Dr. Shyam P Lohani

EVENTS such as loss of a loved one, economic hardship, loneliness, mental and chronic illnesses may become stressful or often traumatic for a person. Amid the COVID-19 pandemic, most of the people in the world are experiencing those stressors. Thus, those who are already at high risk of being stressed are more likely to succumb to suicide. It has been projected that in 2020, suicide accounts for one death every 20 seconds, and the large majority of those occur in low and middle-income countries (WHO, 2016). The stressors caused by the pandemic are sure to exacerbate the suicide rate worldwide.
In Nepal, almost 15 people committed suicide every day with a total of 5,317 persons killing themselves in 2017/18 (Nepal Police, 2018). During the lockdown period from March 24 to May 2 this year, a total of 492 people committed suicide. The figure accounts for almost 11 persons every day which is less than previously reported for the earlier year. Since not a single death from COVID-19 has been reported so far in Nepal, the effect due to bereavement might not have been seen yet. However, the COVID-19 pandemic is feared to make suicide as an overwhelming global public health issue.

Alarming risk factors
Researchers throughout the world warn that a suicide tide might ensue during a pandemic and more importantly, after this public health emergency. The COVID-19 pandemic has brought several alarming risk factors such as social isolation, anxiety and depression, inadequate treatment availability, and poor seasonal timing as reported by JAMA Psychiatry (2020). There is evidence that during the 1918-19 influenza pandemic, there was an increase in the number of suicide deaths in the USA (Wasserman, 1992) and among Hong Kong elders during severe acute respiratory syndrome (SARS) epidemic in 2003 (Cheung et al, 2008).
At the same time, the restrictive measures followed by lockdowns have tremendous effects on economic activities throughout the world, increasing the unemployment rate. The unprecedented number of job losses due to the COVID-19 pandemic, as reported by the International Labour Organisation (ILO, 2020), is estimated to 24.7 million in the high scenario and 5.3 million in the low scenario. However, there is no estimation yet on the number of job losses for Nepali youths at home and abroad. The stressors such as loss of employment and financial hardship are well-recognised risk factors for suicide.
The physical distancing, self-isolation, and nationwide fear are major stressors that are likely to have an adverse impact on mental health in general and on those with mental illnesses in particular. People with psychiatric illnesses might experience worsening symptoms and the general public might develop new mental health problems that are associated with increased suicidal risks like anxiety, depression, and post-traumatic stress disorders. There is heightened risk of development of those psychological manifestations among those infected with COVID-19, their family members as well as frontline healthcare workers.
The other known risk factors for suicide include increased alcohol intake and domestic violence during the lockdown. Those precipitants to suicide must also be addressed with public health responses during and after the COVID-19 pandemic. Social isolation during the lockdown might result in loneliness, another contributor to suicide risk.
The current pandemic is not only a medical tragedy of this century; it might also, unfortunately, leave psychological scars for years. Therefore, it is of paramount importance to develop effective suicide prevention strategies. The suicidal ideation and thoughts are often ephemeral and can effectively be dealt with support, therapy, and coping behaviours.

Preventive measures
Having recognised the stressors and precipitants, the suicide prevention strategies should include all selective, indicative as well as universal interventions. Unemployment is one of the major predictors of suicide. The government should plan for developing financial safety nets to support especially those who have recently become jobless. The impact of the pandemic is more severe on individuals and households in the informal economy, migration, travel, and tourism sectors. In this connection, the Prime Minister Employment Programme could be instrumental in dealing with the problem of unemployment.
The psychological impacts on young people who have been unable to complete their curricula owing to uncertainties are enormous as they are anxious about their prospects. Educational institutions should, therefore, plan alternative ways to deliver their curricula. There should be strategies in place to reduce alcohol consumption with effective communication of safe drinking messages and support people with issues of domestic violence. One of the major risk factors for suicide is access to means. The restriction on lethal means such as banning highly toxic pesticides and illicit drugs might help in decreasing suicide during and after the pandemic. Retailers selling highly toxic pesticides should be especially vigilant when dealing with distressed individuals.
The responsible reporting by media by not disclosing the name of poisons involved for committing suicide may help reduce suicidal cases in the future. The media should report available support or help and treatments while preparing a story on suicides committed. The professionals who come in contact with vulnerable people at the beginning of the problem such as female community health volunteers, police personnel, teachers, community, and religious leaders should be sensitised and trained to identify people in need and provide them with basic psychosocial counselling. The availability and use of suicide prevention lifeline become more important during and after the pandemic. Mental health professionals ranging from psychological counselors to clinical psychologists, suicidologists, and psychiatrists need to come forward to tackle suicide upsurge that is very likely to occur during and after the COVID-19 pandemic. Let us come forward to play our respective roles in preventing suicides during and/or COVID-19 pandemic.

(Prof. Lohani is the Founder and Academic Director of Nobel College. He can be reached at lohanis@gmail.com)