Individuals with untreated psychiatric disorders and suicide in the COVID-19 era

Sher, Leo

doi:10.1590/1516-4446-2020-1210

The coronavirus disease 2019 (COVID-19) pandemic began in China at the end of 2019 and has quickly spread around the world.¹ Millions of people across the globe are infected and hundreds of thousands have died. The COVID-19 crisis is associated with very significant psychological and social consequences that will probably persist for a long time. Millions of people around the world have experienced distress, anxiety, uncertainty, and social isolation.¹,² Millions of people have lost their jobs. This disaster has had a profound impact on the mental state of vulnerable individuals, especially individuals with pre-existing psychiatric disorders. Individuals with pre-existing psychiatric conditions include not only persons who are treated by mental health professionals but also a huge number of people with psychiatric disorders who do not receive psychiatric care.³-⁶ In this article, I propose that individuals with untreated psychiatric disorders may be at an especially high risk for suicide during and after the COVID-19 pandemic.

Many people around the globe who need psychiatric treatment do not get mental health care.³-⁶ According to the U.S. National Institute of Mental Health, in 2017 only 42.6% of adults in the U.S. suffering from psychiatric illness received psychiatric care in the past year.³ More women with psychiatric disorders (47.6%) received mental health services than men with psychiatric disorders (34.8%). Community epidemiological studies in the U.S. indicate that most individuals with mood disorders are either untreated or undertreated.⁴ About 75% of people with psychiatric issues in England do not get the care they need.⁵ A large international study that included information from countries in Europe, North and South America, Asia, Africa, Australia and New Zealand showed that the median untreated rates for schizophrenia, major depression, generalized anxiety disorder, and alcohol use disorder were 32.2, 56.3, 57.5, and 78.1%, respectively.⁶

Psychiatric disorders are associated with suicidal behavior.⁷ Research investigations in the U.S. indicate that more than 90% of suicide victims have a psychiatric disorder.⁷ Besides, most individuals who attempt suicide have a psychiatric condition. The most frequent psychiatric illnesses associated with suicide or severe suicide attempt are mood disorders.⁷ Stressful situations related to the COVID-19 crisis may significantly exacerbate mood and substance use disorders and other psychiatric conditions among individuals with untreated mental illnesses. Moreover, many individuals may start using alcohol and/or drugs. People with comorbid major psychiatric disorders and substance abuse are at an especially high risk for suicide.⁸ For example, research shows that men with comorbid depression and alcohol use disorder have a very high long-term suicide risk (16.2%).⁹ Persons with untreated psychiatric disorders frequently have substantial morbidity and functional impairment and are at elevated suicide risk. COVID-19-related anxiety, uncertainty, social isolation, and economic issues may significantly increase suicide risk among people with psychiatric disorders, especially individuals with untreated mental illness. Economic problems such as job loss may increase suicides both during and after the COVID-19 pandemic.¹,¹⁰ A recent model indicates that job losses due to COVID-19 will lead to between 2135 and 9570 suicides per year worldwide.¹⁰ It is important to note that economic problems reduce access to mental health treatment. Also, finding a job is more difficult for a person with a psychiatric illness than for a healthy person.

It is difficult to reduce suicidal behavior among individuals with psychiatric conditions who are not in treatment. However, some measures may reduce suicides in this population. These measures include:

- Recognition of psychiatric disorders. Improving detection of psychiatric disorders in primary care may be a significant step towards addressing unmet mental health needs and decreasing suicides. Also, community or organizational gatekeepers such as clergy, first responders, school workers, and caregivers of older adults need to be educated about mental illness because they may have an opportunity to identify individuals at risk for suicide and direct them to proper evaluation and treatment.
- Improved access to mental health care may reduce suicides. Governments and non-governmental organizations should try to improve access to psychiatric care during and after the COVID-19 crisis.
- Reduced mental illness stigma. Stigma is a contributing factor to non-help-seeking among people struggling with psychiatric illness.
- The general population needs to be educated about mental illness and when to seek professional help if a person has symptoms of a psychiatric disorder.

In summary, suicide risk will probably increase among individuals with untreated mental illness during and after the COVID-19 pandemic. Public health systems should try to identify these individuals and engage them in mental health treatment.

References

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³ National Institute of Mental Health. Mental illness [Internet]. 2019 Feb [cited 2020 May 28]. http://nimh.nih.gov/health/statistics/mental-illness.shtml#part_154787
» http://nimh.nih.gov/health/statistics/mental-illness.shtml#part_154787
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