A recent paper published in Psychiatric Research assessed trends in suicidal thoughts during the covid-19 pandemic. Using a national survey software platform—Amazon's Mechanical Turk (AMT)—researchers from Arizona surveyed participants between April 9-10, May 11-14, and June 10-13, 2020. Participants were located in areas all around the country and included English speaking adults over the age of 18. 

The main outcome of the study was prevalence of suicidality—which refers to thoughts of suicide, as opposed to any actual attempt or specific planning. Suicidality was measured using the Patient Health Questionnaire-9 (PHQ-9), which is a previously validated survey that is used as a screening tool for major depressive disorder (MDD). One of the questions of the PHQ-9 is "in the last two weeks, how often have you had thoughts that you would be better off dead, or hurting yourself in some way?" Other questions asked by the researchers included self-reported information on lockdown restrictions ('under lockdown' and 'sheltering-in-place') related to covid-19.

A total of 3,120 participants responded to the survey during the above-mentioned time periods. The prevalence of suicidal thoughts for survey participants not under lockdown restrictions at the time of the survey did not statistically change over the three month time period (16 percent in April to 17 percent in June). But, for individuals who self-reported being subject to lockdown restrictions, the prevalence of suicidal thoughts increased significantly from nearly 18 percent in April to around 31 percent in June.

There are some limitations to this study that render the findings somewhat less conclusive. The AMT population, while nationally represented, is skewed towards a slightly younger, more educated, and more affluent patient population who have access to technology. Additionally, it is uncertain whether the authors were able to survey the same participants during each time period to assess individual trends that occurred over time. It is more likely that data reported from each time period is a "cross-sectional" sampling of the population at that time point. This limits our ability to assume any causality between under lockdown/sheltering-in-place orders and suicidal thoughts. Also, the amount of time a shutdown occurred may have unexpected effects. Longer shutdowns that quelled the virus (making it safer for the economy to re-open) may have been associated with better mental health, compared to shorter shutdowns which have led to longer economic fallouts. That was not assessed in this paper. Finally, this study did not include non-English speaking individuals. All of these issues limit certainty and wider applicability of the findings from this study. 

Nevertheless, the results of this study have face validity—meaning that it "makes sense" intuitively. It is not hard to imagine how lockdown restrictions and the associated downstream effects—loss of work, food insecurity, lack of access to transportation—would have an adverse effect on the mental health of the population. 

The findings are a reminder that we should all try to occasionally check-in with family, friends, coworkers, health care providers, and others during the covid-19 pandemic, especially if we live in an area with active lockdown restrictions.  Many people are likely suffering in silence.

When the covid-19 pandemic began to unfold in the United States, unprecedented action was taken by Congress, including a section of the CARES act which temporarily placed a halt on evictions of residential tenants unable to make rent. That provision expired on July 24 and has not yet been revisited. 

Earlier this month, the US Centers for Disease Control and Prevention issued an Agency Order, that essentially renewed this policy and extended it for the duration of the pandemic, or until otherwise stated. Under the order, private individuals may not be evicted from their rental homes or apartments, as long as their inability to pay rent stems from "loss of household income, loss of compensable hours of work or wages, a lay-off, or extraordinary out-of-pocket medical expenses"—the latter of which is defined as any bill greater than 7.5 percent of one's income for the year. The order does not apply to other reasons that a tenant may be evicted—such as criminal behavior, threatening the health and safety of other residents, and property damage. Also, the order does not imply that people who can still afford to pay rent despite the economic problems caused by the pandemic do not have to do so. In addition, the action only applies to individuals earning no more than $99,000 per year (or double that for those filing joint tax returns).  

Of note, the order specifically states that the reason for the action results from what public health officials have learned about the spread of coronavirus and patterns related to eviction and the severity of the overall situation. For example, the order notes that most people faced with eviction would likely be forced to move in with relatives, which would mean entering into and creating more crowded living conditions than they previously had. The agency also sees this policy as reducing homelessness, which is especially important given how many cases have been associated with temporary housing (i.e. homeless shelters).

The legal terrain may be rocky. Legal experts I spoke with stated that an Agency Order from a federal agency such as the CDC is binding and enforceable, even though it has not gone through the formal "rulemaking process" that governs federal rules. This action appears to be possible as a result of the national state of emergency concerning covid-19. However, the CDC also stated that if this particular order were to become a rule, it would not need to go through the longer and cumbersome process that most rules must (including a public comment period) due to the time-sensitive nature of the provisions. That said, it is not clear whether this order would withstand a serious legal challenge, if for example, landlords decided to take the federal government to court over this issue.

Interestingly, the order does not apply to American Samoa, as there are no known coronavirus cases there. Of major American carriers, only Hawaiian Airlines serves Pago Pago directly. Currently, service to American Samoa on that carrier has been suspended with reconsideration occurring after October 1^st.