key: cord-340110-nvjit17f
authors: Singh, Rakesh; Baral, Kedar Prasad; Mahato, Sharika
title: An urgent call for measures to fight against increasing suicides during COVID-19 pandemic in Nepal
date: 2020-06-20
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102259
sha: 
doc_id: 340110
cord_uid: nvjit17f

nan

Nepal, one of the LMICs, ranks seventh in the world and second in South Asia in terms of total number of suicides (Khatri PP, 2019) . The country has been experiencing increasing deaths due to suicide each year with 5124, 5317, and 5785 suicides in the year 2017, 2018 and 2019 respectively (Dhungana, 2020) . During COVID-19 pandemic, suicide cases in Nepal have increased by 20% and the rate of mental health illness is predicted to see a further rise after the pandemic (My Republica, 2020) . Starting from 24 th March 2020, within 74 days of lockdown measures to reduce transmission of COVID-19, on an average 16.5 people have lost their lives in a day while in the year 2019 the rate was 15.8 a day (The Jakarta Post, 2020) . The increase in suicide cases is somehow linked to COVID-19 pandemic and its responses in Nepal (My Republica, 2020) .

COVID-19 has brought many stressors including lost jobs, lost home, business loss, intimate part violence and child abuse due to enforced measures such as lockdown, social distancing and travel restrictions (Clay, 2020) and are primarily related to people's movement and interaction and income. Disrupted daily activities may be exacerbating preexisting mental illnesses.

Disturbed academic routines including suspension of classes, suspension of examinations of students and quick shift of teaching method applied in schools and colleges may be posing fear and threat towards mental wellbeing of the students (Clay, 2020) . Similarly, limiting the social networks among young people and keeping them apart from their loved ones and peers may act as key stressors among youths (Clay, 2020) .

At the same time, travel restrictions and physical distancing have been endangering the lives ofpeople affected with mental illnesses and those who are at the verse risk of developing mental illnesses, as it has been urged by most of the hospitals to ask people and patients not to visit health facilities, unless in an emergency condition. On one hand, this in turn will make both new and old patients having, complaints of and suffering from, mental illnesses unable to -seek health services as psychiatric medicines are also not available over the counter at the pharmacies (The Jakarta Post, 2020) . On the other hand, those in access of health facilities may feel fear to contract COVID-19 infection while seeking health services in the hospital.

Moreover, mental health problem is a stigma in Nepal and the ones who share their feeling attracted towards ending their lives are often labeled as chicken-hearted which encourages an J o u r n a l P r e -p r o o f individual to commit suicide. Social isolation, entrapment, and loneliness are the risk factors of suicide (O'Connor and Kirtley, 2018) and these conditions are likely to increase during the pandemic.

All these reasons including stressors, stigma, and increased risk of mental health problems have some connections behind the increase in the number of suicide cases and suicidal ideation.

Although, there is no such study that has established causal relationship between COVID-19 and suicides, crisis during pandemics have been linked towards increased suicidal cases.

When compared the deaths due to suicide with deaths due to COVID-19, the former is far ahead in Nepal. Though, it is very important to prevent COVID-19 transmission and deaths related to it, it is equally essential to promote and protect mental wellbeing of the people with especial focus on suicide prevention strategies. In line with this, while seeking healthcare services at health facility by COVID-19 patients, their assessment of mental health status should also be done in coordination with psychiatrists and/or psychologist. However, the indicators of mental health services are not optimal in Nepal with: services being concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per a population of 100000, 1.5 beds per a population of 100000 for mental health patients, and less than 1% of its total healthcare budget on mental health (Uprety and Lamichhane, 2016) . So, task shifting approach can be a viable strategy to delivering mental health needs of the people in Nepal. Task shifting approach means the shifting of tasks, from more to less highly trained individuals to make efficient use of these resources, allowing all providers to work at the top of their scope of practice. This includes primary care health workers (PHWs) or lay health workers (LHWs) such as doctors, nurses and other general paraprofessionals not specialized in psychiatry or psychology, and community workers (CWs) such as teachers, who may perform a particular mental health function in delivering promotion, prevention, high risk identification and treatment interventions (Patel et al., 2007) . The taskshifting approach has shown to being effective across a wide range of mental conditions in LMICs (van Ginneken et al., 2013) .

Further, a mechanism should be established to follow-up the discharged COVID-19 recovered patients via telephone by LHWs or CWs or PHWs to assess their mental health status and provide counseling service to help prevent stress, depression and mitigate suicidal thoughts as J o u r n a l P r e -p r o o f COVID-19 recovered patients are at higher risk of discrimination leading to loneliness (Singh and Subedi, 2020). Also, LHWs can be involved in educating caretakers and family members of the COVID-19 recovered patients to assess mental health risks and deliver appropriate preventive measures should be an alternative approach to protect mental wellbeing of COVID-19 recovered patients.

Psychiatrists, psychologists, psychiatric nurse, and trained LHWs and PHWs should do their best not only to aware patients but everyone else on ways to recognizing warning signs of suicide and how to keep them safe with needed care and support (Clay, 2020 showing rage or talking about seeking revenge; and displaying extreme mood swings (Rudd et al., 2006) . Also, at large scale, registration free webinars/video conferencing sessions using online media to aware people on identifying warning signs of suicide, its risk factors and stress management techniques should be a priority for healthcare professionals during crisis. Moreover, during COVID-19 pandemic with social distancing measures at place, to avoid social disconnection among people, the most viable media have been mobile, telephone and social media applications using internet. In this line in Nepal, currently Nepal Telecom and NCell, being the major communication sector, as a corporate social responsibility in response to COVID-19, have been educating public at large regarding mitigating measures of COVID19 including social distancing, hand washing, use of personal protective equipment (such as face mask), anyone can be vulnerable or affected, and sign-symptoms, and if experience symptoms seek health services immediately. While these measures are keys to fight against COVID-19 pandemic, it is also very important to protect and promote one's mental wellbeing in this unusual situation which could lead an individual to stress, depression, suicidal ideation thoughts among people due to perceived isolation and loneliness (Singh and Subedi, 2020) . Along with this, it could be a rational way to integrate health education messages directed towards identifying warning signs of stress, depression and suicidal ideation via the communication sectors while making phone calls as J o u r n a l P r e -p r o o f caller tune in the background to relay messages to seek mental healthcare services from nearest healthcare centers; simple messages showing importance of sharing feelings with family, friends, teachers, colleagues in protecting mental wellbeing; messages displaying or relaying helpline numbers to seek immediate counseling services. Moreover, while disseminating the messages these should be in local language as per culture and community considering the common language being spoken. Similarly, for those who fear from getting discriminated and contracted COVID-19 at health facility, helplines are the suitable ways to help provide them required support to prevent them from adverse consequences including suicide. These include but are not limited to: the Tribhuvan University Teaching Hospital suicide hotline (9840021600) and Patan Hospital crisis helpline for suicide prevention (9813476123) operating 24 hours a day; the Transcultural Psychosocial Organization (16600102005) provides helpline services between Mondays to Friday from 9:30 am to 4:30 pm (The Jakarta Post, 2020) .

Similarly, measures such as keeping self-busy, listening to music, involving in physical exercises and meditation and involving self in gardening activities could be possible strategies to protect and promote mental wellbeing while people are having limited social network, and social distancing measures are at place during crisis situations as that of COVID-19 pandemic.

In conclusion, the issue of mental health during COVID-19 pandemic has come to the forefront in Nepal with extremely concerning impact which includes increased suicidal deaths and suicidal ideation. The suicidal crisis presents an urgent need for launching a massive public awareness campaign across the nation so as to educate every member of the families about warning signs of suicide in order to identify those at risk, provide them with care and support, help them protect their mental wellbeing and prevent suicide. 

COVID-19 and suicide -COVID-19 Special Report

Suicide cases remain a challenge for law enforcement agency even during lockdown

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

Suicide leading cause of deaths

Suicide cases on the rise, mental health experts warn of a 'grim situation

The integrated motivational-volitional model of suicidal behaviour

Treatment and prevention of mental disorders in low-income and middle-income countries

Warning signs for suicide: Theory, research, and clinical applications

The COVID-19 pandemic, personal reflections on editorial responsibility

Over 1,200 people killed themselves during 74 days of lockdown in Nepal

Mental Health in Nepal -A backgrounder

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low-and middle-income countries

World Health Organization WHO, 2020. Suicide Prevention

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