: ‘We shouldn’t be complacent’: Suicide deaths fell during the 2020 pandemic — but what caused the decline?

Total deaths increased by 17.7% year over year, the provisional estimates showed. COVID-19 became the third leading cause of death after heart disease and cancer, while suicide dropped from the country’s 10th leading cause of death to the 11th.

The preliminary 2020 estimate for suicide deaths, 44,843, would mark the second consecutive reduction in recent years. In 2019, 47,511 Americans died by suicide, and in 2018, the number was 48,344. The U.S. suicide rate rose over the previous two decades, increasing by 35% from 1999 to 2018.

While the latest data point sounds promising on its face, study co-author Farida Ahmad, a health scientist at the Centers for Disease Control and Prevention’s National Center for Health Statistics, emphasized that the numbers were still provisional.

It’s too early to tell whether this development is good or bad news, and the current number still remains a “concern,” she told MarketWatch.

“It may not be in the top 10, but it’s still ranked as the 11th leading cause of death,” she added. “We shouldn’t be complacent.”

And the main reason it was knocked out of the top 10: COVID-19, a new entry.

Meanwhile, some suicidologists wonder if this 5.6% decline could be obscuring other factors — and whether there could be alternate explanations for the decrease. 

“On the one hand, it’s fantastic news if it’s true,” said Stacey Freedenthal, a psychotherapist and University of Denver associate professor of social work who studies suicide. And on the other hand, “there may be other things going on,” she said.

The ‘pulling together’ phenonemon

On the positive side, experts say there are reasons not to be skeptical about these numbers. 

For example, previous research shows “different directions in suicide mortality following natural disasters,” one 2013 literature review showed. Some studies suggest that suicide rates can even decrease after a natural disaster. National suicide rates fell during WWI and WWII, a 1994 study found, and not all nations saw an increase after the wars ended.

“While there is no consistency in the findings over the longer term, there is some evidence to suggest a short-term decrease in suicide in the immediate aftermath of a disaster,” wrote the authors of an October 2020 systematic review of research on how epidemics such as the 1918 influenza, SARS and Ebola may have impacted suicide-related outcomes.

“This has been labelled the ‘honeymoon period’ or the ‘pulling together’ phenomenon.”

(The same review, however, found a potential association between previous epidemics and increased risk of suicidal deaths, behavior and thoughts, despite the few relevant studies being of “relatively low methodological quality.”)

Social connections forged and strengthened during the pandemic could also be having a protective effect against suicides, Freedenthal suggested, as Americans forced to maintain physical distance have increasingly connected with their social support networks online or by phone.

Freedenthal, for her part, has gathered on Zoom
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with her family for at least an hour every week over the past year and change. “We never did that before,” she said. “For all of us to be together like this is unusual and precious.”

Shelter-in-place orders and remote work may also have “changed the calculus” for some individuals, leaving them with less alone time, said Jonathan Singer, the president of the American Association of Suicidology and an associate professor of social work at Loyola University Chicago.

Some may have had family members actively monitoring them, or felt reduced helplessness and isolation by constantly being around other people, he said.

And while there isn’t data yet to support this, “it’s possible that the increased access to mental-health care by Zoom and online therapy is having a protective effect,” Freedenthal said.

Though disparities in access remain, use of telehealth for behavioral-health visits boomed in the pandemic’s early months as the government expanded telehealth access in response to COVID-19. 

Singer agreed that it would be hard to correlate use of psychotherapy services with suicide death. But research does show that people who receive mental-health treatment are less likely to attempt suicide, he said.

‘Disbelief and surprise’ about lower rates

That said, “there is disbelief and surprise about these lower rates” among some suicidologists, Freedenthal said. She and other mental-health experts sounded the alarm last year about the increased prevalence of suicide risk factors such as substance use, unemployment, isolation, housing instability and gun ownership during the pandemic.

“I definitely think the topline number is obscuring other numbers,” said Nadine Kaslow, an Emory University School of Medicine professor and past president of the American Psychological Association who researches suicide in youth and adults.

For starters, researchers don’t know whether it’s possible that some of the people who died last year from COVID-19 may otherwise have died by suicide, Singer said — or whether some of the people who died by suicide had COVID-19 at the time, and were therefore counted as coronavirus deaths. 

Though this theory would require additional suicide risk factors at play aside from age, older people — who have accounted for the lion’s share of reported coronavirus deaths — also tend to have higher suicide rates, Freedenthal pointed out.

It’s also possible that some suicides may have been misclassified as other so-called deaths of despair, which include deaths by drug overdose and alcohol-related disease, Freedenthal said. “I would be shocked if some of the deaths that were ruled overdose weren’t actually suicide deaths,” Singer said, adding that it can be difficult to distinguish accidental overdoses from intentional ones.

Ahmad called the potential for such miscategorization “a good question,” and said it was too soon to determine the answer from the early data. Her JAMA article noted that “increases in unintentional injury deaths in 2020 were largely driven by drug overdose deaths.” Various studies have charted increases in overdose deaths during the pandemic.

Experts say 2020’s overall decrease in suicide deaths may also mask racial and ethnic disparities for which national data aren’t currently available. White people were the only racial group whose suicide rate decreased significantly between 2018 and 2019, when the national rate fell for the first time in several years, the CDC said in February.

In Chicago’s Cook County, 97 Black residents died by suicide in 2020 in what marked a decade-long high, according to a report by The Trace and the Chicago Sun-Times; suicides by white residents, meanwhile, dropped to their lowest in almost a decade.

A study published in JAMA Psychiatry uncovered a similar pattern in Maryland: An analysis of records from 1,079 people who died by suicide from January 2017 to July 2020 found that Black residents’ suicide mortality doubled between the period from March 5, 2020 to May 7, 2020 (“when deaths due to COVID-19 peaked and Maryland was locked down”) compared to the averages from 2017 to 2019. 

White residents’ suicide mortality was almost halved during the same period, as well as during the state’s progressive reopening from May 8 to July 7 — the potential result of “greater capacity for remote work or benefits from relief efforts,” the research letter said.

“People talked about the dual pandemics of racism and COVID, and I think there’s a really important intersectional lens that we can’t speak to with this [CDC] data because we have no way to drill down on the information,” Singer said.

While Singer said there can be value in considering potential explanations for the CDC data using the limited information available, he also advised against latching on to any one hypothesis as the answer. “Suicide is multifaceted, and there are many ways that people get to that endpoint — so to be able to point to one thing doesn’t make any sense,” he said.

What happens after the pandemic?

Though the early numbers suggest suicides didn’t increase last year, Freedenthal said she fears the pandemic’s effects will continue to be felt even after it ends. She wonders, for example, what will happen once eviction moratoriums are lifted, pointing out suicide’s associations with homelessness and poverty.

“One of the things that we know is that this can take time,” Kaslow added. “Suicide doesn’t just happen — [like] something bad happens today and there’s an outcome tomorrow. People often pull themselves together to cope during stress and crises, but the impact of the economy and loss, all the death, all the grief, it’s going to get to people. It already is.”

Monthly suicide deaths in Japan decreased by 14% between February and June 2020 compared to the same period in previous years— potentially due to factors like generous government subsidies, school closures and scaled-back work hours — but rose 16% from July to October during the virus’s second wave, according to a study published in January in the journal Nature Human Behaviour. There were bigger increases among women and children.

Kaslow also has her eye on related mental-health indicators such as depression and anxiety, which studies show have increased in prevalence during the pandemic. A CDC study last year found that 10.7% of Americans surveyed in June said they had seriously considered suicide in the previous 30 days, compared to 4.3% who said the same in 2018 about their previous 12 months. 

Mental-health professionals have particular concern for a few populations they view as vulnerable in the year ahead. Melissa Whitson, an associate professor of psychology at the University of New Haven, said it would be important to provide continued mental-health screening and services for frontline healthcare workers.

“A lot of them will be dealing with post-traumatic stress issues,” she said. “We can learn a lot from the type of care that we know works for veterans, for our healthcare workers and the people who were on the front line of this particular ‘war,’ if you will.”

Singer, for his part, said he worried about the gap between people who have endured financial hardship, housing instability or loss of loved ones during the pandemic and “folks who are like, ‘Thank God I can get back to normal.’”

“I think the distance will intensify thoughts of suicide for folks,” because [they may feel] like, ‘Oh, we’re not all weathering the same storm anymore — now it’s just me, and I feel isolated and alone. And if I’m talking about how hard the pandemic was, that’s a burden to others.’” 

Kids returning to in-person schooling, particularly those who have excelled at online learning, may also face “re-entry shock,” added Singer, whose research areas include youth suicide. “You’ll have kids who have literally spent a year and a half at their kitchen table or bedroom, and now they’re surrounded by stuff — bullying and sexual assault and racial aggression, and the school shootings,” he said.

Parents, school personnel and youth suicide-prevention advocates must stand at the ready to screen for child suicide risk and provide immediate support, he said.

Advocates say suicide is often preventable. And while one positive aspect of the pandemic has been an increased focus on mental health, “we don’t want to ignore that” as states begin to reopen, Whitson added.

“There have been lingering effects from lockdowns and the pandemic,” she said. “We can’t just assume we’re all going to be OK now.”

If you or someone you know is having thoughts of suicide, call the free, confidential National Suicide Prevention Lifeline (1-800-273-8255). Additional resources include the Crisis Text Line (text HOME to 741741), the Veterans Crisis Line (press 1 after dialing the national Lifeline), the Trevor Project for LGBTQ youth (1-866-488-7386), the Trans Lifeline (877-565-8860) and the Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline (call 1-800-985-5990 or text TalkWithUs to 66746).

MarketWatch also has expert advice for people who are thinking of suicide or experiencing other mental-health issues during the pandemic.