Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries

BACKGROUND

The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world.

METHODS

We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries' ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms "suicide" and "cause of death", before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis).

FINDINGS

We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72-0·91]); Alberta, Canada (0·80 [0·68-0·93]); British Columbia, Canada (0·76 [0·66-0·87]); Chile (0·85 [0·78-0·94]); Leipzig, Germany (0·49 [0·32-0·74]); Japan (0·94 [0·91-0·96]); New Zealand (0·79 [0·68-0·91]); South Korea (0·94 [0·92-0·97]); California, USA (0·90 [0·85-0·95]); Illinois (Cook County), USA (0·79 [0·67-0·93]); Texas (four counties), USA (0·82 [0·68-0·98]); and Ecuador (0·74 [0·67-0·82]).

INTERPRETATION

This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold.

FUNDING

None.

Zonisamide for add-on treatment of refractory partial epilepsy: a European double-blind trial

The new antiepileptic drug zonisamide was evaluated in a European multicenter parallel-group double-blind trial as add-on treatment for 139 patients with refractory partial epilepsy. During treatment with zonisamide complex partial seizures decreased by 27.7% compared to placebo (P < 0.05) and the median rate dropped from 12/month to 7.1/month with no changes in the placebo group (P < 0.007). During the 12-week double-blind phase a 50% reduction of all seizures was recorded in 29.9% of the patients treated with zonisamide vs. 9.4% during placebo. Complete remission was observed during treatment with zonisamide in 6.2%. The plasma concentrations of the concomitant antiepileptic drugs did not change markedly when zonisamide was added. Adverse events, mostly fatigue, somnolence, dizziness and ataxia, occurred in 59.2% of the patients compared to 27.9% during placebo. Zonisamide was withdrawn in two patients due to adverse events. Kidney stones were not observed nor any relevant clinical chemistry or hematological changes. Zonisamide is an effective antiepileptic drug for add-on treatment of refractory partial epilepsy.

Sex differences in brain activation pattern during a visuospatial cognitive task: a functional magnetic resonance imaging study in healthy volunteers

Sex differences in mental rotation tasks, favoring men, have been noted in behavioral studies and functional imaging studies. In the present study ten female and ten male volunteers underwent functional magnetic resonance imaging in a conventional block design. Regions of activation were detected after performance of a mental rotation task inside the scanner. In contrast to previous studies, confounding factors such as performance differences between genders or high error rates were excluded. Men showed significantly stronger parietal activation, while women showed significantly greater right frontal activation. Our results point to gender specific differences in the neuropsychological processes involved in mental rotation tasks.

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

BACKGROUND

Predicted increases in suicide were not generally observed in the early months of the COVID-19 pandemic. However, the picture may be changing and patterns might vary across demographic groups. We aimed to provide a timely, granular picture of the pandemic's impact on suicides globally.

METHODS

We identified suicide data from official public-sector sources for countries/areas-within-countries, searching websites and academic literature and contacting data custodians and authors as necessary. We sent our first data request on 22nd June 2021 and stopped collecting data on 31st October 2021. We used interrupted time series (ITS) analyses to model the association between the pandemic's emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed and expected numbers of suicides in the pandemic's first nine and first 10-15 months and used meta-regression to explore sources of variation.

FINDINGS

We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income; 25 with whole-country data, 12 with data for area(s)-within-the-country, four with both). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis; more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries' COVID-19 mortality rate, stringency of public health response, economic support level, or presence of a national suicide prevention strategy. Nor were they explained by countries' income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well.

INTERPRETATION

Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these countries/areas-within-countries are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue.

FUNDING

None.

Sex differences in clustering and switching in verbal fluency tasks

Sex differences in executive speech tasks, favoring women, have been noted in behavioral studies and functional imaging studies. In the present study, the clustering and switching components of semantic and phonemic verbal fluency tests were examined in 40 healthy men and 40 healthy women. Possible sex differences in the influence of cognitive factors such as speed of information processing, word knowledge, and/or verbal long-term memory on these verbal fluency factors were also assessed. The results showed that women switched more often between categories in the phonemic fluency test, whereas men showed a trend toward a larger cluster size leading to a smaller total number of words generated. Additionally, higher performance on the Digit Symbol test was associated with better performance on the semantic and phonemic verbal fluency test in men, whereas in women, better memory performance was associated with better performance on these verbal fluency tests. Our data indicate that men and women are using different processing strategies for phonemic verbal fluency tests to optimize verbal fluency task performance. In the current study, women adopted a more successful strategy of balancing clustering and switching in the phonemic fluency task.

Weather and suicide: the present state of knowledge on the association of meteorological factors with suicidal behaviour

OBJECTIVE

To review the available literature on the association between daily and longer-term weather data and the incidence of attempted and completed suicide.

METHOD

A computerized search supplemented by a cross-check of the references sections of the thereby identified papers was performed.

RESULTS

A total of 27 studies looking for a relationship between attempted or completed suicide and weather or climate data were found. Most of the papers reported a statistical association of suicidal acts with at least one weather factor. However, the results are not conclusive and in part contradictory.

CONCLUSION

Possibly due to the high variance in methodological approaches of the studies it is not possible to identify a specific weather condition associated with a generally higher risk for suicide. Weather and seasonal effects may interact with each other. Environmental effects on brain function and weather-related interactions of people may be involved in the occurrence of suicidal behaviour.

Brain activation pattern during a verbal fluency test in healthy male and female volunteers: a functional magnetic resonance imaging study

Sex differences in executive speech tasks, favoring women, have been noted in behavioral studies and functional imaging studies. In the present study ten female and ten male volunteers underwent functional magnetic resonance imaging in a conventional block design. All subjects were selected on the basis of high performance on the verbal fluency task. Regions of activation were detected after performance of a covert lexical verbal fluency task inside the scanner. Men and women who did not differ significantly in verbal fluency task performance showed a very similar pattern of brain activation. Our data argue against genuine between-sex differences in cerebral activation patterns during lexical verbal fluency activities when confounding factors like performance differences are excluded.

Relation between attempted suicide and suicide rates among young people in Europe

STUDY OBJECTIVE

To determine if there are associations between rates of suicide and attempted suicide in 15-24 year olds in different countries in Europe.

DESIGN

Attempted suicide rates were based on data collected in centres in Europe between 1989 and 1992 as part of the WHO/EURO Multicentre Study of Parasuicide. Comparison was made with both national suicide rates and local suicide rates for the areas in which the attempted suicide monitoring centres are based.

SETTING

15 centres in 13 European countries.

PATIENTS

Young people aged 15-24 years who had taken overdoses or deliberately injured themselves and been identified in health care facilities.

MAIN RESULTS

There were positive correlations (Spearman rank order) between rates of attempted suicide and suicide rates in both sexes. The correlations only reached statistical significance for male subjects: regional suicide rates, r = 0.65, p < 0.02; national suicide rates, r = 0.55, p < 0.02.

CONCLUSIONS

Rates of attempted suicide and suicide in the young covary. The recent increase in attempted suicide rates in young male subjects in several European countries could herald a further increase in suicide rates.

Heparin treatment in acute cerebral sinus venous thrombosis: a retrospective clinical and MR analysis of 42 cases

The only randomized data on heparin treatment in acute cerebral sinus venous thrombosis (CSVT) are derived from a small number of patients. The rate of intracranial hemorrhages as a complication of high-dose heparin treatment is still unknown. This retrospective study evaluates the clinical features, neuroimaging monitoring and outcome of 42 patients with proven CSVT. Diagnosis was established by DSA, CT, MR tomography and MR angiography. All patients received heparin intravenously guided by doubling the aPTT value for 3 weeks, followed by oral anticoagulation. Partial or complete recanalization was found in 36 cases. 40 patients improved clinically, in 26 of them complete recovery was observed. One patient deteriorated and developed an apallic syndrome, one further patient died of septic multiorgan failure. Only in one patient was hemorrhagic transformation of infarcted brain tissue observed but without clinical deterioration.

No evidence for an association between serum cholesterol and the course of depression and suicidality

In a number of previous reports, an association of altered, in most cases lower, serum cholesterol levels with depression, suicidal ideation and current or past suicidal behavior has been suggested. In this investigation, the course of serum cholesterol concentrations was measured in depressed patients during treatment. Ninety-two inpatients with a major depressive episode were included. Serum lipid concentrations were assessed at admission, after 1 week and after 4 weeks of antidepressant treatment. Degrees of depression and suicidality were measured with the Hamilton Depression Rating Scale. Although there was a significant reduction in depression and suicidality scores, neither a significant change in serum cholesterol levels nor a correlation between cholesterol levels and clinical improvement was found. Further, there were no significant differences in lipid levels between patients with and without a history of attempted suicide. In patients who had used a violent method, there was a trend for lower total cholesterol levels compared to those who had poisoned themselves. The results of this study do not support the hypothesis of an association of serum cholesterol with the course of depression and suicidal ideation. Cholesterol levels do not appear to be an appropriate biological marker for suicidality during the first 4 weeks of treatment in patients with a major depressive episode.

Effect of mirtazapine treatment on body composition and metabolism

OBJECTIVE

Weight gain is a common side effect of psychotropic medications. Mirtazapine, a widely used antidepressant, induces adverse metabolic effects such as an increase in body weight. The aim of this study was to investigate the influence of mirtazapine treatment on body weight, body fat mass, glucose metabolism, lipoprotein profile, and leptin and its soluble receptor in a prospective, controlled study design.

METHOD

Seven women who met the ICD-10 diagnostic criteria for a depressive episode (ICD-10: F31-F33) were assigned to monotherapy with mirtazapine and observed for a 6-week period. Seven mentally and physically healthy female volunteers matched for age and body weight served as a control group. Data were collected from November 2002 to December 2003.

RESULTS

The mean +/- SD body weight increased from 63.6 +/- 13.1 kg to 66.6 +/- 11.9 kg during mirtazapine treatment (p = .027). Fat mass increased in study subjects from 20.9 +/- 9.6 kg to 22.1 +/- 9.3 kg (p = .018). Insulin, glucose, and the homeostasis model assessment (HOMA) index for insulin resistance and lipid parameters remained stable. Leptin concentrations increased from 23.0 +/- 17.1 ng/mL to 40.9 +/- 27.2 ng/mL (p = .018), whereas the soluble leptin receptor concentrations remained stable during mirtazapine treatment. In the control subjects, the investigated parameters remained stable. Between-group analyses of change scores revealed significant differences for body weight (p = .010), body mass index (p = .013), fat mass (p = .035), and leptin (p = .013).

CONCLUSION

The antidepressant therapy with mirtazapine was associated with a significant increase in body weight, body fat mass, and leptin concentration. In contrast to other psychotropic medications inducing weight gain, such as some second-generation antipsychotics, mirtazapine treatment did not influence the glucose homeostasis.

Facial emotion recognition and its relationship to subjective and functional outcomes in remitted patients with bipolar I disorder

OBJECTIVES

  Outcome in bipolar disorder (BD) is multidimensional and consists of clinical and psychosocial domains. Difficulties in affect recognition and in emotional experience are a hallmark of BD, but there is little research investigating the consequences of this deficit on the psychosocial status of patients who are in remission.

METHODS

  This cross-sectional study examined the relationship of facial affect recognition and treatment outcomes in terms of psychopathology, quality of life, and psychosocial functioning in remitted BD patients compared to healthy volunteers.

RESULTS

  Altogether, 47 outpatients meeting diagnostic criteria for bipolar I disorder according to DSM-IV and 45 healthy control subjects were included in the study. Patients were particularly impaired in the recognition of facial expressions depicting disgust and happiness. For patients, the most frequently observed misidentifications included disgusted faces misrecognized as angry expressions, fearful faces misrecognized as disgusted or surprised expressions, surprised faces misrecognized as fearful expressions, and sad faces misrecognized as fearful or angry expressions. Regarding emotional experience, shame, guilt, sadness, fear, lifelessness, loneliness, and existential fear were experienced more intensely by patients.

CONCLUSIONS

  These findings demonstrate deficits in experiencing and recognizing emotions in BD patients who are in remission and underscore the relevance of these deficits in the psychosocial context.

Association of meteorological factors with suicide

OBJECTIVE

To identify weather factors associated with an increased risk of suicide. In a number of prior studies an influence of meteorological conditions on the incidence of suicide or attempted suicide has been suggested.

METHOD

Official data on the suicide cases of the state of Tyrol, Austria, assessed over a period of 6 years (n = 702) were correlated with a number of meteorological factors assessed at eight weather stations.

RESULTS

The risk of committing suicide was significantly higher on days with high temperatures, low relative humidity or a thunderstorm and on days following a thunderstorm. The multiple logistic regression analysis left "temperature" and "thunderstorm on the preceding day" as significant factors, even after adjustment for sociodemographic and geographical variables.

CONCLUSION

Within the interaction of psychological and environmental influences in the development of suicidal ideation and behaviour, specific meteorological conditions may additionally contribute to the risk of suicide in predisposed individuals.

Decision making under risk and under ambiguity in depressed suicide attempters, depressed non-attempters and healthy controls

BACKGROUND

A number of neuropsychological alterations have been found in patients who have attempted suicide. Most studies investigating decision making (DM) abilities in suicide attempters so far have used one single DM task and included patients with a lifetime history of suicide attempts. These studies have yielded conflicting results.

METHOD

In this study, currently depressed in-patients who had a recent suicide attempt (within the last six months) (n = 21), depressed in-patients without a lifetime history of suicide attempts (n = 31) and a healthy control group (n = 26) were assessed with two tasks for the assessment of DM. The Game of Dice Task (GDT) measures DM under risk and the Iowa Gambling Task (IGT) DM under ambiguity. Further, depression severity, impulsiveness and suicidal intent of the current suicide attempt were assessed.

RESULTS

Both depressed groups differed from controls with respect to marital and partnership status, smoking, impulsiveness and psychiatric family history. In terms of DM, IGT scores did not differ significantly between groups. However, suicide attempters made significantly more risky decisions as assessed with the GDT than both control groups (p < 0.05 for pairwise comparisons, p = 0.065 for overall comparison of the 3 groups).

LIMITATIONS

The available tasks assess DM under laboratory conditions which may not reflect the emotional status of suicidal individuals. No general cognitive assessment was included.

CONCLUSIONS

Depressed suicide attempters differed with regard to DM under risk but not DM under ambiguity. When studying DM it appears crucial to take varying aspects of DM into account.

Evaluation of a multicentre study with Iomazenil--a benzodiazepine receptor ligand

After showing in an earlier publication that Iomazenil is a potent benzodiazepine receptor antagonist, the substance has been distributed to 11 clinical centres in Europe for further tests. The protocol asked for volunteers, epileptic cases and patients with Alzheimer's disease. Prior to the Iomazenil examination, flow images by perfusamine or HMPAO were required, and as comparative methods EEG, computed tomography (CT) and magnetic resonance imaging (MRI) were performed. The results allowed first the determination of the normal distribution of the benzodiazepine receptors in the human brain. The highest uptake was found in medial occipital cortex. Second, the evaluation of the epileptic cases shows a 100% positive prediction value for Iomazenil compared to 92% for flow images. Negative prediction values were calculated as 81% for Iomazenil and 54% for flow images. Furthermore, one group reported the successful diagnosis of Alzheimer's disease at an early stage. The visual image examination was tentatively compared to a more objective semiquantitative one based on quotients of corresponding left/right regions of interest. This semiquantitative method has not proved successful yet, but the problems have been identified. A more precise protocol for further studies is therefore proposed.

In-patient suicide in psychiatric hospitals

OBJECTIVE

In-patient suicides continue to be a matter of concern in hospital psychiatry. In-patients at risk for suicide need to be identified.

METHOD

In-patient suicides in two psychiatric hospitals were assessed over a time-span of 8 years. Cases were detected by comparing police suicide data with the hospitals' admission and discharge records. Further information was then gathered from patients' records.

RESULTS

During the period under investigation 44 in-patients committed suicide, the majority of them being diagnosed with affective disorders (45.4%) or schizophrenia (27.3%). The most commonly used method was 'jumping in front of a vehicle' (34.1%); 79.5% were treated in an open ward at the time of their suicide, 15.9% in a locked unit. The majority of open ward suicides happened outside the hospital; 39.4% of patients had left the ward without giving notice.

CONCLUSION

Additional cautionary measures are warranted especially for patients in open wards.

Analysis of 27 vascular-related proteins reveals that NT-proBNP is a potential biomarker for Alzheimer's disease and mild cognitive impairment: a pilot-study

Alzheimer's disease (AD) is a severe neurodegenerative disease. Cerebrovascular changes often accompany AD-related pathology. Despite a considerable progress in the diagnostic accuracy of AD, no blood biomarkers have been established so far. The aim of the present study was to search for changes in plasma levels of 27 vascular-related proteins of healthy controls, patients with mild cognitive impairment (MCI) and AD. In a sample of 80 participants we showed that out of these 27 proteins, six proteins were slightly changed (up to 1.5×) in AD (alpha2-macroglobulin, apolipoprotein-A1, plasminogen activator inhibitor, RAGE, Tissue Inhibitors of Metalloproteinases-1 and Trombospondin-2) and one marker (serum amyloid A) was enhanced up to 6× but with a very high variance. However, N-terminal pro-brain natriuretic peptide (NT-proBNP) was significantly enhanced both in MCI and AD patients (1.9×). In a second analysis of a sample of 110 subjects including younger healthy controls, we confirmed that NT-proBNP has the potential to be a stable candidate protein for both diagnosis and AD disease progression.

Facial affect recognition in symptomatically remitted patients with schizophrenia and bipolar disorder

Both schizophrenia and bipolar disorder (BD) have consistently been associated with deficits in facial affect recognition (FAR). These impairments have been related to various aspects of social competence and functioning and are relatively stable over time. However, individuals in remission may outperform patients experiencing an acute phase of the disorders. The present study directly contrasted FAR in symptomatically remitted patients with schizophrenia or BD and healthy volunteers and investigated its relationship with patients' outcomes. Compared to healthy control subjects, schizophrenia patients were impaired in the recognition of angry, disgusted, sad and happy facial expressions, while BD patients showed deficits only in the recognition of disgusted and happy facial expressions. When directly comparing the two patient groups individuals suffering from BD outperformed those with schizophrenia in the recognition of expressions depicting anger. There was no significant association between affect recognition abilities and symptomatic or psychosocial outcomes in schizophrenia patients. Among BD patients, relatively higher depression scores were associated with impairments in both the identification of happy faces and psychosocial functioning. Overall, our findings indicate that during periods of symptomatic remission the recognition of facial affect may be less impaired in patients with BD than in those suffering from schizophrenia. However, in the psychosocial context BD patients seem to be more sensitive to residual symptomatology.

Psychiatric hospitalizations during the last 12 months before suicide

OBJECTIVES

Suicide victims frequently have had contact with the mental health care system before they died. In this study, the rates, numbers and lengths of psychiatric hospitalizations of suicide victims during the last year before their suicide commission were assessed.

METHODS

The quarterly and monthly hospitalization rates during the last 12 months of 665 individuals who committed suicide were compared.

RESULTS

Of the suicide victims, 16.4% had been hospitalized at least once. The period after a recent discharge bore the highest risk for suicide commission, with 4.7% (28.4% of those hospitalized) committing suicide within 1 week after their discharge and 7.8% (47.7%) committing suicide within 1 month. Hospitalization rates were significantly higher in the last 3 months as compared with the preceding quarters.

CONCLUSION

Increasing utilization of inpatient treatment facilities should prompt a particularly profound suicide risk assessment and postdischarge treatment planning.

Diagnostic value of different electrophysiologic tests in cervical disk prolapse

We evaluated 24 patients with radiologically verified cervical disk prolapse. EMG abnormalities appeared in 67% of cases studied; dermatomal somatosensory evoked potentials revealed 85% abnormal findings on the affected side, but also revealed abnormalities in adjacent segments. In 38%, F responses were abnormal. We found electrodiagnostic abnormalities at levels without a disk prolapse, probably due to degenerative spondylopathic changes and beginning consecutive vascular compromise.

Two Blood Monocytic Biomarkers (CCL15 and p21) Combined with the Mini-Mental State Examination Discriminate Alzheimer's Disease Patients from Healthy Subjects

Background

Alzheimer's disease (AD) is a progressive neurodegenerative disorder. In AD, monocytes migrate across the blood-brain barrier and differentiate into microglia, are linked to inflammatory responses and display age-dependent decreases in telomere lengths.

Methods

Six monocyte-specific chemokines and the (telomere-associated) tumor suppressor proteins p53 and p21 were determined by multiplex immunoassay in plasma and monocyte extracts of patients with AD or mild cognitive impairment, and levels were compared between patients and controls (without cognitive impairment).

Results

CCL15 (macrophage inflammatory protein-1δ), CXCL9 (monokine-induced by interferon-γ) and p21 levels were decreased in monocytes of AD patients compared with controls.

Conclusion

The combination of monocytic CCL15 and p21 together with the Mini-Mental State Examination enables to differentiate AD patients from controls with high specificity and sensitivity.

[Railroad suicides and attempted suicides in Austria 1990-1994. Extending the hypothesis mass media transmission of suicidal behavior]

Suicide on railways (either by being run over by or jumping in front of a train) is one of the "hardest' suicide methods. In Austria, 617 suicides or attempted suicides on railways were registered between 1990 and 1994. This amounts to 5.73% of all suicides committed in this period with women showing a higher percentage than men. In both men and women there was a predominance of younger age groups; the mean age was higher in women than in men (48.0 vs 40.4 years). There was a significant increase in suicides or attempted suicides on railways after a television report on the stress suffered by train drivers concerning possible suicides. Persuading the mass media to treat the subject of "suicide' with reserve and with greater caution, even when not presenting a distinct suicide model, may be of importance in general suicide prevention.