The suicide pandemic

In 1980, the American Psychiatric Association recognised a new diagnosis - post-traumatic stress disorder, or PTSD - in the aftermath of the Vietnam War. In his book The Body Keeps the Score, Bessel van der Kolk speaks of the collection of symptoms - nightmares, flashbacks, mood disorders, and substance abuse - that characterised the post-war experiences of veterans: a diagnostic framework for which did not exist earlier.

Come 2020, the whole world found itself in the throes of the Covid-19 pandemic. In addition to easily perceptible physical illness, globally, the quality of mental health declined drastically. According to the WHO, pre-pandemic depression and anxiety numbers have risen over 25% since the start of the pandemic. The United States saw 1.2 million suicide attempts and 45,979 deaths by suicide in 2020. India's National Crime Records Bureau data claimed that 1.53 and 1.64 lakh fatalities by suicide occurred in the country in 2020 and 2021, respectively. In Nepal, the already escalating suicide numbers among minors reached 764 and 709 in the fiscal years 2020/21 and 2021/22.

What caused this spike in numbers? While the extended social isolation caused by lockdowns led to a fall in mental health, external factors like unemployment, inflation, financial hardship, and health and safety-related stress did nothing to help. It is unfortunate that in 2021, 25% of suicides in India involved daily wage earners.

Mental illness and suicide emerged as serious global public health concerns in the face of the pandemic, but this trend is far from new. In 2016, in the Eastern Mediterranean, the age-standardised suicide mortality rate was 4.3 per 100,000. In Palestine, the emergency situation explains the high mental illness burden amongst adolescents: about half of them suffer from behavioural or emotional disorders. In the African region, the suicide mortality rate stands at 11; this doesn't include the number of attempted suicides - a number that is 20 times higher. The situation isn't much better in the Pan-American region, with Guyana leading suicide mortality rates at 40.8 deaths per 100,000. According to WHO estimates, psychological conditions, which are correlated with high mortality rates, will soon account for 15% of the world's disease burden.

The suicide burden isn't equitably distributed across demographic groups. Individuals 25 years and younger account for 36% of the US population but are underrepresented in overall healthcare spending and overrepresented in mental health and substance abuse. In 2020, depression rates accelerated most in adolescents and young adults. Globally, women and those between the ages of 20 and 24 were most affected.

Occupationally, too, there are disparities. For ever so long, the world's healthcare community has suffered from burnout, with physicians and other healthcare workers showing startlingly high suicide rates. The pandemic only made things worse. Those on the frontlines of the pandemic were severely disadvantaged: workforce shortages, subsequent burnout and diminishing mental health. Amongst India's healthcare workers, those in the 21-30 year age group reported relatively higher burnout.

The WHO recognises the centrality of mental wellness in overall health. Goal 3 of the SDGs is to ensure the health and promote well-being for all age groups. With a target to decrease premature mortality from NCDs by a third and to promote mental health, suicide mortality is a crucial measure of progress.

Global interventions exist. Last month, the WHO launched a suicide prevention campaign across Africa. Training, analysis and advocacy programmes are underway in Zimbabwe, Kenya, Uganda, Cabo Verde and Ivory Coast. African health ministers have set mental health targets for 2030. In the Eastern Mediterranean, too, the WHO has programmes like the Mental Health Gap Action Programme. In September this year, South East Asian countries adopted the Paro Declaration with the objective of promoting universal access to mental health services. In general, interventions include responsible media coverage, reducing access to means of suicide like toxic pesticides, community-based support, and awareness programmes.

Nonetheless, diminishing mental health costs us. Medically, it costs us in suicide and higher utilisation of inpatient medical services. Economically, US$ 6 trillion by 2030. This also reflects the low levels of investment, in terms of money and resource deployment, across the world - in Africa (50 US cents per capita spent; 1 psychiatrist for every 500,000 citizens, 100 times less than WHO recommendations), the Eastern Mediterranean (treatment gaps as high as 90% in some countries), and South East Asia.

In 1980, the PTSD diagnosis may have been new, but the psychological condition wasn't. Victims of sexual assault, violent crime, neglect and abuse have suffered similar symptoms and helplessness. The experiences of the Vietnam veterans only paved the way for the acknowledgement, advocacy and treatment of these very real problems that had long plagued society.

The Covid pandemic is no different. Skyrocketing mental health issues brought to the forefront not only the suicide pandemic but also the issues that plague delivery of effective prevention programmes - disruptions in already limited mental health services, pre-existing stigma and socio-cultural challenges. The pandemic exposed how ill-equipped governments are with not only awareness and treatment programmes but also quality data. This crisis must serve as an impetus to address not only mental health but also the underlying socio-economic and political factors - political turmoil, inaccessible healthcare, and lack of economic, food, and employment security - that keep people from achieving holistic health.

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