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      Suicide risk and prevention during the COVID-19 pandemic

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          Abstract

          The mental health effects of the coronavirus disease 2019 (COVID-19) pandemic might be profound 1 and there are suggestions that suicide rates will rise, although this is not inevitable. Suicide is likely to become a more pressing concern as the pandemic spreads and has longer-term effects on the general population, the economy, and vulnerable groups. Preventing suicide therefore needs urgent consideration. The response must capitalise on, but extend beyond, general mental health policies and practices. There is some evidence that deaths by suicide increased in the USA during the 1918–19 influenza pandemic 2 and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) epidemic. 3 The current context is different and evolving. A wide-ranging interdisciplinary response that recognises how the pandemic might heighten risk and applies knowledge about effective suicide prevention approaches is key. Selective, indicated, and universal interventions are required (figure ). Figure Public health responses to mitigating suicide risk associated with the COVID-19 pandemic COVID-19=coronavirus disease 2019. The likely adverse effects of the pandemic on people with mental illness, and on population mental health in general, might be exacerbated by fear, self-isolation, and physical distancing. 4 Suicide risk might be increased because of stigma towards individuals with COVID-19 and their families. Those with psychiatric disorders might experience worsening symptoms and others might develop new mental health problems, especially depression, anxiety, and post-traumatic stress (all associated with increased suicide risk). These mental health problems will be experienced by the general population and those with high levels of exposure to illness caused by COVID-19, such as frontline health-care workers and those who develop the illness. The consequences for mental health services are already being felt (eg, increased workloads and the need to find new ways of working). Some services are developing expertise in conducting psychiatric assessments and delivering interventions remotely (eg, by telephone or digitally); these new working practices should be implemented more widely, but with consideration that not all patients will feel comfortable with such interactions and they may present implications for privacy. Making evidence-based online resources and interventions freely available at scale could benefit population mental health. People in suicidal crises require special attention. Some might not seek help, fearing that services are overwhelmed and that attending face-to-face appointments might put them at risk. Others may seek help from voluntary sector crisis helplines which might be stretched beyond capacity due to surges in calls and reductions in volunteers. Mental health services should develop clear remote assessment and care pathways for people who are suicidal, and staff training to support new ways of working. Helplines will require support to maintain or increase their volunteer workforce, and offer more flexible methods of working. Digital training resources would enable those who have not previously worked with people who are suicidal to take active roles in mental health services and helplines. Evidence-based online interventions and applications should be made available to support people who are suicidal. 5 Loss of employment and financial stressors are well-recognised risk factors for suicide. 6 Governments should provide financial safety nets (eg, food, housing, and unemployment supports). Consideration must be given not only to individuals' current situations but also their futures. For example, many young people have had their education interrupted and are anxious about their prospects. Educational institutions must seek alternative ways to deliver curricula and governments need to be prepared to offer them financial support if necessary. Active labour market programmes will also be crucial. 6 The pandemic could adversely affect other known precipitants of suicide. For example, domestic violence and alcohol consumption might increase during lockdown. Public health responses must ensure that those facing interpersonal violence are supported and that safe drinking messages are communicated. Social isolation, entrapment, and loneliness contribute to suicide risk 7 and are likely to increase during the pandemic, particularly for bereaved individuals. Providing community support for those living alone and encouraging families and friends to check in is helpful. Easily accessible help for bereaved individuals is crucial. Access to means is a major risk factor for suicide. In the current environment, certain lethal means (eg, firearms, pesticides, and analgesics) might be more 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 fear 9 and heighten suicide risk. Media professionals should ensure that reporting follows existing 10 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 efforts 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 structures, availability of digital alternatives to face-to-face consultation, and existing supports. The effects might be worse in resource-poor settings where economic adversity is compounded by inadequate welfare supports. Other concerns in these settings include social effects of banning religious gatherings and funerals, interpersonal violence, and vulnerable migrant workers. COVID-19-related stigma and misinformation may be particularly acute in these settings; many of the solutions proposed above will be applicable globally, but additional efforts will be required in resource-poor settings. These are unprecedented times. The pandemic will cause distress and leave many people vulnerable to mental health problems and suicidal behaviour. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention. We should be prepared to take the actions highlighted here, backed by vigilance and international collaboration.

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          Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

          Summary The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on all aspects of society, including mental health and physical health. We explore the psychological, social, and neuroscientific effects of COVID-19 and set out the immediate priorities and longer-term strategies for mental health science research. These priorities were informed by surveys of the public and an expert panel convened by the UK Academy of Medical Sciences and the mental health research charity, MQ: Transforming Mental Health, in the first weeks of the pandemic in the UK in March, 2020. We urge UK research funding agencies to work with researchers, people with lived experience, and others to establish a high level coordination group to ensure that these research priorities are addressed, and to allow new ones to be identified over time. The need to maintain high-quality research standards is imperative. International collaboration and a global perspective will be beneficial. An immediate priority is collecting high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with COVID-19. There is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19. Discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of the pandemic are required. Rising to this challenge will require integration across disciplines and sectors, and should be done together with people with lived experience. New funding will be required to meet these priorities, and it can be efficiently leveraged by the UK's world-leading infrastructure. This Position Paper provides a strategy that may be both adapted for, and integrated with, research efforts in other countries.
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            Patients with mental health disorders in the COVID-19 epidemic

            More than 60 000 infections have been confirmed worldwide in the coronavirus disease 2019 (COVID-19) epidemic, with most of these cases in China. Global attention has largely been focused on the infected patients and the frontline responders, with some marginalised populations in society having been overlooked. Here, we write to express our concerns with regards to the effect of the epidemic on people with mental health disorders. Ignorance of the differential impact of the epidemic on these patients will not only hinder any aims to prevent further spread of COVID-19, but will also augment already existing health inequalities. In China, 173 million people are living with mental health disorders, 1 and neglect and stigma regarding these conditions still prevail in society. 2 When epidemics arise, people with mental health disorders are generally more susceptible to infections for several reasons. First, mental health disorders can increase the risk of infections, including pneumonia. 3 One report released on Feb 9, 2020, discussing a cluster of 50 cases of COVID-19 among inpatients in one psychiatric hospital in Wuhan, China, has raised concerns over the role of mental disorders in coronavirus transmission. 4 Possible explanations include cognitive impairment, little awareness of risk, and diminished efforts regarding personal protection in patients, as well as confined conditions in psychiatric wards. Second, once infected with severe acute respiratory syndrome coronavirus 2—which results in COVID-19—people with mental disorders can be exposed to more barriers in accessing timely health services, because of discrimination associated with mental ill-health in health-care settings. Additionally, mental health disorder comorbidities to COVID-19 will make the treatment more challenging and potentially less effective. 5 Third, the COVID-19 epidemic has caused a parallel epidemic of fear, anxiety, and depression. People with mental health conditions could be more substantially influenced by the emotional responses brought on by the COVID-19 epidemic, resulting in relapses or worsening of an already existing mental health condition because of high susceptibility to stress compared with the general population. Finally, many people with mental health disorders attend regular outpatient visits for evaluations and prescriptions. However, nationwide regulations on travel and quarantine have resulted in these regular visits becoming more difficult and impractical to attend. Few voices of this large but vulnerable population of people with mental health disorders have been heard during this epidemic. Epidemics never affect all populations equally and inequalities can always drive the spread of infections. As mental health and public health professionals, we call for adequate and necessary attention to people with mental health disorders in the COVID-19 epidemic.
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              The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure.

              The 2019 novel coronavirus (COVID-2019) has led to a serious outbreak of often severe respiratory disease, which originated in China and has quickly become a global pandemic, with far-reaching consequences that are unprecedented in the modern era. As public health officials seek to contain the virus and mitigate the deleterious effects on worldwide population health, a related threat has emerged: global media exposure to the crisis. We review research suggesting that repeated media exposure to community crisis can lead to increased anxiety, heightened stress responses that can lead to downstream effects on health, and misplaced health-protective and help-seeking behaviors that can overburden health care facilities and tax available resources. We draw from work on previous public health crises (i.e., Ebola and H1N1 outbreaks) and other collective trauma (e.g., terrorist attacks) where media coverage of events had unintended consequences for those at relatively low risk for direct exposure, leading to potentially severe public health repercussions. We conclude with recommendations for individuals, researchers, and public health officials with respect to receiving and providing effective communications during a public health crisis. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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                Author and article information

                Contributors
                Journal
                Lancet Psychiatry
                Lancet Psychiatry
                The Lancet. Psychiatry
                Elsevier Ltd.
                2215-0366
                2215-0374
                21 April 2020
                21 April 2020
                Affiliations
                [a ]National Institute for Health Research Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol BS8 2PS, UK
                [b ]Centre for Mental Health and Safety, National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust. Manchester, UK
                [c ]School of Public Health and National Suicide Research Foundation, College of Medicine and Health, University College Cork, Cork, Ireland
                [d ]Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK
                [e ]Population Psychiatry, Suicide and Informatics, Medical School, Swansea University, Swansea, UK
                [f ]Department of Psychiatry, Aga Khan University, Karachi, Pakistan
                [g ]Suicidal Behaviour Research Laboratory, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
                [h ]Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
                Author notes
                [†]

                Study group members: Louis Appleby, Ella Arensman, Eric Caine, Lai-Fong Chan, Shu-Sen Chang, Ying-Yeh Chen, Helen Christensen, Rakhi Dandona, Michael Eddleston, Annette Erlangsen, David Gunnell, Jill Harkavy-Friedman, Keith Hawton, Ann John, Nav Kapur, Murad Khan, Olivia J Kirtley, Duleeka Knipe, Flemming Konradsen, Shiwei Liu, Sally McManus, Lars Mehlum, Matt Miller, Paul Moran, Jacqui Morrissey, Christine Moutier, Thomas Niederkrotenthaler, Merete Nordentoft, Rory O'Connor, Siobhan O'Neill, Andrew Page, Michael Phillips, Jane Pirkis, Steve Platt, Maurizio Pompili, Ping Qin, Mohsen Rezaeian, Morton M Silverman, Mark Sinyor, Steven Stack, Ellen Townsend, Gustavo Turecki, Lakshmi Vijayakumar, Paul Yip.

                Article
                S2215-0366(20)30171-1
                10.1016/S2215-0366(20)30171-1
                7173821
                31860459
                76e7270d-8d08-4031-ba20-86cf031999c7
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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