https://orcid.org/0000-0002-2743-0372
Abstract
Background
Suicidal ideation can be triggered or exacerbated by psychosocial stressors including natural disasters and pandemics.
Aims
This study investigated prevalence rates and demographic and clinical correlates of self-reported passive death wishes and thoughts of self-harm among Canadians subscribing to Text4Hope; a daily supportive text message program.
Methods
A survey link was sent out to Text4Hope subscribers. Demographic information was captured and clinical data collected using the Perceived Stress Scale (PSS), Generalized Anxiety Disorder-7-item (GAD-7) scale, and Patient Health Questionnaire-9 (PHQ-9). Data were analysed with descriptive analysis, the chi-square test, and logistic regression.
Results
Responders showed an increase in prevalence rates for passive death wish and thoughts of self-harm compared to baseline Canadian statistics on suicidality. Responders aged ⩽25years, Indigenous, had less than high school education, unemployed, single, living with family, with increased anxiety, disordered sleep, and recent concerns about germs and contamination were at greatest risk.
Conclusions
Our results indicate that suicidal thoughts may have increased in the general population as a result of COVID-19 and signals an urgent need for public education on appropriate health seeking methods and increased access to mental and social support especially during the COVID-19 pandemic and its immediate aftermath.
Introduction
Passive death wish, described as a desire to die during one’s sleep or being killed by an accident, is a general wish not to be alive, typically due to overall dissatisfaction with one’s existence or quality of life (Ayalon & Shiovitz-Ezra, Citation2011; Skegg, Citation2005). Self-harm describes a wide range of behaviours and intentions including attempted hanging, self-poisoning, and superficial cutting (Skegg, Citation2005) in efforts to self-inflict physical pain or near-death experiences most often during periods of extreme emotional distress (Skinner et al., Citation2016). About 11.8% of the Canadian population reported having passive death wishes in their lifetime and about 2.5% reported thoughts of suicide in the past year. A further 4.0% admitted to having suicide plans with about 3.1% attempting suicide in their lifetime (Skinner et al., Citation2016). Suicide is a primary psychiatric emergency, often related to a mental health disorder, usually depression, which may be prevented through adequate pharmacological and appropriate psychosocial interventions (Jayaram, Citation2015). In Canada, about 11 people die by suicide each day, resulting in approximately 4000 deaths by suicide per year. Suicide is the second leading cause of death amongst 15−34 year olds and the cause of one third deaths in those aged 45−59 years. General estimates indicate approximately 20−25 attempts result in 1 completed suicide (Skinner et al., Citation2016). Suicide rates in men are 3−4 times higher than for women, however, women attempt suicide or report having suicidal thoughts three times as often as men (Skinner et al., Citation2016). A history of previous suicide attempts is a strong predictor of suicide across all age groups and all psychiatric diagnoses (Bodner et al., Citation2017). Other common risk factors include: deliberate self-harm practices, family history of suicide, presence of psychiatric disorders, substance use disorders, medical illnesses, and psychosocial factors (such as stress, hopelessness, unemployment, and marital status) (Kawohl & Nordt, Citation2020; Klomek, Citation2020). Passive death wish and recurrent thoughts of self-harm are associated with psychiatric disorders, such as depression, and are important risk factors for the eventual completion of suicide (Ayalon & Shiovitz-Ezra, Citation2011; Klomek, Citation2020; Lee & Ishii-Kuntz, Citation1987). In December 2019, there was an unprecedented outbreak of a pneumonia of unknown aetiology in Wuhan City, Hubei province in China. A novel coronavirus was identified as the causative agent, a beta coronavirus named SARS-CoV-2, which mainly affects the lower respiratory tract and manifests as pneumonia in humans (Thakur & Jain, Citation2020); this virus was subsequently termed COVID-19 by the World Health Organization (WHO). Despite rigorous global containment and quarantine efforts, the incidence of COVID-19 rose steadily, with about 6.6 million confirmed cases and over 400,000 deaths at the time of writing (Skegg, Citation2005). In response to this global outbreak, on 11 March 2020, the WHO declared COVID-19 a public health emergency and a pandemic (WHO, 2020a). In response, Canada implemented a ban on all non-essential travel and events and a closure of all non-essential services including schools and businesses across the country. People were instructed to self-isolate at home and social gatherings (including places of worship, gyms, parks, and restaurants) were under lockdown. This near-total social shut-down was unprecedented in living memory for Canadians, resulting in an abrupt change in lifestyle and routine for many, and disrupting social contact between many families and loved ones. With these changes, many suffered protracted loss of emotional support and social contact and in turn, individuals reported extreme isolation and feelings of helplessness and fear of contracting the virus (McIntyre & Lee, Citation2020). Media outlets and news sources were filled with news of rapidly rising COVID-19 related deaths and there was a corresponding increase in individuals reaching out for mental health and addiction support to cope with these feelings (Ayalon & Shiovitz-Ezra, Citation2011; Skinner et al., Citation2016). Several authors have indicated a concern for possible increases in suicide attempts as a response to the pandemic (Gunnell et al., Citation2020; McIntyre & Lee, Citation2020; Pruitt et al., Citation2020; Sinyor et al., Citation2020).
In Alberta, the Text4Hope program was launched to provide free daily supportive text messages for those seeking mental health support during the COVID-19 pandemic (Agyapong, Citation2020). Albertans were encouraged to enrol in the program and subscribers were invited to complete a series of self-report screening questionnaires aimed at identifying existing psychiatric distress and overall general mental health concerns. Previous studies have reported associations between various psychosocial stressors and increased anxiety and depressive symptoms, including passive death wishes and thoughts of self-harm. However, these associations were multifactorial in nature and were dependent on the presence and nature of an underlying psychiatric disorder, available psychological and social support, and premorbid personality (Bodner et al., Citation2017; Bostwick & Pankratz, Citation2000; McIntyre & Lee, Citation2020; Monteith et al., Citation2021). This study investigated demographic and clinical correlates of passive death wishes and thoughts of self-harm as reported by a general population of Canadians invited to subscribe to the free Text4Hope psychological support program during the COVID-19 pandemic.
Materials and method
This study was a cross-sectional online baseline survey aimed to collect demographics, clinical scores, and data related to death wish and thoughts of self-harm retrieved from the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., Citation2001).
The study had prior ethics approval from the University of Alberta Health Research Ethics Board (Pro00086163) and participant consent was implied by completing the online survey
Study participants and data collection
Data were collected through an online questionnaire, administered for seven consecutive days, as part of a wide-scale baseline survey used at the launch of the Text4Hope program in Alberta. The data were collected from 4 p.m. on 23 March 2020 to 4 p.m. on 30 March 2020.
Text4Hope is a mobile-based program generated by Alberta Health Services (AHS), with the support of other health organizations, during the COVID-19 pandemic (Agyapong, Citation2020; AHS, Citation2020). Clients subscribed to the program by texting “COVID19Hope” to a short code number to receive daily free-subscription supportive text messages over a three-month duration. Messages were designed and reviewed by AHS psychiatrists and mental health therapists, including authors of the study, in alignment with the concepts of cognitive behavioral therapy (CBT). A voluntary survey was provided with the first Text4Hope text message to gather demographic, clinical, COVID-19, and self-isolation related data. No incentives were provided and completing the survey was not a prerequisite for receiving text messages. Survey questions were programmed into Select Survey, an online survey tool.
Statistical data analysis
The following sociodemographic variables were collected: gender, age, ethnicity, education level, social relationship, employment status, and housing condition. Several variables were collapsed into fewer categories to address the data set efficiently. Self-isolation/self-quarantine and clinical characteristics were assessed using validated scales for self-reported symptoms, including the Perceived Stress Scale (PSS) (Cohen et al., Citation1983) (for moderate to high stress; PSS ≥ 14), the Generalized Anxiety Disorder 7-item (GAD-7) scale (Spitzer et al., Citation2006) (for likely generalized anxiety disorder; GAD-7 ≥ 10), and the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., Citation2001) (for expressing trouble falling or staying asleep, or sleeping too much; question three on the PHQ-9 ≥ 1).
A key dependent variable was question nine on the PHQ-9, “Thoughts that you would be better off dead, or of hurting yourself in the last two weeks,” and was initially identified as a four-category variable (Not at all, Several days, More than half the days, and Nearly everyday). For the purpose of analysis, this was collapsed into two categories, PHQ-9 ≥ 1 and PHQ-9 < 1 (have had passive death wish/thoughts of self-harm in the last two weeks and have not had passive death wish/thoughts of self-harm in the last two weeks), respectively.
Descriptive and inferential statistics were run using SPSS (Brooks et al., Citation2020). Age categories, 25 years or less, 26–40 years, 41–60 years and above 60 years were plotted against all independent variables (). Chi-square was employed for univariate analysis to examine associations between the sociodemographic/clinical variables and “Thoughts that you would be better off dead, or of hurting yourself” categorical variable (). Results from the Chi-square analyses were entered into a logistic regression model after calculating correlation coefficients to check for multicollinearity among the independent variables. Odds Ratio (OR) and confidence intervals (CI) were used to report the prediction of the likelihood to develop “thoughts of being better off dead, or of hurting oneself” (). Likelihood to develop “thoughts of being better off dead, or of hurting yourself” was reported as an overall percentage. The results are presented in frequencies and percentages, and statistical significance was defined by critical two-tailed significance value of p ≤ 0.05.
Table 1. Age distribution of demographic and clinical characteristics of respondents.
Table 2. Chi-squared test of association between demographic characteristics and self-isolation or self-quarantine status and likelihood of experiencing passive death wish or thoughts of self-harm in the preceding two weeks.
Table 3. Logistic regression predicting likelihood of experiencing passive death wish or thoughts of self-harm.
Results
Out of 32,805 individuals who subscribed to Text4Hope in the first week of the program, 6041 individuals completed the baseline questionnaire, with a response rate of 18.4%. The likelihood to express passive death wish and thoughts of self-harm was 14.4%, where 488 (9.6%) reported having such thoughts on several days, 157 (3.1%) reported having these symptoms more than half the days, and 89 (1.8%) reported expressing these symptoms nearly everyday. Descriptive statistical analysis of the sociodemographic and clinical data was identified by age groups, as illustrated in .
Of the 6041 respondents, the largest age group was 40−60 years, representing 2539 (43.3%) individuals, 640 (10.9%) were 25 years or less, 2174 (37.0%) were between 26 and 40 years, and 517 (8.8%) were above 60 years. Most respondents identified as female (86.9%). Additionally, Caucasian (82.6%), post-secondary education (85.8%), employed (72.3%), married, cohabiting, or partnered (71.9%), and owning home (66.7%) represented higher frequencies among survey respondents. Of the total responses, 84.9% reported experiencing moderate to severe stress symptoms, while significant anxiety and sleep disturbance symptoms represented 46.9% and 78.0% of the survey responders, respectively.
Univariate analysis
Univariate analyses with Chi-square revealed that all dependent variables in the model showed significant associations with the outcome variable (likelihood to express passive death wish and thoughts of self-harm) p ≤ 0.05, as illustrated in .
Highest likelihood of presenting with passive death wish and thoughts of self-harm compared to individuals within the same demographic groups included those who identified as gender diverse; were aged ≤25 years; identified as Indigenous; had not completed high school education; were unemployed; were single; or were living with their family (i.e., not living independently). Similarly, the following groups all seemed to experience more passive death wish and thoughts of self-harm compared to the other respondents in their respective groups: respondents who had to self-isolate or quarantine; those who experienced moderate to severe symptoms of stress or anxiety; those worried about dirt, germs, and viruses; those who washed their hands repeatedly or in a special way due to fears of contamination with dirt, germs, and viruses both before and during the current pandemic; and those having troubles falling or staying asleep, or sleeping too much in the last two weeks.
Logistic regression
Spearman correlation analysis yielded no evidence for collinearity among the independent variables therefore, binomial logistic regression was run to determine the relationship of the independent variables to likelihood of participants having passive death wish and thoughts of self-harm, respectively. The regression model was statistically significant, Χ2 (29) = 610.78, p < .001 and could explain 13.5%−24.1% of the variance in the likelihood that respondents will present with passive death wish and thoughts of self-harm. The model accurately classified 86.0% of all the cases. shows that nine demographic and clinical factors independently predicted the likelihood of experiencing passive death wish and thoughts of self-harm in the model. The largest contribution was made by the “expressing significant anxiety symptoms” variable, with a Wald of 109.9, where experiencing these anxiety symptoms was associated with a significant higher likelihood to develop passive death wish and thoughts of self-harm, compared to individuals lacking these symptoms in our model (OR 3.4, 95% CI: 2.70−4.26). Male participants were 1.5 times more likely to develop passive death wish and thoughts of self-harm than females (95% CI: 1.2−2.01). Compared to individuals 25 years or younger, participants of all other age groups; 26−40 years, 41−60 years, and those above 60 years showed significantly less likelihood to develop passive death wish and thoughts of self-harm, when controlling for all other variables in the model [(OR 0.68, 95% CI: 0.49−0.95), (OR 0.63, 95% CI: 0.44−0.92) and (OR 0.37, 95% CI: 0.19–0.72), respectively]. Compared to others, individuals that identified as Indigenous or Asian were more likely to develop passive death wish and thoughts of self-harm [(OR 1.61, 95% CI: 1.04–2.48) and (OR 1.9, 95% CI: 1.27–2.93), respectively)]. Similarly, unemployed respondents were almost two times more likely to express passive death wish and thoughts of self-harm, compared to employed respondents (OR 1.90, 95% CI: 1.51−2.48). Likewise, separated or divorced individuals were at a higher risk of developing passive death wish and thoughts of self-harm, compared to the married, cohabiting, or partnered people (OR 1.70, 95% CI: 1.21−2.40). Additionally, individuals living with family or renting their homes were at a higher risk of having death and self-harm thoughts, compared to those owning homes [(OR 2.10, 95% CI: 1.43−3.00) (OR 1.7, 95% CI: 1.36−2.18), respectively].
Individuals who had never been worried about dirt and germs were at a higher risk to develop passive death wish and thoughts of self-harm, compared to those who developed worry about dirt and germs only after the COVID-19 pandemic (OR 1.40, 95% CI: 1.07−1.95). Moreover, individuals expressing moderate/high stress symptoms and those having trouble falling or staying asleep, or sleeping too much in the two weeks pre-survey expressed a significantly higher likelihood to develop passive death wish and thoughts of self-harm in our sample, compared to individuals lacking such symptoms (OR 4.30, 95% CI: 2.25−8.35) (OR 2.35, 95% CI: 1.65−3.34), respectively. Other variables such as educational level, hand-washing, and self-isolation/self-quarantine status did not show significant prediction for the suicidal thoughts.
Discussion
From an overall response rate of 18.4% (6041 out of 32,805 Text4Hope subscribers) our demographic spread showed representation across all of our age categories; 43.3% of respondents were 40−60 years, 37.0% were 26−40 years, 10.9% were 25 years or less, and 8.8% were over 60 years. The reduced representation of ≤25 years could be related to socioeconomic reasons, such as lack of financial independence, reduced economic means, or apathy or disinterest in the support app; and for individuals >60 years of age, a possible lack of technical know-how of mobile technology. The majority of our responders self-identified as female (86.9%), employed (72.3%), with post-secondary education (85.8%), married, partnered, or cohabiting (71.9%), and home-owners (66.7%). This demographic is likely to be more financially stable, and this observation is suggestive that the Text4Hope program and other modern or technology-based health support might be more appealing to this section of the population. From our overall collated data, we observed that 14.4% of our survey population reported having experienced passive death wish or thought of self-harm during this period. This finding, compares to about 11.8% of the Canadian population reported having death wishes in their lifetime and about 2.5% have had thoughts of suicide in the past 12 months (Skinner et al., Citation2016), would suggest an increase in death wish and suicidal thoughts above previously reported or expected rates. The unprecedented changes to societal functioning and abrupt cessation of social supports could be a contributing factor to the rates of passive death wish and thoughts of self-harm observed. Further evaluation of the data might suggest an increase in other factors associated with worsening depressive symptoms, which have been strongly related to suicide attempts and eventual completion of suicide (Bostwick & Pankratz, Citation2000).
Demographic correlates
Our survey observed that multiple demographic factors correlate with likelihood of passive death wish and increased thoughts of self-harm. Males and those aged 25 years or less, were more likely to report passive death wish and self-harm thoughts. Previous surveys have reported gender differences in the occurrence of thoughts of suicide or passive death wish and self-harm ideations or practices. Females, compared to males, report a three-fold increase in suicide attempts, although overall rates of completed suicides in men are 3−4 times higher than in women (Skinner et al., Citation2016), this is inconsistent with our observation, despite an overall majority of our participants identifying as female. It is possible that male participants who had greater symptom severity were more motivated to participate in the survey and it is possible that there are underlying gender differences in psychological effects of self-isolation or self-quarantine. The number of gender diverse respondents was too low for us to make any definitive conclusion with the observation for that group. Previous studies have also reported decreased suicidal risks in married or partnered individuals, particularly if there are children in the home. Suicidal risk is almost double in single people compared to married individuals (Bostwick & Pankratz, Citation2000). Divorce is also associated with increased suicide risks, with divorced men three times more likely to commit suicide compared to divorced women (Hirsch, Citation2006). Our data indicate that separated or divorced participants and those living with family or renting (compared to home-owners) were more likely to report passive death wish and thoughts of self-harm than married, partnered, or cohabiting participants and home-owners. These observed patterns of passive death wish and self-harm thoughts are consistent with existing literature and appear to be maintained during the COVID-19 pandemic.
We did not observe any correlation between level of education and passive death wish or thoughts of self-harm. While unemployment can be a risk factor for depressive symptoms and suicide, sudden loss of employment and a corresponding drop in income and social status, such as those observed during economic recessions, are strongly associated with increased suicide risks (Bostwick & Pankratz, Citation2000). Our survey observed that unemployed participants were twice more likely to report passive death wish and self-harm thoughts than employed participants. However, our data do not include a distinction of long-term unemployment from more recent or COVID-19 related causes of unemployment. We also noted that, compared to other ethnic categories, participants who identified as Indigenous or Asian were more likely to report passive death wishes or thoughts of self-harm.
Clinical correlates
In accord with previous studies, increased occurrence of symptoms such as sleep disturbances, persistent anxiety, and increased perceived stress levels, all correlate with the presence and severity of a depressive disorder which is seen in about 90.0% of suicide victims (Ayalon & Shiovitz-Ezra, Citation2011; Bostwick & Pankratz, Citation2000). Our survey participants reporting significant anxiety symptoms, those experiencing significant sleep disturbances, and those reporting moderate to high stress levels all reported increased experiences of passive death wish and thoughts of self-harm. However, our data did not differentiate from those with pre-existing diagnosis of a depressive disorder or whether these symptoms being reported reached full clinical diagnostic criteria for a depressive disorder.
During the COVID-19 pandemic, there were numerous public awareness initiatives educating the public on hand hygiene and modes of transmission of viral particles. Amongst other methods, the public were encouraged on regular handwashing practices, wearing of face masks in public, and maintaining at least 2 meters distance from each other when in public (physical distancing) (WHO, Citation2020b). There was an increase in public awareness of dirt and germs on communal surfaces such as elevators, railings, and banisters and appropriate shielding of mouth and face when coughing or sneezing. These may have resulted in increased awareness and concerns about dirt and germs in some of our survey population. We observed that individuals who had never been worried about dirt and germs were significantly more likely to experience passive death wish and thoughts of self-harm compared to those who developed worries about dirt and germs only after the COVID-19 pandemic. To our knowledge, there is currently no literature on any correlation between increase passive death wish or self-harm and new onset worries about dirt or germs. We anticipate that further observations following the COVID-19 pandemic will elaborate further on any such associations in the future.
There were no correlations of increased passive death wish or self-harm thoughts and either hand-washing practices or self-isolation in quarantine during the period of our survey. As our survey was completed from 23 March to 30 March 2020, one week into the social restrictions, it possible that the full psychological effects of social isolation/quarantine were yet to manifest (Beland et al., Citation2020; Hotopf et al., Citation2020).
Conclusion
From our data, we observed greater reports of passive death wish and self-harm thoughts, compared to pre-COVID-19 Canadian statistics on suicidality within the population. In particular, individuals identifying as Indigenous or Asian, male, aged 25 years and below, single or divorced, unemployed, non-home-owners, with recent (post-COVID-19 outbreak) concerns about contamination, increased anxiety, and poor sleep patterns were more likely to report passive death wishes or thoughts of self-harm. This is mostly consistent with previous studies which reported greater risks of suicidality amongst single or divorced and unemployed individuals with greater occurrence of depressive symptoms and psychosocial stressors. It is however note-worthy that contrary to previous Canadian statistics on suicide and suicidality, males were 1.5 times more likely to report passive death wishes and self-harm thoughts. This is rather concerning as males have greater risks of completed suicide as they often adopt more lethal means (Ayalon & Shiovitz-Ezra, Citation2011; Skinner et al., Citation2016)
While we do not have the demographic distribution of all individuals who enrolled for the Text4Hope supportive text messages, the demographics mostly represented in our survey were those least likely to report passive death wishes and self-harm thoughts included: females (86.9%), Caucasians (82.6%), employed (72.3%), married, partnered, cohabiting (71.9%), home-owners (66.7%), and those aged greater than 25 years (89.9%). It is therefore important to educate the population at increased risk on appropriate health-seeking behavior and lifestyle adaptations (Pruitt et al. Citation2020) and ensuring prompt access to both mental and social care support services (including psychological support, employment, financial support, and accommodations) especially during and after the COVID-19 pandemic (Gunnell et al., Citation2020; Monteith et al., Citation2021). In comparison, other studies investigating the association between suicides and COVID-19 have reported increases in suicide risk factors through various means such as forced isolation, collective hypervigilance and fear of contracting the disease, economic problems, risk of domestic and intimate partner violence, and risk of alcohol and drug use during isolation (Aquila et al., Citation2020; Brown & Schuman, Citation2021; Gunnell et al., Citation2020; Rana, Citation2020; Santini et al., Citation2020; Thakur & Jain, Citation2020; Wang et al., Citation2020)
Participants in this study were enrolled in the Text4Hope support service to provide supportive psychological therapy delivered by text messaging. Supportive text messages are effective in alleviating symptoms of depression (Agyapong et al., Citation2012; Agyapong et al., Citation2013a; Agyapong et al., Citation2017; O’Reilly et al., Citation2019) and high user satisfaction has been reported for text interventions in mental health (Agyapong et al., Citation2013b; Agyapong et al., Citation2016; Shalaby et al., Citation2020). Text message interventions are cost-effective, geographic location independent, free to the end user, do not require expensive data plans, can reach thousands of people simultaneously (Agyapong et. al., Citation2011; Agyapong et al., Citation2015; Agyapong et al., Citation2016; Agyapong, Citation2020; Agyapong et al. Citation2020) and can be incooperated into global suicide prevention strategies during pandemics.
Study limitations
Our survey was conducted using a series of self-reported questionnaires across a large sample of participants. It was completed by a total of 6041 participants, but despite this large group size, only represented 18.4% of 32,805 persons registered for the Text4Hope program. Our survey outcomes should therefore be interpreted with caution when considering the entire population seeking mental health support via the Text4Hope program. Our study also did not account for individuals with pre-existing mental health conditions or those with severity meeting diagnostic threshold for depressive or anxiety disorders. In addition, although we screened for presence of passive death wishes and its frequency of occurrence, we did not collect information of suicidal planning, intent, or previous attempts. Further studies are recommended to investigate COVID-19-specific changes in suicidal behaviour, plans, and attempts to aid mental health service planning during pandemics.
Authors contribution
The study was conceived and designed by VIOA. AS and RS drafted the initial manuscript. AG, WV and SS contributed to data collection. All authors contributed to study design, reviewing and revising the initial draft manuscript and approved of the final draft prior to submission.
Role of the funder/sponsor
The funder had no role in the design and conduct of the study; collection, management, analysis, the interpretation of the data, manuscript preparation and review, or approval of the manuscript, and decision to submit the results for publication.
Acknowledgement
Support for the project was received from Alberta Health Services and the University of Alberta.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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