IN the last few months since the Covid-19 lockdown was announced, there have been several media reports linking suicides and attempted suicides to the pandemic. While it may be too early to predict the impact, suicide rates will be a marker of the virus’ toll on the nation’s mental health.

Zofeen T. Ebrahim spoke to Dr Murad Moosa Khan, Professor Emeritus, Aga Khan University, Karachi, also the president of the International Association for Suicide Prevention. Having been monitoring reports of suicide in Pakistan, and specially observing the present trends, he finds the present situation “very worrisome”.

Q. Has there been an abnormal spike in suicides and attempted suicides since the lockdown? Is there evidence to link it to Covid-19? Can this be proven historically?

A. There have been a number of reports in newspapers that appear to show suicides taking place as a direct result of Covid-19. At the moment this is the only data we have. We will need to analyse it to see if there was a spike in the number of cases during the pandemic.

However, previous public health emergencies support the concern of increase in suicides after the pandemic: deaths by suicide increased in the USA during the 1918-19 influenza pandemic and studies on Severe Acute Respiratory Syndrome found an increase of suicide among the elderly, associated with social disengagement, mental stress, anxiety, and fears of being a burden on the family.

So it is likely that in the coming weeks and months we may see an increase in the number of suicides and self-harm acts in the country.

Q. Which age bracket would be more prone to inflicting this form of self-harm and why?

A. In Pakistan, the group that is most at risk from suicidal behaviours are those in the age groups from 16-40. The pandemic has disrupted and delayed educational activities, job entry, people have lost their jobs, their incomes have suffered and many businesses have closed down. All this is likely to have a major impact on people’s mental well-being and those who are vulnerable will be the most affected and at risk of suicidal behaviours.

Q. Do you think risk of deaths by suicide may be heightened among people with history of mental illness?

A. People with pre-existing mental illness would be at a higher risk of suicidal behaviour for several reasons. Their treatment may be interrupted; their usual social support and activities may be curtailed; the fear of the infection may have a much greater impact on them. Those with certain specific conditions such as obsessive-compulsive disorders, phobias or anxiety disorders in which fear of dirt or contamination was already present, may have a heightened fear and anxiety of the infection, making them more vulnerable to relapsing and therefore suicidal behaviours.

Q. Could you enlist the reasons for suicide, in these strange times?

A. This is a new illness about which the knowledge is still evolving and there is no known treatment to date. So there is a lot of uncertainty. This generates fear and apprehension. Then there is the economic fallout of the pandemic and businesses, regular work, livelihoods and casual labour have all been affected. This pandemic has pushed even more people into poverty. The combination of uncertainty, fear, poverty and hunger is a dangerous mix leading to hopelessness, one of the critical factors in the final tipping point for suicide.

Q. Once the epidemic is brought under control do you think things will get better?

A. The world is changed already. Travel, communication, work, social life, sports, conferences, studying, healthcare — have all changed, some permanently. Large aspects of life as we knew it is likely to never go back to how it used to be. We will all have to get used to the ‘new normal’. Many people may find adjusting to this difficult and may therefore suffer the consequences.

Q. Could watching/reading too much about coronavirus lead to panic and ultimately taking one’s own life?

A. There needs to be a balance between being well-informed and keeping up to date and being overwhelmed by information. The latter is unhealthy, especially if people are getting information from social media, listening to rumours or anecdotes. Mixed and inconsistent messages from the government confuse people even more and can have a very adverse effect on the more vulnerable, putting them more at risk of suicidal behaviour.

Q. What are the signs family members should keep a lookout for?

A. Any change in one’s behaviour should alert others: being withdrawn, becoming unusually quiet, change in sleeping or eating pattern, disruption of daily routine, expressing hopelessness, talking about death, posting on social media about death, suicide etc.

Q. What interventions are required?

A. Family members and friends are the first point of contact as well as the first line of protection. Checking on people, asking them how they are feeling and if they require any help and doing so regularly is the first vital step. If the person appears distressed or is expressing hopelessness, offer support as well as consider contacting a mental health professional. Even if the person resists this, a friend or family member should contact to discuss the issue and get help on how to manage the distressed individual.

Q. Can the services be provided free of cost to those who are economically in despair and cannot visit hospitals?

A. Yes, they should be. In Pakistan we have a hybrid system of expensive private healthcare, government health facilities and philanthropic institutions. Private facilities are out of reach for the common man while government facilities are overwhelmed by large numbers. Very few philanthropic institutes cater to mental healthcare, though some do and they are free of cost. There is a great need for culturally appropriate, accessible (meaning close to where the person lives) and affordable (either free or very low cost) mental healthcare for Pakistan.

Q. What should the state do?

A. We need national and provincial national mental health plans, under which clinical services, training, education, research, quality control, monitoring, legislation need to be organised. For the present pandemic, each of the provincial mental health authorities should be activated and entrusted with the task of coordinating mental health and suicide prevention response. Vertical standalone programmes like the UNDP and WHO psychosocial programmes should be discouraged. We must learn from the 2005 earthquake and 2014 Army Public School terrorist attack in Pakistan. Lots of standalone vertical mental health programmes and helplines were established, only to disappear within a few weeks.

Published in Dawn, June 9th, 2020