COVID-19 and the 'Echo Pandemic' of Suicide and Mental Illness

Lorenzo Norris, MD

July 30, 2020

Editor's note: This interview was originally published as part of MDEdge's Psychcast podcast series. In this episode, podcast host Lorenzo Norris, MD, assistant professor of psychiatry and behavioral sciences at George Washington University, Washington, DC, spoke with Roger S. McIntyre, MD, professor of psychiatry and pharmacology and head of the Mood Disorders Psychopharmacology Unit at the University Health Network at the University of Toronto, about the "echo pandemic" of mental illness and suicide that may be coming in the wake of COVID-19. Their discussion occurred before the second surge in COVID-19 cases currently affecting the United States.

Lorenzo Norris, MD: What have you and your colleagues started to theorize about the specific aspects of COVID-19 that make it hazardous to mental health?

Roger McIntyre, MD: This whole situation is truly unprecedented, because it's really a triple threat. First is the fear of this viral infection, contracting it, or giving it to loved ones or to other people. Fear is enough of a hazard. Second is the financial and unemployment shock. The numbers that the Department of Labor are reporting haven't been seen since the Great Depression, with almost 15 years of job creation destroyed in basically 4-6 weeks. Third, we're also talking about quarantine, staying at home, social isolation. There's a robust literature to show that quarantine alone is hazardous to mental health. I could not find an event in the history books anything remotely like this, where fear, insecurity, and quarantine are all occurring at the same time.

We have a lot to be concerned about. For example, we know from animal and human studies that unpredictable, never-ending anxiety is the worst type of stressor with respect to maladaptive stress response. What many people are articulating very clearly is their frustration and anger. They're furious that there doesn't seem to be any exit strategy or clear end date, and this itself is a stressor.

The economic uncertainty is something I'm very interested in. People may know Émile Durkheim, the great sociologist from France, from his work classifying suicide as altruistic, egoistic, and anomic. He also described the link between suicide and unemployment. And as we go forward in history, whether it be events like the Great Depression in 1929, the Asian financial crisis in 1998, or the Great Recession just over a decade ago, one of the most powerful and replicated robust observations with respect to social determinants is the link between unemployment and suicide.

On the quarantine side, I can speak from personal experience. In 2003, Toronto, Canada, where I'm located, was the city most affected outside of Asia by severe acute respiratory syndrome. Over 40 people died, including many frontline workers. We learned then that when healthcare workers were asked to quarantine to limit risk for contraction and to socially isolate if they in fact had the condition, that itself had significant hazards on peoples' mental health.

Norris: It's almost like getting hit by an earthquake, a tsunami, and a famine at the same time. What are some of the mental health outcomes that we are going to be dealing with due to that?

McIntyre: Suicide and conditions associated with suicide are most likely what's going to be the codified diagnosis we see increasing.

Most people know that before COVID-19, we've seen a steady increase in suicide and so-called deaths of despair during the past 15 years in America. There's also something that came out of the Great Recession — which was observed not just the United States and Canada, but in Europe — that I call the "1% rule." This shows that for every 1% increase in unemployment, you see a commensurate 1% increase in suicide. That's a remarkably replicated figure. And we have to remember that back in the Great Recession, unemployment numbers were around 8%-9%, whereas now they're in the range of 14%-17%, depending on how it's measured and reported.

We recently published a study in World Psychiatry where we attempted to project the number of suicides that would be occurring over the next 2 years as a consequence of COVID-19, assuming we don't do anything about it. We looked at the trajectory of suicide from the past 10 years, projected unemployment, and consumer sentiment, which speaks indirectly to financial insecurity and has also been linked to suicide. We projected that if the unemployment rate hits between 14% and 20%, and that's unfortunately where it is now, we would have an additional 8000 to 10,000 suicides each year for the next 2 years. And that's on top of the already reported 50,000 suicides that occur already.

I can tell you that I really, really hope that our projection is completely wrong. But unfortunately, it's going to be a reality unless we really try to get ahead of this curve. We all know now what it means when we say, "Flatten the curve." But I say that's only half the sentence. It should be, "Flatten the curve and prevent the additional echo pandemic of suicide and mental disorders linked to suicide."

Norris: That's a horrifying projection.

McIntyre: It's not just horrifying, it's unacceptable.

But the distress is already happening out there. There was a recent report from Express Scripts showing substantial increases in prescriptions for anxiety-related medications, antidepressant-related medications, and prescriptions for sleeping aids and hypnotics. And at the Depression and Bipolar Support Alliance, where I'm a member and chair of the scientific advisory board, we've seen a massive increase in access to our website and people attending our virtual peer support programs.

What is critical for us to keep in mind is that this isn't a fait accompli. We also learned around the Great Recession in some of the European economies as well as in Japan, that when there was smart spending on what I'll call "social resiliency programs" (eg, wage subsidies, certain stopgaps with respect to the provision of income, vocational rehabilitation, access to psychiatric first aid), there was clearly a mitigation of risk.

Norris: We're not just pointing out a problem, we're about offering solutions. The idea of social resiliency programs makes a lot of sense to me and I agree, but I'm going to push back a little bit. Although I don't want to get political, I don't know that we have shown the robustness in terms of our infrastructure in how we coordinate our health programs, [and better address] social determinants of health, at least in America, where we're actually going to be able to address this. At this point in time, I'm hoping we can get something together for the third or fourth wave, which I think is a very reasonable goal. But with the second wave, I'm concerned.

McIntyre: Your point about not getting political is well taken. Not getting political nowadays is like going in the shower and not getting wet. It's just pretty hard to do. We can do the best we can to be politically agnostic and just leave that aside for a moment.

There's both reality and aspiration to how I think. The reality, as you and I both know, is that before COVID-19 happened, timely access to high-quality, affordable, quality, measurement-based, coordinated healthcare was, frankly, a unicorn in many parts of the country. Now that we have this incredible tsunami coming, I think it's a lot of whistling Dixie to think that the infrastructure and status quo we've had for the past 10, 20, 30 years is going to deal with it. I completely agree with that. And frankly, the psychiatry system needed to be destroyed and rebuilt. It was not working for the majority.

But there's an aspirational part of me — and I'm quite willing to accept the accusation of being a Pollyanna — that looks at history and sees that it's during these incredible crises that things really change.

So, let me be aspirational. Everyone knows the whole world's gone virtual and about the increase in telehealth. I'm also aware that many, many patients don't have reasonably good access to Wi-Fi. But let's pretend that that's not the case. Using virtual methods is the only way I can realistically think about the creation of medical homes that are not brick and mortar but are also Health Insurance Portability and Accountability Act (HIPAA) compliant. For those who already have impairing distress, who have a declared mental illness, the brick and mortar is not going to do it, so we have to have it that way. That's why I think some of this government initiative to try and get more broadband connection couldn't be any more urgent than it is now.

I cringe at the phrase "government spending," which usually means throwing things into the furnace with no deliverable, but I do think there can be smart government spending. I'll be accused of being a dreamer for saying so, but guess what? It actually exists in some countries. For example, Japan increased spending on mental healthcare right after the Great Recession. They directed it right towards psychiatric first aid, social services, online services, et cetera, and it made a huge difference. For every 0.2% increase in GDP spending they did in that campaign, they reduced suicide by 1%. Intelligent spending can be done, and I think that evidence-based decisions would support such an idea.

Norris: There's nothing like a crisis to make the whole country convert to telehealth in a few weeks, which is utterly amazing when you think about it. We can't really say that things can't be done, because when they need to be done, we do them.

With these medical homes or virtual environments, the next generation is going to offer better ways of, for example, integrating biodata. For all I know, they're going to leverage facial recognition technology when you're on Zoom so you can detect micro emotional expressions (of course, with HIPAA consent and all that). There's things that we haven't even imagined yet, but we have to be willing, because a new normal requires a new paradigm.

The other thing that I would add is a fire starter, but I've got to say it: We need to look at guns. If we're talking suicide and not talking guns and alcohol, at some point we're going come back around to that.

What other preemptive measures can we do to maybe either prevent or slow down this echo pandemic?

McIntyre: Your comment on guns is well taken and appreciated. That's a very politically radioactive issue. But in our article where we projected out suicides in the United States, we brought up that 50% of suicides in America occur with a gun.

There's that great line from Ernest Hemmingway where someone is asked, "How did you go broke?" He responded, "Two ways. Gradually, then suddenly." That's exactly what happens in suicide. There's robust literature showing that at least 60% of suicides were actually decided about an hour before. It's a highly impulsive act for many people.

Obviously, with a gun, there's not a lot of turning back. In our article we suggested at the very least to separating out cartridges and ammunition from the actual gun itself in different parts of the house, as some additional mitigating factor against the impulsivity. To me, that's very reasonable and, I would at least hope, shouldn't encroach on peoples' political views.

When it comes to preemption and prevention, two categories stand out for me: personal resiliency and social resiliency. We've talked about social resiliency, which can take the form of providing psychiatric first aid by public community centers, wage subsidies, programs for small businesses. I know these programs are not perfect. There are questions about how they've been implemented and executed, but that's a different conversation we can put aside for a moment.

Personal resiliency is going to sound pretty basic, but it works. First, because of what's happened, many of us have become unstructured. But you've got to structure the day. A structured day becomes a structured brain. Second, you've got to get your sleep. That's part of the structure. And sleep is the elixir for everything.

Third, there's portion control, but not just how we usually define it as alcohol or food. We recently performed a study in China, including Wuhan, the epicenter of this, where we found that people spending more than 2-3 hours a day listening to 24-hour cable news were more likely to report clinical levels of depression, anxiety, and insomnia. We found a dose-response curve on this that hinted that there's almost a virus of anxiety. Now, I don't think that social media is something to be avoided or anathema to a good life, but it's about portion control.

Finally, make connections with people. And it's not just making connections with people that you know and loved ones and friends, which is of course very helpful. But many people don't have any friends. So this is where spirituality, places of worship, virtual settings, the pursuit of the arts can come in. These are also very rewarding and enhance quality of life and connecting.

And someone might be thinking, "Wow, this all seems pretty basic." It is basic. And it works. And guess what, it's also cost-effective.

Norris: Basic works. I like basic. Take basic things that we know, but refine them, customize what they mean to you, and then synthesize them with the other basic things. That's how you get complexity.

Dr McIntyre, I really want to thank you for taking this time and speaking with us. You've gotten so many ideas in my head. You always do. Do you have any final words for our audience?

McIntyre: Just a hopeful message: This will be over at some point. We've learned from people who are highly resilient to stressors that they have the ability to recognize that the stress is not permanent. Don't personalize it. Don't make it pervasive. It will not be permanent. And that's the truth. That's not just some slogan or bumper sticker. It'll be over. We've got a lot to learn. Let's prevent this echo pandemic.

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