Updated: May 4, 2020
Over the last few weeks, I have spent far more time and money than I should have at grocery stores since it is the only exercise and social exposure I am getting during this government-imposed quarantine event. As a retired addictions clinician and student of psychology, I have noticed some very subtle but concerning changes in people over the past few weeks.
When all this started, there was a certain fear that gripped America, a rush to take care of our own, trying to control the things we could control. This took the form of buying excessive amounts of toilet paper, paper towels, and foodstuffs that could be hoarded away -- just in case.
Then, we began to accept the fact that five years' worth of toilet paper didn’t do much for the anxiety that boiled within us, and as the store shelves began to fill up again, this phase passed. What didn't fade away was that gnawing feeling inside of us that something was amiss, as there existed a certain incongruence between what we were being told and what our eyes were actually seeing. Suddenly, the focus was on the effects of the virus itself, the numbers of dead and sick being shouted at us like a macabre scorecard on television, radio, and in newspapers. People were still talking to each other but with a certain wariness. Tensions were increasing as politicians admonished mature citizens like children who dared to question the authority of their parents.
Over this past week, that wariness began to turn into anger for some, fear in most. Demonstrations started to occur in cities where people, angry about the loss of their jobs and being forced to stay indoors, took to the streets, and challenged politicians. In local stores, more than once I witnessed frustration explode into arguments, people with tired eyes looking over medical masks as they were forced into involuntary compliance with following arrows showing them what direction to walk.
Watching a once vibrant society walking slowly and quietly in purposeful nanny state compliance, shopping cart in front, was eerily reminiscent of the 1977 movie "The Stepford Wives" (see video below). At checkouts, people stood in squares on the floor in order to meet the “social distancing” requirements. Then came the extension of stay at home orders. Politicians ordering its citizens to wear masks if out in public, tax-payer funded playgrounds and parks would remain closed despite 70 degree sunny days, and schools would be shuttered until September. Public transportation could only be used "if it were absolutely necessary".
At the office, we began fielding more calls from senior clients concerned about their finances and overall social situation. They wanted to know about the senior centers, which for many was the only socialization they had. Were they ever going to open again? What was happening with their friends? Other older adults, who had a job to go to every day, had nothing to do but sit on a couch and stare at the television which spouted 24-7 news about COVID-19. For them, their reason for living had seemingly evaporated in the blink of an eye, their sense of purpose gone. Would it ever come back? Yet another loss in their lives.
Then today happened. It was the first of the month, a big shopping day for seniors as the social security check arrived in their accounts. As I walked the aisles of Market Basket, I saw an elderly woman standing in front of the cans of coffee, tears streaming down her cheeks, wetting the handsome purple and yellow homemade mask that haphazardly covered her face. She wasn't making a sound, just looking at the many brands in front of her, reaching for a yellow bag of Cafe Bustelo with her right hand, while wiping away her cascading tears with her left. I approached her and asked if she was alright or if I could help her with anything.
She looked at me, pulled the mask down from her face, and began talking with a Portuguese accent and broken English. First about the current situation, saying "I have been through many things, including Salazar (an autocrat who ruled Portugal until 1968 and was often called a fascist) and I never see anything like this. This horrible." She spoke of concerns for her children, both losing their jobs and her daughter expecting her second child. "Why bring the baby into world today, why. What life will they have?" Her voice cracking as she unloaded her frustrations and fears.
She told me that she lived at a well known low-income high rise for seniors in New Bedford. She had been cut off from having visitors and had not seen her children in weeks because they were afraid to even pick her up because of fear of giving her the coronavirus. In her words, "I old and I can get sick, you know." As we wrapped up our conversation, her final words to me were, "I not know how much longer I take this, I never, ever think life to be like this. For me, for anybody." And sadly, she is not alone.
The COVID-19 pandemic has led to quarantines and extremely restrictive measures across the world, leading to the crash of the global economy, an increase in the unemployment rate, stock market losses, retirement funds being substantially affected and, in the long term, a major effect on the mental health of people of all ages, but most of all, seniors.
Last week, President Trump made a statement warning of the “surging suicide rate” as a result of the economic shutdown and social isolation. Almost immediately, the Associated Press, no friend of the current occupant of the White House, shot down this statement, calling it “baseless”. The authors of the AP story, Lauren Neergaard, Ricardo Alonso-Zaldivar, and Hope Yen, wrote: “there’s no evidence that suicides will rise dramatically, let alone surpass coronavirus deaths." Further, they stated, that “historically, suicides tend to diminish as society pulls together in a common purpose.”
Here’s the problem with their politically motivated story, historically, suicides do increase during troubled times, including during times when unemployment surges and personal finances have been decimated. And, their story, dismissing the concerns about increased suicides as "baseless", is in direct contradiction to a study by Lancet Psychiatric Report published for May 2020 entitle “COVID-19, Unemployment, and Suicide”. In this study, the Lancet article cited research specifically around other pandemics and economic downturns, which should hold more weight than a group of reporters with a political agenda. Let's review it.
According to Lancet, when it comes to the subject of increased suicidal behaviors, there certainly did exist an uptick not only in attempts but in completions -- especially within the context of economic stressors. The researchers used the number of job losses due to COVID-19 that were a part of the International Labour Organization’s press release from March 18, 2020, in which they reported job losses were expected to number anywhere from approx. 6 million on the low side to nearly 25 million on the high side.
Given these numbers and the associated mental health issues that result, researchers predicted an increase in suicides of anywhere from 4.9% to 5.6%. Again, this is just in those affected by job loss and/or other economic stressors. But there are deeper issues here to explore.
The Lancet article also stated, “The likely adverse effects of the pandemic on people with mental illness, and on the population's mental health in general, might be exacerbated by fear, self-isolation, and physical distancing.”
“Suicide risk might be increased because of stigma towards individuals with COVID-19 and their families. Those with psychiatric disorders might experience worsening symptoms and others might develop new mental health problems, especially depression, anxiety, and post-traumatic stress (all associated with increased suicide risk). These mental health problems will be experienced by the general population and those with high levels of exposure to illness caused by COVID-19, such as frontline health-care workers and those who develop the illness,” continued the Lancet piece.
And one other thing about the Associated Press article, the “coming together” part of their story had to do with the terror attacks of 9-11. What was different about that was we did have a common purpose and we were able to deal with this as a group. At sporting events, concerts, and other social gatherings, as a group, Americans defiantly confronted the terrorists and refused to “let them win”. The major difference, we were not separated and isolated from our support systems. During the coronavirus lockdown, we can’t come together.
So now, let’s look at this data in the context of our seniors. Even before this pandemic, senior suicide was an increasing problem. Of the more than 47,000 completed suicides that occurred in our country in 2017, those 65 and older accounted for more than 8,500 of them, this, based on numbers from the Centers for Disease Control (CDC).
To break this down further, men 65 and older faced the highest risk of suicide, while those 85 and older, regardless of gender, are the second most likely age group to die from suicide. And, by the way, the World Health Organization (WHO) reports that for every completed suicide, there are 20 individuals who attempt it. If these numbers are correct, that means that among seniors 65 and older, there are 180,000 suicide attempts and completions.
Although there are many factors that contribute to the problem of senior suicide, one of the primary reasons cited is loneliness. Obviously, the older we get, the more likely we are to begin to experience losses in multiple areas. These include family members, spouses, pets, friends, and old ways of life. At some point for our seniors, there is no one left who knew them from the past. Add to this, there is a loss of independence, hearing, sight, memory, and good health. Any and all of these factors contribute to their loneliness.
Now let’s add in the COVID-19 pandemic and the social isolation factor. Those in nursing homes who looked forward to seeing loved ones weekly no longer have that due to the quarantines in place. They may have had friends within these facilities who may have gotten sick and died. Staff are no longer able to do daily activities with them as they did in the past for a myriad of reasons, all legitimate for the most part. Yes, they can have iPads, Facetime, ZOOM, but this is not the same as a loved one sitting alongside them, holding their hands while engaging in conversation.
In these cases, the importance of touch cannot be understated. In infant research, lack of touch has been cited as a contributing factor in "failure to thrive" diagnoses. Studies from the 1940s through today continue to support this fact. A more recent study done with Romanian children in orphanages showed that children lacking touch and emotional bonding exhibited higher levels of the stress hormone cortisol, which can cause increases in blood pressure and heartrates, affect blood sugar levels and contribute to depression.
And studies in seniors done by the University of Miami’s Touch Research Institute show that touch for seniors can lessen pain, lower blood glucose levels, improve immune system functioning, and enhance alertness. Sadly, studies regarding seniors and touch are few and far between, but anecdotally, nurses and other direct care staff all tell of the importance of touch and the involvement of loved ones with their patients in nursing facilities.
And what about those seniors who are living alone or in assisted living residences? Most of them have been isolated from family and friends as well - whether it be self-imposed or staff required. In some cases, family members are fearful of visiting them given the fact that they are among the most vulnerable victims of this novel coronavirus. In assisted living residences, nearly all of them have been isolated from family and friends for health-related reasons. Many residents report being kept in their rooms 24 hours a day with their three meals being delivered in the morning - the extent of any social interaction for them.
Most seniors in elderly housing situations have lost access to group events, senior centers, family, and meaningful staff interactions. A large number have described this time as “depressing” and “scary”.
Given that, let’s discuss depression as a contributing factor to senior suicide. Many researchers tend to believe that depression is a larger contributor to this problem than loneliness, given the fact that many who have completed suicide have had regular contact with family and friends.
So if it’s not loneliness, what then causes the depression? According to their research, it is a “lack of purpose”. Most of our seniors have always been self-sufficient, but now they are relying on others for their needs which leads to feelings of hopelessness, powerlessness, and helplessness. Although many who complete suicide do not have a diagnosis of depression, that certainly doesn't mean that clinical depression was not present.
Alcohol and drug abuse, another problem among this age group, was on the rise with seniors prior to this “lockdown”. And just how has coronavirus affected this?
It has been reported that older adults and seniors are purchasing more alcohol during this "lockdown" which most likely indicates their consumption has increased as well. Off-premise alcohol sales were up 55% in the third week of March 2020 as compared to the same month last year, according to data reported by Nielsen, an international measurement and data analytics company.
Prior to the coronavirus lockdown, alcohol was the most commonly abused substance among adults aged 65 and older as alcoholism rates were on the rise among this group. One recent study even found a substantial increase in binge drinking among women aged 60 and above. The most common reason given for the misuse of alcohol among seniors is "coping with stress".
Stress is considered to be one of the most prominent risk factors when it comes to alcohol abuse and there is an interesting physiological fact about this. Chronic alcohol use results in neuroadaptations in stress and reward pathways in the brain, which leads to a dysregulation of cortisol responses. These neuroadaptations lead to increased cravings for alcohol in response to stress.
So, those who drink to relieve stress end up with more stress because drinking leads to the release of more of the stress hormone cortisol. And as discussed earlier, long term isolation increases cortisol levels which contribute to high-stress levels. So, we have a problem that feeds upon itself.
And when it comes to alcohol and suicide, alcohol is a component in nearly 25% of all completed suicides in the United States. Other research has indicated that suicide is 120% more likely among adult alcoholics than the general population. This factor should not be overlooked.
And finally, one last slap at the Associated Press article stating it was "baseless" that suicides occur in response to pandemics or economic downturns. The Lancet not only disagrees but cites specifics:
“There is some evidence that deaths by suicide increased in the United States during the 1918–19 influenza pandemic and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) epidemic.”
Other research also found that “suicides tend to go up during periods of economic downturn: the suicide rate rose to a record high of 21.9 per 100,000 people in 1932, in the depth of the Great Depression.” How will this affect seniors? Many had small jobs that gave them a "sense of purpose".
So let's review what we have discussed and try to put this all together:
All evidence and statistics point to the fact that senior suicide was on the rise prior to the coronavirus lockdown;
Major contributing factors to senior suicide are loneliness and depression, all brought on by social isolation and feelings of “powerlessness, hopelessness, helplessness" and a lack of a sense of purpose - all issues present during this current quarantine event;
Touch and face to face visits are lacking during a time when the most vulnerable population is losing loved ones. This lack of touch has been shown to increase cortisol levels which contribute to increased levels of stress;
Increased levels of stress lead to depression and depression is a factor in senior suicide;
Alcohol use was on the increase among seniors prior to the coronavirus lockdown. Alcohol use is increasing among seniors who are socially isolated. Alcohol is being used to relieve stress, however, alcohol abuse actually fuels stress which becomes a vicious cycle;
Alcohol is connected to at least 25% of completed suicides.
And finally, the signs of mental health problems will be missed by loved ones due to the social isolation of seniors as a result of government-imposed "stay at home" and "quarantine" orders. Doctors, who are using telehealth services and not seeing seniors face to face, will also not see the telltale signs of decompensating mental health.
Given this, we may be entering a "perfect storm" when it comes to a major suicide epidemic with our seniors. In fact, the steps taken in an attempt to halt the spread of coronavirus through the use of social isolation could very well prove worse than the virus itself. We may be sitting on a mental health powderkeg right now and hopefully, we are prepared to address it.