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Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020


What is already known about this topic?

Communities have faced mental health challenges related to COVID-19–associated morbidity, mortality, and mitigation activities.

What is added by this report?

During June 24–30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation.

What are the implications for public health practice?

The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged =18 years across the United States during June 24–30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic† (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18–24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys†† administered by Qualtrics.§§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2–8, May 5–12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals (2,3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** (4), and symptoms of a COVID-19–related TSRD were assessed using the six-item Impact of Event Scale††† (5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey.§§§

Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification,¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (a = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted†††† odds ratios (ORs), 95% CI, and p-values (a = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses.

Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18–24 years (74.9%) and 25–44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey.

Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, initiation of or increase in substance use to cope with COVID-19–associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18–24 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19–related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19–related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group.

Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75–6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20–7.63; p = 0.019).


Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) (2). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 (2). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) (6).

Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers.

The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19–specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic (7). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June (1).

Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation (8), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide (9). Communication strategies should focus on promotion of health services§§§§,¶¶¶¶,***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19–specific screening instruments for early identification of COVID-19–related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently.

† Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others.

§ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was a person who had provided unpaid care to a relative or friend aged =18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing.

¶ Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential versus nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers.

** A minimum age of 18 years and residence within the United States as of April 2–8, 2020, were required for eligibility for the longitudinal cohort to complete a survey during June 24–30, 2020. Residence was reassessed during June 24–30, 2020, and one respondent who had moved from the United States was excluded from the analysis. A minimum age of 18 years and residence within the United States were required for eligibility for newly recruited respondents included in the cross-sectional analysis. For both the longitudinal cohort and newly recruited respondents, respondents were required to provide informed consent before enrollment into the study. All surveys underwent data quality screening procedures including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the United States. Respondents who failed an attention or speed check, along with any responses identified by the data-scrubbing algorithms, were excluded from analysis.

†† The surveys contained 101 items for first-time respondents and 86 items for respondents who also participated in later surveys, with the 15 additional items for first-time respondents consisting of questions on demographics. The survey instruments included a combination of individual questions, validated questionnaires, and COVID-19-specific questionnaires, which were used to assess respondent attitudes, behaviors, and beliefs related to COVID-19 and its mitigation, as well as the social and behavioral health impacts of the COVID-19 pandemic.

§§ icon.

¶¶ Survey weighting was implemented according to the 2010 U.S. Census with respondents who reported gender, age, and race/ethnicity. Respondents who reported a gender of “Other,” or who did not report race/ethnicity were assigned a weight of one.

*** Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored =3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for these respective disorders. This instrument was included in the April, May, and June surveys.

††† Symptoms of a TSRD attributed to the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Those who scored =1.75 out of 4 were considered symptomatic. This instrument was included in the May and June surveys only.

§§§ For this survey, substance use was defined as use of “alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor.” Questions regarding substance use and suicidal ideation were included in the May and June surveys only. Participants were informed that responses were deidentified and that direct support could not be provided to those who reported substance use behavior or suicidal ideation. Regarding substance use, respondents were provided the following: “This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the Substance Abuse and Mental Health Services Administration National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1-800-487-4889. This is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for persons and family members facing mental and/or substance use disorders.” Regarding suicidal ideation, respondents were provided the following: “This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the National Suicide Prevention Lifeline, 1-800-273-TALK (8255, or chat line) for help for themselves or others.”

¶¶¶ Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. icon.

**** Odds of incidence was defined as the odds of the presence of an adverse mental or behavioral health outcome reported during a later survey after previously having reported the absence of that outcome (e.g., having reported symptoms of anxiety disorder during June 24–30, 2020, after not having reported symptoms of anxiety disorder during April 2–8, 2020).

†††† Adjusted for gender, employment status, and essential worker status or unpaid adult caregiver status.

§§§§ Disaster Distress Helpline ( icon): 1-800-985-5990 (press 2 for Spanish), or text TalkWithUs for English or Hablanos for Spanish to 66746. Spanish speakers from Puerto Rico can text Hablanos to 1-787-339-2663.

¶¶¶¶ Substance Abuse and Mental Health Services Administration National Helpline (also known as the Treatment Referral Routing Service) for persons and families facing mental disorders, substance use disorders, or both: icon, 1-800-662-HELP, or TTY 1-800-487-4889.

***** National Suicide Prevention Lifeline ( icon): 1-800-273-TALK for English, 1-888-628-9454 for Spanish, or Lifeline Crisis Chat ( icon).


1. CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020.

2. CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January–June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. icon

3. Czeisler MÉ, Tynan MA, Howard ME, et al. Public attitudes, behaviors, and beliefs related to COVID-19, stay-at-home orders, nonessential business closures, and public health guidance—United States, New York City, and Los Angeles, May 5–12, 2020. MMWR Morb Mortal Wkly Rep 2020;69:751–8. CrossRefexternal icon PubMedexternal icon

4. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86–95. CrossRefexternal icon PubMedexternal icon

5. Hosey MM, Leoutsakos JS, Li X, et al. Screening for posttraumatic stress disorder in ARDS survivors: validation of the Impact of Event Scale-6 (IES-6). Crit Care 2019;23:276. CrossRefexternal icon PubMedexternal icon

6. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. iconexternal icon

7. Horesh D, Brown AD. Traumatic stress in the age of COVID-19: call to close critical gaps and adapt to new realities. Psychol Trauma 2020;12:331–5. CrossRefexternal icon PubMedexternal icon

8. Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: a review. Can J Psychiatry 2008;53:769–78. CrossRefexternal icon PubMedexternal icon

9. Stone D, Holland K, Bartholow B, Crosby A, Davis S, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2017. icon

Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019; PTSD = posttraumatic stress disorder; TSRD = trauma- and stressor-related disorder.

Key Steps to Reduce Suicide Risk

According to experts, mental health professionals can take the following key steps to reduce clients' suicide risk during COVID-19: (1) use evidence-based approaches, such as the Collaborative Assessment and Management of Suicidality and Safety Planning Intervention; (2) screen all clients for suicide risk, including those who do not have a history of suicidal thoughts or behaviors; (3) work with the person at risk on strategies to keep them safe in a crisis, such as identifying sources of support and removing lethal means from their home; (4) follow telepsychology guidelines (10 page PDF)when providing mental health services over phone or video; and (5) educate clients and their families about how to recognize and respond to the warning signs of suicide in members of their community. It is also critical that mental health professionals prioritize self-care. "If we want to have the stamina and capacity to help other people, we have to take care of ourselves," said Jill Harkavy-Friedman, vice president of research at the American Foundation for Suicide Prevention.

CDC's Redfield should sound alarm about suicides amid coronavirus outbreak, critic say - 080720 NEW

This story refers to suicide. If you or someone you know is having thoughts of suicide, please contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Suicides have spiked amid the coronavirus pandemic, specifically among high school students. A guest on Thursday night's edition of "The Ingraham Angle" said Robert Redfield, director of the Centers for Disease Control and Prevention (CDC), should be sounding a louder alarm about the problem.

"It's pretty incredible because a lot of us predicted this might happen. And unfortunately, it appears that it has happened," the guest, Phil Kerpen, president of the Committee to Unleash Prosperity, said.

"Self-harm is the No. 2 cause of death among teenagers after accidents. Kills thousands a year. When you're comparing it to a virus that kills tens a year in that age bracket, even a tiny increase in the percentage is going to be a much bigger number. And we thought that might happen and that has happened.

"The insane thing to me," Kerpen continued, "is this is a big deal and the CDC is not touting it from the platform. They're not going to the White House podium. They're not going on a show like yours and saying it."

Redfield addressed to suicide issue July 14 during a Buck Institute webinar.

"We're seeing, sadly, far greater suicides now than we are deaths from COVID," Redfield said at the time. "We're seeing far greater deaths from drug overdose that are above excess that we had as background than we are seeing the deaths from COVID."

Separately, host Laura Ingraham brought up a German study that said "exposure to children may make adults less likely to contract COVID-19," noting the study wasn't peer-reviewed.

Kerpen responded: "Wouldn't that be an unbelievable irony after all of these strikes and these demands and all of this stuff from these teachers? If it turns out that being around children is actually protective, that the child had colds and other illnesses, they have challenges to the immune system of adults that protect them from future COVID infection?"

‘A Year’s Worth of Suicide Attempts in the Last Four Weeks’: California Doctor Calls for End to Lockdown

The doctor in charge of a Bay Area, Calif. trauma center said the state should end its lockdown orders after an “unprecedented” spike in suicide attempts amid the coronavirus pandemic.

“We’ve never seen numbers like this, in such a short period of time,” Dr. Mike deBoisblanc, head of trauma at John Muir Medical Center, told local station ABC7. “I mean, we’ve seen a year’s worth of suicide attempts in the last four weeks.” He added that he thinks “it’s time” to end the state shutdown.

“I think, originally, this was put in place to flatten the curve and to make sure hospitals have the resources to take care of COVID patients,” he explained. “We have the current resources to do that and our other community health is suffering.”

Trauma nurse Kacey Hansen, who has worked at John Muir Medical Center in Walnut Creek for over three decades, said she had “never seen” so many attempts, most being young adults. “I have never seen so much intentional injury . . . it’s upsetting.”

John Muir Health said in a statement that while “there are a number of opinions on this topic, including within our medical staff,” the organization supports the state’s shelter-in-place order.

Half of Parents Whose Teens Consider Suicide Have No Idea

We were so stunned — and so unaware.” The biggest study of its kind reveals how often parents miss the signs.
John Trautwein’s eldest son, Will, was 15 years old when he took his own life.

The night before, Will studied hard for a test he was supposed to take that day. He was going to get his driver’s permit that weekend and get his braces off the following week. Those were big events in his life that he was preparing for, and his parents had no inkling that their popular, athletic son was contemplating suicide.

“We were so stunned — and so unaware — that we thought someone had come in and killed him,” Trautwein said of his son’s death in 2010.

“If you had told me that my son was unhappy, let alone suicidal,” he told HuffPost, “I would have told you you’re absolutely nuts.”

The largest study to date measuring what, if anything, parents know about their teens’ suicidal thoughts shows that many parents, like Trautwein, said they are completely unaware that their adolescents have thought about taking their own life.

In interviews with more than 5,000 Philadelphia-area kids ages 11 to 17 and their parents, researchers found that among the teens who reported that they had thoughts about taking their own life, 50 percent of their moms and dads said they had no idea.

Three-quarters said they had no idea their children had recurrent thoughts about death.

“Previous research has also found poor agreement not just in suicidal thoughts but in things like depressive symptoms and perceptions of family functioning,” said study author Jason Jones, a research scientist at PolicyLab at Children’s Hospital of Philadelphia. “There’s a lot of evidence that parents are not aware.”

Jones and his team were surprised to find similar disagreement in the other direction, between children’s downplayed reports of their thoughts versus what their parents saw as troubling indicators. A significant number of teenagers denied they had thought about suicide or death, even though their parents told the researchers they had.

“But I think for something as straightforward as this,” he continued. “I mean, ‘Have you ever thought of killing yourself?’ is a pretty direct question. To see the level of disagreement we’re seeing, it’s alarming.”

The findings were published in the journal Pediatrics on Monday.

A Troubling Trend

Suicide is the second-leading cause of death among Americans ages 10 to 24, and it continues to rise for reasons that are not entirely clear.

Experts have identified suicide as a pressing public health crisis — and suicide among young people in particular as an issue that requires a multipronged approach, bringing together health care providers, parents, schools and researchers to better understand the challenges and approaches to prevention. A 2015 national survey reported that 18 percent of high schoolers have had thoughts of suicide (the rate in the current study, which included children as young as 11, was lower, about 8 percent), and it is estimated that two-thirds of adolescents who experience suicidal thoughts don’t get help.

Jones said the new research raises hard questions for health care providers, particularly pediatricians, regarding the best ways to screen for depression and suicidal thoughts among children.

For example, given that some parents said their teens considered suicide but their teens denied it, doctors might consider asking caregivers about what they see or believe might be happening, Jones said. That, however, raises practical concerns, such as how to fit that conversation into the limited window doctors typically have with patients, as well as ethical ones about how much doctors should be taking parents’ subjective opinions into account.

What Parents Need To Look For

Experts say that the message for parents is, perhaps, a bit more clear-cut.

“My takeaway for parents is that they need to know what to look for, and then they need to know what to do with what they find,” said Teri Brister, the director of information and support for the National Alliance on Mental Illness. (Brister was not involved in the study.)

“We tell people, start with your child’s pediatrician,” she added, emphasizing that she is by no means saying that parents must start out with an understanding of how to navigate the complex mental health care system.

And parents should be talking to their children about things like depression and suicide, she added.

“I see it all the time — parents will read about suicide or hear about a study like this and say, ‘Gee, that’s a terrible thing. How sad for those families.’ But they have what I call not-my-kid syndrome,” said Clark Flatt, the president of the Jason Foundation, a nonprofit that he and his family began to help prevent suicide after his younger son, Jason, killed himself in 1997.

Flatt, too, was completely surprised by his son’s death, describing him as a well-liked teenager who played sports, had plenty of friends and seemed to enjoy school.

“You have to look for the warning signs,” Flatt said. “And I don’t mean you have to get up every morning and run through a checklist to see if your child is at risk for suicide. But be aware of the warning signs and the risk factors.”

Those signs include notable mood swings, talking or writing about suicide and using drugs or alcohol. Having suicidal thoughts does not necessarily mean a person will take his or her own life, but it is a major risk factor for a suicide attempt. (The National Suicide Prevention Lifeline offers free, immediate support for people in distress and their loved ones.)

“And ask questions,” Flatt added. “Tough questions sometimes.” It can be a hard but meaningful way to encourage kids to open up.

“This is the trouble with mental illness. It’s very maskable. It’s not something that shows up on tests sometimes. So we want our kids to be able to say, ‘Hey, I’m not OK,’” echoed Trautwein, who started the Will to Live foundation in his son’s honor and wrote a book, My Living Will.

“My son Will was afraid to say ‘I’m not OK’ because I didn’t talk about these things with him,” he said. “He didn’t want me to see him as not OK because he worried that would be disappointing to me. And that breaks my heart.”

If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text SOS to 741-741 for free, 24-hour support from the Crisis Text Line. Outside the U.S., please visit the International Association for Suicide Prevention for a database of resources.

Why Community Advocates Should Include Students at the Beginning

It takes a village to raise a child, the saying goes. To ensure the best outcome, that village should also include fellow young people, not just adults, which is why community advocates should include students at the beginning of their outreach programs.

Community coalitions are always looking to engage students in their area, but often this is transactional as opposed to collaborative. Sometimes that works out well, and the end goal is achieved (student engagement, a decrease in adverse behavior, etc.). However, this type of setup can often leave students feeling as though they’re being sold on something, rather than an ingrained aspect of it holistically.

Bringing students into the decision-making process before implementation seems like a no-brainer, but it’s not always the case. And study after study shows that if students are engaged and buy-in is achieved, positive results will follow. According to one study, “Student engagement in community advocacy activities that addressed environmental influences of cigarette smoking resulted in significant decreases in regular smoking.”[1]

By engaging students and younger generations at the beginning, community coalitions can tap into their enthusiasm to help create a positive change both within the younger community as well as the community writ large. For example, in Omaha, Nebraska, local leaders saw a drastic increase in obesity rates for a specific part of the city. One hypothesis posited that the community’s older generation might have entrenched eating habits and would be resistant to change, so it opted to bring in the younger generation to help create the necessary infrastructure to build a sustainable approach to healthier eating.

Childhood obesity is a major concern within the United States, but it’s especially a concern among the Latinx community. According to Dr. Gopal Singh, “In 2007, 16.4% of U.S. children were obese and 31.6% were overweight. From 2003 to 2007, obesity prevalence increased by 10% for all U.S. children but increased by 23%–33% for children in low-education, low-income, and higher unemployment households. Obesity prevalence increased markedly among Hispanic children and children from single-mother households.”[2]

The study found that this lack of infrastructure was a major impediment to changing the behaviors and outcomes desired, but by engaging students and the younger generations, it created the necessary environment for success down the road. “Our program generated infrastructure and materials to support the growth and institutionalization of youth advocacy as a means of increasing community readiness for addressing obesity prevention.”[3]

Students will actively take part in causes they feel personally invested in. Reaching out to younger generations and giving them a seat at the table at the beginning of community advocacy efforts goes a long way to create stronger bonds and a firm desire to succeed. Rather than relying on students and their peers to engage on the backend of these efforts, bring them into the mix and allow them to help shape what exactly those efforts will be.

Peer pressure is often viewed as a negative aspect of adolescent behavior, but it can work toward positive results, too. When students see their peers becoming part of an “in-group” for something there is a stronger desire to engage. That works with students playing sports, joining clubs, liking similar art, and, in some cases, taking part in advocacy work within their community.

“We argue that the involvement of children’s and adolescents’ peer networks in prevention and intervention efforts may be critical for promoting and maintaining positive behavioral health trajectories,” was how one RAND Corporation study succinctly stated.[4]

Perhaps the most difficult aspect of bringing students into the fold at the beginning of a community advocacy project is getting them in the door, literally. How can you speak to their interests and break through the noise when they’re being pulled in multiple directions all at once? How can you get students interested in your community outreach efforts? This is where Pride Surveys can help. At Pride Surveys, we’ve surveyed students for decades, asking them about their challenges, goals, and environment. We go directly to the source — the students themselves — and find out what’s really going on in their community. This data enables community advocates to better understand the problem areas students face and to better understand how to speak to those problems when attempting to get participation.

[1] “Effects of an Advocacy Intervention to Reduce Smoking Among Teenagers.” Retrieved on August 13, 2019 at

[2] “Rising Social Inequalities in US Childhood Obesity, 2003–2007.” Retrieved on August 20, 2019 at

[3] “SaludableOmaha: Development of a Youth Advocacy Initiative to Increase Community Readiness for Obesity Prevention, 2011–2012.” Retrieved on August 17, 2019 at

[4] “Influence of Peers and Friends on Children’s and Adolescents’ Eating and Activity Behaviors,” Retrieved on August 23, 2019 at

Student Stress and Mental Health During COVID-19

Student stress and mental health is a prevalent and ongoing topic for communities, parents, and educators year-round. With the unexpected occurrence of COVID-19 and students being impacted by distance learning, lack of social interaction, missing graduations, grade delays, and more, it is more important than ever to keep these topics top of mind and to assess regularly.

Drops in grades and an increase in concerning behavior often correlate to student stress and mental health. A Pride Surveys led paper in Alabama examined students feeling threatened in school and how it impacted their English and math test scores. The statistics showed that as students feel more threatened, their scores drop. Students nationwide are oftentimes impacted in their schools by threats and threatening behavior and have a legitimate concern for their safety and the safety of their peers.

2018-19 National Summary Data from Pride Surveys shows that when asked the question, “During the past school year have you been afraid a student might hurt you?”, there was an average of 18.08% of students surveyed who answered “yes.” That number has increased a total of 2.6% over the past four years. Fear of being hurt is a factor in student stress that can negatively impact test scores and student mental health.

From the same data set, the question, “During the past school year have you been hurt by a student who hit, slapped or kicked you?” resulted in an average of 14.74% of students surveyed over five years answering “yes”. This follow-up question shows that many students who are threatened with violence may also be the victim of actual violence. This shows the importance of listening to students’ concerns when they voice them to counselors, teachers, and administrators. While this tells the story of some of the history of in-school related stress due to physical violence and threats of violence, due to COVID-19 and distance learning, a more timely concern currently is that of cyberbullying.

Data that is particularly relevant at this time relates to questions explicitly asked about being threatened or threatening someone over the phone or the internet. defines Cyberbullying as “the use of technology to harass, threaten, embarrass, or target another person. By definition, it occurs among young people.” Looking at data from a convenience sample of over 43,000 students over the three year period of 2016-2018, students were asked the question, “During the past school year have you been threatened or embarrassed by someone using the Internet or a cell phone to post mean messages or photos of you?” The resulting average over three years was a 19.93% rate of “yes” responses. When asked, “During the past school year have you used the Internet or a cell phone to threaten or embarrass someone else by posting mean messages or photos of them?”, the question generated an average of 7.43% stating “yes”. These numbers may well increase while students potentially remain out of school full time or part-time in the fall as we continue to track the data.

Pride Surveys works with our community coalition partners to provide the surveys and analytics for physical violence and cyberbullying so we can help them drive change in their communities and schools and reduce student stress. Schools have specific data about fights on campus (SUR data which has to be recorded), but Pride Surveys data shows what the students are reporting so schools can compare and get a better holistic picture of the school climate and students’ online behaviors which can be hard to track.

Parents can help combat the issues by having open conversations with their kids about what cyberbullying is and any issues they are facing. They can also help prevent problems by being active and engaged participants in their lives, knowing who their friends are, monitoring changes in grades or behavior, and establishing rules and limits about online use. Parents can also try tracking resources that meet their comfort levels, such as MSpy and The Spy Bubble, which will document the sites they visit and the types of media being shared and consumed.

The more we work together between Pride Surveys, community coalitions, and schools, the more we can help navigate situations that lead to student stress and mental health issues, whether they stem from cyberbullying or physical threats. Pride Surveys is here and available to discuss appropriate questions for student surveys, many of which we are now offering online. Contact us today to learn more.


Mental illness in children: Know the signs

Children can develop the same mental health conditions as adults, but their symptoms may be different. Know what to watch for and how you can help.

Mental illness in children can be hard for parents to identify. As a result, many children who could benefit from treatment don't get the help they need. Understand how to recognize warning signs of mental illness in children and how you can help your child.

What is a mental illness?

Mental health is the overall wellness of how you think, regulate your feelings and behave. A mental illness, or mental health disorder, is defined as patterns or changes in thinking, feeling or behaving that cause distress or disrupt a person's ability to function.

Mental health disorders in children are generally defined as delays or disruptions in developing age-appropriate thinking, behaviors, social skills or regulation of emotions. These problems are distressing to children and disrupt their ability to function well at home, in school or in other social situations.

Barriers to treating childhood mental health disorders

It can be difficult to understand mental health disorders in children because normal childhood development is a process that involves change. Additionally, the symptoms of a disorder may differ depending on a child's age, and children may not be able to explain how they feel or why they are behaving a certain way.

Concerns about the stigma associated with mental illness, the use of medications, and the cost or logistical challenges of treatment might also prevent parents from seeking care for a child who has a suspected mental illness.

Common disorders among children

Mental health disorders in children — or developmental disorders that are addressed by mental health professionals — may include the following:

Anxiety disorders. Anxiety disorders in children are persistent fears, worries or anxiety that disrupt their ability to participate in play, school or typical age-appropriate social situations. Diagnoses include social anxiety, generalized anxiety and obsessive-compulsive disorders.

Attention-deficit/hyperactivity disorder (ADHD). Compared with most children of the same age, children with ADHD have difficulty with attention, impulsive behaviors, hyperactivity or some combination of these problems.

Autism spectrum disorder (ASD). Autism spectrum disorder is a neurological condition that appears in early childhood — usually before age 3. Although the severity of ASD varies, a child with this disorder has difficulty communicating and interacting with others.

Eating disorders. Eating disorders are defined as a preoccupation with an ideal body type, disordered thinking about weight and weight loss, and unsafe eating and dieting habits. Eating disorders — such as anorexia nervosa, bulimia nervosa and binge-eating disorder — can result in emotional and social dysfunction and life-threatening physical complications.

Depression and other mood disorders. Depression is persistent feelings of sadness and loss of interest that disrupt a child's ability to function in school and interact with others. Bipolar disorder results in extreme mood swings between depression and extreme emotional or behavioral highs that may be unguarded, risky or unsafe.

Post-traumatic stress disorder (PTSD). PTSD is prolonged emotional distress, anxiety, distressing memories, nightmares and disruptive behaviors in response to violence, abuse, injury or other traumatic events.

Schizophrenia. Schizophrenia is a disorder in perceptions and thoughts that cause a person to lose touch with reality (psychosis). Most often appearing in the late teens through the 20s, schizophrenia results in hallucinations, delusions, and disordered thinking and behaviors.

What are the warning signs of mental illness in children?

  • Warning signs that your child may have a mental health disorder include:
  • Persistent sadness — two or more weeks
  • Withdrawing from or avoiding social interactions
  • Hurting oneself or talking about hurting oneself
  • Talking about death or suicide
  • Outbursts or extreme irritability
  • Out-of-control behavior that can be harmful
  • Drastic changes in mood, behavior or personality
  • Changes in eating habits
  • Loss of weight
  • Difficulty sleeping
  • Frequent headaches or stomachaches
  • Difficulty concentrating
  • Changes in academic performance
  • Avoiding or missing school

What should I do if I suspect my child has a mental health condition?

Post-traumatic stress disorder (PTSD). PTSD is prolonged emotional distress, anxiety, distressing memories, nightmares and disruptive behaviors in response to violence, abuse, injury or other traumatic events.

Schizophrenia. Schizophrenia is a disorder in perceptions and thoughts that cause a person to lose touch with reality (psychosis). Most often appearing in the late teens through the 20s, schizophrenia results in hallucinations, delusions, and disordered thinking and behaviors.

What are the warning signs of mental illness in children?

  • Warning signs that your child may have a mental health disorder include:
  • Persistent sadness — two or more weeks
  • Withdrawing from or avoiding social interactions
  • Hurting oneself or talking about hurting oneself
  • Talking about death or suicide
  • Outbursts or extreme irritability
  • Out-of-control behavior that can be harmful
  • Drastic changes in mood, behavior or personality
  • Changes in eating habits
  • Loss of weight
  • Difficulty sleeping
  • Frequent headaches or stomachaches
  • Difficulty concentrating
  • Changes in academic performance
  • Avoiding or missing school

What should I do if I suspect my child has a mental health condition?

If you're concerned about your child's mental health, consult your child's doctor. Describe the behaviors that concern you. Talk to your child's teacher, close friends, relatives or other caregivers to see if they've noticed changes in your child's behavior. Share this information with your child's doctor.

How do health care professionals diagnose mental illness in children?

Mental health conditions in children are diagnosed and treated based on signs and symptoms and how the condition affects a child's daily life. To make a diagnosis, your child's doctor might recommend that your child be evaluated by a specialist, such as a psychiatrist, psychologist, clinical social worker, psychiatric nurse or other mental health care professional. The evaluation might include:

  • Complete medical exam
  • Medical history
  • History of physical or emotional trauma
  • Family history of physical and mental health
  • Review of symptoms and general concerns with parents
  • Timeline of child's developmental progress
  • Academic history
  • Interview with parents
  • Conversations with and observations of the child
  • Standardized assessments and questionnaires for child and parents

The Diagnostic and Statistical Manual of Mental Disorders (DSM), a guide published by the American Psychiatric Association, provides criteria for making a diagnosis based on the nature, duration and impact of signs and symptoms. Another commonly used diagnostic guideline is the International Classification of Diseases (ICD) from the World Health Organization.

Diagnosing mental illness in children can take time because young children may have trouble understanding or expressing their feelings, and normal development varies. The doctor may change or refine a diagnosis over time.

How is mental illness in children treated?

Common treatment options for children who have mental health conditions include:

Psychotherapy. Psychotherapy, also known as talk therapy or behavior therapy, is a way to address mental health concerns by talking with a psychologist or other mental health professional. With young children, psychotherapy may include play time or games, as well as talk about what happens while playing. During psychotherapy, children and adolescents learn how to talk about thoughts and feelings, how to respond to them, and how to learn new behaviors and coping skills.

Medication. Your child's doctor or mental health professional may recommend a medication — such as a stimulant, antidepressant, anti-anxiety medication, antipsychotic or mood stabilizer — as part of the treatment plan. The doctor will explain risks, side effects and benefits of drug treatments.

How can I help my child cope with mental illness?

You will play an important role in supporting your child's treatment plan. To care for yourself and your child:

  • Learn about the illness.
  • Consider family counseling that treats all members as partners in the treatment plan.
  • Ask your child's mental health professional for advice on how to respond to your child and handle difficult behavior.
  • Enroll in parent training programs, particularly those designed for parents of children with a mental illness.
  • Explore stress management techniques to help you respond calmly.
  • Seek ways to relax and have fun with your child.
  • Praise your child's strengths and abilities.
  • Work with your child's school to secure necessary support.


Teen Suicide: Learning to Recognize the Warning Signs

Many teen suicides can be prevented if warning signs are detected and appropriate intervention is conducted.

The reasons

No two teenagers are alike, but there are some common reasons they consider suicide.

Many teens who attempt suicide do so during an acute crisis in reaction to some conflict with peers or parents.

Such conflicts are common among teens, but those who attempt suicide are particularly reactive to them because they:

  • Have a long-standing history of problems at home or school
  • Suffer from low self-esteem
  • Believe no one cares
  • Are depressed
  • Abuse alcohol or drugs
  • Have experienced other acutely stressful events, such as an unwanted pregnancy, trouble with the law, or not meeting high parental expectations

Signs of trouble

Research shows that nine out of 10 individuals who attempt suicide have a history of mental illness or substance abuse, making these extremely important risk factors.

The warning signs include:

  • Noticeable changes in eating or sleeping habits
  • Unexplained or unusually severe, violent, or rebellious behavior
  • Withdrawal from family or friends
  • Noticeable changes in eating or sleeping habits
  • Unexplained or unusually severe, violent, or rebellious behavior
  • Withdrawal from family or friends
  • Sexual promiscuity, truancy, and vandalism
  • Drastic personality change
  • Agitation, restlessness, distress, or panicky behavior
  • Talking or writing about committing suicide, even jokingly
  • Giving away prized possessions
  • Doing worse in school

How to help

If you notice any of these warning signs in your child, you should take these steps:

  • Offer help and listen. Don't ignore the problem. What you've noticed may be the teen's way of crying out for help. Offer support, understanding and compassion. Talk about feelings and the behaviors you have seen that cause you to feel concerned. You don't need to solve the problem or give advice. Sometimes just caring and listening, and being nonjudgmental, gives all the understanding necessary.
  • Take talk of suicide seriously, and use the word “suicide.” Talking about suicide doesn't cause suicide—but avoiding what's on the teen's mind may make that teen feel truly alone and uncared for. Tell the youngster that together you can develop a strategy to make things better. Ask if your child has a plan for suicide. If he or she does, then seek professional help immediately.
  • Remove lethal weapons from your home, such as guns. Lock up pills, and be aware of the location of kitchen utensils, as well as ropes, which can be used as means to commit suicide.
  • Get professional help. A teen at risk of suicide needs professional help. Even when the immediate crisis passes, the risk of suicidal behavior remains high until new ways of dealing and coping with problems are learned.
  • Getting enough sleep
  • Developing coping skills

Learn More About Mental Health The importance of prevention and wellness

Are We Facing A Post-COVID-19 Suicide Epidemic?

Is the current pandemic putting more people at risk for suicide?

There seems to be no getting away from the current coronavirus disease 2019 (COVID-19) pandemic. Not only is social distancing and health restrictions the new norm in most parts of the world, but we are being besieged by news stories about the enormous loss of life, the dangers being faced by the most vulnerable, health care professionals and other essential personnel at risk, and the natural exhaustion we all feel wondering when it will end.

But what about the long-term consequences to our mental health? Will life go on as before when the pandemic finally passes or are we looking at permanent changes to how we live? Unfortunately, the damage may be more far-reaching than anyone realizes, especially in terms of suicide risk.

While pandemic-related suicides have already been reported in many of the hardest-hit countries, these deaths have been largely overshadowed by the high rate of fatalities linked to COVID-19. In Italy, for example, the first pandemic-related suicide occurred in March of this year when a patient suffering from bronchopneumonia jumped out of the hospital window where he was awaiting test results to see if he was infected. Since then, numerous other suicides have been reported, primarily among front-line health workers, people awaiting test results, and those who have been affected by coronavirus-related bankruptcy.

While similar cases are also being reported internationally, the risk of a pandemic-related risk in suicides remains a particular concern for the United States since it has the largest number of COVID-19 deaths in the world. According to Centers for Disease Control and Prevention statistics, suicide is already the 10th leading cause of death in the U.S., with a 35 percent rise in the suicide rate from 1999 to 2018. But a new article recently published in the Journal of the American Medical Association suggests that we may be at the beginning of something far worse.

Titled " Suicide Mortality and Coronavirus Disease 2019 — A Perfect Storm?", the article suggests that the unprecedented public health actions needed to contain the new pandemic, along with social distancing requirements, stay-at-home orders, and stress due to job loss, may well result in far more suicides in the years to come. Written by a team of mental health professionals led by Mark A. Regger of the University of Washington, the article outlines many of the economic, psychosocial, and health-associated risk factors that can be expected to increase suicide risk. These include:

Economic Stress

Considering all the recent business closures, lost jobs, as well as a shutdown in most public events, the fear of a new economic recession, or even a depression matching that of the 1930s, seems all too real. Research studies have long demonstrated that economic downturns are often followed by increased suicides, but the uncertainty surrounding the current downturn, including the sharp drop in stock markets (and a resulting loss in retirement funds, housing foreclosures, and the question of when, or if, people can return to work), will certainly trigger more deaths in future.

Social Isolation

Research has also shown the importance of social connections in helping people overcome depression and suicidal thoughts. While social distancing remains an important tool in containing the coronavirus threat, the resulting loss of contact with friends and family will certainly add to the emotional burden we are all experiencing. This is especially hard on retirement home residents and hospital patients who, because of health precautions, have been denied regular contact with loved ones except through phone or Skype links. Though social media has become increasingly important in helping to maintain personal contacts, the uncertainty over when distancing rules might be eased can only add to the emotional stress we are all feeling.

Loss of Community and Religious Contact

For Americans who are part of a religious, ethnic, or social community, being able to attend regular events, including religious services, can be essential in feeling connected with others. While some religious congregations have opposed social distancing rules, the closing of most religious and community centres has increased social isolation for many Americans. Given that weekly attendance at religious services has long been shown to reduce suicide risk compared to non-attenders, losing this support may make social isolation harder to bear.

Barriers to Mental Health Treatment

While hospitals and other primary care facilities continue to see clients, mental health services have not been given the same priority. As a result, people dealing with mental health crises have little choice but to wait in overcrowded hospital emergency departments to get the help they need, something that might discourage many of them from even making the effort. Though suicide hotlines and telehealth services are still be available, the wait time is much longer than usual due to increased demand. This means that people contemplating suicide often have nowhere to turn. And this includes front-line health care workers who are at the forefront of dealing with the pandemic.

Other Medical Problems

Along with these other issues, people with existing medical problems are also finding their access to health services being restricted given the surge in coronavirus cases. This means the cancellation of elective surgeries, a much longer wait in hospital emergency departments and urgent care clinics, and having to deal with symptoms such as chronic pain without significant relief. Since many people with chronic medical problems are already vulnerable to suicidal thinking, losing access to medical services can reduce their ability to cope with their issues.

Social and Medial Influences

Since the pandemic began, we have been regularly besieged with round-the -clock news coverage describing the impact of COVID-19, both nationally and internationally. Given the pessimism being conveyed by these news stories, it's hardly surprising that many people are becoming increasingly depressed and angry at the prospect of the pandemic dragging on for months. At the same time, gun sales are also surging in may parts of the country. With access to firearms being a major risk factor in suicides, the number of firearm-related suicides are expected to rise as well.

What About The Future?

Research studies looking at the effects of trauma in previous disasters, including the 2003 severe acute respiratory syndrome (SARS) epidemic in Hong Kong and the 2011 earthquake and nuclear disaster in Fukushima, Japan has shown a significant rise in suicides both during the emergency itself and in the months that followed. With the SARS epidemic in particular, most suicides involved elderly or chronically ill people who were afraid of becoming burdens to their families due to becoming infected, a concern that is already common among many COVID-19 patients.

Finding real solutions won't be easy, especially as the coronavirus pandemic drags on. Even with video conferencing and social media to help people avoid feeling isolated, enhanced suicide prevention services will still be needed along with public education to ensure that people in crisis are aware of what resources are available to them. opportunities to help prevent suicide deaths that might otherwise occur.

But research looking at past crises can also offer some hope as well. Suicide rates actually decreased following national crises such as 9/11 due to the shared support such crises often bring. Despite the pessimism seen in recent weeks due to pandemic worries and racial protests, we can still work together to prevent unnecessary deaths and plan for a better future.


Mark A. Reger, PhD1,2; Ian H. Stanley, MS1,3; Thomas E. Joiner, PhD. (2020). Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm? JAMA Psychiatry. Published online April 10, 2020. doi:10.1001/jamapsychiatry.2020.1060

Lennon, J. C. (2020). What lies ahead: Elevated concerns for the ongoing suicide pandemic. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.


Black Boots, Gender Identity and teen Mental Health First Aid

Since I came out as transgender in seventh grade, I’ve worn the same black boots — black, thick-toed, lace-up. (Not the same pair, though, although not for lack of trying. My last pair became more duct tape than boot, and my mom eventually threw them away before they fully disintegrated.) My black boots have become a staple for me.

People find my boots — and me — intimidating sometimes, at least upon first glance. The rest of my appearance has that effect too, with my often poorly dyed hair and generally odd and mismatched thrift store-sourced wardrobe. See, when you’re transgender, your identity is deeply policed. Cisgender is considered the standard, and that leads to so much judgement surrounding every decision you make as soon as you come out as trans.

When I was young, I had no idea what made me different, only that I felt wrong in my body in a way no one else seemed to. I hadn’t heard of the term “transgender” until I came across it online, and suddenly a lot of the self-loathing I’d been experiencing started to make sense. There are not a lot of positive narratives about transgender people. Upon understanding my identity, I also saw that cis people felt it was something I should be ashamed of. Self-harm became an outlet for some of that embarrassment and hatred toward my body. I often felt as if it would be easier for everyone else if I wasn’t there, because I knew I sparked confusion and fear in my classmates, parents and strangers alike just by existing.

I internalized the expectation that the goal of trans people must be to appear as cisgender as possible, so even with varying degrees of love and acceptance around me, I succumbed to the societal pressure on trans people to hate ourselves for just being who we are. Later, I was hospitalized for suicidal ideation, then released, then sent back, then sent to a longer-term residential program in Los Angeles. Hospital staff had a hard time knowing what to do with me, because I was transgender. Housing, bathrooms, groupings — our binary system is created to discount and disregard trans people. I’m a lucky one, too: I had the privilege to afford mental health services that wouldn’t try to change me, and I never had to deal with the compounding hatred and bias that trans people of color face. Still, it was so isolating and embarrassing and painful to feel like a burden for just being who I was.

However, in my time in hospital, I also first experienced real, meaningful acceptance, and it came from the other patients. Mental illness, like being trans, is often feared and deeply misunderstood. People who are not forced to confront the reality of it in their own lives shy away from the topic because it makes them uncomfortable. Mentally ill people are told that mental illness is wrong, that it warrants hate and shame. So while I still did not know another transgender person, I met people who saw the power of shame and countered it with an active effort toward acceptance and away from judgement.

I’ve come a long, long way since coming out.

Now I’m going into my senior year in high school, and I understand that my identity is not a problem, that the people who are resistant to change because they’re accustomed to a flawed binary worldview are the problem. The confusion and fear that people might feel when they see me — black boots and dyed hair, transgender, mentally ill and proud — is not a reason for me to hide who I am, but incentive to be even prouder. I get to use my experiences and my identity to educate others and show them why their behavior unknowingly perpetuates transphobia and stigma.

I contribute to this movement through activism and advocacy, whether it’s getting gender neutral bathrooms at my school, helping the school redo the whole system of gender-divided overnight trips, organizing teens to run mental health education initiatives in my community, or educating myself about the experiences of other people — Black, and Indigenous and people of color, immigrants, the disability community and anyone else who faces the brunt of society’s ignorance and erasure.

I work to show how the systems and standards we have in place for gender and mental health are inherently broken, that we should not bend the system to accommodate for the few that don’t fit but instead rewrite the whole program so that every person fits, equally and unequivocally. This is what teen Mental Health First Aid helps to do, and why I believe in its mission so much: Kids can help educate each other so that we can help support each other. No one will be left behind.

Learn more about teen Mental Health First Aid and how you can bring the program to a school or youth-serving organization near you.

Novak, a rising senior in California, spends much of his time studying science, advocating for social justice, and playing with his cat. He works with Safespace, a local mental health organization, and engages in activism in many other areas, including LGBT issues, environmentalism, racial justice, and wealth inequity. When not doing school work or advocacy work, he enjoys traveling, changing his hair color, and tending to his vegetable garden.

Teen Suicide: Learning to Recognize the Warning Signs

Many teen suicides can be prevented if warning signs are detected and appropriate intervention is conducted.

The reasons

No two teenagers are alike, but there are some common reasons they consider suicide.

Many teens who attempt suicide do so during an acute crisis in reaction to some conflict with peers or parents.

Such conflicts are common among teens, but those who attempt suicide are particularly reactive to them because they:

  • Have a long-standing history of problems at home or school
  • Suffer from low self-esteem
  • Believe no one cares
  • Are depressed
  • Abuse alcohol or drugs
  • Have experienced other acutely stressful events, such as an unwanted pregnancy, trouble with the law, or not meeting high parental expectations

Signs of trouble

Research shows that nine out of 10 individuals who attempt suicide have a history of mental illness or substance abuse, making these extremely important risk factors.

The warning signs include:

  • Noticeable changes in eating or sleeping habits
  • Unexplained or unusually severe, violent, or rebellious behavior
  • Withdrawal from family or friends
  • Sexual promiscuity, truancy, and vandalism
  • Drastic personality change
  • Agitation, restlessness, distress, or panicky behavior
  • Talking or writing about committing suicide, even jokingly
  • Giving away prized possessions
  • Doing worse in school

How to help

If you notice any of these warning signs in your child, you should take these steps:

  • Offer help and listen. Don't ignore the problem. What you've noticed may be the teen's way of crying out for help. Offer support, understanding and compassion. Talk about feelings and the behaviors you have seen that cause you to feel concerned. You don't need to solve the problem or give advice. Sometimes just caring and listening, and being nonjudgmental, gives all the understanding necessary.
  • Take talk of suicide seriously, and use the word “suicide.” Talking about suicide doesn't cause suicide—but avoiding what's on the teen's mind may make that teen feel truly alone and uncared for. Tell the youngster that together you can develop a strategy to make things better. Ask if your child has a plan for suicide. If he or she does, then seek professional help immediately.
  • Remove lethal weapons from your home, such as guns. Lock up pills, and be aware of the location of kitchen utensils, as well as ropes, which can be used as means to commit suicide.
  • Get professional help. A teen at risk of suicide needs professional help. Even when the immediate crisis passes, the risk of suicidal behavior remains high until new ways of dealing and coping with problems are learned.
  • Don’t be afraid to take your child to a hospital emergency room if it is clear that he or she is planning suicide. You may not be able to handle the situation on your own.


Five Tips to Help Teens Cope with Stress

“More than nine in 10 Generation Z adults (ages 15-21) said they have experienced at least one physical or emotional symptom because of stress, such as feeling depressed or sad or lacking interest, motivation or energy,” according to research published by the American Psychological Association.

High school teens spend most of their time attending classes, participating in extracurricular activities and doing homework. There is constant pressure to do everything and do it well to prepare for a successful career or higher education after high school. This can cause a lot of stress.

When they do have time, research from the U.S. Bureau of Labor Statistics shows that teens most often turn to media and communications activities, including watching TV, using social media and the internet and calling or texting friends. Although these can be helpful ways to relieve stress, the excessive use of technology can lead to lack of human connection and feelings of loneliness.

Use these tips to take a break from the barrage of constant communication and manage your stress in a healthy way.

Get some sleep.

Getting enough sleep helps you grow and develop normally, pay attention throughout the day and maintain overall health. For teens, this means about 8-10 hours each night.

Focus on your strengths.

Take some time to think about what you’re good at and ways to do more of those things. By focusing on and building your strengths, you can keep your stressors in perspective.

Do things that make you happy.

Find activities or hobbies that make you happy and incorporate them into your daily life. This might be a physical sport, an artistic outlet or spending time with family and friends.

Engage in physical activity.

Exercise takes our mind off stress and releases chemicals in our brain that make us feel better. This can be anything from a stroll in the park to a bike ride or basketball game with friends.

Talk to someone.

It can be hard to manage stress alone. Talk to a parent, teacher or other trusted adult about your problems and they may be able to help you find new ways to manage your stress.

If you’re still looking for ways to manage your stress, take a Mental Health First Aid course today. teen Mental Health First Aid (tMHFA) teaches high school students about common mental health challenges and what they can do to support their own mental health and help their friends who may be struggling. Right now, eight high schools across the country have trained students in tMHFA. We’re looking forward to expanding to more schools across the country in the coming years. Learn more about this new program, run by the National Council and supported by Lady Gaga’s Born This Way Foundation.

APA Stress in America™ Survey: Generation Z Stressed About Issues in the News but Least Likely to Vote

Gen Z more likely than other generations to report fair or poor mental health

Headline issues, from immigration to sexual assault, are causing significant stress among members of Generation Z — those between ages 15 and 21 — with mass shootings topping the list of stressful current events, according to the American Psychological Association’s report Stress in America™: Generation Z released today.

Despite these concerns, Gen Z adults who are 18 to 21 years old are the generation least likely to vote in the 2018 midterm elections, the report found.

Specifically, 75 percent of Gen Z members said that mass shootings are a significant source of stress, according to the survey, which was conducted online by The Harris Poll on behalf of APA in July and August 2018 among 3,458 adults and 300 15- to 17-year-olds.

Gen Z members are also more stressed than adults overall about other issues in the news, such as the separation and deportation of immigrant and migrant families (57 percent of Gen Z vs. 45 percent of all adults reported the issue is a significant source of stress) and sexual harassment and assault reports (53 percent vs. 39 percent). Despite this, just more than half of Gen Z adults, between ages 18 and 21, (54 percent) said they intend to vote in the U.S. midterm elections, compared with 70 percent of adults overall.

America’s youngest generation is also significantly more likely (27 percent) than other generations, including Millennials (15 percent) and Gen Xers (13 percent), to report their mental health as fair or poor, the survey found. They are also more likely (37 percent), along with Millennials (35 percent), to report they have received treatment or therapy from a mental health professional, compared with 26 percent of Gen Xers, 22 percent of baby boomers and 15 percent of older adults.

“Current events are clearly stressful for everyone in the country, but young people are really feeling the impact of issues in the news, particularly those issues that may feel beyond their control,” said Arthur C. Evans Jr., PhD, APA’s chief executive officer. “At the same time, the high percentage of Gen Z reporting fair or poor mental health could be an indicator that they are more aware of and accepting of mental health issues. Their openness to mental health topics represents an opportunity to start discussions about managing their stress, no matter the cause.”

More than nine in 10 Gen Z adults (91 percent) said they have experienced at least one physical or emotional symptom because of stress, such as feeling depressed or sad (58 percent) or lacking interest, motivation or energy (55 percent). Only half of all Gen Zs feel like they do enough to manage their stress.

Money and work continued to top the list of significant stressors tracked annually by the Stress in America survey for adults overall. Nearly two-thirds of adults (64 percent) reported money and work each to be a stressor. A new question added this year asking about additional sources of stress revealed that for more than three in 10 Gen Zs, personal debt (33 percent) and housing instability (31 percent) were a significant source of stress, while nearly three in 10 (28 percent) cited hunger or getting enough to eat.

One notable finding was a potential increased tolerance for stress across all generations. The average perceived healthy level of stress increased significantly over the past year, from 3.7 in 2017 to 3.9 in 2018 (on a scale from 1 to 10, where “1” is “little or no stress” and “10” is “a great deal of stress”).

Americans increasingly stressed about the future of the nation

More than 6 in 10 Americans (62 percent) reported that the current political climate is a significant stressor, and more than two-thirds (69 percent) reported that the nation’s future causes them stress. This was a significant increase from those who said the same in 2017 (63 percent). Most Americans (61 percent) also disagreed that the country is on a path to being stronger than ever. Because of their concern for the state of the nation, nearly half of Americans (45 percent) said they feel more compelled to volunteer or support causes they value.

Another key finding was that nearly one-quarter (24 percent) of adults identified discrimination as a significant source of stress, the highest percentage since this was first included in the survey in 2015. In 2018, black adults (46 percent) and Hispanic adults (36 percent) reported discrimination as a significant source of stress, compared with 14 percent of white adults.

To read the full Stress in America report or to download graphics, visit the Stress in America Press Room webpage.

For additional information on stress, lifestyle and behavior changes, visit the Psychology Help Center webpage. Join the conversation about stress on Twitter by following @APA and #stressAPA.


The 2018 Stress in America survey was conducted online within the United States by The Harris Poll on behalf of the American Psychological Association between July 27 and Aug. 28, 2018, among 3,458 adults ages 18 and older who reside in the U.S. Interviews were conducted in English and Spanish. In addition to the main samples, interviews among teens ages 15 to 17 (n=300) were collected. Data were weighted to reflect their proportions in the population based on the 2017 Current Population Survey by the U.S. Census Bureau. Weighting variables for the adults ages 18+ included education, age by gender, race/ethnicity, geographical region, household income and time spent online. Hispanic adults were also weighted for acculturation, taking into account respondents’ household language as well as their ability to read and speak English and Spanish. Country of origin (U.S./non-U.S.) was also included for Hispanic and Asian subgroups. Propensity score weighting was used for the adults to adjust for respondents’ propensity to be online. A propensity score allows researchers to adjust for attitudinal and behavioral differences between those who are online versus those who are not, those who join online panels versus those who do not, and those who responded to this survey versus those who did not. Weighting variables for the teens ages 15 to 17 included parents’ education, age by gender, race/ethnicity, region and size of household. Weighting variables for the Gen Z groups (ages 15 to 21) included education, age by gender, race/ethnicity, region, household income, size of household and employment status. Because the sample is based on those who were invited and agreed to participate in online research panels, no estimates of theoretical sampling error can be calculated.

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States. APA's membership includes nearly 115,700 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives.

A Mental Health Crisis Guide for Schools

Mental health is a combination of our emotional, psychological, and social well-being, affecting how we think, feel, and act. Our mental health also plays a factor in how we handle stress, relate to others, and make decisions. People who manage their mental health well are able to cope with the stressors of life, be productive both in and outside of work, and make meaningful contributions to their communities.

Those who struggle to manage mental health may suffer from a mental illness. A mental illness is a common health condition that involves changes in emotions, thought patterns, and behavior. In fact:

  • About one in five adults in the United States has a mental illness
  • One in 12 has a substance use disorder
  • One in 24 has a serious mental illness

Even though it’s more common in adults, children can develop mental health issues too. Mental health conditions that also affect children and young adults include:

Anxiety disorders: Examples of anxiety disorders include generalized anxiety disorder, social anxiety disorder (social phobia), specific phobias, and separation anxiety disorder. It is possible to have more than one anxiety disorder, and some may require medical treatment.

Attention-deficit/hyperactivity disorder (ADHD): Adult attention-deficit/hyperactivity disorder (ADHD) is a mental health disorder that includes a combination of persistent problems, such as difficulty paying attention, hyperactivity, and impulsive behavior. Though it’s called adult ADHD, symptoms start in early childhood and continue into adulthood.

Autism spectrum disorder (ASD): Autism spectrum disorder is a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behavior. The term “spectrum” in autism spectrum disorder refers to the wide range of symptoms and severity.

Eating disorders: Eating disorders are serious conditions related to persistent eating behaviors that negatively impact your health, emotions, and ability to function in important areas of life. The most common eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Mood disorders: If you have a mood disorder, your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function. You may be extremely sad, empty, or irritable (depressed), or you may have periods of depression alternating with being excessively happy (mania).

Schizophrenia: Schizophrenia involves a range of problems with thinking (cognitive), behavior, or emotions. It may result in some combination of hallucinations, delusions, and disordered thinking and behavior that impairs your child’s ability to function. Childhood schizophrenia is essentially the same as schizophrenia in adults, but it occurs early in life and has a profound impact on a child’s behavior and development. With childhood schizophrenia, the early age of onset presents special challenges for diagnosis, treatment, education, and emotional and social development.

What Is a Mental Health Crisis?

A mental health crisis (33 page PDF) is any situation in which a person’s behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community. Often, a crisis can involve thoughts of suicide for both adults and children.

Let’s look at data and statistics on children’s mental health.

  • 9.4% of children aged 2-17 years (approximately 6.1 million) have received an ADHD diagnosis
  • 7.4% of children aged 3-17 years (approximately 4.5 million) have a diagnosed behavior problem
  • 7.1% of children aged 3-17 years (approximately 4.4 million) have diagnosed anxiety
  • 3.2% of children aged 3-17 years (approximately 1.9 million) have diagnosed depression
  • 1 in 6 U.S. children aged 2–8 years (17.4%) had a diagnosed mental, behavioral, or developmental disorder
  • Among children aged 2-8 years, boys were more likely than girls to have a mental, behavioral, or developmental disorder
  • Among children living below 100% of the federal poverty level, more than 1 in 5 (22%) had a mental, behavioral, or developmental disorder
  • Age and poverty level affected the likelihood of children receiving treatment for anxiety, depression, or behavior problems

While mental health crises are a major threat to public health and can become fatal, clinical professionals are not always the ones on the front lines of intervening in or preventing such crises. Physicians and nurses sometimes are not aware that a patient is vulnerable to a sudden escalation in mental illness, or even that a mental illness is afflicting their patients. This is a major reason why non-clinical professionals with a background in an area such as\general healthcare studies are needed. These individuals are able to help educate the public, develop novel intervention strategies outside of hospitals, and help ensure vulnerable individuals don’t fall through the gaps in a moment of crisis.

However, there is a need for everyone — not just healthcare professionals — to understand the risk factors, warning signs, and interventions that can help others survive a mental health crisis episode.

Warning Signs of Crisis Episode

Signs of a mental health crisis episode may not always be apparent in a child. With the proper education, teachers, principals, and other staff members will know what to look for when the following mental health crisis signs arise.

Abusive behavior: Often an individual will show abusive behavior to themselves and others. This may include self-harm, substance abuse, physical abuse, etc.

Inability to perform daily tasks: This can include even the most simple tasks such as bathing, teeth brushing, brushing hair, and putting on clean clothes.

Increased agitation: When a child shows signs of increased agitation they’ll use verbal threats, are violently out of control, destroy property, and more.

Isolation: Children and young adults tend to isolate themselves in school and work, from both family and friends.

Loses touch with reality (psychosis): This encompasses the inability to recognize family or friends — showing signs of confusion, strange ideas, thinking they’re someone they’re not, not understanding what people are saying, hearing voices, and seeing things that aren’t there.

Paranoia: This is manifested in suspicion and mistrust of people or their actions without evidence or justification.

Rapid mood swings: This includes increased energy levels, the inability to stay still, pacing, sudden depression and withdrawal, as well as becoming suddenly happy or calm after a period of depression.

Other warning signs and risk factors include:

  • Eating or sleeping too much or too little
  • Pulling away from people and things
  • Having low or no energy
  • Having unexplained aches and pains, such as constant stomach aches or headaches
  • Feeling helpless or hopeless
  • Excessive smoking, drinking, or using drugs, including prescription medications
  • Worrying a lot of the time — feeling guilty but not sure why
  • Having difficulty readjusting to home or work life

Suicide Warning Signs

Suicide in teens can be prevented if those around them learn to recognize the warning signs and intervene appropriately:

  • Noticeable changes in eating or sleeping habits
  • Unexplained or unusually severe, violent, or rebellious behavior
  • Withdrawal from family or friends
  • Sexual promiscuity, truancy, and vandalism
  • Drastic personality change
  • Agitation, restlessness, distress, or panicky behavior
  • Talking or writing about committing suicide, even jokingly
  • Giving away prized possessions
  • Doing worse in school

It’s important to take any talk of suicide seriously. “Suicide is a very difficult topic to discuss,” says Jeffrey Borenstein, M.D., an associate clinical professor of psychiatry at Columbia University College of Physicians and Surgeons in an article about the importance of speaking out about suicide. “But silence can have tragic results, and knowledge can save lives. The message that things can get better is more important today than ever before.”

Examples of Triggers for a Crisis Episode

Crisis episode triggers are external events or circumstances that may produce very uncomfortable emotional or psychiatric symptoms, such as anxiety, panic, discouragement, despair, or negative self-talk.

Those with a mental illness typically handle triggers differently than other people. According to author Arlin Cuncic writing for Very Well Mind, from a mental health perspective, “being ‘triggered’ more narrowly refers to the experience of people with post-traumatic stress disorder (PTSD) re-experiencing symptoms of a traumatic event (such as exposure to actual or threatened death, serious injury, or sexual violation) after being exposed to a trigger that is a catalyst or reminder.”

There are both internal and external triggers that can remind a person of a past traumatic event.

  • Internal Triggers:
  • Anger
  • Anxiety
  • Feeling abandoned
  • Feeling lonely
  • Feeling out of control
  • Feeling overwhelmed
  • Frustration
  • Increased heart rate
  • Pain
  • Sadness
  • Stress
  • Tension

External Triggers:

  • Anniversary date
  • Being alone too much
  • Crowded places
  • Ending of a relationship
  • Feeling judged
  • Going to a specific location that is a reminder of a traumatic event
  • Loud noises
  • Money problems
  • News stories about bad events
  • Particular interaction (ex: an argument)
  • A particular time of day (ex: sunset)
  • A particular smell (ex: incense)
  • Physical illness
  • Seeing an overly thin celebrity (in the case of anorexia)
  • Seeing someone else use drugs (for substance abuse)
  • Sexual harassment
  • Violent movies

Being aware of someone’s personal triggers is especially helpful because it allows others to recognize sensitive situations, provide an adequate warning to those who may be triggered, and take other steps to prevent known triggers from leading to a crisis situation.

How to Prevent a Mental Health Crisis

Fortunately, mental health crises can be prevented. As such, how teachers, parents, and peers respond to a child’s mental health crisis is crucial. How an authoritative figure should speak to one suffering from a mental illness crisis varies based on their relationship to them.

Family members and friends: If a family member or friend is showing signs of a mental health crisis, you can help to prevent the situation from occurring/worsening by:

  • Asking questions, listening to ideas, and being responsive when the topic of mental health problems comes up
  • Educating other people so they understand the facts about mental health problems and do not discriminate
  • Expressing your concern and support
  • Finding out if the person is getting the care they need/want — and, if not, connecting them to help
  • Including your friend or family member in your plans — continue to invite them without being overbearing, even if they resist your invitations
  • Offering to help your friend or family member with everyday tasks
  • Reassuring them that you care
  • Reminding them that help is available and that mental health problems can be treated
  • Treating people with mental health problems with respect, compassion, and empathy

Students: When assisting a student who is showing signs of a mental health crisis, educators should:

  • Educate other staff members, parents, and students on symptoms of mental health problems and how they can help
  • Encourage good physical health
  • Encourage helping others
  • Help ensure access to school-based mental health support
  • Help ensure a positive, safe school environment
  • Promote social and emotional competency and build resilience
  • Teach and reinforce positive behaviors and decision-making

Your child/other dependents: It’s important for caregivers to pay special attention to their children, especially after the loss of a loved one, separation of parents, and/or any other major transition. This is because children typically have a hard time understanding difficult situations. However, if you are concerned your child is on the verge of a mental health crisis you should:

  • Ask your child’s primary care physician if your child needs further evaluation by a specialist with experience in child behavioral problems.
  • Ask if your child’s specialist is experienced in treating the problems you are observing.
  • Talk to your child’s doctor, school nurse, or another healthcare provider and seek further information about the behaviors or symptoms that worry you.
  • Talk to your medical provider about any medication and treatment plans.

Communication Tips and Talking Points

Starting a conversation about mental health can be uncomfortable, no matter how necessary. Here are a few tips for parents and educators for talking to children about their mental health.

  • Create a sense of belonging
  • Develop competencies
  • Educate staff, parents, and students on symptoms and help for mental health
  • Encourage good physical health
  • Encourage helping others
  • Ensure access to school-based mental health support
  • Ensure a positive and safe school environment
  • Establish a crisis response team
  • Promote resilience
  • Provide a continuum of mental health services
  • Teach and reinforce positive behaviors/decision-making

Seek Help from a Professional

Mental illness can be treated. Here is a list of medical professionals one can utilize when seeking treatment for mental illness.

Addiction counselor: Addiction counselors treat people with addictions. While this usually involves substance abuse or gambling problems, it can also include less common addictions such as sexual addictions or hoarding.

Art therapist: Art therapy involves using creativity in ways like painting, sculpture, and writing to explore and help with depression, medical illnesses, past traumatic events, and addiction.

Family and marriage counselor: A family and marriage counselor specializes in common problems that can come up in families and married couples, from differences to arguments.

Mental health counselor: “Mental health counselor” is a broad term used to describe someone who provides counseling. Their titles may also include the terms “licensed” or “professional.” It’s important to ask about a counselor’s education, experience, and the types of services involved since the term is vague. Counselors can specialize in fields like job stress, addiction, marriages, families, and general stress.

Psychologist: Psychologists specialize in the science of behaviors, emotions, and thoughts. They work in places like private offices, hospitals, or schools. Psychologists treat a range of issues, from relationship problems to mental illnesses, through counseling. A psychologist usually holds a doctoral degree, such as a Ph.D. Psychologists cannot prescribe medications in most states.

Psychiatrist: Psychiatrists mainly diagnose, treat, and help prevent mental, emotional, and behavioral disorders. They use psychiatric medicine, physical exams, and lab tests. Psychiatrists’ specialties can include children and adolescents, forensic psychiatry, and learning disabilities.

Psychoanalyst: A psychoanalyst follows the theories and practice of Sigmund Freud by helping someone explore their repressed or unconscious impulses, anxieties, and internal conflicts. This is done through techniques like free association, dream interpretation, analysis of resistance, and transference. However, it is important to be cautious in selecting a psychoanalyst. The title and credential are not protected by federal or state law, which means that anyone can call themselves a psychoanalyst and advertise their services.

Psychiatric nurse: Psychiatric nurses are registered nurses who specialize in mental health. They’re known for their therapeutic relationships with the people who seek their help.

Psychotherapist: Psychotherapist is a general term for many types of mental health professionals. This can include psychologists and therapists. These professionals all provide psychotherapy — a type of talk therapy designed to improve your mental health and general well-being.

Religious counselor: Religious counselors are trained to help people with a variety of problems, including crises of faith, marriage and family counseling, and emotional and mental problems.

Social worker: Social workers are public or private employees dedicated to helping people cope with and solve issues in their lives, including personal problems and disabilities. They may also address social problems like substance abuse, housing, and unemployment. They are often involved in family disputes that involve domestic violence or child abuse.

Provide Support

It’s important to provide loved ones with support when they’re suffering from a mental crisis. This ensures that they are not alone in the process and minimizes the damage that may come along with mental illness. Here is how you can help a loved one with a mental illness:

  • Avoid falling into the role of fixer and savior
  • Check out support groups for family members of those experiencing mental illness
  • Have realistic expectations
  • If a loved one is in acute psychiatric distress (experiencing psychosis or feeling suicidal), getting them into the hospital may be the wisest and best choice
  • Inform yourself as much as possible about the illness being faced
  • Instead of guessing what helps, ask
  • Keep yourself healthy and pace yourself — overextending yourself will only cause further problems in the long run
  • Know that even if your actions may seem to have little impact, they are making a difference
  • Offering objectivity, compassion, and acceptance is valuable beyond measure
  • Seek counseling for yourself
  • Start dialogues, not debates

Immediate Crisis Response and Emergency Intervention

Crisis response refers to all the advance planning and actions taken to address natural and man-made disasters, crises, critical incidents, and tragic events. Of course, in an emergency, you should always call 911. However, in some cases, having a crisis response and intervention plan can be helpful as well.

Crisis intervention is beneficial because it can mitigate adverse reactions, facilitate coping and planning, assist in identifying and accessing available support, normalize reactions to the crisis, and assess capacities and need for further support or referral to the next level of care.

The three main goals of crisis intervention are:

  • Stabilize
  • Reduce symptoms
  • Return to adaptive functioning or to facilitate access to continued care

In regards to a suicidal crisis on school grounds, some key principles to remember are:

  • Be direct
  • Be honest
  • Debrief all teachers and staff of the current situation
  • Ensure that the student in crisis is safe
  • Inform parents (when the time is right)
  • Inform the student of what is happening at all times
  • Keep other students safe
  • Know your limits
  • Listen to the student
  • Monitor your surroundings
  • Send someone for help

Parents and teachers can help prevent mental health crises by helping adolescents and teens develop emotional intelligence and healthy coping skills.

Assess the Situation

Before making any rash decisions, assess the situation and ask yourself: Is the person in danger to themselves or others? Is emergency assistance needed? Can I call someone for guidance? Are there resources to help me and the person at risk? What triggered the crisis? Am I capable of handling this on my own?

It is important to assess the situation because the person you are trying to help may not be able to communicate clearly. If you’re able to figure out what is going on using your own assessment of the scenario, you may find it easier to help control the moment.

Emergency Resources and Suicide Prevention Hotlines

Always call 911 in an active emergency situation, especially if someone is trying to harm themselves or others, or is threatening to. Additional help is also available 24/7 via specialized emergency hotlines. Here is a sample list of national hotlines you can call, text, or online chat when in distress:


  • AIDS Info: Treatment, Prevention and Research (800) HIV-0440


  • Al-Anon for Families of Alcoholics Automated meeting information: (800) 344-2666
  • Families Anonymous – a 12-step program similar to Al-Anon, meeting information only: (800) 736-9805
  • SAMHSA National Helpline: 800-662-HELP (4357)

Child Abuse

Crisis and Suicide

  • Youth in crisis text to the national Crisis Text Line Text SOS to 741741
  • Girls & Boys Town National Hotline: (800) 448-3000
  • International Suicide Hotlines
  • National Suicide Prevention Lifeline – for youth and adults: (800) 273-TALK (8255)

Domestic Violence, Rape and Sexual Assault


  • American Association of Poison Control Centers: (800) 222-1222

Online Chat


  • Disaster Distress Hotline (SAMHSA): (800) 985-5990
  • National Eating Disorders Center Helpline: (800) 931-2237 — Open M-F, 9-9 p.m.
  • Shoplifters Anonymous: (800) 848-9595 — Open M-F, 9-5 p.m.; otherwise use the website
  • Veteran’s Crisis Line: (800) 273-8255
  • YouthLine: (877) 968-8491 — Text TEEN2TEEN to 839863


  • Planned Parenthood Hotline: (800) 230-PLAN (7526)

Running Away

  • National Runaway Safeline: 800-RUN-AWAY
  • National Center for Missing & Exploited Children: (800) 843-5678
  • Child Find of America Helpline: (800) 426-5678

Substance Abuse

  • SAMHSA’s National Helpline: (800) 662-4357
  • Poison Control: (800) 222-1222
  • National Institute on Drug Abuse Hotline: (800) 662-4357
  • Cocaine Anonymous: (800) 347-8998

Techniques to De-Escalate a Crisis

Here are 10 tips on de-escalating a crisis. Remember, only do this on your own if you feel comfortable doing so. If not, emergency personnel should be called immediately.

  • Allow silence for reflection
  • Allow time for decisions
  • Avoid overreacting
  • Be empathetic and non-judgmental
  • Choose wisely what you insist upon
  • Focus on feelings
  • Ignore challenging questions
  • Respect personal space
  • Set limits
  • Use non-threatening nonverbals.

The Importance of Mental Health Awareness

To implement preventive measures, we need to deconstruct the stigma associated with mental illness. This will help make communicating about the topic feel more natural and help students realize it is OK to talk about it — and they aren’t alone. Having the proper mental health resources for students ready is just one of the many ways we can take away the stigma and show the importance of mental health awareness.

Mental health awareness is important because with awareness comes more support and care for those who are in need. When the public is educated on everything there is to know about mental health and mental illnesses, it becomes more likely that these topics become less taboo and negative. Mental health can be just as important — if not even more so — as physical health. This is because it can be hard to maintain your physical health without a healthy mental capacity.

Coping Strategies

Students can take action against their mental health issues and should feel empowered to do so. Here is a list of coping strategies and mental health resources for teenagers and college students:

Dealing with Grief

It’s not uncommon to show signs of grief after losing a loved one, decline in health, death of a pet, a miscarriage, divorce, and more. Grief is the emotional suffering you feel when something or someone you love is taken away. If you are not able to handle grief on your own, it’s important to know that you don’t have to — reach out to a parent, teacher, or mental health professional right away.

There are five stages of grief:

  • Denial: “This can’t be happening to me.”
  • Anger: “Why is this happening? Who is to blame?”
  • Bargaining: “Make this not happen, and in return, I will ____.”
  • Depression: “I’m too sad to do anything.”
  • Acceptance: “I’m at peace with what happened.”

To experience these feelings after any emotionally heavy life event is normal. Luckily there are ways to cope with grief:

  • Accept that many people feel awkward when trying to comfort someone’s grieving.
  • Draw comfort from your faith.
  • Join a support group.
  • Talk to a therapist or grief counselor.
  • Talk to friends and family members for support.

Mental Health and Self-Care

Investing in self-care enriches coping skills, energy level, sense of well-being, and the ability to create balance. Applying different self-care techniques — like skin and hair care, reading, baths, meditation, etc. — into your daily routine is beneficial because it allows the mind and body to work together for overall wellness.

Prolonged amounts of stress caused by mental illness can weaken the immune system. This can also lead to more serious health issues such as heart disease, obesity, diabetes, strokes, and high blood pressure. Symptoms of elevated stress levels include but are not limited to:

  • Changes in appetite
  • Decreased in activity levels and/or social connections
  • Difficulty concentrating
  • Feeling anxious, worried, or depressed
  • Increased irritability
  • Sleep disruption

We may not be able to control the stressors of life, but we can control how we react to them. Self-care allows us to do so in a way that is beneficial to our overall well being.

Resources for Mental Illness

In case of an immediate emergency (such as suicidal thoughts, potential to harm yourself or others, or any other life-threatening scenarios) you should always call 911. However, there are other mental health resources that can be utilized for those who need both short-term and long-term solutions:

Support for Schools

Mental health may be an underfunded educational staple for some schools. Luckily there are ways that teachers — backed by the support of lawmakers and principals — can provide support for their students. This can include:

  • Continuing education and awareness workshops for recognizing and addressing mental health issues among students
  • Creating relationships with mental health professionals
  • Peer-to-peer learning
  • Trauma-informed schools

Mental Health Facilities and Government Agencies

Here is a list of mental health facilities and agencies that can help:

It’s important to always remember — if you have a mental illness or are on the verge of a mental crisis, you are not alone. With proper education techniques and the right resources, teachers, parents, and other authority figures will be able to properly care for our youth’s mental health, especially in times of crisis.

Recommended Reading:



Chillingly, Scariest Coronavirus Death Toll May Not Come from COVID-19

A great deal of scientific research indicates the coronavirus containment strategy will cause more deaths than COVID-19 would have.

The link between unemployment and suicides will be a concern that has to be addressed while the majority of the population stays-in to duck the coronavirus pandemic.

  • While many countries are in lock down to prevent COVID-19 deaths, the reaction to coronavirus is likely to kill more people than the disease itself.
  • That’s because coronavirus layoffs have already surged across the US. And unemployment projections are already as high as 4.6 million.
  • Meanwhile, there’s a firm body of scientific literature establishing a strong link between unemployment and higher suicide rates.

Many people will die because of coronavirus, but drastic containment strategies in many countries may leave even more dead. Alarmingly, the death toll from a now imminent coronavirus recession could be much higher than that from COVID-19.

The radically broad coronavirus containment response has included:

The wholesale lockdown of so much of the economy has created such a great financial loss, disruption, and panic that job layoffs have skyrocketed. Years of record low unemployment rates are about to end abruptly and dramatically.

The Next Unemployment Report Will Be Brutal

Reports from businesses and local officials across the country portend a wave of coronavirus unemployment cases unseen since the Great Recession.

While unemployment applications in Ohio increased sevenfold this week to 45,000, filings jumped twelvefold in New Jersey to 15,000 on Monday. Over the weekend Connecticut unemployment cases surged eightfold to 8,000. Rhode Island had 10 unemployment claims on March 11 and 6,282 on March 16.

An NPR/Marist poll conducted over the weekend found 1 in 5 households have already reported someone being laid off or having their hours reduced because of the response to coronavirus. Those earning under $50,000 were hit harder, with 1 in 4 households affected by coronavirus layoffs. Josh Bivens, research director at the Center Left Economic Policy Institute estimates 3 million jobs will be gone by summer.

On Wednesday Treasury Secretary Steven Mnuchin denied reports by multiple outlets that he told GOP lawmakers that unemployment could rise as high as 20% if they failed to pass a coronavirus relief package.

Recession Is Deadlier Than Coronavirus

So far COVID-19, the disease caused by coronavirus has been a factor in over 8,000 deaths globally. But the Great Recession claimed far more lives. A study by researchers at Imperial College London linked 500,000 cancer deaths to the Great Recession. They found unemployment and health care cuts lead to these half a million tragedies.

A prolonged recession period has seen a spike in suicides, multiple studies have suggested.

A study by University of Oxford researchers found 10,000 suicides tied to the Great Recession. That was in the US, Canada, and Europe alone.

There is a robust scientific literature on the link between unemployment and higher suicide rates. Researchers at the University of Otago found labor force status is a strong predictor of suicide death. The paper says unemployment is “strongly associated with suicide death among 18–24 year old men.”

A University of Technology, Taiwan study found recessions increase the suicide rate among older age groups. Meanwhile, expansions decrease the suicide rate among younger and middle age groups:

An economic recession (in terms of an increase in unemployment rate) is more likely to increase the suicide rate among an old age group (55–64 years old) than among other age groups, while an economic expansion (in terms of a decrease in unemployment rate) is more likely to reduce the suicide rate of young (15–24 and 25–34 years old) and middle age groups (35–44 and 45–54 years old) than their counterpart.

Another study by researchers at McMaster University and Seoul National University linked even unstable employment to higher suicide rates, concluding:

Unstable employment had a significant impact on suicide among people aged 25–34.

Therefore, it’s plausible that more people will die amid the recession precipitated by the radically broad coronavirus containment response than from COVID-19 itself.
Source: or

Coronavirus demands social distancing. Will that lead to more deaths of despair? | Q&A

Throughout the 20th century, mortality rates have declined worldwide. The improvements in life expectancy are so impressive that Princeton economist and Nobel Laureate Angus Deaton dedicated a whole book, The Great Escape, to how it happened. But the richest country in world history has seen a reversal of fortune. In the past few years, life expectancy in the United States has declined. It’s against this concerning background that the coronavirus pandemic hit.

In a groundbreaking 2017 paper, Deaton and fellow Princeton economics professor Anne Case explored the trends behind the life expectancy decline. They found that middle-aged white Americans are dying in increasing rates from suicide, drug overdose, and alcohol-related liver disease, and labeled these “deaths of despair.” In their new book Deaths of Despair and the Future of Capitalism, Case and Deaton explore the root causes — and find that the trend reflects structural problems in the American economy. Decades of stagnant wages, decimated unions, outsourced labor, and the decreasing social and economic value of a high school diploma contribute to a sense of isolation and generate pain.

Case and Deaton talked to The Inquirer about deaths of despair, and the potential impact on America’s despair crisis from the coronavirus and the social distancing measures it requires. Responses were edited lightly for clarity and length.

Case: Current economic conditions can’t explain this. It might not just be the loss of a paycheck or that you can’t get as good a job as the one you lost, but that without a good job, you can’t get married or have a stable home life, your community is falling apart, your sense of connection with other people is gone.

The return on having gone to college has skyrocketed, while simultaneously the wages of people who did not go to college started to decline.

[Looking at the opioid crisis] we think that the scourge of oxycodone just being handed out in jelly jars — it would have been a serious problem, but the fact that they were falling into a community that was looking for a way to numb itself made the drug epidemic much, much worse.

Deaton: I grew up in Scotland, we were not very well off. For ordinary people, people who are not very well-educated, getting a job with a large company was just a wonderful thing. Even if it was really menial, like sweeping the floors or working in the mailroom, or guarding the door — you belong to this thing that mattered. And you might have a lifetime career there.

What happens to belonging and despair in a time, like now, that requires social distancing and poses a new health threat?

Deaton: A lot of people are going to be socially isolated. Things that were important for them, like sports games, which feed a sense of solidarity, are going to go away. So it would not be an unreasonable prediction that suicide rates and drinking and drug overdose would go up during this pandemic. The big question, of course, is how long people will put up with that.

Case: Deaths of despair were rising before the Great Recession, during it, and after it was over. There is a structural problem that won’t go away anytime soon. Even had there been no COVID-19 epidemic, we would have anticipated that about 150,000 Americans would die from suicide, drug overdose, and alcoholism in 2020. The problem will be there after this epidemic sweeps through. How much the epidemic adds to that total is unclear.

The mortality rate from suicide, drug overdose, and alcoholic liver disease mortality in Kentucky by educational attainment, for white non-Hispanics age 45-54 who have a bachelor's degree compared to those who don't. From Death of Despair and the Future of Capitalism by Anne Case and Angus Deaton.

Deaton: Let’s say the best case comes, President Trump’s hopes are validated, and when it gets warm, the virus goes away. We’re pretty sure that won’t happen, but let’s say it did. Then we have a short sharp recession and a big bounce back, with a lot of deaths from COVID. Deaths of despair will go on. For COVID, the best case is it’s a one-time event, like the great flu pandemic [of 1918 that was] gone by 1920. So that would be the best case. The worst case is [that COVID-19 is] gone eventually but leaves behind devastation to the economy. And that will add to the distress of the people we’re writing about, so the deaths of despair will go on.

Experts Concerned About Heightened Suicide Risk During Pandemic

Extended social isolation. Layoffs. A run on firearms. These are knock-on effects of the COVID-19 pandemic. They are also conditions that suicide experts say demand more preventative action for at-risk Americans.

One of those experts is Dr. J.P. Jameson, a practicing psychologist and professor at Appalachian State University, who studies suicide.

“There is some concern about isolation,” he said. “We know social connectedness is a protective factor against suicide risk, so this presents an extra layer of challenges to mental health providers and to the general public.”

Millions of Americans are staying home and away from others to prevent the spread of the coronavirus. Doctors and researchers agree this is a necessary step. But they’re also concerned about what this isolation could do to those already at greater risk for suicide.

Increased demand for firearms in response to the pandemic adds to this worry for professionals.

Firearms are by far the most common means of completing suicide in America, partly because they are so lethal. More than 50% of suicides are committed with a firearm. They also account for 60% of gun deaths in America.

Dr. Jameson has researched the relationship between firearms and suicide. He’s also a gun owner and said it’s vital to have frank conversations about firearms with family members who may be at-risk for self-harm.

“Certainly, when we’re introducing something like a firearm into a situation where we have risk factors for suicide, that’s always cause for concern,” he said.

Less Likely To Seek Help

Compounding that problem, people who are more likely to own guns — older, white men — are more likely to complete suicide. They are also less likely to seek help, according to Dr. Michael Anestis, a professor of psychology at the University of Southern Mississippi.

“The folks who tend to die by suicide using a firearm tend to be parts of groups males, older adults, service members, who will often avoid the mental health care system altogether,” he said. “Or if they use the healthcare system will under-report their thoughts of suicides.”

Anestis stresses that it’s not that guns themselves have a mental health effect on people.

“Most gun owners aren’t suicidal and owning a gun doesn’t make you suicidal,” he said.

But he says there are steps people should take for themselves and their loved ones, if they think they are at-risk, to keep distance between firearms and at-risk people in a vulnerable state.

“That means safe storage of firearms or even better yet, storing them legally and temporarily away from home so that when folks are feeling more isolated, maybe more at-risk and less able to access care, it’s also just harder for them to act on those suicidal thoughts,” he said.

In addition to the increased isolation, many Americans are losing their jobs or seeing their businesses shut indefinitely. That means increased financial stress for tens of millions of people. And at the same time services like non-profit suicide prevention hotlines might be needed the most, they are having to send volunteers home temporarily for their safety.

In Boise, Idaho, the state’s Suicide Hotline Director John Reusser said only paid staff are at the call center right now, and only two in the phone room at a time for social distancing.

“It reduces the number of folks we have available to answer calls, especially during the peak times,” he said.

And, while the focus is on getting people the help they need right now, Reusser is concerned about the future. He’s already had to cancel two fundraisers for his organization, and he’s not sure when he’ll be able to raise much-needed funds again.

“I would say definitely there’s there’s concern long-term,” he said. “But I really do think that, you know, I’m personally am trying to sort of take this day by day and not try not to worry about the coming months.”

Resources if you or someone you know is considering suicide:

National Suicide Prevention Lifeline: 1-800-273-8255 or
National Crisis Text Line - text SOS to 741741
For Deaf + Hard of Hearing: 1-800-799-4889 or text SOS to 741741
En español: 1-888-628-9454
Veterans Crisis Line & Military Crisis Line: 1-800-273-8255, Press 1 Crisis Text Line: SOS to 741-741
In emergency situations, call 911

Mental Health Effects of COVID-19 Pandemic: A Ripple or a Wave? 031820

Coronavirus won't be just a medical phenomenon

While most of my work focuses on suicide that humanity has faced for a long time, this brief Note to Readers spotlights on the new emerging global problem: the ongoing outbreak of the coronavirus disease (COVID-19). The effects of coronavirus on mental health have not as yet been studied systematically. I think its reasonable to anticipate that this impact of the virus will have a rippling effect on national and worldwide suicide events, especially based on current hysterical public reactions, including some shared puzzling medical mistrust by patients and providers. Therefore, the coronavirus pandemic is not just a medical phenomenon.

As concerns over the perceived threat grows, stress, panic, sleep disturbances will be experienced, and a wide array of DSM-5 diagnoses will be swiftly applied. Likely among these conditions are generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, severe phobias, and PTSD. And, for some, the particularly neurologically vulnerable phenotype, the tension may trigger an acute adjustment disorder (AD), precipitating or worsening existing suicidality, i.e., thoughts and/or behavior. In others, as a consequence of quick and undifferentiated misdiagnosis, iatrogenic damage may escalate mortality rates.

As noted in earlier posts, the association between stress-responsive acute AD and completed suicide is substantial. It is a diagnosis given following a significant psychosocial stressor. Who can deny the current chaotic impact of this proximal pandemic on the usual social, financial, occupational, and interpersonal order? Suicidal behavior is more common among people diagnosed with AD than people without this diagnosis. In a recent study, those diagnosed with AD had 12 times the rate of suicide as those without an AD diagnosis, after controlling for history of depression and other matched factors.

CDC data from 2018 and provisional AD suicide death temporal associations range from 30% in youth to over 60% in adults. Earlier reports have also demonstrated distinct acute AD phenotypes characterized by behavioral and cognitive symptoms with irresistible and rapid suicide transition in hours to a few days.

At the current level of plausible myopic focus on COVID-19, there will be a strong temptation among clinicians to simplify and generalize a patient's emotional distress, to normalize a patient's presentation as "depression, depressive-like, or depression-lite" and assert an early discharge to GOMER ("get out of my emergency room") to relieve bottlenecks. However, "There is nothing more deceptive than an obvious fact." These cases are frequently subtle, unobvious, and autonomous wherein rationality and competency to provide informed consent are hijacked. Within a matter of minutes to hours, and often while boarded as an unobserved person in the ED, the modified, proverbial "epigenetic transcription clock" begins to tick. Or, as Yogi Berra insightfully put it, "It's getting late early."

Likely, and regrettably, selective serotonin reuptake inhibitors will be precipitously initiated in the office, telemedicine setting, or emergency department for a wide variety of the aforementioned DSM-5 diagnoses. Characteristically, there will be limited follow-up to evaluate drug-emergent side effects. These agents may further redistribute the novel public health risk, that is, attenuate dysphoric symptoms in some, yet, in many others, increase or compound medication associated activation, akathisia, agitation, and self-harm.

At this critical time in our nation's healthcare history, additional errors of commission may occur as a result of this uninformed prescribing action. Clearly, healthcare providers want to improve coronavirus outcomes while reducing the risk of additional patient harms. Pause before narrowly prescribing to double-check.

As Caesar Augustus opined, "Make haste slowly."

How Does the 2020 Stock Market Crash Compare With Others?

Latest Dow declines among worst in terms of point, percentage drops

The stock market crash of 2020 began on Monday, March 9, with history’s largest point plunge for the Dow Jones Industrial Average (DJIA) up to that date.1? It was followed by two more record-setting point drops on March 12 and March 16. The stock market crash included the three worst point drops in U.S. history.

The drop was caused by unbridled global fears about the spread of the coronavirus, oil price drops, and looming recession. Only two other dates in U.S. history had more unsettling one-day percentage falls. They were Black Monday on Oct. 19, 1987, with a 22.6% drop, and Dec. 12, 1914, with a 23.52% fall.2?

Although this dramatic 2020 market crash is still fresh in everyone’s mind, let’s take a closer look at what happened and why. That will allow us to anticipate what may happen next with the economy.

Fall From Record High

The 2020 stock market crash began on Monday, March 9. The Dow fell 2,013.76 points that day to 23,851.02.3. It had fallen 7.79%. What some labeled as Black Monday 2020 was, at that time, the Dow’s worst single-day point drop in U.S. market history.

On March 12, 2020, the Dow fell a record 2,352.60 points to close at 21,200.62. It was a 9.99% drop, almost a correction in a single day. It was the sixth-worst percent drop in history.2?

On March 16, the Dow hit a new record. It lost 2,997.10 points to close at 20,188.52. That day’s point plummet and 12.93% freefall topped the original October 1929 Black Monday slide of 12.8% for one session.

Prior to the 2020 crash, the Dow had just reached its record high of 29,551.42 on Feb. 12. From that peak to the March 9 low, the DJIA lost 5,700.40 points, or 19.3%. It had narrowly avoided the 20% decline that would have signaled the start of a bear market.

On March 11, the Dow closed at 23,553.22, down 20.3% from the Feb. 12 high. That launched a bear market and ended the 11-year bull market that started in March 2009.

Compare to Previous Black Mondays

Before March 16, one previous Black Monday had a worse percentage drop. The Dow fell 22.6% on Black Monday Oct. 19, 1987.2? It lost 508 points that day, closing at 1,738.74. On Black Monday Oct. 28, 1929, the average plunged 12.8%. It lost 38.33 points to close at 260.64. It was part of the four-day loss in the stock market crash of 1929 that started the Great Depression.

Causes of the 2020 Crash

The 2020 crash eventually occurred because investors were worried about the impact of the COVID-19 coronavirus pandemic. COVID-19's mortality rate so far is more deadly than the seasonal flu's rate, but that’s because many more cases of the flu are reported annually. Although less deadly than SARS’s death rate in 2003, COVID-19 is spreading more quickly. On March 11, the World Health Organization (WHO) declared the disease a pandemic.4? The organization was concerned that government leaders weren’t doing enough to stop the rapidly spreading virus.

Investors had been jittery ever since President Donald Trump launched trade wars with China and other countries. By Feb. 27, the Dow had skidded more than 10% from its Feb. 12 record high. It first entered a correction when it closed at 25,766.64.


Often, a stock market crash causes a recession. That’s even more likely when it’s combined with a pandemic and an inverted yield curve.

Warning: An inverted yield curve is an abnormal situation where the return, or yield, on a short-term Treasury bill is higher than the Treasury 10-year note. It only occurs when near-term risk is greater than in the distant future.

Usually, investors don't need much return to keep their money tied up just for short periods of time. They require more to keep it tied up for longer. When the yield curve inverts, however, it means investors require more return in the short term than the long term.

On March 9, investors demanded a higher yield for the one-month Treasury bill than the 10-year note.5? Specifically, the yield curve was:

  • 0.57% on the one-month Treasury bill
  • 0.33% on the three-month bill
  • 0.38% on the two-year Treasury note
  • 0.54% on the 10-year note
  • 0.99% on the 30-year Treasury bond

Investors were telling the world with this market signal that they were so worried about the impact of the coronavirus over the next month that they needed a higher return on the one-month bill than for the 10-year note.

Inverted yield curves often predict a recession. The curve inverted before the recessions of 2008, 2001, 1991, and 1981.

In addition, bond yields across the board were at historically low levels. Investors who sold stocks in the crash were buying bonds. Demand for bonds was so high that it drove down yields to record-low levels.

How It Affects You

If you have retirement savings or other funds invested in the stock market, the crash lowered the value of your holdings. When something like this happens, many people panic and sell their stocks to avoid losing more. But the risk with that strategy is that it’s difficult to know when to re-enter the market and buy again. As a result, you could lose more in the long run, if you miss important market gains in the shorter term. On average, bear markets last 22 months. But some have been as short as three months. Most financial planners recommend you sit tight and wait it out.

Strong demand for U.S. Treasurys lowered yields. Interest rates for all long-term, fixed-interest loans follow the yield on the 10-year Treasury note. As a result, interest rates on auto, school, and home loans should also drop to record-low levels. Keep in mind that, even if 10-year Treasury yields fell to zero, mortgage interest rates would be a few points higher. Lenders must cover their processing costs.

Important: The Federal Reserve on March 15 in a surprise move cut its benchmark interest rate a full percentage point, to zero. It also launched a bond-buying program, referred to as quantitative easing, to mitigate the expected damage to the U.S. economy from the coronavirus.

Is Recession Next?

The bad news is that the combination of a stock market crash and an inverted yield curve can signal a looming recession. A pandemic often slows economic growth, as businesses slow or close and people stay home to nurse their illness or avoid catching it. These factors could easily trigger a recession.

So it makes sense to add to your savings now, if possible, to make sure you have three to six months of living expenses on hand. If you have enough cash on hand, then buying stocks isn’t a bad idea, because prices are low. The driving forces behind the stock market crash of 2020 are unprecedented, but strategies to survive such crashes and recessions have been proven to work throughout history.

The Great Recession, unemployment and suicide


Background How have suicide rates responded to the marked increase in unemployment spurred by the Great Recession? Our paper puts this issue into a wider perspective by assessing (1) whether the unemployment-suicide link is modified by the degree of unemployment protection, and (2) whether the effect on suicide of the present crisis differs from the effects of previous economic downturns.

Methods We analysed the unemployment-suicide link using time-series data for 30 countries spanning the period 1960–2012. Separate fixed-effects models were estimated for each of five welfare state regimes with different levels of unemployment protection (Eastern, Southern, Anglo-Saxon, Bismarckian and Scandinavian). We included an interaction term to capture the possible excess effect of unemployment during the Great Recession.

Results The largest unemployment increases occurred in the welfare state regimes with the least generous unemployment protection. The unemployment effect on male suicides was statistically significant in all welfare regimes, except the Scandinavian one. The effect on female suicides was significant only in the eastern European country group. There was a significant gradient in the effects, being stronger the less generous the unemployment protection. The interaction term capturing the possible excess effect of unemployment during the financial crisis was not significant.

Conclusions Our findings suggest that the more generous the unemployment protection the weaker the detrimental impact on suicide of the increasing unemployment during the Great Recession.

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Great Recession tied to more than 10,000 suicides

The lost jobs, sinking home values and stock market free-fall of the Great Recession led to a significant rise in suicides, according to a new study.

At least 10,000 more Americans and Europeans took their own lives from 2007 to 2010 than during the good economic times of the previous few years, the study found.

"It's a fairly large and substantial increase over what we would have expected," said Aaron Reeves, a sociologist and post-doctoral researcher at the University of Oxford in England, who helped lead the research. "There are, broadly speaking, large mental health implications of the economic crisis that are still being felt by many people."

Suicide rates didn't climb evenly. In Sweden and Austria, rates remained flat during the Great Recession, although those nations' economies struggled as much as others did – suggesting that the link between recession and suicide is not inevitable, said David Stuckler, a professor and health economist at Oxford and the paper's senior author.

"These economic suicides are avoidable," he said.

Sweden had strong support for people who lost their jobs or were struggling financially, Stuckler said.

This finding has important implications for policymakers, said Abdulrahman El-Sayed, a doctor and assistant professor of epidemiology at the Mailman School of Public Health at Columbia University in New York City.

"The social welfare aspects of economic downturns like this can't be ignored," El-Sayed said. "When our economic belts get a little too tight, we shouldn't be cutting things that help the average Joe."

The study showed that men facing financial difficulties are at higher suicide risk than women, probably because society generally expects men – more than women – to be breadwinners. Men are also less likely than women to seek help when they are in trouble, often bottling up their worries, Stuckler said.

Before the Great Recession, suicide rates were falling in most European countries while rising in the USA, Stuckler said, adding that he's not sure what explains the pre-recession climb.

The study showed that antidepressant prescription rates rose by nearly 20% in the U.K. from 2007 to 2010 – although previous research has found that antidepressant use does not have a major impact on suicide rates.

The common stereotypes of suicide are often wrong, the researchers said. Rather than being long-planned, suicides are often impulsive acts of little forethought, said Matthew Miller, co-director of Harvard University's Injury Control Research Center. Suicide attempts are equally common in urban and rural areas of the USA, he said, but more likely to succeed in rural areas, where guns are more available.

People who try to commit suicide with a gun are more likely to succeed than people who try by other means, he said: "If you can't reach for a gun in a moment of crisis, you're more likely to get a second chance."

Resources to Support Mental Health and Coping with the Coronavirus (COVID-19)

SPRC has compiled a selection of web pages and information sheets on mental health and coping with the effects of COVID-19:

Epidemiology of suicide and attempted suicide


Studied suicide attempts (SAs) to investigate (1) social network and social support of suicide attempters (SARs) and (2) direct influences of the social environment on suicide. Data from 101 hospitalized German SARs and from 82 healthy, age- and sex-matched controls indicate that SARs lacked relatives and partners as sources of crisis support, as well as friends and acquaintances for everyday interactions. Data from G. L. Klerman et al (see record 1985-30947-001) show that suicides in 2 West German cities peaked between 1976 and 1978, with the sharpest increase in younger age groups. Data collected on SAs after a television show on suicide supported the hypothesis that fictional suicide models can induce SAs.

Emotional Well-being During the COVID-19 Outbreak

What is Coronavirus (COVID-19)?

The Centers for Disease Control and Prevention (CDC) have described the coronavirus, or COVID-19, as an outbreak of respiratory disease caused by a novel (new) coronavirus that has now been detected in more than 100 locations internationally, including in the United States. The virus has been named “SARS-CoV-2” and the disease it causes has been named “coronavirus disease 2019” (abbreviated “COVID-19”). You can read more about COVID-19 on the CDC’s “Situation Summary

Infectious disease outbreaks such as COVID-19, as well as other public health events, can cause emotional distress and anxiety. Feeling anxious, confused, overwhelmed or powerless is common during an infectious disease outbreak, especially in the face of a virus with which the general public may be unfamiliar. These feelings of distress and anxiety can occur even if you are not at high risk of getting sick.

Coping Tips

People that are feeling emotional distress related to COVID-19 can take actions to help support themselves and others.

  • Set a limit on media consumption, including social media, local or national news.
  • Stay active. Make sure to get enough sleep and rest. Stay hydrated and avoid excessive amounts of caffeine or alcohol. Eat healthy foods when possible.
  • Connect with loved ones and others who may be experiencing stress about the outbreak. Talk about your feelings and enjoy conversation unrelated to the outbreak.
  • Get accurate health information from reputable sources. For health information about COVID-19, please contact the Centers for Disease Control at, your local healthcare provider, or your local 211 and 311 services, if available.
  • If you’re experiencing emotional distress related to COVID-19, please call the National Suicide Prevention Lifeline or your local crisis line.
  • For coping tools and resources, visit the Lifeline website at or Vibrant Emotional Health’s Safe Space at

Helpful Resources

Reliable sources of information about COVID-19:

Other Helpful Resources to Support Your Mental and Emotional Well-being:


Deaths of Despair: The Other Covid-19 Crisis That is Killing Americans

By now everyone is aware that Covid-19 can cause death, primarily in people who are over fifty or have health problems such as asthma, lung disease, diabetes, high blood pressure and other chronic health problems. To protect ourselves we have been asked to practice physical distancing, wear face masks, avoid large gatherings, and wash our hands more thoroughly and more often than any of us have done in our lives.

Yet, there’s another danger that has not been talked about. It’s called “Deaths of Despair.” According to the Centers of Disease Control and Prevention (CDC) “Across the United States, more people are dying from so-called ‘deaths of despair’—suicide, drug and alcohol poisoning, and alcoholic liver disease—than at any other point in recorded history.”

In 2017, the overall death rate from deaths of despair (45.8 people per 100,000) outpaced lung cancer, stroke and car crashes when adjusting for age, according to CDC data. That’s an increase of more than 180 percent since 2000.

In their ground-breaking book, Deaths of Despair, social scientists Anne Case and Angus Deaton say,

“Deaths of despair have contributed to three years of consecutive reductions in average life expectancy, making the U.S. the only wealthy nation in modern times to exhibit such a reversal.”

Published earlier this year the book details the Americans who are a greatest risk and the underlying causes of the problem.

“For the white working class, today’s America has become a land of broken families and few prospects. As the college-educated become healthier and wealthier, adults without a degree are literally dying from pain and despair.”

Case and Deaton tie the crisis to the weakening position of labor, the growing power of corporations, and, above all, to a rapacious health-care sector that redistributes working-class wages into the pockets of the wealthy. Capitalism, which over two centuries lifted countless people out of poverty, is now destroying the lives of blue-collar America.

With the coming of Covid-19 deaths of despair may be on the increase. Nearly 90,000 have died from the virus thus far. Yet, a study by Well Being Trust, and the Washington, D.C.-based Robert Graham Center for Policy Studies in Family Medicine and Primary Care, on May 8, 2020 headlined these startling findings: “The COVID Pandemic Could Lead to 75,000 Additional Deaths from Alcohol and Drug Misuse and Suicide.”

The report says,

“The collective impact of COVID-19 could be devastating. Three factors, already at work, include economic failure with massive unemployment, mandated social isolation for months and possible residual isolation for years, and uncertainty caused by the sudden emergence of a novel, previously unknown microbe. The economics of COVID-19 have already caused a massive jump in unemployment: job loss leading to personal and professional economic loss across all business sectors. Hourly workers as well as salaried professionals have been laid off and furloughed indefinitely.”

The report continues with further causes of increased deaths of despair. “Isolation, whether called social isolation or physical distancing is leading to loss of social connection and cohesion. No groups over 10, no cinema (a mainstay of the Great Depression), no sports, no clubs or social organizations, no church services. Virtual community may not be enough to hold off the impact of isolation and loneliness. And finally, uncertainty. The stress of uncertainty has a serious impact on the emergence and worsening of mental illness. These are unprecedented times, and uncertainty may lead to fear which may give way to dread.”

The study combined information on deaths of despair from 2018 as a baseline (there were 181,686), projected levels of unemployment from 2020 to 2029 and then estimated the additional annual number of deaths based on economic modeling. Across nine different scenarios, the additional deaths of despair range from 27,644 (quick recovery, smallest impact of unemployment on deaths of despair) to 154,037 (slow recovery, greatest impact of unemployment on deaths of despair), with 75,000 being the most likely. “When considering the negative impact of isolation and uncertainty, a higher estimate may be more accurate,” the study concluded.

As a therapist I tell people that before we can decide what course of action is best for us, we have to look at both sides of the question. As we face the decision of when and how to leave our homes and get back to our lives in the community, we have to look at the risks and rewards of both sides of the equation.

What are the risks of going back out and mingling with people and facing an increased risk of getting infected by the virus? What are the rewards and benefits of getting back to interacting with others and getting our economy back on its feet? On the other side of the equation we have to ask what are the benefits of staying close to home and only going out when absolutely necessary? And what are the risks to staying at home with the increased pressures and social isolation?

One of the few public figures who is looking at both sides is David L. Katz, M.D. Dr. Katz is a board-certified specialist in Preventive Medicine & Public Health, the founder and former director of Yale University’s Yale-Griffin Prevention Research Center, Past-President of the American College of Lifestyle Medicine, and Founder/President of the True Health Initiative.

Dr Katz says,

“From the early going, I have championed total harm minimization noting that there was more than one way for the combination of infection and interdiction to hurt and kill people. These weeks (lifetimes?) into the pandemic response, we have new indications that the indirect death toll – so-called ‘deaths of despair’ – looks to rival the direct toll of the virus.”

In our politically charged atmosphere of fear and division, its simpler to choose a side—Left or Right, Democrat or Republican, stay at home or get out in the world. Either/or scenarios may be simpler and may fit our current state of polarization, but they are bad for our health. We need, as Dr. Katz recommends, “total harm minimization.”

Part of this approach recognizes the realities of life and death. No matter what we do we’re not going eliminate harm. Someday we’re all going to die and each death is a tragedy and loss. On any given day there will be deaths of people who stay at home and die from drinking, drugs, and suicide. There will also be people who go back out and mingle and die of heart attacks, accidents, cancer, flu, and yes, some will die of Covid-19, even some young and healthy people.

So, what are we to do? Ultimately, we all have to decide what’s best for us, for those we love, and those we care about. Dr. Katz reminds us that “more and more data are telling us that Covid-19 is two completely different diseases in different populations. It is severe and potentially lethal to the old, the chronically ill and those with pre-existing conditions. It is, however, rarely life-threatening, often mild — and often even asymptomatic — among those under 50 or 60 in generally good health.”

Being that I’m 76 years-old, have had chronic asthma, and lung problems, I’m doing to remain cautious and stay closer to home, maybe for a long time until we have a workable and safe vaccine. I’ll miss some of the community life, but I’ll adapt. Most of my neighbors are younger and healthier and can’t wait to get back out and mingle. No matter how you slice it, we’re in a new world. For me, I’m listening to those I feel I can trust and making decisions that make sense to me. As I learn more and my gut feelings change, I’ll decide accordingly.

Stories from Oregon show how small gatherings can lead to big spread

We are all trying to figure out what our lives should look like with this virus in our communities. It’s not easy to decline invitations to the get togethers we used to have with friends and family. It’s hard for many of us to understand how being with friends and loved ones could be what puts you at risk for getting or spreading COVID-19.

Today, State Health Officer Dr. Dean Sidelinger shared some stories about how we’ve seen COVID-19 spread in our communities starting from seemingly harmless gatherings:

In the first example, 10 people got together for a family party, and two people at the party were likely infectious at the time, though they did not have symptoms. In total, those two cases have led to 20 reported cases spread across 10 households. At least two of the people work with vulnerable populations. One person lived in a multi-generational house with family members with high-risk conditions. So even though the people who went to the party weren’t at higher risk for complications, many of the people who got sick potentially exposed people who are more vulnerable.

In the second example, 20 people rented a beach house for a celebration and were together for three days. No one had symptoms during the trip, but four were potentially infectious at the time. Twelve people from the trip got sick, all adults of various ages. These cases then had links to five workplace outbreaks, with a total of more than 300 cases so far.

These examples show that even a small number of people, if they have multiple exposures, can lead to large numbers of cases.

OHA Director Patrick Allen cautioned everyone to rethink their celebration plans as the Labor Day holiday approaches:

  • Limit your social gatherings outside your household, noting that Gov. Brown has made social gatherings with more than 10 people off-limits.
  • Wear a face covering indoors and outside when you can’t maintain 6 feet of physical distance from people outside your household.
  • If you have a small gathering, consider hosting it outdoors rather than indoors.
  • Wash your hands frequently.

Source: OHA Coronavirus Update 8/27/20

8 ways veterans are particularly at risk from the coronavirus pandemic

From the elderly who are facing deadly outbreaks in nursing homes to communities of color facing higher infection and death rates, different groups face different challenges from the coronavirus pandemic

Among the most hard-hit (22 page PDF) are veterans, who are particularly susceptible to both health and economic threats from the pandemic. These veterans face homelessness, lack of health care, delays in receiving financial support and even death.

I have spent the past four years studying veterans with substance use and mental health disorders who are in the criminal justice system. This work revealed gaps in health care and financial support for veterans, even though they have the best publicly funded benefits in the country.

Here are the eight ways the pandemic threatens veterans:

1. Age and other vulnerabilities

In 2017, veterans’ median age was 64; their average age was 58 and 91% were male. The largest group served in the Vietnam era, where 2.8 million veterans were exposed to Agent Orange.

Younger veterans deployed to Iraq and Afghanistan were exposed to dust storms, oil fires and burn pits, and perhaps as a consequence have high rates of asthma and other respiratory illnesses.

Age and respiratory illnesses are both risk factors for COVID-19 mortality. As of April 13, 241 patients in Veterans Administration health care facilities had died of COVID-19 and 4,000 have tested positive.

2. Dangerous residential facilities

Veterans needing end-of-life care, those with cognitive disabilities, or those needing substance use treatment often live in crowded VA or state-funded residential facilities.

State-funded “Soldiers’ Homes” are notoriously starved for money and staff. The horrific situation at the Soldier’s Home in Holyoke, Massachusetts, where more than 40 veteran residents have died from a COVID-19 outbreak, illustrates the risk facing the veterans in residential homes.

3. Benefits unfairly denied

When a person transitions from active military service to become a veteran, they receive a Certificate of Discharge or Release. This certificate provides information about the circumstances of the discharge or release. It includes characterizations such as “honorable,” “other than honorable,” “bad conduct” or “dishonorable.” These are crucial distinctions, because that status determines whether the Veterans Administration will give them benefits.

Research shows that some veterans with discharges that limit their benefits have PTSD symptoms, military sexual trauma or other behaviors related to military stress. Veterans from Iraq and Afghanistan have disproportionately more of these negative discharges than veterans from other eras, for reasons still unclear.

VA hospitals across the country are short-staffed and don’t have the resources they need to protect their workers. AP/Kathy Willens

The Veterans Administration frequently and perhaps unlawfully denies benefits to veterans with “other than honorable” discharges.

Many veterans have requested upgrades to their discharge status. There is a significant backlog of these upgrade requests, and the pandemic will add to it, further delaying access to health care and other benefits.

4. Diminished access to health care

Dental surgery, routine visits and elective surgeries at Veterans Administration medical centers have been postponed since mid-March. VA hospitals are understaffed – just before the pandemic, the VA reported 43,000 staff vacancies out of more than 400,000 health care staff. Access to health care will be even more difficult when those medical centers finally reopen.

As of Monday, April 13, 1,520 VA health care workers have tested positive for COVID-19, and thousands of health care workers are under quarantine. The VA is asking doctors and nurses to come out of retirement to help already understaffed hospitals.

5. Mental health may get worse

An average of 20 veterans commit suicide every day. A national task force is currently addressing this scourge.

But many outpatient mental health programs are on hold or being held virtually. Some residential mental health facilities have closed.

Under these conditions, the suicide rate for veterans may grow. Suicide hotline calls by veterans were up by 12% on March 22, just a few weeks into the crisis.

6. Complications for homeless veterans and those in the justice system

An estimated 45,000 veterans are homeless (a national disgrace) on any given night, and 181,500 veterans are in prison or jail. Thousands more are under court-supervised substance use and mental health treatment in Veterans Treatment Courts. More than half of veterans involved with the justice system have either mental health problems or substance use disorders.

As residential facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go. They may stay incarcerated or become homeless.

Courts are moving online or ceasing operations altogether. It is unclear whether participants will face delays graduating from court-supervised treatments.

Further, some Veterans Treatment Courts still require participants to take drug tests. With COVID-19 circulating, participants must put their health at risk to travel to licensed testing facilities.

As veterans’ facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go and may become homeless, like this Navy veteran in Los Angeles. Getty/Mario Tama

7. Disability benefits delayed

In the pandemic’s epicenter in New York, tens of thousands of veterans should have access to VA benefits because of their low income – but don’t, so far.

The pandemic has exacerbated existing delays in finding veterans in need, filing their paperwork and waiting for decisions. Ryan Foley, an attorney in New York’s Legal Assistance Group, a nonprofit legal services organization, noted in a personal communication that these benefits are worth “tens of millions of dollars to veterans and their families” in the midst of a health and economic disaster.

All 56 regional Veterans Administration offices are closed to encourage social distancing. Compensation and disability evaluations, which determine how much money veterans can get, are usually done in person. Now, they must be done electronically, via telehealth services in which the veteran communicates with a health care provider via computer.

But getting telehealth up and running is taking time, adding to the longstanding VA backlog. Currently, approximately 75,000 veterans wait more than 125 days for a decision. (That is what the VA defines as a backlog – anything less than 125 days is not considered a delay on benefit claims.)

8. Obstacles to getting stimulus checks

Veterans with the greatest financial need may not automatically receive their stimulus checks. Currently, those living on tax-exempt income from the VA must file a tax return to get a check.

But e-filing a tax return is a significant obstacle for many, especially severely disabled veterans who may not have computers or know how to use e-file software.

There are many social groups to pay attention to, all with their own problems to face during the pandemic. With veterans, many of the problems they face now existed long before the coronavirus arrived on U.S. shores.

But with the challenges posed by the situation today, veterans who were already lacking adequate benefits and resources are now in deeper trouble, and it will be harder to answer their needs.

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