In The Face of COVID: Mental Health Resilience

"That's the kind of data we're getting across the board; that at a population level we're not seeing changes."

"In many ways, things are OK."

"[Humans are dealing with COVID better than anticipated]; overall there's a lot of resilience."

"All the evidence seems to be showing that there is not a tsunami of a mental health crises."

"[But] I think we need to be concerned about vulnerable groups."

Brett Thombs, medical researcher, McGill University 

 

The World Health Organization stated, while on the cusp of declaring COVID-19 a pandemic, that the disease would carry along a tide of loneliness and self-harm through its penetration of every facet of peoples' lives. Canadians were forewarned by the Canadian Mental Health Association of an "echo pandemic" expressed in acute anxiety and depression. With all this in mind, governments around the world began to take note of what lay ahead, funding crisis hotlines and online counselling programs.

Timely proaction in the prevention of suicides which rates as one of the most reliable indicators of mental health in society. But as the situation matured it began to look as though the fears of mental health breakdowns leading to increases in suicide just wasn't going to happen. Not only was there no upward-slanting change in the suicide rate, it began instead to decline to the pleased consternation of record-keepers and health advocates.

Australia, England, Norway all saw that suicide rates appeared to remain the same as they were before the onset of the deadliest times of the first wave. Dr.Thombs and an international group of scientists headed up a massive project in cataloguing and reviewing all of the world's mental health research on COVID-19, calling it a "living systematic review" with an aim to produce a generalized snapshot of the mental health of the world's 7.6 billion people under COVID-19.

The team carefully riffled through over 50,000 studies published globally to gauge everything from anxiety to depression to loneliness under pandemic conditions, rejecting slighter research defined as studies with small sample sizes or flawed data collection like voluntary web surveys, to sift through the total, rejecting research identified for its poor quality and potential bias. The remainder whose conclusions were felt to be trustworthy presents a picture of a world managing to cope fairly well despite the s stressors of COVID.

In the United Kingdom, population-level data expressed the finding that depression and anxiety briefly spiked with the lockdowns, then returned to normal "possibly because individuals adapted to circumstances", the researchers wrote. The global entry of COVID-19 caused suicide rates to plunge 15 percent, a huge survey of Norwegians found, with mental illnesses subsiding noticeably in the first weeks of lockdowns.

Rates of loneliness remained roughly the same, a nationwide survey of Americans discovered, "Despite some detrimental impact on vulnerable individuals, in the present sample, there was no large increase in loneliness but remarkable resilience in response to COVID-19", Florida State University researchers concluded. A cohort of students with pre-existing mental health concerns saw slight improvements to overall wel0-being at McGill University, examining mental health before and after the pandemic struck, representing one of the only major Canadian studies.

Calls to crisis hotlines had soared across the board since the beginning of COVID-19 lockdowns. Dr.Thombs noted that the hotline calls could represent an indication of increased psychological distress, but just as easily reflect more awareness, given funding to these hotlines under lockdown. Young Swiss men presented clear majorities reporting having difficulties coping with "abstaining from cultural events", or "not spending time with people privately". Still, they ranked overall depression and stress as average; clearly the effect of the pandemic failed to bump them into worse mental health.

An Italian study credited the "misery loves company" effect or "come together effect", an unexpected surge of well-being and good feelings in the face of a common enemy, with increasing well-being under lockdown. In that the greater the time Italians spent on social media looking at the pandemic problems of neighbours, the better in comparison they felt of their own situation.

Problems with mental health tensions did occur in a number of smaller demographics, however. Health-care workers, residents in long-term care homes, racialized communities, those with pre-existing mental illness, and youth severed from schools, activities and support services.

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Borderline Personality Disorder

"People with borderline [Borderline Personality Disorder -- BPD] have a very fragile existence. Often they have volatile relationships, with impulsivity and a fear of real or imagined abandonment. They are difficult patients. They have very difficult lives. Suicide cies to the mind as a solution because life is constantly breaking into a thousand pieces. They [BPD patients] are always skating on thin ice."
"They create chaos. It's hard for them not to. One of the things to do [for BPD patients] is to accept the unacceptable. This is what you have to do."
"Suicide is a public health epidemic. But very little is being done. Hospitals in the '90s had more services available than there are now. It's all bare bones now."
Dr. Antoon Leenaars, psychologist, suicide researcher, former president, Canadian Association for Suicide Prevention

"The scientific question is whether we know enough to predict and prevent such events. Unfortunately we don't. And that is why I have suggested working with suicidal patients in outpatient therapy rather than hospitalizing them. Most experts on BPD agree with me on this point."
"This is understandable [feelings of familial guilt], but fails to take into account that some patients have such a strong wish to die that they come to believe this is the only way to relieve their pain. And we don't know whether we could reduce the suicide rate with a better mental-health system. Suicide prevention remains a hope rather than a proven thing."
"One cannot compare different studies to show that we are succeeding in prevention suicide in BPD. I would like to believe that this is the case, given all the effort we have put into helping clinicians and their families identify this disorder. But I see no way to prove it. We do not have good data on how many BPD patients in Canada die by suicide. Again, you cannot generalize from following a clinical sample, and we have no population data."
"Our group in Montreal has shown that the vast majority of patients we treated over the past 15 years went on to recovery. BPD is a disorder that usually gets better with time and responds positively to well-designed psychotherapy."
Dr. Joel Paris, psychiatrist, expert in BPD, professor emeritus, McGill University

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Each day in Canada an estimated eleven people die by suicide, according to the Canadian Association for Suicide Prevention; another 200 Canadians make a suicide attempt daily -- this number considered an underestimate. The Canadian Community Health Survey states that 14.7 percent of Canadians think about suicide while 3.5 percent have attempted suicide during their lifetime, making suicide ranked as the ninth-leading cause of death in the country; the second-leading cause of death, after accidents for people between 15 and 34 years of age.

The Ottawa Hospital emergency rooms of the General and Civic campuses alone in one city yearly see about six thousand people seeking help for a mental-heath crisis. Roughly half of these people have suicidal thoughts. Borderline personality disorder, a condition characterized by fraught relationships, impulsiveness, extreme emotions and occasionally recurrent suicidal behaviour has as its hallmark instability, described as an unsteady sense of self and one's emotions. Depression, eating disorders and substance abuse also mark some people with BPD.

Patients with BPD are frequently dismissed as merely needy drama queens relating to the constant roller-coaster of emotions they can suffer from. Even some  health professionals consider them to be attention-seekers. One to two percent of the population is affected by BPD, but between five and ten percent of people who have BPD end up dying by suicide. And when most suicides are diagnosed, the cause is either depression or BPD, according to Dr. Leenaars. Patients describe the emotional pain that assails them as intolerable.

When a suicide is successful, guilt is the most common reaction from family members and friends. They wonder what else they could possibly have done to prevent the unthinkable from happening. Yet youth suicide in Canada has decreased in recent decades "But we really have no idea why", comments Dr. Paris, once chair of the department of psychiatry at McGill University. Although no research is available to show that organizing safety networks of supportive friends and family is beneficial, Dr. Paris believes they do make a difference in death by suicide.

Still, for people with BPD suicide is not inevitable. Some people move forward in their lives to eventually acquire happiness and stability, and manage well. Once they're in that situation they may look back and wonder at the intensity of the negative emotions that assailed them to the point where they once wanted to die. According to Dr. Paris these changes take place and they're common where patients eventually arrive at a highly improved state. He cites less impulsivity after age 30, linking it to brain maturation where people learn to avoid situations difficult to face.

In addition to which, patients who have been through therapy learn to apply effective skills taught there.

Warning Signs:

• Ideation: thinking about suicide;
• Substance use: problems with drugs or alcohol;
• Purposelessness: feeling like there is no purpose in life or reason for living;
• Anxiety: feeling intense anxiety or feeling overwhelmed and unable to cope;
• Trapped: feeling trapped or feeling like there is no way out of a situation
• Hopelessness or helplessness: feeling no hope for the future, feeling like things will never get better;
• Withdrawal: avoiding family, friends or activities;
• Anger: feeling unreasonable anger;
• Recklessness: engaging in risky or harmful activities otherwise normally avoided;
• Mood change: a significant change in mood

Source: Canadian Mental Health Association

Suicidal Children

"We're seeing a significant increase in suicidal behaviour since 2014. Everyone is wondering why the rates of ideation [suicidal thoughts] and behaviour are increasing."
"It [isolation] contributes to disconnection. They're sleeping more poorly [teens].  Any peer issues at school are following them home. If you're being bullied at school, you're not getting a break."
"People want to make sure that when a teen is in distress, they get the help they need."
"Conversations with teens involve mostly listening. Avoid giving advice. A good night's sleep means good mental health."
"If you suspect your teen is thinking about suicide, ask him or her. Asking questions won't prompt a suicide."
Dr. Allison Kennedy, psychologist, Children's Hospital of Eastern Ontario

"A single suicide attempt is the strongest predictor of future completed suicide."
"Community and general emergency departments are not resourced to give these children the comprehensive assessments and follow-up they need for optimal care."
Dr. Brett Burstein, pediatric emergency room physician, Montreal Children's Hospital

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"There is an overwhelming amount of data from many different sources, and it all points in the same direction: more mental health issues among American young people."
"This is always a tough question to answer, as we can’t prove for sure what the causes are. But there was one change that impacted the lives of young people more than older people, and that was the growth of smartphones and digital media like social media, texting and gaming."
"[While older adults also use these technologies], their adoption among younger people was faster and more complete, and the impact on their social lives much larger."
"[The way young people communicate and spend their leisure time] has fundamentally changed. They spend less time with their friends in person and less time sleeping, and more time on digital media."
Jean Twenge, professor of psychology, San Diego State University

"There’s a lot we don’t know, and we can’t say conclusively what’s driving these [mental health] trends. But in the real world when dealing with the health of children, you need to make your best guess and move ahead before things are unequivocally proven."
"It makes sense to pay attention to adolescent behaviors we know are changing and to target those behaviors for intensive scrutiny, and in the meantime to have [young people] engage in behaviors that don’t lead to poor well-being. There’s this overload of information and stimulation and a much bigger sphere of influence that they’re being exposed to."
"Given what we know about adolescent development and vulnerability and the intensive need for intimate and healthy social connection during these years, you can see how social media may not be developmentally appropriate."
Mary Helen Immordino-Yang, professor of psychology and education, University of Southern California

"I think every generation of adults tries to pin a negative trend they see in young people on whatever the current technological fad is."
"[The data may show depression rising among young people, but he can't see] a clear cost [associated with technology or social media use]."
"Certainly there are some stressors that are inherent in social media use, but there are other stressors as well; [increased competition to get into college and] parents hovering -- It’s probably not one thing, but the cumulative impact of a lot of things."
Laurence Steinberg, distinguished professor of psychology, Temple University

A new study by researchers in Canada found annual visits to American emergency rooms for suicidal thoughts and suicide attempts among children between the ages of five to 18 almost doubled between the years 2007 and 2015, from 580,000 to a staggering 1.12 million. Dr. Burstein, a pediatric emergency room physician at Montreal Children's Hospital, the co-author of the study and his colleagues sampled 300 U.S. emergency rooms to analyze public health data from the Centers for Disease Control and Prevention.

Among the findings' most disturbing conclusions was that 43 percent of children taken to an emergency room were aged between five and 12. There is no available comparable national Canadian data, but Dr. Burstein noted that at Montreal Children's Hospital a 55 percent increase in suicidal behaviour was noted between 2015 and 2018. In the U.S. study an eight-year period was involved whereas in the Canadian one a three-year period produced the results, indicating that the rise in suicide attempts is faster in Canada than in the U.S.

Health professionals, particularly those considered experts in the field of teen studies are uncertain how and what to attribute these figures to. Theories appear for the most part to centre around social isolation due to the rise and impact of technology-driven products where young people have turned increasingly to social media attraction which draws them away from personal real-world interaction, leading them toward an isolated lifestyle with few real social emotional supports.

This situation leaves teens spending more time by themselves. The more time spent on social media, the more time teens spend in their rooms, and consequently less time interacting with others, even with family members and that, even while they're at home. The disconnect between personal and one-on-one relationships in real time with real people has its isolating effect, leaving children adrift and lacking both peer and parental support.

This has led to the appalling realization that the second most common cause of death among adolescents in Canada is suicide, after accidents. Over 10 teen suicides for every 1,000,000 teens distinguishes Canada as one of five countries with the highest teenage suicide rates in 2015, according to a report by the O'Brien Institute for Public Health at University of Calgary. Twenty-two percent of teens between the ages of 13 and 18 had considered suicide in a 12-month period, according to a 2016 survey conducted by Kids Help Phone.

Of the children in the American study, fewer than 13 percent arrived in the emergency room for isolated suicidal thoughts; most -- 87 percent -- were present in the wake of an actual suicidal gesture or attempt; they had gone beyond thinking to action. To Dr. Burstein this suggests that an actual increasing burden of mental health problems among children is involved. Dr. Burstein points out the need for more community-based mental health resources, along with emergency department preparedness, as well as risk reduction interventions once the patient leaves the emergency department.

Signs of suicidal behavior in teens

As with many medical conditions, there typically is no single sign a family can point back to that explicitly indicated a teen was suicidal. There are several signs that may indicate suicide risk, including the following behaviors:
● Depressed mood/mood disorders
● Difficulty regulating emotions
● Difficulty with problem solving
● Hopelessness
● Impulsivity
● Hostility and aggression
● Quitting or struggling to enjoy favorite activities
● Social or interpersonal problems, interpersonal skill deficits
● High situational stress
● Insomnia

Longevity Alert

"These sobering statistics are a wake-up call that we are losing too many Americans, too early and too often, to conditions that are preventable."
Dr. Robert Redfield, director, Centers for Disease Control and Prevention

"I really do believe that people are increasingly [feeling] hopeless, and that that leads to drug use, it leads potentially to suicide."
Dr. William Dietz, disease prevention expert, George Washington University

"Maybe it's starting to slow down [drug overdose epidemic], but it hasn't turned around yet."
"I think it will take several years [yet, before a difference is seen]."
Dr. John Rowe, professor of health policy and aging, Columbia University

Erika Marble visits the gravesite of Edward Martin III, her fiance and the father of her two children, in Littleton, N.H., in 2016. The 28-year old died in 2014 of an overdose of the opioid fentanyl. (Jim Cole/AP)

The Associated Press through VoteCast, took a wide-ranging survey of the electorate discovering pessimistic views about the future among voters. Roughly half of nationwide voters stated their belief that life in America for the following generation would be worse than what is seen today, and close to a quarter felt life would be better, while the same number said it would remain the same. Over 115,000 voters were surveyed nationally when American citizens cast their ballots in this year's midterm elections.

There were over 2.8 million U.S. deaths in 2017 which means there were 70,000 more deaths occurring last year than did in the year before, according to the Centers for Disease Control and Prevention's latest report on U.S. life expectancy. 2017 ranked as the year with the most deaths to have occurred in a single year since government began taking account of such statistics over a century ago. The increase is partially attributed to the nation's growing aging population.

However, younger age groups, in particular middle-aged people, have seen the largest impact on life expectancy calculations, according to experts. The crux of this reality is that last year's suicide death rate represented the highest that has been recorded in the last half-century. Over 47,000 suicides were tracked, an increase from slightly under 45,000 of the year before. U.S. life expectancy has been on the increase for decades, rising several months almost every year, and now the trend has been reversed.

In 2015 the suicide rate was seen to have fallen, the following year levelled off, and then in 2017 there was yet another decline. This represents the longest period of a declining life expectancy rate since the late 1920s, when the First World War and the most serious flu pandemic in modern history coincided, killing close to one million Americans between them. In 1918 life expectancy was 39 years of age. "We've never really seen anything like this" commented Robert Anderson, who oversees CDC death statistics.

Only the cancer death rate alone fell in 2017, while increases were seen in seven other indices; suicide, stroke, diabetes, Alzheimer's, flu/pneumonia, chronic lower respiratory diseases and unintentional injuries. The death rate for heart disease -- recognized as the nation's number one killer -- has stopped falling, whereas in years past, declines in heart disease deaths were significant enough to offset increases in other kinds of death, but that no longer applies.

Dr. William Dietz recognizes from his expertise in disease prevention, an overall sense of hopelessness overtaking people's consciousness as a likely cause of some part of the increase in suicide. He cites financial struggles, a widening income gap, and divisive politics casting a pall over many people. Drug overdose deaths continued to climb as well, surpassing 70,000 in 2017, reflective of the deadliest drug overdose epidemic in U.S. history.

In that category the death rate rose ten percent from the previous year; less than the 21 percent leap between 2016 and 2017. Accidental drug overdoses account for over a third of the unintentional injury deaths while intentional drug overdoses take account for about a tenth of the suicides, according to Dr. Holly Hedegaard, injury researcher at the Centers for Disease Control. As well, gun deaths rose for a third year to nearly 40,000, 1,000 more than 2015, from their 33,500 height until a few years ago.

Suicide Rates by Race/Ethnicity

In 2016, the highest U.S. suicide rate (15.17) was among Whites and the second highest rate (13.37) was among American Indians and Alaska Natives (Figure 5). Much lower and roughly similar rates were found among Asians and Pacific Islanders (6.62), and Black or African Americans (6.03).
Note that the CDC records Hispanic origin separately from the primary racial or ethnic groups of White, Black, American Indian or Alaskan Native, and Asian or Pacific Islander, since individuals in all of these groups may also be Hispanic.