Covid-19 & Suicide - 2
Emergency Rooms See
Significant Rise in Mental Health Visits During Pandemic
- 2/12/21
As the COVID-19 pandemic rages on, people are seeking urgent medical care for a variety of painful conditions. In a recent study from JAMA Psychiatry, researchers compared the rate of emergency room (ER) visits during the period of mid-March and October 2020 to the same months in 2019.1?????? In the March-October period of 2020, the mean ER visitation rate for disaster-associated mental health conditions was 2,540.4 per 100,000 visits. This rate was higher than in 2019, when an average of 2,152.3 ER visits out of every 100,000 involved mental health. The same figure for suicide attempts was 314.2 in 2020 and 250.1 in 2019.?? Researchers also found an increase in ER visitation rates for all drug and opioid overdoses, intimate partner violence, and child abuse and neglect. Rates of ER visits for mental health conditions, suicide attempts, drug and opioid overdoses, and intimate partner violence peaked between April 3 and May 11. However, rates for suspected child abuse and neglect peaked later into the pandemic, between May 24 and 30. Researchers looked at rates instead of numbers because there were fewer visits to the emergency department in 2020 overall. Despite this drop in total visits, between April 11 and October 10 the number of drug-related ER visits each week remained 1% to 45% higher than the numbers for the same weeks in 2019. Dr. Sabrina Romanoff, a Harvard-trained clinical psychologist, saw these mental health trends firsthand at the start of the pandemic while working in the psychiatric emergency room at Harvard’s Cambridge Health Alliance. “Many international Harvard and MIT students presented with health-related concerns that were compounded by anxieties about losing housing coupled with experiences of discrimination and xenophobia,” she says. “This is not a unique phenomenon for emergency departments, which in many ways, serve as an analog to represent local issues existing in the community,” Romanoff adds. “It is a breathing, living, representation of current challenges faced by members of the population. While it provides a pulse for conflicts experienced by those with perhaps the most complex cases and presentations, it also speaks to and embodies challenges experienced by those who do not make it into our department.” How the Pandemic Negatively Influences Mental Health The pandemic’s mental health strain is at the heart of many of the conditions for which people are turning to the emergency department. You would be hard-pressed to find someone not negatively affected by the pandemic, and for many people, that extends to the state of their mental health. “People have experienced multiple losses, from deaths to missing important milestones to fractured relationships due to disagreements or just distance,” says Aimee Daramus, PsyD, a licensed clinical psychologist. “Most of us have never lived through anything like this before, so our entire sense of reality has shifted, and we’ve had to live with the surreal idea that the wrong trip to the grocery store could put us on a ventilator," Daramus says. People with pre-existing mental health conditions are finding their coping mechanisms taken away and symptoms exacerbated. Others are exhibiting symptoms for the first time and given limited support, if any. “Individuals without prior psychiatric concerns are presenting to my clinic with new-onset anxiety and depressive symptoms in the context of psychosocial stressors related to the pandemic,” says Dr. Leela R. Magavi, a Johns Hopkins-trained adult, adolescent, and child psychiatrist and regional medical director for Community Psychiatry, California's largest outpatient mental health organization. In a June 2020 study of U.S. adults from the CDC, 40.9% of participants reported having at least one mental or behavioral health condition, and 13.3% reported starting to or increasing their use of substances as a method of coping with the pandemic. “Individuals of all backgrounds and ages are suffering, and now more than ever, we need to come together to advocate for mental health parity in all domains,” says Magavi. “Mental illness is faceless and can affect anyone and everyone.” Steps You Can Take for Your Mental Health While the pandemic has limited access to some coping mechanisms, there are many options to pursue in care of your mental health without exposing yourself or people around you to COVID-19. Find a Therapist or Start a Support Group Working with a therapist you trust can help you manage mental health issues, but long wait times and session costs may bar you from seeing one. Online therapy may be one solution, or you could turn to a support group. Forming a healthy, safe space to speak with others can provide an opportunity to work through your feelings. “There’s no rule against you starting your own informal online support group with a few other people and some ground rules about communication,” says Daramus. I"ndividuals of all backgrounds and ages are suffering, and now more than ever, we need to come together to advocate for mental health parity in all domains. Mental illness is faceless and can affect anyone and everyone."— Dr. Leela R Magavi Be Aware of How You Spend Your Time If you’ve fallen into a routine that bores or depresses you, it can feel harder to shake with limited options for activities. However, ignoring it can emphasize the negative feelings you’re experiencing and perpetuate that mood. "So many people are barely hanging on. There’s nothing wrong with feeling wrecked when terrible things are happening. That’s a natural response to a bad situation." - Aime E Daramus Be aware of how you’re spending your time and the thoughts festering inside your head. “Taking breaks from reading about COVID-19 or watching the news, and instead spending time exercising and practicing mindfulness techniques could help individuals decrease ruminative thinking,” says Magavi. Engage with People in Safe Ways Fortunately, there are countless ways to interact with loved ones that don’t require being in the same room. “Utilize technology to get as close to face-to-face interaction as you can,” says Romanoff. “We are social creatures. We need to connect to others to survive. Research has found in-person communication to improve mood and reduce depression." Romanoff adds to plan an activity that involves others, like running in a park or walking somewhere you'll see other people. Whether or not you have someone specific to make plans with, being around others can help your mood and overall well-being. Celebrate Good Things As the pandemic brings pain into so many people’s lives, you may feel guilty celebrating anything good happening. While it’s important to be sensitive to other people’s feelings and experiences, burying anything positive in your life may negatively impact you. “When something good happens to you, share it with the people who care about you,” says Romanoff. “This is a two-way street. Oftentimes the best way to reduce loneliness is to hear about the experiences of others.” Contact a Mental Health Hotline Are you struggling with your mental health and unsure who to talk to or what steps to take? A mental health hotline can provide you with free, anonymous assistance. Below are a few mental health hotline options to reach out to.
When to Visit an Emergency Department If you or someone you know struggles with mental health conditions, there are clear signs that an emergency department visit is warranted. “If you feel like harming or killing yourself, if you’re unable to care for yourself due to mental health problems, if you or someone else is manic, hallucinating, or violent, the emergency room can be the right move,” says Daramus. Alternatively, you can enter an intensive outpatient or partial hospitalization program. However, an emergency department can provide immediate relief and protection. What This Means For You As easy as it is to feel isolated at this time, remembering that you are far from the only person feeling these things can have a real impact on your mental health. “I see a lot of people who think
that they’re the only one who feels like they’re
falling apart, but that’s not true,” says Daramus.
“So many people are barely hanging on. There’s
nothing wrong with feeling wrecked when terrible things are
happening. That’s a natural response to a bad
situation.” Reaching out to loved ones and getting help
are the first steps towards improved mental health. CDC
Issues Advisory as Drug Overdose Deaths Spike— Is
COVID-19 response to blame? Probably, 12/7/20 Approximately 81,230 drug overdose deaths occurred in the U.S. in the 12 months ending May 2020, with the largest spike after the COVID-19 public health emergency started, from March 2020 to May 2020. Drug overdose deaths were rising before March, but the findings suggest they accelerated during COVID-19, the agency said. "The disruption to daily life due to the COVID-19 pandemic has hit those with substance use disorder hard," said CDC Director Robert Redfield, MD, in a statement. "As we continue the fight to end this pandemic, it's important to not lose sight of different groups being affected in other ways. We need to take care of people suffering from unintended consequences." The number of deaths increased 18.2% from the 12-month period ending in June 2019 to the 12-month period ending in May 2020 and appeared to be driven largely by deaths involving synthetic opioids like illicitly manufactured fentanyl, according to the CDC. Of 38 jurisdictions with available synthetic opioid data in the CDC's analysis, 37 reported increases in synthetic opioid overdose deaths. Eighteen reported increases greater than 50%. Ten western states reported more than a 98% increase in synthetic opioid-involved deaths. Cocaine-related overdose deaths also increased by 26.5% in the 12-month period; these were likely connected to using cocaine together with illicitly manufactured fentanyl or heroin, the CDC noted. Overdose deaths involving stimulants like methamphetamine increased by 34.8% and exceeded the number of cocaine-involved deaths. These deaths have been increasing with and without synthetic opioid co-use and at a rate faster than overdose deaths involving cocaine, the agency said, noting the rise was consistent with the growth of methamphetamine in the illicit drug supply and increases in methamphetamine-related treatment admissions. The advisory recommended that naloxone use and overdose education be expanded, that awareness and availability of treatment for substance use disorder be improved, and that drug overdose outbreaks and spikes be monitored more rapidly. "The increase in overdose deaths is
concerning," said Deb Houry, MD, MPH, director of CDC's
National Center for Injury Prevention and Control. "CDC's
Injury Center continues to help and support communities
responding to the evolving overdose crisis. Our priority is
to do everything we can to equip people on the ground to
save lives in their communities." The
coronavirus pandemic is pushing America into a mental health
crisis - May 4, 2020 Isolation and economic upheaval caused by the coronavirus pandemic are already resulting in a sharp spike in people seeking mental health help. (Amanda Andrade-Rhoades for The Washington Post) Three months into the coronavirus pandemic, the country is on the verge of another health crisis, with daily doses of death, isolation and fear generating widespread psychological trauma. Federal agencies and experts warn that a historic wave of mental-health problems is approaching: depression, substance abuse, post-traumatic stress disorder and suicide. Just as the initial outbreak of the novel coronavirus caught hospitals unprepared, the United States’ mental-health system — vastly underfunded, fragmented and difficult to access before the pandemic — is even less prepared to handle this coming surge. “That’s what is keeping me up at night,” said Susan Borja, who leads the traumatic stress research program at the National Institute of Mental Health. “I worry about the people the system just won’t absorb or won’t reach. I worry about the suffering that’s going to go untreated on such a large scale.” Data shows depression and anxiety already roiling the nation. Nearly half of Americans report the coronavirus crisis is harming their mental health, according to a Kaiser Family Foundation poll. A federal emergency hotline for people in emotional distress registered a more than 1,000 percent increase in April compared with the same time last year. Last month, roughly 20,000 people texted that hotline, run by the Substance Abuse and Mental Health Services Administration. Online therapy company Talkspace reported a 65 percent jump in clients since mid-February. Text messages and transcribed therapy sessions collected anonymously by the company show coronavirus-related anxiety dominating patients’ concerns. “People are really afraid,” Talkspace co-founder and CEO Oren Frank said. The increasing demand for services, he said, follows almost exactly the geographic march of the virus across the United States. “What’s shocking to me is how little leaders are talking about this. There are no White House briefings about it. There is no plan.” The suicides of two New York health-care workers highlight the risks, especially to those combating the pandemic. Lorna Breen, a top New York emergency room doctor, had spent weeks contending with coronavirus patients flooding her hospital and sometimes dying before they could be removed from ambulances. She had no history of mental illness, her relatives have said in interviews, but struggled increasingly with the emotional weight of the outbreak before she died. Days later, reports emerged that a Bronx emergency medical technician also killed himself. Researchers have created models — based on data collected after natural disasters, terrorist attacks and economic downturns — that show a likely increase in suicides, overdose deaths and substance use disorders. And yet, out of the trillions of dollars Congress passed in emergency coronavirus funding, only a tiny portion is allocated for mental health. At the same time, therapists have struggled to bring their practices online and to reach vulnerable groups because of restrictions on licensing and reimbursement. Community behavioral health centers — which treat populations most at risk — are struggling to stay financially solvent and have begun closing programs. “If we don’t do something about it now, people are going to be suffering from these mental-health impacts for years to come,” said Paul Gionfriddo, president of the advocacy group Mental Health America. That could further harm the economy as stress and anxiety debilitate some workers and further strain the medical system as people go to emergency rooms with panic attacks, overdoses and depression, he said. Just as the country took drastic steps to prevent hospitals from being overwhelmed by infections, experts say, it needs to brace for the coming wave of behavioral health needs by providing widespread mental health screenings, better access to services through telehealth, and a sizable infusion of federal dollars. Dire warnings in data When diseases strike, experts say, they cast a shadow pandemic of psychological and societal injuries. The shadow often trails the disease by weeks, months, even years. And it receives scant attention compared with the disease, even though it, too, wreaks carnage, devastates families, harms and kills. Mental-health experts are especially worried about the ongoing economic devastation. Research has established a strong link between economic upheaval and suicide and substance use. A study of the Great Recession that began in late 2007 found that for every percentage point increase in the unemployment rate, there was about a 1.6 percent increase in the suicide rate. Using such estimations, a Texas nonprofit — Meadows Mental Health Policy Institute — created models that suggest if unemployment amid the coronavirus pandemic ends up rising 5 percentage points to a level similar to the Great Recession, an additional 4,000 people could die of suicide and an additional 4,800 from drug overdoses. But if unemployment rises by 20 percentage points — to levels recorded during the 1930s Great Depression — suicides could increase by 18,000 and overdose deaths by more than 22,000, according to Meadows. “These projections are not intended to question the necessity of virus mitigation efforts,” cautioned authors of the Meadows report, “but rather to inform health system planning.” Suicide experts and prevention groups have deliberately refrained from discussing too widely death projections such as those from the Meadows Institute. Experts say reporting excessively or sensationally on suicide can lead to increases in suicide attempts, an effect known as contagion. And the factors involved in any suicide are often complex, they point out. “Could the numbers go up? Yes, but it isn’t inevitable. We know suicide is preventable,” said Christine Moutier, chief medical officer for the American Foundation for Suicide Prevention. Research has shown interventions make a marked difference, such as limiting access to guns and lethal drugs, screening patients for suicidal thoughts, treating underlying mental conditions and ensuring access to therapy and crisis lines to call and text. “That’s why we need to act now,” Moutier said. On Wednesday, a coalition representing more than 250 mental-health groups announced it was convening a national response to the problem of pandemic suicide — an effort that will include at least one federal agency, the National Institute for Mental Health. ‘Poisonous fire hydrant’ Front-line workers — health-care providers, grocery store workers, delivery people — are especially vulnerable to the coming storm of mental health problems. “We’re used to dealing with sick people and seeing terrible things, but what’s devastating with covid is the sheer volume. It’s like drinking from a poisonous fire hydrant,” said Flavia Nobay, an emergency room doctor. As infections soared in March in New York, Nobay took leave from her duties at the University of Rochester Medical Center to volunteer as an ER doctor in Queens. Weeks later, the experience still haunts her: Watching families crumple in the ambulance bay knowing they may never see relatives again. Hearing the relentless alerts every few minutes of crashing patients and respiratory arrest. Sending patients home because they weren’t quite sick enough, knowing they may be coming right back. Or even worse, the chance they may not make it back. “It chips away at your soul,” Nobay said. “You have to hold on to the positive and how you’re helping in the ways you can. That hope is like medicine. It’s as important and tangible as Tylenol.” Crisis Text Line making a difference . April 8, 2020 Data from Crisis Text Line shows social isolation, unemployment and forced quarantines are having a significant effect on people’s mental health. "We're seeing about a 50% increase in volume." said the co-founder and CEO of Crisis Text Line Nancy Lublin. "It's mostly breen anxiety so 78% of our conversatioins., the number one issue we're seeing right now is anxiety. Anxiey mentioning symptomy. Anxiety explicity mentioning virus, COVID-19, coronavirus. Anxiety about the illness. And it has mirrored locations where the virus has showed up most. (Note: The map showed California, Washington State, Colorado, and Texas and no other states until it got to Wisconsin and Tennessee.) So the15 top states for coronavirus are the 15 top locations where we're seeing volume right now." The Crisis Text Line offers an opportunity tobreak the stigma about taking about mental health and normalize what texters are feeling. To give them a safe place, to not judge, whatever they're going through, it's safe where we are in that conversatioon. A study of 1,257 doctors and nurses in China during that country’s coronavirus peak found that half reported depression, 45 percent anxiety and 34 percent insomnia. Before the pandemic, doctors and nurses were already acutely prone to burnout, research shows, because of the workload, pressure, chaos and increasingly dysfunctional health-care system. “We’re now hitting a period of uncertainty where a lot of people are asking themselves how long they can keep it up,” said Liselotte Dyrbye, a Mayo Clinic doctor and leading researcher on burnout. “The teapot can only boil for so long." A broken system when it’s needed the most This approaching wave of mental injuries will be met in coming months by a severely broken system. In the United States, 1 in 5 adults endure the consequences of mental illness each year. Yet less than half receive treatment, federal statistics show. As suicide rates have fallen around the world, the rate in the United States has climbed every year since 1999, increasing 33 percent in the past two decades. (Editor's Note: Suicide in the last 5 years in Oregon has risen 15%, but suicide amoung 10-24 year-old Oregonians has risen 35% from 2015-2023 - the most recent numbers) Part of the problem, experts say, is the markedly different way the United States treats mental illness compared with physical illness. In normal times, a heart attack patient rarely has trouble securing a cardiologist, operating table and hospital bed. But patients in mental crises, studies show, consistently struggle to get their insurance to pay for care. Even with insurance, they struggle to find therapists and psychiatrists willing to take that payment. Those who can afford it often end up paying out of pocket. Experts warn that such parity and access problems may only worsen with the pandemic, which has upended the functions of hospitals, insurance companies and mental health centers. In a joint letter Wednesday, leaders in mental health and substance abuse treatment pleaded for the Trump administration’s help. The letter — signed by the American Psychological Association, the American Psychiatric Association, the National Alliance on Mental Illness and 12 other organizations — asked federal officials to save community mental health centers facing financial collapse. The letter also asked the government to lift reimbursement restrictions that have prevented therapists from using phone calls to treat patients. On Thursday, the Trump administration indicated it would do so. A survey of local mental health and drug addiction centers showed the pandemic has already left many on the brink of financial collapse, preventing them from providing services that generate much of their reimbursement revenue. More than 60 percent said they would run out of funding in less than three months and had already closed some programs. In a letter to Congress in early April, mental health organizations estimated that $38.5 billion is needed to save treatment providers and centers and that $10 billion more is needed to respond to the coronavirus pandemic. On Friday, the federal substance abuse and mental health agency said it had been allocated less than 1 percent of the amount advocated by mental health groups — $425 million in emergency funding — and has awarded $375 million to states and local organizations. While Congress recently authorized $100 billion in emergency funds for hospitals and medical providers, very little will go to mental health and addiction service providers because they mainly receive funding through Medicaid. And most of the emergency provider money is being distributed through Medicare. “We are facing the loss of mental health centers and programs at a time when we are going to need them more than ever,” said Chuck Ingoglia, president of the National Council for Behavioral Health, which represents 3,326 treatment organizations. Glimmers of hope There are glimmers of hope, experts say, amid the gloomy outlook. The sudden push into telemedicine could make services more accessible in years to come. And the national mental health crisis could spark reforms and movement toward better treatment. And while almost everyone is experiencing increased stress, the effect for many will be transient — trouble sleeping, shorter fuses. The difficulty is identifying and treating those who develop deeper, worrisome mental problems such as post-traumatic stress disorder and severe depression. “To control the virus, it’s all about testing, testing, testing. And for the mental health problems ahead, it’s going to be all about screening, screening, screening,” said Gionfriddo of Mental Health America. For years, Gionfriddo’s nonprofit has offered questionnaires on its website — widely used in medicine — to help people screen themselves for mental-health problems. Since the pandemic began, those daily screenings have jumped 60 to 70 percent. And since February, the number of people screening positive for moderate to severe anxiety and depression has jumped by an additional 18,000 people compared with January. Speaking from her parents’ home in Pittsburgh, Ananya Cleetus said she has felt the increased strain. First came the closure of her school, the University of Illinois at Urbana-Champaign, bringing to an end her ambitious plans for the semester in computer engineering. Then came the loss of her therapist, forbidden by licensing rules from treating her across state lines. And social media didn’t help — all those posts of people baking bread and living their best #quarantinelife, making hers feel all the more pitiful. It was getting increasingly hard to get out of bed, said Cleetus, 23, who has bipolar disorder and helps lead a student advocacy group. “It took me a few weeks and talking to friends to finally realize this wasn’t just something wrong with me,” Cleetus said. Since then, she has poured her energies into creating a daily routine and an online guide for fellow students struggling with the pandemic and mental health. “This virus is messing with everyone. The anxiety, isolation, uncertainty,” she said. “Everyone’s struggling with it in one way or another.” If you or someone you know needs
help, call the National Suicide Prevention Lifeline at
800-273-TALK (8255). Crisis Text Line also provides free,
24/7, confidential support via text messageing to people in
crisis when they text SOS to 741741.
4th CCSD
suicide raises concern of mental health crisis during
COVID-19 pandemic 2:0 Josh Curtis says he has noticed a difference with his oldest son, Braxton. “It’s really sad. An 11-year-old child to see these kinds of behaviors,” said Curtis, a father of six. “He’s at the point now he just doesn’t care.” It is a recent shift in behavior for the normally active sixth grader. “He was in sports he was in dance,” Curtis said. “He was a star student previously in accelerated classes, and now he’s just not going to class and he just doesn’t care.'” Curtis attributes the change to the pandemic and distance education. “He’s even telling his friends he’s depressed every day,” Curtis said. Health experts are seeing similar situations. It causes concern as suicides continue happening this school year. Dr. Sheldon Jacobs with the Southern Nevada Chapter of the National Alliance on Mental Illness says there is a mental health crisis in our community. “We’ve had 4 deaths involving suicide amongst our Clark County School District students so that’s been very, very difficult,” Dr. Jacobs said. Along with suicides, psychiatric hospitalizations are also rising among children — a result of our current circumstances “Due to being more isolated. Being away from their friends not being in school physically,” Dr. Jacobs said. “We are seeing increasingly more incidents of suicide attempts and completion from kids younger than 12, even 8, 9, 10,” added Dinisha Mingo, CEO of Mingo Health Solutions. Curtis tells 8 News Now he is talking with his son and even considering counseling. “We’re trying what we can and at this point, we’re kind of at a loss,” Curtis said. The Nevada Coalition for Suicide Prevention says suicide is the leading cause of death for teens aged 12 to 19 in Nevada. For a list of mental health resources available for parents, CLICK HERE. There is also another resource parents
can turn to: Reggie Burton of the Avery Burton Foundation.
Burton’s organization was established to help families
and their loved ones who may be suffering silently,
sometimes leading to tragic outcomes. To read his tips on
talking to children about depression, mental health during
the COVID-19 pandemic and more, click
here.
Mental
Health, Substance Use, and Suicidal Ideation During the
COVID-19 Pandemic — United States, June 24–30,
2020 What is already known about this topic? Communities have faced mental health challenges related to COVID-19–associated morbidity, mortality, and mitigation activities. What is added by this report? During June 24–30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation. What are the implications for public health practice? The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers. The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged =18 years across the United States during June 24–30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic† (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18–24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic. During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys†† administered by Qualtrics.§§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2–8, May 5–12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals (2,3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** (4), and symptoms of a COVID-19–related TSRD were assessed using the six-item Impact of Event Scale††† (5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey.§§§ Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification,¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (a = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted†††† odds ratios (ORs), 95% CI, and p-values (a = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses. Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18–24 years (74.9%) and 25–44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey. Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, initiation of or increase in substance use to cope with COVID-19–associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18–24 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19–related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group. Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75–6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20–7.63; p = 0.019). Discussion Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) (2). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 (2). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) (6). Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers. The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19–specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic (7). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June (1). Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation (8), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide (9). Communication strategies should focus on promotion of health services§§§§,¶¶¶¶,***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19–specific screening instruments for early identification of COVID-19–related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently. † Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others. § Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was a person who had provided unpaid care to a relative or friend aged =18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. ¶ Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential versus nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers. ** A minimum age of 18 years and residence within the United States as of April 2–8, 2020, were required for eligibility for the longitudinal cohort to complete a survey during June 24–30, 2020. Residence was reassessed during June 24–30, 2020, and one respondent who had moved from the United States was excluded from the analysis. A minimum age of 18 years and residence within the United States were required for eligibility for newly recruited respondents included in the cross-sectional analysis. For both the longitudinal cohort and newly recruited respondents, respondents were required to provide informed consent before enrollment into the study. All surveys underwent data quality screening procedures including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the United States. Respondents who failed an attention or speed check, along with any responses identified by the data-scrubbing algorithms, were excluded from analysis. †† The surveys contained 101 items for first-time respondents and 86 items for respondents who also participated in later surveys, with the 15 additional items for first-time respondents consisting of questions on demographics. The survey instruments included a combination of individual questions, validated questionnaires, and COVID-19-specific questionnaires, which were used to assess respondent attitudes, behaviors, and beliefs related to COVID-19 and its mitigation, as well as the social and behavioral health impacts of the COVID-19 pandemic. §§ https://www.qualtrics.com/external icon. ¶¶ Survey weighting was implemented according to the 2010 U.S. Census with respondents who reported gender, age, and race/ethnicity. Respondents who reported a gender of “Other,” or who did not report race/ethnicity were assigned a weight of one. *** Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored =3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for these respective disorders. This instrument was included in the April, May, and June surveys. ††† Symptoms of a TSRD attributed to the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Those who scored =1.75 out of 4 were considered symptomatic. This instrument was included in the May and June surveys only. §§§ For this survey, substance use was defined as use of “alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor.” Questions regarding substance use and suicidal ideation were included in the May and June surveys only. Participants were informed that responses were deidentified and that direct support could not be provided to those who reported substance use behavior or suicidal ideation. Regarding substance use, respondents were provided the following: “This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the Substance Abuse and Mental Health Services Administration National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1-800-487-4889. This is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for persons and family members facing mental and/or substance use disorders.” Regarding suicidal ideation, respondents were provided the following: “This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the National Suicide Prevention Lifeline, 1-800-273-TALK (8255, or chat line) for help for themselves or others.” ¶¶¶ Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.htmlexternal icon. **** Odds of incidence was defined as the odds of the presence of an adverse mental or behavioral health outcome reported during a later survey after previously having reported the absence of that outcome (e.g., having reported symptoms of anxiety disorder during June 24–30, 2020, after not having reported symptoms of anxiety disorder during April 2–8, 2020). †††† Adjusted for gender, employment status, and essential worker status or unpaid adult caregiver status. §§§§ Disaster Distress Helpline (https://www.samhsa.gov/disaster-preparednessexternal icon): 1-800-985-5990 (press 2 for Spanish), or text TalkWithUs for English or Hablanos for Spanish to 66746. Spanish speakers from Puerto Rico can text Hablanos to 1-787-339-2663. ¶¶¶¶ Substance Abuse and Mental Health Services Administration National Helpline (also known as the Treatment Referral Routing Service) for persons and families facing mental disorders, substance use disorders, or both: https://www.samhsa.gov/find-help/national-helplineexternal icon, 1-800-662-HELP, or TTY 1-800-487-4889. ***** National Suicide Prevention Lifeline (https://suicidepreventionlifeline.org/external icon): 1-800-273-TALK for English, 1-888-628-9454 for Spanish, or Lifeline Crisis Chat (https://suicidepreventionlifeline.org/chat/external icon). References 1. CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm 2. CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January–June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERmentalhealth-508.pdfpdf icon 3. Czeisler MÉ, Tynan MA, Howard ME, et al. Public attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance—United States, New York City, and Los Angeles, May 5–12, 2020. MMWR Morb Mortal Wkly Rep 2020;69:751–8. CrossRefexternal icon PubMedexternal icon 4. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86–95. CrossRefexternal icon PubMedexternal icon 5. Hosey MM, Leoutsakos JS, Li X, et al. Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019;23:276. CrossRefexternal icon PubMedexternal icon 6. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdfpdf iconexternal icon 7. Horesh D, Brown AD. Traumatic stress in the age of COVID-19: call to close critical gaps and adapt to new realities. Psychol Trauma 2020;12:331–5. CrossRefexternal icon PubMedexternal icon 8. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatry 2008;53:769–78. CrossRefexternal icon PubMedexternal icon 9. Stone D, Holland K, Bartholow B, Crosby A, Davis S, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdfpdf icon Abbreviations: CI =
confidence interval; COVID-19 = coronavirus disease 2019;
PTSD = posttraumatic stress disorder; TSRD = trauma- and
stressor-related disorder.
Trends in
suicide during the covid-19 pandemic As many countries face new stay-at-home restrictions to curb the spread of covid-19, there are concerns that rates of suicide may increase—or have already increased.1 2 Several factors underpin these concerns, including a deterioration in population mental health,3 a higher prevalence of reported thoughts and behaviours of self-harmamong people with covid-19,4 problems accessing mental health services,4 and evidence suggesting that previous epidemics such as SARS (2003) were associated with a rise in deaths by suicide.5 Widely reported studies modelling the effect of the covid-19 pandemic on suicide rates predicted increases ranging from 1% to 145%,6 largely reflecting variation in underlying assumptions. Particular emphasis has been given to the effect of the pandemic on children and young people. Numerous surveys have highlighted that their mental health has been disproportionately affected, relative to older adults,3 7 and some suggest an increase in suicidal thoughts and self-harm.8 Supposition, however, is no replacement for evidence. Timely data on rates of suicide are vital, and for some months we have been tracking and reviewing relevant studies for a living systematic review.6 The first version in June found no robust epidemiological studies with suicide as an outcome, but several studies reporting suicide trends have emerged more recently. Overall, the literature on the effect of covid-19 on suicide should be interpreted with caution. Most of the available publications are preprints, letters (neither is peer reviewed),9 10 11 or commentaries using news reports of deaths by suicide as the data source.12 Nevertheless, a reasonably consistent picture is beginning to emerge from high income countries. Reports suggest either no rise in suicide rates (Massachusetts, USA11; Victoria, Australia13; England14) or a fall (Japan,9 Norway15) in the early months of the pandemic. The picture is much less clear in low income countries, where the safety nets available in better resourced settings may be lacking. News reports of police data from Nepal suggest a rise in suicides,12 whereas an analysis of data from Peru suggests the opposite.10 Any change in the risk of suicide associated with covid-19 is likely to be dynamic. The 20% decrease in Japan early in the pandemic seemed to reverse in August, when a 7.7% rise was reported.9 Evidence from previous epidemics suggests a short term decrease in suicide can occur initially—possibly linked to a “honeymoon period” or “pulling together” phenomenon.5 Trends in certain groups may be hidden when looking at overall rates, and the National Child Mortality Database has identified a concerning signal that deaths by suicide among under 18s may have increased during the first phase of lockdown in the UK.16 Preventive action We must remain alert to emerging risk factors for suicide but also recognise how known risk factors may be exacerbated—and existing trends and inequalities entrenched—by the pandemic. In 2019, suicide rates among men in England and Wales were the highest since 2000, and although suicide in young people is relatively rare, rates have been rising in 10-24 year olds since 2010.17 Tackling known risk factors that are likely to be exacerbated by the pandemic is crucial. These include depression, post-traumatic stress disorder, hopelessness, feelings of entrapment and burdensomeness, substance misuse, loneliness, domestic violence, child neglect or abuse, unemployment, and other financial insecurity.15 Appropriate services must be made available for people in crisis and those with new or existing mental health problems.14 Of greatest concern, is the effect of economic damage from the pandemic. One study reported that after the 2008 economic crisis, rates of suicide increased in two thirds of the 54 countries studied, particularly among men and in countries with higher job losses.18 Appropriate safety nets must be put in place or strengthened for people facing financial hardship, along with active labour market policies to help people who are unemployed obtain work.Responsible media reporting also has a role: promoting the importance of mental health support, signposting sources of help, reporting stories of hope and recovery, and avoiding alarmist and speculative headlines that may heighten risk of suicide.19 20 It is still too early to say what the ultimate effect of the pandemic will be on suicide rates. Data so far provide some reassurance, but the overall picture is complex. The pandemic has had variable effects globally, within countries and across communities, so a universal effect on suicide rates is unlikely. The impact on suicide will vary over time and differ according to national gross domestic product and individual characteristics such as socioeconomic position, ethnicity, and mental health. One guiding principle, however, is that suicide is preventable, and action should be taken now to protect people’s mental health. We must remain vigilant and responsive, sharing evidence early and internationally (such as in the International Covid-19 Suicide Prevention Research Collaboration 21) in these evolving uncertain times. Footnotes Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: AJ chairs the Welsh government’s National Advisory Group on Suicide and Self-harm Prevention. DG is a member of the National Suicide Prevention Strategy Advisory Group (England) and Samaritans policy and research committee. LA is co-chair of the National Suicide Prevention Strategy Advisory Group (England). Provenance and peer review: Commissioned; not externally peer reviewed. References 1. Gunnell D, Appleby L, Arensman E, et al., COVID-19 Suicide Prevention Research Collaboration. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry2020;7:468-71. doi:10.1016/S2215-0366(20)30171-1 pmid:32330430CrossRefPubMedGoogle Scholar 2. Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019: a perfect storm?JAMA Psychiatry2020. [Epub ahead of print.] doi:10.1001/jamapsychiatry.2020.1060 pmid:32275300CrossRefPubMedGoogle Scholar 3. Pierce M, Hope H, Ford T, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. Lancet Psychiatry2020;7:883-92. doi:10.1016/S2215-0366(20)30308-4 pmid:32707037CrossRefPubMedGoogle Scholar 4. Iob E, Steptoe A, Fancourt D. Abuse, self-harm and suicidal ideation in the UK during the COVID-19 pandemic. Br J Psychiatry2020;217:543-6. doi:10.1192/bjp.2020.130 pmid:32654678CrossRefPubMedGoogle Scholar 5. Zortea TC, Brenna CTA, Joyce M, et al. The impact of infectious disease-related public health emergencies on suicide, suicidal behavior, and suicidal thoughts: a systematic review. Crisis2020:1-14. [Epub ahead of print.] doi:10.1027/0227-5910/a000753 pmid:33063542CrossRefPubMedGoogle Scholar 6. John A, Okolie C, Eyles E, et al. The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review. F1000 Res2020;9:1097doi:10.12688/f1000research.25522.1CrossRefGoogle Scholar 7. O’Connor RC, Wetherall K, Cleare S, et al. Mental health and wellbeing during the COVID-19 pandemic: longitudinal analyses of adults in the UK COVID-19 Mental Health & Wellbeing study. Br J Psychiatry2020:1-17. [Epub ahead of print.] doi:10.1192/bjp.2020.212. pmid:33081860CrossRefPubMedGoogle Scholar 8. Zhang L, Zhang D, Fang J, Wan Y, Tao F, Sun Y. Assessment of mental health of Chinese primary school students before and after school closing and opening during the covid-19 pandemic. JAMA Netw Open2020;3:e2021482. doi:10.1001/jamanetworkopen.2020.21482 pmid:32915233CrossRefPubMedGoogle Scholar 9. Ueda M, Nordström R, Matsubayashi T. Suicide and mental health during the COVID-19 pandemic in Japan.medRxiv 2020 [Preprint.] doi:10.1101/2020.10.06.20207530Abstract/FREE Full TextGoogle Scholar 10. Calderon-Anyosa R, Kaufman J. Impact of COVID-19 lockdown policy on homicide, suicide, and motor vehicle deaths in Peru.medRxiv 2020.[Preprint.] doi:10.1101/2020.07.11.20150193Abstract/FREE Full TextGoogle Scholar 11. Faust J, Shah S, Du C, Li S, Lin Z, Krumholz H. Suicide deaths during the stay-at-home advisory in Massachusetts.medRxiv 2020. [Preprint.] doi:10.1101/2020.10.20.20215343Abstract/FREE Full TextGoogle Scholar 12. Pokhrel S, Sedhai YR, Atreya A. An increase in suicides amidst the coronavirus disease 2019 pandemic in Nepal. Med Sci Law2020:25802420966501. doi:10.1177/0025802420966501 pmid:33036544CrossRefPubMedGoogle Scholar 13. Coroners Court of Victoria. Coroners Court monthly suicide data report. Report 2. https://www.coronerscourt.vic.gov.au/sites/default/files/2020-10/Coroners%20Court%20Suicide%20Data%20Report%20-%20Report%202%20-%2005102020.pdf 14.National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide in England since the COVID-19 pandemic- early figures from real-time surveillance. 2020. http://documents.manchester.ac.uk/display.aspx?DocID=51861 15. Qin P, Mehlum L. National observation of death by suicide in the first 3 months under COVID-19 pandemic. Acta Psychiatr Scand2020.pmid:33111325Google Scholar 16. National Child Mortality Database. Child suicide rates during the covid-19 pandemic in England: real-time surveillance. 2020. https://www.ncmd.info/wp-content/uploads/2020/07/REF253-2023-NCMD-Summary-Report-on-Child-Suicide-July-2023.pdf 17. Iacobucci G. Suicide rates continue to rise in England and Wales. BMJ2020;370:m3431. doi:10.1136/bmj.m3431 pmid:32883661FREE Full TextGoogle Scholar 18. Chang SS, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ2013;347:f5239. doi:10.1136/bmj.f5239 pmid:24046155Abstract/FREE Full TextGoogle Scholar 19. Niederkrotenthaler T, Voracek M, Herberth A, et al. Role of media reports in completed and prevented suicide: Werther v. Papageno effects. Br J Psychiatry2010;197:234-43. doi:10.1192/bjp.bp.109.074633 pmid:20807970Abstract/FREE Full TextGoogle Scholar 20. Hawton K, Marzano L, Fraser L, Hawley M, Harris E, Lainez Y. Reporting on suicidal behaviour and covid-19—need for caution. Lancet Psychiatry2020. doi:10.1016/S2215-0366(20)30484-3.CrossRefGoogle Scholar 21 International Covid-19 Suicide Prevention Research Collaboration. https://www.iasp.info/COVID-19_suicide_research.php. Footnotes Provenance and peer review: Commissioned; not externally peer reviewed. Competing interests: The BMJ has
judged that there are no disqualifying financial ties to
commercial companies. The authors declare the following
other interests: AJ chairs the Welsh government’s
National Advisory Group on Suicide and Self-harm Prevention.
DG is a member of the National Suicide Prevention Strategy
Advisory Group (England) and Samaritans policy and research
committee. LA is co-chair of the National Suicide Prevention
Strategy Advisory Group (England). Suicide claimed
more Japanese lives in October (2020) than 10 months of
COVID - 11/11/20 To date, more than 17,000 people have taken their own lives this year in Japan. October self-inflicted deaths were up 600 year on year, with female suicides, about a third of the total, surging over 80%. Women, who have primary responsibility for childcare, have borne the brunt of pandemic-induced job losses and insecurity. They're also at greater risk of domestic violence, which help centers say has worsened here this year, as it has around the world. Child suicides, while a much smaller portion of the total, are also higher. "We need to seriously confront reality," chief government spokesman Katsunobu Kato said this week, announcing bolstered efforts to counsel potential victims via suicide hotlines and social media. Yokohama-based psychiatrist Chiyoko Ueda, in an interview published this week on a local news site, said the mental health distress caused by COVID was evident in her clinic. Among the things she said patients have told her: "My self-esteem is low because I'm worried about money; The stay-home situation has disrupted my life; My kids and I don't get along." Japan has grappled with high suicide rates for a long time and for complex reasons, but the overall numbers had been on a downward trend this year, until they reversed course in July — possibly as the initial "we're all in this together" pandemic positivity waned, and the buffering impact of public subsidies disappeared. That month Japan added an additional $10 million for suicide prevention, after $24 million was budgeted last spring. Until this year, Japan had been making steady progress to reduce suicides, which surpassed 34,000 in 2003. Improved counseling and efforts to combat karoshi, or being worked to death, helped bring down suicides to around 20,000 last year — the lowest number since record-keeping began in 1978. While Japan still has the highest suicide rate among the world's wealthy G-7 nations, at 16 per 100,000, it had hoped to continue making progress, with a goal of lowering it to 13 per 100,000 by 2026, a level comparable to other developed countries. The U.S. suicide rate, meanwhile, has been on the rise, passing 14 per 100,000 in 2018. "A mental health epidemic" Deteriorating mental health in Japan - which reports suicide data far more quickly than most countries - could prove to be a worrying harbinger of the pandemic's insidious impact elsewhere. Earlier this year, U.S. researchers warned that the pandemic could trigger 75,000 "deaths of despair," stemming from unemployment, lack of social contact and other mental health stressors. "We're in the midst of a mental health epidemic right now, and I think it's only gonna get worse," Dr. Vivian Pender, president-elect of the American Psychiatric Association, told CBS "Sunday Morning" recently. "You don't think the worst is over?" correspondent Susan Spencer asked her. "No, not at all. No, I think in a way the worst is yet to come, in terms of mental health. There's gonna be tremendous grief and mourning for all the lost people, and the lost opportunities, and the lost dreams and hopes that people had." More than half (53%) of American
adults said in a recent survey that their mental health had
suffered because of the pandemic. Prescriptions
for antidepressants shot up 14%
after the initial outbreak. Do
Face Shields Protect Against COVID-19? A Mask and Shield
Explainer The Centers for Disease Control and Prevention and the American Academy of Pediatrics both recommend all adults and children over age 2 wear a face mask in addition to social distancing, unless they have breathing difficulties or would be unable to remove the mask themselves. More than three-fifths of states now require people to wear masks in public, though some of these, such as Ohio, Texas, and Virginia, do not require children under 10 to wear masks. In addition, many states and school districts have required universal mask-wearing as a condition for in-person classes. Some, like South Carolina, have bought mask and other personal protective gear for their schools. Widescale mask wearing has been shown to reduce the spread of the virus, particularly in conjunction with social distancing and regular hand and surface cleaning. But there are drawbacks in an educational setting. “Covering the lower half of the face reduces the ability to communicate, interpret, and mimic the expressions of those with whom we interact,” said Manfred Spitzer, the medical director of the Psychiatric University Hospital in Ulm, Germany, and the founder of the Transfer Center for Neurosciences and Learning, in a recent study in the journal Trends in Educational Neuroscience. “Positive emotions become less recognizable, and negative emotions are amplified … [reducing] bonding between teachers and learners, group cohesion, and learning—of which emotions are a major driver.” In contrast to opaque masks, transparent face shields allow students to see a teacher’s full range of expressions—but do they really protect against COVID-19? How does COVID-19 spread in the air? The coronavirus that causes COVID-19 spreads through both large droplets and tiny aerosols that enter the air when someone who is infected speaks, sneezes, or coughs. The Centers for Disease Control and Prevention considers someone at higher risk of becoming infected if they come within six feet of someone with COVID-19 for a total of 15 minutes over the course of 24 hours. A brief, close argument can expose someone to more viral particles than people speaking softly, and studies so far suggest children produce similar amounts of the virus as adults do, though preadolescents appear to be significantly less likely to transfer the infection. Virus droplets are seen dispersing when someone wearing a face mask coughs or sneezes. As with the first set of images above, lasers highlight the emerging spray a) before the cough; b)after a half-second; c)after 3.8 seconds, and d) after 16.6 seconds. Virus droplets are seen dispersing when someone wearing a face mask coughs or sneezes. As with the first set of images above, lasers highlight the emerging spray a) before the cough; b)after a half-second; c)after 3.8 seconds, and d) after 16.6 seconds. —Source: Physics of Fluids "You know, kids will be kids; they will not use their inside voice; they may yell and they may talk very loudly," said Tina Tan, a pediatric infectious disease doctor at Lurie Children's Hospital in Chicago and a coronavirus expert with the Infectious Disease Society of America. "We know that when you do that, if you're infected, you actually generate smaller particles by which the virus can be transmitted.?And these smaller particles stay in the air for longer periods of time and travel for further distances. The aerosolized virus can also drift up in response to body heat, according to Jose-Luis Jimenez, a chemistry professor and aerosols expert at the University of Colorado, who developed an online transmission estimator to gauge how far the virus may spread under different conditions or using different kinds of masks. What does a mask do? Masks provide layers of fabric or other materials to filter airborne droplets and aerosols that carry the coronavirus particles. A dense cotton weave—or the random shred of multi-sized fibers in an N95 mask—tend to trap both larger and smaller particles more efficiently. To be most effective, masks need to be worn by all people who are within six feet of one another, and particularly those in enclosed spaces such as classrooms. Even if a mask only effectively traps half of virus particles as an infected person exhales, if their neighbor sits father away and also wears a mask, the chance of viral particles reaching them is significantly cut down. One recent study in the journal Infectious Disease Modeling found, for example, that if 4 in 5 people in New York wore masks that can screen half of viral particles (a common standard for properly worn surgical and cloth masks), it would reduce the projected death rate from COVID by as much as 45 percent over two months. Can I use a face shield instead of a face mask? No. Face shields are meant to be worn with, not instead of a face mask; they are often used along with masks, goggles, and head coverings. That’s because masks are meant to fit as tightly as possible to someone’s face, preventing droplets and aerosols from escaping around the edges. They need to fit snugly from just under the chin to the bridge of the nose. "When you look at somebody that wears a mask, there actually is a seal that forms," Tan said. "If you have a mask that's very loose and hangs on a person, it's not going to be very effective because the particles can actually fall through those cracks between the mask and your face. It's similar with a face shield that might cover the front but doesn't go around the sides." For the same reason, face masks with valves are not as effective at preventing the spread of the coronavirus; the valves make it easier for people to exhale, but that reduces the protection the mask gives to other people. A study in the journal Physics of Fluids this July shows how easily the virus can travel far from a face shield or from a mask worn improperly or with an exhalation valve. That can make a big difference when it comes to spreading the virus. For example, a study of the seasonal flu found face shields stopped a majority of large droplets after a cough by someone with the flu but did little to block smaller aerosolized particles of the virus. Within a half hour of someone coughing, these smaller particles dispersed through the room, and the face shield blocked only about 23 percent of them. The CDC does not recommend anyone use a face shield alone and is still evaluating how effective face shields are against the coronavirus when used with other protective gear. Homemade cloth masks containing at least two layers of fabric are considered more effective than wearing nothing, but the CDC does not consider homemade masks as real protective gear. They do not protect as well as a medical mask. Whether face masks are homemade or medical, teachers or students should check to make sure there are no gaps between the mask and skin on the nose, chin, or cheek. While health-care workers use commercial testing kits to ensure their masks fit properly, at least one study found that people could make an accurate test at home using an essential oil diffuser and a two-gallon bag. What should teachers do to help students see their faces? This can put teachers, particularly those of young children and English-language learners, in a difficult position. Spitzer noted that teachers may need to increase body language and voice expression to make up for smiles and other normal expressions that are likely to be covered by masks. Tan noted that some have recommended teachers use face shields in conjunction with regular cloth or surgical masks and remove the face mask during parts of a lesson that require students to watch the teacher’s mouth to help students follow their expressions better. The face shield can still help prevent larger droplets from getting on a teacher’s face or eyes if a student coughs or sneezes while they are close. But Tan cautioned that repeatedly lowering and raising a face mask during the day increases teachers’ exposure to the virus. In August, the U.S. Food and Drug
Administration also cleared a transparent plastic surgical
mask for use in hospitals and schools during the pandemic.
There have not yet been experimental studies comparing the
relative effectiveness of transparent versus cloth or fiber
face masks in reducing COVID-19 transmission. However,
Allysa Dittmar, the president of ClearMask, the company
which makes the mask, said it could be useful for
“those who can benefit from improved visual
communication, such as children, older adults, deaf and hard
of hearing people, and those who do not speak the same
language.” Intimacy,
sex, and COVID-19 A refresher course on how the coronavirus spreads Evidence shows that the virus spreads person-to-person through sustained close contact.
The definition of “sustained close contact” may change as we learn more, but running or walking by someone who has the virus is a lower risk scenario. Being in the same room as an infected person so that you’re breathing the same air for a while is a higher risk scenario. Expert opinion differs on what close contact entails and how many minutes of close contact is high risk. Generally, being within six feet of someone infected with the virus that causes COVID-19 for longer than a few minutes can put you at increased risk of getting the virus. How safe is intimacy with a partner? True, many forms of intimacy require a closer distance than the six feet of separation recommended by the Centers for Disease Control and Prevention (CDC). Yet this does not mean that you should isolate yourself from your spouse or partner and stop being intimate at all. If both of you are healthy and feeling well, are practicing social distancing and have had no known exposure to anyone with COVID-19, touching, hugging, kissing, and sex are more likely to be safe. Similarly, sharing a bed with a partner who is healthy should not be an issue. Be aware, though, that the CDC reports that some people may have the virus and not yet have symptoms during the early part of the incubation period (presymptomatic). Additionally, some people never develop obvious symptoms of COVID-19 (asymptomatic). In either case, it’s possible that the virus might spread through physical contact and intimacy. What about intimacy if one partner has been ill? If you or your partner have been sick with COVID-19 and are now recovering, this CDC page explains ways to prevent the spread of germs, including not sharing bedding –– or presumably, a bed –– and abstaining from all intimate contact until
However, one study suggested that the virus may shed for up to 14 days, so you may want to minimize contact for up to 14 days. During this time, the person who is sick should self-quarantine and limit use of common spaces as much as possible. It’s important to wipe down all common surfaces, wash all bedding, and take other steps recommended by the CDC if a person is ill. The good news? Public health authorities in Shenzen, China found that there was a 14.9% transmission rate among household contacts. Risks to household members are minimized through steps that include self-quarantine for the person showing signs of illness and excellent hand hygiene for the whole household. What if your partner works in a job where there’s a high risk of catching the virus? If your partner works in a high-risk field such as healthcare or has contact with the general public, decisions around intimacy or even self-quarantine in the absence of symptoms are personal. Some healthcare workers have quarantined themselves from their families, while others practice good hand hygiene and have a separate set of clothing dedicated for work. You and your partner should discuss what you are both comfortable with, since there are no evidence-based guidelines currently, given that this is a novel virus. What about starting a new relationship? For those people who would like to start a new relationship, that should be considered carefully. All of us should be practicing social distancing at this time due to the pandemic, and dating does not comply with recommendations for social distancing. While this time is challenging, social distancing is of the utmost importance to keep you and your loved ones safe. Are any forms of intimacy and sex completely safe right now? Six feet of separation required by social distancing may not entirely slow you down. Masturbation, phone sex with a partner who doesn’t live with you, and sex toys (used just by you) could play a big role in sexual intimacy, particularly in this moment. And if you’re not in the mood for sex and are wondering how anyone can engage in intimacy in this moment, that’s also normal. People have different psychological responses to stress. If living through a pandemic has dampened your sexual desire, it will return once life returns to normal. If you do have a regular intimate
partner, keep in mind that coronavirus is not the only issue
that you should be concerned about. You should use
contraception if you are not planning on conceiving, and you
should use a condom to protect against sexually
transmitted infections. For
more information, see the Harvard
Health Birth Control Center. No
one knows why these Covid-19 patients’ symptoms keep
relapsing On April 11, more than a month after she first fell ill with Covid-19, Melanie Montano spritzed perfume around her bedroom to test her senses. She couldn’t smell anything. The next morning, Montano woke up and noticed a “faintly fragrant” scent; her symptoms were finally subsiding. She had more energy for household chores, phone calls with friends, and remote work. “I felt a massive wave of encouragement zap me back to life,” said Montano, 32, who lives in New Jersey. Then, five days later, fever, shortness of breath, and crippling gastrointestinal issues suddenly returned. “This has been the pattern, on-and-off, ever since.” Now, more than two months after she first fell ill, Montano still has symptoms. In May, the World Health Organization announced that Covid-19 recoveries were taking longer than expected and that some patients were experiencing what appeared to be a “relapse” of symptoms. This contradicted an earlier WHO report, which stated that recovery for non-severe Covid-19 cases should only take two weeks. That guidance has been questioned, as more stories of long recoveries and lingering symptoms emerge. It’s too early to really know what is causing symptom relapse, according to several physicians I spoke to, but almost all of them reported treating or hearing about patients who had cycling symptoms. Doctors and research scientists aren’t sure whether potential relapses mean patients are still infectious — and whether the recurrent symptoms are from other infections, viral reactivation, chronic post-viral conditions, or the virus simply taking its normal course. For patients who think they’ve recovered from Covid-19, symptom relapses can be emotionally, physically, and financially devastating. For researchers looking for answers, the relapses remain one of the ongoing mysteries of Covid-19. When it just keeps coming back In researching symptom relapse, I spoke with more than a dozen patients who believed they’d experienced the return of symptoms at least once during their lengthy recoveries from Covid-19. Almost all first became sick in March, tested positive for Covid-19 within the following month, and are still experiencing symptoms today. Most sought medical care during their perceived symptom relapse(s), but few were satisfied with the advice they got. Susan Nagle, 54, of Massachusetts, first experienced symptoms in late March and tested positive in April. A month into her illness, her symptoms began to disappear. She was finally fever-free, and her fatigue, chest pain, and shortness of breath improved significantly. “I was starting to be able to get projects done around the house ... and I realized I wasn’t walking around with my pulse oximeter,” Nagle said. Then, on May 9, Nagle’s fever returned, spiking at 101 degrees Fahrenheit. Eventually her chest pain and breathlessness came back, as well. Today, Nagle is battling symptoms that she says are “worse than they were at the start.” Susan Nagle first experienced chest pain, shortness of breath, fatigue, and fever in late March. After a reprieve in April, her symptoms returned in early May. Courtesy of Susan Nagle Cara Schiavo, 31, of New Jersey, experienced a similar episode. She tested positive for Covid-19 on March 10 and was sick with fever, shortness of breath, and chest pain. On week four, her symptoms started to subside. “I felt like I was getting back to my old self,” Schiavo said. “I started walking, exercising, and even told family and friends [I’d] recovered.” A week later, her symptoms returned, along with new dermatological and GI issues. “Relapse to me is a scary word,” Schiavo said. Until the WHO’s recent announcement, it was mostly just Covid-19 survivors and patients using the word “relapse.” Until she joined an online support group where others were discussing it, Montano said, the concept of “relapse” felt like a “feverish supposition.” Nagle said she doesn’t think of her experiences as relapses. “I think this is [just] what it means to have Covid-19,” she explained. Not knowing if they’re infectious, relapsed patients are staying home from work and fear their illness will get worse Many of the patients I spoke with have not been able to return to work, even remotely, because they still feel sick, and some fear that excess activity triggers their symptom relapses. None have received confirmation from doctors about whether they’re still infectious. Montano and Schiavo sought medical care when their symptoms returned, but neither was satisfied with the answers they received. “My [primary care doctor] was less than helpful,” Montano told me. Schiavo says her doctor dismissed her symptoms as anxiety. After three months of isolating at home, Montano relapsed again in late May, and her doctor suggested she be retested for Covid-19. She went to a drive-through testing center, where she had to self-administer a nasal swab, and received a negative result. The test result confused Montano, given her recurrent fever and other symptoms, but she has continued to isolate at home in case she is still infectious. Daniel Kuritzkes, the chief of the division of infectious diseases at Brigham and Women’s Hospital in Boston, says that patients returning to work face “a real challenge,” given the lack of information on contagiousness. When asked whether patients like Montano should be concerned about returning to work due to their lingering symptoms, Kuritzkes said, “We don’t have a good answer for that at the moment.” The question of when to return to work is especially confusing for health care workers and others who employers sometimes require to test negative before they can resume their jobs, he added. Angela Aston, 49, is a registered nurse in Texas who contracted Covid-19 in late March while treating a patient. She hasn’t returned to work since April 23, when she thought she had recovered from the virus, after being fever-free for 72 hours. But at the end of her shift that day, Aston noticed she was feeling “shaky and weak,” and by the following afternoon, her fever and shortness of breath had returned. “I was confused [and] anxious,” Aston told me. “I had a meltdown in the staff lounge.” While Aston is eager to return to work, none of her doctors know if she’s actively infectious, and she says her workplace has “no idea” when it would be safe for her to return. “The [CDC’s] return-to-work guidelines say three days no fever, but those guidelines are not appropriate for me,” Aston said. “People freak out if a person with recent Covid-19 has an elevated temperature and wants to be around them. Even if it has been 10 days with no fever.” Aston has been retested three times — one negative result, followed by two positives. Since return-to-work guidelines vary and retesting can be unreliable, many relapsed patients face confusion and financial distress. Zackary Berger, a primary care doctor and associate professor at the Johns Hopkins School of Medicine, thinks retesting relapsed patients isn’t helpful because the test results aren’t always reliable. Some researchers estimate the rate of false negatives to be around 30 percent, due in part to discrepancies in how tests are administered and the variety of types of tests that are being used. A recent study from South Korea suggests that patients may test positive even after they have fully recovered and are no longer infectious. Because the 285 survivors did not appear to have infected any of their 790 close contacts, and the virus in their samples did not appear to be alive, researchers now believe tests may be picking up small remnants of the virus that remain in the body even after recovery. Berger says he sees many patients who need documentation that they’re virus-free to return to work, but his institution does not recommend retesting, given the concerns about current testing methods. The Centers for Disease Control and Prevention recommend guidelines for health care workers returning to work after being sick, which are dependent on test availability and follow either a test-based strategy (fever and respiratory symptoms have improved, and the worker has tested negative) or a symptom-based strategy (the worker has been fever-free for 72 hours and 10 days have passed since symptoms first appeared). Aston wants to go back to work and is frustrated by the duration of her illness. “When am I going to be free from this?” she asked. “For another 10 days? 20 days? Because my fever always comes back.” Montano feels similarly alone. “I felt anxious, I felt confused, and I felt the need to slap on a facade that aligned with the speedy, two-week recovery period depicted in the news,” she said. Aston knows she’s lucky to still be earning wages, even though she can’t return to work. On May 4, almost two months into her illness, Montano lost her job as a post-graduate academic writing instructor, when the position was made redundant. Now, Montano’s struggling to find a new source of income, while managing her recurring symptoms. “The job-hunting process is already work in itself, and it’s been exhausting having to push myself harder than my body is able to,” Montano said. “My first inclination is to tackle the job search with full-force, but the stark reality is my debilitating fatigue continues to impede any successful attempts to be proactive.” Aston has found her fever often returns after she gets out of bed and moves around. One doctor she consulted suggested she stay in bed to avoid future relapses. She found this advice unrealistic. “Not a single health care provider has offered any solid, tangible guidelines on what to do next to address my issues,” she said. For patients like Montano, Nagle, and Aston, who say they can’t see an end in sight, long-term impacts may be physical, mental, and financial. Gary Phelan, an employment lawyer in Connecticut, told me the Equal Employment Opportunity Commission has not yet decided whether Covid-19 will be recognized as a disability under the Americans with Disabilities Act because the virus is so new. Phelan, who has represented Covid-19 patients, says “until the EEOC takes that position it will lead to more uncertainty and, as a result, ... more Covid-19 victims losing their jobs or not being accommodated.” We don’t know why people are relapsing. Here are some early guesses. Based on the limited understanding of Covid-19, here are four possible explanations for patients who seem to experience symptom relapse. All are currently theoretical; the physicians I spoke to warned that science and medicine are still struggling to catch up with the novel virus. We don’t yet have hard evidence that any of these explanations are the true culprit, and other infections may explain symptom relapse, too. 1) The virus might be reactivating. The word “relapse” implies a resurgence of something previously dormant or nonexistent, and many patients I spoke to assumed they’re experiencing some kind of viral reactivation. According to Bernard P. Chang, an emergency physician and psychologist at Columbia University in New York City, “viral reactivation is the concept that a latent or ‘not active’ virus that is already within your system ‘awakens’ or switches to an active phase and begins causing symptoms in patients.” Viral reactivation is well known in other illnesses, such as herpes, which remains dormant in between outbreaks. But it’s not a proven (or disproven) aspect of the new coronavirus. Kuritzkes thinks it is unlikely that SARS-CoV-2 can reactivate because the virus infects and spreads differently than ones that do so. Right now, this is a possibility, but we don’t yet have scientific data either way. 2) People might be getting reinfected. Can someone get the coronavirus, completely clear it from their system, and then catch it all over again? The answer would depend on whether people can develop immunity to the coronavirus (and if so, for how long). Scientists and researchers are urgently trying to answer this question, as governments all over the world pin hope on a wave of immune survivors who can travel freely and revive the economy. Recent studies on immunity bode well for the possibility, but the WHO warns there’s no guarantee. One such experiment found that rhesus macaques monkeys that were infected once were not able to be reinfected. But that’s just one study, and a lot of research remains to be done. In order to determine if humans can become immune, scientists will need to further study B cells and T cells (which help to create antibodies), improve the accuracy of antibody tests, and determine what level of antibodies confirm some level of immunity. 3) It might be the normal course of Covid-19. Jeremy Faust, an ER doctor and colleague of Kuritzkes at Brigham and Women’s Hospital in Boston, told me that mild viral symptoms often “return or get a little worse after initially recovering,” citing the common cold as one example. “Some may simply have coronavirus symptoms that come and go, but slowly improve over time, like a pendulum running out of energy,” he explained. “I can’t think of any illness that doesn’t ebb and flow in terms of symptom resolution, to some extent. So in that regard, coronavirus may be no different.” 4) Relapses might be chronic post-viral syndromes. Many of the patients I spoke with were concerned their condition might be chronic because of how long their symptoms had lasted and how regular their relapses were. “My fear is that ‘relapses’ are my new normal and this has done permanent damage,” Nagle told me. “I have yet to hear a story of someone who has had the same symptoms for the same length of time and are now back to whatever they called normal before they were infected.” Despite some patients’ fears that their symptoms will never end, Kuritzkes is optimistic. He urges people facing nonlinear recoveries to “not get discouraged” though they should speak to a health care provider if they experience high fevers, joint swelling, or persistent fatigue. “Based on what we know about coronaviruses generally, it is very likely that all of these individuals will completely recover,” he said. Kuritzkes, Chang, and Berger all mentioned post-viral syndromes as a possible explanation for symptom relapse — although Kuritzkes doesn’t think such post-viral syndromes are likely to be common — and many patients I spoke with had received similar information from their doctors. Neil Stone, a specialist in tropical and infectious diseases at University College London Hospitals, recently tweeted that he’d seen an uptick in hospitalizations of patients recovering from Covid-19 and theorized that the “wide array of covid phenomena which we don’t yet understand ... may one day come to be known as Post Covid Syndrome.” According to Kuritzkes, post-viral fatigue syndrome, for instance, is sometimes found in patients who’ve had mononucleosis, among other infections. “I’ve heard anecdotally of some [Covid-19] patients who seem to be experiencing something akin to that,” he explained. “Since we’ve only got three to four months of experience in the United States, it’s very hard to say what proportion would go on to develop ... some form of post-viral fatigue syndrome.” Some researchers are also concerned that Covid-19 might trigger ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome), after noticing that some patients with pre-existing ME/CFS experienced an exacerbation of those symptoms after contracting Covid-19. The Open Medicine Foundation, an organization dedicated to ME/CFS research, recently announced a study that will examine the prevalence of potential chronic conditions like ME/CFS in patients with Covid-19. Another possibility Kuritzkes suggests is that patients with relapsing symptoms may be experiencing an inflammatory syndrome similar to Kawasaki disease, which has recently been linked to cases of Covid-19 in children and young adults. It causes an inflammation of blood vessels that can lead to severe cardiac complications. However, we don’t yet know if this syndrome can develop in people of all ages. Like many other aspects of the current
pandemic, the question of relapse remains unanswered, and
the stakes are increasingly high. Almost 2 million people
have been diagnosed with Covid-19 in the US alone, and
experts believe infection
rates may peak again in the fall.
Stories of relapsed patients indicate that those who fall
ill and survive may still face devastating consequences of
the disease. Supporting
Teenagers and Young Adults During the Coronavirus Crisis Here are some tips for parenting teenagers (and young adults suddenly home from college) during this time. Emphasize social distancing The first challenge with teens and young adults may be getting them to comply with the guidelines for social distancing. Teenagers tend to feel invincible, points out David Anderson, PhD, a clinical psychologist at the Child Mind Institute, and they may think that the new coronavirus is not as problematic for their age range as it is for older people. Parents are reporting a lot of pushback when teens are told they can’t go out and get together with friends. “They want to see their friends, and don’t see why the social distancing should apply to them,” says Dr. Anderson. Parents are asking what to tell them. “Our answer is that exposure to this virus is an exponential thing, and that it’s not really about them,” says Dr. Anderson. “It’s not really about the fact that they feel fine. It’s the fact that they could be asymptomatic carriers and they could kill others, including their grandparents.” One thing to emphasize, he adds, is: “You just can’t know that your friends are well. And while you may be comfortable taking that risk, you’re also bringing that back in your house.” It’s also important to help your teenagers understand that no one really knows yet how the coronavirus affects people of different age groups — contracting the virus might be very dangerous for your teenager, even though the facts are still unclear. Understand their frustration over not seeing friends For teenagers and young adults, friends are hugely important, and they are supposed to be — bonding with peers is one of the essential developmental tasks of adolescents. If your teen is sulking about being stuck at home with parents and siblings, a direct conversation might be helpful, says Rachel Busman, PsD, a clinical psychologist at the Child Mind Institute. Acknowledge that you know it’s frustrating for them to be cut off from friends. Listen to what they’re feeling, validate those feelings and then be direct about how you can work together to make this situation bearable. Loosening rules about time spent on social media, for instance, will help compensate for the socializing time lost with school closings. Encourage them to be creative about new ways to interact with their friends socially. Support remote schooling Parents are reporting feeling pressured and confused about how to help kids with remote learning. With younger children, notes Dr. Anderson, it’s more a matter of finding fun activities that can be educational. But with older students, keeping up with expectations from school can be challenging, especially for those with ADHD, learning disorders or organization issues. “I’m completely overwhelmed by trying to figure out how to structure a school day,” one mom told us. “I was never planning on homeschooling my kids. I don’t have training in this.” You can help teenagers — and college students who’ve been sent home — create a realistic schedule for getting work done in defined periods, building in breaks and times for socializing, exercising and entertainment. The key principle: do a session of work first, then reward yourself with something relaxing. Keep in mind that it’s not going to be as effective as school, but it may get to be more effective over time as everyone on the school front, as well as the home front, works to improve remote learning. Encourage healthy habits Teenagers and young adults will do better during this stressful time if they get adequate sleep, eat healthy meals and exercise regularly. Keeping a consistent sleep schedule, with predictable times to wake up and go to bed, is especially important to maintaining a positive mood and their ability to fulfill academic expectations. Some ideas to keep moving include:
Healthy habits are particularly important for young people who may be struggling with anxiety or depression. Losing the routines you’ve come to rely on can be a big source of stress, so Jill Emanuele, PhD, a clinical psychologist at the Child Mind Institute, recommends establishing new routines. “Make sure you’re eating properly and sleeping and being social and engaging in pleasant activities, ” she says, while also warning that young adults should avoid sleeping too much when they’re housebound. “There’s more of an ability to sleep at home, and while rest is important right now you still need to be active.” Dr. Emanuele also notes that having family members around more often can feel overwhelming or create strain. “Families will need to diffuse tensions in the home with parents and siblings, because everyone is going to be stressed out more,” she says. “How to do it will be different for every family, but parents are going to want to think about when to give young people more freedom and how to make sure that their kids’ time is still structured. Everyone should be contributing in some way.” Validate their disappointment For many the most painful part of the coronavirus crisis will be losing important experiences: high school sports seasons, proms, theater productions, high school and college graduations. And while we’re all missing out on very valued activities, adds Dr. Anderson, “it’s especially problematic for teenagers who are wired in their brains to think about novelty and pleasure seeking and seeking out new frontiers to be limited in this way.” Give them room to share their feelings and listen without judgment (or without reassuring them that everything will be fine). Some will be worried about missing activities expected to help them with college applications and scholarships. Kids are understandably wondering how this will affect their futures. Again, give them room to share how they are feeling and acknowledge the real stress they may be under. Then express confidence in your child’s ability to rebound. Help them practice mindfulness Mindfulness techniques can be very helpful in this kind of situation, where our routines are disrupted and we may feel overwhelmed by frustration and disappointment. Mindfulness teaches us to tune into our emotions in any given moment and experience them without judgment. In what’s called “radical acceptance,” we let ourselves sit with our emotions rather than fighting them. As Joanna Stern, PsyD, a clinical psychologist at the Child Mind Institute, explains, “You tell yourself it’s okay to feel anxious right now. It’s okay to feel scared. It’s okay to feel angry. You’re accepting the feelings you have and validating them because we’re all having those feelings. It’s really important that you accept them as they are rather than fighting them.” In other words, says Dr. Stern,
“We say to ourselves: ‘This sucks, and I’m
going to be sad about it, and I’m going to be angry
about it, and I’m going to feel anxious about it,’
or whatever it is. This then allows us to move on and say,
‘Okay, so now what needs to be done?’” Stories
from Oregon show how small gatherings can lead to big
spread Today, State Health Officer Dr. Dean Sidelinger shared some stories about how we’ve seen COVID-19 spread in our communities starting from seemingly harmless gatherings: In the first example, 10 people got together for a family party, and two people at the party were likely infectious at the time, though they did not have symptoms. In total, those two cases have led to 20 reported cases spread across 10 households. At least two of the people work with vulnerable populations. One person lived in a multi-generational house with family members with high-risk conditions. So even though the people who went to the party weren’t at higher risk for complications, many of the people who got sick potentially exposed people who are more vulnerable. In the second example, 20 people rented a beach house for a celebration and were together for three days. No one had symptoms during the trip, but four were potentially infectious at the time. Twelve people from the trip got sick, all adults of various ages. These cases then had links to five workplace outbreaks, with a total of more than 300 cases so far. These examples show that even a small number of people, if they have multiple exposures, can lead to large numbers of cases. OHA Director Patrick Allen cautioned everyone to rethink their celebration plans as the Labor Day holiday approaches:
Source: OHA Coronavirus
Update 8/27/20 Coronavirus:
How is America Feeling? Part 10 - MAY 22, 2020 1. Many of our top issues have shifted significantly pre and post-COVID. Suicidal ideation has decreased as a percentage of our conversations.Pre-COVID (Jan 2020 till mid-March 2020): 29% of conversations. Post-COVID (mid-March till now): 22% 2. Race, with a focus on LatinX texters (source: Texter Survey) In prior updates, we’ve mentioned how some races and ethnicities are being disproportionately impacted by COVID:Asian Americans are experiencing 3x higher rates of racism and discrimination compared to other texters. 3. Job Loss and Finances Mentions of job loss remain high but may be cresting: last week, 29% of conversations mentioned job loss or financial issues; this week, it’s down to 28%. 4. Self-Care (Data is from the last two weeks, highest value by row marked in green) By Gender Texters who identify as female are more likely to rely on helping friends and family as a form of self-care, By Race Two populations disproportionately impacted by the coronavirus outbreak, American Indian / Alaska Native and Asian, are currently more likely than other races/ethnicities to use most forms of self-care. By household Income Texters from households with incomes below $20K (per year) and >$75K are most likely to help friends and family as a form of self-care and resilience. Source: www.crisistextline.org/mental-health/coronavirus-how-is-america-feeling-self-care-part-10/ Dealing with
Coronavirus How to Deal with Isolation Even in Isolation, you’re not alone. Text HOME to 741741 for free, 24/7 support at your fingertips. Change is hard. This kind of rapid change is especially hard. In an effort to slow the spread of Coronavirus (COVID-19), schools have closed for the year and businesses have shuttered indefinitely. Health officials are imploring the public to stay home and cancel any in-person social interactions. Weddings? Proms? Coffee with friends? All canceled. A few things that aren’t canceled? Empathy. Kindness. Our faith in humanity. These mandatory closures in the interest of public health are causing massive disruptions in everyday life. And, while the first few days of isolation may feel like a welcome chance to lay low for a bit, here’s the reality: the news is scary, we’re in this for the long haul, and lack of human interaction can feel really freakin’ lonely. Here are some ways to prioritize your mental health if you’re feeling anxious and lonely:
For Students Even if school every day can be the worst, finding out it’s canceled for the rest of the year is an entirely different story. That means no more learning, seeing friends, or special traditions like prom or graduation. There’s no sugar coating it—that sucks. Here are a few tips to cope with the disappointment.
For Parents School closures have really thrown a wrench in everyone’s lives. Many parents rely on schools and daycare so that they can get to work to support their families. With kids stuck at home, many parents are forced to homeschool their kids while also keeping up with work remotely. Nothing about it is easy—in fact, it’s really hard shit. Here are a few ways to keep your mental health in check. Stick to a routine. This one can be hard considering everything about your routine has been flipped on its head… Still, maintaining some sort of schedule can be helpful to create a bit of normalcy in this unexpected and anxiety-inducing situation. Collaborate. If you have a partner who is also working from home, try alternating shifts of who is looking after the kids. And, communicate your needs to your team! Everyone has to be a little flexible right now—even your coworker who needs to pivot so you can take care of your family. Flexibility. Parents need time to focus on themselves too, so scrap those electronics limits! Be kind. Seems simple, but for real: you deserve kindness. From yourself. From your family. From your kids. From your coworkers. You’re doing the best you can. We’re here to talk about it if you need to vent. Text HOME to 741741 to connect with a Crisis Counselor. For Financial Stress In many ways, the rapid change to the economy is just as scary for a lot of folks as COVID-19 itself. Layoffs are happening immediately, freelancers aren’t able to book jobs, and for most of the country that already lived paycheck to paycheck, the loss of work is detrimental. This change can drum up anxiety about how to stay safe and healthy while also supporting your family. We hear you. It’s hard. You deserve to grieve. It’s okay to be scared. We can’t make it better, but we can listen. Text HOME to 741741 to reach a Crisis Counselor or message us on Facebook. For Healthcare Workers Healthcare workers, you’re
heroes. Truly. The impending pressure on the healthcare
industry means that you’ll be working harder, faster,
and smarter to save as many lives as possible. And,
you’ll do it all understanding the great risk to your
own health. It’s understandable to be overwhelmed by
this. You matter. Your life matters. We can’t make
everyone healthy, but we can support you. If you’re on
the front lines and need mental health support text HOME to
741741 to reach a Crisis Counselor. We know you have our
back. Having yours is the least we can do. Working
Moms Bear Brunt of Home Schooling While Working During
COVID-19 - 8/18 While there was no immediate impact on detachment or unemployment, working mothers in states with early stay-at-home orders and school closures were 53.2% more likely to take leave from their jobs than working mothers in states where closures happened later, according to new research by the U.S. Census Bureau and Federal Reserve. Of those not working, women ages 25-44 are almost three times as likely as men to not be working due to childcare demands. While one study found that dads increased their childcare role during the pandemic, it also showed moms spent the most time in caring for children. Around one in five (18.2%) of working-age adults said the reason they were not working was because COVID-19 disrupted their childcare arrangements (Figure 1). Of those not working, women ages 25-44 are almost three times as likely as men to not be working due to childcare demands. About one in three (30.9%) of these women are not working because of childcare, compared to 11.6% of men in the same age group. Parents who kept their jobs during the stay-at-home orders had limited options: to take paid or unpaid time off, quit or adjust work hours to nonbusiness hours such as evenings or weekends to care for children. School closures and stay-at-home orders particularly affected working moms but had no immediate impact on fathers’ leave or leave of women without school-age children, according to the new study. In addition, the experimental Household Pulse Survey started by the Census Bureau in response to COVID-19 has looked deeper into the dynamics of how working parents are balancing it all within their households and the unique anxiety they feel when caring for young children in this environment. Working Moms Bear the Brunt As the weeks wore on, the percent of mothers age 25 to 44 not working due to COVID-19 related childcare issues grew by 4.7 percentage points, compared to no increase for similar men Among working adults who did not have anyone in their household experience a loss of income due to the COVID-19 pandemic, 9.5% of those in households with children had low confidence in paying next month’s mortgage compared with 4.9% in households without children under age 18. Among women, this difference was 10.2% and 6.3%, respectively. Among these same working women, 22.8% of those in households with children had low confidence in their ability to afford food for the next four weeks compared with 16.7% of those without children in the household. Working-age women in households with children were more anxious than men: 36.9% versus 30.0% reported being anxious more than half the days or nearly every day. These women also reported more worry: 32.3% compared with 25.3% of men. Unsung Heroes Parents are among the unsung heroes of this crisis. They have adapted their households and juggled work, children’s schooling and other household needs. However, the pandemic uniquely affected mothers’ work in formal labor markets. (Editor's thought: And the pandemic uniquely affected fathers having to work out-side the home since men are more ceceptible to the virus than are women.) As the nation moves forward in this
crisis, research shows that particular attention will need
to be paid to schooling and child care, not just for the
sake of the children but also for working moms.
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