Following congressional testimony last week about frontline workers’ experiences during the Covid-19 epidemic, members of the U.S. House of Representatives raised the specter of a rise in “deaths of despair” due to Covid-19 shutdowns. They implied that the country had a moral obligation to reopen quickly, if only to avoid current and future deaths from suicide, homicide, opioids, and alcohol.

A comment by a trauma physician in California that his hospital had seen “a year’s worth of suicide attempts in four weeks” went viral this week, picked up by Fox News and presidential adviser Kellyanne Conway to support the argument to reopen the country, even though the remark was incorrect and there’s been no rise in suicide deaths in his county this year.

As an emergency physician and a psychiatrist, we have very real concerns about the well-being of our communities and our neighbors. We are the ones who are first to see the rise in anxiety and stress and changes in physical and mental health in our communities.

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We also know that tying deaths of despair directly to measures being used to reduce the spread of Covid-19 is, simply, wrong.

Deaths of despair are tragic and preventable. But they are not new. The label was first used in 2017 by two economists to describe the increase in U.S. deaths from suicide, overdose, and alcohol in the 2010s. Anne Case and Angus Deaton wrote that these deaths reflected rising hopelessness and inequity among American society. A series of investigations since have corroborated their findings. All three types of death have been on the increase among all Americans for the past decade, in parallel with a decadelong rise in hopelessness, inequity, and easy availability of lethal means. Where was the alarm from these politicians then?

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We do not actually know that these deaths are increasing during the Covid-19 pandemic. Police and crisis hotlines may — or may not — be receiving extra calls for domestic violence and child abuse. Firearm homicide rates are staying steady. Suicides are certainly occurring, but there is no evidence to date that their rate is on the rise (and we may not know the impact of the pandemic on suicide for years to come). Despite ample evidence that anxiety is increasing during the pandemic, anxiety alone is rarely a driver for suicide. It is not even a risk factor for it.

Right now it is all too easy to blame every tragedy on Covid-19. Science warns us, however, not to make this fundamental error of attribution.

Projections about future increases are also misleading. Earlier this month, a report by the Well Being Trust projected that these categories of deaths would likely skyrocket during the Covid-19 pandemic due to unemployment, isolation, and uncertainty. We know that the economy is deeply tied to physical and mental health. Yet these projections are based on data from the Great Recession, meaning the models weren’t able to factor in the unique aspects of what is happening today, such as how new technologies make possible increased virtual social connection and support.

And as the authors of the Well Being Trust report acknowledge, even if the models are correct, they are mutable. An increase in suicide, homicide, and deaths from alcohol and opioids is not a foregone conclusion. A complex constellation of risk factors, only a few of which are directly tied to Covid-19, are known to drive these tragic deaths. We have evidence-based interventions that can reduce the rates of many of the risk factors for all of these deaths whether or not the country is practicing social distancing, hand-washing, and mask wearing.

It is also wrong to imply that reopening the country will, in and of itself, stop deaths of despair. Jobs may or may not rebound when social distancing rules are relaxed. Much of the decline in travel and eating in restaurants predated formal rules about social distancing. Whether unemployment leads to desperation depends on whether we as a society feed and clothe those without incomes. Newly purchased firearms will still be in people’s houses and all too easy to use in a moment of despair even when we are not social distancing.

If politicians really care so much about vulnerable citizens, where were they a year ago, or five years ago, when those in the public health community began to raise the alarm about the rising tide of these deaths? And where are they now, in addressing the underlying social issues that drive despair and that won’t be fixed by reopening?

We would love nothing more than to see these politicians advocating for community cohesion; helping provide personal protective equipment for frontline health care workers; creating new tools to help reduce hunger; helping women have economic independence so they can leave abusive partners; and funding novel solutions to isolation and loneliness. But, ironically, those who are quickest to cite deaths of despair as a reason to reopen the country are too often the last to vote to fund research and services that could prevent them.

Whether these kinds of deaths increase or decrease is up to us. But reopening won’t solve what put us in this situation. As individual citizens, we can look out for our neighbors. We can learn the warning signs for mental health disorders and ask for help. But to truly create change, the government needs to fund the research to help us all do better — and fund the essential social supports and treatment that we know make a difference.

We have been through mass casualties before. And we have seen great ideas fall victim to inertia, thoughts, and prayers. To avert deaths of despair, evidence-driven actions speak louder than words.

Megan L. Ranney is an emergency physician, associate professor of emergency medicine and public health at Brown University, and co-founder of GetUsPPE.org. Jessica Gold is a psychiatrist and assistant professor of psychiatry at Washington University in St. Louis.

  • As a mental health clinician, I challenge the following assertion made by the authors: “Despite ample evidence that anxiety is increasing during the pandemic, anxiety alone is rarely a driver for suicide. It is not even a risk factor for it.”

    The author’s statement is not reflected in the literature, and I include one abstract below that contradicts the authors assertion about the lack of relationship between anxiety and suicide:

    Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

    Depress Anxiety. 2010 Sep; 27(9): 791–798.
    doi: 10.1002/da.20674

    NIHMSID: NIHMS221019

    PMID: 20217852

    The Relationship Between Anxiety Disorders and Suicide Attempts: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions
    Josh Nepon, MD,1 Shay-Lee Belik, Msc,1,2 James Bolton, MD FRCPC,1 and Jitender Sareen, MD FRCPC1,2,3

    Abstract

    Background

    Previous work has suggested that anxiety disorders are associated with suicide attempts. However, many studies have been limited by lack of accounting for factors that could influence this relationship, notably personality disorders. The current study aims to examine the relationship between anxiety disorders and suicide attempts, accounting for important comorbidities, in a large nationally representative sample.

    Methods
    Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave 2. Face-to-face interviews were conducted with 34,653 adults between 2004 and 2005 in the United States. The relationship between suicide attempts and anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder, posttraumatic stress disorder [PTSD]) was explored using multivariate regression models controlling for sociodemographics, Axis I and Axis II disorders.

    Results
    Among individuals reporting a lifetime history of suicide attempt, over 70% had an anxiety disorder. Even after adjusting for sociodemographic factors, Axis I and Axis II disorders, the presence of an anxiety disorder was significantly associated with having made a suicide attempt (AOR=1.70, 95% CI: 1.40–2.08). Panic disorder (AOR=1.31, 95% CI: 1.06–1.61) and PTSD (AOR=1.81, 95% CI: 1.45–2.26) were independently associated with suicide attempts in multivariate models. Comorbidity of personality disorders with panic disorder (AOR= 5.76, 95% CI: 4.58–7.25) and with PTSD (AOR= 6.90, 95% CI: 5.41–8.79) demonstrated much stronger associations with suicide attempts over either disorder alone.

    Conclusion
    Anxiety disorders, especially panic disorder and PTSD, are independently associated with suicide attempts. Clinicians need to assess suicidal behavior among patients presenting with anxiety problems.

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