key: cord-0967912-j3rq7ycs
authors: Nelson, Pamela Anne; Adams, Susie M.
title: Primary Cares’ Role in Suicide Prevention during the COVID-19 Pandemic
date: 2020-07-19
journal: J Nurse Pract
DOI: 10.1016/j.nurpra.2020.07.015
sha: d086d880672f6d80c7f4e88c009263a8146758e8
doc_id: 967912
cord_uid: j3rq7ycs

Primary care providers (PCPs) have an important role in suicide prevention, knowing that among people who die by suicide, 83% have visited a PCP in the prior year, and 50% have visited that provider within 30 days of their death, rather than a psychiatrist.(1) The psychosocial impact of the COVID-19 pandemic poses increased risk for suicide and other mental health disorders for months and years ahead. This article focuses on screening tools, identification of the potentially suicidal patient in the primary care setting, and a specific focus on suicide prevention during widespread, devastating events, such as a pandemic.

Emergency 25 Suicide assessment should be part of a routine evaluation for patients with mental health 26 issues, not only in the behavioral health practice but also in primary care. In a time of mass 27 crisis, such as economic recession, natural or manmade disaster, or illness pandemic, suicide risk 28 awareness should be heightened. Determining who might be the most vulnerable to the health 29 and subsequent economic crisis is critical. Older persons, those with lower immunity status, 30 individuals who live alone, and persons who are suddenly unemployed, may be at greater risk for 31 suicide. Workers on the "front lines" during a pandemic are a category of people who are at a 32 higher risk for suicidal ideation that can be easily overlooked as being high risk. These would 33

include not only health care workers and first responders, but also workers who are suddenly in 34 high demand, such as those working in grocery stores, covering the media, delivering goods, or 35 employed in the government or financial sectors. Patients with pre-existing mental health 36 diagnoses should be placed in a higher risk category, as well. 37

Additional populations at higher risk include those with low socio-economic status, 38 homeless persons, and minorities, as health disparities are exacerbated during periods of 39 economic and social upheaval, as well as natural or manmade disasters. Health disparities, like 40 obesity, hypertension, and diabetes mellitus, which are linked to racial and socio-economic 41 status, also seem to have a link to the COVID-19 pandemic, as they were reported in 89.3% of a 42 population sample in a Center for Disease Control (CDC) survey. 13 Also, the rates of COVID-19 43 occurred in 55% of the non-white population, according to this same survey by the CDC, which 44 was taken from a sample of 14 states, and represented approximately 10% of the U.S. 45 population. 13 46 47

During a pandemic like COVID-19, mandated self-isolation and sequestering can have a 48 profound effect on mental health. People with chronic, debilitating illnesses, and those with pre-49 existing mental health diagnoses, have symptoms that often worsen under isolative conditions. 14 50

Isolation can have extreme, adverse effects on mental health, especially on those with major 51 depressive disorder and schizophrenia, which can cause worsening of symptoms that can lead to 52 suicidal ideations. 14 However, social isolation can impact even those without pre-existing mental 53 health conditions. Social isolation often leads to loneliness and a decreased ability to cope. 54

Subsequently, loneliness and isolation can also increase susceptibility to illness. 14 People living 55 alone, or those facing increased isolation, are at a higher risk for despair, hopelessness, and 56 suicide. 57

In 2016, the rate of hospitalizations for substance use disorders in New Orleans increased 59 after Hurricane Katrina. 15 After the 9/11 attack, substance use of people living in the New York 60 area notably increased the following year, suggesting a cause for concern. 16 Substance use 61 during the COVID-19 pandemic is climbing in the U.S., as well. 17 These traumatic events often 62 lead to anxiety, depression, and post-traumatic stress disorder (PTSD). Alcohol and other 63 chemical depressants increase a neurotransmitter, gamma amino-butyric acid (GABA), which 64 inhibits the central nervous system (CNS), promoting a sense of comfort and relaxation. 65

Drinking alcohol or using other substances as a means of "coping" may seem like a reasonable 66 solution to a victim of a pandemic or natural disaster, especially if mental health resources are 67 limited. Increased alcohol use will exacerbate the patient's symptoms over time, and eventually 68 lead to increased substance use and dependency, along with worsening overall mental and 69 physical health. What is also alarming is that increased substance use is a risk factor for suicide. 70

Practice Guidelines for the Assessment of Suicide Risk 71

The American Psychiatric Association (APA) Practice Guidelines 18 recommends that a 72 suicide assessment include the following: 73

• Inquiry regarding suicidal ideation, plan, and intent 74

• History of prior suicidal ideation, plan, and past attempts 75

• History of non-suicidal self-injury 76

• Assessment of current mood, symptoms of anxiety, feelings of hopelessness, and 77 presence of impulsivity (Table 1 ) 78

• History of psychiatric hospitalization and emergency department visits for psychiatric 79 complaints 80

• History of substance use disorder or change in use of substances (Table 1 ) 81

• Screening for stressors (including the current pandemic) ( Table 1 ) 82

Examples of ways to phrase questions relating to suicidal ideation, plan, and intent 18 83

Assessing for suicidal ideation 84

• Have you had thoughts that you would like to go to sleep and not wake up? (Table 1) 

The Patient Health Questionnaire-2 (PHQ-2) is a 2-item screening tool for depression 105 widely used in primary care practice settings. 20 It includes the first two items of the Patient 106

Health Questionnaire-9 (PHQ-9). A positive result on the PHQ-2 should prompt the interviewer 107 to utilize the full PHQ-9, a 9-item screening tool (Table 2) to identify the severity of depression 108 and possible suicidal ideation. 21 109 110 Table 2 . PHQ-9

Over the last 2 weeks, how often have you been bothered by the following problems? 1. Little interest or pleasure in doing things?* Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 2. Feeling down, depressed, or hopeless?* Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 3. Trouble falling asleep, staying asleep, or sleeping too much?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 4. Feeling tired or having little energy?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 5. Poor appetite or overeating?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 6. Feeling bad about yourself-or that you're a failure or have let yourself or your family down?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 7. Trouble concentrating on things, such as reading the newspaper or watching television?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 8. Moving or speaking so slowly that other people have noticed? Or, the opposite? Being so fidgety or restless that you have been moving around a lot more than usual?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 9. Thoughts that you would be better off dead or of hurting yourself in some way?

Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 111

Interpretation:* The PHQ-2 total score is acquired by adding the score obtained from the first 112 two items of the PHQ-9. If the score is 3 or greater, a major depressive disorder is likely. The PHQ-2 and PHQ-9 are both tools that are used to assess symptoms over the previous 127 two-week period. 20,21 In addition to the PHQ-2 and the PHQ-9, during a pandemic, probing 128 questions could also be used to determine the extent that stressors have impacted the patient's 129 current severity of depressive symptoms. Protective factors, such as social support systems, are 130 essential to assess. The patient's motivations for suicide or their "triggers" may not always 131 include the typical factors such as seeking revenge, escaping emotional or physical pain, or 132 having feelings of loneliness, purposelessness, self-hatred, or hopelessness. 133

• Do you feel that the pandemic has affected you emotionally or mentally? 134

• Have you or your family been impacted financially by the pandemic? Have you lost your 135 job or have your hours been cut back? Are you worried about finances? 136

• Do you have to work more because of the pandemic? 137

• Have you or your family been exposed to the virus? 138

• Are you worried about getting sick? (anticipatory anxiety) 139

• Do you live alone? Have you been more isolated because of the pandemic? 140

• How have you been spending your free time? 141

• Has your alcohol or drug use increased? 142

• Have you lost anyone close to you? 143

• Have you or your support system been otherwise affected by the pandemic? 144

Below is a list of risk factors and protective factors (Table 3 ). While having one or more risk 146 factors increases the likelihood of suicide, protective factors may help people deal more 147 effectively with stressful events and often mitigate or even eliminate the risk of suicide. 148 Brief, therapeutic interactions are useful for long-term suicide prevention. 25 Interventions 151 directed toward the symptoms of suicide, like hopelessness, will help the clinician address the 152 issue in collaboration with the patient to prevent suicide. 25 The concept of hopelessness has been 153 widely demonstrated in the literature to have a crucial impact on suicidality. 26 Focusing 154 therapeutic interventions on the concept of hopelessness will allow the nurse practitioner to 155 emotionally connect with patients who are contemplating suicide, and allow them the 156 opportunity to convey genuine concern and acknowledge how difficult the patient's situation is. 157

The focus of this conversation provides an opportunity for further exploration in the therapeutic 158 discussion and conveys the nurse practitioner's desire to help the patient achieve a more positive 159 perspective on life. to fearful experiences, frequently, many patients may lack resilience, a quality that allows some 166 individuals to recover without permanent damage. This lack of resilience leads some patients to 167 feel highly anxious, overwhelmed, and hopeless. Also, we need to be hypervigilant and screen 168 every patient about suicidal thoughts and behaviors. Even patients who have never had mental 169 health issues in the past are at a greater risk during a pandemic due to the level of stress we are 170 all experiencing. 171

• Guide patients to accurate resources, like the CDC, which will help to empower them. As 173 nurse practitioners, we can guide our patients by giving them correct information about 174 the pandemic. Many patients try to gather as much information as possible, often leading 175 to misinformation. Providing patients with useful, evidence-based tips and precautions, 176 like handwashing and wearing masks, can give them a better sense of control. 177

• Teach patients that the pandemic can be stressful, and that fear and anxiety are normal 178 reactions. As a result, stress can affect one's health in a variety of ways. Stress can cause 179 changes in sleeping and eating patterns and cause an increase in substance use. It can also 180 affect one's mental health, even if there is no previous history of mental health disorders. 181

An exacerbation or worsening of other chronic health conditions may occur. 182

• Encourage patients to take care of themselves physically. It is vital to get enough sleep 183 while maintaining a good sleep routine, getting physical exercise, eating healthy food, 184 and avoiding tobacco, alcohol, and drugs. 185

• Educate patients on stress reduction techniques. Encourage patients to stick to a routine, 186 which is essential to mental health. Instruct patients to maintain consistent mealtimes, and 187 set aside time for activities that they enjoy. Advise them to limit their exposure to news 188 and media. Encourage them to use their support system for comfort, connect with family 189 members and friends, and be of service to others. (Table 4) . 208

• Protect patients from the risk of suicide. Knowing the risk factors (Table 3) can help 209 identify patients who are especially prone to suicide during a pandemic. Increased 210 feelings of isolation, anxiety, depression, fear, and a lack of resilience may create a 211 scenario in which a patient who previously had no risk factors in a pre-pandemic era, is 212 now is at a higher risk. Likewise, focusing on their protective factors (Table 3) Table 4 

If you or someone you know needs immediate help in the U.S., call the line for hope to talk to someone live in your local area. They can listen to you and direct you to local resources if further assistance is needed. If someone has talked to you about suicide, and you believe they are currently a threat to themselves or someone else but will not take your help, call 911. Our current COVID-19 crisis provides a unique challenge to healthcare workers, given its 223 level of uncertainty. Experts are unable to provide information regarding when the crisis will 224 abate, which further manifests the degree of ambiguity. Undoubtedly, this degree of uncertainty 225 does not offer encouragement or hope to those grappling the most with their mental health during 226 these difficult times. However, as nurse practitioners, we can give these patients reassurance that 227 they are not alone, and that fact, in particular, may provide some semblance of normalcy during 228 their struggle. 229

Indeed, the stress of a pandemic can create the onset of a new diagnosis of mental illness, 230 such as major depressive disorder or anxiety disorder. Identifying and treating a new onset of 231 psychiatric illness, or one that is exacerbated by current events would hopefully abort a 232 subsequent suicidal event. Likewise, arming a patient with coping mechanisms that can increase 233 resiliency is an essential therapeutic intervention that should not be marginalized. With projected 234 increases in depression and suicidal behavior due to the COVID-19 pandemic, PCPs have a 235 critical role in screening, identifying, and preventing suicide for their patients. 27 236 237

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