Letter to the Editor regarding ‘What happened to the predicted COVID-19-induced suicide epidemic, and why?’

Abstract

To the Editor Glozier et al. (2023) propose that one of the reasons the Covid-19-induced suicide pandemic predicted did not materialise was because ‘People were not as distressed by the pandemic and lockdown as predicted’. They claim that the apparent absence of a mental health crisis and an associated suicide spike are ‘good news gone under the media and advocacy radar’. We believe that victory celebrations are premature. First, suicide rates have a complex and non-linear relationship with population mental health. Excessive focus on this most extreme, categorical metric of mental distress obscures a continuum of psychological harms related to lockdowns. A comprehensive health and well-being measure is therefore more defensible as a bellwether of policy success. In their analysis, Glozier et al. do reference the Mental Health Index-5 (MHI-5) data subset extracted from the wide-ranging HILDA telephone survey undertaken in August–September 2020 (reported by Butterworth et al., 2022). They consider these data to provide the ‘most convincing and rigorous evidence’ for their hypothesis. However, responses were collected only midway through the second of six lockdowns in Victoria, where residents were ultimately subjected to 262 days of shelter-in-place mandates and curfews which ended in October 2021. Much of the extant domestic and international literature purporting to show a minimal impact of lockdowns on mental health (Pirkis et al., 2021) also fails to examine changes in mental health over long-enough timescales to plausibly capture the mental health impact of lockdowns. Second, since the start of the pandemic, there have been abnormally long delays in the recording of causes of death by the State’s coroners, meaning that suicides have almost certainly been under-reported, giving the false impression of an averted mental health crisis. Local ambulance data (John et al., 2023) reveal that rates of callouts for suicide and self-injury escalated soon after Covid-19 containment measures were imposed in early 2020. NSW emergency department presentations for females aged 13–17 have grown at a rate of 47.1% per annum since early 2020 (Sara et al., 2023). The duration of stay-at-home orders for children and adolescents that excluded them from school and socialisation was positively correlated with behavioural problems (Sicouri et al., 2023). According to the Australian Institute of Health and Welfare (AIHW) (2022), phone calls to mental health services (e.g., Lifeline, Beyond Blue and Kids Helpline) rose sharply during the early pandemic period. The current excess demand for acute mental health services following an apparent hiatus during the early months of lockdown may reflect the reversal of a temporary re-direction of mental health demand from hospitals and clinics to other non-statutory agencies. In July 2022, PBS mental health prescriptions were up 12% from 2019 (AIHW, 2022). Considered in aggregate, these statistics point to an emerging mental health crisis with likely sustained, cumulative sequelae, including suicides. We might therefore view suicide rates as a lagging indicator of population distress caused by lockdowns. Consistent with this thesis, the Coroner’s Court of Victoria reported in February 2023 that in 2022 the state experienced the highest rates of suicide since 2000 when data were first collected (Coroners Court of Victoria Media Release, 2023). Cumulative suicide rates in 2022 were also higher in NSW compared to 2019–2021 (AIHW 2022). The Victorian Coroner formed the view that the suicide spike from August–December 2022 may ‘signal an emerging trend’ and opined that ‘social isolation, mental health issues, substance abuse, familial conflict and financial stressors’ are all risk factors for suicide. Lockdowns led to a proliferation of all of these fundamental determinants. A systematic review published in the Australian & New Zealand Journal of Psychiatry (ANZJP) (Pai and Vella, 2021) identified loneliness during lockdowns as contributing to depression in the post-lockdown period. In Victoria, where restrictions and curfews were maximally onerous, the most dramatic increase in suicides was seen in the 65+ cohort in whom loneliness is already a public health epidemic. Beyond suicides, ‘deaths of despair’ also appear to have risen due to pandemic lockdowns. During lockdowns, many poorer Australians who were unable to work from home and barred from normal socialising will have turned to substance use. Bottle shops remained open when most other businesses underwent forced closures. According to the Australian Bureau of Statistics (ABS) (2021), the death rate from alcohol in 2021 was the highest in 10 years. The ABS has also recorded new peaks since 2019 in drug- and alcohol-related deaths with secondary mental and behavioural disorders. In such cases, it can be almost impossible to disambiguate deliberate and accidental overdoses. We believe that more research is needed to fully gauge the scale of the serious and sustained impacts of lockdowns on mental health which have, until recently, ‘flown under the research radar’. The weight of emerging evidence suggests strongly that lockdowns are a deadly policy option, especially for the most vulnerable groups in society.