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As the pandemic continues, clinicians should be on the lookout for patients at risk of committing homicide-suicide, Elias Ghossoub, MD, director of the psychiatry residency training program at the American University of Beirut in Lebanon, said Saturday at the annual meeting of the American Academy of Psychiatry and the Law.

"COVID-19 is a once-in-a-lifetime cataclysmic event that's forcing the global population to react and adapt, leaving in its trail a mental health burden too difficult to carry for some of the most vulnerable," he said. "Family interventions involving primary care practitioners, mental health specialists, social workers, media and governmental agencies are highly needed to reduce the incidence of homicide-suicide among older adults and minimize its impact on the public."

Homicide-suicide -- defined as an incident in which a person commits a homicide and then commits suicide within one week of the homicide -- seems to be over-represented among older adults, Ghossoub said. that about 25% of homicide-suicides are committed by those age 55 or older, according to Ghossoub.

What does this issue have to do with the pandemic? Once the pandemic started and lockdowns were implemented, news stories began to appear about homicide-suicides perpetrated by older adults, said Ghossoub. For instance, "on March 25, 2020, Alan Smith, a 71-year-old man living in Cambridge, U.K., ." The incident "was attributed to anxiety and the COVID-19 lockdown, particularly about the possibility of running out of food and medicines."

"The risk of homicide-suicide among older adults increased during the COVID 19 pandemic ... because of several reasons," he continued. "First, physical distancing and quarantine measures -- protocols established to slow the spread of the virus -- may be associated with increased rates of depression, anxiety, and an increased risk of suicide among older adults," said Ghossoub. "We also know that there has been an increase in intimate partner violence, and that there has been an increase in firearm ownership rates, particularly in the United States."

To find out more, Ghossoub and colleagues conducted a "rapid review" of literature on the topic, using the keywords "homicide-suicide," "murder-suicide," "older adults," and "elderly." The search yielded 104 records, which the researchers narrowed down to nine studies after reading the articles and looking at references. The studies were published between 1998 and 2019.

Through the studies, the researchers identified several possible risk factors for those likely to commit homicide-suicide:

• Male sex
• Being in a caregiving role
• Health issues in one or both individuals in the couple
• Domestic violence/relational discord
• Legal issues
• Depression
• Suicidal ideation
• Access to firearms

However, Ghossoub stressed that "one major limitation to our study involves the scarcity and heterogeneity of research regarding older adult homicide-suicides" and that "it would be an overreach to claim to have identified a typical profile of an older perpetrator of homicide-suicide ... Homicide-suicide is a cross-cultural phenomenon, a result of the interplay of diverse personal and environmental antecedents and emerging stressors."

On the whole, "we do know that the COVID 19 pandemic has led to a surge in mental health issues," said Ghossoub. For example, "according to which surveyed adults across the U.S. in late June 2020, 31% of respondents reported symptoms of anxiety or depression, 13% reported having started or increased substance use, 26% reported stress-related symptoms, and 11% reported having serious thoughts of suicide in the past 3 days," he said. "These numbers are nearly double the rates we would have expected before the pandemic."

How might these incidents be prevented? Ghossoub recommended that based on the literature review, healthcare professionals in the emergency department and in primary care offices should screen adults for depression, suicidality, or substance use disorder. In addition, for those who have tested positive for COVID-19 or who have been in contact with a carrier or a particularly vulnerable population, "screening for domestic violence and access to weapons at home should also become part of routine history-taking questions in this population."

If an older patient with mental illness has access to firearms in their house, "immediate interventions through a social worker should include providing gun risk education to other family members, or contacting law enforcement officials," said Ghossoub. "Referrals to specialized mental health professionals should be made readily available to older adults with a suspected underlying mental illness." These can include tele-mental health services, which can provide quick access to subspecialists. "Moreover, psychiatric inpatient units specifically designed for suicidal and or homicidal patients with COVID-19 can ensure appropriate acute medical and psychiatric care," he said.

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