NIMH Experts Discuss Suicide Prevention Strategies
JOSHUA GORDON: Thank you for joining us today. I'm Joshua Gordon, the director of the National Institute of Mental Health or NIMH, which is part of the National Institutes of Health. NIMH is hosting this discussion today because it's National Suicide Prevention Awareness Month. Suicide is a major public health concern. More than 48,000 people die by suicide each year in the United States, making it the 10th leading cause of death overall. Suicide is complicated and tragic, but it is often preventable. The rates of death by suicide though in the United States, they've been steadily increasing over the past two decades. And although the COVID-19 pandemic's impact on suicide rates is still unknown, we're seeing rising rates of symptoms of depression and anxiety as well as increased reports of suicidal thoughts and surveys conducted over the past few months. In this context, the NIMH is ever more committed to bending the curve of suicide in the US. And together with the National Action Alliance for Suicide Prevention, NIMH has pledged to reduce the suicide rate by 20% by 2025. We seek to accomplish this goal through a research agenda that prioritizes near-term solutions.
JOSHUA GORDON: During the next half hour, we will discuss the latest in suicide prevention research, including ways to identify risk and effective prevention strategies. For this discussion, I'm joined by my NIMH colleagues Dr. Jane Pearson who's a special advisor to me on suicide research and oversees the suicide research portfolio throughout the institute, as well as Dr. Stephen O'Connor who is chief of the Suicide Prevention Research Program in the NIMH Division of Services and Intervention Research. Before we get into our discussion, it's important to note that we cannot provide specific medical advice or referrals on this program. If you need help finding a provider, please visit www.nimh.nih.gov/findhelp. If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-8255. That's 1-800 273-TALK. You can also ask for help in the comments section of this feed. Someone from NIMH will assist. All of the websites and phone numbers I've just mentioned will also be posted in the comments section of the feed so that you can easily access them. But for now, let's start talking about the topic that's on everyone's mind, which is, of course, the COVID-19 pandemic. Dr. Pearson, can you tell us what we know right now about the impact that the pandemic is having on people's mental health in general and on suicide rates?
JANE PEARSON: Well, I'll do the best I can given what information we have. Early on in the pandemic, we had a number of research experts in suicide talk about forecasts on what could happen to suicide rates, and most of the projections were that they would go up. And like you mentioned earlier, we won't know the actual suicide rates for some time, and that's partly because suicide is hard to determine, and it takes longer than other types of death. And in this pandemic, I think medical examiners, coroners are really challenged to deal with all kinds of things going on. So early on, there were projections because we started learning how much the shutdown would affect employment, isolation, and so on. And even though some of those were quite dire predictions, I think it did get us all thinking about well, what could we do to mitigate those effects. So in that sense, even though those projections seem quite dire, they're also very helpful in getting us mobilized to do something about it.
JANE PEARSON: Since those projections, we've had a number of surveys conducted. And this is a really tough time to conduct surveys. You're basically dependent on people willing to either answer a web questionnaire or answer their cell phones. It's a real challenge. And we've seen a number of surveys coming across where things are-- as you mentioned, more people are having depression, anxiety. We don't know if they're clinical in the sense that people are significantly impaired because it's really hard to tell from some of these surveys that are not completely well, which we say, weighted across the population and have the best sampling. But all indications are that people are struggling, and it's been a challenge. One of those surveys did discuss or asked respondents about their suicidal thoughts. And if you ask people during the pandemic, "Has it increased?" People will say, "Yes." And if we also try to compare to previous surveys, like times last year, and try to match by somebody's age or gender, it looks like those increases are happening. And another pattern we've seen is that this seems to be affecting younger people much more than older adults. And NIMH recently had a workshop on older adults and social isolation, and one of the takeaways from that meeting was that older adults are often better equipped to deal with challenges like this. And I think with all the uncertainty going on for young people in terms of schools, jobs, the transitions they would have expected not happening, it's understandable why some of those rates have gone up in younger people.
JOSHUA GORDON: Why are older adults better equipped to handle with the challenges of the COVID pandemic? And can we teach anything to the young ones about it to help get them through this period?
JANE PEARSON: Well, we should have our other experts at NIMH talk about this some more, but my take of it is that as you get older, you get more selective in terms of your social supports. So as long as you're still connecting to the people who are most important to you, that helps you maintain your trajectory and your your path. If you're used to having many, many interactions - and we've seen this happening in college situations where young people want to congregate; they don't want to be isolated - it makes it more of a challenge. And I think older adults also kind of take the longer view because they've had the experience of taking the longer view. They've been through a lot, and they can also see that this won't last forever. So there's a number of life experiences, I think, that they can draw from and build off of. That's not to say there's not older adults who are struggling at this time, but as we look at these surveys, that's sort of the pattern that's showing up.
JOSHUA GORDON: Some people, though, are at higher risk, especially during this pandemic. Dr. O'Connor, can you talk more about what we can learn from previous research regarding risk factors?
STEPHEN O'CONNOR: Sure, Dr. Gordon. So first of all, individuals who have a history of suicidal behaviors or thoughts may be at increased risk. For these individuals, the following protective measures are encouraged: number one, have an updated safety plan that you develop with your therapist or crisis counselor. If appropriate, your significant others or family members can be part of your plan. In essence, a safety plan is identifying warning signs and when you're going to be feeling worse, thinking about internal and external coping strategies to help you get through dark windows of time, and having at your ready a list of care providers or emergency numbers or settings where you could go to receive care immediately if necessary.
STEPHEN O'CONNOR: Second, consider ways to avoid or reduce triggers for a risk in your current environment. So some examples there might be access to alcohol, other drugs, or excessive media exposure. Another thing to think about as a direct or indirect result of the COVID-19 pandemic, individuals with a history of mental health or substance use conditions may experience a worsening or recurrence of symptoms. Others may experience these symptoms for the first time. Risk patterns often vary by life stage as you and Dr. Pearson were just discussing. There are other demographic factors to consider as well, including level of education, mental and substance use disorders, and where one lives, in rural or urban environments. All of that has to do with access to care. Economic stress is a major factor to consider. Economic stressors may play a very large role. We learned from the 2008 US recession, for example, that economic stressors such as home foreclosures were associated with increased risk.
STEPHEN O'CONNOR: In this unprecedented crisis, clinician well-being is essential for safe, high-quality patient care. Similarly, a healthy first responder workforce is necessary to provide timely, effective, and comprehensive support to the community. We do not yet know of healthcare workers or first responders are at increased risk for suicide. However, even before COVID-19, clinicians of all kinds across all specialties and care settings were experiencing alarming rates of burnout, as well as stress, anxiety, depression, substance use, and suicidality. For first responders, the challenging dangerous training situations they face put them at increased risk for trauma.
JOSHUA GORDON: With this in mind, then identifying folks who are at risk so that we can intervene and identifying ways that we can do that to mitigate suicide risk, this has to be a top priority for us from a research perspective. Right? So like the response to the virus itself, we need to work on surveillance and mitigation strategies that can help prevent suicide and other morbidity and mortality. Dr. Pearson, can you talk more about the impact of COVID-19 on school-based mental health services, which we know can be an important prevention strategy?
JANE PEARSON: Right. So we do know that kids typically, about a third of them, get their healthcare in schools-- or mental health services, I should say, not always a full-blown healthcare system in the school. And this has been on a lot of people's minds, and it's been in the news and concerns about this. And there's going to be certain kids we know from pre-COVID that are more challenged and have more mental health concerns, if not full-blown disorders. So it's really important to think about how these kids are being reached. And it's a challenge for schools to get out their academic plans and get that rolling, but we've heard, anecdotally, a lot of schools checking in on kids and making sure they're okay in terms of how they're feeling psychosocially - how are they doing at home? - and that's really important for kids who might just get their primary support out of schools where they might be struggling at home to an abusive situation. If there's sexual minorities and they don't have a lot of support at home, that's a clear challenge for those youth who might get most of their support in school.
JANE PEARSON: So we have to be thinking about how we can keep these kids connected to some type of support. Certainly, telehealth has fastly expanded during this time. And for some people, that has been a real lifeline, and it's made it easier for some groups who might not have before had access to care. But it's hit and miss where it's going to take a while to sort out how this played out for different groups during the pandemic. There's a lot to learn from this in terms of what we would like to see continued. There's many things that we think schools will have to do as they're rolling this out. From kindergarten, all the way to college, we've been hearing a lot about college students struggling, especially those who have to be quarantined and don't have a lot of support. So there's a lot of pieces here going on. We don't know the degree to which these youth are suicidal, per se, but we do know they're struggling, and we do have to make sure that we give them the resources they need. And just as we were giving them the National Lifeline here, the Crisis Text Line, making sure kids know how to reach those resources is really important. And if we've got supportive family members who can also help, it's really important to give them that information as well. I think you're on mute.
JOSHUA GORDON: Thanks, Dr. Pearson. Yeah. I know the Crisis Text Line is 741741, and that's an important number to remember, especially for college-age kids who like to use text as a way of communicating, and that's-- I know, from the Crisis Text Line, folks that they've been experiencing much-increased volume in the context of the pandemic, and I'd imagine that's continuing. Another factor, an important factor to think about with regard to college-age youth is, at least according to the CDC's latest survey, they are experiencing higher rates of suicidal ideation. Why don't we know yet whether that's impacting suicide rates in the US?
JANE PEARSON: I can respond, and we can also see if Stephen wants to add. So I think we mentioned before understanding what ideation is is important, and we know that does serve as a risk factor over time in terms of trajectories. But not all people who think about suicide are going to act on it, and it takes a lot of longitudinal research to figure that out. From our typical surveys, which I was mentioning at the top of this program, it's been really difficult to fill those surveys in a way that we've been used to to understand different subgroups and have the complete sampling we would like to see. So we're not sure how the ideation part is relating to behaviors within this tight time period. From what we hear from emergency rooms, we know there's been a lot of concern about people going into an emergency room as part of a hospital where people were at times asked not to even go because of some hospital settings being overwhelmed by COVID patients. And we just don't know what those patterns are going to mean because also, people could be diverted to a different hospital, depending on how COVID was being managed in a hospital system. So even if we saw some patterns now, it's still hard to make sense out of what that means in terms of rates of people coming in with an attempt or not or serious ideation. So there's going to be a lot to look at later, but in the meantime, I think we have to anticipate who might need help and try to get them make those linkages wherever we can to make sure people can connect digitally. If you want to add anything, Stephen?
STEPHEN O'CONNOR: Well, I think that that's a great description of sort of the limitations of how far the data can take us right now. Just kind of speaking clinically, I think one of the reasons that most people who have thoughts of suicide don't make suicide attempts and don't die by suicide is because that thought, it represents something, and that's the conversation that we want to have with someone who's having those thoughts, is what does that exactly represent because typically, it doesn't actually represent a desire to be dead. It represents a very personal experience of suffering and maybe feeling trapped and maybe just not feeling like you have control over your destiny or how to move forward. So by virtue of just having those conversations-- and it doesn't have to be a mental health professional; it can be a family member. It can be a friend. It could be a spiritual leader. But once you start having the conversation and you give people permission to explore that and express that, it really helps them kind of step back and say, "What is it really that's kind of happening within myself?" And then think about a plan to move forward that's more life orient.
JOSHUA GORDON: Thank you, Doctors Pearson and O'Connor. We're going to spend a few minutes of our discussion now talking about what we're doing here at the NIMH to respond to COVID as it pertains to suicide prevention and other mental health issues. NIMH staff have developed a number of resources for the public, including new coping with COVID-19 shareables webpage, featuring experts discussing coping strategies, and also stories about the mental health impact of COVID-19, whether it be from news or radio or videos. And everyone should know they can access that at www.nimh.nih.gov/covid19. Dr. O'Connor, can you talk more about the research that NIMH is conducting and supporting to improve mental health outcomes for those impacted by the pandemic?
STEPHEN O'CONNOR: Sure. So the NIMH Intramural Research Program, it's conducting research on the impact of COVID-19 on mental health. These studies were looking at the impact of anxiety in motivation, as well as the impact on healthcare workers. NIMH, like other NIH institutes, is working with suicide prevention grantees to help them adapt and apply ongoing research to the current crisis. Adapting effective interventions to digital platforms and determining their feasibility and effectiveness is of particular interest. NIMH also supports research on the mental health impacts of trauma in smaller-scale contexts to understand why people react differently to trauma and the underlying mechanisms of trauma and to develop new treatments. NIMH also issue what we call a notice of special interest to support research to strengthen the mental health response to COVID-19 and future public health emergencies.
JOSHUA GORDON: So this is really important work being done by scientists really across the US. When might we be able to see some of the results from these studies? We're already seeing some surveys and other science being released. When can we anticipate some of these findings being published or being released so that we can understand and mitigate the effects of the pandemic?
STEPHEN O'CONNOR: Right. Well, short answer is not soon enough, but the real answer, because we have to protect the integrity of the science, is that these studies started, some a few years ago; some just really launched, and so there was kind of a slowdown in terms of people being able to conduct their research or recruiting participants. The grantees that I work with, in particular, they might have been halfway through a clinical trial where they were recruiting 300 suicidal individuals, and they just have done a fantastic job of utilizing all the resources that they could, being very nimble and turning a lot of their approaches into virtual care delivery. So I think for the most part, we're going to find that a lot of our treatment studies are going to cross the finish line on time, and that will just vary. Potentially, we'll learn in the next six months to a year about some of those that were further along. And then other studies, it could be two or three years, but again, a lot of that is just to protect the rigor or ensure the rigor of the research because with the clinical trials, we want to make sure that we don't interfere with the science that's taking place.
JOSHUA GORDON: I think one point to emphasize here is we want to make sure we learn the lessons we can learn from this pandemic so that it can be helpful to maximize mental health in the context of other emergencies to come. Just like what we've been talking about today in terms of understanding coping mechanisms and risk and resilience factors that's from previous research in the context of other emergencies and in the context of other demands on the mental healthcare system, that's how we know we need to shore up things for kids who get mental healthcare from schools. That's how we know that social connectedness, that physical health, and that goal setting, etc., that these are effective coping mechanisms in the context of the current crisis.
JOSHUA GORDON: I would add to that as well that the NIMH strongly recommends resources provided by the CDC and the Substance Abuse and Mental Health Services Administration or SAMHSA to help cope with the stress related to the pandemic, and people can visit those websites, www.cdc.gov/covid19 or www.samhsa.gov, that's S-A-M-H-S-A, dot gov for resources that can be really helpful, in addition, of course, to NIMH's own website. Now, one of the questions that I get asked all the time as a psychiatrist and as the leader of the NIMH is, what can be done to help those who are suffering right now? And often, I'm asked, well, how can someone who's already suffering from a mental illness, let's say schizophrenia, which severely disrupts the ability of people to be able to handle and accept incoming information - they may not be able to tell reality from falsehood - how can we help those with serious mental illnesses grapple with the additional stresses of the pandemic? Dr. Pearson, do you have anything to say about that or Dr. O'Connor?
JANE PEARSON: Well, I think we've been discussing how the telehealth piece had to be quickly implemented and adapted, but we also know that people might need to be seen by individuals if that's not going to work. So we've heard, from the field, a lot of quick adaptations around making sure people are safe. And there are resources through the SAMHSA's supported Suicide Prevention Resource Center that actually describe a lot of ways you can adapt and also the zerosuicide.org website where clinicians can adapt to the current situation to make sure if you're are doing telehealth or following up people, you build in more of the safety features, some of the safety planning that Stephen was mentioning that are virtually thinking through a second line if you're a clinician doing work to make sure you can have a way to connect somebody if you have to and check on somebody's welfare. In terms of specifics around people, with serious mental illness and managing that, I think a lot of centers have had to pivot and figure out how they can help and keep people safe from COVID while they're at facilities, and I know that's been a struggle for many folks. So it's required a lot of flexibility, but I think we've had a lot of principles to build from to bring to those adaptations. And again, this could be part of some of the research studies that were saying if people are in the middle of a protocol, they will be explaining how they've adapted, and we're going to learn a lot from those as we go forward. Stephen.
STEPHEN O'CONNOR: Yeah. Those sound like great ideas. And I really like that you mentioned some of the research that we're funding because we have recently funded a study where they are specifically looking at people with schizophrenia or on that spectrum with those disorders. And they have thought about how do you extend the treatment out of the office into the home because traditionally, there are a lot of barriers just for people to be able to get into the office to receive care. And now with concerns about the pandemic, it only exacerbates those. And so again, you're sort of seeing the research adjusting to the demands of the current pandemic.
JOSHUA GORDON: Yeah. I'm glad you brought that research up. We do need to ensure we learn the best ways to approach serious mental illness and the consequences of emergencies like the current pandemic. And let me just add that I think it's really important that people take care of themselves, both from a mental health perspective and from the perspective of other health problems through the pandemic. And although it took some time, I think most doctors' offices have been reopening, and they've ensured that they have the right personal protective equipment to be able to see people in person when necessary and continue to offer telemedicine when that is working. So we need to think about that from a mental health perspective, as well as a general health perspective.
JOSHUA GORDON: I want to close by mentioning one other aspect of our partner the Substance Abuse and Mental Health Services Administration has to offer those who are suffering from stress in the current pandemic that SAMHSA runs a disaster distress helpline that's available 24 hours a day, 7 days a week. It's a national hotline dedicated to providing immediate crisis counseling for people experiencing emotional distress related to this and other disasters. That toll-free number is 1-800-985-5990. It's 1-800-985-5990, or you can text TalkWithUs to 66746. Both those numbers will connect you with a trained crisis counselor.
JOSHUA GORDON: So we've given you lots of resources. We've talked a lot about what we know and what we don't know with regards to the effects of the pandemic and about ways that we can cope with those effects. And we hope that these and other efforts will ensure that we make it through this pandemic in as strong and resilient a condition as possible and, in particular, that we use these resources to help those most in need. And we can prevent the majority of suicides and other unfortunate consequences of the mental health effects of these times as much as possible. Thank you so much for joining us today. I want to thank Doctors Pearson and O'Connor for their comments and for their answers to my questions. I hope that everyone is staying safe. And another reminder, finally, just please reach out for help if you need it.