Preventing suicide in the context of the <scp>COVID</scp>‐19 pandemic
Authors: Roger S. McIntyre, Yena Lee
Journal: World Psychiatry (2020)

The impact of the COVID-19 pandemic on the labour market, as well as the government's response to mitigate risk via social isolation and quarantine, has resulted in the greatest and most rapid change in the employment sector ever recorded in the US. Notwithstanding emergency government financial response, it is anticipated that a significant percentage of the labour market will contract1. Moreover, the predicted increase in unemployment is expected to approximate, and perhaps exceed, that reported during the Great Depression lasting from 1929 to 1939 (i.e., 24.9%)2. The foregoing rapid rise in unemployment and associated economic insecurity is likely to significantly increase the risk for suicide. In fact, during the most recent economic recession, a 1% rise in unemployment was associated with a rise in the suicide rate of 0.99% in the US (95% CI: 0.60-1.38, p<0.0001)3. Similarly, each percentage point increase in unemployment was accompanied by a 0.79% rise in suicide (95% CI: 0.16-1.42, p=0.016) in individuals 65 years of age or younger in Europe (e.g., Spain, Greece)4. During the 1997-1998 Asian economic recession, unemployment was a critical determinant mediating the increase in suicides in Japan, Hong Kong, and South Korea5. We used time-trend regression models to assess and forecast excess suicides attributable to the economic downturn following the COVID-19 pandemic. Suicide mortality was estimated for three possible scenarios: a) no significant change in unemployment rate (i.e., 3.6% for 2020, 3.7% for 2021); b) moderate increase in projected unemployment rate (i.e., 5.8% for 2020, 9.3% for 2021), mirroring unemployment rates in 2008-2009; and c) extreme increase in projected unemployment rate (i.e., 24% for 2020, 18% for 2021). The annual suicide mortality rate accelerated in the US by 1.85% (95% CI: 1.70-2.00, p<0.0001) between 1999 and 2018. We found that a percentage point increase in unemployment was associated with an increase in suicide rates of 1.00% (95% CI: 1.02-1.06, p<0.0001) between 1999 and 2018. The suicide rate was 14.8 per 100,000 in 2018 (N=48,432). In the first above-mentioned scenario (i.e., unemployment rate remains relatively consistent), the predicted suicide rates per 100,000 are 15.7 (95% CI: 15.3-16.1) in 2020 and 16.2 (95% CI: 15.7-16.8) in 2021. The foregoing suicide rates would result in 51,657 suicides in 2020 and 53,480 in 2021 (assuming 2019 pop­ulation size of 329,158,518). In the second scenario (i.e., moderate increase in projected unemployment rate), suicide rates per 100,000 will increase to 16.9 in 2020 (95% CI: 16.4-17.5; N=52,728) and 17.5 in 2021 (95% CI: 16.8-18.2; N=55,644). This second scenario would result in a total of 3,235 excess suicides over the 2020-2021 period, representing a 3.3% increase in suicides per year (when compared to the 2018 rate of 48,432). In the third scenario (i.e., extreme increase in projected unemployment rate), suicide rates per 100,000 are projected to increase to 17.0 in 2020 (95% CI: 16.6-17.5; N=56,052) and 17.4 in 2021 (95% CI: 16.8-18.0; N=57,249). This rise in suicide rate would result in 8,164 excess suicides over the two-year period, representing an 8.4% increase in suicides (when compared to the 2018 rate of 48,432). What is especially concerning about our projections is the genuine uncertainty with respect to the labour market post-COVID-19, as well as the tremendous financial uncertainty and decrease in consumer sentiment, all of which are independent and additional contributors to suicide6. Moreover, social isolation and quarantine, which are critical viral transmission risk mitigation strategies, are recommended nation-wide. Social isolation is well established as a significant risk factor for suicidality7. Multiple studies have reported that government policy response can significantly mitigate the increased risk of suicide due to economic hardship and unfavourable labour market dynamics. For example, in Japan, a 1% per capita increase in local government expenditures was associated with a 0.2% decrease in suicide in the years following the 2008 recession8. The Japanese experience was replicated in Europe, wherein government spending, especially on social programs intended to mitigate suicide risk, significantly reduced projected suicides in Denmark9. Preventing suicide in the context of the COVID-19-related unemployment and financial insecurity is a critical public health priority. In addition to financial provisions (e.g., tax deferral, wage subsidy), investing in labour market programs that intend to retrain workers is warranted. Furthermore, government support for employers is critical to reduce the massive increase in unemployment and contraction of the labour market. Proactive public-private partnerships that aim to provide psychological first-aid and psychiatric emergency services to persons at imminent risk of suicide are essential. Individual resilience enhancement strategies should be implemented (e.g., exercise, sleep hygiene, structured daily schedule, better diet). Approximately half of suicides in the US are committed with a gun; recommendations surrounding appropriate gun and ammunition storage are warranted. For persons with clinically significant depressive/anxiety symptoms or persons experiencing features of post-traumatic stress disorder or drug/alcohol abuse, timely access to comprehensive treatment should be part of the COVID-19 management strategy.