This is the third installment of our 6-part series on mental health issues exacerbated by the COVID-19 pandemic. In this installment, we will discuss identifying and treating an attempted suicide by a patient with major depressive disorder exacerbated by the COVID-19 pandemic.
A 22-year-old Hispanic man presents to the outpatient office after being admitted to the intensive care unit (ICU) following an overdose of antihistamines and alcohol. His medical history is significant for major depressive disorder that was diagnosed 3 years ago, which has been treated by his primary care provider (PCP) with sertraline (100 mg/d). The patient reports experiencing depressive symptoms after his first year of college and has been seen by his PCP approximately every 6 months. He has not reported any suicidal thoughts in the past.
The night before his hospitalization, the patient was at a local bar with friends and had several drinks. He went home and took a large number of over-the-counter antihistamine tablets. He was found the next morning by his roommate with an empty bottle near his bed. His roommate was unable to arouse him and called 911. No note or explanation for his actions was found. His friends who were with him during the evening did not know of any stressors and did not report any concerns when they dropped him off at his apartment.
The patient experienced a seizure en route to the hospital as well as in the emergency department.
Once he was medically stable, the patient was transferred to an inpatient psychiatric facility for continued care. He reported feeling depressed for several weeks and had been drinking daily for the last several weeks, which was not his usual behavior; he usually drinks on the weekends and only with friends.
He stated that he was feeling overwhelmed trying to transition to in-person classes at his university after taking online classes during the COVID-19 lockdown. He had been working extra hours to resolve some of the debt that he incurred when he was not working during the COVID-19 lockdown. He has not shared his thoughts with family or friends.
Once hospitalized, the patient was restarted on sertraline 100 mg/d, which was increased during the inpatient psychiatric hospitalization to 150 mg/d. The patient was encouraged to follow up with an outpatient psychotherapist and a mental health provider for medication management.
Suicide Screening/Mental Status Examination
The patient presents to the primary care office 3 weeks after hospitalization and reports that he has continued the medication as ordered but he has not kept any of the outpatient appointments and is drinking alcohol daily. He denies any suicidal thoughts at the time of the appointment. The patient’s vital signs were recorded at his initial visit (Table 1). The patient also provided records of laboratory tests from his hospitalization, which included a complete blood cell count, complete metabolic panel, urine drug screen, urinalysis, and thyrotropin level. All his discharge laboratory results were within normal limits.
Table 1. Vital Signs
|Blood pressure, mm Hg||110/77|
|Heart rate, beats/min||77|
|Respiratory rate, breaths/min||18|
The Columbia-Suicide Severity Rating Scale (C-SSRS) can be used to assess suicide risk. Inquiring about suicidal thoughts or plans does not increase the risk for suicide. If the patient has suicidal thoughts, inquire about a plan. Does the patient have a plan, and do they have the means to complete the suicide? Another brief validated tool to identify and assess patients at high risk for suicide is the Ask Suicide-Screening Questions (ASQ) tool. The ASQ is a set of 4 screening questions that takes 20 seconds to administer. The Joint Commission approves the use of the ASQ for all ages.1
The patient is dressed appropriately but slightly disheveled. He is calm and cooperative but not very forthcoming with information. The patient’s speech is normal in tone and rate, but he has a flat affect and appears to be depressed. He describes his mood as “OK.” He denies any hallucinations and does not appear to be responding to internal stimuli or verbalizing anything delusional.
Of note, the patient has been noncompliant with the prescribed follow-up treatment. He notes that he did keep his appointment with the PCP for his prescription refill but he lacks insight into the severity of his symptoms, the negative effects of his alcohol use, and the importance of psychotherapy.
The patient has been experiencing depressive symptoms for the last 3 years without complete remission (Table 2).2 He is diagnosed with persistent depressive disorder.
Table 2. Signs and Symptoms of Persistent Depressive Disorder2
|Changes in appetite: poor appetite or overeating|
|Changes in sleeping patterns: sleeping too much or not sleeping enough|
|Depressed mood for most of the day on most days|
|Difficulty making decisions|
|Over at least 2 years, the depressive symptoms have not resolved completely|
More than 45,000 Americans died as a result of suicide in 2020 and an additional 1.2 million attempted suicide, according to the Centers for Disease Control and Prevention (CDC).3 These statistics also include the first months of the COVID-19 pandemic prior to the availability of a vaccine when nearly 400,000 people died from COVID-related deaths.4
At the beginning of the pandemic, concern was raised that there may be an increase in the rate of suicide based on past behavior during pandemics.5 However, despite record increases in homicides and a spike in drug overdoses, the rates of suicides did not increase in the first year of the pandemic.4 At this point, data do not support an overall increase in suicide rates globally but some evidence suggests an increased risk after past pandemics.6 The CDC reports that suicide rates increased by 30% between 2000 and 2018 but declined in 2019 and 2020.1
During the 2003 severe acute respiratory syndrome (SARS) epidemic in Hong Kong, increased suicide rates were seen in older people with a preexisting diagnosis of depression or anxiety.7 “Loneliness and disconnectedness among the older adults in the community were likely to be associated with the excess older adults’ suicides in 2003,” researchers reported.7 Findings from the National Child Mortality Database suggested that suicide rates among people younger than 18 years of age had increased during the beginning of the lockdowns in the United Kingdom.8 “Numerous surveys have highlighted that [children and young people’s] mental health has been disproportionately affected, relative to older adults,” suggesting a possible increase in suicidal thoughts and self-harm, researchers reported.8 However, a clearer picture has emerged suggesting either no rise in suicide rates or a fall during the first year of the COVID-19 pandemic.8
In the United States, suicide was the second leading cause of death for people aged 10 to 14 years and 25 to 34 years in 2020.1 People attempt or complete suicide for a variety of reasons; not surprisingly, having a history of depression increases the risk. Other factors that can increase the risk for suicide include hopelessness, substance abuse, genetic factors, violent relationships, isolation, lack of support, financial stressors, lack of access to mental health professionals, and stigma regarding seeking help for mental health (Table 3).3
Table 3. Reasons People Attempt Suicide3
|History of: |
• Financial stress
• Genetic factors
• Lack of support
• Substance abuse
A patient may present to the PCP in need of mental health services for several reasons such as no access to mental health providers, no financial resources to seek help, or hesitation to seek care due to stigma. Be aware of cultural beliefs that are present when developing a treatment plan. When treating a patient who has attempted suicide, it is important to have an outlined treatment plan:
- If the patient is stable, continue medication
- Use the C-SSRS to access current suicidal thoughts9
- Inquire about support systems
- Discuss reasons for not attending scheduled outpatient appointments
- Assess for excessive alcohol abuse
Ask if the patient has a support system with family or friends and why he did not reach out to them in the past. Discuss what he can do in the future if he has these thoughts. Reinforce the importance of attending scheduled appointments. Education may be needed regarding the importance of these appointments and expected benefits.
If the patient does not follow up with a mental health professional, it is appropriate to have him return in 2 weeks. Consider the possible increase of sertraline to 200 mg/d if the patient is still having residual depressive symptoms.
Regarding the patient’s drinking, it is important to take a thorough history of his drinking (and drug) history. Is the patient drinking more frequently? Does the patient feel that he can stop drinking or has he tried to stop drinking on his own? How successful was he? Assess whether the patient needs specific treatment to address alcohol abuse or addiction.
Educate the patient on the negative effects of alcohol especially the depressive effects and the effect it can have in lowering inhibitions and possibly leading to impulsive behavior. Discuss if a higher level of care is needed such as intensive outpatient treatment or 12-step program.
The US Government recently launched the 988 Suicide & Crisis Lifeline, which provides immediate support to anyone in the United States who is having suicidal thoughts. The hotline is available 24 hours a day, 7 days a week. The staff at the hotline provide free and confidential support.10
Suicide can be prevented. The CDC recommends that the following actions can be taken to decrease the risk for suicide and suicide attempts:
- Improve financial security
- Make sure the home environment is safe
- No abusive relationships
- No lethal weapons in the home
- Increase access to mental health providers
- Educate the public regarding risk for suicide and what treatment is available
- Encourage peer groups
- Have an appropriate postsuicide attempt treatment plan.
Humans are neurologically wired to be connected to other people. People feel connected when they feel they are being heard and seen in relationships that are nonjudgmental and relationships that provide strength to the participants. Isolation, loneliness, and a feeling of powerlessness can result from not being connected to others.11 The COVID-19 pandemic forced society into social isolation, which could contribute to a sense of disconnection. Recent research shows an increase in depressive symptoms, anxiety, phobias, and even trauma related to isolation during COVID-19 quarantines. Economic stressors also play a role in increased symptoms of mental health disorders.12
The next installment in the mental health series will be on substance use disorder. The second installment of this series “Depression After COVID-19: Identification and Treatment in Primary Care” is available here.
Christy Cook-Perry, DNP, PMHNP, ANP, is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences.
Shirley Griffey, DNP, PMHNP, is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.
Jennifer Allain, DNP, MSN, APRN, FNP-C, is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences.
- National Institute of Mental Health. The ask suicide-screening questions (ASQ) tool. Accessed September 10, 2022. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2022.
- Suicide Data and Statistics. Centers for Disease Control and Prevention. Suicide Prevention. Accessed September 1, 2020. https://www.cdc.gov/suicide/suicide-data-statistics.html
- National Center for Health Statistics. Suicide in the US declined during pandemic. Centers for Disease Control and Prevention. News release. Accessed September 2, 2022. https://www.cdc.gov/nchs/pressroom/podcasts/2021/20211105/20211105.htm
- Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry. 2020;7(6):468-471. doi:10.1016/S2215-0366(20)30171-1
- Kahil K, Cheaito MA, Hayek RE, et al. Suicide during COVID-19 and other major international respiratory outbreaks: a systematic review. Asian J Psychiatr. 2021;56:102509. doi:10.1016/j.ajp.2020.102509
- Cheung VT, Chau PH, Yip PSF. A revisit on older adult suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry. 2008;23(12):1231-1238. doi:10.1002/gps.2056
- John A, Pirkis J, Gunnell D, Appleby L, Morrissey J. Trends in suicide during the COVID-19 pandemic. BMJ. 2020;371:m4352. doi:10.1136/bmj.m4352
- Columbia-Suicide Severity Rating Scale. https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf
- 988 Suicide and Crisis Lifeline. Accessed July 16, 2022. https://988lifeline.org
- Brown B. Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience. Diversified Publishing, 2022.
- Dsouza DD, Quadros S, Hyderabadwala ZJ, Mamun MA. Aggregated COVID-19 suicide incidences in India: fear of COVID-19 infection is the prominent causative factor. Psychiatry Res. 2020;290:113145. doi:10.1016/j.psychres.2020.113145