Earlier this week, one of Manhattan’s top emergency room doctors committed suicide . She had been serving heroically on the front lines of the fight against COVID-19, treating patients in the hardest hit city in the nation. Her death follows a number of recent White House Coronavirus Task Force briefings where the President suggested suicides would increase during this crisis. As hard as it may be for some to fathom taking your own life, this is something many have grappled with and may confront again as our country struggles to fight a massive economic downturn and a pandemic.
Since 2001, suicide has increased by 31 percent , making it the tenth  leading cause of death in the United States. While it is unfortunate that it took a pandemic for leaders to express concerns about Americans’ mental health, right now is as good a time as any to talk about mental health and highlight the very real problems with mental health care access in this country.
To be clear, it is true that mental health declines during times of economic contraction; however, the equation is not: economy crashes therefore mental health declines –– it is a far more nuanced relationship.
Consider the iconic images of investors jumping from windows of the New York Stock Exchange in response to the crash known as “Black Thursday.” In fact, there were fewer suicides  during the four weeks after Black Thursday than during the same period the prior year. Even though watching investments disappear during an economic downturn is scary and discouraging, that alone is rarely enough to trigger suicidal behavior.
While economic conditions broadly correlate  with the number of suicide attempts, psychiatric research suggests that unemployment, specifically unemployment duration, may be the key economic factor driving this correlation. At the same time, a study  assessing unemployment and suicide during the Great Recession showed that countries with more generous unemployment protection programs did not experience significant increases in suicide incidence due to increased unemployment. This indicates that government programs may be able to blunt the negative effects of economic downturns on suicide rates by having robust social safety nets.
Understanding this correlation, we must also watch closely as the pandemic exposes and magnifies the flaws in our mental health system and the true burden of mental illness in our country.
As with most mental health conditions, people who have never spent significant time with individuals experiencing suicidal thoughts may find it difficult to understand what could drive someone to want to take their own life. Given the focus on agency and free will in most western cultures, many observers fail to realize that suicide is rarely the result of free will . In fact, research suggests that 90 percent  people who commit suicide suffer from psychiatric disorders. That is to say, few people make a conscious, rational decision to commit suicide that is not skewed by disordered thinking associated with psychiatric illness.
To further complicate matters, stress often exacerbates symptoms, sometimes enough to cause suicidal ideation or behavior. The prevailing neurobiological model  of what precipitates a suicidal crisis is that external stressors — such as job loss, illness or interpersonal conflict — exacerbate a pre-existing mental illness in a way that amplifies feelings of pain, hopelessness, impulsiveness, aggression and isolation. Without question, the coronavirus pandemic is at least somewhat stressful for most people. This does not mean that everyone will experience degrading mental health, and certainly most people will not consider or attempt suicide.
However, for people who do find themselves struggling with mental illness during the pandemic, the current situation presents unique challenges that are difficult to overcome. One of the most discouraging and ironic symptoms of many mental illnesses is a desire to withdraw from social interaction, which also often means the person will not reach out for help during a crisis. Given our responsibility to social distance to stop the spread, it is easier for a person in crisis to socially isolate themselves without their support system noticing. This can exacerbate negative thoughts and potentially lead to self-harm.
The reality of mental illness is that disasters and crisis seem to increase its severity, because much of what bubbles to the surface is underreported and untreated mental illness. We live in a country where one in five adults  experience mental illness and one in 25 experience serious mental illness ; however, the average delay between symptom onset and treatment initiation is 11 years . Those statistics do not begin to summarize the true extent of suffering that these individuals endure, but they do mean you most likely know someone who is struggling with mental illness. However, in 2018, only 40 percent of adults who experienced mental illness received treatment .
Thankfully, because of this crisis we are talking about mental health and suicide, but it’s important to remember that it does not infect people and spread like COVID-19. It was always there, and people have been quietly suffering all along.
While we all do our part to mitigate the coronavirus pandemic and as we move into recovery phases, we must include mental health in the discussion. The nation has experienced a trauma unlike anything most Americas have encountered, and that will have psychological effects for people with underlying mental illness and those without. With millions unemployed, we must address how to provide care for people without insurance. We also must find ways to provide access to psychiatric services for people living in the 60 percent  of counties without a practicing psychiatrist.
If we want to prosper post-COVID-19, we have to remember that mental illness, just like viruses, does not just go away on its own.
If you or someone you know is in an emergency, call The National Suicide Prevention Lifeline  at 800-273-TALK (8255) or call 911 immediately. Additional resources  for people experiencing mental illness and their loved ones are available from the National Alliance on Mental Illness.
Image credit: Corona Borealis Studio
- “suicide”: https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html?smtyp=cur&smid=tw-nytimes
- “31 percent”: https://nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-Suicide-FINAL.pdf
- “tenth”: https://www.cdc.gov/nchs/products/databriefs/db362.htm
- “were fewer suicides”: https://www.nytimes.com/1929/11/14/archives/citys-suicides-fewer-figures-refute-tales-of-increase-owing-to.html
- “correlate”: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2301-6
- “study”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316842/
- “suicide is rarely the result of free will”: https://www.cambridge.org/core/services/aop-cambridge-core/content/view/59FCAEEBFFA6488AB1AAC4ADC5428773/S2045796018000562a.pdf/reflections_on_causes_of_suicidal_behaviour.pdf
- “90 percent”: https://www.cambridge.org/core/services/aop-cambridge-core/content/view/59FCAEEBFFA6488AB1AAC4ADC5428773/S2045796018000562a.pdf/reflections_on_causes_of_suicidal_behaviour.pdf
- “neurobiological model”: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2301-6
- “one in five adults”: https://nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-You-Are-Not-Alone-FINAL.pdf
- “serious mental illness”: https://nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-You-Are-Not-Alone-FINAL.pdf
- “11 years”: https://nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-Mental-Health-Care-Matters-FINAL.pdf
- “received treatment”: https://nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-Mental-Health-Care-Matters-FINAL.pdf
- “60 percent”: https://nami.org/mhstats
- “The National Suicide Prevention Lifeline”: http://www.suicidepreventionlifeline.org/GetHelp/LifelineChat.aspx
- “resources”: https://nami.org/help