Last Friday’s shocking announcement that Knox County had seen eight suicides in a 48-hour period — nearly 10 percent of a normal year’s total of local cases handled by the Knox County Regional Forensic Center — appeared to shake local officials to the core.

Suicide rates have been rising in both good times and bad during the first two decades of the 21st century.

“That’s startling and disturbing and really, really challenging,” Dr. Martha Buchanan, director of the Knox County Health Department, said in her daily briefing on Friday.

Buchanan choked back tears as she delivered a message to those who feel overwhelmed by the unprecedented circumstances of the novel coronavirus pandemic. 

“If there’s anyone out there who is struggling, I encourage you to reach out. Reach out to your pastor. Reach out to your friend. There are some hotlines you could reach out to,” she said.

“It’s OK if you’re struggling,” she continued. “It’s OK if you’re scared. Just talk about it.”

The suicide numbers gave Knox County Mayor Glenn Jacobs second thoughts about the county’s response to the coronavirus, which is manifested by a Safer at Home order that has closed all nonessential businesses and banned gatherings of more than 10 people.

“That number is utterly shocking and makes me wonder, is what we are doing now really the best approach?” he said in his weekly video briefing.

Both agreed that residents should continue to limit going out in public, practice social distancing and good personal hygiene, and take responsibility for their safety. Buchanan emphasized the human need to help one another in a dark time, while Jacobs — without making any specific proposal — shaded toward getting the economy moving again as a defense against despair.

The clear implication was that the coronavirus and its response contributed to the spike in suicides. That might be the case, suicide experts say, but they caution against confusing corellation and causation, especially when suicide often has multiple factors in each individual case.

“You need to be careful with causation,” said William Hahn, an instructor and psychologist with the University of Tennessee Student Counseling Center. “You can’t say it’s a cause and effect.”

Financial Stressors

The economic hit from the pandemic landed faster and harder in Knox County than the coronavirus itself. Companies, universities and Oak Ridge National Laboratory began curtailing business travel early in March. One week ago today, less than 24 hours after Gov. Bill Lee imposed statewide restrictions and recommendation, Buchanan issued a Safer at Home order that closed all nonessential businesses in Knox County.

According to the state Department of Labor and Workforce Development, new unemployment claims in the week ending March 21 soared to 39,096 from 2,702 the week before. County-level numbers aren’t available yet, but the 16-county East Workforce Development Area centered on Knoxville saw about 6,800 new claims. Those numbers don’t include new claims filed last week after the Safer at Home order was issued.

James Bullard, president of the U.S. Federal Reserve Bank of St. Louis, told Bloomberg News in a recent interview that unemployment nationally could reach a staggering 30 percent for the second quarter of the year, higher than the peak during the Great Depression. 

The $2 trillion emergency relief bill passed by Congress last week is designed to at least cushion the blow to businesses and individuals, but a recent report in the Harvard Business Review cautioned against relying too much on forecasts at this time because “multiple dimensions of the crisis are unprecedented and unknowable.”

Meanwhile, the number of presumed positive coronavirus cases has risen steadily. Knox County, the state’s third most populous county, reported 41 cases as of Sunday, which ranks 6th among all 95 counties. Seven Knox County patients are being treated in area hospitals for COVID-19, the disease caused by the novel coronavirus.

In his video address, Jacobs, a libertarian-leaning Republican, referred to tweets from former U.S. Sen. Bob Corker in support of President Donald Trump’s expressed desire to “re-open” the economy by Easter, April 12. (On Sunday, Trump instead extended social distancing guidelines to April 30.) While he did not propose easing the Safer at Home order issued last week, the mayor made it clear he was concerned about reviving businesses.

“So far, the response to COVID-19 has been to sacrifice the global economy,” Jacobs said. “In fact, I’ve heard people say you can have a healthy economy or healthy people. This is a false dichotomy. The truth is, a sick economy produces sick people.”

Underlying Conditions

Experts emphasize that suicide is complex and individual, however. UT’s Hahn said the people most at risk of committing suicide are those with underlying psychological conditions, particularly mood disorders such as depression.

External factors, like divorce or job loss, can push someone with underlying psychological issues over the edge of the abyss. “People who are vulnerable are more vulnerable right now,” he said.

The link between unemployment and suicide has been long established. A study published in the American Journal of Public Health in 2011 found that between 1928 and 2007, the overall suicide rate generally rose during recessions and fell during economic expansions, especially among working-age adults between the ages fo 25 and 64 years old.

Since the turn of the century, however, the overall suicide rate appears to have been unaffected by economic cycles. The suicide rate was already rising when the Great Recession hit in 2007. Between 2000 and 2016, the suicide rate increased from 10.4 to 13.5 per 100,000 Americans, according to a National Center for Health Statistics analysis.  

And the national suicide rate has been steadily rising through the economic recovery from the Great Recession, despite a roaring stock market and record low unemployment rates. 

Even before the coronavirus hit, the rate of suicides in the United States reached levels not seen since World War II. According to the American Foundation for Suicide Prevention the suicide rate was 11.75 per 100,000 in 2018 and stood at 14.21 percent in 2018. In Tennessee, the rate has been higher — 16.6 per 100,000 in 2018.

The coronavirus struck like a bomb on the economy. Almost overnight, restaurants, retail stores and manufacturing plants shut their doors, with or without a government mandate. New claims for unemployment skyrocketed. With little or no warning, thousands of people were out of work. Many of those who have jobs work in isolation at home. People who live alone have been cut off from much direct human contact.

Determining whether a death is a suicide is a long investigative process, according to Capt. John Kiely, who commands the Major Crimes Unit of the Knoxville Police Department. 

All suspicious deaths are considered homicides until that possibility is ruled out, he said. Likewise, no death is ruled a suicide until other explanations are eliminated. “These investigations are aimed at giving victims and families justice and peace of mind,” he said.

Police and the Medical Examiner’s Office conduct independent death investigations, though they work together and share information to arrive at their conclusions. Kiely said investigators look at the totality of evidence before making a determination about a case and that even a note left by the deceased is just one piece of the puzzle.

Understanding a person’s state of mind is difficult, he said. Overdoses, for example, can be intentional or accidental. “Those are the tough calls,” Keily said. “If you don’t have it beyond a shadow of doubt, you don’t want to call it a suicide.”

Despite the timing, Hahn said it’s premature to make assumptions about last week’s spike in suicides. “These are questions we can only know in retrospect,” Hahn said. “There’s a rush to draw conclusions.”

Reaching Out

The increase in the number of suicides in recent days has not been accompanied by a corresponding rise in the number of calls to suicide hotlines.

“We were anticipating a huge increase in the number of calls, but we’re not seeing that yet,” said Bruce Marshall, executive director of the Contact Care Line, which typically receives about 10 calls a day from Knox County residents.

However, he said, every single caller to the Contact Care Line lately has mentioned the coronavirus pandemic. Counselors have even stopped tracking the numbers. “It’s essentially 100 percent,” Marshall said. “It’s on the top of everyone’s mind.”

Marshall, Buchanan and Hahn encourage people to talk to one another. Asking a friend, family member or loved one who seems despondent about their condition could prompt them to open up about their fears, they say. 

“Just asking the question can open up dialogue,” Hahn said.

Marshall said that in many cases, it doesn’t matter whether the listener has professional credentials. “Ninety-nine percent of that is knowing you’re not alone, that people will listen,” he said.

Hahn said people can take other concrete steps to reduce the chances they or a loved one would take their own lives. He recommends limiting or abstaining from the consumption of alcohol, which is implicated in about half of suicides. 

Another important measure is restricting access to drugs and guns — methods that make suicide easier to accomplish. More than half the people in the U.S. who commit suicide shoot themselves.

“We love our guns and there are a lot of guns in East Tennessee, but it’s a good time to lock them up,” Hahn said.

Though talking with someone in need can help, people should not hesitate to phone a helpline to contact a professional crisis counselor. “If somebody's got a concern about themselves or someone else, I would tell them to call,” Marshall said.

(Contact Care Line can be reached through the National Suicide Prevention Lifeline, 1-800-273-TALK (8255); the Tennessee Statewide Crisis Line can be reached at 1-855-274-7471; text “TN” to 741-741 for the Crisis Text Line.)

“These are challenging times,” Buchanan said. “We’re acknowledging our humanity and all that goes with it, all the amazing stuff and all the scary stuff that goes with being human, that human condition.”