Between COVID and Substance Use, Deaths of Despair May Continue to Rise

What’s happening – It’s all too easy to find reports of increased use of alcohol and drugs as a coping mechanism for the stresses of the pandemic. Social isolation, economic uncertainty, boredom, and anxiety about the future are just some of the drivers of this behavior. But when does increased use become an addiction? A recent study by NIAAA Director George F. Koob looks at alcohol use disorder (AUD) during COVID and how it could increase “deaths of despair” – that is, deaths from overdose, suicide, and liver-related problems. His team used AUD as an example to explore the role of negative emotional states in the addiction cycle, while incorporating the effects of the pandemic.

“It is possible that increases in pandemic-related stress combined with elevated substance use could fuel an increase in mortality from overdoses, suicide, and alcohol-related liver disease. The pandemic challenges us to develop new ways to meet the expanding needs of the etiology, diagnosis, prevention, and treatment of addiction…” Dr. Koob et al concluded.

The details – Read the full study by Koob et al in the American Journal of Psychiatry and see our Q&A with Dr. Koob about addiction treatment. Brush up on your terminology: hyperkatifeia or drug withdrawal, coined in 2010 by Koob, Shurman, and Gustein, and deaths of despair, coined in 2015 by Case and Deaton. In case you’re not convinced, their newly released book on this topic, Deaths of Despair and the Future of Capitalism, is on the just-announced NY Times 100 Books of the Year.

The perspectives

Why it’s complicated – The combination of substance use, mental illness, COVID-19, and the social upheaval of the pandemic is complicated indeed. Even experiencing two of these factors presents a challenge for treatment. For example, a new study in Lancet Psychiatry found that the probability of being diagnosed with a psychiatric disorder after surviving COVID-19 is nearly 20% and that nearly 6% of COVID-19 survivors will receive their first diagnosis of mental illness. Other examples include:

  • A NIDA blog by Dr. Volkow notes that people with SUDs have a higher risk of contracting COVID-19 and suffering from virus-related complications.
  • The WHO warned last spring that alcohol consumption can make a person more vulnerable to COVID-19 and urged governments to restrict access to it. The agency also stressed that drinking high-strength alcohol does not kill the virus, seeking to dispel the myth circulating at the time. They also published a fact sheet in several languages that may be worth sharing with patients.
  • Surveys from European Addiction Research, University of Michigan, and the Kaiser Family Foundation asked people about substance use and mental health during the pandemic.

The conversation

  • @WBOY12News (WBOY 12News) in West Virginia tweeted that, “Since the pandemic, the state has seen an increase in overdoses and deaths due to overdose but has also seen more people in recovery.”
  • In a reply to a Boston Globe article about rising COVID-19 rates, physician @khanaftab9003 (Aftab Khan) said, “COVID-19 is associated with 3-4 times higher rates of depression, anxiety, PTSD and substance abuse. In one hand we need social distancing and quarantine measures to curb the spread, but on the other hand these mitigation strategies are causing great deal of mental disorders…”
  • A general observation: Many news articles posted to Twitter about rising COVID-19 rates and the possibility of lockdowns and restrictions receive replies demanding a focus on helping people with mental health issues, substance abuse, suicide, unemployment, economic hardship, and death due to what commenters feel were caused by the initial lockdowns. The feeling expressed among these Twitter users that those issues are being ignored.

In practice – How to manage alcohol and substance abuse in older adults. A review of medication-assisted treatment for AUD, with helpful takeaways from psychiatric residents.


True or False? You can consider addiction treatment finished after a short-term detox program. Get the answer directly from George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) at the National Institutes of Health.

Get the Answer

Self-Harm Is Growing in Teens: Patterns to Watch For

What’s happening – Teens who know someone who self-harms may be more likely to engage in the behavior, too. A new study suggests that non-suicidal self-injury (NSSI) behaviors like skin cutting, scratching, and burning without the intent to die, might be “contagious” among teenagers. Researchers also found that knowledge of a friend’s NSSI was significantly associated with suicidal ideation and attempt, in addition to that person’s own NSSI behavior. The authors conclude that training adolescents (and educating parents) to resist peer pressure and reducing the acceptability and normalization of NSSI may put an end to this pattern.

The details – Read the full study by Syed et al in Acta Psychiatrica Scandinavica.

Also of note

  • Both boys and girls are at high risk for self-harm, according to a 2018 study on the prevalence of NSSI in adolescents, reporting rates for boys between 6.4% to 14.8% and between 17.7% to 30.8% for girls.
  • A JAACAP article demonstrated that low conscientiousness, high avoidance, and parent’s substance abuse history could be predictors of NSSI in adolescent girls.

Why it’s complicated – In the past, NSSI was considered a symptom of borderline personality disorder but the definition has changed over time. NSSI is associated with other psychiatric diagnoses and can also be present in people without any other psychiatric diagnosis. The DSM-5 added NSSI disorder as a Condition for Further Study in 2013. While research is still ongoing, the need to focus on adolescent mental health has been thrown into sharp view due to the pandemic.

What’s being done –

  • On its resource page, NAMI recommends the mHealth app Calm Harm for teens struggling with self-harm. The app is created by the UK charity stem4 and uses principles of dialectical behavior therapy (DBT). The app now provides a brochure that can be shared with adolescents focused on managing the urge to self-harm during the pandemic.  A Twitter search for Calm Harm shows many favorable reviews by app users.
  • Last week, Instagram implemented new tools to ban self-harm and suicide posts in the UK and Europe. The company strengthened its policies in 2019 and said it aims to strike a balance between prohibiting self-harm content and allowing people to share stories of recovery. A review of self-harm on Instagram was published in September 2020 in PLOS One.

The conversation

  • @NCISH_UK (The UK’s National Confidential Inquiry into Suicide and Safety in Mental Health) Tweeted links to a 3-part webinar series by the Royal College of Psychiatrists about COVID-19 and suicide prevention.
  • Pediatrician and child psychiatrist @PinskyElizabeth (Elizabeth Pinsky, MD) linked to an article about increased depression and thoughts of self-harm in adults 18-24, tweeting “We don’t yet have these data, but I am convinced the numbers for children and adolescents are going to be just as devastating — if not worse.”
  • Another physician, @aciaranello (Andrea Ciaranello, MD, MPH), replied to @PinskyElizabeth with this CDC report showing mental health-related visits for children aged 5 to 11 rose 24% and kids 12 to 17 years increased 31% compared with 2019.

In practice – A discussion of predictors (and potential prevention of) mental health disorders in children and adolescents. mHealth apps are also available for use in treating eating disorders.


The Cycle of Poor Sleep and Cognitive Decline Isn’t Going Away

What’s happening – Getting too little or too much sleep is associated with a decline in cognitive function, according to a recent paper published in JAMA. Researchers examined nearly 20,000 people in China and England and found that sleeping for less than 4 hours or more than 10 hours led to increased cognitive decline when compared to the reference group who slept for 7 hours each night. The team reported an inverted U-shaped association between sleep duration and global cognitive decline.

The details – Read the full study by Yanjun et al in JAMA Network Open.

Why it’s complicated – During normal sleep, the glymphatic system “cleans” the brain of waste, notably beta-amyloid and tau proteins. If the glymphatic system is unable to clear them, due to sleep-duration or sleep-quality issues, these proteins can build up in the brain as plaques and tangles, contributors to Alzheimer’s and dementia. Research indicates that as we age, glymphatic function slows, quality of sleep declines, and the risk of dementia increases. Inadequate sleep in older people can affect physical, mental, and cognitive health, including the risk of developing dementia.

And as with all aspects of life, COVID-19 is complicating sleep. We know that stress leads to poor sleep, which in turn leads to increased stress and anxiety – sometimes about not getting enough sleep. Finding solutions that work is essential to ending the cycle.

The perspectives –

  • A commentary in the same issue of JAMA discusses the findings and notes the challenges for sleep researchers on the issue of sleep duration and cognitive function.
  • In April 2020, a survey of 4,913 caregivers in Italy showed that sleep disturbances worsened or manifested among elderly dementia patients during the quarantine.
  • An ongoing worldwide study into sleep disturbances caused by the pandemic seeks to survey several thousand adults about their sleep habits.
  • See reports of COVID-19’s effects on insomnia and advice on how to cope from Columbia University, Neurology Today, UC Davis, and Psychology Today, to name a few.

The conversation

  • @phx_ua (The Sleep Medicine Fellowship at the University of Arizona College of Medicine – Phoenix) tweets, “As more data and literature emphasizes the link between sleep and cognition, poor sleep and increased risk of dementia, it is imperative for sleep clinicians to continue to learn from our behavioral and cognitive experts to collaborate on ways to help our patients. #findacure”
  • Harvard researcher @smpzzz (Shaun Purcell) linked to his team’s paper published this week in Nature about sleep architecture and cognitive performance in seniors, tweeting that “individuals who, compared with similarly aged peers, had better cognitive performance tended to have profiles of sleep more often seen in younger, healthier individuals.”
  • @NatGeo (National Geographic) says, “Sleep is a simple way to bolster the immune system against colds, influenza, and other respiratory infections” and links to their public report on COVID-19 and sleep.

In practice – Why patients with schizophrenia can’t sleep and what to do. Managing sleep dysfunction and other challenges in veterans with PTSD.

Last Updated: Jul 20, 2021