The COVID-19 pandemic is an unusual kind of natural disaster, but like other natural disasters, we are anticipating a high number of casualties. Unlike earthquakes and floods, these casualties will accumulate more slowly and, as a result, will be less visible. Building codes, evacuation plans and other disaster preparedness efforts have limited loss of life in recent natural disasters in the United States, but infectious diseases are more complex. Epidemics are not simple events in one geographic area with immediate damage and subsequent relief efforts mounted from other areas. Global travel and supply chains have spread the effects in ways that reduce the ability of other neighboring regions to provide disaster relief. The novelty of COVID-19 prevents the government and others from responding with as much confidence.   

Public health efforts, including social distancing, have blunted the impact in the short term, but uncertainty about the future remains. Meanwhile, those very public health efforts have disrupted structures, relationships and services that are normally available to buffer stress. Schedules are off, gyms, schools, and other venues are closed and there are many unintended consequences. While loss of life may have been limited, the effects of social and economic disruption mount. All of these factors and the uncertainty about them contribute to the experience of stress. 

STRESS AND DISASTER RESPONSE

Stress is not necessarily a bad thing. Despite the protracted and uncertain nature of the current COVID-19 threat, we have seen adaptive responses that are typical of disasters. The population is informed and, as a whole, has responded remarkably well to civil authorities about sheltering in place and social distancing. With some exceptions, communities have complied with orders, essential services have continued, and neighbors are supporting each other. Visits to emergency departments have been low. Existing hospital capacity has been successfully redirected and, in general, demand for healthcare has not yet overwhelmed the system. Natural supports like religious services, funerals and other gatherings are not safe, forcing people to rely on other forms of communication. Many have remarked on the discipline, inventiveness and spirit that the public has displayed.

The population at large is composed of communities and individuals with a range of resources, coping skills and resilience. Vigilance in times like these is rewarded, and a certain amount of worry is required. At first, most individuals will deploy their coping skills and demonstrate resilience in the face of a challenge. Many people will rise to the occasion and function at a higher level than usual. Some are more vulnerable and will feel the effects sooner and more sharply. Those with the reserve capacity to do so will aid others in distress so that the burden is shared. However, as time goes by, both individuals and communities may exhaust their reserves, their coping skills will become taxed, distress will increase and their functioning will decline, sometimes leading to a crisis. Anxiety that is normal and appropriate, helping to focus attention and prime adaptive behavior up to a point, may crescendo and reduce cognitive flexibility and efficiency, and can cause even minor decisions to seem slow and difficult. A large or persistent disaster that is initially felt in terms of loss of life and property is eventually felt in economic terms with loss of jobs, housing and food security. The end result for some will be exhaustion, helplessness and hopelessness.

HOW DISASTERS AFFECT SUICIDAL BEHAVIOR

Suicide occurs for a variety of reasons. At one time, it was said that suicide is almost always the result of mental illness; however, disasters suggest something more complex. Because almost everyone in a disaster initially comes together and responds adaptively, the suicide rate can decline during disasters. Suicidal behavior is not common in grief either. People, including those with mental health conditions, focus on their immediate survival and helping others in a disaster. This is not terribly surprising. Survivors of suicide attempts often report regretting the act immediately. People can find new meaning in disasters, and meaning is protective. Attending to the disaster and learning new behaviors can crowd out suicidal thoughts, at least temporarily. Relationships can be restored. In some ways, disasters can bring out the best in people, and this is reflected in suicide rates and other markers of social connectedness. An example is the new ritual of going outside and cheering or howling for healthcare workers that began in New York City and has quickly spread to other areas.

ECONOMIC HARDSHIP IS DIFFERENT

While wars and disasters are associated with declines in suicidal behavior, changes in economic status at the individual and societal levels are associated with increases in suicide. Poverty per se does not necessarily dispose people to death by suicide. However, economic losses can. Males particularly may be affected by job losses and a perceived inability to care for their families financially. Life insurance may be viewed as a way of helping the family when a person otherwise feels helpless. Hence, as the pandemic continues, job losses mount and financial pressures increase, the suicide rate may climb.

WHAT TO DO

Everyone is vulnerable in a pandemic. Below are some steps you can take to help yourself and those close to you.

• Take your own emotional temperature and breathe.
• Be attentive to signs of stress and irritability in those around you. Small things can be very helpful. Just asking how people are holding up or noticing that someone seems worried or upset is helpful. People like to be seen for the most part. Noticing people and giving them the opportunity to talk, even if it seems superficial, is a useful gesture.
• If people really seem troubled, it might be appropriate to say something like, “Sometimes people reach their limit and think they’d be better off dead or that others would be better off without them. Have you?” Many people have had thoughts like this at some point in their life. It’s a common thing, and asking about it gives people permission to talk about it. It doesn’t encourage people to do it or make it more likely that they will. They might or might not want to admit it but the question itself reflects concern and may start a helpful conversation either way. If the person equivocates or says “not really,” that might mean, “yes, but I’m nervous talking about it.” Of course, that means you should keep talking.
• We think that sharing stories of hope and recovery is particularly powerful. If you can, share something difficult from your life that you overcame - something that both normalizes struggling and suggests hope. Offering to help personally with things that are drivers of distress may work even if the offer is declined.
• People in a crisis often reflect on simple conversations that conveyed caring and helped them soldier on. Since suicidal thoughts usually occur in a crisis that can be expected to pass, getting through the crisis is really critical. Be prepared to follow up if you have concerns.
• Seek professional help, which may include taking medications for acute stress.
• If you or someone you know is experiencing an emergency, call Colorado Crisis Services at 1-844-493-TALK or the National Suicide Prevention Lifeline at 1-800-273-8255.

WHAT THE FUTURE HOLDS

Remember, the most dangerous time may be when the novelty wears off or when things seem to be getting back to normal. Temporary supports will disappear. The connections provided by the threat of a common enemy may wear thin. Decisions put on hold for the crisis will eventually require attention again. Taken together, these factors may all result in a delayed wave of stress and psychological casualties. Hopefully, we will learn something from this experience and invest in more efforts that promote individual and community resilience. 

If you would like to learn more about medications and suicide, the reasons benzodiazepines appear frequently in deaths by suicide will be the subject of the 12th Annual Aaron Bailey Memorial Suicide Prevention Lecture on May 20, 2020.

Michael H. Allen, MD
Professor, Department of Psychiatry and Emergency Medicine
University of Colorado Anschutz Medical Campus

Listen to Dr. Neill Epperson and Dr. Michael Allen discuss suicide and suicide prevention during the COVID-19 pandemic.

Mind the Brain CME Information
CME Survey for the May 19, 2020 Edition

 

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