DEFINITION

• The annual suicide rate in the U.S. was 14.12 per 100,000 as of 2023.[1]
  • This rate had increased steadily since 2000, when it was 10.4 per 100,000.
  • For the first time in 20 years, the U.S. suicide rate decreased in 2019 and 2020, but immediately afterwards it increased again at a faster pace than before, and we now have a higher suicide rate than we have had since WW2.
  • 78% of completed suicides are by males, and 89% are by whites.
  • 55% of suicides are via firearm, 26% via suffocation, and 12% via poisoning.
• Previous pandemics have been associated with increases in suicide rate.
  • The U.S. reported an increase in suicides during the Spanish flu of 1918-19.[2]
  • Hong Kong observed an increase in elderly suicides during the 2003 SARS outbreak.[3]
  • Africa experienced an increase in suicides during the Ebola epidemic.[4]
  • Possible risk factors for suicide during pandemics include isolation, fear, marginalization, psychological disorders, economic fallout, and increased domestic abuse.[5]
• The COVID-19 pandemic exacerbates multiple factors that were concerning for increasing suicides.[6]
  • SARS-CoV-2 infected 76 million people worldwide in 2020.[7]
  • Economic stress is associated with higher suicide rates.[8] The pandemic has forced many businesses to close or scale back as a result of lockdown measures.
  • Social isolation is associated with increased suicidal thoughts.[9] The main U.S. public health strategy to mitigate the spread of COVID-19 has been social distancing.
  • Participation in religious communities is associated with lower suicide rates.[10] Churches and community centers have also been forced to close, contributing to social isolation and possible higher suicide rates.
  • Continuous media coverage of the pandemic may intensify anxiety and fear for individuals with preexisting mental health conditions.
  • Barriers to mental health treatment that have arisen due to the pandemic include increased restrictions at healthcare facilities.
  • In the U.S., firearm sales have surged, with a 41% increase in March 2020 and >50% increase in August and October 2020, relative to 2019 rates.[11]

APPROACH

• Multiple reports based on the early months of the pandemic had not found significant changes in the overall rates of suicide.
  • In Massachusetts, U.S., the rate of suicides during the stay-at-home period from March to May 2020 was similar to that of the same period in 2019.[12]
  • In Victoria, Australia, the number of suicides through September of 2020 was comparable to that through September of 2019 and other years prior.[13]
  • In England, the average number of suicides per month pre-lockdown (January-March 2020) was 84.0 and post-lockdown (April-August 2020) was 85.4.[14]
  • In Norway, the rate of suicides from March to May 2020 was 2.8 per 100,000, which is not significantly different from the rate for the five previous years.[15]
  • More comprehensive analyses covering longer periods have largely confirmed these initial findings. A major international study examining 33 countries found no evidence of increased suicide rates in the majority of countries during the first 9-15 months of the pandemic, with some countries actually showing decreases.[16]
  • However, this overall pattern masks important variations across different populations and time periods
• Certain groups may be more vulnerable to the effects of the pandemic and experience increased suicide rates.
  • Elderly: In older Americans, social disconnectedness is associated with higher perceived isolation, depression, and anxiety. Self-isolation further disproportionately affects elderly individuals who do not have close family and friends, or who have decreased literacy in or access to digital resources.[17]
  • Youth: Preliminary data from England suggest that child suicide deaths may have increased during the first phase of lockdown, possibly due to disruptions to education, extracurricular activities, and support services.[18]
    • This concern has been reinforced by subsequent studies. In Japan, suicide rates among children and adolescents increased significantly during the pandemic, with a 49% increase among those under 20 years old in 2020.[19]
    • Similar patterns have been observed in other countries, suggesting that young people may be particularly vulnerable to the mental health impacts of pandemic-related disruptions.
  • Racial minorities: In Maryland, U.S., progressive closure of businesses from March to May 2020 was associated with decreased daily suicide mortality among white residents but increased daily suicide mortality among Black residents.[20]
  • Unemployed: The pandemic is predicted to cost 25 million jobs worldwide.[21] Global studies of the Great Recession in the early 2000s found that suicide risk was elevated by 20-30% between 2000 and 2011 with a peak during 2008.[22]
  • Mentally ill: Individuals with preexisting mental health issues are likely to be affected by illness relapse, interruption in psychiatric services, increased isolation, and possible exacerbation by anxiety due to the pandemic.[23]
  • Healthcare workers: Medical staff have reported increased hopelessness, guilt, and insomnia, all of which can increase the risk for suicide.[24]
  • Women: While historically men have higher suicide rates, several studies have documented disproportionate increases in suicide among women during the pandemic. In Japan, female suicide rates increased by 37% in October 2020 compared to previous years, while male rates showed smaller changes.[19] This may reflect the disproportionate burden of childcare, domestic violence, and job losses in service industries that predominantly employ women.
• Consistent with studies of previous epidemics, we saw a short-term decrease in suicide initially but an increase later.
  • Studies of natural disasters have suggested a short-term decrease in suicide in the immediate aftermath of a disaster but an increase later. Referred to as "the honeymoon period" or the "pulling together" phenomenon, this has been attributed to increased social connectedness, community cohesion, and mutual support in the acute phase of a pandemic.[25]
  • In the early phase of the pandemic, the number of suicide deaths in Japan was lower than that of prior years, but the number started to exceed historical trends in July 2020.[26]

APPLICATION

• Adequate and equitable access to mental health care should be ensured, for example through increased tele-psychiatry and mental health help lines.
• Sale of common mechanisms of suicide, particularly firearms, should be restricted.
• Digital connectedness should be encouraged to prevent social isolation.
• Economic supports, such as government stimulus, unemployment income, and rent and loan forgiveness, should be considered.
• The mental health of frontline workers should be fostered, for example by allowing for flexible shifts and adequate rest, and offering mental health care and peer support.

COMMENTS

• While initial data showing no overall increase in suicide deaths during the early pandemic period have been largely confirmed by subsequent research spanning longer time periods,[16][27] important nuances have emerged. The pandemic’s impact on suicide rates has been heterogeneous, with some populations—particularly youth, women in certain countries, and people of color—showing concerning increases even as overall rates remained stable or decreased.
• It is imperative to remain vigilant and prevent mental health crises, as the pandemic may have long-term impacts on mental health if not immediate ones. The pandemic has generated much anxiety and stress for many and has exacerbated numerous known suicide factors.
• It is particularly important to support at-risk populations, such as the elderly, youth, racial minorities, unemployed, and frontline workers. Methods include ensuring equitable access to mental health care, fostering digital community support, and providing economic relief.
• As we move into the post-acute phase of the pandemic, continued vigilance is essential. Research suggests that the mental health impacts of economic recessions and social disruptions may manifest with significant delays,[27] making ongoing monitoring and support systems crucial for years to come.

References