The decline in the nation’s suicide rate during the first year of the COVID-19 pandemic may suggest advancements in preventative programs and treatment supports have resulted in better outcomes.
But stakeholders contend a closer examination of the figures shows a more complicated picture – one that raises questions about the long-term effects of the pandemic, as well as why the decline did not occur evenly.
The nation’s overall suicide rate fell by 3% from 2019 to 2020, even as a number of studies have highlighted the pandemic’s mental health toll on Americans. One analysis found nearly 41% of more than 5,400 adults surveyed in June 2020 reported having at least one adverse mental or behavioral health condition, with nearly 11% stating they had seriously considered suicide within the past 30 days – roughly twice the estimated share of adults in 2018 who’d considered suicide within the past year. Nearly 31% of those surveyed reported having symptoms of anxiety or depressive disorder, 26% reported having symptoms of trauma- and stressor-related disorder tied to the pandemic, and 13% reported starting or increasing substance use as a means of coping with stress or emotions related to the pandemic.
The results of a follow-up survey conducted in September 2020 found 33% of respondents reported having anxiety or depression symptoms, while nearly 12% reported having serious thoughts of suicide in the previous month.
“We did see a lot of the things that we would consider as risk factors for suicide – job loss, financial instability, interpersonal violence – things like that,” says Colleen Carr, director of the National Action Alliance for Suicide Prevention.
Yet the suicide figures for 2020 from the Centers for Disease Control and Prevention seem to refute concerns expressed by many early in the pandemic who felt the crisis and its related stressors – including economic fallout and social isolation tied to safety measures employed to stem the coronavirus’ spread – might drive an increase.
Carr says more awareness among people of their mental health needs, along with greater access to behavioral health care services through telehealth platforms, likely played a large role in the decline. She says people also may have experienced “a coming together moment” in the face of the pandemic, providing them with a sense of shared purpose to do their part to help themselves, loved ones and others during the emergency.
Previous research suggests suicide metrics can remain stable or even decrease in the immediate aftermath of a disaster. A study published in 2006 in the Bulletin of the World Health Organization compared the prevalence of suicidality among New Orleans residents before and less than a year after Hurricane Katrina and found rates of suicidal thoughts, plans and attempts were similar during both periods, even as the estimated prevalence of mental illness was higher after the hurricane. Researchers also called the “lower conditional likelihood of suicidality among people believed to have mental illness” after the hurricane their “most striking finding,” and suggested that areas of personal growth triggered by the hurricane may have had a protective, if potentially temporary, effect.
Later on, however, a study published in 2008 in the journal Molecular Psychiatry found increases in the prevalence of both suicidal thoughts and plans – though not attempts – more than one year after the hurricane compared with when they were interviewed less than a year after it occurred.
While Carr acknowledges the nature of the COVID-19 pandemic is different than other disasters, she says evidence within prior studies does suggest the effects of the pandemic on the nation’s suicide rate may be seen in the coming years after the current emergency has passed.
Notably, a CDC analysis published last year found that after an initial drop, the average number of weekly emergency department visits for suspected suicide attempts among adolescent girls was 26% higher in the summer of 2020 and nearly 51% higher in early 2021 compared with reference periods in 2019.
“There was and still is a real concern about what impact the pandemic will have on suicide,” Carr says, particularly as people may still be contending with the lingering effects of economic uncertainty and social unrest.
Rajeev Ramchand, a senior behavioral scientist at the Rand Corp. and co-director of the RAND Epstein Family Veterans Policy Research Institute, says another reason why the decline in the suicide rate may not be as clear-cut as the data would suggest is if some deaths linked to another cause were actually self-inflicted.
In particular, Ramchand says he questions whether a larger portion of the more than 91,000 drug overdose deaths that occurred in 2020 – representing a more than 30% rate increase from 2019 – might have been a result of suicide. According to a CDC report on 2020 overdose deaths released in December, 91% were classified as unintentional, 4.7% as suicides, less than 1% as homicides and 4.1% as “of undetermined intent”.
“Given the dramatic increase in overdose deaths coupled with the fact that medical examiners and coroner offices were so overwhelmed because of COVID, could there just have been some misclassification of suicide deaths as unintentional?” Ramchand says. “The rate increase was so dramatic that I think we have to be asking that question.”
A closer look at the data also reveals a decline in suicide in 2020 that was heavily concentrated among whites. The rate of such deaths fell by 4.5% among white individuals in 2020 from 2019, with the group accounting for more than 75% of the nearly 46,000 suicide deaths in 2020.
That marked the only statistically significant change in rate among broader racial and ethnic groups included in the CDC’s analysis, though drilling down further reveals additional disparities: While the year-over-year rate dropped by nearly 10% among white females and by 3% among white males, it rose by close to 6% among Hispanic males and by 29% among multiracial females. The rate also rose by 4.6% among people 25 to 34 years old, while just seven states saw significant year-over-year declines.
Separately, a December 2020 study published in JAMA Psychiatry that examined racial differences in suicide mortality in Maryland found from March 5 to May 7 of 2020 – when the state came under lockdown orders – suicide mortality among Black individuals appeared to double versus a comparative pre-pandemic timeframe, while mortality among white residents appeared to fall substantially. A study of suicide data in Connecticut yielded a similar finding.
Aside from the disproportionate impact of COVID-19 itself on people of color when it comes to outcomes such as hospitalizations and deaths, evidence points to the pandemic having a heavy impact on many members of these communities in other areas as well, including job loss and housing instability.
Jill Harkavy-Friedman, vice president of research for the American Foundation for Suicide Prevention, says the pandemic has been a stressor for people who were already vulnerable to suicide. She says suicide is normally associated with a range of risk factors – like a mental health disorder, a chronic disease or a disability – coupled with having fewer protective factors, such as access to health care services.
“We know that has been disproportionately low for minority populations,” Harkavy-Friedman says of access to mental health care. “So, if you have increased risk and then you have lack of access to care, that’s a way in which it could affect suicide rates.”
Dr. Christine Crawford, associate medical director for the National Alliance on Mental Illness, says higher rates of mental health care utilization among white patients may lead many clinicians to conclude patients of color are at lower risk for suicide, in turn causing them to ask those patients less frequently about whether they have thoughts about taking their own life.
“I wonder if there was just a different attitude with regards to safety assessment when it came to Black people, that it was a missed opportunity for a number of especially young Black people to really be able to speak openly about thoughts that they might have had about harming themselves and not wanting to be alive,” Crawford says.
Harkavy-Friedman says such disparities highlight a vital need to develop more culturally relevant approaches to suicide prevention that are more effective in reaching underrepresented populations.
“I think there are a lot of opportunities for intervention, but we’re just not there yet, we’re not doing it,” Harkavy-Friedman says. “We have to do better, we have to try more.”
Harkavy-Friedman says the AFSP has been working with different ethnic organizations to develop strategies and craft ways to have conversations within communities where the topic of suicide and suicide prevention are not usually discussed.
“When you have those conversations, it helps raise awareness and provides education that helps bring down the community rate for suicide,” Harkavy-Friedman says. “It’s really about engagement, it’s about inclusion, it’s about listening and empowering people to develop efforts in their own communities.”
Laura Leone, a consultant on practice improvement and consulting for the National Council for Mental Wellbeing, says the most successful suicide prevention programs are ones that diversify their approaches and make community outreach a part of their efforts.
“This is not a one-size-fits-all approach,” Leone says. “We need varying approaches and to not just assume a few different things is going to work for everyone.”
Crawford says a potential positive that has come out of the pandemic has been the increased willingness among people of all racial and ethnic groups to talk about their mental health and well-being. She hopes such openness can lead to new opportunities for expanding mental health care supports and services within underserved communities.
“I think more people are able to better appreciate just how significantly impairing depression and anxiety and other mental health symptoms really are,” Crawford says. “My hope for the future is that not only can we normalize conversations around mental health and emotional wellness, but we can also normalize conversations around mental health treatment.”