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In the Midst of a Pandemic, Where are the Patients?

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Eight months into the pandemic we must confront a bit of a paradox: While standardized surveys have shown an increase in the incidence of mental symptoms or disorders, including anxiety, depression, and suicidal ideation, we have not seen a corresponding increase in mental health visits, nor, quite fortunately,  have we observed a corresponding increase in suicide.

Let’s look at what data we have, recognizing that at this early stage few, if any, durable observations can be made. First, we need to look at the most feared outcome of a pandemic-mediated increase in mental illness: suicide. Mortality in mental disease is largely a function of suicide. Although decades of research have assisted in elucidating risk factors associated with suicide, our ability to predict suicidal behavior in individuals is frustratingly—and often devastatingly—imperfect. Population suicide rates are similarly difficult to predict, and predicting causality is harder still when we have no good historical referents.

We do not have clear evidence that rates of suicide spiked in earlier pandemics, such as the 1918 global flu pandemic or the SARS epidemic in Asia during the early 2000s. Of course, cultural shifts and other differences mandate caution in comparing suicide across these pandemics. Better epidemiological methods have resulted in more accurate reporting than a century ago, and more advanced thinking regarding suicide and its causes have destigmatized reporting of deaths as suicide. Such changes are not universal, however, and differing cultural responses to suicide still leads to underreporting in some countries. Another tragic confound is that in the United States the overall rate of suicide per 100,000 citizens has been inexorably climbing for reasons that aren’t completely clear and now stands at approximately 15/100,000, a rate previously unseen in civilian populations—with far higher rates for susceptible groups.

A search of the National Library of Medicine’s PubMed database found a total of 269 publications on suicide and the COVID-19 pandemic in 2020, with first references appearing in April 2020 and continuing at a relatively steady pace thereafter; an average of 37 publications monthly in the July–October timeframe. In contrast, no other year save 2010 had more than one citation annually for search terms of “suicide” and “pandemic.”

What does this outpouring of recent research tell us? I think the major takeaway is that it is reasonable to be concerned, but at the same time alarmism is unwarranted. Simultaneously, however, there are certain populations differentially affected by the virus for whom suicide may be a larger concern. Presuming a link between unemployment and suicide, several authors have predicted rises in suicide in individual nations and globally. On the basis of pandemic-related unemployment, Lancet Psychiatry in May 2020 predicted a global rise in suicide of between 2,000 and 8,000 annually against a backdrop of approximately 800,000 suicides.

At this point, however, the only survey extant that reports on deaths due to suicide during the pandemic is a Norwegian study, which found no elevation in overall deaths due to suicide in the first three months of the pandemic.

Data are generally lacking with regard to psychological consequences of the pandemic. Few direct surveys exist. Those that have been published indicate increased reporting of mental distress, but no surveys to date indicate significantly increased demand for mental health services. This, of course, doesn’t mean that increased demand isn’t there, and there are anecdotal reports of college counseling centers or various emergency services experiencing marked increases in patient load, but no systematic reporting of this phenomenon has yet emerged.

One very recent study does indicate that patients with a COVID-19 diagnosis are both more likely to be diagnosed with mental health disorders (principally anxiety disorders or adjustment disorder, although mood disorders and insomnia were also called out) after being treated, and that there was a slightly higher rate of COVID-19 diagnoses in those who had previously been diagnosed with a mental disorder. Overall, slightly less than 6% of patients had a new diagnosis of a mental disorder after the COVID-19 diagnosis. This study is interesting in its own right—it is a meta-data analysis, scraped from the electronic records of 70 million patients, of whom 62,000 had a diagnosis of COVID-19. It is not surprising that patients with COVID-19 do experience higher rates of anxiety and perhaps depression, but studies of this nature do not allow us to determine the clinical significance of these diagnoses: Were they an artifact of the practice of requesting a mental health consult for a patient with a lengthy hospitalization and complicated recovery? We simply do not know, but the data bear watching.

The US Centers for Disease Control and Prevention reported a survey conducted during the latter part of June 2020 that assessed over 5,500 respondents for symptoms of trauma-related stress disorders, including suicidal ideation. The authors reported a four-fold increase in reported depressive symptoms compared to one year earlier, and a three-fold increase in anxiety symptoms. Suicidal ideation was reported to be up, though not at the same levels of other psychological symptoms. Another survey conducted during the pandemic found higher than expected rates of depression, particularly among vulnerable groups. In addition to unemployment, the related condition of food insecurity may also serve as a risk factor.

There remains the specter of a wave of suicide following the acute phase of the pandemic. We have little data on post-pandemic levels of suicide and other mental disorders, but the available data on suicide during prior pandemics do not reveal an association between increased suicide during such pandemics (post-pandemic rates were not assessed in the aforementioned study).

To sum up, an increased incidence of suicide during the COVID-19 pandemic has not been observed. Some increases in reported suicidal ideation, including calls to suicide hotlines, have been reported. The little data we have on suicide during or after previous pandemics does not indicate that we are on the edge of a precipice insofar as suicides are concerned, but vulnerable groups should be perhaps more carefully monitored than before. On this note, in October, the National Suicide Hotline Designation Act was signed into law. This act creates a three-digit phone number, similar to 911, that will link callers to the National Suicide Prevention Lifeline. The number will be 988, but please note that this number is not scheduled to be operating until July 2022. In the meantime, those with suicidal ideation should call the existing number, 1-800-273-TALK (8255).

If we exclude suicidal ideation and suicide from the analysis, we are left with both anecdotal and survey data indicating a rise in mental health symptoms, which is only to be expected. I have reported in this space before that overall visits to healthcare providers have declined during the pandemic due largely to two factors: healthcare facilities limiting non-emergent services and the reluctance of patients to seek in-person care. As you recall, we surveyed psychologists shortly after the pandemic began and then again in the early fall. The majority of our respondents to the initial survey reported an immediate and significant negative effect on their practices, but noted some recovery in the second survey, which revealed that approximately 35% of respondents noted an increase in patients since the pandemic began. Our survey methodology did not allow us to discern if this number represents recovery to pre-pandemic levels or an overall increase in patient load. Nationwide, however, there are no numbers suggesting that visits to mental health providers have increased. Like primary care, this may reflect patients’ reluctance to seek in-person care. There is also the question of telehealth: Psychologists and other providers, including physicians, have seen some offset in the decrease of office-based visits as telehealth utilization has increased. It is too early to tell if these trends are enduring, so we really cannot use these observations to predict future changes in demand for mental health services.

Even though a tsunami of pandemic-related mental health problems is in my opinion quite unlikely, it behooves us to prepare for a potentially large increase in mental health problems either as the pandemic continues, or, once an effective vaccine has become available, in its aftermath. We would be foolhardy in the extreme if we did not do so. We have known for some time that even a modest increase in demand for psychological services will result in shortages in our workforce. The National Health Service in Great Britain is predicting a 25% increase in demand for psychological services in the coming years. Accordingly, they have increased funding to provide for an additional 25% of training slots in psychology. In the US such calculations are not so linear. While the Department of Health and Human Services can incentivize training via student loan repayment schemes and funding for graduate psychology education, centralized allocation of training resources and opportunities are not available. But we can take this opportunity to call on graduate programs to increase the number of psychologists they train, rethink our training priorities such that we take less time to educate licensed psychologists, and sharpen our focus to more effectively impart clinical skills during the graduate experience. These are all priorities that we have long deferred. Pandemic or not, the time to address them is now.

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