ON 11 March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. By the end of March, several organisations had made available resources to tackle population stress and to minimise the negative effects of the pandemic on mental health. Specialised publications issued warnings about the possible effects of COVID-19 on suicidal behaviours. As WHO states, “mental health is an indivisible part of public health and significantly affects countries and their human, social and economic capital,” not being “merely the absence of mental disorders or symptoms.”
On 18th March, WHO noted that the COVID-19 crisis was generating stress throughout the population and published “Mental health and psychosocial considerations during the COVID-19 outbreak” in order to “support mental and psychosocial well-being in different target groups during the outbreak” (WHO 2020: 1).
According to Gunnell et al. (2020), “mental health consequences are likely to be present for longer and peak later than the actual pandemic” (p. 470). Furthermore, “suicide is likely to become a more pressing concern as the pandemic spreads and has longer-term effects on the general population, the economy, and vulnerable groups” (Gunnell et al. 2020: 468).
In a recent paper (Ribeiro 2020), I reviewed the literature on past pandemics that are described to have caused a rise in violent deaths – namely, suicides – associated with the fear of contracting the disease, the infection itself, and the suffering and grief from the loss of loved ones.
Pandemics, fear, and suicide
The actions to combat the H1N1 pandemic in 2009 resemble what was done to fight the Spanish flu in 1918 (Bertucci 2009). We may now say that measures to contain the spread of COVID-19 are also very similar to those taken in the 20th century, as are the feelings of fear and anxiety experienced by the population.
In the US, the Spanish flu significantly reduced social interaction, isolated members of the mass public, and created a “high level of fear among those afflicted and others who may have had contact with them” (Wasserman 1992: 244). In October 1918, the City of Newark ordered the closure of all schools, churches, theatres, moving picture houses, dance halls, saloons, and sporting arenas (Galishoff 1969).
In Brazil, from the beginning of October 1918, cities closed public places such as schools, parks, theatres, and cinemas; religious meetings were drastically reduced; funerals with accompaniment on foot were prohibited; “kisses and hugs were condemned, and shaking hands became an unwanted act” (Bertucci 2009: 230). The Spanish flu stalled the daily routine in São Paulo, and along with fear and tragedy, there was a range of contradictory behaviours, from suicide to an irascible struggle for life (Bertolli 2003).
Tragedies that took place “in the delirium of fever” were repeated with a frequency that alarmed the inhabitants of the city of São Paulo. Bertucci mentions “shots, stab wounds, blows, drowning, jumping to death” and notes that “people with the flu attempted suicide or killed whoever was closest” (Bertucci 2002: 128).
According to Mamelund (2017: 8), “a significant rise in suicides was reported from several countries across the globe” during the 1918–1920 pandemic, and many can be traced to mental disturbances from the fear of contracting the disease or the stress of infection with the flu itself.
During the 2003 SARS epidemic, there is some evidence that deaths by suicide increased among older people in Hong Kong. Based on a complete suicide database, Cheung et al. (2008) concluded that the SARS epidemic was likely associated with the excess of older-adult suicides in 2003, especially in April.
In the present pandemic, Reger et al. (2020) have warned that secondary consequences of social distancing could increase the risk of suicide, stressing the importance of changes in a variety of economic, psychosocial, and health-associated risk factors.
Expected economic downturn
Economic effects of the coronavirus disease can negatively affect populations’ health, especially mental health. At the beginning of March 2020, McKibbin and Fernando anticipated that “even a contained outbreak could significantly impact the global economy in the short run” (McKibbin and Fernando 2020: 1). In the most extreme scenario of a temporary global pandemic, they projected that the average GDP loss in 2020 would be 6.7%, with an 8.4% loss for the US and the euro area, excluding some countries.
With all schools closed for three months and many people avoiding work even when they were not sick, Wren-Lewis (2020) projected that UK GDP-loss over a year could be less than 5%. However, if people started worrying sufficiently to cut back on social consumption, the economic impact would be more severe. Wren-Lewis noted that “the biggest impacts on GDP occur when we have people reducing their social consumption in an effort not to get the disease” (Wren-Lewis 2020: 111).
IMF chief economist Gopinath (2020) explained that the coronavirus epidemic involves both supply and demand shocks. On the one hand, business disruptions had lowered production, creating shocks to supply; on the other hand, the reluctance of consumers and businesses to spend had lowered demand (Gopinath 2020: 43).
Baldwin and Weder di Mauro (2020a) pointed out that COVID-19 was most definitely spreading economic suffering worldwide and that the virus could be as contagious economically as it was medically. They noted that the size of the economic damage was still uncertain but would certainly be large and governments needed to focus on mitigating that damage (Baldwin and Weder di Mauro 2020b). Indeed, in the World Economic Outlook of June (IMF 2020), the IMF anticipated a contraction of 4.9% of the global economy in 2020, 1.9 percentage points worse than the April forecast.
Recessions and unemployment effects on mental health and suicide
I also reviewed the literature on the association between past recessions, the related increases in unemployment, and their impact on mental health and additional suicides in different countries.
Quantifying the suicide impact of the Great Recession, which began in 2007, Reeves et al. (2014) estimated that the recession was associated with at least 10,000 additional economic suicides between 2008 and 2010. Nearly all European societies experienced a rising suicide rate. Chang et al. (2013) also concluded that after the 2008 economic crisis, rates of suicide increased in 27 European and 18 American countries studied, especially among men and in countries with higher levels of job loss. They found that “there were about 4,900 excess suicides in the year 2009 alone compared with those expected based on previous trends (2000–07)” (Chang et al. 2013: 4).
Similarly, Nordt et al. (2015) estimated that in all world regions, the relative risk of suicide associated with unemployment was elevated by about 20–30% between 2000 and 2011. They also found about 5,000 excess suicides associated with unemployment in 2009 since the economic crisis in 2008.
Looking at the Asian economic crisis (1997–1998), Chang et al. (2009) estimated that the crisis was associated with a rise in suicide mortality in some of the affected countries – Japan, Hong Kong, and Korea – with a combined 10,400 excess suicides in 1998 compared to 1997.
In terms of age groups, Gavrilova et al. (2000) found that rises in suicide mortality during the economic crisis in Russia in the early 1990s were more prominent in young and middle-age groups than in age groups older than 70 years.
For the current COVID-19 pandemic, Kawohl and Nordt (2020) anticipated that the expected rise in the unemployment rate will affect suicide rates. In a ‘high’ scenario, they estimated that an increase in the worldwide unemployment rate from 4.9% to 5.6% will be associated with a rise of about 9,570 suicides per year. In a ‘low’ scenario, unemployment will rise to 5.1%, with an associated increase of about 2,135 suicides per year.
Some alerts to the near future
As Reeves et al. (2014) stressed, “recessions will continue to hurt, but need not cause self-harm”. The authors pointed out that helping the newly unemployed to return to work may increase mental-health resilience during economic shocks. Since the majority of suicides occur among people with clinical depression, ensuring secondary prevention – access to effective treatment and antidepressants – may also moderate the impact of economic shocks on suicide by controlling depression associated with financial uncertainty.
Diagnosing depression and suicide potential acquires greater importance during periods of economic crisis. Christodoulou and Christodoulou (2013) wrote: “mental illness prevention and mental health promotion should be integral parts of clinical management and service planning in times of financial crisis” (Christodoulou and Christodoulou 2013: 282).
Similarly, Thakur and Jain (2020) recommended anticipating the changes in sociopsychological needs and planning for mental rehabilitation interventions. For example, they suggested making telephone counselling widely available, along with 24/7 crisis-response services for emotional, mental, and behavioural support. Kawohl and Nordt (2020) also underlined the importance of hotlines and psychiatric services. They pointed out that mental health providers should raise awareness in the political realm and in society that rising unemployment is associated with an increased number of suicides.
Fear and anxiety are intrinsic to humans and can be positive in some situations. However, depression and suicide are not necessary and are avoidable. The recipe to mitigate them in times of pandemics and recessions is already known: investment in mental healthcare, including suicide prevention services, and active employment policies.