DOI: 10.22491/1678-4669.20200016

DOSSIER COVID

 

 

Social distancing during pandemics: Suicide risk and prevention in the face of psychosocial impacts of COVID-19

 

Distanciamento social em pandemias: o risco e a prevenção do suicídio frente aos impactos psicossociais da COVID-19

 

Distanciamiento social en pandemias: el riesgo y la prevención del suicidio frente a los impactos psicosociales de COVID-19

 

 

Aneliana da Silva Prado^I; Joanneliese de Lucas Freitas^II

^IInstituto Federal do Paraná
^IIUniversidade Federal do Paraná

Endereço para correspondência

 

 

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ABSTRACT

Social distancing strategies have been used to mitigate pathogen transmission rates during pandemics. Such mitigation measures can lead to psychosocial and economic impacts that negatively affect the mental health of populations and, consequently, increase suicide risk, especially in people who were already vulnerable. Based on a reflection on mental health and pandemics, this study aimed to present the negative implications of the COVID-19 pandemic for mental health and articulate them to suicide risk in the general population. We emphasized the importance of adopting proactive mental health care measures combined with sanitary measures. We concluded that large-scale governmental actions are necessary to improve and expand the Brazilian Psychosocial Care System, in addition to cross-sector measures aimed at improving protective factors and mitigating risk factors, especially regarding socioeconomic and relational vulnerability.

Keywords: suicide; COVID-19; pandemics; mental health.

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RESUMO

Estratégias de distanciamento social têm sido utilizadas para mitigar a taxa de transmissão dos patógenos durante pandemias. Essas medidas podem gerar impactos psicossociais e econômicos que afetam negativamente a saúde mental das populações e, consequentemente, aumentar o risco de suicídio, especialmente em pessoas que já apresentavam vulnerabilidade. A partir de uma reflexão sobre saúde mental e pandemias, este trabalho objetivou apresentar as implicações negativas da pandemia de COVID-19 para a saúde mental e articulá-las ao risco de suicídio na população geral. Explicitamos a necessidade de se adotar medidas proativas no cuidado em saúde mental articuladas com estratégias sanitárias. Concluímos que ações governamentais massivas para o fortalecimento e a ampliação da Rede de Atenção Psicossocial são necessárias no Brasil, além de medidas intersetoriais que visem o fortalecimento dos fatores de proteção e a atenuação dos fatores de risco, especialmente no que se refere à vulnerabilidade socioeconômica e relacional.

Palavras-chave: suicídio; COVID-19; pandemias; saúde mental.

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RESUMEN

En pandemias, se han utilizado estrategias de distanciamiento social para mitigar la tasa de transmisión. Estas medidas pueden generar impactos psicosociales y económicos que afectan negativamente la salud mental de las poblaciones y, en consecuencia, aumentan el riesgo de suicidio, especialmente en personas que ya tenían vulnerabilidad. Apoyado en una reflexión sobre salud mental y pandemias, este estudio tiene como objetivo presentar las implicaciones negativas de la pandemia de COVID-19 para la salud mental y articularlas con el riesgo de suicidio. Son explicitadas la necesidad de adoptar medidas proactivas en la atención de salud mental que se articulen con estrategias sanitarias. Se concluye que en Brasil es necesaria una acción gubernamental masiva con respecto al fortalecimiento y expansión de la Red de Atención Psicosocial, además de las medidas intersectoriales destinadas a fortalecer factores de protección y mitigar factores de riesgo, especialmente con respecto a la vulnerabilidad socioeconómica y relacional.

Palabras clave: suicidio; COVID-19; pandemias; salud mental.

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For years, studies have presented data indicating the possibility of new pandemics. According to Mayor (2000), the World Health Organization (WHO) published a document in 1999 that suggested establishing multidisciplinary prevention and control strategies by the participating countries. In that document, the WHO emphasized the risks faced by low-income and developing countries, where vaccine and health resources are scarce (Mayor, 2000). Unfortunately, the warning became a reality twenty years after that publication.

On March 12, 2020, the WHO declared COVID-19, caused by the SARS-CoV-2 virus, a global pandemic (Brooks et al., 2020; Viner et al., 2020). The mortality of this highly contagious virus varies mainly according to age and associated clinical conditions (Ministério da Sáude [MS, 2020). Therefore, broad social distancing has been implemented by most countries as the primary strategy to mitigate the risk of infection with this virus to prevent many people from getting sick at the same time and consequently overloading the public health system (Brooks et al., 2020; Zheng, 2020). In this paper, the term "social distancing" is used in a broad sense to refer to all measures adopted to reduce contact between people to reduce infection. Social distancing includes both the notion of isolation—when a person is sick—and that of quarantine, which restricts the circulation of healthy people who may have been exposed to the infectious agent (Huremovic, 2019a). The WHO uses the term "social distancing" to refer to measures applied to specific social environments as well as to society as a whole, in order to reduce COVID-19 transmission (World Health Organization [WHO], n.d.).

In the face of this dramatic public health context, mental health is also an issue of concern. Either because of the fear of COVID-19 infection and its possible health complications, or the adverse side effects of quarantine—which can affect daily interpersonal relationships, and even economic and political fields and their macro-relationships—or even the grief experiences caused by the losses of this period, the psychosocial and economic impacts of the pandemic can be expected to affect the mental health of people worldwide (Shah et al., 2020). Although there are many nuances, and it is not possible to list all of them, these examples illustrate a reality in which approximately one-third to half of the population exposed to an epidemic may experience psychological distress (Brooks et al., 2020).

Many factors contribute to psychological stress in quarantine conditions (Huremovic, 2019b). We can observe an increase in feelings such as hopelessness, anxiety, confusion, anger, irritability, fear, frustration, and boredom. We can also notice the emergence of sleep disorders, aggressiveness, symptoms of post-traumatic stress disorder (PTSD), and suicidal ideation, as well as access to inadequate supplies and information, and financial losses. Furthermore, stigma and discrimination have emerged against infected persons, their relatives, and healthcare professionals who can be considered "potential vectors" (Brooks et al., 2020; Mamun & Griffiths, 2020; Shah et al., 2020; Zheng, 2020). Based on a psychological perspective, Huremovic (2019a) summarizes social distancing's consequences in two words: isolation and uncertainty, which can be related to both tangible and symbolic aspects of the adopted measures. Although these feelings are expected emotional responses during crises and pandemics—such as the COVID-19 pandemic—we must remain alert to the intensity of suffering considering that feelings of helplessness, despair, and hopelessness are known as suicide warning signs (Botega, 2015; Brooks et al., 2020; Huremovic, 2019b).

In this regard, the very symptoms of COVID-19 infection—such as fever, hypoxia, and cough, along with treatment side effects—can increase anxiety and mental distress (Xiang et al., 2020; Zheng, 2020). A study with 1210 participants from 194 Chinese cities in the early phase of the COVID-19 outbreak showed that 53.8% of the respondents considered the psychological impact of COVID-19 to be moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels (Wang et al., 2020). However, to date, no epidemiological data are available on the mental health of diagnosed or suspected COVID-19 persons or COVID-19 frontline health workers (Xiang et al., 2020). In Brazil, the cases of stress and anxiety have more than doubled in this period, and the incidence of depression has increased by 90%, as reported by the State University of Rio de Janeiro (Jansen, 2020). Mamun and Griffiths (2020) suggest conducting nationwide epidemiological studies to identify the levels of fear, concern, and helplessness, as well as other mental health problems related to the COVID-19 pandemic.

The consequences of the global reach of COVID-19 have resulted in a considerable increase in socioeconomic and emotional vulnerability situations. Simultaneously, some protective factors mostly related to the quality of interpersonal relationships and social support, livelihood conditions (employability), and access to mental health services, among others, have decreased (Brooks et al., 2020; Reger, Stanley, & Joiner, 2020). This situation is worrying since any form of psychosocial vulnerability increases suicide risk (Prado, 2019). In this paper, the expression vulnerability and its psychosocial, socioeconomic, relational, and emotional expressions refer to the risk factors epidemiologically associated with suicidal behavior (Benincasa, & Rezende, 2006; Botega, 2015; Botega, Werlang, Cais, & Macedo, 2006; Gunnel et al., 2020; Hawton, Saunders, & O'Connor; Joiner, 2007; O'Connor, & Kirtly, 2018).

Suicidal behavior (which, in this case, includes suicide ideation, attempt, and death) is a complex and multidetermined phenomenon in which biological, psychological, social, cultural, and economic factors, among others, interact in its development. Suicidal behavior is a major public health problem worldwide: the number of suicides has been steadily increasing. Currently, 800,000 people die by suicide every year, representing one death every 40 seconds—and these numbers are underestimated. Suicide is the second cause of death among people aged 15 to 29 worldwide. In Brazil, suicide represents the fourth cause of death for this age group (MS, 2017; World Health Organization [WHO], 2014). In the health field, suicide is usually presented in terms of risk and prevention, which may either be observable or not (Botega, 2015; Botega et al., 2006; MS, 2017; Hawton et al., 2012; Joiner, 2007; Scavacini, 2018; WHO, 2014). According to Benincasa and Rezende (2006), risk factors are "elements with a high probability of triggering or being associated with the triggering of an unwanted event, and they are not necessarily causal factors" (p. 94). On the other hand, protective factors are personal or social resources that mitigate or neutralize the impact of risks. Some protective factors are resilience, self-esteem, ability to solve problems, cognitive flexibility, meaningful interpersonal relationships and social support, access to mental health services and treatment, employability, spirituality, having small children, having a steady partner, being in a culture that values cooperation, among others (Botega et al., 2006; Keller & Werlang, 2005).

The evaluation of suicidal behavior based on risk and protective factors has limitations because human experience is more extensive, profound, and complex than can be presented in a list. Nevertheless, analyzing a complex phenomenon in small factors or variables can be useful to develop public policies focused on health care strategies, and help laypeople understand the process involved in this phenomenon. By better understanding this phenomenon, people can claim their right to health promotion actions. Thus, we recognize the limitation of the proposed analysis and invite the reader to extrapolate to real-life what is presented in this paper. Therefore, based on what has been reported about previous pandemics, the objective of this study is to reflect on possible relationships between psychosocial and economic impacts of the COVID-19 pandemic and suicide risk. We also seek to recommend some preventive and mental health promotion measures for this period based on the specialized literature, especially considering the Brazilian context.

 

Pandemics: psychosocial impacts and suicide risk

Daily life has dramatically changed, for instance, because of the risk of Sars-CoV-2 infection or even the risk of income reduction or loss. The COVID-19 pandemic has impacted many people's lives by causing eventual plan changes and interrupting life projects. In addition to the emotional and relational challenges involved in "staying at home", many people still have to deal with the impossibility of adopting social distancing because of their occupations or livelihood, especially in developing countries such as Brazil. There is also a stigma that infected people are afraid to face, increasing contamination because they omit the diagnosis and avoid seeking medical care (Shah et al., 2020). Some people also avoid seeking health care precisely because they are afraid of being infected in these environments. Losing one or more loved ones is another factor that affects many people's lives in this period.

In similar circumstances, such as the Severe Acute Respiratory Syndrome (SARS) outbreak in 2002, several mental disorders were reported, including depression, panic attacks, anxiety, psychomotor agitation, suicidal behavior, delirium, and psychotic symptoms (Shah et al., 2020; Zheng, 2020). SARS survivors developed PTSD, and their depression worsened. Furthermore, the number of suicides in older adults increased among those affected by the disease in the two years following the outbreak. Regarding the Middle East Respiratory Syndrome (MERS) outbreak in 2012, according to Shah et al. (2020), survivors who experienced critical conditions of the disease reported worse quality of life than those who were indirectly affected. Huremovic (2019b) emphasizes the importance of considering the particularities of the psychological needs of people who experienced isolation or quarantine as social distancing measures.

Considering the similarities in terms of viral infection and the media coverage of the MERS and SARS pandemics, Shah et al. (2020) argue that the measures to mitigate the COVID-19 transmission have severe impacts on the mental health of people, especially on those who become ill with COVID-19 or who experience grief as a result of this disease. Therefore, we understand that the impact on the population's mental health exists, especially when quarantine is long-lasting and has significant social and economic effects. This impact is greater on those who already had previous psychological distress or were directly affected by the disease (Ornell, Schuch, Sordi, & Kessle, 2020). Thus, we highlight four aspects as a source of concern during this period, which are epidemiologically considered as risk factors for suicidal behavior: increased use of psychoactive substances, loneliness and unemployment resulting from social distancing measures, and limited availability of mental health services. As previously mentioned, since suicide is a complex multidetermined phenomenon, it is important to elucidate that these factors do not constitute the causality of suicidal behavior. Hence, these factors cannot be analyzed separately, and other variables must be considered as well (Prado, 2019).

Collective and large-scale experience of fear and anxiety with a consequent increase in psychoactive substance use, especially alcohol, is an additional stressor for people who already had mental disorders before the pandemic (Haider, Tiwana, & Tahir, 2020). When community and spiritual support systems are less accessible to the population, this scenario becomes even more severe for people with suicidal ideation (Reger et al., 2020). The increased use and use disorder of psychoactive substances is of particular concern because they cause changes in cognition and impulsivity—factors that considerably impact increasing suicide risk (Botega, 2015; Gunnell et al., 2020).

Moreover, loneliness and unemployment, which were worsened due to the pandemic, have already been well-acknowledged in the literature as factors for increased risk of suicide (Weems, Carrion, McCurdy, & Scozzafava, 2020). Based on these two factors and on data from world suicide rates, Weems et al. predict an increase of almost 50,000 deaths above the expected number because of the pandemic's side effects. The following data demonstrate the relevance of socioeconomic vulnerability to suicide risk: in 2016, 79% of suicides occurred in low-and middle-income countries, which represents the highest percentage of suicide mortality in the world (World Health Organization [WHO], 2019). Some specific characteristics, such as being male, low socioeconomic status, and low-income countries, increase risks, and raise suicide rates (Weems et al., 2020). Historically, increased suicide rates have been observed during periods of economic crisis (Durkheim, 1897/1987; Panayi, 2020). In this respect, Reger et al. (2020) suggest that prolonged economic difficulties may be associated with an increased suicide rate in the United States of America (USA). Regarding particularly loneliness, it is a factor strongly associated with suicidal thoughts and behaviors, which is the reason why it is part of the main theories about this phenomenon (Joiner, 2007; O'Connor & Kirtley, 2018; O'Connor & Portzky, 2018; Reger et al., 2020).

Social distancing is a protective measure for the pandemic. However, it can also be a significant risk factor for those who already live with mental disorders such as depression, anxiety, schizophrenia, and psychoactive substance use disorder, known to be disorders associated with high suicide risk. Therefore, the closure of mental health services—which were already insufficient to meet the demand of countries like Brazil for mental health care in general—become of great concern. This concern includes people who already used these services and other groups that are now considered at-risk, such as COVID-19 frontline health workers—who have their physical and mental health highly impacted, presenting an increased suicide risk when compared to the general population (Mao, Fung, Hu, & Loke., 2018; Ornell et al., 2020; Stehman, Testo, Gershaw, & Kellogg., 2019). These professionals, who already face precarious conditions and suffering at work, may suffer even more during this period because of a constant fear of being infected, becoming vectors, and their patient's deaths from the disease. Therefore, the continuity of these services must be ensured (even remotely) to their regular users and high-risk groups that have already been recognized and mapped. Moreover, initiatives to promote mental health and psychoeducation for the population must be planned (Haider et al., 2020; Ornell et al., 2020; Reger et al., 2020).

Considering the high-risk groups for COVID-19, older adults, in particular, deserve attention because they are also a high-risk group for suicide—they represent the highest suicide rates in Brazil (MS, 2017). According to Mamun and Griffiths (2020), suicide among older adults increased after the SARS outbreak in 2003. This information can serve as a warning for the COVID-19 pandemic. Panayi (2020) points out that loneliness and isolation can make a person feel worthless and less important due to limited social support services during this period. Other studies also indicate feelings such as loneliness, not-belonging, and a sensation of being a burden to others as the main predictive factors for developing suicide ideation in all age groups (Hawton et al., 2012; Joiner, 2007).

School closures are another dramatic example regarding the wide population reach of the COVID-19 pandemic. This measure is necessary and effective to contain the spread of the virus and as prohibiting mass gatherings (Huremovic, 2019a). However, the concern with damages caused by school closure is also inevitable, especially for the most vulnerable population who have school meals as their main source of food (Viner et al., 2020). Students with special educational needs can experience significant developmental delays because of the lack of socialization. Social distancing can interrupt the process of development and independence that adolescents experience. Furthermore, it can deprive adolescents of certain rites of passage and make them deal with uncertainties about the future—not to mention students living in student residences (The Lancet Child Adolescent Health, 2020). Therefore, creating strategies that minimize infection risks is fundamental, as well as increasing government investments in education, because education is a predictor of health and well-being of the population that prepares the future generations of workers of a country (Viner et al., 2020). Moreover, creative solutions to problems faced by society have been found in educational environments.

Despite this, the literature also presents some considerations that can make quarantines caused by pandemics slightly less dramatic. Experiencing difficult times, such as these, can make people reflect on and change how they understand life and deal with death. This may lead some people to a sense of value and care for themselves and others, as well as make them fear their own death, thus reducing their vulnerability to suicide (Reger et al., 2020). An example of this is voluntary social distancing, which tends to reduce the quarantine's emotional impact because it is a necessary self-care measure.

The existence of a "common enemy" (in this case, the virus) can potentially create a sense of need for mutual care, which could lead to solidarity and minimize the feeling of loneliness by strengthening social connection as a result of shared experience (American Psychological Association [APA], 2020; Durkheim, 1897/1987; Huremovic, 2019a). This pulling-together effect has been observed, for instance, concerning the September 11 terrorist attacks in the USA (Reger et al., 2020).

However, this phenomenon's potential impact as a mental health protective factor can vary greatly depending on local culture and other related factors (mainly social ones), as the coherence of the government's strategies to communicate with the people. Therefore, Botega et al. (2006) emphasize the role of culture in characterizing risk or protective factors and their relevance regarding suicidal behavior. The authors explain that societies that value interdependence and encourage people to talk about their feelings and struggles favor protective factors for suicidal behavior. On the other hand, cultures in which individualization and independence are overvalued and understand asking for help as a sign of weakness tend to increase vulnerability to suicide risk.

In that regard, Zortea, Dickson, Gray and O'Connor (2019) also indicate that exposure to respectful, reliable, and reciprocal relationships with unconditional acceptance and care can significantly reduce suicidal thoughts and behaviors. Moreover, this can work as a strategy to restore mental health by promoting psychological well-being. Therefore, during quarantine, communication technologies—mainly social media and video conferencing applications—can be powerful social support tools to minimally keep a protective network and a psychosocial relationship even if "artificially" (Haider et al., 2020). Although the expression "social distancing" refers to isolation, it is worth remembering that the proposed distancing must be physical, not affective, and that maintaining connections is of fundamental importance to manage mental health and relationships (Reger et al., 2020). Furthermore, maintaining a routine and a healthy lifestyle based on a healthy diet, physical exercises, leisure, and relaxation techniques, is also relevant to reduce stress and promote health during this period (Shah et al., 2020).

Beyond individual possibilities—which are not limited to the mentioned examples—strategies for promoting mental health, economic and psychosocial terms, must be articulated on a large scale with strategies for fighting COVID-19 before, during, and after the pandemic to minimize suicide risk (Huremovic, 2019b; Mamun & Griffiths, 2020; Reger et al., 2020). Thus, in order to reduce adverse effects on mental health, the first guideline is to strengthen safe and official sources of information and curb the creation and spread of fake news, which is widely disseminated on the internet, because it can increase anxiety (Mamun & Griffiths, 2020; Ornell et al., 2020; Shah et al., 2020). Sensational news reporting on the pandemic and its impacts must also be avoided, and the population must be educated to read and evaluate information critically. Regarding this aspect, it is worth reiterating that suicide news has to follow the WHO guidelines because exposure to inappropriate suicide coverage during an already difficult period can further increase its risk (Associação Brasileira de Psiquiatria, 2016; WHO, 2000). In this regard, we highlight the initiative Health Without Fake News(Saúde Sem Fake News) of the Brazilian Ministry of Health, which has provided a WhatsApp number to which the population can text and check health-related information in order to fight fake news. On the other hand, a technical report from the Center for Research and Studies on Disasters (Centro de Estudos e Pesquisas em Emergências e Desastres em Saúde — CEPEDES) of Oswaldo Cruz Foundation (FIOCRUZ) indicates that the spread of misleading and ambiguous information in social media has hindered the adoption of social distancing measures in Brazil. This fact, in addition to contradictory or impractical messages from the President of Brazil, has increased and prolonged the negative consequences of the pandemic on the Public Health System, resulting in the overload of the health care system and its capacity for current and COVID-19-related problems, as well as encouraging the use of treatments with no scientific evidence (Silva et al., 2020, p. 8).

 

Mental health prevention and promotion during pandemics: Perspectives and challenges

Some strategies are recommended based on the specialized literature to contribute to mental health prevention and promotion during the COVID-19 pandemic and reduce suicide risk. Initially, it is worth mentioning that preventing disasters and conflicts and, consequently, pandemics, is by itself a universal preventive measure for suicide with a potential for wide population reach (Hawton et al., 2012). Therefore, it is of paramount importance that governments consider scientific data that predict and indicate possible disasters when planning public policies. Suicide can be prevented, and the forms of prevention that are already known should be used during this period to reduce its risk.

Therefore, considering the socioeconomic reality of developing countries that were already facing economic problems before the pandemic, such as Brazil, a budget must be allocated to create policies and interventions directly focused on the mental health of the population (Huremovic, 2019a). Such actions become even more urgent in regard to people who were already considered vulnerable before the pandemic. Nevertheless, in the present Brazilian context, the adoption of measures to prevent and treat mental health problems that go against those recommended by the scientific literature can be observed. Examples of this are medicalizing emotional suffering; cutting public budget for collective equipment for mental health prevention and promotion aimed at referring patients to psychiatric inpatient care units; reducing investments (human and material resources) in social protection sectors such as education, social assistance, art, and culture; and disarticulating the harm reduction policy.

Campaigns that emphasize the benefits of voluntary physical distancing, maintaining social and emotional connections are suggested as strategies that cause a positive impact. Moreover, we can indicate preventive measures such as implementing of debt and loan forgiveness programs, reducing postgraduate programs fees, reducing training programs' length and other approaches to encourage individuals to pursue a career in mental health (Weems et al., 2020). Regarding the latter, the literature suggests that governments implement national programs that include preparation to face epidemics and pandemics to improve the responses of institutions and health professionals to these situations (Ornell et al., 2020; Shah et al., 2020; Zheng, 2020).

Regarding specific strategies for the pandemic, Xiang et al. (2020) suggest some actions: (1) establishing multidisciplinary mental health teams to support patients and health professionals, and specialized treatment for patients with associated mental disorders; (2) communicating regularly and accurately with patients and health professionals about the COVID-19 outbreak in order to reduce feelings of fear and uncertainty—information about treatment plans and health status updates should be given regularly to patients and relatives; (3) health services must offer virtual psychological support to patients, family members, and the general population, and also use secure communication channels between patients and family members in order to reduce social distancing; and (4) suspected or diagnosed COVID-19 patients and health professionals should be regularly screened for depression, anxiety, and suicidal ideation. Huremovic (2019b) also describes these actions.

For most patients and health professionals, emotional and behavioral responses related to negative emotions are part of the adaptive process. On the other hand, people who show more significant aggravation in mental distress should receive specialized care; it is apparent that, in general, this population already experienced suffering before the pandemic. Mamun and Griffiths (2020) recommend offering support to people showing pre-suicidal behavior, such as individuals who express feelings of helplessness and hopelessness and feel trapped or like a burden to others.

Although providing remote care may sound strange and raise several concerns, such as insecurity about how to perform it and assurance of confidentiality, it is worth mentioning that suicide preventive measures carried out remotely have proven effective and are considerably better strategies than performing no intervention. Shah et al. (2020) indicate telephoning and emailing Caring Letters as examples for reducing suicide rates in randomized clinical studies. The authors emphasize that making follow-up calls is especially important for people infected with COVID-19 and who present suicide risk factors. Mamun and Griffiths (2020) also suggest telemedicine as an important strategy to help people who already have mental health problems. Nevertheless, we recognize that this service is quite inaccessible to the population in low-income and developing countries. Therefore, in terms of public policies, investment in planning collective actions should be a priority.

There is no universal protocol action protocol for crises, disasters, or pandemics concerning mental health (Ribeiro & Freitas, 2020; Ornell et al., 2020). However, as an intervention indicated in the literature, we emphasize Psychological First Aid (PFA) for psychosocial support to populations regarding the ability to reduce acute stress and promote effective coping strategies (Haider et al., 2020, Ribeiro & Freitas, 2020; Shah et al., 2020). In summary, PFA's practice involves active listening followed by guidance on practical issues that need to be resolved, such as contacting someone, making the patient feel safe and comfortable, and providing information about their current concerns and needs (Shah et al., 2020). Especially during a lockdown, offering help with elementary issues such as food and medicine to those in need can significantly contribute to reducing stress (Mamun & Griffiths, 2020).

In this context, mental health professionals, psychologists, psychiatrists, and social workers are responsible (1) to contribute with information on the most common adverse psychological effects of the pandemic and on the warning signs of suicide risk; (2) to encourage health promotion behaviors among people; (3) to integrate health services available to the population; (4) to facilitate problem-solving; (5) to empower patients, families, caregivers and health professionals; (6) to promote self-care among health professionals; (7) to learn more about suicide prevention techniques; (8) to screen each patient for suicidal ideation and behavior and develop a safety plan when necessary; and (9) defend the access to mental health services especially for poor populations affected by the pandemic and for patients and families who had the disease, among other actions (APA, 2020; Mamun & Griffiths, 2020). Regarding item 8, according to APA (2020), a safety plan in cases of suicidal behavior must involve, at least: (a) warning signs or triggers of suicidal crisis; (b) coping strategies; (c) contact information of people, professionals, and crisis care centers (such as the Center for Appreciation of Life—Centro de Valorização da Vida) for people who ask for help, including the contact of the reference professional; (d) methods to make an environment safer; and (e) a list of reasons to live. During pandemics, the safety plan must include only appropriate actions for this period (APA, 2020).

In the various perspectives presented for the prevention and promotion of mental health, we also acknowledge the difficulty of implementing such strategies in a country that already presented problems in its public health system before the pandemic. Unfortunately, there are not enough services or services properly organized to provide the necessary psychological support or to perform the proposed screening (Shah et al., 2020). Nevertheless, we understand that the description made in this paper demonstrates that mental health care is possible (and necessary) and indicates the importance of not neglecting public investment in mental health. The challenges are not peculiar to Brazil: in other countries, such as the United States of America, the mental health system is not prepared to deal with the increased demand (Wan, 2020). Specialists from that country have warned about a historical wave of mental disorders, emphasizing increased cases of depression, suicide, and drug and alcohol use disorder (Wan, 2020). Therefore, we conclude that in addition to efforts and investments that have been applied against COVID-19, concern, planning, and intervention are imperative in the psychosocial and economic spheres to reduce negative impacts on mental health.

 

Conclusions

Based on social distancing, it is possible to observe increased psychosocial vulnerability factors resulting from containment measures on the COVID-19 pandemic. Studies conducted on previous situations such as the SARS and MERS cases indicate that the effects on people's mental health last for a long time, even after quarantine, and are of both direct and indirect nature. Fear, anxiety, stress, irritability, and confusion are some of the most present emotions. The stigma attributed to those infected and survived and to bereaved relatives has been observed in epidemics and pandemics.

Therefore, to minimize the already acknowledged impact on mental health and take proactive measures to promote health, it is essential to develop and implement actions of assessment, support, and treatment of mental health, as well as to make them available and expand the services. Moreover, primary care professionals should receive psychological support and training in psychological first aid. In Brazil, it is necessary to strengthen and increase the psychosocial care network to provide better psychosocial support to the population.

Furthermore, considering that suicide prevention results from a series of intersectoral actions aimed at strengthening protective factors and mitigating risk factors, especially regarding the socioeconomic and relational vulnerability, we recommend that actions in this regard be implemented simultaneously with strategies to respond to the pandemic. We hope that in the face of the large losses due to the COVID-19 outbreak, governments worldwide do not hesitate to follow scientific predictions and work on strategic planning that evaluates the crisis as a whole to reduce the losses of lives by the pandemic and its impacts. Finally, although social distancing is essential to reduce infection rate, we observe that the pandemic's side effects on the mental health of populations increase suicide risk. Therefore, actions must be carried out to prevent or at least mitigate these effects to preserve human life from this other public health issue: suicide.

 

Acknowledgements

The authors would like to thank the Academic Publishing Advisory Center (Centro de Assessoria de Publicação Acadêmica, CAPA—www.capa.ufpr.br) of the Federal University of Paraná (UFPR) for assistance with English language translation and editing.

 

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Endereço para correspondência:
Rua Pedro Ivo, 560, apt. 08, Centro
Curitiba – PR, CEP: 80010-020
Telefone: (41) 9.9236.5647
Email: anelianaprado@gmail.com

Received in 29. may. 20
Revised in 14. oct. 20
Accepted in 31.dec.20

 

 

Aneliana da Silva Prado, Mestre em Educação Profissional e Tecnológica pelo Instituto Federal do Paraná (IFPR), Doutoranda em Psicologia Clínica pela Universidade Federal do Paraná (UFPR), é Psicóloga do Instituto Federal do Paraná (IFPR).
Joanneliese de Lucas Freitas, Doutora em Psicologia pela Universidade de Brasília (UnB), é Professora Associada da Universidade Federal do Paraná (UFPR). Email: joanneliese@gmail.com