Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis

The effect of the COVID-19 pandemic and school closures on self-harming and suicidal behaviors in adolescents: A comprehensive meta-analysis

INTRODUCTION

The COVID-19 pandemic has significantly affected adolescents' mental health, raising concerns about the potential increase in self-harming and suicidal behaviors (SIB). This study aimed to evaluate the pandemic's impact on SIB among adolescents and explore the effects of school closures and psychiatric vulnerabilities to inform future interventions.

METHODS

A systematic review and meta-analysis were conducted using PubMed, resulting in 420 studies, of which 36 studies (comprising 53 samples) met the inclusion criteria, encompassing 1,754,106 adolescents. Effect sizes were calculated using proportion effect size. Heterogeneity across studies was assessed using Q-statistics and I², while Egger's test was applied to evaluate publication bias. Differences between clinical and community samples, as well as the influence of psychiatric symptoms or disorders, were examined.

RESULTS

Clinical samples demonstrated higher rates of SIB compared to community samples, with adolescents having psychiatric symptoms or disorders being more vulnerable. Overall, the pandemic was associated with a decline in SIB rates compared to pre-pandemic levels. Suicidal ideation decreased by 4.14% in combined samples and by 7.13% in community samples. Self-harm rates fell by 5.38% and 6.62% in combined and community samples, respectively. In contrast, clinical samples showed a distinct trend, with suicidal ideation decreasing by 29.39%, while self-harm rates increased by 32.51% and suicide attempts rose by 22.41%.

CONCLUSION

The COVID-19 pandemic's impact on adolescents' SIB varied significantly across population types and levels of psychiatric vulnerability. While general declines were observed, the pronounced increases in self-harm and suicide attempts among clinical samples highlight the need for tailored mental health interventions. Addressing these disparities is essential for future mental health strategies and crisis preparedness.

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.

The trajectory of anxiety and depressive symptoms and the impact of self-injury: A longitudinal 12-month cohort study of individuals with psychiatric symptoms

BACKGROUND

Individuals reporting self-injury are at greater risk of several adverse outcomes, including suicide. There is reason to be concerned how these individuals cope when stressful life events increase. This study aimed to investigate the trajectories of anxiety and depressive symptoms and the predictive value of self-injury history in individuals with psychiatric symptoms during the unique and stressful conditions of the COVID-19 pandemic.

METHODS

In a longitudinal population cohort study (N = 1810) ranging from 2020 to 2022, anxiety (measured by Generalized Anxiety Disorder, GAD-7) and depressive symptoms (measured by Patient Health Questionnaire, PHQ-9) were self-reported monthly during 12 months. Latent growth curve models with and without self-reported self-injury history as predictors were conducted.

RESULTS

Overall, anxiety and depressive symptoms decreased from baseline, but remained at moderate severity at follow-up. Individuals reporting suicidal or nonsuicidal self-injury reported significantly higher symptom severity at baseline. In addition, individuals reporting suicidal self-injury demonstrated a slower rate of decline in the symptom load over the course of 12 months.

CONCLUSIONS

Over the course of 12 months, anxiety and depressive symptoms decreased in individuals with psychiatric symptoms, but still indicate a psychiatric burden. Individuals with a history of self-injury could be more vulnerable in face of stressful conditions such as those experienced during the COVID-19 pandemic.

Suicidal ideation and attempts among adolescents from a tertiary hospital in Turkey: A comparative study of pre and postpandemic periods

AIM

This study aims to compare changes in rates of suicidal ideation (SI) and attempts (SA) among adolescents during pre, mid and later periods of the pandemic.

MATERIAL AND METHOD

This study included adolescents who presented to the adolescent medicine clinic in Turkey between March-May 2019 (prepandemic = T0), March-May 2021(mid period of the pandemic = T1) and March-May 2022 (late period year of the pandemic = T2). SI and SA data were assessed through the electronic hospital records of the "HEEADSSS" inventory.

RESULTS

The charts of 2113 adolescents were evaluated. The rates of both SI (p = .015) and SA (p = .026) were determined to be higher during the pandemic (T1+T2) compared to the pre-pandemic period, with a 1.4-fold increase in SI and a 1.5-fold increase in SA. The rates of SI did not differ according to gender, (p = .090). In contrast, SA rate was significantly higher in females (7.3%) than males (3.6%) (p = .001).

CONCLUSION

This study reveals an increase in SI and SA among adolescents during the first 2 years of the pandemic. In challenging times, health professionals should prioritize the identification and treatment of mental health issues, including screening for depression and suicide risk.

Reactive Astrocytosis-A Potential Contributor to Increased Suicide in Long COVID-19 Patients?

BACKGROUND

Long COVID-19 is an emerging chronic illness of significant public health concern due to a myriad of neuropsychiatric sequelae, including increased suicidal ideation (SI) and behavior (SB).

METHODS

This review provides a concise synthesis of clinical evidence that points toward the dysfunction of astrocytes, the most abundant glial cell type in the central nervous system, as a potential shared pathology between SI/SB and COVID-19.

RESULTS

Depression, a suicide risk factor, and SI/SB were both associated with reduced frequencies of various astrocyte subsets and complex proteomic/transcriptional changes of astrocyte-related markers in a brain-region-specific manner. Astrocyte-related circulating markers were increased in depressed subjects and, to a less consistent extent, in COVID-19 patients. Furthermore, reactive astrocytosis was observed in subjects with SI/SB and those with COVID-19.

CONCLUSIONS

Astrocyte dysfunctions occurred in depression, SI/SB, and COVID-19. Reactive-astrocyte-mediated loss of the blood-brain barrier (BBB) integrity and subsequent neuroinflammation-a factor previously linked to SI/SB development-might contribute to increased suicide in individuals with long COVID-19. As such, the formulation of new therapeutic strategies to restore astrocyte homeostasis, enhance BBB integrity, and mitigate neuroinflammation may reduce SI/SB-associated neuropsychiatric manifestations among long COVID-19 patients.

Neurobiology and medico-legal aspects of suicides among older adults: a narrative review

The task of preventing suicide in older adults is an important social burden as older adults aged above 65 are exposed to singular psychological aspects that increase suicide risks. Moreover, when an older adult corpse is found, the medico-legal inspection represents a fundamental tool to identify the exact cause of death, classifying or excluding it as suicide. In this scenario, this review aims to explore the neurobiological factors that could be related to suicidal behavior in older adults. A further goal of this review is the exploration of the medico-legal aspects surrounding older adult suicides, clarifying the importance of forensic investigation. Particularly, this review examines issues such as neurotransmitter imbalances, cognitive impairment, neuroinflammation, psychosocial factors related to geriatric suicide, and neurodegenerative diseases. Additionally, medico-legal aspects such as policy considerations, legal frameworks, mental health assessments, ethical implications and forensic investigation were explored. Considering the importance of this phenomenon, especially in western countries, a need has emerged for focused screening tools on suicidal behavior among older adults, in order to contain it. Therefore, this review makes an exhaustive appraisal of the literature giving insights into the delicate interplay between neurobiology as well as mental health in relation to older adult suicide within a medico-legal context. The comprehension of different aspects about this complex phenomenon is fundamental to propose new and more effective interventions, supporting tailored initiatives such as family support and improving healthcare, specifically towards vulnerable ageing societies to reduce older adult suicide risks.

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.

Trend of suicide by self-immolation in a 13-year timeline: was the COVID-19 pandemic a potentially important stressor?

Introduction

Self-immolation is an uncommon way of attempting and committing a suicide, with a fatality rate of 80%. The risk factors in self-immolation victims vary depending on demographic characteristics, socio-economic and cultural factors as well as religious beliefs. Whether the COVID-19 pandemic was a potentially important stressor for self-immolation is still unknown, with insufficient studies examining this issue. Therefore, in this study, we aimed to examine the trend of self-immolation in a 13-year timeline, and the potential association of COVID-19 pandemic with the increase in the incidence and severity of self-immolation injuries in Serbia in 2021.

Materials and methods

The study included hospitalized patients due to intentional burns caused by self-immolation in the period from January 1, 2008 to December 31, 2021. Joinpoint regression analysis was used for the analysis of continuous linear trends of self-immolation cases with change points.

Results

While a rising trend was observed in the 2008-2013 time segment, followed by a decline in the upcoming 2013-2016 time segment, a significant increase reached its maximum during COVID-19 pandemic (2021), with annual percent change of 37.1% (p = 0.001). A significant increase in the median number of cases per year was observed during 2021 compared to the previous periods (7.5 vs. 2). Frequency of patients with a psychiatric diagnosis vs. those without a psychiatric diagnosis was significantly higher during than before the COVID-19 period (66.7 vs. 36.1%, p = 0.046).

Conclusion

In our study, a significant increase in the frequency of suicide attempts by self-immolation during COVID-19 pandemic was noticed. There was also an increased frequency of pre-existing psychiatric illness among patients during the pandemic period. With limited high-quality data available, the study adds to a rising body of evidence for assessment of outcomes of the pandemic on mental health and recognition of stressors for self-immolation.

A comparison of rate and methods of probable suicide for 2 years pre and post the onset of the COVID-19 pandemic

OBJECTIVES

To examine and compare rates and methods of probable suicide in a Western region of Ireland during a 24 month period since the onset of the COVID-19 pandemic compared with a similar period immediately prior to the pandemic onset.

METHODS

Post-mortem reports between March 1st 2018 and February 29th 2020 were reviewed and compared with data from March 1st 2020 to February 28th 2022. Relevant demographic data, rates and methods of probable suicide and lifetime engagement with mental health services were compared across the two time points.

RESULTS

Identical rates of probable suicide (85 individuals at both time points) were demonstrated with no difference evident in the utilisation of violent compared to non-violent methods.

CONCLUSIONS

This study demonstrates that despite previous reports of increased rates of self-harm and some evidence of increased mental distress since the onset of the COVID-19 pandemic, no change in rates of or methods employed by individuals who died by probable suicide were evident in this geographical region.

Psychological interventions for healthcare professionals during the COVID-19 pandemic: A systematic review

Healthcare professionals were especially vulnerable to pandemic, both to become infected and to develop a psychological problem. The aim of this systematic review is to analyze the effectiveness of psychological interventions for healthcare professionals in reducing the experienced psychological impact. From the 405 identified studies, 10 were included in this review. Four databases were searched and the risk of bias of included studies was assessed. The studies considered were randomized controlled trials. The screening and selection process was conducted by two independent reviewers. All studies presented results related with depression, anxiety, and stress during pandemic. Six were delivered using new technologies. The most effective were two psychological interventions with frequent contact and feedback provided by a mental health professional. The psychological interventions compared with non-intervention groups presented more significant results than those compared with another intervention. The highlights of this systematic review were the urgency of designing effectiveness psychological interventions for healthcare professionals to reduce the emotional burden associate with this job. These interventions should be maintained over the time, supported by a professional and provided from the workplace. These proposals presented promising results but were more psychological resources than psychological interventions.

Resilience and Suicidal Thoughts in Young People: Based on the Rafsanjan Youth Cohort Study

BACKGROUND

Suicide is a serious public health problem, and suicide attempt is defined as one of the important indicators of mental health in a society. The present study investigated the relationship between resilience and suicidal thoughts in Rafsanjani youth.

METHODS

This cross-sectional descriptive study examined 3006 young people aged 15-35 who referred to Rafsanjan Cohort Study (RCS). Connor and Davidson's questionnaire was used to measure resilience. The data, including demographic characteristics and cases related to suicide, were extracted from the computer system, which is part of the Rafsanjan Youth Cohort Program. Independent t-test, one-way analysis of variance, Tukey's post-hoc test, Pearson's correlation coefficient and multiple linear regression model were used to analyze the data.

RESULTS

A total of 3006 individuals were studied, of whom 1685 (56.1%) were women, and 1321 (43.9%) were men. The average age of the participants was 25.75±6.09 years. Men had a significantly higher average score of resilience (P<0.001) and suicidal thoughts (P=0.002) than women. In addition, the average score of suicidal thoughts in divorced and widowed people was significantly higher than single and married people (P=0.029). It was shown that older age groups had higher average resilience (P<0.001) and fewer suicidal thoughts (P=0.003), and people over 30 years had the lowest average suicidal thoughts.

CONCLUSION

The results indicate an inverse and significant relationship between resilience and suicidal thoughts in both men and women. Therefore, more evaluations are necessary to investigate the factors affecting resilience and take measures to improve it among young people.

Decrease in suicide rates in Brazil during the COVID-19 pandemic

Natural disasters such as public health epidemics may potentially affect suicide rates. The global COVID-19 pandemic poses an unprecedented challenge for healthcare systems and general populations worldwide. In this retrospective ecological study, we aimed to examine any changes in the suicide rates during the COVID-19 pandemic and to assess the relationship between COVID-19 death rates and deaths by suicide in Brazil. Data on suicide and COVID-19 case numbers were extracted from the Ministry of Health agencies and grouped weekly. We performed a time series analysis of suicide rates, a comparison of mean suicide rates between the pre-COVID-19 period and the COVID-19 period, and conducted a Poisson regression to examine the relationship between deaths due to COVID-19 and suicide rates. Our results showed decreased suicide rates during the COVID-19 pandemic. We also found that deaths owing to COVID-19 impact those owing to suicide after 10 weeks in the upward direction; however, we did not observe for enough time to see a change in the suicide rate curve. These findings are fundamental to understand suicidal behaviors in epidemic situations. However, the field needs more studies evaluating the impact of significant public health events on suicidality, incorporating extended follow-up periods.

Prevalence of suicidal ideation and correlated risk factors during the COVID-19 pandemic: A meta-analysis of 113 studies from 31 countries

The purpose of this study was to estimate the prevalence of suicidal ideation and correlated risk factors during the COVID-19 pandemic. Web of Science (WOS) and PubMed were searched according to a pre-set strategy. A total of 132 studies were identified, 104 of which were included in the meta-analysis. The prevalence of suicidal ideation was approximately 14.7% (95%CI: 12.5%, 16.8%, P < 0.01) in the general population, approximately 22.4% (95%CI: 17.1%, 27.8%, P < 0.01）in adolescents, approximately 21.0% (95%CI: 12.8%, 29.2%, P < 0.01) in psychiatric patients, approximately 20.6% (95%CI: 18.7%, 22.5%, P < 0.01）in university students, approximately 18.9% (95%CI: 8.3%, 29.5%, P < 0.01) in younger adults, approximately 10.6% (95%CI: 1.0%, 20.2%, P = 0.031) in COVID-19 patients and approximately 7.4% (95%CI: 4.3%, 10.5%, P < 0.01) in healthcare workers. The prevalence in North America was approximately 16.0% (95%CI: 13.6%-18.4%, P < 0.001), approximately 14.5% in Asia (95%CI: 9.5%-19.4%, P < 0.001), approximately 10.5% in Europe (95%CI: 8.5%-12.4%, P < 0.001), and approximately 20.5% in South America (95%CI: 19.5%-21.5%, P < 0.001). The following were risk factors which might be correlated with suicidal ideation: severe anxiety symptoms, mild to moderate depression, a strong feeling of loneliness/social isolation, poor sleep quality, having COVID-19-related experience, having quarantine or lockdown experience, being female, being single or divorced, having financial problems and having a history of suicidal ideation/attempt. This article reports the prevalence of suicidal ideation and discussing potential risk factors during the pandemic among general population and vulnerable groups. Early detection and follow-up were necessary for the noteworthy population.

Risk of hospitalization for self-harm among adults hospitalized with SARS-CoV-2 in France: A nationwide retrospective cohort study

While much work has shown a link between the global SARS-CoV-2 pandemic and poor mental health, little is known about a possible association between hospitalization with SARS-CoV-2 infection and subsequent hospitalization for self-harm. Analyses performed on the French national hospital database between March 2020-March 2021 in 10,084,551 inpatients showed that hospitalization with SARS-CoV-2 infection was not associated with hospitalization for self-harm in the following year. However, hospitalization with SARS-Cov-2 was related to an increased risk of self-harm in patients with a suicidal episode at the inclusion (aHR=1.56[1.14-2.15]), suggesting an effect of SARS-CoV-2 in patients with a recent history of self-harm.

Suicidal ideation in the general population in China after the COVID-19 pandemic was initially controlled

BACKGROUND

The COVID-19 pandemic increases the risk of psychological problems including suicidal ideation (SI) in the general population. In this study, we investigated the risk factors of SI after the COVID-19 pandemic was initially controlled in China.

METHODS

We conducted an online questionnaire via JD Health APP in China in June 2020. Demographic data, feelings and experiences related to the COVID-19 pandemic and psychological problems were collected. The participants (n = 14,690) were divided into the non-SI and SI groups. A binary logistic regression analysis was used to examine the correlates of SI.

RESULTS

Nine percent of the participants (1328/14690) reported SI. The regression analysis showed that SI was positively associated with ethnic minority (OR = 1.42 [1.08-1.85]), age (e.g. 18-30 years: OR = 2.31 [1.67-3.20]), having history of mental disorders (OR = 2.75 [2.27-3.35]), daily life disturbance due to health problems (OR = 1.67 [1.38-2.01]), being around someone with the COVID-19 (OR = 1.58 [1.30-1.91]), being uncertain about effective disease control (OR = 1.23 [1.03-1.46]), and having depressive symptoms (OR = 4.40 [3.59-5.39]), insomnia symptoms (OR = 2.49 [2.13-2.90]) or psychological distress (OR = 1.87 [1.59-2.18]).

LIMITATIONS

The main limitation is that the cross-sectional design of this study could not allow us to further explore the causality of SI.

CONCLUSIONS

The prevalence of SI was relatively high in general population after the COVID-19 pandemic was initially controlled in China. SI should be monitored continually after the COVID-19 pandemic.

Suicide before and during the COVID-19 Pandemic: A Systematic Review with Meta-Analysis

Synthesizing evidence to examine changes in suicide-related outcomes before and during the pandemic can inform suicide management during the COVID-19 crisis. We searched 13 databases as of December 2022 for studies reporting both the pre- and peri-pandemic prevalence of suicidal ideation, suicide attempts, or rate of death by suicide. A random-effects model was used to pool the ratio of peri- and pre-pandemic prevalence of suicidal ideation and attempt (Prevalence Ratio-PR) and rate of death by suicide (Rate Ratio; RR). We identified 51, 55, and 25 samples for suicidal ideation, attempt, and death by suicide. The prevalence of suicidal ideation increased significantly among non-clinical (PR = 1.142; 95% CI: 1.018-1.282; p = 0.024; k = 28) and clinical (PR = 1.134; 95% CI: 1.048-1.227; p = 0.002; k = 23) samples, and pooled estimates differed by population and study design. Suicide attempts were more prevalent during the pandemic among non-clinical (PR = 1.14; 95% CI: 1.053-1.233; p = 0.001; k = 30) and clinical (PR = 1.32; 95% CI: 1.17-1.489; p = 0.000; k = 25) participants. The pooled RR for death by suicide was 0.923 (95% CI: 0.84-1.01; p = 0.092; k = 25), indicating a nonsignificant downward trend. An upward trend of suicidal ideation and suicide attempts was observed during the COVID-19 pandemic, despite suicide rate remaining stable. Our findings suggest that timely prevention and intervention programs are highly needed for non-clinical adult population and clinical patients. Monitoring the real-time and long-run suicide risk as the pandemic evolves is warranted.

What happened to the predicted COVID-19-induced suicide epidemic, and why?

Two years ago, in the early stages of the COVID-19 pandemic, there were widespread and grim predictions of an ensuing suicide epidemic. Not only has this not happened but also by the end of 2021 in the majority of countries and regions with available data, the suicide rates had, if anything, declined. We discuss four reasons why the predictions of suicide models were exaggerated: (1) government intervention reduced the economic and mental costs of lockdowns, (2) the pandemic itself and lockdowns had less of an effect on mental health than assumed, (3) the evidence for a link between economic downturns, distress and suicide is weaker and less consistent than the models assumed and (4) predicting suicide is generally hard. Predictive models have an important place, but their strong modelling assumptions need to acknowledge the inherent high degree of uncertainty which has been further augmented by behavioural responses of pandemic management.

Monkeypox Virus and Other Emerging Outbreaks: An Overview and Future Perspective

Monkeypox (MPX) is a zoonotic disease caused by the MPX virus from the poxviridae family of orthopoxviruses. Typically, endemic in central and west Africa, it has now become a matter of concern since cases have been reported in non-endemic countries around mid-June 2022, especially in the European region, with the transmission not related to travel. The diagnosis is made by PCR testing of the skin lesions. Even though treatment is symptomatic, antiretrovirals, such as tecovirimat, are used in severe cases. Vaccination with second and third generation vaccines is approved for prophylaxis in high risk individuals. Unfortunately, these options of treatment and prevention are only available in high income countries at the moment. This review, through a thorough literature search of articles from 2017 onward, focuses on epidemiology, clinical manifestations, challenges, treatment, prevention and control of MPX virus and how they can be corelated with other viral outbreaks including COVID-19, Acute Hepatitis of unknown origin, Measles and Dengue, to better predict and therefore prevent its transmission. The previous COVID-19 pandemic increased the disease burden on healthcare infrastructure of low-middle income countries, therefore, this recent MPX outbreak calls for a joint effort from healthcare authorities, political figures, and NGOs to combat the disease and prevent its further spread not only in high income but also in middle- and low-income countries.

Excess maternal mortality in Brazil: Regional inequalities and trajectories during the COVID-19 epidemic

BACKGROUND

The COVID-19 pandemic has exceeded 6 million known disease-related deaths and there is evidence of an increase in maternal deaths, especially in low- and middle-income countries. We aimed to estimate excess maternal deaths in Brazil and its macroregions as well as their trajectories in the first 15 months of the COVID-19 epidemic.

METHODS

This study evaluated maternal deaths from the Mortality Information System of the Ministry of Health, with excess deaths being assessed between March 2020 and May 2021 by quasi-Poisson generalized additive models adjusted for overdispersion. Observed deaths were compared to deaths expected without the pandemic, accompanied by 95% confidence intervals according to region, age group, and trimester of occurrence. Analyses were conducted in R version 3.6.1 and RStudio version 1.2.1335.

RESULTS

There were 3,291 notified maternal deaths during the study period, resulting in a 70% excess of deaths regardless of region, while in the North, Northeast, South and Southeast regions, excess deaths occurred regardless of age group. Excess deaths occurred in the March-May 2021 trimester regardless of region and age group. Excess deaths were observed in the Southeast region for the 25-36-year-old age group regardless of the trimester assessed, and in the North, Central-West and South regions, the only period in which excess deaths were not observed was September-November 2020. Excess deaths regardless of trimester were observed in the 37-49-year-old age group in the North region, and the South region displayed explosive behavior from March-May 2021, with a 375% excess of deaths.

CONCLUSIONS

Excess maternal deaths, with geographically heterogenous trajectories and consistently high patterns at the time of the epidemic's greatest impact, reflect not only the previous effect of socioeconomic inequalities and of limited access to maternal health services, but most of all the precarious management of Brazil's health crisis.

Have Deaths of Despair Risen during the COVID-19 Pandemic? A Systematic Review

This systematic review synthesized literature on potential impacts of protracted isolation and other disruptions during the COVID-19 pandemic on deaths of despair (suicide, overdoses, and drug-related liver diseases). Five electronic databases were searched yielding 70 eligible articles. Extant evidence mostly from high-income countries indicates COVID-19-related disruption may not have influenced suicide rates so far, but there have been reports of increased drug-related and liver disease mortality. Minority groups and women were more vulnerable, indicating the need for stronger equity focus on pandemic recovery and resilience strategies. Further high-quality studies with longer-term follow-up, especially from low-income countries, will inform these strategies.

Reasons and trends in youth's suicide rates during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic posed many mental health challenges to youth through unprecedented infection control measures such as nationwide school closures. Despite this, few studies have investigated trends in suicide among youth during the pandemic, let alone their reasons.

METHODS

Population-level data on crude monthly suicide rates (2016-2021) and reasons of suicide (2018-2020) among youth aged 10-19 years were obtained from the Japanese Ministry of Health, Labour and Welfare and the National Police Agency, respectively. Using an event study design (with a Poisson regression model to calculate changes-in-changes (CiC) estimates) and interrupted time series analysis, we investigated changes in monthly suicide rates during the first 12 months of the pandemic (May 2020 to April 2021) compared to pre-pandemic levels (May 2016 to March 2020). Additionally, we investigated the changes in reasons of suicide (family-related, mental illness, social concerns, and academic concerns).

FINDINGS

In the event study analysis, suicide rates among youth increased during the pandemic relative to pre-pandemic levels, especially between August-November 2020 (e.g., ratio of the suicide rate in November 2020 relative to previous years, 1.86; 95% confidence interval (CI), 1.30 to 2.66). Though suicide levels returned closer to pre-pandemic levels by December 2020, they remained slightly elevated into 2021. In the interrupted time series analysis, suicide rates increased from May to August 2020 (0.099 cases per 100,000 youth per month; 95% CI, 0.022 to 0.176), followed by a decrease from September to December 2020 (-0.086 cases per 100,000 youth per month; 95% CI, -0.164 to -0.009). We observed elevated suicide rates for all major reasons from summer to autumn 2020, especially suicides attributed to family-related problems and social concerns. Furthermore, rates of suicides attributed to mental illness remained higher than pre-pandemic levels into December 2020.

INTERPRETATION

Suicide rates among youth remained slightly elevated compared to pre-pandemic levels into 2021. The reasons of the increase in suicide rates were multifactorial, including mental health issues and disruptions in social relationships. During a pandemic, interventions that provide mental support as well as opportunities for regular social interactions to youth may be beneficial.

FUNDING

Norwegian Agency for International Cooperation and Quality Enhancement in Higher Education.

Changes in self-harm attempts after the COVID-19 pandemic based on pre-hospital medical records

Although many concerns have been raised on increased self-harm or suicide attempts since the emergence of the coronavirus disease 2019 (COVID-19) pandemic, the numbers of studies reported no consistent increase. This study aimed to analyze the data on the request for emergency medical service (EMS) in Daegu Metropolitan City in Korea to investigate the effects of the COVID-19 pandemic on the incidence and types of suicidal patients. Data of 4480 cases requesting EMS related to self-harm or suicide 1 year before and after the COVID-19 pandemic were retrospectively comparatively analyzed (February 19, 2019-February 18, 2021). The number of EMS requests for self-harm and suicide increased after the pandemic compared to that before the pandemic (daily mean request 5.83 [±2.597] vs 6.43 [±2.918]). In particular, the number of female patients increased per day on average (2.61 [±1.717] vs 3.17 [±1.893]). With respect to the reasons for the request, committed self-harm and attempts to commit self-harm increased, whereas the presumption against suicide decreased. With respect to consciousness levels, the number of alert patients increased, whereas the number of transport cases decreased. For the method of the attempt, hanging and carbon monoxide/gas poisoning decreased, whereas jumping from a height and drowning increased. The number of patients with psychiatric history and those with other chronic illnesses increased. In multivariate regression analysis, women (OR 1.227, 95% CI = 1.072-1.405, P = .003), patients with psychiatric diseases (OR 1.223, 95% CI = 1.031-1.450, P = .021), patients with other chronic illnesses (OR 1.510, 95% CI = 1.127-2.023, P = .006), and CO or gas poisoning (not attempted) (OR 1.349, 95% CI = 1.038-1.753, P = .025) showed statistically significant differences. Among the request for EMS, requests for committed self-harm and attempts to commit suicide increased. Medical support and measures for mental health and emergency medical systems should be established for female patients and patients with psychiatric or other chronic diseases.

Global trends of suicidal thought, suicidal ideation, and self-harm during COVID-19 pandemic: a systematic review

Background

Suicide is one of the leading causes of death. The current systematic review is done to know the trend of suicidal thoughts, suicidal ideation, and self-harm during COVID-19 pandemic.

Main text

The search was done by using PubMed, ScienceDirect, and Google Scholar databases. With the help of Mendeley portal, articles were retrieved on the basis of inclusion criteria like to know the risk factors, vulnerable group, complete article PDFs, prevention strategies, aims, results, and limitations. The shortlisted data from search was tabulated, and the PRISMA chart was framed based on the inclusion and exclusion criteria.

Result

Sixteen studies that satisfied the inclusion criteria were organized and selected. The variables and global scenario were considered in databases. It has been noticed that trends of suicidal thoughts, suicidal ideation, and self-harm remains the same in some countries like Japan, whereas in some countries like Bangladesh and France, trends of suicides had increased during the pandemic period. The probable cause could be lockdown, social isolation, and stoppage of recreational activities.

Conclusions

The trends of suicidal ideation, suicidal thoughts, and self-harm are more in vulnerable categories like health care professionals, university students, elderly individuals, and psychiatrically ill patients. In health care professional, it is due to the increased risk of contagion and watching deaths closely. In university students, it is due to the lack of recreational activities and social isolation. Among elderly, it is due to thinking themselves as overburden. The increase in suicidality in psychiatric ill patient admitted during COVID-19 pandemic is due to unknown cause.

Nightmares mediate the association between traumatic event exposure and suicidal ideation in frontline medical workers exposed to COVID-19

BACKGROUND

Trauma experience increases the risk of suicidal ideation, but little is known about potentially psychological mechanisms underlying this relationship. This study aims to examine the relationship between coronavirus disease 2019 (COVID-19)-related traumatic event (CTE) exposure and suicidal ideation among hospital workers, and identify mediating roles of sleep disturbances in this relationship.

METHODS

Workers in seven designated hospitals in Wuhan, China, were invited to participate in an online survey from May 27, 2020, to July 31, 2020. Participants completed a self-report questionnaire to evaluate demographic characteristics, level of CTE exposures, nightmare frequency, insomnia severity, symptoms of depression and anxiety, and suicidal ideation. A series of correlation analyses were performed, and a mediation model was generated to examine correlations between CTE exposure, sleep disturbances, and suicidal ideation.

RESULTS

A total of 16,220 hospital workers were included in the final analysis, 13.3% of them reported suicidal ideation in the past month. CTE exposure was significantly associated with insomnia severity, nightmare frequency, and suicidal ideation. After controlling potential confounders, nightmares but not insomnia, depression, or anxiety were shown to be independent risk factors for suicidal ideation. Pathway analyses showed that the relationship between CTE exposure and suicidal ideation was fully mediated by nightmares (proportion mediated 66.4%) after adjusting for demographic characteristics and psychological confounders.

LIMITATIONS

Cross-sectional design precluded the investigation of causal relationships.

CONCLUSIONS

CTE exposure increases risk of hospital workers' suicidal ideation that is mediated by nightmares, suggesting nightmares intervention might be considered as a component when developing suicide prevention strategies.

Quality of Life and Mental Health in Children and Adolescents after the First Year of the COVID-19 Pandemic: A Large Population-Based Survey in South Tyrol, Italy

BACKGROUND

Methodological heterogeneity of studies and geographical variation limit conclusions about the impact of the COVID-19 pandemic on the mental health of youth. This study aimed to explore the health-related quality of life and mental health of children and adolescents in the second year of the pandemic in South Tyrol, Italy.

METHODS

An online survey representative for the age and gender of the children and adolescents in South Tyrol was conducted among 5159 families with children and adolescents aged 7-19 years, between 28 May and 16 June 2021. The survey collecting parental ratings and self-rated questionnaires from children and adolescents aged 11-19 years included instruments to measure health-related quality of life (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), and depression (CES-DC). The results were compared with data from corresponding studies conducted in Germany.

RESULTS

Decreased health-related quality of life and increased conduct problems, peer-related mental health problems, anxiety, and depressive and psychosomatic symptoms in children and adolescents observed in the second year of the pandemic in Germany were confirmed in the second year in South Tyrol. Children and adolescents with low socioeconomic status, a migration background, and limited living space were significantly affected. Female sex and older age were associated with increased psychosocial problems and a positive family climate supported the mental health of children and adolescents during the pandemic.

CONCLUSIONS

Confirmation of findings of decreased health-related quality of life and increased emotional problems after the first year of the pandemic supports the ongoing call for low-threshold health promotion, prevention, and early intervention programs to support children and adolescents who have been severely affected by the pandemic.

Associations between COVID-19 mobility restrictions and economic, mental health, and suicide-related concerns in the US using cellular phone GPS and Google search volume data

During the COVID-19 pandemic, US populations have experienced elevated rates of financial and psychological distress that could lead to increases in suicide rates. Rapid ongoing mental health monitoring is critical for early intervention, especially in regions most affected by the pandemic, yet traditional surveillance data are available only after long lags. Novel information on real-time population isolation and concerns stemming from the pandemic's social and economic impacts, via cellular mobility tracking and online search data, are potentially important interim surveillance resources. Using these measures, we employed transfer function model time-series analyses to estimate associations between daily mobility indicators (proportion of cellular devices completely at home and time spent at home) and Google Health Trends search volumes for terms pertaining to economic stress, mental health, and suicide during 2020 and 2021 both nationally and in New York City. During the first pandemic wave in early-spring 2020, over 50% of devices remained completely at home and searches for economic stressors exceeded 60,000 per 10 million. We found large concurrent associations across analyses between declining mobility and increasing searches for economic stressor terms (national proportion of devices at home: cross-correlation coefficient (CC) = 0.6 (p-value <0.001)). Nationally, we also found strong associations between declining mobility and increasing mental health and suicide-related searches (time at home: mood/anxiety CC = 0.53 (<0.001), social stressor CC = 0.51 (<0.001), suicide seeking CC = 0.37 (0.006)). Our findings suggest that pandemic-related isolation coincided with acute economic distress and may be a risk factor for poor mental health and suicidal behavior. These emergent relationships warrant ongoing attention and causal assessment given the potential for long-term psychological impact and suicide death. As US populations continue to face stress, Google search data can be used to identify possible warning signs from real-time changes in distributions of population thought patterns.

Social distancing and influenza mortality in 1918 did not increase suicide rates in the United States

Recent research has suggested that the social distancing mandates introduced in the United States during the main waves of the 1918-20 influenza pandemic caused an increase in suicide rates. However, that finding relies on poor-quality, temporally mismatched data and has signs of omitted variable bias. Similarly, a long-standing finding that American suicide rates in 1918-20 were also boosted by the influenza mortality of the time has gone unquestioned in the literature, despite the original research admitting its risk of ecological fallacy. Using higher-powered mortality data, I cast doubt on both findings by analyzing the experiences of the pandemic in 43 of the largest American cities of the time. In line with some populations' experiences of COVID-19, I report tentative evidence that social distancing mandates during the 1918-20 pandemic may have been associated with decreased suicide rates. Larger, cross-national investigations of the effects of historical pandemics and social distancing mandates on mental health and suicide are needed.

Determining What Changed Japanese Suicide Mortality in 2020 Using Governmental Database

The pandemic of 2019 novel coronavirus disease (COVID-19) caused both COVID-19-related health hazards and the deterioration of socioeconomic and sociopsychological status due to governmental restrictions. There were concerns that suicide mortality would increase during the COVID-19 pandemic; however, a recent study reported that suicide mortality did not increase in 21 countries during the early pandemic period. In Japan, suicide mortality was reduced from 2009 to 2019, but both the annual number of suicide victims and the national suicide mortality rates in 2020 increased compared to that in 2019. To clarify the discrepancy of suicide mortality between the first and second half of 2020 in Japan, the present study determines annual and monthly suicide mortality disaggregated by prefectures, gender, age, means, motive, and household factors during the COVID-19 pandemic and pre-pandemic periods using a linear mixed-effects model. Furthermore, the relationship between suicide mortality and COVID-19 data (the infection rate, mortality, and duration of the pandemic) was analysed using hierarchal linear regression with a robust standard error. The average of monthly suicide mortality of both males and females in all 47 prefectures decreased during the first stay-home order (April-May) (females: from 10.1-10.2 to 7.8-7.9; males: from 24.0-24.9 to 21.6 per 100,000 people), but increased after the end of the first stay-home order (July-December) (females: from 7.5-9.5 to 10.3-14.5; males: from 19.9-23.0 to 21.1-26.7 per 100,000 people). Increasing COVID-19-infected patients and victims indicated a tendency of suppression, but the prolongation of the pandemic indicated a tendency of increasing female suicide mortality without affecting that of males. Contrary to the national pattern, in metropolitan regions, decreasing suicide mortality during the first stay-home order was not observed. Decreasing suicide mortality during the first stay-home order was not observed in populations younger than 30 years old, whereas increasing suicide mortality of populations younger than 30 years old after the end of the first stay-home order was predominant. A decrease in suicide mortality of one-person household residents during the first stay-home order was not observed. The hanging suicide mortality of males and females was decreased and increased during and after the end of the first stay-home orders, respectively; however, there was no decrease in metropolitan regions. These results suggest that the suicide mortality in 2020 of females, younger populations, urban residents, and one-person household residents increased compared to those of males, the elderly, rural residents, and multiple-person household residents. Therefore, the unexpected drastic fluctuations of suicide mortality during the COVID-19 pandemic in Japan were probably composed of complicated reasons among various identified factors in this study, and other unknown factors.

Impact of the COVID-19 pandemic on child and adolescent mental health services

The COVID-19 pandemic and government lockdown restrictions have had an impact on children and young people worldwide. In this editorial, we explore how and why referrals to UK children and adolescent mental health services (CAMHS) have changed during the pandemic and summarise the emerging data on the potential reasons behind this.