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Psiquiatría en tiempos de virus

Sergio Strejilevich (Argentina) José Bitran (Chile) Danilo Quiroz (Chile)

Viernes 15 mayo (y todos los viernes)

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ID 346-429-571

“SUICIDIO Y SUICIDALIDAD EN PANDEMIA”

Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?

Suicide rates have been rising in the US over the last 2decades. The latest data available (2018) show the high-est age-adjusted suicide rate in the US since 1941.1 It iswithin this context that coronavirus disease 2019(COVID-19) struck the US. Concerning disease modelshave led to historic and unprecedented public healthactions to curb the spread of the virus. Remarkable so-cial distancing interventions have been implementedto fundamentally reduce human contact. While thesesteps are expected to reduce the rate of new infec-tions, the potential for adverse outcomes on suiciderisk is high. Actions could be taken to mitigate poten-tial unintended consequences on suicide preventionefforts, which also represent a national public healthpriority.

COVID-19 Public Health Interventionsand Suicide RiskSecondary consequences of social distancing may in-crease the risk of suicide. It is important to considerchanges in a variety of economic, psychosocial, andhealth-associated risk factors.

Economic StressThere are fears that the combination of canceled publicevents, closed businesses, and shelter-in-place strate-gies will lead to a recession. Economic downturns areusually associated with higher suicide rates comparedwith periods of relative prosperity.2 Since the COVID-19crisis, businesses have faced adversity and laying off em-ployees. Schools have been closed for indeterminableperiods, forcing some parents and guardians to take timeoff work. The stock market has experienced historicdrops, resulting in significant changes in retirementfunds. Existing research suggests that sustained eco-nomic stress could be associated with higher US sui-cide rates in the future.

Social IsolationLeading theories of suicide emphasize the key rolethat social connections play in suicide prevention.Individuals experiencing suicidal ideation may lackconnections to other people and often disconnectfrom others as suicide risk rises.3 Suicidal thoughtsand behaviors are associated with social isolation andloneliness.3 Therefore, from a suicide prevention per-spective, it is concerning that the most critical publichealth strategy for the COVID-19 crisis is social dis-tancing. Furthermore, family and friends remain iso-lated from individuals who are hospitalized, evenwhen their deaths are imminent. To the extent thatthese strategies increase social isolation and loneli-ness, they may increase suicide risk.

Decreased Access to Community and Religious SupportMany Americans attend various community or reli-gious activities. Weekly attendance at religious ser-vices has been associated with a 5-fold lower suicide ratecompared with those who do not attend.4 The effectsof closing churches and community centers may fur-ther contribute to social isolation and hence suicide.

Barriers to Mental Health TreatmentHealth care facilities are adding COVID-19 screening ques-tions at entry points. At some facilities, children and otherfamily members (without an appointment) are not per-mitted entry. Such actions may create barriers to mentalhealth treatment (eg, canceled appointments associ-ated with child restrictions while school is canceled). In-formation in the media may also imply that mental healthservices are not prioritized at this time (eg, portrayals ofoverwhelmed health care settings, canceled elective sur-geries). Moreover, overcrowded emergency depart-ments may negatively affect services for survivors of sui-cide attempts. Reduced access to mental health care couldnegatively affect patients with suicidal ideation.

Illness and Medical ProblemsExacerbated physical health problems could increase riskfor some patients, especially among older adults, inwhom health problems are associated with suicide. Onepatient illustrated the psychological toll of COVID-19symptoms when he told his clinician, “'I feel like (you)sent me home to die.”5

Outcomes of National AnxietyIt is possible that the 24/7 news coverage of these un-precedented events could serve as an additional stressor,especially for individuals with preexisting mental healthproblems. The outcomes of national anxiety on an indi-vidual’s depression, anxiety, and substance use de-serve additional study.

Health Care Professional Suicide RatesMany studies document elevated suicide rates amongmedical professionals.6 This at-risk group is now serv-ing in the front lines of the battle against COVID-19. A na-tional discussion is emerging about health care work-ers’ concerns about infection, exposure of familymembers, sick colleagues, shortages of necessary per-sonal protective equipment, overwhelmed facilities, andwork stress. This special population deserves supportand prevention services.

Firearm SalesMany news outlets have reported a surge in US gun salesas COVID-19 advances. Firearms are the most common

VIEWPOINT

Mark A. Reger, PhDVA Puget Sound HealthCare System, Seattle,Washington; andDepartment ofPsychiatry andBehavioral Sciences,University ofWashington, Seattle.

Ian H. Stanley, MSVA Puget Sound HealthCare System, Seattle,Washington; andDepartment ofPsychology, FloridaState University,Tallahassee.

Thomas E. Joiner, PhDDepartment ofPsychology, FloridaState University,Tallahassee.

CorrespondingAuthor: Mark A. Reger,PhD, VA Puget SoundHealth Care System,1660 S Columbian Way(S-116), Seattle, WA98108 (mark.reger@va.gov).

Opinion

jamapsychiatry.com (Reprinted) JAMA Psychiatry Published online April 10, 2020 E1

© 2020 American Medical Association. All rights reserved.© 2020 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by Danilo Quiroz on 05/15/2020

Estrés económico

Aislamiento social

Dism

inuc

ión d

e acc

eso a

la

com

unid

ad o

apoy

o rel

igio

so

Barreras de acceso a atención salud m

ental

Angustia asociada a la cobertura de los medios y RRSS

Acceso a medios letalesDistanciamiento físico / no social

Cobertura apropiada de los medios

Tele-consulta / e-health

Programas de

apoyo económico

Suicidio por armas de fuego y prevalencia de armas en el hogar en una muestra de estados en EEUU (2013)

Justin Thomas Briggs and Alexander Tabarrok, Firearms and suicides in US states. International Review of Law and Economics 37 (2014) 180-188.

Impacto de las recesiones económicas y tasas de suicidio

Chang, S.-S., et al. (2013). "Impact of 2008 global economic crisis on suicide: time trend study in 54 countries." BMJ : British Medical Journal 347: f5239. Reeves, A., M. McKee and D. Stuckler (2014). "Economic suicides in the Great Recession in Europe and North America." Br J Psychiatry 205(3): 246-247.

Menores tasas de suicidio en el área metropolitana de New York en el mes posterior al 9/11

Claassen et al

circle around Somerset County. As a result, no pre-/post-9/11 ratedifferences achieved significance and no control year or controlconditions were analysed.

Finally, there were also no significant post-9/11 rate trends inthe area within 150 miles of the Flight 93 crash site. The suiciderate fluctuated above pre-9/11 rates on a monthly basis, but – likethe 150-mile circle around the Pentagon – the post-9/11 180-dayrate average around the Flight 93 crash site remained essentiallyunchanged from the equivalent pre-9/11 rate.

Discussion

This study examined trends in daily US suicide rates around thecrash sites after the 11 September 2001 terrorist attacks and foundthat although the attacks did not significantly influence nationalrates, the rates for individuals whose place of residence was within150 miles of the World Trade Center were reduced. The effect wasmost prominent during the first 2 months after the attacks, butinfluenced average daily rates across a 180-day time period as well.The effect was observable in an area extending 150 miles outwardsfrom Ground Zero, and the lack of post-9/11 rate change for othercause-specific mortality conditions within this geographic areasuggests that the effect was not related to overburdeneddeath investigation and registration systems. The absence of acorresponding effect in years preceding 2001 suggests that theeffect was also not because of seasonal rate fluctuations. Thenotable absence of any such effect in the area surrounding boththe Pentagon and the Flight 93 crash sites contrasts sharply withthe World Trade Center pattern.

New York City and European response patterns

The decline in New York City suicide rates is perhaps notsurprising, given the profound impact of the event and its sequelaeon the daily lives of those who lived within the city. Countless

news reports from that time period document the increased socialcohesion among New York City residents, which included highlevels of support for Ground Zero clean-up workers anduniformed civil servants.17,18 This sociological response patternsupports the Durkheimian position that increased group cohesionin post-attack Manhattan and surrounding areas directlyprecipitated the declining suicide rates.

Two alternative explanations seem less likely. The first is thatincreased access to mental health treatment available in the cityvia free, walk-in Project Liberty mental health clinics during themonths after the attacks mediated the drop in suicide rates.19–21

The second possibility is that, perhaps because of the mediaattention, a temporary increase in tolerance for mental healthhelp-seeking may have occurred over the months following theattacks independent of any increase in group cohesion, producingan environment more supportive of treatment-seeking than usual.Although either possibility may have contributed to themaintenance of lower suicide rates over the latter part of the180-day study time period, it is not likely that either would haveprecipitated a significant drop in rates beginning immediatelyafter the attacks. Instead, it seems more likely that suicide ratesdropped on the morning of 12 September in direct response tothe event itself.

In the weeks and months following 9/11, the World TradeCenter attack was widely understood to be an attack on thefinancial structure of first-world economies.22 As two of the mostpowerful economic centres in the world,23 it is therefore perhapsnot so surprising that popular reaction and suicide rateperformance in New York City and Great Britain mirrored eachother. Within hours of the attacks British Prime Minister TonyBlair declared that Britain stood ‘shoulder to shoulder’ withAmerica against the ‘new evil of mass terrorism’.24 As a populationwell acquainted with acts of terrorism, British people seem to haveresponded in-kind during those initial post-attack days.

362

Fig. 4 Suicide rates per 100 000 people for 2001 by time interval and geographic region.Claassen, C. A., et al. (2010). "Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites." British Journal of Psychiatry 196(5): 359-364.

Contagio / Modelamiento

• Impacto de la exposición a suicidio de pares

• Cobertura que hacen los medios

• Clusters de suicidio

Tasas globales de suicidio en Estados Unidos 1900 - 2014

Adaptado de Maris, R. W. and D. A. Jobes (2019). Suicidology, Guilford Publications.

Algunas característica del problema clínico del suicidio

• El suicidio es un evento raro

• La suicidalidad es un fenómeno extremadamente frecuente

• La capacidad del clínico para predecir un suicidio es prácticamente nula (que es diferente a identificar grupos de alto riesgo)

• Baja comprensión y pobre descripción de los fenómenos suicidales

el modelo “escalonado” o progresivo de evolución de la suicidalidad no es de utilidad para predecir conducta suicida

Suicidalidad ≠ Depresión

Suicidalidad ≠ trastorno psiquiátrico

Suicidalidad ≠ auto agresión

Suicidalidad ≠ impulsividad

Aspectos relacionados al clínico: emociones, valores, exposición legal, ética

Escucha activa, apoyar, enseñar.

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Gunnell, D., et al. "Suicide risk and prevention during the COVID-19 pandemic." The Lancet Psychiatry.

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Gunnell, D., et al. "Suicide risk and prevention during the COVID-19 pandemic." The Lancet Psychiatry.

Intervenciones selectivas e indicadas

Intervenciones universales

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

Comment

2 www.thelancet.com/psychiatry Published online April 21, 2020 https://doi.org/10.1016/S2215-0366(20)30171-1

readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.

Irresponsible media reporting of suicide can lead to spikes in suicides.8 Repeated exposure to stories about the crisis can increase fear9 and heighten suicide risk. Media professionals should ensure that reporting follows existing10 and COVID-19-specific guidelines.

Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide

and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These e!orts need to be appropriately resourced and coordinated.

The suicide-related consequences of the pandemic might vary depending on countries’ public health control measures, sociocultural and demographic

For COVID-19-specific guidelines on reporting on

suicide see https://www.iasp.info/pdf/2020_briefing_

statement_ABversion_reporting_on_suicide_during_

covid19.pdf

Figure: Public health responses to mitigating suicide risk associated with the COVID-19 pandemicCOVID-19=coronavirus disease 2019.

Mental healthservices andindividualprovidersDeliver care indi!erent ways (eg, digitalmodalities);develop support forhealth-care sta!a!ected by adverseexposures (eg,multiple traumaticdeaths); ensurefrontline sta! areadequatelysupported, givenbreaks andprotectiveequipment, and canaccess additionalsupportGovernmentAdequateresourcing for interventions

Mental healthservices andindividualprovidersClear assessmentand care pathwaysfor people who aresuicidal, includingguidelines forremote assessment;digital resources totrain expandedworkforce;evidence-basedonline interventionsand applicationsCrisis helplinesMaintain or increasevolunteer workforceand o!er moreflexible ways ofworking; digitalresources to trainexpanded workforce;evidence-basedonline interventionsand applicationsGovernmentAdequate resourcing for interventions

GovernmentProvide financialsafety nets (eg,food, housing, andunemploymentsupports,emergency loans);ensure longer-termmeasures (eg, activelabour marketprogrammes) areput in place

Government Public healthresponses thatensure that thosefacing domesticviolence have accessto support and canleave home

GovernmentPublic healthresponses thatinclude messagingabout monitoringalcohol intake andreminders aboutsafe drinking

CommunitiesProvide support forthose who areliving aloneFriends and familyCheck in regularly,if necessary viadigital alternativesto face-to-facemeetingsMental healthservices andindividualprovidersEnsure easilyaccessible help isavailable forbereavedindividualsGovernmentAdequateresourcing forinterventions

RetailersVigilance whendealing withdistressedindividualsGovernment andnon-governmentalorganisations Carefully framedmessages about theimportance ofrestricting access tocommonly used andhighly lethal suicidemethods

Media professionalsModerate reporting,in line with existingand modifiedguidelines

Researchers and data monitoring expertsEnhanced surveillance of risk factors related to COVID-19 (eg, via suicide andself-harm registers, population-based surveys, and real-time data from crisis helplines)

Mental illness Experience ofsuicidal crisis

Financial stressors Domestic violence Alcoholconsumption

Isolation,entrapment,loneliness, andbereavement

Access to means Irresponsiblemedia reporting

Selective and indicated interventions(Target individuals who are at heightened risk ofsuicide or are actively suicidal; designed to reducerisk of suicide among these individuals)

Universal interventions(Target the whole population and focus on particular risk factors without identifying specific individualswith those risk factors; designed to improve mental health and reduce suicide risk across the population)

El evento suicida es un hecho de baja frecuencia y predictibilidad =

suicidalidad +

ambivalencia +

compromiso de conciencia +

acceso a medios letales +

una serie de sucesos desafortunados …

Referencia • Reger, M. A., et al. (2020). "Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?" JAMA Psychiatry.

• Chan, S. M., F. K. Chiu, C. W. Lam, P. Y. Leung and Y. Conwell (2006). "Elderly suicide and the 2003 SARS epidemic in Hong Kong." Int J Geriatr Psychiatry 21(2): 113-118.

• Wasserman, I. M. (1992). "The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920." Suicide Life Threat Behav 22(2): 240-254.

• Reeves, A., M. McKee and D. Stuckler (2014). "Economic suicides in the Great Recession in Europe and North America." Br J Psychiatry 205(3): 246-247.

• Nordt, C., et al. (2015). "Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000-2011.” The Lancet Psychiatry 2(3): 239-245.

• Gunnell, D., et al. "Suicide risk and prevention during the COVID-19 pandemic." The Lancet Psychiatry.

• Kawohl, W. and C. Nordt (2020). "COVID-19, unemployment, and suicide." The Lancet Psychiatry 7(5): 389-390.

• Klomek, A. B. (2020). "Suicide prevention during the COVID-19 outbreak." The Lancet Psychiatry 7(5): 390.

• Claassen, C. A., et al. (2010). "Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites." British Journal of Psychiatry 196(5): 359-364.

• Chang, S.-S., et al. (2013). "Impact of 2008 global economic crisis on suicide: time trend study in 54 countries." BMJ : British Medical Journal 347: f5239.

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Psiquiatría en tiempos de virus

Sergio Strejilevich (Argentina) José Bitran (Chile) Danilo Quiroz (Chile)

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“SUICIDIO Y SUICIDALIDAD EN PANDEMIA”