It has been a tough year for many people around the world as we struggle to deal with the coronavirus pandemic. Within the United States, we have not only surpassed the 6 million mark of people infected with the virus, but our deaths from the virus are nearing 200,000. We are more than six months into a period of extended social distancing and quarantine, and most of us are feeling depleted. To add to this stress, we also have a second pandemic we are battling, the racism pandemic.
As the mom of a biracial daughter and the wife of a Black man, seeing repeated reports about Covid-19 racial disparities adds to the emotional toll this virus is taking on me and on so many in underrepresented communities. Looking at Covid-19 rates of infection and deaths across the United States, the racial disparity is alarming (https://covidtracking.com/race/dashboard). Further draining my energy are situations like when State Senator Stephen Huffman, a practicing ER physician from Ohio, proposed the question “Could it just be that African-Americans- or the colored population- do not wash their hands as well as other groups?” during a meeting about coronavirus racial disparities and whether racism should be declared a public health crisis (Gabriel, 2020). Amidst the challenges we all are facing with the virus, learning about, and experiencing repeated acts of racism, discrimination, and racial bias is adding to our struggle. As we bear direct witness to the murder of George Floyd and the seven shots that paralyzed Jacob Blake, and learn concerning details about the murder of Breonna Taylor, for which there continues to be no justice months later, the emotional pain and outrage felt negatively impacts our mental health.
While hard to predict, the joining together of the psychological vulnerability and stress produced by the combination of the virus and racism within our country might be creating a perfect storm that leads to significant increases in mental health problems and risk of suicide. These two pandemics being simultaneously present is unprecedented. However, I am a strong believer that by taking a historical view of how pandemics and natural disasters have impacted suicide rates in the past, we will get a glimpse into our future. Past studies looking at the psychological effects of natural disasters (e.g., hurricanes, tsunamis, and earthquakes) and other pandemics show rates of suicidal thinking and behaviors declined initially, but over time rates tend to increase and surpass baseline rates (Kessler et al., 2006; Kessler et al., 2008; Pietrzak et al., 2012). Key considerations for increased mental health problems and suicide risk include variables such as chronicity of the stressors and how closely one is impacted by the event(s), including losing loved ones, job, home, and financial losses. As we consider the impact of the coronavirus on these variables, the death and unemployment rates suggest we might be dealing with elevated risk for suicide within our country due to the pandemic. One might also argue that if you factor in the psychological impact of racism on communities of color, this group may experience even greater rates of suicide risk during these pandemics and in the aftermath. On a more uplifting note, I want to mention that when communities of people bond together over the coronavirus and racism pandemics, this can increase feelings of belongingness and strengthen relationships that serve as a protective factor against suicidal thinking and behaviors.
Obviously, potential solutions to the coronavirus and racism pandemics will be multifaceted and complex. However, actively contributing to such solutions is good for our mental health. So, I want to share some literature that will help us as mental health providers assess suicide risk in culturally diverse populations. In 2013, Chu et al. published a journal article entitled “A Tool for the Culturally Competent Assessment of Suicide: The Cultural Assessment of Risk for Suicide (CARS) Measure.” In this article, the authors note that suicide risk assessment models have often left out or minimized cultural variations associated with suicide presentation and risk. To address this need, the authors created the CARS measure. This 39-item self-report instrument is consistent with the Cultural Theory and Model of Suicide developed by Chu, Goldblum, Floyd, & Bongar in 2010. It examines cultural differences in suicide by looking at risk and protective factors across four ethnic and sexual minority groups (African-American, Asian-American, Latinx-American, and LGBTQ) and is estimated to take just five to seven minutes to complete. The CARS instrument can be used with the general population, as it was found to predict suicidal behavior for both minority and non-minority individuals. It is recommended that the CARS be used as part of a comprehensive risk assessment, which will always include a clinical interview assessing risk and may also include other self-report measures.
In 2018, Chu et al. published their shortened version of the Cultural Assessment of Risk for Suicide (CARS-S) measure. Considered a screener version of the full measure, the 14-item CARS-S is beneficial for use in busy clinical mental health settings, as well as in primary care and emergency room settings. It takes approximately two minutes to administer. The CARS-S focuses on culturally-based risk and protective factors, using cultural expressions of suicidal distress to assist in the identification of diverse individuals at elevated risk for suicide. As is noted above, the CARS-S should also be used as part of a comprehensive risk assessment for suicidal thinking and behaviors, which includes a clinical interview.
This is by no means an exhaustive list of suicide prevention, assessment, and intervention resources for culturally diverse populations, but I hope it gets you thinking…as a mental health provider, how do I assess suicide risk and treat suicidal thinking and behaviors with diverse groups? What can I do better? So, where does this leave us as a nation? We are still amid these pandemics. And while the resources shared in this blog don’t necessarily fix the large-scale social, psychological, and emotional issues mentioned, hopefully they give us accurate information, ideas to consider, and tools to aid in our work as mental health providers trying to help our patients navigate this overwhelming time.
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.
Erin Frick, Psy.D., is a clinical psychologist and Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
CDC (2020, 24 July). Health equity considerations and racial and ethnic minority groups. CDC. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013). A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) measure. Psychological Assessment, 25(2): 424-434. https://doi.org/10.1037/a0031264
Chu, J., Hoeflein, B., Goldblum, P., Espelage, D., Davis, J., & Bongar, B. (2018). A shortened screener version of the Cultural Assessment of Risk for Suicide. Archives of Suicide Research, 22: 679-687.
Emory University (2020, September 3). Covid-19 health equity interactive dashboard. Emory University. https://covid19.emory.edu/
Gabriel, T. (2020, June 11). Ohio lawmaker asks racist question about Black people and hand-washing. The New York Times. https://www.nytimes.com/2020/06/11/us/politics/steve-huffman-african-americans-coronavirus.html
Kessler, R. C., Galea, S., Jones, R. T., Parker, H. A. (2006). Mental illness and suicidality after Hurricane Katrina. Bulletin of the World Health Organization, 84(12): 930-939.
Kessler, R. C., Galea, S., Gruber, M. J., Sampson, M. J., Ursano, R. J., & Wessely, S. (2008). Trends in mental illness and suicidality after Hurricane Katrina. Molecular Psychiatry, 13: 374-384.
Pietrzak, R. H., Tracy, M., Galea, S., Kilpatrick, D. G., Ruggiero, K. J., Hamblen, J. L., Southwick, S. M., & Norris, F. H. (2012). Resilience in the face of disaster: Prevalence and longitudinal course of mental disorders following Hurricane Ike. PLoS ONE 7(6):1-14. doi:10.1371/journal.pone.0038964