Suicide, economic strain, and COVID-19

by glsmith7 (04/25/2020 9:06 pm)

Note: If you or someone you know is feeling suicidal, help and hope is available and effective. Please call the resources here. [Hotline: 1-833-456-4566] If you or someone else is in immediate danger, call 911 immediately.

All medications have potential side effects. All treatments have potential downsides. Even a decision to do nothing is a decision–and it has a potential negative effects.

As we head into yet another week of lockdown with no clear end in sight, unemployment climbs and GDP continues to drop. This is a “side effect,” if you will, of the public health “treatment” for the COVID-19 outbreak. And it is a not insignificant question to ask when those side effects begin to outweigh the benefits (or if they already have).

I don’t think anyone knows this for certain. There’s more we could say, but that’s a subject for another time.

One worry that deserves our immediate attention, however, is that economic strain or job loss may increase the risk of suicide.

There’s a fair amount to unpack here.

Correlation and Causation

In the first place, one of the first things you learn in statistics is that “correlation does not equal causation.” Just because something goes along with something else, doesn’t mean that the first thing caused the other thing (in Latin this is called the post hoc ergo prompter hoc fallacy–“after it, therefore because of it”). For example:

This graph plots highway deaths against number of imported lemons. It is a very close fit–highway deaths drop as the number of lemons imported has increased.

But, these statistics likely have nothing causative to do with each other–its just that a number of changes over the years have made people less likely to die in a motor vehicle accident (better crumple zones, air bags, trauma systems, etc.) And, over the same period of time, they’ve bought more lemons from Mexico.

The numbers are “correlated” (they go together) but they are not causative (they go together because there’s a causative link somewhere). Banning lemon imports wouldn’t cause traffic deaths to shoot up.

Correlation and Causation–Economic stress and suicide

So, does economic stress lead people to commit more suicide?

This will be hard to answer definitively, because they only way to be sure would be to run a trial on people where you treated them exactly the same environment, in exactly the same situation, and then subjected one to job loss and the other not, and see who suicided more. This is not possible, and even if it was, it would be grossly unethical.

So, what we need to do is see if we can control for “confounding” variables–are there other factors that we can account for that “explain” the apparent link? If there are, then there may well not be a real link. If we can’t control for them, that increases our confidence (but does not “prove”) that the two factors really are linked.

There’s a great paper here called “Unemployment and suicide. Evidence for a causal association?” It looks at data from 2.1 million people in New Zealand (published in 2003).

They found that on average, being out of work made you 2.5x more likely to suicide. They looked for confounders and found some. Things that accounted for some of this apparent difference included:

if men had less education, or if a person did not have access to a car, they were more likely to suicide when controlling for other factors (And these factors are doubtless linked causitively to some degree to being unemployed–if you have no job, you’re less likely to own a car. Not having a car may also make it harder to get or keep a job. Less education typically puts you at an economic disadvantage, and so on.)
not being married was a huge one: single women were 1.81x more likely to suicide, as were single men by 2.08x.
The vast majority of suicide comes with mental illness. If mental illness is controlled for, this explains about half the increase in risk (i.e., if these people’s mental illness had been adequately treated, that would have likely reduced their risk of suicide even if they were unemployed).
They also controlled for socioeconomic status–i.e., is it just being “poor” that makes you suicidal, even if you have a job? This did not have an effect.

So, despite controlling for some variables, we’re left with a chunk of people at higher risk for suicide. And, since despair goes along with suicide, and unemployment can lead to despair, there’s a plausible link here–and so it is pretty broadly believed that financial stressors do have something of a causative link to suicide. (See this recent study from U of Calgary about Alberta, which shows a 2.8% rise in suicide rates for every 1% rise in unemployment. See also Thomas Joiner, Why People Die By Suicide, loc. 1217.)

Talking about these issues

So, it seems relatively clear that there’s probably some fire with all this smoke.

How, then, should we discuss and deal with suicide in general, and the risk of suicide due to economic strain?

Remember that mental illness is associated with 95+% of suicides.

Most people don’t consider suicide. Most people who consider suicide never act on it. And most people who act on it do not actually die. This should be encouraging. Having suicidal feelings does not mean one is destined to die by suicide, or even attempt suicide. Even one death is too many, however, and devastating for those involved.

Most suicide experts think that mental illness is virtually a necessary precondition for suicide [Thomas Joiner, Why People Die By Suicide, loc. 2067; Scott O. Lilienfeld and John Ruscio and Steven Jay Lynn and Barry L. Beyerstein, 50 Great Myths of Popular Psychology: Shattering Widespread Misconceptions about Human Behavior (Great Myths of Psychology), kindle loc:4254] (and some think that you can strike out the “virtually”). As one suicide researcher who herself tried to commit suicide:

Everyone who has known me and who hears of this will have a different hypothesis to offer to explain why I did it [decided to suicide]. Practically all of these hypotheses will be dramatic—and completely wrong. Any sane doctor knows that the reasons for suicide are invariably psychopathological. Difficulties in life merely precipitate the event—and the true suicide type manufactures his own difficulties. [Kay Redfield Jamison, Night Falls Fast: Understanding Suicide (New York: Knopf Doubleday Publishing, 1999), kindle loc:1255.]

In a way, this is good news, because it means if you effectively treat mental illness, you can really reduce suicide risk (the conditions most at risk are unipolar depression, bipolar disorder, schizophrenia, substance use disorder, and borderline personality disorder).

People who are unemployed are probably at highest risk for depression and/or substance abuse (which in itself will cause or worsen depression).

Suicide is very complex

We must be very cautious of “single cause” suicide models. People do not suicide over a single stressful event or thing, even if it continues over a long period of time. Instead, it is usually a combination of factors. If an event seems to “trigger” a suicide, that is usually not accurate–at most, there will have been a “final straw” that added onto a lot of other issues. Remove those other issues, and the final straw wouldn’t have triggered. Remove just the final straw, and another final straw can usually present itself.

Media can influence suicidality

Public health research demonstrates that the way in which the media talks about suicide can increase the risk for suicidal behavior. This is called “suicide contagion.” As Joiner put it, “Indeed, publicizing suicide in careless ways can be a menace to public health.” [Joiner, loc. 1846.]

What causes this increase in risk? Part of it is probably to do with the fact that suicide violates a number of taboos–it is very difficult to bring ourselves to harm ourselves. The more comfortable and familiar we get with that idea, the easier it becomes.

Further, when we see others suicide, or even hear of it, if we identify with them, the vulnerable person will be more likely to act:

Specific media guidelines have been developed to decrease the pernicious effects of inappropriately publicizing deaths by suicide. A consortium of agencies, including the Centers for Disease Control and Prevention, the National Institute of Mental Health, and the American Association of Suicidology, came together to develop the guidelines. The recommendations include not portraying the person who died in romantic or heroic terms, reporting the death with few details about method and location of death, and not conveying that the suicide was an inexplicable act of an otherwise high-achieving person. In general, the guidelines are intended to minimize identification with the person who died. [Joiner, loc. 1849, emphasis added.]

We are now all part of the media

With the rise of social media, blogs, Facebook, etc., we all have access to a printing press. It would be wise, therefore, to examine the “rules” around talking about suicide so that we don’t inadvertently cause what we’re trying to avoid. We can have the best of intentions–wanting to raise awareness–but if we talk about suicide in certain ways, we make it more, not less, likely to happen. The full guidelines for media are here. A few worth emphasizing in the context of COVID-19:

Risks increase with “Short, sensationalized stories with overly simplistic explanations for a person’s struggles with suicide (e.g, cyberbullying or breakup “cause” suicide).” That’s almost a perfect definition of Twitter and Facebook–we may share things that are short, and punchy, often intended to stir an emotional response. But it’s precisely those sorts of things that promote risk. So, if you are posting short things on “unemployment causes suicide” or “COVID-19 will raise suicide risks,” without a lot more information and nuance, you’re probably going to contribute to the problem you want to solve.
“Suicide is complex. Be sure to avoid single cause explanations. Certain events or factors can precipitate a suicide, but there are almost always multiple underlying causes.” As we’ve seen, mental health has a massive relationship to suicide. So, rather than focusing on one factor, we need to help people see that this is a complex issue, for which only a certain subset are uniquely vulnerable.
Limit the audience’s exposure to grieving family and friends and memorial services. Social media posts are often couched in emotional terms, describing a friend or family member who’s succumbed. That breaks this rule.
Avoid suggesting that a suicide achieved results or was a noble end. This could include using it as a spur to achieving certain results (“Stop the lockdown so no one else must die!!”) Stopping the lockdown may be a good policy idea, but implying or saying that the suicides can play a role in shaping that policy increases contagion. That may seem surprising, but remember that you’re almost always dealing with mental health issues–and so the vulnerable person’s reasoning is not working at 100% capacity.)
Avoid use of sensationalistic or intentionally provocative terms. “Sensationalistic” and “provocative” promote clicks and shares, and so are very common in social media. It’s not a great medium for nuance–and suicide needs nuance.
Avoid speculation about an individual’s thoughts and feelings leading up to the suicide. Again, blaming an economic setback and what the person “thought” about this can be perilous.
Avoid referencing social networking sites used to eulogize or memorialize someone who died by suicide.

Why this last one? As discussed above, a common thread in all of these recommendations is to avoid having the susceptible person identify with the suicidal person and their suicidal act.

And you see, this is what social media is very good at–it is our friends and family who post things, and they often post things that emotionally resonate with them. So, vulnerable people are probably more predisposed to identify in a harmful way with a suicide account on social media than they might be for one reported on TV or in the newspaper.

And, if you’re unemployed, you may spend a lot of time on social media because you have way more time on your hands than you’d like. So your exposure may increase just when your vulnerability is highest.

How to prevent suicide

There is much we can do to help those who might be struggling with suicidal thinking–from whatever cause(s). If we struggle ourselves, there is hope.

Some things we all can do:

encourage anyone with depression or other mental illnesses to seek help from a qualified professional. There are both medication and non-medication approaches to these illnesses that have been demonstrated to be effective. Remember, without mental illness, the risk of suicide is very low, regardless of whatever else may be going on in someone’s life.
Avoid simplistic, one-cause explanations of suicide, especially when those causes involve things external to the person who is suicidal.
Be ready to listen. “Two thirds to three fourths of individuals who commit suicide had previously expressed their intentions to others.” [Lilienfeld, et al., kindle loc:4801.]”
Ask people if they have thought about suicide. People often worry that this will increase suicide risk and “put it in people’s minds” if they aren’t thinking about it. Research has discredited this idea; asking is protective, not harmful.

Things that reduce suicide risk

There are many things that are “protective” against suicide. These include:

being a woman;
being married;
having strong social supports and being connected to a community;
avoiding the use of alcohol, marijuana, or other drugs;
engaging in religious belief, practice, and community;
being oriented toward the future and the hope or belief that things can and will improve.

So, while our local community has some risk factors (as everywhere does) we have a lot of things going for us. And, we can each do things that will increase people’s “connectedness” and reduce risk further.

And finally, remember that COVID-19’s social impact will end. When we remember that it is not a permanent condition, that is protective too:

[we must remember] the nontrivial, life-and-death psychological processes of people seriously contemplating suicide. They perceive themselves to be ineffective or incompetent, but it’s not just that. They also perceive that their ineffectiveness affects others, too. Finally, they perceive that this ineffectiveness that negatively affects everyone is stable and permanent, forcing a choice between continued perceptions of burdening others and escalating feelings of shame, on the one hand, or death on the other hand.When I refer to “perceived burdensomeness,” I would like to emphasize the term perceived.
People who are contemplating suicide perceive themselves a burden, and perceive that this state is permanent and stable, with death as a solution to the problem. It is very important to point out that their perceptions are mistaken. Indeed, that their perceptions are mistaken is the basis for the psychotherapeutic treatment of suicidal symptoms. Any perception, mistaken or not, can influence behavior. My contention is that perceived burdensomeness, though mistaken, influences suicidal behavior. [Thomas Joiner, Why People Die By Suicide, loc. 1075. Kindle Edition]

Many of us–especially men–define ourselves by our work. When we can’t provide in the way we want to, that is shattering to our sense of self and purpose. And that leads us to perceive of ourselves as worthless, or burdensome, or someone that people would be better off without.

That is simply, utterly, false. In my experience, there are very few things more devastating for a family than to have someone they love die by suicide. It is something that families never really get over, especially children. You will not make their lives better–you will make their burdens unutterably worse.

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