En español | The coronavirus outbreak has upended nearly every aspect of people's lives — and their mental health is no exception. A new paper in JAMA Psychiatry speculates that the risk of suicide may rise in the U.S. during the pandemic, as people increasingly grapple with economic challenges, social isolation, decreased access to community and religious support, and other daily disruptions.
Older adults may be at particular risk for suicide, the paper's authors note, possibly because they're more likely to have medical problems that are insufficiently treated or that worsen during the crisis. Studies show that a variety of health conditions — including cancer, chronic pain and dementia — “precipitate about 50 percent of suicides among adults 65 or older,” says lead author Mark. A. Reger, chief of psychology services at VA Puget Sound Health Care System and associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle.
Though it is unknown whether a coronavirus infection is a risk factor for suicide among older adults, health care workers and families should “remain vigilant,” especially “given the prior research on the association of health problems with suicide,” Reger says.
Social isolation takes a toll on older adults
This concern about suicide during the pandemic is occurring against a backdrop of suicide rates that have already been increasing over the past two decades. From 1999 through 2018, suicide rates among women were highest in those between the ages of 45 and 64; the rates were highest for men age 75 and older, according to the Centers for Disease Control and Prevention (CDC).
"Many of us can imagine life after this [pandemic], but some older people don't have that future orientation,” says Marjorie E. Weishaar, clinical professor of psychiatry and human behavior at the Alpert Medical School at Brown University. “Many older adults are aware that they don't have the stamina and vigor they used to have, or they feel trapped by a sense of uselessness during this time. In assisted living facilities, some older adults are aware that death is more imminent for them. Also, the death of friends is really a blow, and it contributes to survivor guilt."
Nevertheless, the biggest risk factors are related to social isolation, which, Weishaar says, “makes everybody's mood worse and it makes clinical depression worse.”
"Without access to family, social or religious activities, older adults are painfully isolated,” agrees Sandra Swantek, M.D., chief of geriatric psychiatry at the Rush University Medical Center in Chicago. “In that setting a person could lose sight of the future and become hopeless and potentially suicidal."
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Worrisome signs of suicidal risk
There is a wide-ranging list of common symptoms of suicidal tendencies. Feeling hopeless or trapped is one; talking or writing frequently about death or dying is another. But in older adults, depression may reveal itself in more physical symptoms, “such as fatigue and sleep difficulties,” explains Lindsey C. McKernan, an assistant professor of psychiatry and behavioral sciences in physical medicine and rehabilitation at the Vanderbilt University Medical Center in Nashville. Co-occurring health conditions and chronic pain can also worsen with distress, she adds.
"It's important to note that some of the warning signs include things that our social distancing life is leading us to have to do right now, like spending time alone and not engaging in regular activities one enjoys,” says Andrea Gottlieb, a psychologist and dialectical behavioral therapy project coordinator at the Sheppard Pratt Health System in Baltimore.
If an older friend or loved one doesn't answer the phone when you call many days in a row or doesn't reach out to family like they usually would to say hi or check in during the pandemic, it could be a sign of potential suicidal tendencies, Gottlieb says. Not moving around the home or doing hobbies per usual is also concerning.
Other red flags? Lack of engagement in normally enjoyable activities, giving away valued possessions, and an inability to talk about anything positive. Be attuned, as well, to statements that might indicate that a loved one no longer cares about life or doesn't want to be a burden. These could include declarations like, “You'd be better off not having to worry about me"; “I feel like I've lived too long"; or “I wish I could go to sleep and not wake up."
"Sometimes, a person may hint at suicidal ideation with statements that point to significant distress,” Swantek explains. “Suicidal thoughts may be a symptom of depression, and depression at any age is a treatable illness.”
If you notice a dramatic shift in a loved one's mood, ask about it; you may be able to help allay or debunk some of her thoughts and worries. Even if you can't, you can help the person find psychological services.
Essential mood-protection strategies
While none of us can control the course of the coronavirus pandemic or the physical distancing mandates, we can all take steps to protect our emotional well-being during this trying time. Here are key ways you can improve your emotional equilibrium — and help your family and friends to strengthen theirs.
Stay connected from afar. Be creative about “getting together.” Have dinner or host a game night with distant friends and family members over Zoom, FaceTime or other virtual connections. Also, grandparents can help grandkids with learning at home, such as by reading or playing math games remotely, suggests Kimberly Roaten, a clinical psychologist at UT Southwestern Medical Center in Dallas.
"If your loved one is not savvy with using technology, get on the phone with them and teach them what to do,” Gottlieb advises. “Write out the steps. If it's you who needs help and you're not sure how to navigate internet resources for chatting with people, call someone you know who does know how to do this and ask them to be patient and walk you through it.”
If family members don't have internet access or a smartphone, go the old-fashioned route with phone calls.
Rediscover previously enjoyable activities. If you or a relative has recently been too busy to engage in former favorite hobbies, this may be the perfect time to pick them up again. Consider getting back to puzzles, baking or cooking, reading, knitting, drawing or painting, walking in nature, playing a musical instrument, taking an online yoga class, organizing photos or taking a virtual museum tour.
Ask how you can help. If a loved one is struggling with depression or anxiety during this time, “offer to help them the way they need help,” Gottlieb says. Start by asking, “What can I do to help you?” If the person doesn't know, make some suggestions, such as calling every day just to say “Hi.” You can also remind him to go for a walk outside, or send a small care package of things he would usually like to do, eat, read or watch.
Stick with a daily routine. Even while living with shelter-in-place and quarantine mandates, you can establish a daily regimen with specific activities — eating, sleeping, reading, exercising, engaging in a hobby, checking in with friends and family members, and so on, McKernan says. “Keeping this routine consistent can be grounding and can reestablish a sense of control in uncertain times.”
Put yourself on a news diet. As the JAMA Psychiatry paper notes, “It is possible that the 24/7 news coverage of these unprecedented events could serve as an additional stressor, especially for individuals with preexisting mental health problems.”
The solution? “Do what the CDC and your governor tell you to do, then limit how much you watch the news,” Weishaar recommends. Instead, redirect your attention toward more constructive and positive entertainment, such as classic movies, baking or cooking shows, travel or wildlife documentaries, or something you can learn on TV.
Seek help for distress. You can find remote help or counseling for the way you're feeling. Many therapists are offering telehealth visits or online support groups during the pandemic. If you or a family member has seen a therapist in the past, check to see if that practitioner is offering teletherapy.
"Encourage people with a history of depression or another mental health condition to stay engaged in their treatment. They should not stop taking medications or therapy,” Roaten urges. (Of course, if a friend or loved one is relating the desire to commit suicide or is seeking ways to do so, take this behavior seriously and call 911 or obtain immediate help from a mental health clinician, Reger says.)
As stressful and difficult as the pandemic is, there could end up being a sliver of a silver lining. As Reger and his colleagues pointed out in the JAMA Psychiatry paper, the situation could produce a “pulling-together effect,” in which people support one another and strengthen social connectedness during this shared experience.
"Remember that we are all in this together and we will pull through this as a community,” Reger says. “Reach out and stay connected. Look for ways to help others. Simple things such as leaving encouraging notes for postal workers can help people feel like they are part of the community working together to get through this crisis.”