Suicide numbers during the first 9-15 months of the COVID-19 pandemic compared with pre-existing trends: An interrupted time series analysis in 33 countries

Preventing suicide: a public health approach to a global problem

Suicide is prevalent in all countries and is largely preventable. The causes of suicide are multiple and varied. Social determinants of suicide are crucial, but to date these have received insufficient policy attention. This paper, which is the first in a Series on taking a public health approach to suicide prevention, argues for a major change in the way we think about suicide and its prevention. This Series paper presents a public health model that emphasises the broad social determinants of suicide and describes a framework through which these might be addressed. We argue for a policy reset that would take national suicide prevention strategies to the next level. Such policies would become whole-of-government endeavours that tackle major social determinants of suicide at their source. We also argue that high-quality data and methodologically rigorous evaluation are integral to this public health approach.

Preventing suicide: a call to action

The public health approach to suicide prevention requires us to move away from thinking about suicide as a purely clinical problem and to pay heed to the array of social determinants (such as financial hardship or domestic violence and abuse) that might lead people to consider suicide as an option. Clinical factors are important, and, indeed, clinical or indicated interventions are entirely appropriate for people who have reached a point of crisis and should be a mainstay of national suicide prevention strategies. However, our Series stresses the need for selective and universal interventions that tackle the pervasive problem of suicide in a more upstream way, preventing people reaching a crisis point. Many social determinants can best be addressed by sectors outside health, so we are calling for a whole-of-government commitment to suicide prevention. We make recommendations for actions in the areas of policy, practice, research, and advocacy. People with lived experience of suicide should have genuine involvement in all of these actions.

COVID-19 impacted the suicidal ideation among health care workers and medical students: An interrupted time-series analysis of data from 30 countries

AIM

To investigate the impact of public health emergencies on the prevalence of suicidal ideation among healthcare workers (HCWs) and medical students.

METHODS

The prevalence of suicidal ideation among HCWs and medical students was searched for analysis. The platforms included PubMed, medRVix, bioRvix, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. Interrupted time-series analysis was employed to determine whether the COVID-19 pandemic influenced the prevalence and trends of suicidal ideation. To account for autocorrelation and heteroskedasticity, Newey-West standard errors were utilized with a lag of order one.

RESULTS

Seventy studies with 145,641 HCWs and medical students from 30 countries were included in the final analysis, with 30 studies before COVID-19 and 40 studies during the pandemic. Before the pandemic outbreak (April 2020), the monthly increasing rate was 0.063 % (95 % CI: -0.009 %, 0.135 %, z = 1.73, P = 0.084). The tendency of suicidal ideation prevalence increased by 1.116 % (95%CI: 0.888 %, 1.344 %, z = 9.60, P < 0.001). In other words, the calculated monthly growth rate of suicidal ideation after the pandemic outbreak is 1.179 % (95%CI: 0.968 %, 1.391 %, z = 10.93, P < 0.001) per month. The overall growing trend of prevalence of suicidal ideation during the pandemic is 1.896 % per month in America; 1.590 % in Europe; 0.443 % (95%CI: 0.213 %, 0.673 %, z = 3.77, P < 0.001) in Asia; 1.055 % in HCWs; and 0.645 % in medical students.

CONCLUSION

This study highlights that the COVID-19 pandemic can significantly impact the prevalence of suicidal ideation among HCWs and medical students, and the prevalence showed an upward trend.

Identifying Reddit Users at a High Risk of Suicide and Their Linguistic Features During the COVID-19 Pandemic: Growth-Based Trajectory Model

BACKGROUND

Suicide has emerged as a critical public health concern during the COVID-19 pandemic. With social distancing measures in place, social media has become a significant platform for individuals expressing suicidal thoughts and behaviors. However, existing studies on suicide using social media data often overlook the diversity among users and the temporal dynamics of suicide risk.

OBJECTIVE

By examining the variations in post volume trajectories among users on the r/SuicideWatch subreddit during the COVID-19 pandemic, this study aims to investigate the heterogeneous patterns of change in suicide risk to help identify social media users at high risk of suicide. We also characterized their linguistic features before and during the pandemic.

METHODS

We collected and analyzed post data every 6 months from March 2019 to August 2022 for users on the r/SuicideWatch subreddit (N=6163). A growth-based trajectory model was then used to investigate the trajectories of post volume to identify patterns of change in suicide risk during the pandemic. Trends in linguistic features within posts were also charted and compared, and linguistic markers were identified across the trajectory groups using regression analysis.

RESULTS

We identified 2 distinct trajectories of post volume among r/SuicideWatch subreddit users. A small proportion of users (744/6163, 12.07%) was labeled as having a high risk of suicide, showing a sharp and lasting increase in post volume during the pandemic. By contrast, most users (5419/6163, 87.93%) were categorized as being at low risk of suicide, with a consistently low and mild increase in post volume during the pandemic. In terms of the frequency of most linguistic features, both groups showed increases at the initial stage of the pandemic. Subsequently, the rising trend continued in the high-risk group before declining, while the low-risk group showed an immediate decrease. One year after the pandemic outbreak, the 2 groups exhibited differences in their use of words related to the categories of personal pronouns; affective, social, cognitive, and biological processes; drives; relativity; time orientations; and personal concerns. In particular, the high-risk group was discriminant in using words related to anger (odds ratio [OR] 3.23, P<.001), sadness (OR 3.23, P<.001), health (OR 2.56, P=.005), achievement (OR 1.67, P=.049), motion (OR 4.17, P<.001), future focus (OR 2.86, P<.001), and death (OR 4.35, P<.001) during this stage.

CONCLUSIONS

Based on the 2 identified trajectories of post volume during the pandemic, this study divided users on the r/SuicideWatch subreddit into suicide high- and low-risk groups. Our findings indicated heterogeneous patterns of change in suicide risk in response to the pandemic. The high-risk group also demonstrated distinct linguistic features. We recommend conducting real-time surveillance of suicide risk using social media data during future public health crises to provide timely support to individuals at potentially high risk of suicide.

Different trends in suicide rates among foreign residents in Japan and Japanese citizens during the COVID-19 pandemic

BACKGROUND

Suicide rates in Japan have increased during the COVID-19 pandemic, and foreign residents may be more vulnerable to mental stress during such crises. Therefore, we aimed to compare the trends in suicide rates during the COVID-19 pandemic between foreign residents and Japanese citizens.

METHODS

Vital statistics of Japan data from January 1, 2016 to December 31, 2021 were used to calculate quarterly sex-specific suicide rates for foreign residents and Japanese citizens. An event-study analysis was conducted to evaluate whether suicide rates during the COVID-19 pandemic increased compared to pre-pandemic estimates; foreign residents and Japanese citizens were compared using difference-in-difference-in-differences estimates.

RESULTS

Between 2016 and 2021, 1,431 foreign residents and 121,610 Japanese citizens died from suicide in Japan. Although the suicide rate for foreign residents was lower than that for Japanese citizens, Korean residents, who comprise approximately half of the foreign decedents, had largely higher suicide rates than Japanese citizens. The event-study analysis indicated that suicide rates increased among foreign residents for both men and women, and continued for men by the end of 2021. In Japanese citizens, after a decline in suicide rates in the second quarter of 2020, suicide rates increased both among men and women, and lasted for women until the fourth quarter of 2021. The difference-in-difference-in-differences analyses confirmed the initial decline in the second quarter of 2020 in suicide rate only in Japanese men and women, and the persistent increase through 2021 in foreign men.

CONCLUSIONS

We found differential trends in suicide rates between foreign and Japanese men and women during the COVID-19 pandemic featuring a persistent increase in foreign men. Suicide prevention measures should be focused on these high-risk subpopulations.

The impact of the first year of COVID-19 pandemic on suicides in a collection of 27 EU-related countries

Disasters, including epidemics, have a characteristic course, both in terms of the specific events and the human reactions to them. However, it is difficult to predict whether the COVID-19 pandemic will eventually lead to an increase in suicide rates. We aimed to provide a general pattern of the change in suicide rates in the countries linked to the European Union by direct comparison of the years 2019 and 2020 by gender and age group, grouped according to the predominant religions. Overall, 27 countries were included in the analysis. Incidence rate ratios and their 95% confidence intervals were calculated to characterise annual changes in the incidence of suicide deaths. In almost two-thirds of the countries studied, suicide rates did not increase. The largest increases were observed in Catholic-majority and 'mixed' Catholic-Protestant countries, but this was significant only for the oldest age group (over 65 years). This increase was even more marked within some Catholic-majority countries (Hungary, Ireland, and Spain) during the first months of the pandemic. There was no statistically significant increase overall in the suicide death rates in Europe. However, the pattern of suicide rates has changed significantly in some countries, and by age group and religion, respectively.

Suicides, Other External Causes of Death, and Psychiatric Status in Suicide Attempters: A National Registry-Based Analysis in Israel, 2006-2020

OBJECTIVE

To assess risk factors and rates of suicide and other external cause deaths, among suicide attempters compared to the total population, stratified by psychiatric hospitalization discharge and mental diagnosis.

METHODS

A national registry-based analysis of suicide and external cause mortality was performed among suicide attempters between 2006 and 2020 in Israel in the National Hospital ED database. Data was stratified by psychiatric hospitalization status by linking to the national psychiatric case registry. Age adjusted mortality rates were calculated.A multivariate cox regression model assessed the relative risk of demographic factors and psychiatric diagnosis and hospitalization on outcomes.

RESULTS

Among 57,579 first suicide attempters, of whom 16,874 had a psychiatric hospitalization, there were 853 suicides (1.5%) and 473 deaths from other external causes (0.8%), 485 suicides (2.9%) and 199 external cause deaths (1.2%) in the psychiatric group. Suicide risk was highest in the year after the attempt, but continued throughout the study, particularly in the psychiatric hospitalized group. Suicide rates within one year of first suicide attempt were 137 (95% CI 122-152) times higher than the total population, 190 (155-233) times in females and 128 (112-145) times in males, 178 (153-207), 243 (181-325) and 158 (132-190) times higher, respectively, in those with a psychiatric hospitalization.

CONCLUSIONS

We found a greatly increased risk for suicide and significant increase for other external causes of death amongst a cohort of suicide attempters, compared to the total population, particularly those with a history of psychiatric hospitalization.

Temporal evolution of suicide by levels of rurality and deprivation among Japanese adults aged 20 years or over between 2009 and 2022

PURPOSE

Previous studies have reported that levels of rurality and deprivation are factors associated with suicide risk. Reports on the association between rurality, deprivation and suicide incidence during the COVID-19 pandemic are scarce. The study aims to investigate how suicide rates evolved in areas with different levels of rurality and deprivation among Japanese adults aged 20 years or older between 2009 and 2022.

METHODS

This study used population density in 2020 as an indicator of rurality and per capita prefectural income in 2019 as a proxy for deprivation in Japan's 47 prefectures. Joinpoint regression analysis was performed to analyze secular trends in suicide rates by rurality and deprivation.

RESULTS

Suicide rates for both men and women at different levels of rurality and deprivation remained roughly parallel during the research period. Suicide rates for men and women at all levels of rurality and deprivation were on a downward trend until around 2019, just before the onset of the pandemic. Following this, suicide rates in women showed a clear upward trend, while the trend in suicide rates for men also changed around 2019, with a slightly increasing or flat trend thereafter. Changes in suicide rates were greater among women and those aged 20-59 years.

CONCLUSIONS

In Japan, time trends in suicide rates for both men and women have changed before and after the pandemic, but levels of rurality and deprivation across the 47 prefectures do not appear to have contributed much to these changes.

Situation Analysis of Suicide and Self-Harm in the WHO Eastern Mediterranean Region

OBJECTIVE

An estimated 41,000 lives are lost to suicide each year in World Health Organization Eastern Mediterranean Region Office (WHO EMRO) countries. The objective of this study was to conduct a situation analysis for suicide and self-harm in the WHO EMRO region.

METHODS

Data on suicide were obtained from the WHO Global Health Estimates for the years 2000-2019. Information on risk groups efforts to prevent self-harm and suicide in the EMRO region were retrieved through scientific studies, grey literature, and public websites.

RESULTS

During 2000-2019, the age-standardized suicide rate was 6.7 per 100,000 inhabitants, albeit there are concerns regarding data quality. Self-harm and suicide remain criminal acts in more than half of the countries. Few countries have a national plan for prevention of suicide. Toxic agents, such as pesticides and black henna, are easily available and frequently used for suicide in some areas, as are firearms and self-immolation. Successful prevention measures include means restriction and psychosocial interventions after self-harm.

CONCLUSION

Many WHO EMRO countries remain underserved in terms of mental health care. Decriminalization of suicide and means restriction might be further promoted. Online-based tools for mental health literacy and psychosocial therapy are other options to explore.

Impact of COVID-19 restrictions on self-poisoning behaviour with mild analgesics in Danish youth

BACKGROUND

The COVID-19 pandemic prompted the implementation of precautions to contain the disease, including lockdowns and social isolation. Previous studies have investigated suicide rates among children and adolescents during the pandemic and have found varying results. We speculated how the two lockdowns influenced suicidal behaviour in children and adolescents in Denmark.

OBJECTIVE

This study aimed to investigate the effect of lockdowns during the COVID-19 pandemic on suicide attempts, as measured by the incidence rate in all self-poisonings with mild analgesics among children and adolescents.

METHODS

This national Danish registry-based study on children and adolescents used Poisson regression and interrupted time series analysis to examine the incidence rates and trends of self-poisonings with mild analgesics from 2019 to mid-2021.

RESULTS

For the period of this study, 1655 self-poisonings were registered. During the first lockdown, there was a slight, not statistically significant, decrease in self-poisoning rates (incidence rate ratio [IRR]) 0.98) compared to no lockdown. During the second lockdown, there was a significant increase in self-poisonings for the whole Danish population (IRR 1.85) with girls being slightly higher at risk (IRR 1.87). Being a girl or between the ages of 13-17 years old were risk factors for self-poisoning.

CONCLUSION

These findings indicate that the restrictions enforced during the second lockdown greatly impacted youth mental health, especially girls, leading to an 85% increase in self-poisonings. We hope for increased awareness of mental health in children and adolescents during possible future lockdowns.

University Students with Current Suicidal Ideation and Perceived Changes during the COVID-19 Pandemic: A Qualitative Study

INTRODUCTION

Mental health problems seemed to have increased among university students during the COVID-19 pandemic. To deepen our understanding of the pandemic's effects in this population, we conducted qualitative research to investigate any perceived changes in students during the pandemic, differentiating the sample based on the presence or absence of current suicidal ideation (SI).

METHODS

A wide sample of Italian university students (n = 1,214) completed an online questionnaire during the COVID-19 pandemic, March 2020-June 2021. We conducted a computer-assisted content analysis of an open-ended question about the perceived changes that occurred to them during the pandemic.

RESULTS

(1) Four thematic clusters were identified: "The psychological impact of the pandemic," "New ties and new loneliness," "An uncertain forethought" and "Discovering the value of relationships." (2) In subjects characterized by severe SI, the state of confinement at home was related to the most intense emotional states and worries. (3) Students with severe SI were different from the others, in particular using the lemma "panic," which was the only psychological state specifically associated with this group.

CONCLUSIONS

Students with current severe SI experienced higher level of psychological distress and suffering compared to the other groups during the pandemic.

Hospitalizations and emergency department visits for self-harm in Canada during the first two years of the COVID-19 pandemic: A time series analysis

BACKGROUND

Rates of hospitalizations and emergency department (ED) visits due to self-harm are important indicators for understanding the impact of the COVID-19 pandemic on mental health. The objective of this study was to assess changes in self-harm hospitalizations and ED visits in Canada during the first two years of the pandemic.

METHODS

Rates of self-harm hospitalizations and ED visits during the pandemic were predicted based on regression analyses that modeled trends over a 5-year pre-pandemic period from fiscal year 2015 to 2019. The ratios of observed and model predicted (expected) rates in 2020 and 2021 were estimated separately to assess changes during the pandemic.

RESULTS

Overall, rates of self-harm hospitalizations and ED visits were lower than expected during the pandemic, especially in 2020. In 2021, rates for females returned to near-expected levels; but they remained lower than expected for males. Females aged 10-14 years had higher than expected rates. The rate ratio of observed rate over expected rate was 1.2 in 2020 but further increased to 1.8 in 2021 for both hospitalizations and ED visits. Higher than expected rates were also observed among females aged 15-19 years in 2021 only.

LIMITATIONS

Suicide attempts and non-suicidal self-harm cases could not be distinguished.

CONCLUSIONS

We observed lower than or close to expected rates of self-harm hospitalizations and ED visits during the pandemic for most population groups. The increased rates for young females highlights the importance of continued surveillance post-pandemic and targeted mental health services and suicide prevention programs.

Characteristics of drug overdose suicide attempts presenting to the psychiatric emergency department of Beijing Anding Hospital

BACKGROUND

Overdose-related suicide attempts represent a significant portion of self-harm presentations in the psychiatric emergency department (ED). Identifying specific patient characteristics associated with these attempts holds promise for pinpointing drug classes with elevated risk and paving the way for tailored suicide prevention interventions. This study aims to examine the demographic profiles of ED patients who had experienced overdose-related suicide attempts.

METHODS

This retrospective study was conducted at Beijing Anding Hospital, Capital Medical University, from January 2020 to December 2021. Patients with psychiatric drug overdose suicide attempts presenting to the psychiatric ED were included. Sociodemographic characteristics and the specific classes of drugs involved were collected, and analysed descriptively.

RESULTS

This study examined 252 overdose patients, excluding 51 patients treated with alcohol or nonpsychiatric drugs, and a total 201 cases were included. The mean age of the patients was 28 ± 16 years (median 23, range 12-78), and 82% (n = 165) of the sample were females. Notably, nearly half (45%) of the patients were aged ≤ 20 years. While the number of cases decreased with increasing age, a significant increase was observed in 2021 compared to 2020. Benzodiazepines (BZDs) were the most frequently implicated substance class (n = 126, 63%), followed by antidepressants (n = 96, 48%), antipsychotics (n = 44, 22%), Z-drugs (n = 43, 21%), and mood stabilizers (n = 36, 18%). For adolescents, antidepressants (n = 52, 71%) overtook BZDs (n = 38, 52%) as the most common drug. The monthly distribution of cases revealed peaks in April and November. Furthermore, 21% (n = 42) of patients ingested more than two psychotropic medications concurrently. Finally, approximately half (n = 92) of the patients required inpatient admission for further treatment. Comparisons between hospitalized and nonhospitalized patients did not reveal any significant differences.

CONCLUSIONS

The present study revealed a greater prevalence of suicide overdose attempts among young females receiving prescriptions for antidepressants and/or BZDs. This finding suggests a potential need for enhanced monitoring of suicidal behaviour in this specific population when prescribing psychotropic medications. These findings contribute to the growing body of knowledge regarding drug overdose suicide attempts in psychiatric emergency settings and underscore the importance of further research to develop targeted prevention interventions.

Suicidal ideation, suicide plans and suicide attempts among Australian adults: Findings from the 2020-2022 National Study of Mental Health and Wellbeing

OBJECTIVE

This study aimed to describe the epidemiology of suicidal ideation, suicide plans and suicide attempts, examine services received for suicide attempts, and explore the relationship between suicide attempts and self-harm without suicidal intent.

METHODS

We used survey data from the 2020-2022 National Study of Mental Health and Wellbeing, which involved a nationally representative sample of Australian adults aged 16-85 (n = 15,893). Comparisons were made with the 2007 National Study of Mental Health and Wellbeing (n = 8841).

RESULTS

In 2020-2022, the proportions of adults who had experienced suicidal ideation, suicide plans and suicide attempts during their lifetime were 16.6%, 7.5% and 4.9%, respectively. The proportions who had experienced these in the past 12 months were 3.3%, 1.1% and 0.3%. The odds of experiencing suicidal ideation and making a suicide plan were significantly higher in 2020-2022 than in 2007. Groups at heightened risk of suicidal ideation, suicide plans and/or suicide attempts in the previous 12 months were males, young people, people who were gay, lesbian, or bisexual or used some other term to describe their sexual identity, people outside the labour force, people from disadvantaged areas and people with mental disorders. Two-fifths of those who attempted suicide during the previous 12 months did not use health services following their attempt, and two-thirds also self-harmed without suicidal intent.

CONCLUSION

The implications of these findings for the forthcoming National Suicide Prevention Strategy are discussed. Suicidal thoughts and behaviours confer risk for suicide and are significant problems in their own right. Their prevention requires a strong whole-of-government response.

Self-harm presentations to hospital trauma centre emergency departments during the first year of the COVID-19 pandemic

The COVID-19 pandemic raised concerns regarding increased suicide-related behaviours. We compared characteristics and counts of Emergency Department (ED) presentations for self-harm, an important suicide-related outcome, during versus prior to the pandemic's first year. We included patients presenting with self-harm to the ED of two trauma centres in Toronto, Canada. Time series models compared intra-pandemic (March 2020-February 2021) presentation counts to predictions from pre-pandemic data. The self-harm proportion of ED presentations was compared between the intra-pandemic period and preceding three years. A retrospective chart review of eligible patients seen from March 2019-February 2021 compared pre- vs. intra-pandemic patient and injury characteristics. While monthly intra-pandemic self-harm counts were largely within expected ranges, the self-harm proportion of total presentations increased. Being widowed (OR=9.46; 95 %CI=1.10-81.08), employment/financial stressors (OR=1.65, 95 %CI=1.06-2.58), job loss (OR=3.83; 95 %CI=1.36-10.76), and chest-stabbing self-harm (OR=2.50; 95 %CI=1.16-5.39) were associated with intra-pandemic presentations. Intra-pandemic self-harm was also associated with Intensive Care Unit (ICU) admission (OR=2.18, 95 %CI=1.41-3.38). In summary, while the number of self-harm presentations to these trauma centres did not increase during the early pandemic, their proportion was increased. The association of intra-pandemic self-harm with variables indicating medically severe injury, economic stressors, and being widowed may inform future suicide and self-harm prevention strategies.

Suicide prevention: reflections on progress over the past decade

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.

Suicidal thoughts and behavior of adolescents with depression in Reunion Island - evolution before and after the initial Covid-19 lockdown

BACKGROUND

The number of patients consulting with suicidal thoughts and behavior in the health care centers have increased since the Covid-19 pandemic. This increase has been particularly important among adolescents. Most often these patients are diagnosed with anxiety or depressive symptoms. We only have a limited amount of information on depression and STB in adolescents since epidemiological monitoring in health care institutions is based on computerized coding derived from ICD-10. This coding system is very specific for the different forms of depression yet fails to provide accurate coding for suicidal thoughts and behavior. The objectives of this study were to compare the numbers of adolescents with depression who were admitted with suicidal thoughts and behavior before and after the initial Covid-19 lockdown and to highlight possible gender disparities.

METHODS

Patients' medical charts for this retrospective research were obtained from the Department of Adolescent Psychiatry at the University Hospital Centre of Reunion Island, manually screened, and then analyzed. We included all adolescents diagnosed with depression who had had their first consultation between January 1, 2019 and July 31, 2021. The number of patients presenting suicidal thoughts, self-harm and suicide attempts were compared before and after the initial Covid-19 lockdown.

RESULTS

Three hundred and sixty-one adolescents diagnosed with depression participated in the study (33.5% males, 66.5% females). Their average age was 16 (SD=1.7). The number of admitted patients increased from 9 to 16 new adolescents with depression and STB each month between the period before and after the first lockdown, with a large proportion of female patients (increase of 74.1%).

CONCLUSION

This study showed an increase in the number of adolescents consulting for suicidal thoughts or behavior in an adolescent psychiatry department in Reunion Island after the initial Covid-19 lockdown. They were mainly female. This increase has strained an already overburdened mental health system by doubling the number of adolescents that each health care provider has had to help which increases the risk of inadequate care by rapidly increasing the workload but with constant resources.

Suicide mortality in Spain during the COVID-19 pandemic: Longitudinal analysis of sociodemographic factors

The COVID-19 pandemic has compromised public health response across the globe. Several countries reported increasing number of suicides during the pandemic. This study aimed to analyze the suicide mortality series in Spain (2000-2021), with a particular interest in depicting longitudinal trends during the COVID-19 pandemic. Moreover, it intended to identify sociodemographic groups with a higher increase in suicide victims during the pandemic. To do so, suicide cases from the National death index data were used. Weighted annual mortality rate was compared between pre-pandemic and pandemic years. Poisson time series models were used to analyze the trend in suicide mortality, considering sociodemographic variables (sex, age, migration status, marital status, and urbanicity). As a result, weighted mortality rate for 2020 was 8.92 (CI95 = [8.29, 9.57]) and 9.21 for 2021 (CI95 = [8.56, 9.88]). Annual mortality from the pandemic years was significantly higher than mortality from the prepandemic ones (p < .01). Poisson regression revealed a significant increase of cases during the pandemic months, RR = 1.05 (CI95 = [1.02, 1.08]); being significant for both sexes, and migration groups (RR > 1.02, across series). A significantly increased number of suicides was also observed for mid-age adults, large urban areas, and single people (RR > 1.05, across series). To sum up, our study supports an increasing number of suicide victims in Spain during the pandemic. We show that the COVID-19 influence on suicide risk factors (e.g., lack of social support networks) plays a critical role in the increasing trend of specific sociodemographic groups.

Suicide prevention in Hong Kong: pushing boundaries while building bridges

Hong Kong is a natural laboratory for studying suicides-small geographic footprint, bustling economic activity, rapidly changing socio-demographic transitions, and cultural crossroads. Its qualities also intensify the challenges posed when seeking to prevent them. In this viewpoint, we showed the research and practices of suicide prevention efforts made by the Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP), which provide the theoretical underpinning of suicide prevention and empirical evidence. CSRP adopted a multi-level public health approach (universal, selective and indicated), and has collaboratively designed, implemented, and evaluated numerous programs that have demonstrated effectiveness in suicide prevention and mental well-being promotion. The center serves as a hub and a catalyst for creating, identifying, deploying, and evaluating suicide prevention initiatives, which have the potential to reduce regional suicides rates when taken to scale and sustained.

The Impact of the COVID-19 Pandemic on Unassisted Suicide and Assisted Suicide Rates in French-Speaking Switzerland: Differences by Gender

Aims: Most studies on the impact of COVID-19 have shown a decrease or no change in unassisted suicide rates, but effects on assisted suicide have not been studied. We aimed to estimate the association between the COVID-19 pandemic and both types of suicide. Methods: Between 2017 and 2021, 1280 assisted suicides and 535 unassisted suicides were recorded in three Swiss cantons. We conducted descriptive and time series analyses on monthly suicide rates, categorized by gender. Results: Among women, a decrease in assisted suicide rates was found during the acute phases of the pandemic. Among men, assisted suicide rates increased gradually from the onset of the pandemic. Regarding unassisted suicide rates, no significant change was observed in women, while in men, there was a decrease, which was larger at the end than at the onset. Conclusions: COVID-19 had contrasting effects on assisted and unassisted men and women suicide rates.

Temporal Fluctuations of Suicide Mortality in Japan from 2009 to 2023 Using Government Databases

In Japan, suicide mortalities consistently decreased before the COVID-19 pandemic (from 2009 to 2019) but, conversely, increased after the pandemic outbreak from 2020 to 2022. To provide up-to-date suicide statistics in Japan, this study determined the temporal fluctuations of standardized suicide mortalities (SMRs), disaggregated by sex and age, by joinpoint regression analysis using the government suicide database, named the "Basic Data on Suicide in Region". From January 2009 to December 2023, three temporal fluctuation patterns of SMRs pertaining to working age and older adults were detected, such as attenuations of decreasing trends before the COVID-19 pandemic (from around the mid-2010s), a sharply increasing trend that coincided with the pandemic outbreak, and gradually decreased during the pandemic, but no changes at the end of the COVID-19 pandemic. In particular, the SMRs of working-age females sharply increased concurrently with the pandemic outbreak, whereas those of males did not change. However, before the pandemic, decreasing trends of the SMRs of working-age males diminished in the mid-2010s, but those of females consistently decreased. The SMRs of working-age males indicated non-significant but sharply increasing trends in early 2022, a trend that was not observed for females. In contrast to working-age adults, the SMRs of adolescents already began to increase in the mid-2010s and also indicated consistently increasing trends between the periods during and after the pandemic. These results suggest, contrary to our expectations, that the impacts of both the outbreak and end of the COVID-19 pandemic were limited regarding the increase in SMRs from 2020. Therefore, when revising suicide prevention programs in the post-COVID-19 era, it should be noted that focusing on pandemic-associated factors alone is not sufficient.

Impacts of Working Hours, Wages, and Regular Employment Opportunity on Suicide Mortalities of Employed and Unemployed Individuals before and during the COVID-19 Pandemic in Japan

Standardized suicide mortality rates per 100,000 population (SMRs) in Japan consistently decreased from 2009-2019, but these decreasing trends were reversed to increase in 2020. To clarify the mechanisms of recent increasing suicide in Japan, temporal fluctuations of SMRs disaggregated by sex and employment status (employed and unemployed individuals) and labor indices such as working hours, wages, and regular employment opportunity index (REO) from January 2012 to June 2023 were analyzed using interrupted time-series analysis. Additionally, temporal causalities from labor indices to SMRs were analyzed using vector autoregressive and non-linear auto-regressive distributed lag analyses. Decreasing trends among employed SMRs of both sexes were attenuated after the enactment of the "Work Style Reform Program" in 2018, but male SMRs were unaffected by the COVID-19 pandemic. However, female employed SMRs sharply increased, synchronized with the "Work Style Reform Act" and the COVID-19 pandemic outbreak (the COVID-19 impact was greater than the "Work Style Reform Act"). Additionally, unemployed SMRs of both sexes sharply increased with the revision and scale-down of countermeasures against economic deterioration caused by COVID-19 ("revision of economic supportive countermeasures against economic deterioration caused by COVID-19"). Unexpectedly, after enacting the "Work Style Reform Act", wages decreased due to possibly decreasing working hours. Increasing REO, which consistently increased, was a protective factor for male suicides, but unemployed SMRs were not affected by any labor indices. It has been established that controlling a heavy workload plays an important role in suppressing the deterioration of physical and mental conditions, including suicide; however, this study suggested that, at least within appropriate ranges of working hours, decreasing working hours due to excessive management probably contributes to increasing suicides of some vulnerable individuals via de-creasing their wages. Although governmental welfare and economic support measures had to be revised according to rapidly changing situations during the COVID-19 pandemic, this study also suggested that temporal gaps among a part of revisions of several welfare and economic support measures were unexpectedly involved in drastically/sharply increasing suicides of unemployed individuals in 2022.

Suicide risk, related factors and the impact of COVID-19 amongst suicide prevention helpline callers: A network analysis

BACKGROUND

The COVID-19 pandemic brought along many known risk factors for suicide. It is important to map out contributing and protective factors for suicide risk and examine possible changes in these associations during pandemics such as COVID-19. The current study aimed to examine how information on risk and protective factors obtained through a suicide prevention helpline is linked to the assessed suicide risk and the possible impact of the COVID-19 pandemic.

METHODS

Data on 9474 calls registered by operators of the suicide prevention helpline of Flanders (i.e., part of Belgium) were analysed using network analysis. Using network analyses allowed for a data-driven examination of direct and indirect pathways through which risk and protective factors are associated to perceived suicide risk. The network before and during COVID-19 were compared to examine the possible impact of the pandemic.

RESULTS

Our findings suggest that different vulnerability and protective factors contribute to perceived suicide risk. Experiencing a break-up, abuse, previous attempt(s), experienced difficulties with the healthcare system and availability of resources were directly and uniquely associated with perceived suicide risk before and during COVID-19.

LIMITATIONS

Main limitations of this study are the possible bias of operator assessment accuracy, absence of several important psychological risk factors and the use of cross-sectional data.

CONCLUSIONS

The current study provides insight in the effect of COVID-19 on suicidality and its risk and protective factors amongst suicide prevention helpline users, a population with high risk of suicide. Implications for suicide prevention helplines are discussed.

Mental health impacts of COVID-19: A retrospective analysis of dynamic modelling projections for Australia

Background

In early 2020, we developed a dynamic model to support policy responses aimed at mitigating the adverse mental health effects of the COVID-19 pandemic in Australia. As the pandemic has progressed, it has become clear that our initial model forecasts overestimated the impacts of infection control measures (lockdowns, physical distancing, etc.) on suicide, intentional self-harm hospitalisation, and mental health-related emergency department (ED) presentation rates.

Methods

Potential explanations for the divergence of our model predictions from observed outcomes were assessed by comparing simulation results for a set of progressively more refined models with data on the prevalence of moderate to very high psychological distress and numbers of suicides, intentional self-harm hospitalisations, and mental health-related ED presentations published after our modelling was released in July 2020.

Results

Allowing per capita rates of spontaneous recovery and intentional self-harm to differ between people experiencing moderate to very high psychological distress prior to the pandemic and those developing comparable levels of psychological distress only as a consequence of infection control measures substantially improves the fit of our model to empirical estimates of the prevalence of psychological distress and leads to significantly lower predicted effects of COVID-19 on suicide, intentional self-harm hospitalisation, and mental health-related ED presentation rates.

Conclusion

Accommodating the influence of prior mental health on the psychological effects of population-wide social and economic disruption is likely to be critical for accurately forecasting the mental health impacts of future public health crises as they inevitably arise.

Annual Research Review: Sex, gender, and internalizing conditions among adolescents in the 21st century - trends, causes, consequences

Internalizing conditions of psychopathology include depressive and anxiety disorders; they most often onset in adolescence, are relatively common, and contribute to significant population morbidity and mortality. In this research review, we present the evidence that internalizing conditions, including depression and anxiety, as well as psychological distress, suicidal thoughts and self-harm, and fatal suicide, are considerably increasing in adolescent populations across many countries. Evidence indicates that increases are currently greatest in female adolescents. We present an epidemiological framework for evaluating the causes of these increases, and synthesize research on whether several established risk factors (e.g., age of pubertal transition and stressful life events) and novel risk factors (e.g., digital technology and social media) meet conditions necessary to be plausible causes of increases in adolescent internalizing conditions. We conclude that there are a multitude of potential causes of increases in adolescent internalizing conditions, outline evidence gaps including the lack of research on nonbinary and gender nonconforming populations, and recommend necessary prevention and intervention foci from a clinical and public health perspective.

The COVID-19 pandemic and changes in spatio-temporal patterns of suicide: monthly variations among localities in Argentina

The aim of this study was to assess space-time clustering of suicide in Argentina between 2017 and 2020. A spatio-temporal scan statistic using a space-time permutation model was employed to retrospectively detect clusters of total suicides by sex and by age group. From 2017 to 2020, six statistically significant spatio-temporal clusters were identified in Argentina with either more or less suicides than expected. Two clusters extended from May 2019 to July and September 2020, while the remaining four clusters were detected only during 2020. The start of the COVID-19 pandemic seems to have changed the spatio-temporal patterns of suicide in Argentina. Despite the national decrease in the number of suicides during 2020 compared to previous years, the spatio-temporal analysis revealed both areas with decreases and increases in suicide. This heterogeneous scenario highlights the need for the study of local effects behind the emergence of these spatio-temporal suicide clusters.

[Suicides among children, adolescents, and young adults during the COVID-19 pandemic - An analysis of police data from three German federal states]

OBJECTIVE

The COVID-19 pandemic severely affected young people, resulting in increased psychological distress and rising prevalence rates for mental disorders. There is concern that completed suicides have increased in addition to the observed increase in suicide attempts.

METHOD

The study is based on the police crime statistics (01/2017 to 12/2022) of three federal states in Germany, representing 13% of Germany's overall population. Suicide counts and rates for the child, teenage, adolescent, and young adult age groups were compared between the pre-pandemic and pandemic periods using chi-squared tests.

RESULTS

860 people under age 30 died from suicide. Suicide rates did not differ between the pre-pandemic and pandemic periods in any of the age groups studied.

CONCLUSION

So far, there has been no discernible increase in suicides among young Germans. Ongoing suicide monitoring is recommended.

Are autopsies on minors a taboo?: The experience of Milan in a 19-year retrospective study

Forensic autopsy is an important tool for the proper management of non-natural deaths in minors. However, it seems that autopsy in minors is a practice which may not be performed routinely. In this framework, we conducted a study analyzing autopsies of minors (under 18 years of age in Italy) performed at the Institute of Forensic Medicine in Milan in the period 2001-2019. For the period 2015-2019, we extrapolated all deaths due to non-natural causes in minors to investigate how many and which of these deaths were not subjected to forensic autopsy. Of the total, 344 minors (235 males and 109 females) underwent autopsies, with an overall downward trend of about 80% since 2004. Most autopsies occurred between the ages of 0 and 1 year, and the fewest between the ages of 5 and 9 years. The place of death was home in most cases, and accidental death was most common, followed by natural death, suicide, and homicide, with prevalence varying by age group. Blunt force trauma predominated among accidental death in all age groups, followed by asphyxia. Similar findings were observed for suicides, although there was a more differentiated pattern for suicides between the ages of 15 and 17 years. Among homicides, blunt force trauma, asphyxia, and gunshot wounds were fairly evenly distributed across all age groups. Between 2015 and 2019, a total of 86 minors died of a non-natural cause, and a forensic autopsy was performed in only 33 cases (38%). Our data shows that fewer and fewer autopsies are being performed over the last years, which indicates a dangerous lack of forensic investigation of children and adolescent deaths, with enormous implications for prevention of child abuse.

Nightmare frequency is a risk factor for suicidal ideation during the COVID-19 pandemic

The association between nightmare frequency (NMF) and suicidal ideation (SI) is well known, yet the impact of the COVID-19 pandemic on this relation is inconsistent. This study aimed to investigate changes in NMF, SI, and their association during the COVID-19 pandemic. Data were collected in 16 countries using a harmonised questionnaire. The sample included 9328 individuals (4848 women; age M[SD] = 46.85 [17.75] years), and 17.60% reported previous COVID-19. Overall, SI was significantly 2% lower during the pandemic vs. before, and this was consistent across genders and ages. Most countries/regions demonstrated decreases in SI during this pandemic, with Austria (-9.57%), Sweden (-6.18%), and Bulgaria (-5.14%) exhibiting significant declines in SI, but Italy (1.45%) and Portugal (2.45%) demonstrated non-significant increases. Suicidal ideation was more common in participants with long-COVID (21.10%) vs. short-COVID (12.40%), though SI did not vary by COVID-19 history. Nightmare frequency increased by 4.50% during the pandemic and was significantly higher in those with previous COVID-19 (14.50% vs. 10.70%), during infection (23.00% vs. 8.10%), and in those with long-COVID (18.00% vs. 8.50%). The relation between NMF and SI was not significantly stronger during the pandemic than prior (rs = 0.18 vs. 0.14; z = 2.80). Frequent nightmares during the pandemic increased the likelihood of reporting SI (OR = 1.57, 95% CI 1.20-2.05), while frequent dream recall during the pandemic served a protective effect (OR = 0.74, 95% CI 0.59-0.94). These findings have important implications for identifying those at risk of suicide and may offer a potential pathway for suicide prevention.

Recovering from the first shock? Changes in suicidality during the first two years of the COVID-19 pandemic in a country with traditionally high levels of completed suicides

BACKGROUND

Hungary was among the few countries where suicidality increased in the first year of the COVID pandemic. In this study, we sought to investigate whether that elevated suicide mortality had changed by 2021, when the number of fatalities due to COVID-19 was much higher than in 2020.

METHODS

We used an interrupted time-series analysis with (quasi-) Poisson regression, controlling for linear trend and seasonal effects, to estimate the effect of the pandemic on the suicide rates of various subpopulations. For both pandemic years the changes in risk of suicide were compared to the period between 2015 and 2019.

RESULTS

Although the pandemic had a significant adverse effect on suicidality in 2020 in the Hungarian total population and in males, by 2021 this effect had vanished. In the total population, those aged 25 years and older had elevated suicidality in 2020 but neither age group in the total population had elevated suicidality in 2021. In the total population, increased risks of suicide death could be observed among residents of the capital city (in 2020 and 2021), villages (in 2020), and - in terms of regions - "Central Hungary" (in 2020 and 2021). Only the risk of violent suicides was significantly higher for both the total and male populations (and only in 2020).

LIMITATIONS

We used non-individual level data.

CONCLUSIONS

The increased suicidality in 2020 had abated by 2021. In the paper, we discuss the possible explanations for our findings.

Suicide prevention during disasters and public health emergencies: a systematic review

Background

Disasters and public health emergencies increasingly affect populations around the world, posing significant wide-ranging challenges for societies as well as for effective public health and suicide prevention. Intervention research is essential to inform evidence-based responses. Yet, despite evident public concern and growing research interest in heightened suicide risks and impacts, little is known about effective suicide prevention interventions in these contexts. We conducted a systematic review to examine the outcomes of suicide prevention strategies implemented in disasters and public health emergencies.

Methods

We searched five databases (Medline, Embase, PsycINFO, Web of Science, PTSDpubs) from inception to December 2022 for peer-reviewed quantitative studies that reported relevant intervention outcomes (changes in the frequency of suicide, suicide attempts, self-harm) for populations affected by disasters and public health emergencies. We assessed the quality of eligible studies using the Quality Assessment Tool for Quantitative Studies, and distilled review findings through narrative synthesis. The study protocol was registered with PROSPERO (CRD42021276195).

Results

Ten eligible and mostly observational studies were included in this review, which examined a range of universal, selective, and indicated interventions. Three of five studies of interventions in public health emergencies indicated the potential effectiveness and buffering effects of generic disaster related mental health support, access to urban parks, as well as the beneficial role of video-enabled tablets in facilitating treatment access and outcomes. Similarly, three of five studies of interventions in disaster contexts provided evidence of the beneficial role of universal economic security measures, national gun laws and buy back schemes, and volunteer-delivered mental health support. Overall, four of six studies with favorable outcomes examined interventions specifically deployed in disaster or public health emergency contexts, whereas two studies examined ongoing existing interventions. Three studies, respectively, of suicide prevention focused interventions or generic interventions reported favorable outcomes. The quality of included studies was variable, with two studies being rated as 'strong', four studies rated as 'moderate', and four studies rated as 'weak'.

Conclusion

Notwithstanding the limited scope and variable quality of published evidence, our review findings highlight the breadth of interventions that have been applied in such contexts with some success. There is a need for further research on effective interventions and intervention adaptations to inform evidence-based suicide prevention responses to disasters and public health emergencies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276195, PROSPERO ID CRD42021276195.

Excess suicides in Brazil during the first 2 years of the COVID-19 pandemic: Gender, regional and age group inequalities

BACKGROUND

While the COVID-19 pandemic's total impact on global mortality is uncertain, an estimated 15 million excess deaths occurred during the first two pandemic years, suggesting that a broad impact, since several causes of death showed a substantial rise.

AIMS

To estimate excess suicides in Brazil and evaluate differences within and between subgroups during the first 2 years of the COVID-19 pandemic.

METHOD

Based on suicide data from the mortality information system of the Brazilian Ministry of Health, the expected number of suicides was estimated by age group, gender, 4-month periods and regions through quasi-Poisson generalized additive models. Analyses were performed in R software and RStudio.

RESULTS

Between March 2020 and February 2022, 29,295 suicides were reported in Brazil, close to what would be expected (30,116; 95% Confidence Interval (95% CI): [28,009, 32,224]), albeit in males and females aged 30 to 59 years and 60 years and over, there were excess suicides in at least one of the six 4-month periods evaluated, especially in the second pandemic year. In the Southeast region, a 28% increase was observed in women 60 years and older during the second year. In the North region, suicide increased 23% and 32% among women aged 30 to 59 years during the first and second pandemic years, respectively. The Northeast region had a 16% excess in suicides among men aged 30 to 59 years and 61% among women 60 years old and older during the second pandemic year, reaching 83% in July to October 2021.

CONCLUSIONS

During the first 2 pandemic years, the pattern of suicides was not homogeneous in Brazil. There were substantial excess suicides in women aged 30 to 59 years from the North and Northeast, while among the elderly and men there was a consistent pattern in several four-month periods throughout Brazil.

The impact of the COVID-19 pandemic on mortality in Sweden-Did it differ across socioeconomic groups?

The characterization of the socioeconomic profile of COVID-19 mortality is limited. Likewise, the mapping of potential indirect adverse outcomes of the pandemic, such as suicide and alcohol abuse, along socioeconomic lines is still meagre. The main aim of this paper is to (i) depict SES-differences in COVID-19 mortality, and (ii) to assess the impact of the COVID-19 pandemic on suicide and alcohol mortality across socioeconomic groups. We used Swedish monthly data spanning the period January 2016-December 2021. We chose education as indicator of socioeconomic status (SES). The following causes of deaths were included in the analysis: COVID-19, all-cause mortality excluding COVID-19, suicide and a composite index of alcohol-specific deaths. SARIMA-modelling was used to assess the impact of the pandemic on suicide and alcohol-specific mortality. Two alternative measures of the pandemic were used: (1) a dummy that was coded 1 during the pandemic (March 2020 and onwards), and 0 otherwise, and (2) the Oxford COVID-19 Government Response Tracker's Stringency Index. There was a marked SES-gradient in COVID-19 mortality in the working-age population (25-64) which was larger than for other causes of death. A SES-gradient was also found in the old-age population, but this gradient did not differ from the gradient for other causes of death. The outcome from the SARIMA time-series analyses suggested that the pandemic did not have any impact on suicide or alcohol-specific mortality in any of the educational and gender groups.

Trends and projections of cause-specific premature mortality in Australia to 2044: a statistical modelling study

Background

Long-term projections of premature mortality (defined as deaths age <75 years) help to inform decisions about public health priorities. This study aimed to project premature mortality rates in Australia to 2044, and to estimate numbers of deaths and potential years of life lost (PYLL) due to premature mortality overall and for 59 causes.

Methods

We examined the past trends in premature mortality rates using Australian mortality data by sex, 5-year age group and 5-year calendar period up to 2019. Cigarette smoking exposure data (1945-2019) were included to project lung cancer mortality. Age-period-cohort or generalised linear models were developed and validated for each cause to project premature mortality rates to 2044.

Findings

Over the 25-year period from 1990-1994 to 2015-2019, there was a 44.4% decrease in the overall age-standardised premature mortality rate. This decline is expected to continue, from 162.4 deaths/100,000 population in 2015-2019 to 141.7/100,000 in 2040-2044 (12.7% decrease). Despite declining rates, total numbers of premature deaths are projected to increase by 22.8%, rising from 272,815 deaths in 2015-2019 to 334,894 deaths in 2040-2044. This is expected to result in 1.58 million premature deaths over the 25-year period 2020-2044, accounting for 24.5 million PYLL. Of the high-level cause categories, cancer is projected to remain the most common cause of premature death in Australia by 2044, followed by cardiovascular disease, external causes (including injury, poisoning, and suicide), and respiratory diseases.

Interpretation

Despite continuously declining overall premature mortality rates, the total number of premature deaths in Australia is projected to remain substantial, and cancer will continue to be the leading cause. These projections can inform the targeting of public health efforts and can serve as benchmarks against which to measure the impact of future interventions. They emphasise the ongoing importance of accelerating the prevention, early detection, and treatment of key health conditions.

Funding

No funding was provided for this study.

Patterns of Hospital Presenting Suicide-Related Ideation in Older Adults before and during COVID-19: Findings from a National Clinical Service in Ireland 2018-2021

OBJECTIVE

To examine changes in trends of hospital-presenting suicide-related ideation in older adults living in Ireland, during the first 24 months of the COVID-19 pandemic and 2018-2019.

METHODS

Data on presentations of patients aged 60 and older from participating hospitals of the National Clinical Programme for Self-Harm and Suicide-related Ideation were used to compare trends during the first two years of the COVID-19 pandemic (2020-2021) with the preceding period (2018-2019). Poisson regression models were used to estimate trends in the pre-pandemic and pandemic periods.

RESULTS

There were 1531 presentations for suicide-related ideation to hospital emergency departments in older adults between January 1, 2018-December 31, 2021, with most presentations involving males (57.2%, n = 876). There was a 27% increase in suicide-related ideation presentations during the pandemic years (2020-2021) when compared to 2018-2019 (RR: 1.27, p = .001, 95%CI: 1.14-1.40), with females showing a 29% increase (RR: 1.29, p = .001, 95%CI: 1.11-1.51) and males a 23% increase (RR: 1.23, p = .002, 95%CI: 1.08-1.40). When examining these trends by years, there were only significant increases in 2021, and no significant increases were observed in 2020.

CONCLUSIONS

The study findings show that in the second year following the start of the pandemic, significant increases were observed in suicide-related ideation hospital-presentations in older adults. While immediate changes in trends were not observed in the first year of the pandemic, it is important to consider the pandemic's medium and long-term impact on older adults' mental health, to provide adequate support and reduce suicide risk among those presenting with suicide-related ideation.

The impact of the COVID-19 pandemic on rates of adolescents receiving psychopharmacological medication in Austria

BACKGROUND

The COVID-19 pandemic has impacted many aspects of everyday life, including the (mental) healthcare system. An increase in depression and anxiety symptoms has been reported worldwide, and is particularly pronounced in females and young people. We aimed to evaluate changes in prescription rates for psychopharmacological medication, which is often used to treat depression and anxiety.

METHOD

Based on data from the Austrian public health insurance institutions, we conducted an interrupted time series analysis of antidepressants and antipsychotics, comparing prescription rate developments before and throughout the COVID-19 pandemic (2013 to 2021), with a special focus on adolescents (10-19 years) in comparison to the general population. Data were based on all public prescriptions in the outpatient sector nationwide. Age- and sex-stratified time-series models were fitted to the pre-COVID period (first quarter (Q1) of 2013 to second quarter (Q2) of 2020). These were used to generate forecasts for the period from the third quarter (Q3) of 2020 to the fourth quarter (Q4) of 2021, which were subsequently compared to observed developments in order to assess significant deviations from the forecasted development paths.

RESULTS

For the majority of the evaluated period, we found a significant excess of antidepressant prescriptions among both male and female adolescents (10-14 and 15-19 years) compared to the forecasted development path, while the general population was mostly within 97.5% confidence intervals of the forecasts. Regarding antipsychotics, the interrupted time series analysis revealed a significant excess in the group of female adolescents in almost all quarters, which was especially pronounced in the 15-19 age group. Prescription rates of antipsychotics in the general population only showed a significant excess in two quarters.

CONCLUSION

Increased rates of adolescents receiving psychopharmacological treatment echo the epidemiological trends of an increase in depression and anxiety symptoms reported in the literature. This increase is especially pronounced in female adolescents.

Prevalence and correlates of suicidal ideation in the general public during the fifth wave of COVID-19 pandemic in Hong Kong

Introduction

Literature reveals increased suicidal ideation in the general population during pandemic. However, few COVID-19 studies comprehensively assessed factors associated with suicidal ideation, and mixed findings were observed. We aimed to examine prevalence and correlates of suicidal ideation in general public during the peak of fifth COVID-19 wave in Hong Kong based on a broad array of relevant measures.

Methods

This survey assessed 14,709 community-dwelling adults during March 15-April 3, 2022. Comprehensive assessment was administered including socio-demographics, pre-existing mental/physical morbidity, mental-health symptoms, resilience, loneliness, coping strategies, and pandemic-related factors. Presence of suicidal ideation was evaluated by ratings of item 9 on Patient-Health-Questionnaire-9.

Results

A total of 2,249 (15.3%) participants exhibited suicidal ideation. Multivariable-regression analysis found that being single and unemployed, pre-existing mental disorder, more severe depressive and anxiety symptoms, higher levels of loneliness and engagement in avoidant coping were significantly associated with suicidal ideation. Conversely, attaining tertiary educational level or above, greater resilience and adopting problem-focused coping were associated with lower likelihood of suicidal ideation. Although univariate-analyses revealed that a number of pandemic-related factors were linked to suicidal ideation, none remained significant in the multivariable model.

Conclusion

A significant proportion of people experienced suicidal ideation during the peak of fifth COVID-19 wave. Risk and protective factors identified would facilitate early identification of high-risk individuals and provision of targeted interventions to minimize suicidal ideation and risk of self-harm. Caution should be exercised due to study limitations of a cross-sectional design which precluded establishing causality among variables, and reliance on self-reported data.

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

AIMS AND METHOD

Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time.

RESULTS

Recent literature proposes a safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted.

CLINICAL IMPLICATIONS

Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.

Excess mortality in US Veterans during the COVID-19 pandemic: an individual-level cohort study

BACKGROUND

Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality.

METHODS

We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e. excess mortality rates, number of excess deaths) and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively.

RESULTS

Of 5 905 747 patients, the median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103 164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46).

CONCLUSIONS

Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasizing the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.

ED Visits for Schizophrenia Spectrum Disorders During the COVID-19 Pandemic at 5 Campus Health Systems

Importance

Although substantial research has reported grave population-level psychiatric sequelae of the COVID-19 pandemic, evidence pertaining to temporal changes in schizophrenia spectrum disorders in the US following the pandemic remains limited.

Objective

To examine the monthly patterns of emergency department (ED) visits for schizophrenia spectrum disorders after the onset of the COVID-19 pandemic.

Design, Setting, and Participants

This observational cohort study used time-series analyses to examine whether monthly counts of ED visits for schizophrenia spectrum disorders across 5 University of California (UC) campus health systems increased beyond expected levels during the COVID-19 pandemic. Data included ED visits reported by the 5 UC campuses from 2016 to 2021. Participants included persons who accessed UC Health System EDs had a diagnosis of a psychiatric condition. Data analysis was performed from March to June 2023.

Exposures

The exposures were binary indicators of initial (March to May 2020) and extended (March to December 2020) phases of the COVID-19 pandemic.

Main Outcomes and Measures

The primary outcome was monthly counts of ED visits for schizophrenia spectrum disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes, categorized within Clinical Classification Software groups, were used to identify ED visits for schizophrenia spectrum disorders and all other psychiatric ED visits, from the University of California Health Data Warehouse database, from January 2016 to December 2021. Time-series analyses controlled for autocorrelation, seasonality, and concurrent trends in ED visits for all other psychiatric conditions.

Results

The study data comprised a total of 377 872 psychiatric ED visits, with 37 815 visits for schizophrenia spectrum disorders. The prepandemic monthly mean (SD) number of ED visits for schizophrenia spectrum disorders was 519.9 (38.1), which increased to 558.4 (47.6) following the onset of the COVID-19 pandemic. Results from time series analyses, controlling for monthly counts of ED visits for all other psychiatric conditions, indicated 70.5 additional ED visits (95% CI, 11.7-129.3 additional visits; P = .02) for schizophrenia spectrum disorders at 1 month and 74.9 additional visits (95% CI, 24.0-126.0 visits; P = .005) at 3 months following the initial phase of the COVID-19 pandemic in California.

Conclusions and Relevance

This study found a 15% increase in ED visits for schizophrenia spectrum disorders within 3 months after the initial phase of the pandemic in California across 5 UC campus health systems, underscoring the importance of social policies related to future emergency preparedness and the need to strengthen mental health care systems.

Suicide trends in Germany during the COVID-19 pandemic and the war in Ukraine

AIMS

The later phase of the COVID-19 pandemic overlaps with geopolitical and economic consequences from the Ukraine war. Financial hardship and concerns about gas supply may add to pandemic factors and lead to increased suicide rates in Germany.

METHODS

Age- and sex-stratified suicide data from police crime statistics covering 35 % of the German population were used for an interrupted time-series analysis and for a projection of total German suicides in 2022.

RESULTS

For both sexes, a trend reversal from constant or declining suicide rates to an increase was observed. This increase is particularly pronounced in 2022 and mainly relates to the 60+ age group that is highly vulnerable to suicide. The projection of the overall German suicide rate is at a level last observed in 2015.

CONCLUSIONS

The key challenge now is to combat potential causes of this rise in suicide rates to avert the emerging upward trend.

A Proposed Pastoral Response to the Increase in the Number of Suicide Cases in the Philippines During the COVID-19 Pandemic

This paper aims to provide a pastoral response to the increase in the number of suicides in the Philippines during the COVID-19 pandemic. This paper will look into the reasons and statistics related to suicide since there was a sudden spike in number during the pandemic. The See-Discern-Act method is used in this study so that the current social issue will be viewed from the teachings of the Church. First, we will discuss the reports on the cases of mental health issues. This issue has alarmed several professionals that focus on protecting one's mental health. Second, we will discuss key concepts from the Catechism of the Catholic Church to present the view on suicide. Also, John Paul II's Evangelium Vitae will be cited to provide a perspective on the value of human life. The Compendium of the Social Doctrine of the Church will also be tackled to explain the Church's view on mental health and well-being. Third, we will attempt to unearth the mental well-being of some Filipinos concerning suicide cases in the Philippines in light of the Church's teachings. Hence, our goal is to provide a perspective on this problem using the teachings of the Church on human life so that we may draw a proposed pastoral theological response. Hence, we propose that the Church must provide plans for prevention, intervention, and postvention when it comes to people involved in any suicide case as these actions are aligned with the goal of the Church to take care of those who suffer from mental illness and emphasize the value of human life.

Factors associated with suicide risk among Brazilian graduate students during the COVID-19 pandemic

Though pandemic-related suicides are a concern, little is known about factors potentially linking graduate student life and suicide risk. This study identified factors associated with suicide risk among Brazilian graduate students (N = 5,344) during the COVID-19 pandemic. Utilizing the Mini International Neuropsychiatric Interview, this study revealed that 31.5% of participants presented some risk for suicide: 16.6% "low risk," 4.7% "moderate risk," and 10.2% "high risk." Higher income and religious affiliation were identified as protective factors. Identified risk factors encompass non-heterosexual orientation, a history of depression or posttraumatic stress or common mental disorders diagnoses, the use of medications-both general and psychopharmaceuticals-without medical prescription, antipsychotics use, alcohol consumption, lack of health insurance, and dissatisfaction with life as a result of accessing social media networks. The high vulnerability of graduate students to suicide risk highlights the need for institutional suicide prevention initiatives.

Comparison of all completed suicides in Frankfurt am Main (Hessen) before and during the early COVID-19 pandemic

To research the effect of the COVID-19 pandemic on mental health, the prevalence and characteristics of all completed suicides in the city of Frankfurt am Main were compared for a 10-month period before the pandemic (March 2019-December 2019) with one during the early pandemic (March 2020-December 2020). Medicolegal data collected in the context of the FraPPE suicide prevention project were evaluated using descriptive statistical methods. In total, there were 81 suicides during the early pandemic period, as opposed to 86 in the pre-pandemic period. Though statistically not significant, the proportion of male suicides (73%) was higher during the early pandemic period than before (63%). The age-at-death was comparable in the pre-pandemic and pandemic periods (average, 54.8 vs. 53.1 years). Between these two periods, there was no difference in respect to the three most commonly used suicide methods by men: fall from a height (26% vs. 22%), intoxication, and strangulation (each 24% vs. 19%). For women, there was, however, a shift in methods from strangulation (38%), intoxication (28%), and fall from a height (19%) to fall from a height (50%), strangulation (18%), intoxication, and collision with a rail vehicle (14% each). There was a trend towards more suicides among non-German nationals during the early pandemic (suicide rate/100,000 inhabitants: German, 14.3 vs. 11.5; non-German, 4.4 vs. 8.8). Before the pandemic, 54% of the suicides were known to have a mental illness in contrast to 44% during the early pandemic. Overall, no increase in completed suicides could be observed in Frankfurt am Main during the early pandemic.

Impact of the COVID-19 pandemic on acute mental health admissions in Croatia

Background

The pandemic of COVID-19 had a profound impact on our community and healthcare system. This study aims to assess the impact of COVID-19 on psychiatric care in Croatia by comparing the number of acute psychiatric cases before coronavirus disease (2017-2019) and during the pandemic (2020-2022).

Materials and methods

The paper is a retrospective, comparative analyzes of the hospital admission rate in Diagnosis Related Group (DRG) classes related to mental diseases, and organic mental disorders caused by alcohol and drug use. This study used DRG data from all acute hospitals in Croatia accredited to provide mental health care services and relevant publicly available data from the Croatian Institute of Public Health (CIPH) and the Croatian Health Insurance Fund (CHIF). All hospital admissions for acute psychiatric patients in Croatia were tracked during both periods under study.

Results

During the pandemic, the average number of all such cases decreased by 28% in secondary and tertiary hospitals, and by 11% in specialist psychiatric hospitals. It was also found that during COVID-19, there was a decrease in case numbers in DRG classes related to major affective disorders and anxiety, alcohol, and drug intoxication (31, 48, 34 and 45%, respectively). However, the same period saw an increase in hospital activity for eating disorders and for involuntary admissions related to schizophrenia and paranoia (30, 34 and 39% respectively). There were no changes in the admission rate for cases related to opioid use.

Conclusion

The COVID-19 pandemic resulted in both a steep decrease in the overall number of psychiatric cases inpatient treatment at mental health facilities and their DRG casemix. Increasing our understanding of how pandemics and isolation affect demand for psychiatric care will help us better plan for future crises and provide more targeted care to this vulnerable group.

Trends in mortality from non-natural causes in children and adolescents (0-19 years) in Europe from 2000 to 2018

BACKGROUND

Non-natural mortality in children and adolescents is a global public health problem that varies widely from country to country. Data on child and adolescent maltreatment are not readily available, and mortality due to violent causes is also underestimated.

METHODS

Injury-related mortality rates (overall and by specific causes) from 2000 to 2018 in selected European countries were analysed to observe mortality patterns in children and adolescents using data from the Eurostat database. Age-standardized mortality rates per 100,000 person-years were calculated for each country. Joinpoint regression analysis with a significance level of 0.05 and 95% confidence intervals was performed for mortality trends.

RESULTS

Children and adolescent mortality from non-natural causes decreased significantly in Europe from 10.48 around 2005 to 5.91 around 2015. The Eastern countries (Romania, Bulgaria, Poland, Slovakia, Czech Republic) had higher rates; while Spain, Denmark, Italy, and the United Kingdom had the lowest. Rates for European Country declined by 5.10% per year over the entire period. Larger downward trends were observed in Ireland, Spain and Portugal; smaller downward trends were observed for Eastern countries (Bulgaria, Czech Republic, Poland, Slovakia) and Finland. Among specific causes of death, the largest decreases were observed for accidental causes (-5.9%) and traffic accidents (-6.8%).

CONCLUSIONS

Mortality among children and adolescents due to non-natural causes has decreased significantly over the past two decades. Accidental events and transport accidents recorded the greatest decline in mortality rates, although there are still some European countries where the number of deaths among children and adolescents from non-natural causes is high. Social, cultural, and health-related reasons may explain the observed differences between countries.

Trends in suicide mortality in Spain from 1998 to 2021 and its relationship with the COVID-19 pandemic: A joinpoint regression analysis

In the European Union, a rate of 11.9 cases per 100,000 was estimated in 2019.In Spain, suicide is the leading cause of external death. Social crises can have an impact on suicide rates. We analyzed changes in suicide mortality trends in Spain following the COVID-19 pandemic. We used statistical data from the National Institute of Statistics of Spain (1998-2021). We calculated age-specific rates, age and sex-adjusted rates, and analyzed trends and changes using joinpoint-regression models. Rates decrease in both sexes at the ages of 65 and older. In women, they increase in the ages of 1-29 years and 45-59 years. In men, they decrease in the ages of 15-39 years. Among women, age-adjusted rates remained stable between 1998 and 2021, with a non-significant annual decrease of 0.4 %. Among men, there was a significant annual decrease of 0.7 %. The years 2020 and 2021 had 8 % higher mortality compared to the two years prior to the COVID-19 pandemic. Suicide mortality in Spain slightly decreased among men and remained stable among women between 1998 and 2021, but there seems to be an increase following the COVID-19 pandemic.

An unusual case of a triple suicide pact at the time of the COVID-19 pandemic

In December 2020, the World Health Organization (WHO) declared SARS-CoV2 a global pandemic. Home confinement, low social contacts, and fear of virus transmission played a major role as risk factors for suicides during the following period. Suicide pacts, in particular, showed a different pattern. A rare case of a triple suicide pact among members of the same family nucleus is presented. The victims were an elderly, severely ill woman and her adult children (a son and daughter), linked by a morbid relationship. The last time the family was seen alive was 40 days before the discovery. All corpses presented decompositional changes. After a full autopsy, the cause of death was determined to be a lethal intake of morphine for the mother and acute blood loss due to self-stabbing at the neck for the siblings. The younger woman was under the effects of a large amount of heparin. Toxicological analysis was positive for opioids and alcohol in both siblings. Suicide pacts have rarely been described during the COVID-19 pandemic. In the few cases reported, the victims were more often relatives than people in a romantic relationship. The involvement of three people is unusual, as is the use of different suicide methods among the victims. In the presented case, the elderly mother's imminent death from terminal cancer, her concern over dying in a nondomestic environment, and the siblings' fear of being alone likely led to the conception of the suicide pact. Social isolation and economic difficulties also played a contributing role.

A Rapid Systematic Review of the Prevalence of Suicide and Self-Harm Behaviors in Adolescents During the COVID-19 Pandemic

Background: COVID-19 has caused psychological, social, and physical isolation in adolescents resulting in varying rates of suicidal behavior and self-harm. Aims: We investigated the pandemic's impact on adolescent suicidal behavior and self-harm by reviewing the existing literature. Methods: We searched PubMed using keywords: adolescent, suicide, suicidal behavior, self-harm, prevalence, and COVID-19 and included studies reporting primary data only. Results: Of the 551 studies identified, we included 39 studies in the final analysis. Two of the six high-quality population-based suicide registry studies reported increased suicide rates during the pandemic. Seven of fifteen emergency department-based studies out of which four were of high quality and three high-quality population-based health registry studies reported increased self-harm. A few school and community-based surveys and national helpline data also reported an increase in suicidal behavior or self-harm. Limitations: Methodological heterogeneity of the included studies. Conclusions: There is wide variation in study methodology, population, settings, and age groups in the included studies. Suicidal behavior and self-harm were increased in specific study settings and adolescent populations during the pandemic. More methodologically rigorous research is needed to evaluate the impact of COVID-19 on adolescent suicidal behavior and self-harm.