The mental health crisis is a parallel pandemic of COVID-19 across the globe. There are increased concerns about pandemic-related risks of suicide in Canada and elsewhere. Studies from different countries present a complex picture with varying suicide trends, but increased rates of depression, anxiety and suicidal ideation were found to be consistent across countries.
Data from previous pandemics show a significant positive association between pandemic and suicide. The Toronto Transit Commission reported a nearly one-third increase of suicide attempts or fatalities during the first eight months of the pandemic. Suicide prevention is a critical public health response to COVID-19.
There are many complex pandemic-related risk factors for suicide:
- Anxiety and fear of being infected and becoming a contagion for one’s family;
- Financial stressors;
- Decreased social interactions with friends and community activities, disruption of life goals and normal activities;
- Catastrophic thinking;
- A sense of hopelessness and helplessness;
- Increased family stressors due to working/schooling from home;
- Relationship conflicts and break-ups;
- Increased risk of family violence.
A recent study shows that people in quarantine are twice as likely to have suicidal thoughts.
Frontline health-care providers are also at increased risks of mental health distress. Furthermore, usual adaptive and coping resources may be decreased — less social support from friends and family, limited or no access to primary care, community support, health-care services and social recreational activities.
The impact of diminished coping resources is particularly critical to vulnerable populations experiencing pre-existing social, economic and health inequities. Elderly people are cut off from supportive programs and in-home services, and those in long-term care homes have had family visits restricted.
People with pre-existing mental illness are more likely to experience deteriorated physical and mental health. Some children and youth are beset by the uncertainty of learning modes and disruption of social connections; many report experiencing difficulty focusing on online learning.
For Indigenous, Black and racialized communities, pre-existing social inequities are translated into disproportionate burden of COVID-19 cases related to increased risk of workplace exposure, inadequate housing and reliance on public transportation. For immigrants and refugees, disruption of community support and limited access to linguistically appropriate services are worsened during the pandemic.
These increased stressors and decreased coping resources may interact to escalate the risk of self-harm and suicide.
The following vignettes are anonymized composites of cases based on real clinical presentations. They provide a human story behind the complex issues at hand:
Ms. Smith is a veteran intensive-care nurse. She presented to the emergency department with worsening depression and suicidal thoughts, with an unsuccessful overdose attempt after a recent breakup. She feels that her partner did not show understanding when she came home from her shift exhausted, and they had frequent fights. She suspects that her partner is abandoning her to avoid the risk of infection.
Every day, work is like a war zone, always short-staffed, and the manager seems heartless. She is resentful that many colleagues are taking sick time, and that the system learned nothing from the first wave. She cannot take care of patients like she used to due to isolation precautions and work demands, and she is feeling numb facing so much illness and death.
While she gives reassurances to anxious families and dying patients, she feels like a fraud and a failure, ashamed of her own helplessness and hopelessness. She blames herself for not having more positive thoughts and not doing more meditation, and has begun to use alcohol to fall asleep at night.
Ms. Chan is a 75-year-old widow living alone with multiple medical illnesses. She does not speak English. All her regular community activities and medical appointments have been shut down and she has been feeling terrified because of her high-risk COVID-19 category.
At the beginning of the pandemic, most people were not wearing masks and gave her dirty looks for wearing one. She was anxious about people disregarding elevator capacity at her apartment, sometimes seeming to crowd around her deliberately. Once, while lining up at the grocery store, the person behind her yelled at her to go back to her home country. She was so shocked that she left her cart there and headed straight home.
She began to feel useless and hopeless. Her daughter started dropping off food for her at the door weekly. She tried to get her daughter to come in to listen to her fears, but her daughter angrily told her that she could not take any more stress and stormed off. Ms. Chan asks if she can get medically assisted suicide to end her meaningless suffering.
These brief composite cases illustrate the complex contextual determinants of suicide risk. People become vulnerable when multiple internal and external factors conspire to overwhelm their capacity to cope. There is a need to proactively reach out to those who are isolated, disadvantaged and marginalized, as well as to front-line health-care workers at high risk of burnout.
Suicide prevention is possible through increased public awareness of the warning signs, responsive mental health care and access to comprehensive interventions that address the complex psychosocial and structural determinants.
In response, our PROTECH (Pandemic Rapid-response Optimization To Enhance Community resilience and Health) team has applied our resilience-building Acceptance and Commitment to Empowerment model to address pandemic stress and sense of hopelessness associated with suicide. The PACER online intervention integrates Acceptance and Commitment Therapy and social justice-based Group Empowerment Psychoeducation, comprising six self-guided reflective online modules with live video group conferencing.
Participants are encouraged to acknowledge and make room for their distressing thoughts and feelings without believing in them, while finding renewed value and meaning in their life. The group sessions facilitate social connection and mutual support. The social justice perspective supports participants to make sense of their suffering in a larger social context, enabling them to engage in “self-care” and “we-care” actions that promote personal and collective resilience.
Since June 2020, we have implemented 12 cohorts of PACER (Pandemic Acceptance and Commitment to Empowerment Response) training with two priority populations: front-line health-care providers and the Chinese/Asian Canadians who experienced COVID-19 related racism. Our preliminary results showed significant reduction in distress and increased resilience.
We have used the train-the-trainer approach and mentored 20 PACER graduates to become co-facilitators. We will continue to start new PACER cohorts biweekly over the next six months with a goal of delivering 30 additional cohorts.
The global pandemic has had a devastating impact on us all. To combat catastrophic demoralization, it is critical to proactively support people to reconnect with their values, meaning of life, one other and the larger world. Our spirit to survive and thrive collectively is bigger than the virus.
If you are experiencing suicidal thoughts, you need to know you’re not alone. If your life or someone else’s is in danger, call 911 for emergency services. For support, call Canada Suicide Prevention Service (CSPS) at 1-833-456-4566. Visit Crisis Services Canada for more resources.
Kenneth Po-Lun Fung received funding from New Frontiers in Research Fund (NFRF) and Mount Sinai Hospital–University Health Network Academic Medical Organization (MSH-UHN AMO), and the Canadian Institute of Health Research (CIHR). He is affiliated with the University of Toronto, Asian Initiative in Mental Health (AIM) at Toronto Western Hospital, and Society for the Study of Psychiatry and Culture (SSPC).
Josephine Pui-Hing Wong received funding from the New Frontiers in Research Fund (NFRF) and Mount Sinai Hospital – University Health Network Academic Medical Organization (MSH-UHN AMO ), and the Canadian Institute of Health Research (CIHR). She is affiliated with the Sex Information and Education Council of Canada (SIECCAN), and the Committee for Accessible AIDS Treatment (CAAT).depression pandemic covid-19 treatment therapy quarantine canada