The Impact of COVID-19 on the Suicide Prevention Helpline in The Netherlands
Abstract
Abstract.Background: Although the number of suicides did not increase in 2020, there are concerns about the mental health consequences of the COVID-19 pandemic. Aims: To present the demand for the Dutch suicide prevention helpline during times of lockdown and to describe the coronavirus-related problems discussed. Methods: An observational and exploratory study analyzing the frequency of helpline requests and registration data (n = 893 conversations). Results: Demand for the helpline did increase, but with no distinctive relation with the lockdown measures. During the first lockdown, approximately a quarter of the analyzed helpline conversations were registered as coronavirus-related by the counselors. Most frequently mentioned conversation topics were the interruption to or changes in professional help, social isolation and loss of structure, and ways to find a distraction from suicidal thoughts/rumination. Limitations: Observational study design prevents causal inferences, and demand for the helpline is impacted by multiple factors. Conclusion: These coronavirus-related problems made help-seekers vulnerable to suicidal thoughts and a reduced desire to live. That many suffered from loneliness is concerning as this contributes to the risk of suicidal ideation. The distress among help-seekers due to the sudden loss of mental health care underscores the importance of maintaining contact with those in care and lowering the threshold for help.
The COVID-19 pandemic has had a major impact on societies around the world, with governments implementing varying “lockdown” approaches to prevent further spread of the virus and overburdening of the healthcare system. Mental health experts have expressed concern that the number of suicides might increase as a result of the pandemic, as known risk factors for suicide such as social isolation, loneliness, financial stress, domestic violence, and alcohol consumption would likely increase during the lockdown (Gunnell et al., 2020; Reger et al., 2020). Fortunately, the first study to examine suicides in 21 high- and upper-middle-income countries, including the Netherlands, shows a consistent pattern of suicide numbers remaining unchanged or even declining in the first months of the pandemic (Pirkis et al., 2021). However, this does not take away concerns about the short- and long-term impact of the pandemic on mental health.
Findings from self-report surveys among the general public indicate an increase in suicidal ideation associated with the impact of COVID-19 measures. O’Connor et al. (2020) analyzed mental health and well-being during the first 6 weeks of the pandemic in the United Kingdom and saw an increase in suicidal ideation during the initial weeks of lockdown, with one in seven young adults reporting suicidal thoughts in the last measurement. Lockdown measures have had a profound impact on access to mental health care. In the Netherlands, the influx of patients into mental health care has fallen sharply since the first measures were announced. In May 2020, the Dutch Healthcare Authority reported a reduction of around 50% of the number of referrals from general practitioners to specialized mental health (Dutch Healthcare Authority & Trimbos Institute, 2020). Reduced access to mental health care and worsened mental health in the general public could lead to an increase in the demand for informal care, like national helplines. A study by Arendt et al. confirmed an increase in the number of calls to the national crisis hotlines in both Germany and Austria between January and April 2020, while the lifting of some of the governmental restrictions in Austria occurred at the same time as a decrease in the number of calls (Arendt et al., 2020).
Up to this point, few peer-reviewed studies have investigated the content of helpline conversations during the pandemic. Our study explores the coronavirus-related problems of a specific at-risk population, namely users of the suicide prevention helpline in the Netherlands: 113 Suicide Prevention. Since its foundation in 2009, mental health professionals, volunteers, and clinical interns provide round-the-clock anonymous support by phone and chat. A 2013 study on the chat service gave some insight into its visitors' profile, with the vast majority of visitors being female (73%), younger than 35 years (76%), and in suicidal crisis (86%) (Mokkenstorm et al., 2017). No research has yet been done on the characteristics of callers to the telephone helpline. Demand for the helpline is strongly influenced by increasing brand awareness and media coverage since brand awareness increased from 15% in January 2017 to 75% in 2020, and media often refer to the helpline in their news items concerning suicidality.
The aim of our study is twofold. First, we investigate if there was a greater demand for the suicide prevention helpline since the start of the pandemic and, more specifically, during the lockdown measures. Second, we explore the nature of the coronavirus-related problems help-seekers mention during their conversation with the helpline at the time of the first lockdown. We expected a rise in demand for the helpline during the lockdown measures and a decrease in demand after the lifting of the governmental restrictions. Regarding the topic of the helpline conversations, we expected to see calls about known risk factors for suicide such as loneliness and social isolation, financial problems, and increased substance abuse (Turecki et al., 2019). Our study is exploratory in nature because of the unusual conditions in which it unfolded. After the pandemic began, we started as soon as possible to register the problems help-seekers were struggling with as a result of the pandemic. By focusing on a specific at-risk population, we still believe it provides important insights into the mental health concerns of the COVID-19 pandemic.
Methods
Demand for the Dutch Suicide Prevention Helpline
The data set used to determine the demand for the helpline contained the (anonymized) weekly number of chat and phone call requests of the years 2017 up to 2020. By using data at a weekly level, we eliminated minor daily fluctuations. We decided to look at the number of call requests rather than the actual conversations that were conducted, to eliminate fluctuations in reachability, and to create a more accurate view of the helpline's demand. It would be of interest to determine to what extent the demand for the helpline can be attributed to new help-seekers and to which extent to previous users or frequent callers of the helpline. However, due to the anonymity of our helpline, this is unfortunately not possible. The duration of helpline conversations is not included in this study as a new helpline policy was introduced during the studied period; during peak hours, a more efficient form of call handling was used to considerably shorten calls and increase the helpline's reachability. Consequently, it is not possible to draw conclusions about the length of the conversations and their development over time in the context of the pandemic.
Nature of the Coronavirus-Related Problems in the Helpline
As of March 19, 2020, the following two nonmandatory questions were added to the registration data of chat and phone call conversations in the helpline: “Were the consequences of the coronavirus one of the reasons to contact the helpline?” (yes/no). “If yes, what problems did the person asking for help mention?” As a response to the last question, counselors could write a summary. Incoming chat requests first go to triage. In triage, a triage psychologist determines the situation of the help-seeker. Only when physical safety is guaranteed by the help-seeker (distances themselves from hazardous means/location during the conversation), the chat is transferred to a counselor. Because triage psychologists are busy taking multiple incoming chats at the same time, we only collected registration data from the transferred chats. Between March 19 and June 1, 2020, the helpline handled 15,170 chats. Of those chats, 3,738 (25%) were transferred and these counselors registered the prevalence of coronavirus-related problems in 1,586 (42%) chat conversations. During the study period, there was no triage system for the incoming phone calls, meaning that a phone call directly goes to an available counselor. Between March 19 and June 1, 2020, counselors of the helpline handled 8,864 phone calls. After 30% (2,655) of the phone calls, counselors answered the coronavirus-related questions.
The summaries of the coronavirus-related conversations were coded to explore the nature of the problems. A test sample was coded by two researchers (MB, SM) and led to 13 categories: loneliness/social isolation, loss of distractions/routine/structure, interruption or change in regular care, feelings of entrapment/being stuck at home, fear of the coronavirus and feelings of insecurity, (unsafe) home situation or relationship problems, (imminent) unemployment or financial problems, increased feelings of depression/anxiety, concerns for someone else with suicidal thoughts, (physical) separation from loved ones, work or study stress/increased workload, increased substance abuse, and other. The full sample was then coded by the first author, and the second author checked the coded data, while conflicts were discussed with the last author to increase the reliability of the coding. Conflicts were then presented by the first author to the last author and consensus was sought. Cases could contain multiple categories. In the case of a chat, the help-seekers' self-reported age, gender, and living situation were analyzed based on answers to a compulsory prechat questionnaire. The age of five chat callers could not be included due to an invalid entry. For telephone calls, gender was, when possible, coded based on the summary provided by the counselors. Please see Electronic Supplementary Material 1 (ESM 1) for a flowchart of the chat and phone call samples. All analyses were conducted using IBM SPSS Statistics version 25.0 and Microsoft Excel version 16.0.
Ethical Approval
This study was approved by the Medical Ethical Committee of Amsterdam UMC (registration number: 2020.0689).
Results
Demand for the Helpline
Figure 1 displays the demand for the helpline for 2017 to 2020. The graph illustrates many fluctuations and seasonal effects and shows a steady increase in demand for the helpline for the past few years. When looking at 2020, we see a noticeable higher demand in the majority of the weeks compared to 2019. The graph shows an upward trend from the second half of 2019 that continued into Spring 2020. Contrary to our expectation, the first lockdown measures did not lead to an increase in demand for the helpline; instead, the graph indicates a decrease in demand. Although we see an increase in demand after the start of the second partial lockdown, which seems to last throughout the winter, this is mostly in line with the previous years during the fall.
Nature of the Coronavirus-Related Problems
Approximately a quarter of the chat (23%) and phone call (26%) conversations were registered as coronavirus-related by the counselors. After the removal of not completed or not-coronavirus-related cases, the summaries of helpline conversations provided by the counselors led to a data set containing information of 296 chat conversations and 597 phone calls. In the telephone sample, it was possible to identify the gender of the caller in 491 of the 597 cases, with 62% of them being female. Of the chat users, the vast majority were female (76%) with 82% of the users stating that they were younger than 35 years. Most of them lived with their parent(s) (42%), almost a quarter lived alone (24%), and 19% with a partner and/or children. The ratio between genders differed between chat and telephone (χ2 (1, n = 780) = 20.2, p ≥ .01). Figure 2 shows the proportion of coronavirus-related calls accounted for by the different coronavirus-related problems. For privacy reasons, numbers smaller than five are not presented. Below we discuss the most prevalent type of problems.
Interruption to or Change in (Professional) Care
Most of the coronavirus-related calls concerned the topic of the interruption to or change in regular care. In 30% of the coronavirus-related chat conversations and 31% of the phone calls, help-seekers talked about the cancellation or postponement of professional help, the difficulties in getting in touch with their therapist, the change from face-to-face to remote therapy, the reduction in the number of contact moments, and the increasingly long waiting lists. Help-seekers were distraught about the fact that their treatment or assistance for mental or physical problems came to a sudden halt. Some help-seekers were not allowed to leave their residential facility and were feeling trapped and isolated. Others had family members living at home while they were normally in an assisted living residence or treatment facility.
Loneliness and Social Isolation
As expected, many help-seekers suffered from feelings of loneliness and social isolation. Eighteen percent of coronavirus-related chat conversations and 26% of phone calls covered this topic. Many were affected by the closure of community centers, schools, and bars, not being able to play sports and engage in hobbies and the obligation to work from home. Some help-seekers were feeling locked up, isolated, and bored. Others were in self-isolation because they were vulnerable to the virus due to chronic illness, medical conditions, or treatments. There were help-seekers in need of a listening ear and someone to talk to due to loneliness that triggered (a relapse into) depression.
Lack of Distractions, Loss of Routine, and/or Structure
Another frequently mentioned problem, often related to loneliness and social isolation, was the loss of structure and routine and a way to find a distraction. In 18% of the coded chat conversations and in 13% of the phone calls, help-seekers mentioned having too much spare time, losing structure in the day by not being able to go to work or school, not finding a way to distract themselves from suicidal thoughts and rumination. Some help-seekers mentioned that without the activities in life, they lost their desire to live.
Fear of the Coronavirus and Feelings of Insecurity
Ten percent of both the coronavirus-related chat and phone call conversations, were about the fear of getting infected with the virus and receiving proper care, and being afraid of leaving the house or going to the hospital or general practitioner. They also related to being worried about loved ones getting or being infected with the virus or about the guilt of maybe having infected others, and being worried about future perspective and quality of life when the measures would continue for a long period of time, which worsened their depression or suicidal thoughts. Help-seekers also mentioned that the fear of infection worsened their anxiety attacks, hypochondria or mysophobia. Others talked about the triggers of the frightening footage of hospitals abroad.
(Unsafe) Home Situations and/or Relationship Problems
Ten percent of the coded chat conversations and 5% of the phone calls covered the topic of the help-seekers home situation. Counselors described conversations about help-seekers feeling trapped at home and experiencing more stress, arguments, and tensions at home or being stuck in unsafe, violent, or abusive home situations due to the lockdown measures.
Concerns for Someone Else With Suicidal Thoughts
In 7% of the coronavirus-related calls (3% chat, 9% phone call), counselors spoke to people who were concerned about someone else who was potentially struggling with suicidal thoughts. These included relatives, friends, teachers, and professionals who spoke about someone who was socially isolated, had lost their job, was unable to access care or experienced changes in professional care, relapsed into addiction or depression, or shared personal messages about suicidal ideation.
(Imminent) Unemployment and/or Financial Problems
Around 5% (5% chat, 6% phone calls) of the conversations were with individuals who were worried about becoming unemployed or experiencing financial difficulties. Help-seekers mentioned losing their jobs due to the lockdown, being self-employed and out of work, their lack of money and prospects, and losing their purpose in life due to the loss of their job.
Other
The category other consists mostly of conversations with help-seekers who had difficulties with the coronavirus measures, disagreed or were angry with the authorities, experienced difficulties due to travel restrictions, felt that there was too much focus on the coronavirus, or experienced worsening of their current situation.
Discussion
The objectives of our study were to investigate whether the demand for the national suicide prevention helpline increased during the pandemic and to explore the nature of the coronavirus-related problems mentioned during the helpline conversations. The numbers of chat and phone call requests showed a steady rise in demand for the helpline, but with no distinctive relation with the lockdown measures, at least as yet. In contrast to Arendt et al., the first lockdown measures did not lead to an increase in demand for the helpline; on the contrary, the results even indicate a decrease in demand. This is in line with a study by Brülhart et al. (2021), which found no increase in calls to the national Lifeline in the United States during the first COVID-19 wave but saw an increase above prepandemic levels during subsequent waves. As to the calls during the first lockdown, it is interesting to notice that only approximately a quarter of the chat and phone conversations were labeled as “coronavirus-related” by the counselors. As predicted, loneliness was a prominent topic in the coronavirus-related conversations. But financial problems and increased substance abuse did not come up as often as we expected. The most common coronavirus-related topic was the interruption to or change in regular care. Help-seekers were struggling with the sudden cancellation or postponement of professional help, the difficulties in getting in touch with their therapist, the change from face-to-face to remote therapy, and the increasingly long waiting lists. The second and third most talked about topics were feelings of loneliness/social isolation, and the loss of distractions, routine, and structure. The results also suggest differences in coronavirus-related problems per medium, with, on average, more calls in the telephone helpline from people who are worried about someone else or from help-seekers experiencing loneliness. Conversations concerning the topics of (unsafe) home situations and relationship problems, and work/study stress seem to occur more often in the chat. The fact that many help-seekers struggled with loneliness and social isolation is cause for concern, as feelings of loneliness and a lack of mutually caring relationships are considered a strong predictor for suicidal ideation and behavior (Van Orden et al., 2010). According to the integrated motivational–volitional model of suicidal behavior, having little or no social support, together with feeling a burden and depleted resilience increases the likelihood of suicidal ideation or intent (O’Connor & Kirtley, 2018). Furthermore, a study among high-risk individuals revealed that increased feelings of isolation predicted suicidal thinking during the pandemic (Fortgang et al., 2021). In addition, the current study provides new insights to the study of Mokkenstorm et al. (2017) that a bigger proportion of males uses the phone compared to the chat.
Strengths and Limitations
This study provides a rather unique insight into the demand for a suicide prevention helpline and the impact of the pandemic on a young at-risk population that often remains out of sight. However, there are some limitations to this study that should be considered. First, it should be noted that besides media coverage, the number of calls to the helpline was influenced by the launch of two new phone numbers in the summer of 2020. This limits the extent to which changes can solely be attributed to the pandemic. Second, as not to burden help-seekers, counselors were asked to label a conversation coronavirus-related or not and write a summary of the problems discussed. This in combination with the relatively low response rate of the counselors means we were probably only able to analyze a selection of the actual coronavirus-related conversations in the helpline. However, we have no reason to believe that the labeling of the conversations did not happen randomly. Furthermore, just like many helplines, 113 Suicide Prevention struggles with frequent callers; a relatively small number of help-seekers who account for a considerable proportion of the use of the services (Pirkis et al., 2016). This means that there is a possibility that individuals are included in the data set more than once.
Future Research
With possible ripple effects of the pandemic on the economy, it is important to monitor risk factors in the high-risk population long term. Additionally, a larger sample would make it possible to see whether the coronavirus-related problems differ between demographic groups in the helpline. We therefore strive for cross-national monitoring of coronavirus-related conversations and more mandatory registration for counselors.
Practical Implications
The exploration of the coronavirus-related problems shows that, during the first lockdown, help-seekers were overwhelmed by the cancellation or postponement of professional help or the sudden loss of contact with their caretaker. They were distraught about the fact that their treatment for mental or physical problems came to a sudden halt. It is likely that caretakers and organizations were caught off guard by the pandemic and the accompanying social distancing measures and may not have been able to instantaneously transition to remote care. Nevertheless, some help-seekers stated that they did not want to receive an alternative form of care such as telephone or video calling. However, the distress of help-seekers reflects the importance of maintaining contact with those in care and lowering the threshold for help, especially in times of social distancing and isolation. This will likely remain a key concern as waiting times in mental health care are expected to increase due to delayed care and a shortage of healthcare workers. The World Health Organization (2020) revealed that this is a worldwide concern as mental health services across the globe have been disrupted as a result of the pandemic. It has therefore strongly urged world leaders to invest in mental health services.
Conclusions
In summary, our study provides an insight into the impact of the coronavirus pandemic on the Dutch suicide prevention helpline. Analysis of the weekly demand for the helpline revealed an overall increase in demand for the helpline in 2020, but it is not known whether this is a direct effect of the pandemic. An exploration of coronavirus-related conversations in the helpline during the first lockdown showed that the predominantly young and female help-seekers struggled most with interruption or change in regular care, feelings of loneliness and social isolation, and the loss of distractions, routine, and structure.
Electronic Supplementary Material
The electronic supplementary material is available with the online version of the article at https://doi.org/10.1027/0227-5910/a000863
Margot C. A. van der Burgt, MSc, is a PhD student at 113 Suicide Prevention and affiliated with the Department of Psychiatry at Amsterdam UMC, The Netherlands. Her research focuses on the various interventions of 113 Suicide Prevention, both offline and online, with an emphasis on (barriers toward) help-seeking.
Saskia Mérelle, PhD, is a senior researcher and clinical epidemiologist and works at 113 Suicide Prevention. She currently supervises five PhD students and several clinical professionals. Her key interests are epidemiology, eHealth, suicide prevention among youth, and innovative technological research.
Aartjan T. F. Beekman, MD, PhD, is a psychiatrist and head of the Department of Psychiatry at Amsterdam UMC, The Netherlands. He is also a board member of GGZ inGeest. He has (co)authored more than 600 international papers, mostly in the area of affective disorders.
Renske Gilissen, PhD, is the head of the research department at 113 Suicide Prevention where she currently supervises 20 researchers and is co-promotor of seven PhD students. She is also principal investigator of the Sure-Net consortium (Suicide Research Netherlands).
We would like to thank the counsellors of 113 Suicide Prevention for their participation in this study and Salim Salmi for providing the helpline data and his assistance.
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