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Key points
- Although a surge of suicides was predicted, suicide rates actually declined during the pandemic.
- Predicting suicide at both the individual and population level is at worst impossible and at best an imperfect science.
- Rather than focusing on suicide prediction, clinical practice and public health efforts should focus on reducing risk.
My next series of posts will feature a multi-part interview on the topic of suicide with Dr. Tyler Black, a child and adolescent psychiatrist, suicidologist, and educator who practices ER psychiatry in British Columbia. In this first part, we discuss suicide during the COVID-19 pandemic.
Joe Pierre: Throughout 2020, there was a lot of prognosticating about how we would see a huge surge or "tsunami" of suicides among both adults and children based on anticipated associations with pandemic stress, lock-downs, school closures, and economic woes. A lag-time exists with data collection at a national level so that we don’t yet have final official numbers from the likes of the CDC, but it’s fairly clear now based on that the numbers reported thus far have failed to provide evidence of a suicide surge. In fact, the rate of completed suicides in 2020 appears to have decreased compared to 2019.
Aside from the well-established (if little known) fact that even experts are often terrible prognosticators, what do you make of the data? Why were predictions off the mark?
Tyler Black: We have virtually no reliable ways to predict future suicide rates. The moral panic around the "tsunami of suicides" that would follow COVID was incited by the lay opinion that this makes sense, a media that loves to make people afraid, and media "experts" whose main expertise is being on camera and furthering their career. This same brand of expertise was offered post 9-11, and post Great Recession, and will likely continue so long as it advances the expert's "brand" and the media attention-getting.
Many of the predictions relied on the unemployment link; however, even the link between unemployment and suicide has many confounders. Recent studies have shown that government austerity is a strong predictor of increased suicide rates during unemployment periods (i.e. if governments spend more, people die less).
The best position to take early on was the position of non-prediction. It is the position that I take clinically every day, and that smart health care workers, public health experts, and policy makers should adopt. Because we don't have the ability to predict, we should focus on areas that we know reduce suicide rates:
- Spending during economic hardship
- Protection, support, and services for people with mental illness
- Means reduction and restriction
- Material support to underprivileged and minoritized people
- Strong and targeted support for Indigenous people in culturally safe and appropriate ways
We know that suicides decreased in 2020 in both Canada and the US, as well as many other developed countries. This added to the decrease in 2019 in the US, and completely on par for the relatively stable yet improving rates in Canada for the past 20 years.
JP: One important possibility to consider is that while the overall numbers are down, there might be particular groups of people, or areas of the world or our countries, where suicide rates did actually increase in 2020. If we’re hypothesizing that pandemic stressors have an impact on suicide rates, then we should take into account how people were affected by the pandemic in different ways. Some lost their jobs, some didn’t. Some really missed their social lives, others were more comfortable being relieved of social pressures. Being out of school might be a protective factor against suicide for some children, while for others it might have the opposite effect.
In keeping with this view, there have been some news articles suggesting that in 2020 suicide rates have indeed gone up for African Americans living in particular parts of the US. And there are other data suggesting that 2020 suicide rates might have increased in places like New Jersey or Puerto Rico. What more do we know about more vulnerable subpopulations in North America where prognostications about increasing suicide rates might have been right after all?
TB: We have seen a signal that subpopulations could be more at risk. While white adults in the US have shown a decrease in suicide rates, there have been multiple subgroup analyses showing that non-white adults have had either no change or an increase. It's happened in enough data sets that I'm rather confident it was a true effect in 2020.
It's important to note that this trend precedes the pandemic, so it could be that the pandemic worsened the divergence of the paths rather than causing them to diverge. There has been significant burden in the US for racialized and minoritized groups, so the pandemic is an easy "blame" target, but I suspect the larger societal issues are at play.
For younger Americans, rather than a decrease we are seeing minimal changes. As kids have returned to school in the past few months across the US (a year into the pandemic), we have seen increases in distress presentations to hospital (not deaths by suicide). Many like to quickly politicize this and either blame lockdowns or the government pandemic response. I think it’s more nuanced than this—prior to the pandemic, kids were far more likely to die of suicide during school days or months than non-school days or months. School is a major stress for kids and *adding it* to the pandemic distresses is a complex machinery of risks and benefits. For some, unquestionably worth it. For others, its adding stress and distress. I wrote an op-ed about this a while back that I think holds up very well.
JP: Now that we’ve discussed how bad predictions about suicide were in 2020, do you want to speculate what will happen in 2021 and 2022? Might we see a delayed effect with suicide rates going up related to the pandemic after all?
TB: At some point, suicide rates will increase again. They can only increase or decrease. It is the fool that believes that they can predict future suicide rates. I realize I'm probably calling a lot of suicidologists fools right now, but it’s a foolish thing to do. Suicidologists have to be honest and humble—we read data that is months to years old; it isn't even current in the moment we are speaking. We have almost no predictive ability. Most of the media suicidologists early in the pandemic took the position of increase based on the idea that "US rates were increasing for 20 years"—they didn't even know that the CDC was going to show that 2019 showed a decrease in the US. So their already foolish prognostications were compounded by the fact that it was based on an incorrect assumption.
There’s little value in trying to predict, and worse, these experts undermine the very advocacy they espouse because when the rates don't increase, it adds fuel to the "you tried to scare us into spending on X" mistrust. So, to stay true to my principles, I will not make a prediction. I will instead remind the reader that we know many ways, despite our inability to predict, to reduce suicide rates. If we can get off of the impossible task of prediction, and start to do the hard work of significantly supporting mental health care, providing resources to the underprivileged and those struggling, tackling addiction as a health care issue, and providing universal health care to all Americans, we can actually reduce suicide rates without knowing what tomorrow holds.
JP: You’ve written about the wisdom of school closures during the pandemic and how predictions about suicide were used to make politicized arguments about opening schools up. As a child psychiatrist and as we head into the start of a new school year, where do you stand on this issue now? Beyond the issue of suicide, where does the risk-benefit analysis stand with regard to allowing children to return to school relative to the mental health risks of being out of school? What kind of precautions do you see as necessary if children do return as anticipated?
TB: I'm very proud of my province, British Columbia. There was an early shutdown, and as more information came in, BC schools were opened. BC schools have been opened throughout the 2020-2021 academic year except for targeted shutdowns. The best policy position has always been that a health authority should shut down schools when the pandemic parameters require it, but schools should be the last to close and the first to open. As it stands, if BC were a US State it would have the lowest death rate of any American state. I think our health authority should have shut down schools temporarily during our peak and it could have been better, but the general push to keep schools open before anything else opens is the right direction.
Vaccinations obviously change the game here, but schools are germ pools of indoor crowding and better ventilation, smaller class sizes, and robust sick policies (we still reward kids for "perfect attendance," despite the CDC cautioning against any such thing) would do very well to decrease transmission not just of COVID, but all communicable diseases.
Kids know the score. Worried parents and worried teachers aren't often listening to kids. Most kids are OK with missing school (shocker, I know). Most kids know the idea behind preventing the virus from killing grandparents even if they aren't at as much risk themselves. Most kids want to do the right thing. Most kids today love being online and can have rich and rewarding online social experiences. We should probably listen to kids more.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the National Suicide Prevention Lifeline, 1-800-273-TALK, or the Crisis Text Line by texting TALK to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.
