key: cord-0872020-ns7ulgnk
authors: Hari Hara, Suchandra; Bhaskaran, Aandi Subramaniyam; Narayana, Manjunatha; Chennaveerachari, Naveen Kumar; Suresh, Bada Math; Reddi, Venkata Senthil Kumar
title: Suicide prevention in the context of COVID-19: An Indian perspective
date: 2021-09-11
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2021.102858
sha: 5e952590e73a2a8bede6f0bd3f04315c19cf1f8b
doc_id: 872020
cord_uid: ns7ulgnk

The ongoing COVID-19 pandemic has impacted the health and wellbeing of communities worldwide. Measures to limit transmission, have enhanced vulnerability of individuals to well identified risk factors associated with mental illness and suicide. These include sense of loneliness, anxiety, depression, insomnia, harmful alcohol, PTSD and drug use. Given that the potential for increased rates of suicide persist, suicide prevention agenda remains urgent and essential. The same is one of the cornerstones of resilience in a society that will face an array of challenges due to this global pandemic. In this article, we recommend few possible strategies for attenuating suicide risk amidst the COVID-19 pandemic with particular relevance to the Indian context.

India contributed to more than 25% of worldwide suicides in 2016 (230,314 of 800,000) (Naghavi, 2019) . These findings, translating to 631 suicides per day, demonstrate its immense burden in India (Dandona et al., 2018; Naghavi, 2019) . Additionally, the Indian Government's population based study, the National Mental Health survey (NMHS 2015-16) , noted significantly high rates of suicidal ideation (5·1%) and attempts (0·3%) underscoring the elevated suicide risk in India (Amudhan et al., 2020) . The ongoing COVID-19 pandemic's adverse impact, both direct and indirect, are yet to be determined but universally acknowledged to be widespread. The immediate consequences have affected the health and wellbeing of both individuals and communities worldwide. Whilst emotionally challenging universally, the pandemic has been proposed to escalate incidence of mental illness and suicide (Druss, 2020; Liu et al., 2020) . Conversely, a lack of objective evidence concerning suicides undermines these claims (Deisenhammer and Kemmler, 2021; Gunnell et al., 2020; Kahil et al., 2021) .

Consequently, a cautious approach to attributing suicide risk to the pandemic has been advocated recently (Knipe et al., 2021; Tandon, 2020 Tandon, , 2021a Tandon, , 2021b . Whether pandemic associated increment in suicides remain unclear, there exists a universal consensus that the pandemic has exacerbated previously identified risk factors associated with mental illness and suicide (Panigrahi et al., 2021; Wasserman et al., 2020) . Thus, an urgent focus to formulate strategies that mitigate these risks has been recommended. In India, variable suicide risk factors, pandemic burden and greater proportion of impacted population warrants an immediate need to evolve curated strategies that attenuate suicide risk during these challenging times.

During the first wave, many countries opted for widespread measures to limit transmission, including nationwide lockdowns, quarantine, and self-isolation. The WHO speculated that these measures caused an abrupt deviation of lifestyle (restricting activities, routines, and livelihoods) leading to an increase in loneliness, anxiety, depression, insomnia, harmful alcohol, and drug use, and self-harm or suicidal behavior n.d.) . Prior studies have highlighted that unemployment, sudden economic bankruptcy, alcoholism, J o u r n a l P r e -p r o o f interpersonal conflicts, marital disharmony, domestic violence, prior mental illness and prior suicide attempts are major risk factors for suicide (Gururaj et al., 2004; Nock et al., 2008) . Taken together, of concern was the high probability that COVID-19 pandemic would increase suicides across the globe, with some recent literature demonstrating the same (Sripad et al., 2021) . In India, the impact was notably profound on marginalized groups and those employed in the informal sector (migrant workers, daily wage earners). Lacking basic daily necessities, unemployment, homelessness, financial crisis and emotional burden, they constituted a group highly vulnerable to extreme psychological distress and possibly suicide. The widespread fear and anxiety of contracting COVID-19 and stigma and discrimination faced by those infected, contributed to suicides during the pandemic (Sripad et al., 2021) . Suicides were reported across the world both in developed and developing countries, across the general population and among health care professionals (Thakur and Jain, 2020) . In addition, there have been reports reporting increased rates of alcohol use, domestic violence and child abuse during pandemic that potentially increase vulnerability to suicide (Campbell, 2020; Green, 2020; MacMillan et al., 2021) .

In addition to factors identified during the first wave of pandemic, the abrupt onset and widespread debilitating impact of the second wave overwhelmed the country, bringing forth new and unforeseen challenges. The second wave of the pandemic adversely impacted many countries. In India, the rapid escalation of infection rates contributed to a plethora of crisis which included widespread panic among the public, health care facilities being overwhelmed, healthcare professional burnout, acute shortage of essential medical supplies/ equipment and high mortality rates. Furthermore, the infodemic pertaining to virus mutations, vaccine efficacy, medication use and emergent secondary complications among survivors exacerbated distress and fear in the population (Raut and Huy, 2021) . The second wave was associated with higher overall mortality in India. COVID specific lack of access to health care and appropriate treatment, with consequential morbidity, mortality may contribute to symptoms of posttraumatic stress disorder and other anxiety disorders. Additionally, of great concern is the J o u r n a l P r e -p r o o f likelihood of prolonged and complex grief emerging as a consequence of concurrent loss of multiple family members, children/ young adults losing both parents to COVID and inability to carry out the last rights. Thus, grief and trauma resulting from the second wave are likely to manifest variably, thereby warranting alternate management strategies.

The Media has contributed significantly to creating awareness about the pandemic, illness, and illness appropriate behavior as well as addressing "vaccination hesitancy". However, its persistent focus on dramatic and graphic crises, whilst well-intentioned to ensure resolution of crisis faced by individuals, counterproductively amplified the angst, distress and created a sense of despair among people. Adopting a balanced approach, wherein focused attempts to seek resolution of existing challenges faced by the community are concurrent with positive narratives that foster positive emotions and hope among the affected community could have potentially attenuated the above.

Given it remains unclear how long COVID-19 pandemic may persist, only time would tell whether individuals would adapt to the "new normal" wherein maintaining social distancing, following precautionary measures, avoiding large religious and public gatherings is expected to be the norm rather than an exception. The adverse outcomes associated with COVID-19 including financial distress, unemployment, school dropouts, loss of family members and emotional burden may potentially persist. This could worsen the mental well-being of an already compromised population thereby contributing to increased prevalence of mental illness and suicide (Wasserman et al., 2020) . Hence it is important that particular focus be given to mental health by adopting a proactive approach that plans to attenuate, minimize and hence prevent long term adverse outcomes of these challenging times.

The suicide prevention agenda remains urgent and essential, and should be one of the cornerstones of resilience in a society that will face an array of challenges as a result of this global pandemic (Wasserman et al., 2020) . Stakeholders and mental health professionals are advocating for various measures to mitigate this risk from the pandemic (Tandon, 2021a;  J o u r n a l P r e -p r o o f Tandon and Nathani, 2018) . Studies across the world have identified the need for effective suicide prevention strategies for handling suicide (Thippaiah et al., 2019; Zalsman et al., 2016) . We recommend few possible strategies for mitigating suicide risk amidst the COVID-19 pandemic that have particular relevance to developing countries.

1. National policy for Suicide prevention:

Considering the burden and regional variations of suicide in the community, WHO has recommended formulation of national level suicide prevention policies. Till date, of 195 countries only 38 countries report having a national suicide prevention strategy(Suicide, n.d.). With the ongoing pandemic and increasing risk factors for suicide in the community, policy makers in developing countries by prioritizing a national suicide prevention strategy would communicate a government's commitment to suicide prevention. Reducing access to the means (Milner et al., 2017; Studdert et al., 2020) , raising awareness and decreasing stigma, developing suicide help clinics, strengthening community health care centers for early identification and treatment, follow up care for people who attempted suicide and provision of community care should be of prime importance. A pandemic specific section that focuses on addressing the unique mental health consequences like PTSD, complicated grief would be essential. Additionally, identifying specific pandemic specific vulnerable groups would be the need of the hour wherein resilience, positive mental health and well-being would need to be the focus of care to minimize risk of suicide.

As per WHO 2012 report on suicide, only 59 countries have decriminalized suicide(Suicide, n.d.), a priority area given that the laws which consider suicide to be a crime, limit timely access to care and increase suicide associated stigma. Recently in India, the Mental Healthcare Act 2017, Section 115, has decriminalized suicide, facilitating help seeking and sub section (2) in the same section had made state responsible for rehabilitation of the persons attempting suicide("Mental Healthcare Act, 2017,"). Of equal importance would be to advocate for the adoption of standardized definitions for aiding/ abetting suicide that further reinforce effectiveness of changes made. This would be particularly relevant given the various complex issues contributing to suicide risk are exaggerated because of the pandemic.

Reports across the world are showing increase in domestic violence during COVID-19 times (Piquero et al., 2021) . Women with ongoing Interpersonal and marital issues are at high risk of domestic violence and suicide (Indu et al., 2020) . Only few countries like USA, UK, Australia, and Scandinavian countries have policies against domestic violence(GOV.UK, n.d.; The National Plan to Reduce Violence against Women and their Children 2010 -2022 | Department of Social Services, Australian Government, n.d.). National policies focusing on women empowerment by integrating facilitatory financial independence, proactive employment and crisis care centers can enhance autonomy and independence. These strategies would address gender inequalities in developing countries thereby reducing female vulnerability to mental illness and suicide.

Social distancing, an essential tool to curtail COVID-19 spread, is unfortunately associated with negative effects on mental health including a fear of being separated from loved ones and caregivers. Recommendations include promoting work from home, and advisories on minimizing non-essential travel restricted social life. Conversely, the same have offered opportunities to enhance quality time among families, reconnect with friends via media platforms, and engage in mindfulness activities. Hence it is essential to advocate "Physical distancing" rather than "social distancing". By physical distancing the infected ones should be encouraged to stay in touch with family members through telephones or online communication. Forming online groups that have live synchronous sessions can be a viable interim alternative to in-person interactions

Childhood and adolescence are a critical developmental period wherein experiences lay the foundations for an individual's long term mental health. Given prolonged school closures and strict social distancing measures can adversely impact the same, monitoring the well-being of children and adolescents is essential. The established benefits of Life skills management programs in attenuating suicide risk and associated factors, the need of the hour is a focused effort to incorporate them within the academic curriculum. Additionally needed, as a consequence of the pandemic, would be specific initiatives to support children and adolescents facing bereavement and issues related to parental unemployment or loss of household income.

Minimizing the Covid-19 infodemic, a priority area, could be achieved by sensitization, ongoing liaison and collaborations with the media to enhance balanced information dissemination. Furthermore, the significant influence of the media can be harnessed to create awareness, reduce stigma and facilitate timely access to mental health care for those impacted by the pandemic. In an era of easy accessibility to information and misrepresentation of same, adopting these approaches are equally relevant to scientific publications on COVID-19 and suicide. In the early stages of the pandemic various reports alluded to a rise in suicide rates, J o u r n a l P r e -p r o o f however, analysis of objective data revealed a decrease or no change in the suicide rates (Pirkis et al., 2021) . Few journals noted the potential adverse ramifications and exercised caution while publishing literature on suicide. Such measures are essential to curb misinterpretation and ensure responsible dissemination of scientifically accurate information (Tandon, 2020 (Tandon, , 2021b .

During the pandemic, the government has initiated various technology-based resources to facilitate a systematic approach to care, create awareness, and dispense vaccinations in the community, demonstrating that technology can be effectively used to help the needy. Pandemic containment measures affect access to mental health care services. Given the associated risk of mental illness and suicide due to the same, it highlights the need for an alternate approach to mental health care provision. Tele psychiatry services breach pandemicrelated barriers, consequently are effective in providing care to Psychiatric patients. Accessible and cost-saving tele-counseling with 24x7 crisis response service for emotional, mental, and behavioral support warrant widespread implementation. Whilst, India having identified Telepsychiatry as the need of the hour during pandemic, approved Telepsychiatry operational guidelines, they would also help address long term mental health sequelae of the pandemic(Telepsychiatry-Operational-Guidelines-2020.pdf, n.d.).

Psychological first aid helps to stabilize and de-escalate stress and facilitates access to continued care. During the pandemic, disaster management teams working in collaboration with Psychiatric teams focused on handling the psychological distress. Measures like Psychological first aid, debriefing, brief counseling were core interventions for people in quarantine homes and isolation. Assessing mental well-being routinely should be encouraged for those in quarantine as well as affected by COVID-19.

With reports suggesting the harmful effects of substance use on suicide during the pandemic, there is a need to introduce policies to control alcohol use and other substances, increasing deaddiction centers, equipping community hospitals with adequate resources, and creating awareness on harmful effects of alcohol.

The COVID-19 pandemic has placed healthcare professionals worldwide in an unprecedented situation, having to make impossible decisions and work under extreme pressures. Working for long hours in high-risk infection zones, getting exposed to infection, staying away from families may lead to mental breakdown (Gilleen et al., 2021) . To ensure that COVID infected patients receive optimal care, it is essential to protect the mental health of health care workers (HCWs) that would permit them to work effectively in challenging conditions. Mental health care provision in the form of helplines, dedicated in-house mental health clinics, teleservices, regular debriefing, and peer support groups would minimize adverse mental health outcomes amongst HCWs.

'Creating Hope Through Action' is the theme for The Suicide Prevention Day, 2021 (IASP, n.d.) . Through this, the International Association for Suicide Prevention (IASP) aim to emphasize every individual's role in the community and empower them with skills to reach out to those in distress, thereby bringing GKT into the picture. GKT programs are useful in training and imparting knowledge to laypersons, non-specialized health workers and other professionals. In addition, developing automated and asynchronous online training programs should be the new norm in identifying and preventing suicide at the community level.

The mental health impact of the pandemic has been felt across all sectors. A collaborative approach that seeks commitments from NGOs, private sector organizations and CSR initiatives is essential for mental health care penetration and attenuate suicide risk in the community. Community based capacity building to identify and assist those in distress within their organizations as well as supporting the community, especially marginalized sections, and rural population would be a key focus for this intervention.

The pandemic hasn't spared any group. Volunteers (Individuals and groups) supplemented the provision of support to those directly affected by the pandemic. The same has developed a sense of connectedness amongst members of society at a critical juncture that fostered hope and ignited a sense of purpose. Large numbers of individuals and groups evolved quickly to offer firsthand support to those in crisis. Encouraging ongoing community driven proactive initiatives that attend to the welfare of victims of the pandemic and forming survivor support J o u r n a l P r e -p r o o f groups would be critical initiatives that would attenuate suicidal risk and long term adverse mental health outcomes.

Recommendations for Indian population based on vulnerability data (NCRB): Death by consuming poison constituted around 25 % of the total death by suicide. By restricting the access to the potential poisons like fertilizers death by suicide can be controlled and the same has been shown in some of the studies. Government should create a common facility for distribution of fertilizers and should make efforts to shift to organic farming where the need for chemical fertilizers are avoided.

To conclude, the pandemic will potentially contribute to an increase in rates of mental illness and suicide. While focus remains largely on managing COVID-19 infected patients, mental health needs of all impacted by COVID may be overlooked. It is essential that concurrent attention be provided to those vulnerable to suicide and every country should evolve strategies to prevent deaths by suicide. National Human Rights Commission (NHRC), India has emphasized the importance of suicide preventive measures during COVID-19 in its advisory(Bhawan -MHcj arfsranr National Human Rights Commission.pdf, n.d.). In India, increasing coverage by mental health care decentralization of DMHP and training primary care health providers in assessing and managing mental health issues is the need of the hour. Programs like gate keeper training will create a skilled human resource base at the community level resulting in task shifting. Task sharing can be achieved, wherein the community level workers assess and facilitate linkage for management by DMHP teams or trained primary health care doctors. Resource deficiency and complex multifactorial risks associated with suicide strongly indicate the need for an intersectoral and transectoral approach involving other stakeholders. The same would be essential to minimize adverse mental health outcomes of the pandemic.

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