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        Are COVID-19 survivors at increased risk for suicide?
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        Are COVID-19 survivors at increased risk for suicide?
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The coronavirus disease 19 (COVID-19) outbreak first emerged in China late last year. The COVID-19 epidemic has spread to all continents. Millions of people got sick with COVID-19. In this letter to the editor, I suggest that the COVID-19 survivors especially individuals who had severe COVID-19 are at increased suicide risk. Suicidality among individuals who had COVID-19 may be related to both psychological and neurobiological factors.

Psychological factors that may increase suicide risk among COVID-19 patients include learning about their diagnosis, anxiety, and distress related to symptoms of the disease and stress related to hospitalisation and hospital treatment. Realising that they have COVID-19 may be very stressful, especially for low-resilient individuals. Symptoms of the disease, especially severe symptoms, as well as social isolation and fear of infecting other people may lead to a serious psychological trauma. Individuals who needed an admission to an intensive care unit (ICU) are at especially high risk of developing post-traumatic stress disorder (PTSD), depression, anxiety, sleep abnormalities, and cognitive impairments (McGiffin et al., Reference McGiffin, Galatzer-Levy and Bonanno2016). Ventilation adjustments, gaps in anaesthesia and/or analgesia, long sedation, restraint use, and other ICU-related factors contribute to a profound psychological effect of ICU hospitalisations. A recent study in China indicated that 96.2% of recovering COVID-19 patients had significant post-traumatic stress symptoms (Bo et al., Reference Bo, Li, Yang, Wang, Zhang, Cheung, Wu and Xiang2020).

Multiple lines of evidence indicate that stress-related disorders including depression, PTSD, and sleep disorders are associated with suicidal ideation, suicide attempts, and death by suicide (Sher, Reference Sher2019). Sleep abnormalities are a stand-alone risk factor for suicidal behaviour. Cognitive impairments are also associated with suicidality (Sher, Reference Sher2019). Many recovering COVID-19 patients have physical symptoms for a long time and experience psychosocial difficulties such as loss of employment and financial issues. Both physical symptoms and psychosocial stressors contribute to suicidal behaviour (Sher, Reference Sher2019).

COVID-19 has neurobiological effects (Asadi-Pooya & Simani, Reference Asadi-Pooya and Simani2020). Studies have shown human coronavirus infections are associated with neuroinvasion and neurotropism (Asadi-Pooya & Simani, Reference Asadi-Pooya and Simani2020). A recent review of the effect of COVID-19 on the central nervous system indicates that neurological manifestations are present in about 25% of the patients (Asadi-Pooya & Simani, Reference Sher2020). Headache, dizziness, acute ischaemic stroke, ataxia, seizures, and other neurological conditions have been observed in COVID-19 patients. Neurological conditions including ischaemic stroke and headache are associated with increased suicide risk (Hudzik & Marek, Reference Hudzik, Marek, Cannon and Hudzik2014).

COVID-19 survivors should be regarded as individuals at elevated risk for suicide. The single most significant predictor of suicide is the presence of depression. Recovered COVID-19 patients need to be screened for depression and suicidality. Many coronavirus disease survivors will need long-term psychological interventions. There should be specific strategies to enhance the psychological condition of COVID-19 survivors and reduce suicidality in this population. We need to examine what kind of early interventions in coronavirus disease survivors may decrease psychiatric morbidity and suicidality in the future.

References

Asadi-Pooya, AA and Simani, L (2020) Central nervous system manifestations of COVID-19: a systematic review. Journal of Neurological Sciences 413, 116832. doi: 10.1016/j.jns.2020.116832.
Bo, HX, Li, W, Yang, Y, Wang, Y, Zhang, Q, Cheung, T, Wu, X and Xiang, YT (2020) Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. Psychological Medicine doi: 10.1017/S0033291720000999 [Epub ahead of print].
Hudzik, TJ and Marek, GJ (2014) Neurological disease and suicidal behavior. In Cannon, KE, Hudzik, TJ (eds.). Suicide: Phenomenology And Neurobiology. Cham, Switzerland: Springer International Publishing.
McGiffin, JN, Galatzer-Levy, IR and Bonanno, GA (2016) Is the intensive care unit traumatic? what we know and don’t know about the intensive care unit and posttraumatic stress responses. Rehabilitation Psychology 61, 120131. doi: 10.1037/rep0000073.
Sher, L (2019) Resilience as a focus of suicide research and prevention. Acta Psychiatrica Scandinavica 140, 169180. doi: 10.1111/acps.13059.