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."
Russell Copelan, MD (Ret.), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed residency and fellowship in emergency department psychiatry. He is a reviewer for Academic Psychiatry and founder of , an originator and distributor of violence assessments. Read more of his posts here.