Meaning in life and demoralization: a mental-health reading perspective of suicidality in the time of COVID-19.

Consequences on mental health have been reported in general population, vulnerable individuals, psychiatric patients, and healthcare professionals. It is urgently necessary to study mental health issues in order to set priorities for public health policies and implement effective interventions. Suicidality is one of the most extreme outcomes of a mental health crisis. It is currently too early to know what the effect of COVID-19 will be on suicidality. However, authoritative commentary papers alert that most of the factors precipitating suicide are, and probably will be for a long time, present at several individual existence levels. A number of prevention measures and research considerations have been drawn up. A point of the latter, recommended by the International COVID-10 Suicide Prevention Research Collaboration, states that "the COVID-19 suicide research response should be truly multidisciplinary. This will foster research that addresses the different aspects and layers of risk and resilience.It will also foster research that informs prevention efforts by taking a range of perspectives" (Niederkrotenthaler et al., 2020). In this light, we would like to propose a reading perspective of suicidality that takes into account Meaning in Life (MiL) and demoralization. Both of the constructs were studied in heterogeneous populations with extreme life situations having led to a fracture between a "before" and an "after", and play a role in affecting suicidality, respectively as resilience and risk factors. In clinical practice, during these unprecedent times, we wish that this more inclusive approach could: 1) contribute to prevention, by delineating more individualized suicidal risk profiles in persons conventionally non-considered at risk but here exposed to an extremely uncommon experience, 2) enrich supportive/psychotherapeutic interventions, by broadening the panel of means to some aspects constitutive of the existential condition of a person who is brutally confronted with something unexpected, incomprehensible and, in some ways, still unpredictable.

Introduction

A mental health crucial and urgent problem, inlcuding suicidality

The COVID-19 epidemic has caused a disruption of people’s daily lives worldwide. Many countries have banned gatherings of people and enacted strict confinement and quarantine measures to control the spread of this highly communicable virus. There have been economic consequences, including a reduction in the manufacture of essential goods, disruption of supply chains, and loss of employment. Consequences in healthcare have included overloading the capacity of medical systems as well as postponement of non-essential medical procedures and medical checkups which have put patients at higher risk. In addition to effects on the physical health, there have been severe consequences on the mental health with probable far-reaching consequences that will peak later than the actual pandemic (1, 2). They have been reported in the general population (3, 4, 5), vulnerable individuals (including the elderly, patients with chronic long-term health conditions, people residing in high COVID-19 prevalence areas, and having in their entourage a member infected or who has died) (6, 7) patients with previous mental health disorders (8), and healthcare professionals (5, 8-12). It is urgently necessary to recognize and study mental health issues in order to set priorities for public health policies and implement effective psychiatric interventions (1, 2).

Suicidality is one of the most extreme outcomes of a mental health crisis. It is currently too early to know what the effect of COVID-19 will be on suicidality (13). Very few studies addressed the impact of epidemics on the latter (7). Evidence of an increase in suicide deaths was only reported in the USA during 1918-1919 Spanish Flu epidemic (14) and in Hong Kong during 2003 Severe Acute Respiratory Syndrome (SARS) epidemic among older people (15). However, authoritative commentary papers published during Covid-19 pandemic alert that most of the factors precipitating suicide are, and probably will be for a long time, present at several individual existence levels (7, 13, 16, 17). These factors include social isolation/entrapment/loneliness (particularly for bereaved persons), loss of employment/financial stressor, increased alcohol consumption, increased domestic violence, access to certain lethal means (eg, firearms, pesticides, and medicines) maybe more readily available because of stockpiles at home, intensive exposure to hopelessness stories by the media, emerging or exacerbated psychological and psychiatric suffering, barriers to mental and somatic health, and stigma. The list is long, but not exhaustive (7, 13, 16, 17). Case reports of suicides related to COVID-19 have begun to appear in the literature (18, 19).

A number of prevention measures and research considerations have been drawn up (7, 13, 16, 17). A point of the latter, recommended by the International COVID-10 Suicide Prevention Research Collaboration, states that “the COVID-19 suicide research response should be truly multidisciplinary. This will foster research that addresses the different aspects and layers of risk and resilience relating to the health consequences of COVID-19, including suicide and suicidal behavior. It will also foster research that informs prevention efforts by taking a range of perspectives” (13). In this light, we would like to propose a reading perspective of suicidality’s protective and risk factors during the COVID-19 pandemic that takes into account two constructs, Meaning in Life (MiL) and demoralization, which are taking place in the psychiatric literature besides the well-defined psychiatric nosographic entities, in approaching individuals exposed to this extremely uncommon experience.

The constructs of Meaning in Life and demoralization

First introduced by V. Frankl’s (in the 1950s) (20) and Frank’s (in the 1970s) [21], both of the constructs were historically investigated in a wide variety of heterogeneous populations involving holocaust and wars survivors, combat troops, immigrants, disadvantaged individuals (also from an economic viewpoint), community samples, and patients with somatic diseases (especially, cancer patients requiring palliative care) and mental diseases (22-31). In most of these conditions, individuals were confronted with extreme life situations that have led to an often-incomprehensible fracture between a “before” and an “after” (20-31).

MiL, initially defined trough three inherent assumptions, 1) the perception and search for beauty, 2), creativity, and 3) the effort to choose one’s attitude, also under despondent circumstances (20), was later described from a multitude of different theoretical perspectives (25,26). Among these, an integrated model of meaning-making has been proposed facing a particular environmental encounter (22). In this context, global and situational meaning were distinguished and meaning made and meaning-making efforts were taken into account as well (22). This model thus allowed for considering the process aimed at adjusting one’s experiences of events that are discrepant with one’s beliefs, plans, and desires (22). Another model was also recently proposed, in which two constructs are distinguished: the presence of MiL and the search for MiL, having different clinical implications (23). It was further suggested that a consensus in various MiL’s conceptualizations could be reached on three dimensions: 1) coherence, or a sense of comprehensibility and ability to making sense; 2) purpose, or a feeling of aims and direction in life; and 3) significance, or a focus on how important one’s life as a whole feels (24). Notably, coherence is activated in situations where meaning is disrupted and the individual experiences distress and the related necessity to construct or reconstruct a framework to understand suffering and chaos, conditions that can be assimilated to a pandemic.

Likewise, the first definition of demoralization as “a persistent failure to cope with internally or externally induced stresses that the person and those close to him expect him to handle. Its characteristic features, not all of which need to be present in any one person, are feelings of impotence, isolation, and despair” (21), were enriched and refined by subsequent multiple theoretical contributions (27-31). Notably, “feelings of impotence, isolation and despair” are feelings that can be experienced during a pandemic and especially the subjective impotence which is considered the clinical hallmark of demoralization (27). A widely used model of demoralization is the one in which the construct of demoralization is supported by the presence of five sub-constructs: 1) loss of meaning, 2) hopelessness, 3) helplessness, 4) sense of failure, and 5) dysphoria (28, 29). According to this model, interestingly, the two constructs of MiL and demoralization are intimately and opposing linked, because meaninglessness is one of the sub-constructs underlying the construct of demoralization( 28, 29). Precisely this link could be the key, in the specific context of the Covid-19 pandemic, to utilize these theorical model in psychotherapeutic interventions. That is, exploring with the patients the sub-constructs of demoralization and the sense that the patient attributes to them, in order to restructure and reinforce a MiL that allows him to mitigate his suffering.

Role of Meaning in life and demoralization in suicidality

Both MiL and demoralization play a role in affecting suicidality, respectively as resilience and risk factors. MiL emerged as a protective factor against suicidal ideation (SI), suicide attempt (SA), and completed suicides, directly or through mediation/moderation models with other suicidality-related variables (for a review, see 32). As it has been shown by recent works performed by our group in a cohort of patients attending an emergency department for SI and SA, higher presence of MiL was associated with lower SI and SA2 (33. The main themes that these suicidal patients identified as MiL carriers, or potential carriers, in their existences were interpersonal/affective relationships, with emphasis on family, children, and grandchildren (34). Higher levels of emoralization, at the contrary, were strongly and positively correlated particularly with SI (35).

The exploration of MiL and demoralization in suicidality is intended as only complementary to the recognized and essential well-established risk/protective factors, psychiatric diseases, and neurobiological substrates (36-40).

Conclusion

Implications for clinical practice

These are unprecedent times (7, 16). In clinical practice, we wish that a more extensive characterization of resilience and risk factor in suicidality also under the perspectives of MiL and demoralization in people confronted with the COVID-19 pandemic can be useful, as recently recommended (13). This approach, first, can contribute to prevention, by delineating more individualized suicidal risk profiles in persons conventionally non-considered at risk but here exposed to an extremely uncommon experience. Second, it can enrich supportive/psychotherapeutic interventions, by broadening the panel of means to some aspects constitutive of the existential condition of a person who is brutally confronted with something unexpected, incomprehensible and, in some ways, still unpredictable (41-45).