Abstract
The unprecedented impact of the COVID-19 pandemic has caused havoc in various realms of life. The psychological impact of the pandemic has already presented in the form of fear and uncertainty, acute reaction to stress, disturbances in sleeping and eating patterns, anxiety, depression, post-traumatic stress disorder and suicide attempts and completed suicides (Joseph, Gunaseelan, et al., 2020; Klomek, 2020; Nayar et al., 2020). Suicide is probably going to become an even more major concern as the pandemic unfolds (Gunnell et al., 2020). Literature has pointed out towards the probability of increase in rates of suicide attempts and completed suicide during the pandemic, though exact numbers are not yet known (Sher, 2020a, 2020b; Thakur & Jain, 2020).
Psychological issues which could lead to suicidal thoughts include social isolation, anxiety, fear and uncertainty (of getting infected/of infecting others/of availability of specific treatment or vaccinations in the near future), poor sleep quality and eating habits (Sher, 2020a, 2020b). Exacerbation of mental health issues in those already diagnosed with mental health issues, relapse of illness due to disruption in treatment compliance and limitations in reaching to hospitals and, alcohol and substance use (Joseph, Shoib, et al., 2020), may also be responsible for the surge in suicidal behaviour. Social factors which could lead to suicidal thoughts currently include financial crisis, unemployment, restricted supplies of essential commodities, intimate partner violence, school closures (causing poor child growth/increased exposure of certain children to violence at home/missing mid-day meals for those dependent on it), being in vulnerable groups (homeless/jobless persons/children/older adults), those diagnosed with COVID-19, burnout in frontline healthcare workers, family members of affected persons, hospitalization in COVID-19 critical care units, stigma and discrimination regarding the outbreak as well as, mental health issues due to it, restrictions to participate in religious congregations or to visit religious places and, an ‘infodemic’ phenomenon including misinformation, rumours and conspiracies (Gunnell et al., 2020; Joseph, Mishra, et al., 2020; Joseph, Singh Bhandari, et al., 2020; Sher, 2020b).
Suicide prevention and timely intervention: consensus recommendations
Evidence-based suicide prevention strategies focusing on the COVID-19 pandemic have been laid out by the World Psychiatric Association (WPA). The strategies include – a) restricting access to lethal methods of suicide (restricting sales of – firearms, pesticides, medications per person); increasing awareness among the public about the safe storage of potentially lethal objects. b) Interventions to reduce the harmful use of alcohol, restricting the sale of alcohol, at the same time, increasing awareness among both at risk and the general population about the effects of alcohol. c) Continue gatekeeper training through online mode and, increase the number of volunteers to participate in the program through awareness. d) Raising awareness about mental health and suicide among youths through school-based interventions as soon as school re-opens. e) Ensuring adherence to the World Health Organization (WHO) guidelines for responsible media reporting and avoiding sensationalizing pandemic related suicide. e) Providing financial support to the mental health care services, ensuring accessibility to the services, developing telemedicine services and providing mental health support to the frontline healthcare workers. f) Remote assessment and management (if not in person feasible) of both people with mental disorders and those who are at-risk and ensuring continuity of care of people with mental disorders. g) Increasing awareness about the possible negative effects of the pandemic and, educating about the mental health resources available (Wasserman, 2020).
Recognizing psychological and social factors related to the current mental health issues and suicide is very important. During such times, focus may be given more for those who are already on psychiatric treatment and this would lead to loss of attention to others in crisis. For an exemplar; a person who never underwent psychiatric treatment may suffer from worry and sleep disturbance during this pandemic, but, his issues may not be identified or addressed by family members or primary health care workers or professionals and this may lead suicidal thoughts (Sher, 2020a).
Selective, indicated and universal interventions are the need of the hour to prevent suicide. These may be ‘Selective’, ‘Indicated’ and ‘Universal’ elaborated as following: • Selective and Indicated – ‘Target individuals who are at heightened risk of suicide or are actively suicidal; designed to reduce risk of suicide among these individuals’, for individuals with ‘mental health issues’ and those, ‘experiencing suicidal crisis’. These may include ensuring adequate delivery of mental health care using digital platforms/telepsychiatry modes, supporting frontline health care workers, ensuring adequate supplies of personal protective equipment, framing policies to allocate resources swiftly for those affected. • Universal – ‘Target the whole population and focus on particular risk factors without identifying specific individuals with those risk factors; designed to improve mental health and reduce suicide risk across the population’, for domains such as ‘monetary stressors’, ‘intimate partner violence’, ‘substance/alcohol use’, ‘issues due to isolation, quarantine, loneliness, fear and bereavement’, ‘controlling access to objects which may be used by those with suicidal thoughts’, ‘regulation of media and information’, ‘dealing with school and college closures’ and ‘support to jobless persons’. These may include offering of financial resources by government authorities, ensuring access to care and support for those suffering from intimate partner violence, regulation of misinformation and rumours through media, making retailers mindful of how psychologically vulnerable persons may attempt gain to access to means of harming themselves, encouraging community support teams and regulation of alcohol and substance use policies (Gunnell et al., 2020; Joseph, Mishra, et al., 2020).
The current challenges should be looked at optimistically to further advance the domain of suicide prevention. The present-day state of the pandemic in which all are suffering has shown that, the public in general are more receptive to information regarding mental health issues such as anxiety, depression and suicidal behaviour compared to earlier. At the same time, sharing of information regarding such psychological issues may have led to an indirect decline in stigma and discrimination. People have also begun to understand the significance of social support as a need for life (Klomek, 2020).
The increasing popularity of telepsychiatry and digital platforms can further help to alleviate the stigma associated with visiting a mental health professional and also becomes a relatively accessible and user-friendly means for those at risk to communicate with the service providers. The potential of telepsychiatry and digital platforms in dealing with the mental health crisis amidst the pandemic has been well-proven. Helpline numbers have been already there to support those in crisis, but, this could be advanced a step further with use of current technology. Public awareness regarding the accessibility to and the advantages of such services would ensure that those who need help can access and afford mental health services. At the same time, mental health professionals should be keeping in mind, the potential demerits of these platforms especially in cases of emergency (Hazarika et al., 2020; Lodha & de Sousa, 2020).
Policy makers and Government have a great role to play in the prevention of suicidal thoughts amongst people affected in this pandemic. Offering financial nets such as, loans in emergency, provision of shelter, food and support for those who have lost their jobs is important. Resources should be allocated based on the needs of people (Gunnell et al., 2020; Nayar et al., 2020). Primary health care workers should also be pooled in, and trained to identify those in psychological crisis to fill in the gaps and ensure more helping hands.
Mental health professionals should be well aware of the various theoretical explanations, cognitive styles of affected persons and approaches to deal with the current mental health crisis (Joseph, Gonçalves, et al., 2020; Nayar et al., 2020). Prevention of suicide was, is, and, will always be a challenge. Lessons learnt from the past, and the understanding of psychological repercussions in the current scenario should help us structure more rigorous suicide prevention strategies.
Footnotes
Author Contributions
SJJ- conceptualization and design, initial drafting, critical appraisal, critical revision, final drafting; SSB- critical appraisal and critical revision, final drafting
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
