COVID-19 Pandemic, where restrictions have limited the easy accessibility to in-person visits. “A stitch in time saves nine.” When it comes to suicide prevention, timely intervention is an absolute must. Many patients who are experiencing suicidal ideations, and needing help, fear visiting the emergency room because of the potential for risk of contracting COVID and may avoid reaching out or going to the emergency room. Setting up separate waiting rooms for behavioral health patients may alleviate this fear and prompt them to each out. Research studies have focused on successful interventions for suicide prevention. At every followup visit, clinicians and prescribers need to be vigilant regarding patients changing mental status and take appropriate measures to address the immediate issues. Flagging the charts of patients at high risk for Suicide will keep the providers on an alert. Screening patients for suicide risk and developing a safety plan, customized to each individual, is pivotal.

Crisis response planning is an effective strategy. Since every individual is unique, trying to know the warning signs, their support system, and developing coping strategies catering to individual needs, have proven to mitigate the risk for suicide [8]. Circumstances may change rapidly; updating the coping strategies and reviewing with patients are paramount. One of the most crucial aspects of preventing Suicide is restricting access to means. Means restriction counseling by providers should be emphasized. Ensuring the safe storage of firearms reduces the Risk of Suicide.

Family members need to be engaged and kept aware of patients’ vulnerability and ensured that the guns are removed from their possession and secured away. Stringent laws and regulations, and restrictions on possession of lethal weapons by individuals who are high risk, could be effective [9]. It is of equal significance to ensure safe storage and monitoring of prescription pills. Service providers and family should exercise due diligence in ascertaining that patients are not stockpiling their medicines, especially highrisk medications such as benzodiazepines, which are commonly prescribed for patients with anxiety and pose a significant risk for overdose deaths [10].

Individuals with risk for Suicide should not have easy access to cleaning supplies, or other harmful products, such as pesticides, which are typically used in overdose deaths. In addition, bringing awareness to patients that they do not have to suffer abuse from their spouses, partners, or family member and that they can seek help gives them a sense of security and hope. Often, patients are unaware of the available resources, making them feel isolated, lonely, and helpless, succumbing to the crisis. Educating patients about the possible resources is of utmost importance. Providing patients with resources such as contact information for a suicide hotline, domestic violence hotline, and those needing assistance with substance use crises is of prime importance. Creating fliers, tear-offs, handouts, cards with crisis information goes a long way besides a safety plan, as individuals with the above crisis are vulnerable for Suicide. According to research studies, public awareness campaigns have proven successful and beneficial in reducing men’s suicide rates [11].

Other possible ways of potentially reducing the risk for Suicide are decreasing wait time on a suicide hotline, increasing the number of counselors available, answering and providing comfort and reassurance when a person in need is trying to reach out for help. The individual at risk needs a few words of compassion and expression that someone cares at their weak moment for all you know. Caring and supportive words could uplift the spirits and may change one’s decision to put an end to life, preventing the dreadful from happening. Family members need to stay vigilant and be on the lookout for individuals with increased risk for Suicide. The family should make efforts to visit or stay in touch with individuals at risk via audio or video call. In the event of failure of a patient to keep appointments, leaving a message indicating their missed appointment, and providers intent on following up soon gives a sense of hope and security.

Especially for those at increased risk for Suicide, making a caring contact call before the end of the week, assigning a simple task, or having them come up with a small project to do over the weekend gives them an engaging activity. Following up with patients if they were able to accomplish the tasks, and providing feedback, makes them feel accountable. If a patient is not reachable by phone, sending a caring contact card or letter indicating “we care,” and “we are here for you” could make a day and night difference in someone’s life. A randomized control study conducted by Motto demonstrated that those who received caring letters intervention had a lower rate of Suicide and suicide death than those who did not receive the caring letters [12].

Failure to reach patients with repeated attempts should not be taken lightly. Requesting a wellness check by the police, sending caring contact cards are reasonable options. From the government, private sectors and foundations, grants, and funding could be of immense help in implementing emergency response for suicide prevention. Assistance with housing and employment are other ways to support individuals that are at risk for suicide. Government and public health should collaborate with mental health organizations in bringing policies and measures that focus on suicide prevention. On a small scale, for those struggling to make ends meet due to a job loss and going through difficulty keeping up with basic needs, such as food, or medications, wraparound funds by an agency is a plausible.

Conclusion

COVID-19 Pandemic is a rapidly evolving situation, with a lot of uncertainty. Trying to deal with a crisis such as this is a daunting task, which could overwhelm anyone. Change is constant, but keeping up with the demands and challenges that come with the changes, demonstrates one’s strength and resilience. In order to keep up with the ongoing challenges, we must implement changes and make amends to cater to the present needs.

We must provide education and necessary tools to the patients that need assistance and make them aware that Suicide is not the solution to their problems, and there are better ways to cope. We must work closely with our fragile patient population to provide them the necessary support in developing more meaningful solutions and strategies that can keep them from sliding down the hill. If we can change their negative perception and instill hope and belief that there is light at the end of the tunnel, we are making significant progress towards suicide prevention and zero Suicide.

Behavioral health organizations, Public health, and the government should collaborate to assist those in dire need of help in these trying times. There are no cutting corners when it comes to patient care and safety. Many times, when we look in retrospect, following the loss of a patient to Suicide, we ponder as to whether a particular intervention at the right time could have saved a patient’s life. Exercising due diligence is of utmost importance. Necessary steps should be taken even if there is the slightest hint that the patient has the potential to harm themselves. We need to make every effort to support and protect our patient population. Risk reduction meetings are beneficial and provide valuable information regarding improvement areas. With combined and persistent efforts, we can avert catastrophe from occurring. As a community, we all need to continue to work towards suicide prevention and zero Suicide. This Pandemic has shown us that we cannot take things for granted, as yesterday’s normalcy seems like today’s luxury. One needs to develop a positive attitude towards life, be thankful for every day, and instill such an attitude in our patient population.



References

  1. Gunnell D, Louis A, Arensman E, Haton K, John A, et al. ()2020) Suicide risk and prevention during COVID-19 Pandemic. The Lancet Psychiatry 7: 468-471.
  2. Windfuhr K and Kapur N (2011) Suicide and mental illness: A clinical review of 15 years findings from the UK National Confidential Inquiry into Suicide. Epub 100: 101-121.
  3. Tighe J, Nicholas J, Shand F, Christensen H (2018) Efficacy of Acceptance and Commitment Therapy in Reducing Suicidal Ideation and Deliberate Self-Harm: Systematic Review JMIR Ment Health 5: e10732
  4. Lambert GW, Reid C, Kaye DM, Jennings GL, Esler MD (2002) Effect of sunlight and season on serotonin turnover in the brain. The Lancet 360: 1840-1842.
  5. Gao J, Zheng P, Jia Y, Chen H, Mao Y, et al. (2020) Mental health problems and social media exposure during COVID-19 outbreak. Plos One.
  6. Suicide Prevention Resource Center.
  7. Telemedicine Improves Access to Mental Health Care. Sources: JAMA; National Alliance on Mental Illness; Journal of Affective Disorders.
  8. Bryan CJ, Mintz J, Clemans TA, Leeson B, T scott Burch, et al. (2017) Effect of Crisis Response Planning vs. Contracts for Safety on Suicide Risk in U.S. Army Soldiers: A Randomized Clinical Trial. Journal of Affective Disorders 212: 64-72.
  9. Andrés Antonio Rodríguez and Hempstead Katherine (2011) Gun Control and Suicide: The Impact of State Firearm Regulations in the United States, 1995-2004. Science Direct Health Policy 101: 95-103.
  10. Agrawal R, Verma S, Halappanavar Monica (2020) Measuring the Effectiveness of Benzodiazepine Prescriptions Control in Community Setting Using Prescription Drug Monitoring Program (PDMP). Community Mental Health Journal.
  11. Matsubayashi T, Ueda M, Sawada Y (2014) The effect of public awareness campaigns on suicides: Evidence from Nagoya. Japan Journal of Affective Disorders 152-154: 526-529.
  12. Motto JA and Bostrom AG (2001) A randomized controlled trial of Postcrisis suicide prevention, Psychiatry Serv 52: 828-833.