From the Editor

Will suicide rates rise with COVID? How will mental health care delivery change? Are we overlooking the most vulnerable?

This week’s Reading will focus on the latest in the literature on the COVID and mental health care, with three selections.

In the first, we consider a paper on COVID and suicide. In a JAMA Psychiatry paper, Mark A. Reger (of University of Washington) and his co-authors consider the impact of the global emergency on suicide. They are practical, and explain that there are clear opportunities for suicide prevention. In responding to COVID, they call for a “comprehensive approach that considers multiple US public health priorities, including suicide prevention.”


What is the role of digital mental health during and after this pandemic? In the second selection, we consider a new JMIR Mental Health paper. Dr. John Torous (of Harvard University) and his co-authors note the greater use of telemental health, apps, and other forms of e-mental health care. They write: “The COVID-19 crisis and global pandemic may be the defining moment for digital mental health, but what that definition will be remains unknown.”

Finally, in the third selection, we look at an essay by Andrew Solomon. The Pulitzer Prize-finalist author discusses pandemic and mental health, worrying that those in need may be overlooked. “When everyone else is experiencing depression and anxiety, real, clinical mental illness can get erased.”



Selection 1: Suicide Mortality and Coronavirus Disease 2019 – A Perfect Storm?

Mark A. Reger, Ian H. Stanley, and Thomas E. Joiner

JAMA Psychiatry, 10 April 2020


Suicide rates have been rising in the US over the last 2 decades. The latest data available (2018) show the highest age-adjusted suicide rate in the US since 1941. It is within this context that coronavirus disease 2019 (COVID-19) struck the US. Concerning disease models have led to historic and unprecedented public health actions to curb the spread of the virus. Remarkable social distancing interventions have been implemented to fundamentally reduce human contact. While these steps are expected to reduce the rate of new infections, the potential for adverse outcomes on suicide risk is high. Actions could be taken to mitigate potential unintended consequences on suicide prevention efforts, which also represent a national public health priority.

So begins a paper by Reger et al.

The authors are concerned about the effect of the pandemic. “Secondary consequences of social distancing may increase the risk of suicide.” They focus on eight consequences; five are summarized here:

Economic Stress

“There are fears that the combination of canceled public events, closed businesses, and shelter-in-place strategies will lead to a recession. Economic downturns are usually associated with higher suicide rates compared with periods of relative prosperity.” They also note the decline in the stock market and the decision of many businesses to lay off workers.

Social Isolation

“Individuals experiencing suicidal ideation may lack connections to other people and often disconnect from others as suicide risk rises. Suicidal thoughts and behaviors are associated with social isolation and loneliness. Therefore, from a suicide prevention perspective, it is concerning that the most critical public health strategy for the COVID-19 crisis is social distancing.”

Decreased Access to Community and Religious Support

“Weekly attendance at religious services has been associated with a 5-fold lower suicide rate compared with those who do not attend.The effects of closing churches and community centers may further contribute to social isolation and hence suicide.”

Illness and Medical Problems

“Exacerbated physical health problems could increase risk for some patients, especially among older adults, in whom health problems are associated with suicide.”

Outcomes of National Anxiety

“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 authors emphasize the opportunities for suicide prevention.

Physical Distance, Not Social Distance

“Efforts can be made to stay connected and maintain meaningful relationships by telephone or video, especially among individuals with substantial risk factors for suicide. Social media solutions can be explored to facilitate these goals.”

Tele-Mental Health 

“There is national momentum to increase the use of telehealth in response to COVID-19.”

Increase Access to Mental Health Care

“As COVID-19 precautions develop in health care settings, it is essential to consider the management of individuals with mental health crises.”

Distance-Based Suicide Prevention

“There are evidence-based suicide prevention interventions that were designed to be delivered remotely.” They note, for example, the evidence for brief contact interventions.

Media Reporting

“Because of suicide contagion, media reports on this topic should follow reporting guidelines and include the National Suicide Prevention Lifeline (1-800-273-TALK). The hotline remains open.”

The authors end on an optimistic note: “There are opportunities to enhance suicide prevention services during this crisis.”

This is a practical, thoughtful commentary.

We can all appreciate that our patients are under more stress – and the evidence suggests that the suicide rate will rise, mirroring what we see in economic downturns (in contrast to times of war, when rates seem to drop). The authors do an excellent job of arguing that, while we are in a time of crisis, there is a way forward. The suggestion about media reporting is particularly tangible, and would come at no cost.


Selection 2: Digital Mental Health and COVID-19: Using Technology Today to Accelerate the Curve on Access and Quality Tomorrow

John Torous, Keris Jän Myrick, Natali Rauseo-Ricupero, and Joseph Firth

JMIR Mental Health, 26 March 2020


The COVID-19 crisis and global pandemic has highlighted the role of telehealth and digital tools like apps to offer care in times of need. Many clinicians and patients alike are now realizing the full potential of these digital tools, as they are forced to, for the first time, utilize them to connect in a time when in-person and face-to-face visits are impossible. Harnessing this surge in interest, enthusiasm, and acceptance has immediately been recognized as an opportunity for the field. Thus, the field’s next steps will also be critical in ensuring digital health is used today to deliver the best care during the current crisis, ready for any resulting mental health spike following the immediate crisis, and prepared to support future crises as well as care as usual. In this perspective piece, we draw largely from our team’s experience with digital health and recognize the impressive global innovation and research in this space that cannot be captured in any single piece.

So begins this commentary by Torous et al.

Telehealth is the right solution to deliver mental health care in today’s crisis. The only established contraindication to telehealth need for workforce training, high-quality evidence, and digital is a patient not wishing to partake.

They welcome recent changes in (US) regulations making it easier to use telehealth.

Torous et al. also see a robust role for apps.

“Tools like apps also have an important role, given their availability and scalability, but with similar caveats.” They offer several:

  • Limited evidence. “Current evidence for apps for behavior change remains limited, and self-help for mental health remains equally limited.”
  • Poor quality studies. “Although companies will boast about positive outcomes from randomized controlled trials, results from higher-quality studies with valid comparisons groups, proper statistical analysis, and low risk of bias do not tell the same story.”
  • Challenges with privacy. “Picking from those different apps is challenging as many offer little protection of user data, make exaggerated claims, may be ineffective, and often are quickly abandoned because of usability issues.”

Still, they see a role for apps. “In our experience, the most effective apps are the ones that can be customized to each patient and fit with their personal care goals and needs as well as apps for peer support.” They also wonder if digital health (and apps in particular) may have a more robust role in lifestyle modifications.

Looking beyond the immediate consequences of infection with the virus and the mental health impact of self-quarantine and social distancing, a second mental health crisis looms. In times of economic recession, there is often high prevalence of mental health disorders, misuse of substances (or substance use disorder), and deaths from suicide.

How can digital health move forward?

First, better training. “Among some of these new efforts required, a critical one is teaching medical professionals, trainees, and peer support specialists how to use digital and mobile technologies for delivering care.”

Second, attempts to address inequity. “Ensuring all patients, especially the most vulnerable ones, have the digital literacy and competency to partake in digital care is a matter of equity and social justice.”


They close:

Ensuring the right use of telehealth and app tools today in this crisis and investment in people and training to support them tomorrow during the potential mental health fallout of the current crisis as well as readiness for tomorrow can cement the future of digital mental health as simply mental health.

The comments are insightful. Despite the enthusiasm of the authors, this paper is balanced and thoughtful.

Torous et al. are right in suggesting that mental health services have been fundamentally changed by the pandemic, as providers embrace telehealth, largely out of necessity. But they are also right in suggesting that the changes could go further. We have achieved Digital Health 1.0, allowing us to connect better with our patients (telehealth vs. in person). But what might Digital Health 2.0 look like, as we move past connection, into the realm of empowering our patients with monitoring of their health and then offering tools in real-time?


Selection 3: When the Pandemic Leaves Us Alone, Anxious and Depressed

Andrew Solomon

The New York Times, 9 April 2020


For nearly 30 years – most of my adult life – I have struggled with depression and anxiety. While I’ve never felt alone in such commonplace afflictions – the family secret everyone shares – I now find I have more fellow sufferers than I could have ever imagined.

Within weeks, the familiar symptoms of mental illness have become universal reality. A new poll from the Kaiser Family Foundation found nearly half of respondents said their mental health was being harmed by the coronavirus pandemic. Nearly everyone I know has been thrust in varying degrees into grief, panic, hopelessness and paralyzing fear. If you say, ‘I’m so terrified I can barely sleep,’ people may reply, ‘What sensible person isn’t?’

But that response can cause us to lose sight of the dangerous secondary crisis unfolding alongside the more obvious one: an escalation in both short-term and long-term clinical mental illness that may endure for decades after the pandemic recedes. When everyone else is experiencing depression and anxiety, real, clinical mental illness can get erased.

So opens an essay by Solomon.

Though he notes that New York State has deployed 8,000 mental health care workers, he still worries that mental health care will be neglected.

“The unequal treatment of the two kinds of health –  physical over mental – is consonant with our society’s ongoing disregard for psychological stability. Insurance does not offer real parity of coverage, and treatment for mood disorders is generally deemed a luxury.”

He argues that “the mental health ramifications of pandemics” have been “studiously ignored.”

He draws on the literature.

  • He cites a 2013 study on H1N1. “Because pandemic disasters are unique and do not include congregate sites for prolonged support and recovery, they require specific response strategies to ensure the behavioral health needs of children and families. Pandemic planning must address these needs.”
  • And another study. “While information for the medical aspects of disaster surge is increasingly available, there is little guidance for health care facilities on how to manage the psychological aspects of large-scale disasters that might involve a surge of psychological casualties.”

Solomon notes that even social isolation can be problematic. Though he feels that many will not be psychologically affected, he wonders about those with mood and anxiety problems. He wonders too about “touch deprivation” and its effects.

The authorities keep saying that the coronavirus will pass like the flu for most people who contract it, but that it is more likely to be fatal for older people and those with physically compromising preconditions. The list of conditions should, however, include depression generated by fear, loneliness or grief. We should recognize that for a large proportion of people, medication is not an indulgence and touch is not a luxury. And that for many of us, the protocol of Clorox wipes and inadequate masks is nothing compared with the daily task of disinfecting one’s own mind.

The essay is beautifully written and makes good points. His most important: we can’t forget about mental health care in this pandemic.

Solomon doesn’t do an extensive literature review – which is fair, given that this is an essay, not a research paper – but there are significant studies about SARS and its impact. (I’ll return to this point in a future Reading.) And so, while today we worry about ventilators and oxygenation, the challenge in the near future will be around culturally-adapted psychiatric care and PTSD.

Solomon’s essay is deeply personal, and includes his conversation with his young son about the pandemic. At points, the argument becomes more romantic, and readers can decide if they are persuaded about touch deprivation.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.