Much has been made of the potential impact of Covid lockdowns and restrictions on the rate of suicides. Social isolation, unemployment, increasing rates of domestic violence, remote learning, and general anxiety about the crisis have all led to worsening mental health for millions of people. It has been a common refrain of those who are opposed to lockdowns and restrictions, that suicides will increase. Multiple posts have circulated on social media claiming dramatic increases in suicide numbers. While there is little to no data in Ireland or the US to support these claims, there is also no data to debunk them. Worryingly, official suicide statistics for 2020 will not be available for Ireland or the US until 2022. Without real-time reporting of suicide numbers, the true impact of the Covid crisis may not be known until it is too late.
In Japan, where real-time suicide numbers are available, a dramatic increase in suicide rates, particularly among women, has been observed since July 2020. In October, female suicides increased by 83% and male suicides increased by 22% compared to October 2019. While Japan has had a serious problem with suicide for many decades, their suicide rates have been steadily declining year-on-year since 2010, with 2019 showing the lowest number of suicides in Japan since records began in 1978. The pandemic has obviously had a detrimental effect on the economic security and mental health of people around the world. A study by CARE International of 10,000 people in almost forty countries showed that 46.6% of respondents reported losing income, while 20.2% reported mental health issues resulting from the pandemic. A study by Erin N. Marcus, Professor of Clinical Medicine at the University of Miami, found that US adults were three times more likely to have clinically significant anxiety or depression in 2020 compared to 2019. She noted the potential detrimental effects of the lockdowns on grief. Rituals such as wakes and funerals are crucial to the grieving process, and with these limited, Professor Marcus warns this could contribute to the development of Prolonged Grief Disorder which carries a great risk of depression, suicide, and alcohol and drug abuse. The frequency of alcohol consumption has also increased during the pandemic, and heavy drinking has become more common.
In Ireland, there has been an increase in the number of prescriptions for sleeping tablets, anxiety medications, and anti-depressants. The presentations of self-harm and other mental health emergencies have also increased. During the second month of the pandemic, fifty percent of admissions to St. John of God’s psychiatric hospital in Dublin were for illnesses related to the pandemic restrictions. A mental health survey carried out by NUI Maynooth and Trinity College Dublin found that, one month into the pandemic, 41% of respondents reported loneliness, 23% reported feeling depressed, 20% had clinically significant anxiety, and 18% had PTSD. Worryingly, despite the increase in mental health problems, there has been a reluctance to seek professional help, as people avoid healthcare settings for fear of catching Covid. Phone support lines have consequently borne the brunt of the mental health pandemic.
Counter-intuitively, where real-time suicide numbers are available, no increase in suicides has been observed despite the impact of lockdowns. In Victoria and Queensland, Australia, between February and August 2020, there was no increase in suspected suicides compared to the same period for 2019. In the UK, while suicides increased slightly compared to 2019, researchers have attributed this to the general trend of increasing suicide rates over the last number of years. A study in Massachusetts found no increase in suicides during the March to May lockdown period compared to an average of that period from 2015 to 2019. However, we cannot allow this data to lull us into a false sense of security. Japan actually saw a decrease in suicides during the initial phase of the pandemic response, with a 20% decrease in April and May, when the State of Emergency was in place. Several psychiatrists have attributed this to the phenomenon of “group trauma” in response to a national crisis which appears to act as a preventative measure against suicide. Despite being literally socially isolated, people can feel a figurative sense of national community in response to the crisis. The crisis can also give people a sense of purpose, even those who have become unemployed; by following government guidelines, individuals can feel they are contributing to the pandemic response, that they are helping their country.
This theory of a national crisis acting as a preventative measure against suicide has been used to explain why suicide rates fell during the two world wars. However, other academics have challenged this interpretation, attributing the decline in suicides during World War II to the improved economic prospects after the Great Depression and a reduction in the competition for jobs as young men were mobilized for war. A better example that supports the theory is Northern Ireland during the Troubles. Despite the violence and fear precipitated by the civil war, suicide rates fell during the Troubles, even though unemployment increased massively over this period, from 6% in 1975 to 21% by 1984. When the Troubles were at their worst and conflict deaths were high, the suicide rate was lower than when conflict deaths were low. While society was divided along sectarian lines, social integration within those two sects naturally solidified in response to the conflict. In the ten years following the end of the conflict in 1998, suicide rates have almost doubled, even though employment and prosperity have drastically increased. Those who were children or young people during the worst years of the conflict had the highest suicide rates during the ten years following the peace agreement. As such, while the national crisis may pass, the trauma inflicted by the crisis may not, and without the preventative measure of the communal crisis response, that trauma can lead to more suicides. This may explain why Japan saw a decrease in suicides during the initial phase of the pandemic, followed by a huge increase once Japanese society returned to relative normality.
It must also be noted that, while suicide rates overall do not appear to have increased, suicides among young people have increased. One study in the UK found that suicide rates among those under twenty increased 40% during the April to May lockdown compared to the pre-lockdown period and this represented a 50% increase compared to 2019. Covid-related factors contributed to 48% of those suicides. Similarly, in Ireland, Dr. Denis McCauley, chair of the Irish Medical Organisation’s GP committee, reported an increase in suicides among young people; while the majority of those suicides were young men, the most marked increase was observed among young women, matching the trend seen in Japan.
The pandemic response in Ireland, the UK, and the US has not been as effective as in Japan. While Japan has returned to relative normality, our societies are still in the crisis phase. Therefore, there is still a risk that suicide rates will increase once we have the pandemic under control. It must also be noted that the restrictions we have put in place have been much more onerous than those implemented by Japan and have been in place much longer. The impact of the pandemic on the mental health and well-being of people in our societies will probably be much worse as a result. The increase in suicides in the post-crisis period may be even greater than has been observed in Japan. The government response to the pandemic must focus on balancing risks, as it is impossible to eliminate them. Every measure that reduces the risk of contagion and death has the potential to increase the risk of other dangers. Closing cancer screening services during the initial lockdown in Ireland may have limited Covid transmission, but it has also led to an estimated 2,000 missed cancer diagnoses. Early diagnosis is vital to the treatment of any cancer, so the risk of death to those 2,000 people has been significantly increased. There are no win-win situations when it comes to implementing onerous restrictions, there are only trade-offs.
Without real-time reporting of suicides in Ireland and the US, there may be no way to determine the trade-off we are making between Covid containment and the mental health of the public until it is two years too late. The primary reason that there is a two-year delay in suicide reporting is that suicide is a legal verdict ruled by a coroner, as is homicide, rather than a medical assessment, as is a heart attack. Suicide is not a verdict that a coroner will come to lightly. A suicide results in more troubling grief for the family of the deceased, as it can result in them blaming themselves or resenting the deceased. Life insurance policies do not pay out if the insured commits suicide, and coroners, being aware of this, are careful in their assessment of the cause of death. Suicide is also particularly troubling for those who are religious, as most religions consider suicide to be a mortal sin. For these reasons, coroners can spend months investigating and weighing up evidence before coming to an official verdict of suicide.
But such a rigorous assessment is not necessary when reporting suicides for the purposes of real-time surveillance. As real-time reports are not issued to family members and have no bearing on insurance claims, a more cursory assessment is all that is required. In Australia and the UK, real-time suicide statistics are compiled based on the police reports of the deaths. The data collectors analyse these reports and assess the probability of the death being a suicide. The data collectors then liaise regularly with coroners to update their data to reflect the coroner’s findings. Implementing a real-time suicide surveillance system is no mean feat, and there are many impediments to rolling one out nationwide. Implementing one in the US is fraught with obstacles. Independent police departments are various across the US at state, county, municipal, and local levels. Coordinating standardized data collection from each of these for a national surveillance system would be difficult. Medical reports could alternatively be used to assess the probability of a suicide, but as hospitals in the US are private and independent, compelling hospitals to comply with a standardized reporting system would be a huge task.
Ireland, on the other hand, has no such impediments. We have a single, centralized police force and a national health service, either of which could be directed by government to contribute to a nationwide suicide surveillance system. Professor Ella Arensman, Director of Research at the National Suicide Research Foundation, has already shown that real-time suicide surveillance is possible in Ireland. Beginning in 2016, Professor Arensman and her team at the UCC School of Public Health began implementing a Suicide and Self-Harm Observatory for county Cork. Her team collects data from the HSE Patient Mortality Register and liaises with coroners to verify collected data over time. This data is reported every two weeks. The data is then shared with the HSE’s Resource Officers for Suicide Prevention, allowing them to provide targeted interventions in the community where required. Arensman’s observatory has also been used to dispel rumours about suicide clusters that have been reported in the media. Such rumours can cause unnecessary panic in the community, resulting in unnecessary referrals to mental health services. Such reports can also give rise to what is known as “suicide contagion”, whereby reports of suicide can vindicate the suicidal thoughts of mentally ill people, causing them to act on those suicidal urges. The Covid crisis has highlighted another imperative of real-time suicide reporting: informing government policy. Without knowing in real-time the effects of government interventions to prevent the spread of Covid, the government cannot make an informed cost/benefit analysis.
In early 2018, HSE Suicide Resource Officers in Kerry and Donegal expressed an interest in expanding Prof. Arensman’s observatory to their counties, and three other counties have expressed interest since then. However, as of January 2021, the observatory is still confined to county Cork. Prof. Arensman was contacted for an update on the progress in expanding the observatory nationwide, though no reply has been received as yet. Naturally, the government and the HSE are focused on tackling the third wave of Covid, but we cannot allow them to take a narrow view of public health. We may be able to save the elderly a few more years of life, but will it be at the cost of decades off the lives of young people? To properly assess the impact of Covid restrictions, the government and HSE should provide Professor Arensman’s team with the resources and support they need to take their Suicide and Self-Harm Observatory nationwide. The HSE already has the infrastructure necessary to do so, all that is required is the political will.