COVID-19 is an emerging public health problem, which started in China at the end of 2019 and gradually affected the majority of countries including India(1). Doubtful information about this novel disorder along with the nonavailability of proper treatment has presented some ubiquitous challenges to our mental health (2). This pandemic has become a fertile ground for many mental health issues and more people are affected by mental health issues in any pandemic than by the pandemic itself (3). Quarantine and other essential measures taken during such pandemics like social distancing, and isolation along with the resultant social and economic breakdowns can result in the emergence and precipitation of many psychological issues. These issues are very common in the aftermath of any pandemic and sometimes can lead to increased suicidal behavior like suicidal thoughts, attempts, or complete suicide(4). As learned from previous epidemics like the SARS virus epidemic, pandemics increase the risk of suicidal behavior (2). Ever since the COVID-19 cases started escalating in India, many cases of suicide have been reported the first being on 12th Feb 2020 in the Chittoor district of Andra Pradesh. He was a 50-year-old male and ended his life by hanging himself from a tree, after getting apprehensive of being infected and spreading the coronavirus (5). Another person who was suspected to be infected with COVID-19 allegedly committed suicide by jumping off from the seventh floor of Safdarjung Hospital in Dehli after he was referred by airport authorities for isolation and testing (6). In Mumbai, a 29-year-old female committed suicide after testing positive for the coronavirus by hanging herself inside the bathroom of the hospital (7). Similarly, a 42-year-old businessman man in Gujarat committed suicide, after he was put under quarantine (8), but later his test for COVID-19 turned out to be negative. Similarly, more than 39 people across India have committed suicide because of corona scare, and more than 40 people have died or attempted suicide owing to the unavailability of alcohol due to the countrywide lockdown (9). The first case that came to notice developed intense fear and anxiety due to the apprehension of being infected which was precipitated by a video on social media. The second case was a case of a suspected COVID-19 who was put under administrative quarantine and developed severe anxiety culminating in suicide. The third case was of a COVID-19-positive patient who developed severe fear after testing positive. Similar patterns of suicide were observed in previous epidemics, where the victims were more fearful of contracting the disease and had fear of being a risk to their families.2 The fourth, patient was a businessman with a history of travel and was kept under quarantine. The quarantine period is reported to be a stressful period, with a lot of psychological distress. This psychological distress if not addressed can lead to suicide. (4) In all of the above case scenarios, it appears that suicidal behavior can occur in isolation, under quarantine, or in a person who is suspected to have COVID 19 and suicide could have been prevented if there was proper dissemination of information regarding COVID-19. Further, in people addicted to drugs the stoppage of illicit drugs due to unavailability during lockdown can also cause suicide.
Suicide is a grave public health problem in India and it is a hidden and silent epidemic, with many contributory factors. Mental illness illnesses are the primary reasons for the majority of suicides, while both physical and mental illness, disturbed emotional relationships and economic difficulties were the major reasons for suicide in vulnerable populations (10). The level of apprehension and fear of COVID among the Indian population is increasing as the cases are escalating with the passage of time. Although the risk of suicide in this coronavirus pandemic has not been systemically studied, as per recent reports of suicide, it is anticipated to be a contributory factor in suicide. Different people react differently to stressful events. Fear and anxiety about getting COVID-19 and loneliness due to isolation and quarantine measures can be overwhelming and cause strong emotions in predisposed persons. People who respond more strongly to a crisis include patients of all age groups, those with substance abuse disorders, healthcare providers, and patients with previous mental health issues.11 Nevertheless the suicides occurring due to COVID-19 are preventable and further research on suicide risk in relation to COVID-19 is the need of the hour to gain more insight and to prevent such tragedies. Additionally, patients who are suspected of COVID-19 infection, people who have been quarantined and healthcare providers need more care. Therefore it is important to intervene at the right time so that the physical and mental health of patients is maintained and suicides are prevented. Based on our recent experience in India, we would like to propose to the stakeholders, the clinicians, and the policymakers to increase awareness about mental health and suicidal risk associated with an infectious disease pandemic like the current COVID-19 pandemic. Early detection of suicidal risk and treatment can alleviate the suffering of patients and reduce the number of suicides. 12 We would like to suggest the following recommendations to the general public, health care providers, and patients with mental health issues in our population.
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Avoid rumors and misinformation about COVID-19 to prevent fear and panic in the general public regarding COVID-19. Special vigilance should be kept on Social media, newspapers, and multimedia to prevent the spread of misinformation among the general masses. There should be cautious and careful use of social media and other telecommunication services. All patients with COVID-19 presenting with any mental health issues should be evaluated. Rapid identification of people with suicidal warning signs like hopelessness, helplessness, worthlessness or fear, or thoughts of death. Quick suicidal risk assessment scales need to be used to evaluate the risk of suicide. provision of treatment via mobile teams or inpatient care (depending on severity ), and monitoring the people (e.g. Suspected or diagnosed COVID-19, quarantined people) for any psychological distress. We recommend integrating suicidal risk screening assessment in the protocol for COVID-19 testing. There is also a need to augment access to intervention for people who are experiencing psychological distress related to COVID-19. There is a need to create more mental health resources in India both online and offline such as coping tips and self-help skills. We recommend the institution of 24*7 crisis helplines(national and local ). Crisis helplines(national and local) should be augmented and have improved access for the benefit of people with suicidal risk. (11)
Telemedicine or Online mental health interventions should be promoted for catering to people who have mental health issues. Suicidal risk assessment scales via one line mental health helpline can be useful to prevent this tragedy. Further, there is a paramount need for nationwide suicidal programs and campaigns on mental health that will emphasize the consequences of pandemics on mental health and well being of a person. It will be therefore very imperative for district mental health programs to incorporate the suicidal campaign and psychoeducation about psychological distress and suicidal risk
Social contact and maintaining routines can be supportive of our mental health and well-being. Present basic support and care to people during the lockdown. Enhancing self-care and mental health hygiene in health care providers. (12)
The current COVID-19 pandemic is a quite challenging problem in India due to the fact that our health systems particularly mental health systems were not prepared for this outbreak. We thus recommend screening for the possibility of suicides and including suicide risk assessment and increasing access to mental health services. Mental health services should be extended to all hospitals across the country. It is, therefore, an imperative need for innovative assessment of mental health care to address the much-needed psychological and social aspects of suicide in these times of crisis.
References
- World Health Organization (WHO) (2020). Coronavirus disease (COVID-19) technical guidance: Infection prevention and control / WASH. Retrieved on April 2, 2020, from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control.
- Cheung Y.T., Chau P.H., Yip P.S. A revisit on older adults’ suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int. J. Geriatr. Psychiatry. 2008;23(12):1231–1238.
- Reardon S. Ebola’s mental-health wounds linger in Africa. Nature. 2015;519:13-4.
- Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., y Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: a rapid review of the evidence. Lancet, 395(10227), 912–920. https://doi.org/10.1016/S0140-6736(20)30460-8.
- https://economictimes.indiatimes.com/news/politics-and-nation/man-suspected-of-covid-19-commits-suicide/articleshow/74700431.cms?from=mdr.
- https://www.indiatoday.in/india/story/covid-19-positive-woman-commits-suicide-in-mumbai-1667178-2020-04-15
- https://www.msn.com/en-ae/news/world/covid-19-man-commits-suicide-over-coronavirus-scare/ar-BBZUrTu.
- https://www.indiatvnews.com/news/india/coronavirus-in-india-42-year-old-businessman-gujarat-palanpur-home-quarantine-commits-suicide-604298.
- https://gulfnews.com/world/asia/india/the-human-cost-of-indias-coronavirus-lockdown-deaths-by-hunger-starvation-suicide-and-more-1.1586956637547.
- Shoib S, Kim YK. The Frontiers of Suicide. Advances in Experimental Medicine and Biology. 2019 ;1192:503-517. DOI: 10.1007/978-981-32-9721-0_25.
- Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., y Ho, R. C. (2020). Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. International Journal of Environmental Research and Public Health, 17(5). https://doi.org/10.3390/ijerph17051729.
- Duan, L., y Zhu, G. (2020). Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry, 7(4), 300–302. https://doi.org/10.1016/S2215-0366(20)30073-0
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