What's New in Critical Illness and Injury Science? Mental health and COVID-19: Self-inflicted and interpersonal violence amid a pandemic

We are living in difficult times. This month's issue of the International Journal of Critical Illness and Injury Science has a collection of articles relating to trauma, and this led me to reflect on how this pandemic may affect the human psyche in times of injury. More specifically, how can the influence of COVID-19 on a person's mental health contribute to violence or allow the consideration of violence? The stresses of disease, isolation, confinement, political philosophy, and the economy are creating a concerning, if not toxic, milieu for society. The result of any combination of these factors can lead to violence against self or others, specifically suicide, domestic violence (or gender-based violence [GBV]), street crime, and political violence. They are important concerns related to this pandemic, and the medical community should reflect and act on these matters during this COVID-19 pandemic.

This once-in-a-century catastrophic pandemic has presented the U.S. and the rest of the world with an unprecedented challenge. While mitigation of COVID-19's physiological effects is extremely important, what is also important is its effects on the economy as a driver of concern and dissent throughout the world. The resultant unemployment has reached frightening levels, as has the fear of global famine in low-income countries.[1,2] While some portions of the workforce can work from home, many cannot, and these individuals and their families are confronted with precarious circumstances.[3,4] In April 2020, 22 million U.S. workers became unemployed due to COVID-19, for a total of 33.5 million since March 13, 2020.[5] Ten years of job gains in America have disappeared. There were 7.1 million Americans unemployed before this date, so the total of Americans unemployed is now over 40 million for a real rate of 24.9%; at the peak of the depression, the unemployment rate was 25.6%.[6] This economic impact may be primarily due to the states' “stay at home” orders, and while such orders were quite necessary, the socioeconomic disruption that occurred has the potential to lead to violence. The types of violence that are addressed here fall into four categories: (1) suicide, (2) domestic violence, (3) street crime (rape, murder, assault, robbery, drugs, etc.), and (4) political violence.

Loss of a job and financial problems are well-recognized factors for suicide.[7] These problems are at the forefront of the COVID-19 pandemic. Quarantine can compound these factors, in that it is associated with adverse psychological effects, and these effects can last for a prolonged period of time,[3,8] especially in those who are already suffering from depression.[9] The severe acute respiratory syndrome epidemic in the first decade of this century created increased suicidal ideation and behavior among certain at-risk groups.[10] In no uncertain terms, this is occurring now in the general population and the medical profession.[10,11,12] Preventing suicide and mitigating its risk during this pandemic is extremely important, and this can be difficult when face-to-face meetings between patients and health professionals cannot occur. Therefore, “mental health services should develop clear remote assessment and care pathways for people who are suicidal and staff training to support new ways of working (with patients).”[13] In this vein, attention should be paid the population's access to means for suicide through readily available products, such as firearms, pesticides, and analgesics.[13,14] The concern for an epidemic of suicide in the U.S. is particularly worrisome because, in pre-COVID 2018, there were 24,432 firearm-related suicides reported.[15] Mannix et al. state that in regard to the U.S., “We are therefore a society primed for a suicide epidemic triggered by COVID-19.”[14] There is little doubt that the world is in the mid of a global psychological pandemic as it relates to suicides.[16]

It is not only violence to self that should concern society but also domestic and family violence, specifically GBV. The COVID-19 planet-wide lockdown has involved 80% of the world's population, which includes 1.6 billion children and 2 billion adults with their partners (ages 18–49).[17] It is evident that domestic abuse has risen worldwide during the COVID-19 pandemic.[18] Furthermore, there is a relationship between confusion, anger, posttraumatic stress disorder, and increases in substance abuse during periods of quarantine, which also increases the propensity for family violence.[8] Social distancing, isolation, quarantine, and job losses during the COVID-19 pandemic in China contributed to an increase in domestic violence.[19,20] Those caring for children need to maintain contact with family members during times of peril in order to keep children well-adjusted and feeling safe.[21] The Secretary-General of the United Nations, Antonio Guterres, wrote on Twitter, “I urge all governments to put women's safety first as they respond to the pandemic,” because public health emergencies expose the vulnerabilities of women and inequality, generally, and result in increased acts of violence.[22]

The growth of domestic violence during the COVID-19 pandemic will likely follow historical patterns of previous epidemic/pandemic catastrophes; more stressors, more violence.[23] During these times of pandemic and quarantine, women are on the frontline of family care and frequently sail into harm's way.[24] What is particularly troubling is that 33% of women who have been in any relationship have experienced sexual or physical violence from an intimate partner,[25] and in humanitarian and emergency situations, this is compounded.[26] Losing support networks, family members, and sources of health care, as can happen in a pandemic, may lead to an increase in GBV.[24] The basis for such an inequitable situation is that, for the most part, women are assigned to the arena of care work, which includes household chores, caring for children, and the infirm. They sustain their families and community and are underpaid, undervalued, and are essentially rendered invisible in much of the world.[27] In addition, “any outbreak has the potential to create an inordinate amount of racism, hysteria, xenophobia, and thereby causes “othering” that exacerbates the life of minorities and migrants, especially women.”[28,29]

Typical/usual street violence seems to have decreased with the closure of bars and nightclubs and bans on after curfew movements.[17] Marupeng reports that since March 27, when the South African government imposed a pandemic lockdown with a ban on alcohol sales, there were a 71% decrease in homicides, an 85% decrease in rape, and an 83% decrease in serious assaults when compared with the same week of the previous year.[30] Reports of a similar nature have emerged from Latin America, and even San Francisco, CA, has seen 50% in assault and robberies.[17] However, this has not happened everywhere. Mexico's daily homicide totals have not abated. Ferri claims that this is probably occurring because the cartels are in more intense competition regarding dwindling chemical procurements, transportation difficulties, and falling prices.[31] Furthermore, as alluded to above, the U.S. citizenry has readily available access to firearms. In March of this year, the acquisition of firearms by Americans doubled compared for the same month of the previous year.[32] While there is no documented reason for this finding, a concern about possible criminal acts of desperation or general lawlessness during these times of economic hardship, as well as the perceived threat of a government crackdown on the purchase of weapons, may have been factors.[17] It remains to be seen how such an increase in gun sales mingled with a public's fear of “others” will affect the U.S. over the ensuing months.

Violence as it relates to politics is also on the mind of many of the world's governments and citizenry. Several recent events in the U.S. have brought this concern to the foreground. The storming of the Michigan State House by armed protesters opposing their governor's lockdown order[33] and the targeting of the Ohio Health Director's home (she is Jewish) by Nazis who chanted antisemitic slurs as they voiced their opposition to her shelter-in-place order[34] are prime examples. What kind of environment provides fertile ground for this to occur? Peter Knoope, of the journal Clingendael Spectator, recently addressed eight reasons of why COVID-19 may lead to political violence.[35] Political instability may not only occur in a country but also between countries. He points out the following concerns: (1) major differences in welfare and income between segments of society; (2) competition over basic needs, for example, food and health care; (3) availability of firearms in the face of high societal stress; (4) high levels of domestic violence, which are an early indicator of trouble – what men do in their home, they will also do outside of it; (5) charismatic political leaders using identity politics to encourage violent actions; (6) the inability of certain judicial systems to prevent anger and frustration; (7) crises, such as COVID-19, on which governments are tightly focused, could allow exploitation of situations by extremist groups (e.g., Boko Haram); and (8) the loss of confidence and trust by citizens in their governments. Knoope concludes by stating, “Current high levels of trust in the government is delicate. The same leadership that is obeyed at the present, can be blamed for the loss of life tomorrow.”[35]

For extremist groups that are antithetical to the West and high-income countries, COVID-19 is celebrated as an opportunity to unravel Western democratic norms.[36] Jihadi groups in West Africa found that the pandemic has given them openings to conduct larger raids and increase cross-border incursions. Shia militias continue cross-border attacks despite their contribution to the spread of COVID-19 through their operations, as have ISIS, al-Shabaab, and the Taliban. In addition, far-right operators are using social media platforms in the U.S. and the United Kingdom to target religious minorities and have found ways to enter “Zoom” courses at universities to disrupt classes and harass educators.[36]

As physicians, health-care professionals, educators, public health workers, and administrators, we must remain keenly aware of the health-care, socioeconomic, and political aspects of our respective environments. We must remain vigilant with respect to opportunities that may arise wherein we can use our influence to prevent and mitigate the effects of disruptive and violent circumstances and events. Our participation in the public discourse regarding violence during this pandemic is of paramount importance.