Staff Perspective: COVID-19, Connectedness, and Suicide Prevention
September is National Suicide Prevention Month and one goal is to help provide information on suicide prevention programs and resources. Although it is important to focus on suicide prevention every day of every year, given the challenges of 2020, this year it may be even more important. There has been a lot in the media over the past 6+ months about the Coronavirus Disease 2019 (COVID-19) and how it may impact suicides. We are seeing coronavirus-related increases in anxiety, depression, substance use, and suicidal thoughts (Czeisler et al., 2020; Panchal et al., 2020). Although it is too soon to say whether the suicide rate has actually increased during the COVID-19 pandemic due to lack of real-time national data, both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have issued warnings about potential increases in deaths by suicide. In fact, a recent article published by the CDC indicated that about 10.7% of Americans surveyed in June said they had seriously considered suicide in the past 30 days, which is more than double the 4.3% who said the same in 2018 referring to the previous 12 months (Czeisler et al., 2020).
Let’s be honest, COVID-19 has altered the day-to-day lives of individuals around the world. Likely most of you reading this have been impacted in one way or another. Researchers have been working to identify potential contributors to suicide risk during the pandemic, and while specific studies and researchers make no definitive claims about how these factors will affect suicide rates, they do propose factors of concern. For a good summary of some potential contributors to suicide mortality related to COVID-19, I encourage readers to review a recent article published by Reger and colleagues (2020). In the article they cover a variety of factors that may play a role in increased suicide risk to include: economic stress, social isolation, decreased access to community and religious support, barriers to mental health treatment, outcomes of national anxiety, as well as several other factors. While these are all important factors to consider, I want to focus on social isolation.
Key theories of suicide have identified a connection between suicidal thoughts and a lack of social connection with others (Joiner, 2005; Klonsky & May, 2015). We also know that social connectedness is a key protective factor for suicide prevention. So how does this all fit in with the current pandemic and social distancing guidelines? And what about individuals who have to quarantine due to sickness or potential exposure? It can be a slippery slope. Social distancing can lead to social isolation, which in combination with a variety of factors such as unemployment/financial hardship, depression, anxiety, and uncertainty can lead to feelings of hopelessness and helplessness. Let’s take a look at some recent research.
Calati and colleagues (2019) performed a narrative review of the literature looking at the link between social isolation and suicide. They found that social isolation is strongly associated with suicidal outcomes and that the subjective feeling of loneliness has a major impact, even transculturally. Based on these findings, not only should providers assess for objective indicators of social isolation (e.g., living alone), but also subjective feelings of being alone (e.g., loneliness). As the authors recommend, providers should also ensure clinical interventions address any identified deficiencies with a focus on developing or improving social skills, increasing social support, increasing the occasions for social contacts, and focusing on maladaptive social cognitions (if present).
Additionally, studies of the psychological impact of the use of quarantining have shown that isolation due to quarantine can lead to negative health outcomes. Brooks and colleagues (2020) reviewed 24 papers focusing on the effects of quarantine and found negative psychological effects related to quarantining to include post-traumatic stress symptoms, confusion, and anger. Qualitative studies identified a range of psychological responses to include confusion, fear, anger, grief, numbness, and anxiety-induced insomnia. Factors that increased symptomology were longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Another factor to consider is that quarantine usually requires separation from friends and loved ones, which can increase feelings of loneliness.
Social connectedness is important! It is important for psychological and physical well-being and it is important for suicide prevention. In fact, it is so important that the Department of Defense (DoD) theme for this year’s Suicide Prevention Month is Connectedness with the slogan of "Connect to Protect" (Defense Suicide Prevention Office, 2020). Now more than ever, finding ways for individuals to connect with others (friends, family, community, resources) is very important.
So what does this mean for behavioral health providers? It means that it is more important than ever to know, recognize, and respond to warning signs of suicide. Providers need to assess for risk factors and warning signs, to include social isolation/loneliness, and be prepared to intervene as appropriate. Additionally, with challenges to accessing mental health services, more providers and patients are engaging in telehealth services. Therefore, having ready access to resources/clinical tools is extremely important. One specific thing providers can do is help patients find a sense of connection. This may mean thinking outside of the box, especially when addressing safety planning and other interventions.
It is important to remind individuals that physical distancing does not mean the same as social distancing. We need to help individuals we are working with brainstorm creative ways to socialize with others such as video calls with friends and family, attending a church service online, setting up family game nights or even dinners in an online format, social distancing meet-ups, etc. I even know individuals who are finding ways to exercise with others from a distance. Whether that is doing FaceTime workouts together, social distance walks/outdoor workouts, or walking and talking on the phone with someone. Even with all that is going on in 2020, there is still a lot that we can do. We can be aware of suicide risk factors and warning signs. We can take care of ourselves and find ways to develop healthy ways to cope with stress. We can check in with friends, family, colleagues, and others. And both in and outside the therapy/telehealth room we can #BeThere and #ConnectToProtect.
CDP Resources:
- Here at CDP we have a variety of COVID-19 behavioral health resources that include resources for assessing and treating suicide as well as delivering services via telehealth. These include a self-care tip sheet for hospitalized or quarantined patients as well as social distancing resources.
- With increased telehealth efforts taking place nationwide, providers also need ready resources that they can access from a distance. To assist with this, check out the CDP Patient Forms page for forms and handouts that can be utilized in psychotherapy treatment. There are fillable versions of outcome measures that are in the public domain, including the Columbia Suicide Severity Rating Scale (C-SSRS). Additionally, there are other forms/handouts that can be used in a telehealth setting with patients such as thought records, as well as a fillable problem-solving worksheet and a daily mood log.
- If additional training is what you are looking for then make sure to check out one of our upcoming training events to include our two-day Cognitive Behavioral Therapy for Suicide Prevention workshops. Additionally, if you're reading this the morning of publication, it is not too late to sign up for the CDP monthly webinar that takes place today at 1200 EDT. Dr. Kate Comtois from the University of Washington will be presenting on Key Elements for the Effective Management and Resolution of Suicidality. If you miss the live event, you will be able to find the recording in the next few days in the archived webinars section of the CDP website.
Other Resources:
- For additional resources, I suggest you check out the Psychological Health Center of Excellence’s (PHCoE) recently released toolkit to assist providers with the assessment and management of patients at risk for suicide. It includes a variety of clinical tools and resources such as printable and digital versions of the Safety Plan Worksheet, a printable Crisis Response Plan, a provider factsheet on lethal means counseling, and a suicide risk provider pocket guide.
- Additionally, the Department of Veterans Affairs has put together resources for providers. One tool I really like is the Means Safety Messaging pocket card. It includes information on how to start and have that conversation with patients regarding means safety, and it also covers firearm storage options as well as medication safety recommendations. Means safety and lethal means counseling is one of the most important things that can be done to decrease suicide. Given some of the potential contributors outlined above and the reality that individuals are more likely to be in their home, socially distancing with potential access to personally owned firearms, it is more important than ever to be having these discussions.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Lisa French, Psy.D., is the Chief of Staff at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References:
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G.J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet, 395, 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8
Calati, R., Ferrari, C., Brittner, M., Oasi, O., Olie, E., Caravalho, A. F., & Courtet, P. (2019). Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. Journal of Affective Disorders, 245, 653-667. doi.org/10.1016/j.jad.2018.11.022
Czeisler, M. E., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., Weaver, M. D., Robbins, R., Facer-Childs, E. R., Barger, L. K., Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Morbidity and Mortality Weekly Report, 69(32), 1049–1057. http://dx.doi.org/10.15585/mmwr.mm6932a1
Defense Suicide Prevention Office. (2020, July 17). 2020 suicide prevention month campaign planning guide: A how-to guide for suicide prevention month. Author. https://www.dspo.mil/Portals/113/Documents/SPM2020/DOD%20SPM%202020%20Guide.pdf?ver=2020-07-24-100139-717
Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Klonsky, D. E., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the "ideation-to-action" framework. International Journal of Cognitive Therapy, 8(2), 114-129.
Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., & Chidambaram, P. (2020, August 21). The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
Reger, M. A., Stanley, I. H., & Joiner, T. E. (2020). Suicide mortality and Coronavirus Disease 2019 – A perfect storm? JAMA Psychiatry, E1-E2. doi:10.1001/jamapsychiatry.2020.1060
September is National Suicide Prevention Month and one goal is to help provide information on suicide prevention programs and resources. Although it is important to focus on suicide prevention every day of every year, given the challenges of 2020, this year it may be even more important. There has been a lot in the media over the past 6+ months about the Coronavirus Disease 2019 (COVID-19) and how it may impact suicides. We are seeing coronavirus-related increases in anxiety, depression, substance use, and suicidal thoughts (Czeisler et al., 2020; Panchal et al., 2020). Although it is too soon to say whether the suicide rate has actually increased during the COVID-19 pandemic due to lack of real-time national data, both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have issued warnings about potential increases in deaths by suicide. In fact, a recent article published by the CDC indicated that about 10.7% of Americans surveyed in June said they had seriously considered suicide in the past 30 days, which is more than double the 4.3% who said the same in 2018 referring to the previous 12 months (Czeisler et al., 2020).
Let’s be honest, COVID-19 has altered the day-to-day lives of individuals around the world. Likely most of you reading this have been impacted in one way or another. Researchers have been working to identify potential contributors to suicide risk during the pandemic, and while specific studies and researchers make no definitive claims about how these factors will affect suicide rates, they do propose factors of concern. For a good summary of some potential contributors to suicide mortality related to COVID-19, I encourage readers to review a recent article published by Reger and colleagues (2020). In the article they cover a variety of factors that may play a role in increased suicide risk to include: economic stress, social isolation, decreased access to community and religious support, barriers to mental health treatment, outcomes of national anxiety, as well as several other factors. While these are all important factors to consider, I want to focus on social isolation.
Key theories of suicide have identified a connection between suicidal thoughts and a lack of social connection with others (Joiner, 2005; Klonsky & May, 2015). We also know that social connectedness is a key protective factor for suicide prevention. So how does this all fit in with the current pandemic and social distancing guidelines? And what about individuals who have to quarantine due to sickness or potential exposure? It can be a slippery slope. Social distancing can lead to social isolation, which in combination with a variety of factors such as unemployment/financial hardship, depression, anxiety, and uncertainty can lead to feelings of hopelessness and helplessness. Let’s take a look at some recent research.
Calati and colleagues (2019) performed a narrative review of the literature looking at the link between social isolation and suicide. They found that social isolation is strongly associated with suicidal outcomes and that the subjective feeling of loneliness has a major impact, even transculturally. Based on these findings, not only should providers assess for objective indicators of social isolation (e.g., living alone), but also subjective feelings of being alone (e.g., loneliness). As the authors recommend, providers should also ensure clinical interventions address any identified deficiencies with a focus on developing or improving social skills, increasing social support, increasing the occasions for social contacts, and focusing on maladaptive social cognitions (if present).
Additionally, studies of the psychological impact of the use of quarantining have shown that isolation due to quarantine can lead to negative health outcomes. Brooks and colleagues (2020) reviewed 24 papers focusing on the effects of quarantine and found negative psychological effects related to quarantining to include post-traumatic stress symptoms, confusion, and anger. Qualitative studies identified a range of psychological responses to include confusion, fear, anger, grief, numbness, and anxiety-induced insomnia. Factors that increased symptomology were longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Another factor to consider is that quarantine usually requires separation from friends and loved ones, which can increase feelings of loneliness.
Social connectedness is important! It is important for psychological and physical well-being and it is important for suicide prevention. In fact, it is so important that the Department of Defense (DoD) theme for this year’s Suicide Prevention Month is Connectedness with the slogan of "Connect to Protect" (Defense Suicide Prevention Office, 2020). Now more than ever, finding ways for individuals to connect with others (friends, family, community, resources) is very important.
So what does this mean for behavioral health providers? It means that it is more important than ever to know, recognize, and respond to warning signs of suicide. Providers need to assess for risk factors and warning signs, to include social isolation/loneliness, and be prepared to intervene as appropriate. Additionally, with challenges to accessing mental health services, more providers and patients are engaging in telehealth services. Therefore, having ready access to resources/clinical tools is extremely important. One specific thing providers can do is help patients find a sense of connection. This may mean thinking outside of the box, especially when addressing safety planning and other interventions.
It is important to remind individuals that physical distancing does not mean the same as social distancing. We need to help individuals we are working with brainstorm creative ways to socialize with others such as video calls with friends and family, attending a church service online, setting up family game nights or even dinners in an online format, social distancing meet-ups, etc. I even know individuals who are finding ways to exercise with others from a distance. Whether that is doing FaceTime workouts together, social distance walks/outdoor workouts, or walking and talking on the phone with someone. Even with all that is going on in 2020, there is still a lot that we can do. We can be aware of suicide risk factors and warning signs. We can take care of ourselves and find ways to develop healthy ways to cope with stress. We can check in with friends, family, colleagues, and others. And both in and outside the therapy/telehealth room we can #BeThere and #ConnectToProtect.
CDP Resources:
- Here at CDP we have a variety of COVID-19 behavioral health resources that include resources for assessing and treating suicide as well as delivering services via telehealth. These include a self-care tip sheet for hospitalized or quarantined patients as well as social distancing resources.
- With increased telehealth efforts taking place nationwide, providers also need ready resources that they can access from a distance. To assist with this, check out the CDP Patient Forms page for forms and handouts that can be utilized in psychotherapy treatment. There are fillable versions of outcome measures that are in the public domain, including the Columbia Suicide Severity Rating Scale (C-SSRS). Additionally, there are other forms/handouts that can be used in a telehealth setting with patients such as thought records, as well as a fillable problem-solving worksheet and a daily mood log.
- If additional training is what you are looking for then make sure to check out one of our upcoming training events to include our two-day Cognitive Behavioral Therapy for Suicide Prevention workshops. Additionally, if you're reading this the morning of publication, it is not too late to sign up for the CDP monthly webinar that takes place today at 1200 EDT. Dr. Kate Comtois from the University of Washington will be presenting on Key Elements for the Effective Management and Resolution of Suicidality. If you miss the live event, you will be able to find the recording in the next few days in the archived webinars section of the CDP website.
Other Resources:
- For additional resources, I suggest you check out the Psychological Health Center of Excellence’s (PHCoE) recently released toolkit to assist providers with the assessment and management of patients at risk for suicide. It includes a variety of clinical tools and resources such as printable and digital versions of the Safety Plan Worksheet, a printable Crisis Response Plan, a provider factsheet on lethal means counseling, and a suicide risk provider pocket guide.
- Additionally, the Department of Veterans Affairs has put together resources for providers. One tool I really like is the Means Safety Messaging pocket card. It includes information on how to start and have that conversation with patients regarding means safety, and it also covers firearm storage options as well as medication safety recommendations. Means safety and lethal means counseling is one of the most important things that can be done to decrease suicide. Given some of the potential contributors outlined above and the reality that individuals are more likely to be in their home, socially distancing with potential access to personally owned firearms, it is more important than ever to be having these discussions.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Lisa French, Psy.D., is the Chief of Staff at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References:
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G.J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet, 395, 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8
Calati, R., Ferrari, C., Brittner, M., Oasi, O., Olie, E., Caravalho, A. F., & Courtet, P. (2019). Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. Journal of Affective Disorders, 245, 653-667. doi.org/10.1016/j.jad.2018.11.022
Czeisler, M. E., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., Weaver, M. D., Robbins, R., Facer-Childs, E. R., Barger, L. K., Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Morbidity and Mortality Weekly Report, 69(32), 1049–1057. http://dx.doi.org/10.15585/mmwr.mm6932a1
Defense Suicide Prevention Office. (2020, July 17). 2020 suicide prevention month campaign planning guide: A how-to guide for suicide prevention month. Author. https://www.dspo.mil/Portals/113/Documents/SPM2020/DOD%20SPM%202020%20Guide.pdf?ver=2020-07-24-100139-717
Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Klonsky, D. E., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the "ideation-to-action" framework. International Journal of Cognitive Therapy, 8(2), 114-129.
Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., & Chidambaram, P. (2020, August 21). The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
Reger, M. A., Stanley, I. H., & Joiner, T. E. (2020). Suicide mortality and Coronavirus Disease 2019 – A perfect storm? JAMA Psychiatry, E1-E2. doi:10.1001/jamapsychiatry.2020.1060