Despair in the time of COVID: A look at suicidal ingestions reported to the California Poison Control System during the pandemic

Self-harm by single- and multi-agent medication poisoning in a retrospective analysis of a Poison Control Center database from January 2018 to December 2022

PURPOSE

Medication poisoning is the most common method of self-harm. Longitudinal studies incorporating pre- and post-COVID-19 pandemic data are required to describe the phenomenon and to evaluate the long-term impact on mental health.

METHODS

Calls to the Poison Control Center of Policlinico Umberto I Hospital - Sapienza University of Rome, Italy, were analyzed retrospectively for characteristics and clinical presentation of cases of interest from January 2018 to December 2022.

RESULTS

A total of 756 cases of self-harm by medication poisonings were recorded in the study period. A reduction in rate of cases in 2020 was followed by a return to pre-pandemic levels by 2021. When separately analyzing single- and multi-agent cases, occurrence of cases involving just one medication increased since early 2021, with a peak in 2022 (7.8% of total calls, 95% CI 6.2-9.5, from 4.9%, 95% CI 4.1-5.8 in 2018). This increase in the rate of cases, mostly of none or mild severity, was driven by youth aged 12-21, in which the relative proportion of single- versus multi-agent cases showed an increasing trend since 2020 (from 42.6% in 2018 to 78.6% in 2022). Acetaminophen was the medication most frequently involved and benzodiazepines the largest class. A psychiatric background was increasingly seen in 2022, especially in age group 12-21.

CONCLUSION

Single-agent medication self-harm may be an increasingly prevailing phenomenon. Young adolescents with a psychiatric background might be most vulnerable to this behavior in the COVID-19 pandemic aftermath. Healthcare professionals should expect favorable clinical outcome and improve both counseling and psychotherapy supervision in individuals at risk.

Changes in suicide in California from 2017 to 2021: a population-based study

BACKGROUND

Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years.

METHODS

We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages.

RESULTS

Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas.

CONCLUSIONS

The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.

Pediatric Suspected Suicides and Nonfatal Suicide Attempts Reported to United States Poison Control Centers Before and During the COVID-19 Pandemic

INTRODUCTION

This study investigated the characteristics and compared the trends of pediatric suspected suicide and nonfatal suicide attempts reported to United States (US) poison control centers (PCCs) before and during the first year of the COVID-19 pandemic.

METHODS

An interrupted time series analysis using an ARIMA model was conducted to evaluate the trends of suspected suicides and nonfatal suicide attempts among children 6-19 years old reported to the National Poison Data System during March 2020 through February 2021 (pandemic period) compared with March 2017 through February 2020 (pre-pandemic period).

RESULTS

The annual number of cases of suspected suicides and nonfatal suicide attempts increased by 4.5% (6095/136,194) among children 6-19 years old during March 2020 through February 2021 compared with the average annual number during the previous three pre-pandemic years. There were 11,876 fewer cases than expected from March 2020 to February 2021, attributable to a decrease in cases during the initial three pandemic months. The average monthly and average daily number of suspected suicides and nonfatal suicide attempts among children 6-12 years old and 13-19 years old was higher during school months than non-school months and weekdays than weekends during both the pre-pandemic and pandemic periods.

CONCLUSIONS

There was a greater than expected decrease in the number of suspected suicides and nonfatal suicide attempts among children 6-19 years old reported to US PCCs during the early pandemic months, followed by an increase in cases. Recognizing these patterns can help guide an appropriate public health response to similar future crises.

Changes in self-harm and suicide in California from 2017-2021: a population-based study

Background : Self-harm and suicide are major public health problems with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of fatal and nonfatal intentional self-harm in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. Methods: We used California-wide death data and University of California (UC)-wide hospital data to summarize fatal and nonfatal instances of intentional self-harm across race/ethnicity, age, education, gender, region, and method of harm. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. Results : Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10-19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20-29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. Counts and rates of nonfatal, intentional self-harm in UC hospitals increased in 2020 (2160; 30.7 per 100,000) and 2021 (2175; 30.9 per 100,000) compared to pre-pandemic (2083; 29.6 per 100,000), especially among young people (age 10-19), females, and Hispanic Californians. Conclusions : The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of self-harm and suicide across the California population. Marginalized racial groups, females, and younger people experienced increased risk for self-harm, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal and nonfatal self-harm injuries and reduce related inequities.

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.

The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review

BACKGROUND

Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.

AIMS

To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.

METHOD

A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.

RESULTS

Fifty-one studies were included: 57% (29/51) were rated as 'low' quality, 31% (16/51) as 'moderate' and 12% (6/51) as 'high-moderate'. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17-56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.

CONCLUSIONS

Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

Temporal trends in calls for suicide attempts to poison control centers in France during the COVID-19 pandemic: a nationwide study

Concerns have been raised about early vs. later impacts of the COVID-19 pandemic on suicidal behavior. However, data remain sparse to date. We investigated all calls for intentional drug or other toxic ingestions to the eight Poison Control Centers in France between 1st January 2018 and 31st May 2022. Data were extracted from the French National Database of Poisonings. Calls during the study period were analyzed using time trends and time series analyses with SARIMA models (based on the first two years). Breakpoints were determined using Chow test. These analyses were performed together with examination of age groups (≤ 11, 12–24, 25–64, ≥ 65 years) and gender effects when possible. Over the studied period, 66,589 calls for suicide attempts were received. Overall, there was a downward trend from 2018, which slowed down in October 2019 and was followed by an increase from November 2020. Number of calls observed during the COVID period were above what was expected. However, important differences were found according to age and gender. The increase in calls from mid-2020 was particularly observed in young females, while middle-aged adults showed a persisting decrease. An increase in older-aged people was observed from mid-2019 and persisted during the pandemic. The pandemic may therefore have exacerbated a pre-existing fragile situation in adolescents and old-aged people. This study emphasizes the rapidly evolving situation regarding suicidal behaviour during the pandemic, the possibility of age and gender differences in impact, and the value of having access to real-time information to monitor suicidal acts.

Impact of the COVID-19 pandemic on suicidal attempts and death rates: a systematic review

BACKGROUND

The COVID-19 pandemic has exacerbated the risk factors associated with suicidal behavior and thus, prioritizing its prevention is recommended.

METHODS

This study systematically reviewed the global evidence on the incidence of suicide/suicidal attempts and the trend in suicidal rates during the COVID-19 pandemic. Cross-sectional and cohort studies investigating the outcomes of suicidal death and suicidal attempts at any setting during the COVID-19 pandemic were searched in Medline, Embase, and PsycINFO databases for papers published from December 2019 to May 2021.

RESULTS

Out of 1052 studies18 studies with 12,746 suicidal attempts and 33,345 suicidal deaths were included in the final analysis. The mental health impact of social distancing, COVID-19 quarantine, and financial crises due to loss of employment were associated risk factors with suicide and/or suicidal attempts during the COVID-19 pandemic. Six common thematic recommendations for preventing suicidal deaths and suicidal attempts were identified.

CONCLUSIONS

Unexpected behavior changes during the COVID-19 pandemic may have contributed to the increasing trend of suicidal attempts reported. Domestic conflicts and violence, financial loss, anxiety and depression, and pre-existing mental health condition/s should be considered in preventing suicidal attempts and deaths secondary to the COVID 19 pandemic. Early detection and timely intervention for individuals with suicidal behavior is crucial and collated recommendations in the current study can be utilized for those preventive interventions. More systematic suicide risk screening process should be introduced who are at risk, along with an evidence base prevention approach.

Characteristics of pepper spray-related injuries reported to the National Electronic Injury Surveillance System during 2000-2020

INTRODUCTION

Exposure to pepper spray may result in adverse dermal, ocular, and inhalation effects. Furthermore, pepper spray, including the more potent bear spray, was used by both law enforcement and protesters in 2020 in the protests related to racial justice and COVID-19 pandemic restrictions. The objective of this study was to characterize pepper spray-related injuries treated at United States (US) emergency departments (EDs).

METHODS

Data were obtained from the National Electronic Injury Surveillance System, a database of consumer product-related injuries collected from approximately 100 US hospital EDs. Pepper spray-related injuries reported during 2000-2020 were identified by reviewing all records that included the letter groups "pep" or "bear" in the Narrative field and "spray" in the Narrative field or Product code 1619 in the Product_1, Product_2, or Product_3 fields.

RESULTS

A total of 1112 pepper spray-related injuries were identified, resulting in a national estimate of 34,582 pepper spray-related injuries, of which 43.4% were reported during 2014-2020. Of the estimated exposures, the age distribution was 14.5% 0-5 years, 18.5% 6-12 years, 18.2% 13-19 years, 19.6% 20-29 years, 11.8% 30-39 years, 9.1% 40-49 years, and 8.3% 50 years or older; 55.9% of the patients were male. The exposure route was 52.0% ocular, 25.7% dermal, 13.6% inhalation, 2.9% ingestion/oral, and 14.1% unknown.

CONCLUSIONS

Patients with pepper spray-related injuries tended to be older children and young adults, and the majority of patients were male. The route of exposure of most of the injuries was ocular.

The Impact of the COVID-19 Pandemic on Psychiatric Emergency Service Volume and Hospital Admissions

Background

During the COVID-19 pandemic, there have been an increasing number of emergency department visits for behavioral health reasons, even as overall emergency department volumes have decreased. The impact of the pandemic and related public health interventions on specialized psychiatric emergency services has not been described. These services provide high-intensity care for severely ill patients who are likely to be homeless and underserved.

Objective

We describe the change in total volume and psychiatric hospitalization rates among three psychiatric emergency services across the United States.

Methods

Changes in volumes and hospitalization were assessed for statistical significance using a seasonal autoregressive integrated moving average with exogenous factors model from January 2018 to December 2020.

Results

The pandemic's impact on volumes and hospitalization varied by site. In Denver (CO), there was a statistically significant 9% decrease in overall volumes, although an 18% increase in hospitalizations was not significant. In New York City (NY), there was a significant 7% decrease in volumes as well as a significant 6% decrease in hospitalizations. In Portland (OR), volumes decreased by 4% and hospitalizations increased by 6% although differences did not reach statistical significance.

Conclusions

There has been a decrease in volume at these services after the pandemic, but there are substantial variations in the magnitude of change and demand for hospitalization by region. These findings suggest a need to understand where patients in crisis are seeking care and how systems of care must adapt to changing utilization in the pandemic era.