COVID, Mental Health and Suicide in Youth: What does it mean? (part II)
In part I of this post I discussed what we know about and how we can understand reports of increased rates of mental health complaints, symptoms, and mental illness during the COVID pandemic. Among the most disturbing and worrisome reports during the pandemic have been about the increase in suicidal thoughts in young people “brought on” by the pandemic. I’d like to discuss several questions in this context. First, do we know that rates of suicidal thoughts are currently higher among young people than they were pre-pandemic? If they are, what might that mean or reflect? Even if they are not higher, what are we to make of the very high rates of suicidal ideation among teens and young adults?
Have suicidal thoughts increased during the pandemic?
There are quite a few reports of higher rates of suicidal thoughts among young people during the pandemic. For example, Pediatrics reported that among teens coming to pediatric emergency rooms for all problems, screenings for suicidal thoughts showed evidence of suicidal thoughts about 1.5 times higher than in pre-COVID periods. The authors though noted that visits to the ERs were decreased substantially during COVID and it is possible that kids coming into the ERs during this period may have been more ill or in more distress than in previous times. It is difficult to draw reliable conclusions from this report. If we look at data from general populations of college students comparing data gathered during the pandemic to earlier surveys from the Healthy Minds Study, we find that rates of suicidal thoughts were no different during the fall ’20 semester than during the previous fall.
So, it is unclear whether rates of suicidal thoughts in young people have actually increased during the COVID pandemic.
How high are rates of suicidal thinking in young people?
Even if rates of suicidal thoughts have not increased during the pandemic, rates of suicidal thoughts, attempts and suicide among young people are genuinely concerning. Suicidal thoughts (and attempts) are quite common in young people. For those age 18-25, more than 1 in 10 reported prior year thoughts of suicide and nearly 1 in 50 reported a suicide attempt in 2019. Among 14-18 year old youth, in 2019 nearly 1 in 5 reported thoughts of suicide and 1 in 10 reported an attempt.
It is indeed fortunate that the vast majority of youth reporting suicidal thoughts and attempts (many of which do not result even in ER visits) do not go on to die by suicide. Among college students for example, there are more than 1000 with suicidal thoughts for each student who dies by suicide. Interestingly, as people mature, the gap between thoughts, ideation and actual death by suicide narrows significantly. Middle aged and older people do not as commonly think about suicide but when they do, there is a larger chance they may act on the thoughts.
Suicides have been increasing in the past 15 years or so among young people. I believe at least in part this reflects our doing a worse job addressing suicidal thoughts and behaviors among young people.
What should we make of these survey-based reports?
It is not uncommon, when reading discussions of suicidal thoughts to have the sense that they are being noted simply as symptoms of psychiatric illness, that is, as a sign of pathology. I would like to suggest a broader view of reports of suicidal thoughts which might help us understand why we might see an upsurge in reported thoughts of suicide during stressful times like the COVID pandemic, and why that may reflect larger problems that have influenced the increase in suicides observed among young people over the past 15 years.
What does it mean for someone to report on a survey that they’ve had serious thoughts of suicide or self-harm in the past year? Let’s consider another question. To what extent do we recall specific pieces of mental content, thoughts, fantasies, ideas, feeling that may have occurred at some point say eight months ago? If I were to ask whether you had thoughts in the last year about going on a Caribbean cruise or whether at some point you were very angry at a close friend or a spouse-it is possible you might recall a specific moment or incident-but it is just as possible you will make your best guess based on how you feel about the past year in general and this might very well be influenced by how you feel right now or even by the other questions you’ve just seen in the survey. It is not likely that reports of any feeling or thought over the prior year are objectively precise. Reports on surveys such as these are at best subjective and impressionistic.
Why so much suicidal ideation in youth then?
Young peoples’ moods can be intense, rapidly changeable, and often they are not all that good at expressing themselves verbally. In fact, it is important to maturation to get better at being aware of and being able to articulate our feelings, needs, and thoughts. Our own mental health and our relationships with others depend on these observations and our ability to discern these things in others-what we call empathy. Much of good child rearing, education and psychotherapy are directed to helping children and young people (and adults when these skills have not sufficiently developed earlier) to build these skills.
I would like to suggest that when young people who might be linguistically limited in their ability to convey distress, pain, and psychological turmoil report that they are having thoughts of suicide or even make suicide attempts, they are conveying their pain and distress-sometimes in the only way they know how. This is, of course, cause for concern and carries potential for danger-as they may act on the thought, they may not appreciate the risks they are taking when they act and when younger they may not fully appreciate the finality of death.
It stands to reason then that during times in which there is more strife at home, or stress in their environment, like during a pandemic-more young people may find themselves in distress and some portion of them will articulate this by saying they are having thoughts of self-harm.
Beyond this, as young people grow, it is typical-and maybe important and necessary-for them to wrestle with questions around their life goals and expectations-where do they imagine themselves living? What kind of work do they imagine doing? What kind of family structure or unit makes sense? The unexpected social and economic disruptions flowing from the pandemic and the political turmoil of recent years has disturbed and even up ended many of these expectations for young people. It is inevitable for some of them to wonder “what will happen now?” or “what is the point of planning?” or even “what will my life look like in 10 years?” or, “how can I go on?”, especially if they have lost loved ones or if one’s family has experienced economic hardship because of the pandemic. These questions can be painful and disturbing but there is also value in trying to examine one’s life trajectory and what might give meaning to experience.
My point is that we cannot look at reports of suicidal thoughts or even attempts in young people simply as symptoms of mental illness. While they might be, we need to understand these fairly common phenomena as communications of an inner state of distress and uncertainty-and the inability to fully articulate and manage the underlying feelings-often in response to life circumstances. The thoughts and acts need to be explored and unpacked in the context of personal, family, and social history, while helping young people understand and articulate their emotional life and learn the range of actions, decisions, and strategies they might use to manage their distress and to work with others to move forward and set a life course. These reports of suicidal thoughts are always concerning but can pave the way to developmental opportunities that can be quite dramatic-leading to deep and meaningful growth. Too often in treatment, we have stopped trying to understand the underlying feelings and concerns and their contexts. We intervene to keep the young person safe during a “crisis” and wait for things to quiet down again once the “medication has kicked in” or until something has changed. It is little surprise we have done worse in preventing youth suicide in recent years.
The COVID pandemic has reminded us in stark terms that we need to explore context and meaning to help young people learn to articulate, understand, and manage their emotional and life challenges. We ought to absorb this lesson from the challenges of the COVID pandemic.