As parts of the U.S. express optimism with regard to “flattening the curve” of COVID-19 infection, the national conversation has broadened to include not only reopening the economy, but also the public health toll of coronavirus beyond our nation’s ICUs. As mental health researchers, we have taken note as the discussion has started to include suicide.
While published news reports and commentaries have increasingly pointed to COVID-19’s potential to increase suicide rates — and calls to suicide prevention hotlines have increased up to 800% — some suicide experts maintain this is not a forgone conclusion, and point to historical statistics showing that suicides diminish in times of national crisis. Washington has even chimed in, noting that Americans who commit suicide will need to be counted among the pandemic’s victims.
While the jury will remain out for some time, regarding the pandemic’s ultimate impact on suicide we believe a closer look at the aftermath of the 2002-2004 SARS outbreak, and emerging suicide-related research at the University of Utah, combine to suggest that the issue of suicide and COVID-19 points to something that American health care and research organizations would do well not to lose sight of.
Numerous follow-up studies of the SARS outbreak of 2002-04 have been conducted, and the results are concerning, as nations look toward the recovery phase of the COVID-19 pandemic. For example, three months after discharge from hospital, lung function deficits were detected in half of adult SARS survivors in Singapore. One year after SARS, a study published by the American Medical Association reported that 44% of survivors had seen a psychiatrist, and nearly 1 in 5 were unable to work. In Hong Kong, patients showed impaired overall health after two years, and 30% of health care workers with SARS had not returned to work, suggesting there may be significant losses to our health care system workforce, in terms of front line medical staff and first responders.
In considering the potential for increased suicides in the wake of COVID-19, a synergistic confluence of risk factors has been overlooked. For one thing, the published research does suggest that economic downturns can contribute to increased suicide rates. Indeed, research from 2014 has linked a dramatic spike in North American and European suicides with the subprime mortgage crisis. Another study in The Lancet found suicide rates increased from 2008-2010 some four times faster than in the years prior to the recession.
Adding to the pandemic’s economic and personal stressors, the long-term respiratory and psychological problems described may combine to increase COVID-19’s impact on mental health, depression and even suicide. For example, it has been shown that hypoxic medical conditions impact suicide risk, increasing the odds of suicide up to fourfold. In estimating the cumulative effect of these factors, there is also the distinctive feature of COVID-19, i.e., that severe cases often occur in elderly males with preexisting medical conditions. And because elderly men — and in particular those with social isolation, i.e., the near-universal approach to combating COVID-19 — are already at greater risk for suicide, this segment of the population warrants monitoring, regardless of infection status.
While the extant literature on suicide, with regard to both macroeconomics and hypoxic respiratory disease, points to legitimate concerns in the wake of COVID-19, there is one widely unacknowledged factor: altitude. Our own research at the University of Utah, and that of suicide researchers from Europe, Asia and South America, has suggested that the rate of suicide increases with altitude. The reason for this is relatively straightforward: the brain requires oxygen to function, and living at even moderate altitude dramatically reduces the partial pressure of oxygen in the system. It is well-established in lung disease patients, for example, that this reduction has a negative impact on the brain’s ability to function, making the relationship between altitude, oxygen and suicide an intuitive one.
More than 200 scholarly articles have already been published on the psychological fallout of the pandemic, and international experts have likened COVID-19’s potential impact on suicide to a “perfect storm.” Ours is not the first research group to point to the unmet need for treatments designed to reduce suicide in patients with hypoxic medical conditions. However, as the U.S. and the world enter the rehabilitation phase of this global crisis, while seeking to maximize the lessons learned, there is a need to recognize that among them lies the prospect of transforming science and medicine’s understanding of suicide.
Just as the current global crisis will produce disruptive technologies and previously unimagined innovations in both online education and workplace telecommuting, so too are unprecedented opportunities to study and prevent suicide destined to become available, as the world emerges from the COVID-19 pandemic. Here’s hoping the U.S. will take the lead on this, and remain mindful of leveraging this unique, albeit unwelcome window of opportunity.
Editor’s note: If you or someone you know is in crisis, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Residents of Utah may also seek help through the SafeUT app.
Colleen Fitzgerald, Perry Renshaw, Andrew Prescot, Deborah Yurgelun-Todd, Danielle Boxer and Doug Kondo are suicide researchers at the University of Utah and the Salt Lake City Deptartment of Veterans Affairs Medical Center. This material is the result of work supported with resources and the use of facilities at the VA Salt Lake City Health Care System. The authors’ views are their own.