1. Introduction

Although the COVID-19 pandemic was over long ago, the mental health toll and the long-lasting scar is expected to be intact for a long. The mental health crisis that emerged from this unprecedented took a stringent toll on people of all races across the globe. Since the global confirmed cases of COVID-19 exceeded over 700 million [1], the worldwide mental health impact of the pandemic is outrageous. In order to curb the spread of the pandemic, social distancing to complete rigorous lockdown was implemented worldwide [2], and thus, spontaneous physical interaction between people was curtailed. Apart from the social disruption, economic stagnation due to the COVID-19 pandemic severely impacted global mental health [3]. Initially, the global healthcare authorities prioritized the physical health complications due to the COVID-19 pandemic, and unfortunately, the mental health issues that arose were slightly disregarded due to resource constraints. There is mounting evidence implied the impact of previous pandemics on mental health is mostly due to food insecurity in society [4, 5, 6]. Although the financial upheaval of the COVID-19 pandemic has been overcome globally expeditiously, the scar on mental health will be endured for a long while. We must not forget that multifarious mental health problems were well documented in the previous courses of the pandemic. Infected people demonstrated widespread mental health problems (e.g., depression, memory impairment, confusion, sleep disturbance and insomnia, psychosis, different manias, anxiety, irritability, PTSD, fatigue, etc.) during the Severe acute respiratory syndrome (SARS-CoV), and Middle East respiratory syndrome coronavirus (MERS-CoV) pandemic outbreaks [7]. Undoubtedly, stress, anxiety, and depression symptoms are common in different pandemics among the general people [8, 9]. However, the patterns, prevalence, and odds of suicidality due to the COVID-19 pandemic remain primarily unresolved. Undoubtedly, the social and economic impact of the pandemic could be inferred as the greatest global threat as it manifested the direct financial crisis, leading to burdensomeness and increased suicidal behavior [10]. The conjectured impacts of financial turmoil, curtailed social interaction and less access to resources owing to the pandemic and its association with suicidality are well documented. However, the trajectories of suicidal behavior are yet to be comprehended. Diversified self-risk behaviors were observed during the lockdown and social distancing, and the situation deteriorated the suicidal behaviors [11, 12, 13, 14]. Limited access to healthcare facilities [15], loneliness [16], financial constraints [10], and comorbid mental health problems [17] are the critical leading causes for the suicidality during and post COVID-19 pandemic time.

1.1 Objective of the chapter

Globally, suicidality has been considered a massive public health threat during and post-COVID-19 pandemic time. Contemplating the consequences, profound discussion is anticipated to comprehend the suicidal behavior due to COVID-19 and other infectious pandemics in different cultural and individual settings. This chapter will address the prevalence and characteristics of suicidal behavior as the direct and indirect impact of the COVID-19 pandemic through the mediation of loneliness.

2. Multidimensional landscape of loneliness and suicidality in the wake of COVID-19 pandemic

2.1 Loneliness and stigma at the meditational role between COVID-19 crisis and suicidal behavior

A major concern of suicidality surfaced ever since the world experienced the biggest man-made experiment or the rigorous lockdown to curb the further spread of COVID-19 pandemic [18]. It is anticipated that the limited social and physical interaction triggered the perceived loneliness and emerged the suicidal ideation and behavior consequently [19]. When it comes to predicting suicidal behaviors (ideation, planning, capability, risk behavior), loneliness happens to be the most prevalent factor. In addition, there are several health concerns associated with perceived loneliness and social isolation as they often predict poor mental health than directly [20]. Therefore, the role of loneliness is found mostly as meditational in the path of the COVID-19 pandemic and suicidal behavior [21]. Since loneliness is often prevalent with plenteous other mental health problems (e.g., depression, anxiety, stress, PTSD, suicidal behavior, aggression, substance and behavioral addiction etc.), it has long been considered as one of the fundamental challenges to human civilizations [22]. The increased risk of suicidal behaviors due to the COVID-19 pandemic is well documented by the existing literature [23, 24, 25, 26]. Theoretically, this upsurge in suicidal behavior may be attributable to both comorbid mental and physical health conditions along with the pandemic-induced financial constraints and reduced social and physical isolation. Simultaneously, widespread and multi-dimensional stigmas surfaced along with loneliness in the wake of the COVID-19 pandemic as well as in the previous epidemic outbreaks. Stigmatization often thwarts the overall pandemic-curbing procedure by negatively motivating people to report health status and seek medical assistance [27]. Moreover, stigma directly induces loneliness through the elevated likelihood of social exclusion [28]. Stigma-induced loneliness plays a significant role in the mediating path of COVID-19 and suicidality. Individuals experience more suicidality when they are socially isolated, owing to the stigma associated with the epidemic [29]. Furthermore, elevated rates of burnout and stress were reported among frontline public health professionals due to the repeated stigmatization. Professional stress is frequently associated with loneliness, which is severely counterproductive to fight against the pandemic [30]. This problem is exacerbated further when healthcare facilities become inaccessible [25]. Indubitably, the mental health toll, including the suicidal risk and behaviors are burdensome during the surge of the outrageous global pandemic. However, mental health professionals mostly pay attention to immediate actions focusing on traumas and other ailments. The inadequate long-term considerations leave a prolonged scar and footprint on the overall global mental health.

2.2 Loneliness and individual differences in the path of suicidal behavior

In multiple lines of literature, diversified age and professional groups have shown widespread patterns of suicide behavior in surge and post-COVID-19 pandemic time. Interruptions and constant changes in academic settings, social and physical isolation, and unpredictability for the future have all put adolescents and young adults in a predicament [31]. Long-term shutdown of academic institutions attenuated adolescents’ spontaneous social interactions, which may lead to perceived loneliness and despair. On the contrary of age spectrum, the pandemic-induced restrictions have had a disproportionate impact on the elderly, particularly those residing in care facilities [32], making them more susceptible to infection and causing them emotional and mental anguish [33, 34]. Unique challenges have been discerned among different professional groups during the pandemic. Owing to excessive stress, traumatic experiences, and professional burnout, healthcare professionals have been confronted with significantly higher suicidal thoughts, ideation, and suicidal behaviors [35, 36]. Individuals working in the hospitality, tourism, and entertainment sectors [37, 38] experienced the financial crisis and subsequent unemployment more acutely than others [39]. Apart from healthcare professionals, other high-risk professionals, e.g., police, military, and other paramilitary forces, have confronted unique challenges globally during the COVID-19 pandemic. It is evident that the exacerbated risk of infection for high-risk professions surfaced with elevated stress and fear [40]. The mental health dynamics of high-risk professions are compounded due to the existing organizational stress and other comorbid situations. Globally, military forces have been deployed as the last key resources to mitigate the health risks induced by COVID-19. It is evident that military personnel are often prone to widespread mental health problems (e.g., stress, anxiety, depression, PTSD, etc.), which have the likelihood to increase during unprecedented events like the COVID-19 pandemic [41]. Another significant portion of the population is often forgotten during the wake of any health emergency, the prisoners. Since the prisons across the globe lack resources (e.g., healthcare, accommodation, nutrition, hygiene, mental health, etc.), left them highly vulnerable during emergencies. Overcrowd, fear of transmission, lack of information, sudden changes in life, and environmental and health conditions- all these are responsible for inmate’s mental health problems [42]. Additionally, the infrequent and uncertain visits of friends and family due to social distancing might lead to widespread mental health problems [43].It is anticipated that the mental health toll and suicidal behaviors are associated with the financial crisis and unemployment. Another level of complexity has been found in the dynamics of age and professional categories. Additionally, limited marketplace and higher competition posed inflated challenges for the newbies in the workforce during the pandemic period. Although most people adopt remote work because of the flexibility, a major portion has struggled with the adaptation process, resulting in occupational hazards and perceived loneliness.

2.3 Navigating the multidirectional association between comorbid mental health issues, loneliness, and suicide

The complex association between comorbid mental health issues, loneliness, and suicidal behavior has surfaced during the COVID-19 era, which has had far-reaching and multifaceted consequences on global mental health. Individuals with comorbid mental health conditions confronted unprecedented challenges in the surge of any pandemic [39]. Social isolation and inaccessible healthcare facilities exacerbate the worse situation further. Integrating comorbid mental health problems with isolation and perceived loneliness increases the likelihood of suicidal behavior. Individuals with pre-existing depression and anxiety symptoms are more susceptible to loneliness during social isolation, resulting in higher suicidal risks [44]. Loneliness is often associated with depressive and anxiety symptoms due to its overlapping components [45]. Depression can be triggered by perceived loneliness as it often jeopardizes belongingness [46], which resulting the moderation the path of loneliness to the suicidal behavior. It is evident from the existing literature that both isolation and perceived loneliness have aversive consequences on mental health outcomes (e.g., depression, anxiety etc.) of elderly and middle-aged population [47, 48, 49]. During most of the pandemic period, new and complex mental health issues surface and pose unique challenges to professionals. Two recent phenomena are noteworthy: cave syndrome, which is characterized by elevated anxiety and extreme reluctance to engage in outdoor and social activities [50]. Additionally, hikikomori- a social withdrawal and self-isolating condition that has been exacerbated due to the rigorous restrictions imposed by the pandemic along with the fear of infection [51]. Amidst the global public health crisis, the multidirectional effect of comorbid mental health conditions, loneliness, and suicidal behaviors exacerbated the risk factors in multiple folds. It can be inferred that individuals with comorbid mental health conditions perceive higher loneliness that can amplify suicidal behaviors since often the, individuals with pre-existing mental health conditions are more susceptible to suicidal thoughts and creativity.

2.4 Economic crisis leading towards loneliness and suicidality

The global financial sectors have reshaped awfully due to the relentless spread and aftermath of the COVID-19 pandemic. Global mental health impendent an insidious impact of that recession, which simultaneously surfaced loneliness and suicidal behavior [52]. A number of countries have experienced the pandemic-induced economic downfall, exacerbating socioeconomic vulnerabilities and weakened social safety networks [53]. Often, the economic turmoil spotlights the physical health consequences during the wake of the pandemic and fades the mental health tolls. Obnoxiously, mental health outcomes of any pandemic have a deep-rooted distressful effect on public health [54]. Apparently, the individual mental health toll mounts with the pandemic since it instigates acute financial instability, loss of jobs, and continuous stress [55]. Financial susceptibility leads individuals to isolation, which consequently persuades perceived loneliness [56]. Social reciprocity declines due to financial hardship, which further stimulates loneliness.

Consequently, perceived loneliness is the strongest predictor of impending suicidal behavior. Socioeconomic isolation and withdrawal are often prevalent among those who are more vulnerable to financial downfall [57]. This disparity surfaces due to the unanticipated shifts in financial plans and extensive uncertainty. Frequently, financial and emotional resilience are disrupted collaterally, triggering suicidal behaviors [58].

2.5 Loneliness is bidirectional with severe behavioral and substance addiction

Mental health professionals are profoundly concerned about the complex correlations between behavioral addiction and substance abuse, and perceived loneliness in the contest of the COVID-19 pandemic. Conventionally, loneliness has been considered as the negative consequence of any addiction. However, the recent pandemic landscape revealed the bidirectional correlation between loneliness and addictions [59, 60]. Loneliness has spawned a variety of behavioral addictions and substance abuse since perceived loneliness has increased through social distancing and curtailed of social interactions to curb further viral transmission [61]. Predominantly, loneliness is characterized by perceived disconnection and alienation, which can stimulate addictive behaviors. In order to cope with loneliness, individuals can develop addictive behaviors to get rid of the alienation and emotional turmoil [62].

Conversely, addictive behaviors lessen social connections, and vulnerable individuals are submerged in severe loneliness [63]. The catalyst role of the pandemic has been found to exacerbate the bidirectional association between loneliness and addictive behaviors. Surprisingly, addictive behaviors have a deep-rooted history of positive correlation with suicidal behaviors [64]. The issue is further magnified by the limited access to the support system during the pandemic time.

2.6 Lack of resilience to cope with loneliness

The recent pandemic highlighted the need for resilience as a life skill in dealing with the widespread emotional turmoil of loneliness. Loneliness, which could be considered an intermittent mental state, becomes severe for those who are unable or unwilling to cope with the difficulties [65]. Resilience can be inferred as “the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and ‘bouncing back’ in the face of adversity.” [66]. Individuals are more susceptible to the detrimental impacts of loneliness when they lack resilience. Resilience continually acts as a protective factor to buffer the adverse and discrepant mental health outcomes persuaded by loneliness [67]. Without proactive resilience, individuals encounter negative emotional states ineffectively. The COVID-19 epidemic sheds light on the significance of fostering resilience as an essential life skill. The psychological competencies that people need to face and overcome loneliness may be significantly enhanced by building resilience.

3. COVID-19, loneliness, and suicidal behaviors: the role of mental health interventions

In the midst of the epidemic, mental health professionals must act promptly to ensure effective intervention plans targeting the complex relationship between loneliness and suicidal behaviors. To lessen the severity of risk factors concerning increased suicidal behaviors, there are several suggested intervention plans. These consist of enabling those dealing with behavioral addiction and substance abuse, fostering more robust and more effective social networks, creating emergency response mechanisms that are strong and accessible, limiting alcohol consumption, overcoming the economic crisis, reducing aggressive behaviors, and restricting the spread of fabricated news and information. In order to combat loneliness, easily accessible telemental health services, community integration could play a vital role. Only the social engagement where the perceived belongingness is highlighted could ensure the safeguard against escalating severity of loneliness and consequent suicidal behaviors. One probable effective protection against the adverse consequences of loneliness involves maintaining significant relationships using regular phone or video conversation. There is no better way to strengthen mental health than using digital platforms, which provide crucial chances for emotional support, belonging, and the reinforcement of social relationships. Additionally, communities may build supporting networks even when they lack physically close by using technology-enabled platforms for social interaction to share stories, ask for advice, and console one another. A preventative measure against the negative mental health consequences of social isolation, which may include thoughts of suicide, is to maintain interactions with others, even if just online. Specialized care and attention are required for high-risk individuals during the period of emotional distress and self-harm risk. In this regard, it is imperative to rightly recognize the individuals prone to professional help-seeking hesitancy and acute reluctance due to fear, hopelessness, and other associated stigmas. On top of everything, the COVID-19 pandemic strained the global healthcare system, causing the strive for maintaining physical health, resulting in severe disruption in mental healthcare for vulnerable individuals. Therefore, protective factors are essential to ensure mental health amidst the physical healthcare challenges and priorities. Easy access to mental healthcare could be a great addition to the overall intervention plan globally.

4. Conclusion

This chapter sheds light on the immense influences of loneliness on the suicidal behavior that is instigated during and post-COVID-19 period. As the world move forward to normalization, the correlation between these two dynamics surfaces profoundly. The primary reason for alarming loneliness in the wake of the pandemic was found to be linked with the rigorous lockdown and curtailed social interactions. Within the global public health framework, perceived loneliness was exacerbated by the overlapping fear of infection and an uncertain future, subsequently turning into a mental health Tsunami. Comorbid mental health conditions, addiction, and socioeconomic circumstances often impede the indefatigable measures to contend with perceived loneliness during any pandemic. Unfortunately, the profound association between loneliness and suicidal behaviors is often disregarded in the public health as well as mental health frameworks. However, it is evident that unresolved issues of loneliness can manifest and be palpable in mental health outcomes (e.g., suicidal ideation, thoughts, and behaviors).

Along with the mental health outcomes during the wake of the pandemic, it mandates an in-depth focus on the dynamics of loneliness and suicidal behaviors. Future in-depth research could reveal the complex correlations between mental health, loneliness, and suicidality in the wake of any pandemic. Primarily, longitudinal studies could reveal the long-term and comparatively static impacts of loneliness on suicidality, focusing on possible moderating and mediating effects. Additionally, qualitative studies could explain the subjective experiences to shed light on the individual challenges and underlying mechanisms. Furthermore, the global public health sector could benefit from intervention research targeting the development of strategic interventions to mitigate loneliness and suicidality. In order to ensure adequate public interventions, prioritizing the issue should be the topmost task. Resilience at the individual and community levels can be achieved by acknowledging loneliness as the silent mental health pandemic within the vicious cycle of the actual pandemic.

Acknowledgments

I would like to express my sincere gratitude to Professor Weijian Li, School of Psychology, Zhejiang Normal University, Jinhua, 321004, China, for his continuous support and guidance. Besides, this chapter was supported by the Postdoctoral Research Fund of the School of Psychology, Zhejiang Normal University, Jinhua, 321004, China (No. ZC304022990), which also warrants a sincere appreciation.

Acronyms and abbreviations

COVID-19	Coronavirus disease of 2019
MERS-CoV	Middle East respiratory syndrome coronavirus
PTSD	Post-Traumatic Stress Disorder
SARS-CoV	Severe acute respiratory syndrome

Shurong Wang

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