Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?

Reger MA, Stanley IH, Joiner TE.
JAMA Psychiatry. 
Published online April 10, 2020.
doi:10.1001/jamapsychiatry.2020.1060

Suicide rates have been rising in the US over the last 2 decades. The latest data available (2018) show the highest age-adjusted suicide rate in the US since 1941.1 It is within this context that coronavirus disease 2019 (COVID-19) struck the US. Concerning disease models have led to historic and unprecedented public health actions to curb the spread of the virus. Remarkable social distancing interventions have been implemented to fundamentally reduce human contact. While these steps are expected to reduce the rate of new infections, the potential for adverse outcomes on suicide risk is high. Actions could be taken to mitigate potential unintended consequences on suicide prevention efforts, which also represent a national public health priority.

COVID-19 Public Health Interventions and Suicide Risk

Secondary consequences of social distancing may increase the risk of suicide. It is important to consider changes in a variety of economic, psychosocial, and health-associated risk factors.

Economic Stress

There are fears that the combination of canceled public events, closed businesses, and shelter-in-place strategies will lead to a recession. Economic downturns are usually associated with higher suicide rates compared with periods of relative prosperity.2 Since the COVID-19 crisis, businesses have faced adversity and laying off employees. Schools have been closed for indeterminable periods, forcing some parents and guardians to take time off work. The stock market has experienced historic drops, resulting in significant changes in retirement funds. Existing research suggests that sustained economic stress could be associated with higher US suicide rates in the future.

Social Isolation

Leading theories of suicide emphasize the key role that social connections play in suicide prevention. Individuals experiencing suicidal ideation may lack connections to other people and often disconnect from others as suicide risk rises.3 Suicidal thoughts and behaviors are associated with social isolation and loneliness.3 Therefore, from a suicide prevention perspective, it is concerning that the most critical public health strategy for the COVID-19 crisis is social distancing. Furthermore, family and friends remain isolated from individuals who are hospitalized, even when their deaths are imminent. To the extent that these strategies increase social isolation and loneliness, they may increase suicide risk.

The info is here.

The Hype of Virtual Medicine

Ezekiel J. Emanuel
The Wall Street Journal
Originally posted Nov. 10, 2017

Here is an excerpt:

But none of this will have much of an effect on the big and unsolved challenge for American medicine: how to change the behavior of patients. According to the Centers for Disease Control and Prevention, fully 86% of all health care spending in the U.S. is for patients with chronic illness—emphysema, arthritis and the like. How are we to make real inroads against these problems? Patients must do far more to monitor their diseases, take their medications consistently and engage with their primary-care physicians and nurses. In the longer term, we need to lower the number of Americans who suffer from these diseases by getting them to change their habits and eat healthier diets, exercise more and avoid smoking.

There is no reason to think that virtual medicine will succeed in inducing most patients to cooperate more with their own care, no matter how ingenious the latest gizmos. Many studies that have tried some high-tech intervention to improve patients’ health have failed.

Consider the problem of patients who do not take their medication properly, leading to higher rates of complications, hospitalization and even mortality. Researchers at Harvard, in collaboration with CVS, published a study in JAMA Internal Medicine in May comparing different low-cost devices for encouraging patients to take their medication as prescribed. The more than 50,000 participants were randomly assigned to one of three options: high-tech pill bottles with digital timer caps, pillboxes with daily compartments or standard plastic pillboxes. The high-tech pill bottles did nothing to increase compliance.

Other efforts have produced similar failures.

The article is here.

Sex and Other Sins: Public Morality, Public Health, and Funding PrEP

Guest Post by Nathan Emmerich
BMJ Blogs
Originally posted October 5, 2016

Here is an excerpt:

Consider the following thought experiments. Imagine a drug that could be taken to significantly lessen the risk that a smoker would develop lung cancer, or a drug that would lessen the risk of ‘at risk’ individuals developing diabetes. In such cases would we be inclined to refuse public funds for such drugs merely because such individuals could lessen their risks even more by giving up smoking, or by losing weight and eating a healthy or, at least, healthier diet?

There is, certainly, something regrettable about having to spend public money on a drug that offsets risks generated by an individual’s own behaviour. Nevertheless, from an epidemiological – and therefore public health – perspective, the notion that an individual makes a choice about whether or not to smoke, or to have a bad diet, is too simplistic, even when we place the issue of addiction to one side. Thus, even when smoking cessation programmes are available and even when nutritional advice is within easy reach (as it increasingly is), plenty of people still smoke and consume a less than healthy diet.

Smoking and bad diets are correlated with a variety of demographic factors, and our choices are always made within particular cultural and socio-political contexts. Even so, some have questioned if the NHS should be funding stomach-stapling operations for those who are overweight, or if smokers and non-smokers can expect to receive the same level of treatment and care.

The entire blog post is here.

Vermont Senate approves amended death with dignity bill

By Dave Gram
The Associated Press
Originally published February 13, 2013

The Vermont Senate on Wednesday gave preliminary approval to an amended bill allowing doctors to prescribe a lethal dose of medication to terminally ill patients.

But even some backers of the measure, which passed 21-9, called the amended version a travesty. And other long-time backers of what they call ‘‘death with dignity’’ or ‘‘end-of-life choices,’’ along with opponents of physician-assisted suicide, were so angry about the amendment that they voted against it.

‘‘I will be voting yes for this bill, as much as I detest it,’’ said Sen. Claire Ayer, D-Addison and chairwoman of the Senate Health and Welfare Committee.

She said she hoped much of the original language — which mirrored Oregon’s first-in-the-nation Death With Dignity Act — would be restored when the measure moves to the House.

‘‘I want to be on that conference committee,’’ Ayer said, referring to the six-member panel of lawmakers who work out the differences between the House and Senate bills after they have cleared both chambers.

The entire story is here.

One in 10 suicides is among people with a physical illness

By Anne Gulland
BMJ 2011; 343:d5464

A report on the link between suicide and physical ill health has found that one in 10 people who take their own life is chronically or terminally ill.

The report, by think tank Demos, is one of the first such comprehensive studies to look at the links between suicide and physical ill health. It says that the figure, which came from coroners and primary care trusts (PCTs), is likely to be a substantial underestimate because coroners do not always include the relevant health information with their inquest reports.

Demos believes that the findings provide strong evidence that people with chronic and terminal illnesses should be regarded as a high risk group for suicide and should be given better “medical, practical, and psychological support.”

Demos believes that the findings provide strong evidence that people with chronic and terminal illnesses should be regarded as a high risk group for suicide and should be given better "medical, practical, and psychological support."

<snip>

The government launched a consultation on suicide in July which identified five high risk groups for suicide: people in the care of mental health services (1200 suicides a year); people in the criminal justice system (80 suicides in prison a year); adult men aged under 50 (2000 suicides a year); people with a history of self harm (950 suicides a year), and occupational groups such as doctors, nurses, and farmers.

There were 4390 suicides in England in 2009, which, using Demos's calculation, would mean that more than 400 of these were among people with a chronic or terminal illness.

Demos believes that this group should be identified as high risk.

<snip>

Louise Bazalgette, author of the report, said it was important that doctors treating people with a chronic or terminal illness were aware of the issue.

"Doctors should be thinking about the possibility that a person with chronic health problems may be depressed and struggling. They should ask them if they ever feel suicidal," she said.

<snip>

Simon Gillespie, chief executive of the Multiple Sclerosis Society, said: "There is a big difference between someone wanting to end their life having explored and received every care option, and someone giving up hope because they feel they have nothing available to them. The right care and support can make a huge difference to an individual's life."

Clare Wyllie, head of policy and research at the Samaritans, said it was important that a suicide prevention strategy was implemented locally.

"It is vital that commissioners of local NHS, social care and public health services recognise that poor physical health and poor mental health are often closely linked [and] that depression is often undiagnosed in people with poor physical health," she said.

Thanks to Ken Pope for this information.