COMMENTARY

New Projections on Suicide, Substance Abuse, and COVID-19

Stephen M. Strakowski, MD; Nassir Ghaemi, MD, MPH; Andy Keller, PhD

Disclosures

May 08, 2020

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This transcript has been edited for clarity.

Stephen M. Strakowski, MD: Hello. I'm Steve Strakowski, and I'm glad to be back with you all again here at Medscape. We are talking today about something that's obviously on everyone's mind: the COVID-19 pandemic, and particularly how it impacts mental health.

I'm the vice dean for research and a professor of psychiatry at the Dell Medical School at the University of Texas at Austin. We, like everyone, are scrambling to address the COVID-19 pandemic. Within that context, we really have started to focus on mental health concerns and events that we have to pay attention to.

I'm very pleased and fortunate today that we have two experts joining me for a conversation about mental illness, and in particular, a couple of major risks that may be arising from this odd circumstance that we're living in.

First, I'd like to introduce Dr Andy Keller. Andy is the president and CEO of the Meadows Mental Health Policy Institute in Texas. This institute is very well known nationally for being a leader in policy toward improving the care of people with mental illness and for helping programs around the state of Texas redesign or analyze their outcomes to improve care. Andy, welcome.

Andy Keller, PhD: Thanks, Steve. It's great to be here. This is a really important topic.

Strakowski: Andy has some interesting data that we're going to look at in a moment.

The second expert I've brought in is Nassir Ghaemi, who is a professor of psychiatry and pharmacology at Tufts University in Boston, which has been heavily hit already by COVID-19. Nassir is an expert in psychopharmacology and the treatment of mood disorders.

He's also written a number of very interesting books that span from clinical psychopharmacology to the lay press, talking about how mental illnesses have impacted and been present in some of the leaders who have shaped our country and the world. He was on Stephen Colbert's show, in fact, discussing that book not too long ago. As I told him earlier, I was impressed that he was able to keep up quite well.

Nassir and I have known each other a long time because we were residents together at McLean Hospital, 72 years ago or something like that. Nassir, welcome.

Nassir Ghaemi, MD, MPH: [Laughs] Thanks, Steve. It's great to be here.

Strakowski: Andy, I know the Meadows Mental Health Policy Institute has been starting to focus on the impact of all the events around this pandemic and that you've done some projections on the risk of suicide because of these events. Could you talk to us about what you have found?

Keller: Yes, Steve, absolutely. It's complicated because there are so many things going on at once. This is really an unprecedented situation that we're all living through. The Lancet published a rapid review a little over a week ago that talked about the effects of quarantine and the effects of social isolation, which I thought was a really nice summary.

There was another review earlier in the week that assessed other factors, such as anxiety about a pandemic. There are multiple things going on, including what looks to be a pretty bad economic recession or maybe even depression, according to some estimates.

What we did at the Institute was to try to sort through that. We picked the variables that we knew we could predict from—the things that we had been through as a society before. The main one is our economic recession. There's a pretty good dataset out there about what economic recessions can do to both risk and prevalence of deaths from suicide and overdose. That's what we extrapolated.

Before talking about the data, it's important for people to keep in mind that all projections are wrong but some are useful. We're hoping this one is useful. There are two ways in which we're sure the projection is wrong. First, we're only looking at one set of variables and there will be other variables, some of which will be negative. There are other variables that are within our control. Primarily, the fact is that suicide is preventable and treatable, and we know how to help people if we can identify them and if we can be available to respond and provide help.

We're hoping that these data help us to be more ready to listen and help or respond when we see signs that someone might be contemplating dying from suicide. The projections are concerning. Basically, what we're showing is a linear frame that goes from our current, pretty high levels of suicide in this country. They've never been higher in terms of rates, but we know that they have the chance to go up.

We posited what a 5% increase in unemployment and a 20% increase in unemployment would look like; 20% is actually less than what the Great Depression experienced, and 5% is around the increase in unemployment that we saw in the Great Recession in the last decade. We're talking about just under 1000 people being lost for every 1% increase in unemployment; 780 is the exact number we projected.

Hopefully we can do something about that and have that actually be lower, just like we did with the COVID-19 projections, which folks may remember looked like they were going to be much worse weeks ago than they are looking now. A big reason for that is that we've done things to mitigate, to respond, to help people, and to prevent more illness. That's what we're hoping to see folks do by looking at these data.

Strakowski: One of the challenges here is that the interventions that we use to decrease the spread of COVID-19 work against helping people who might be contemplating suicide: isolating, withdrawing, and less social contact.

Nassir, I know you've thought about this topic for years as part of your interest in treating people with mood disorders. Tell us what your thoughts are on this, and what are some of the things we should be paying attention to as a society?

Ghaemi: In general, there's an analogy we make, either to natural disasters or to economic depression. In a sense, what we're dealing with today is a natural disaster that's leading to an economic depression. It's really both things.

It's also a different kind of natural disaster, which usually are one-time events, like a flood, a hurricane, or a tsunami. Now this one is ongoing. We've never seen that before, so this is going to be new.

I looked at the natural disaster literature and the economic depression literature, but I think the economic literature applies more because it has more of a longer-term effect. I have this slide here from Milan about the suicide rate after the financial crisis in 2008. What's interesting is that there's a decent literature demonstrating that suicide rates often seem to be elevated in periods where the economy is doing well, like it has been in the US for the past 5-10 years. Economically we've been fine, but the suicide rates have been going up.

In Milan in 2008, if you look at the suicide rate, which is the gray line, it didn't really change after the economic crisis. Despite unemployment rates going up, which is the black line, in this study, the economic situation did not correlate with suicide risk. What did correlate was psychiatric illness and physical disease, which we know are the major risks.

As was mentioned earlier, models are always a little unclear. It may be that we will have an increase in suicide rates with this crisis, which is unique because it's both a biological natural crisis and a financial crisis, but maybe we won't. The Milan data suggest that the population as a whole is very resilient. The risk is for the people we know are already at risk, which are those people with psychiatric conditions or people with chronic physical diseases. Maybe we just need to double our attention to those persons.

I want to mention a couple other things that might be risk factors. As you mentioned, suicide has been a major interest of mine for many years, given that I focus on people with depression and bipolar illness, which are the most important risk factors for suicide.

We know that there is a seasonal pattern where there's increased risk in the spring and the fall. In fact, the months with the highest suicide rates are April and May, which is right now. Now is the time to be potentially concerned. If we have a second peak of the infectious pandemic in the fall, we might find that the rates will start going up then or maybe in the following spring. We need to pay attention to those risk factors.

From what I've read so far, the first published case of suicide related to the COVID-19 pandemic was in Bangladesh. It involved a villager who had been stigmatized by other villagers for being positive. Now there's another case, reported on by the BBC, of a Muslim villager in India who was stigmatized by Hindu villagers for carrying the virus. The person ended up testing negative after he committed suicide.

I also think that perhaps more so in less developed countries where there are other ethnic and religious tensions, there are cultural factors that play into increasing suicide rates.

Strakowski: Those are really interesting points, Nassir. I think they raise the important and critical component of all this work, which is that there are likely to be groups who are more at risk than others, and identifying those risk factors is going to be important.

My big worry in this country is that we already had a dramatic increase over the past 5 years in suicides in young people in the 15- to 24-year-old age group. Those are the same people who I worry about within the context of now being shuttered away from their peers, which is critical at that age. In families where abuse rates are going to now go up, they would have previously been under surveillance or been able to escape. Then, superimposed on top of this is the opioid epidemic in this country, which is also a risk to the young folks, and may be a double risk both from parental substance abuse and from their own.

Andy, what are your thoughts about that? I know you have also modeled the substance abuse problem as a consequence of this epidemic.

Keller: Yes, we have, Steve. I think it kind of fits well with what Nassir was talking about, because one of the things that we've seen with suicide, and that we also see with substance use–related deaths, is that they really vary by community across the country.

When we look at the suicide rates over the past few years—and we've looked at this in different counties in Texas—we really don't see a big change in the urban counties. Where we see the higher rates of suicide that have increased dramatically in the past few years are really in our smaller and more rural counties, which in many cases is where we also are seeing higher rates of substance use disorder. I think that the "deaths of despair" construct, at least in Texas counties, does seem to be the case.

The group you talked about—younger people, adolescents, young adults—are at risk, but then the highest-risk group in the country are people like me, which includes men in their 50s. We're seeing those increases in rural areas. If we take the same economic data, we would expect to see a mix. We would expect in some areas to not see changes and then in others to see larger changes.

We're projecting about 100,000 additional cases of substance use disorders related to the recession, and our data show the projected deaths due to drug overdoses. These are overdoses related to all illicit drugs. It's not only the illicit use of opioids, but also of cocaine and methamphetamine. It doesn't include alcohol. We're still working to try to factor that in, so I think this is probably a conservative estimate.

The increases we're expecting to see are actually larger. The deaths are larger in magnitude than the deaths related to suicide: a little over 1200 additional folks dying for every 1% increase in the unemployment rate, which again is, I'm sure, a wrong projection, but it's something that shows directionality and potential magnitude that hopefully leads us to be more aware in our response.

Strakowski: Thank you, Andy. Nassir, what are the two things we need to be doing differently or better during this pandemic to keep an eye out for these potential consequences?

Ghaemi: If I had to pick out two things, one is that I would ask clinicians to be very aware of the seasonal patterns and to have a lot of attention paid to suicide risk right now, in April and May, in the spring and again in the fall. Another point would be that I think that the biggest risk is going to be after the immediate crisis, although this may end up being a constant crisis that lasts. Right now may not be the highest risk. It may be 3-6 months from now or 6-12 months from now. We should be preparing right now for how we can really attend to people and help them at that time.

Strakowski: Andy, is there anything you want to add?

Keller: I think that last point that Nassir made is really important. He talked about disasters earlier, and one thing we've seen here—we have a lot of experience with hurricanes here in Texas—is that the effects are typically 3 months out; that's when people's resilience begins to break.

We do have, I think, some time to ramp up and be ready. I would recommend, too, that we really look at primary care strategies, because if we don't expand detection and treatment more to primary care with partnerships with psychiatry—using things like collaborative care—we're just not going to have the bandwidth to be available.

Strakowski: Thank you both. Those are very, very important points.

For our audience out there, who are mostly healthcare workers, please stay safe. We appreciate the work that everyone's doing. Andy is a clinical psychologist. Nassir is a clinical psychiatrist and so am I. We're all working in this space.

We extend our greatest sympathies to people who've lost family members and friends to this epidemic already.

As we focus on the virus, we're at times forgetting that all of these other illnesses and problems are continuing to happen and may be exacerbated by the pandemic and the consequences of the pandemic.

We hope that you all find this conversation useful. We look forward to your comments and questions as they come in to Medscape. Thank you.

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