Suicide Risk and Prevention During the COVID-19 Pandemic: One Year On

Abstract

Emerging data from high and upper-middle-income countries indicate that suicide rates generally did not increase during the initial months of the COVID-19 pandemic, yet the pandemic’s impact on suicide is complex. We discuss the nuances of this relationship, how it may evolve over time, and describe the specific steps that governments and societies must take to mitigate harm and prevent suicides in the late stages and aftermath of the pandemic.

Keywords:

• COVID-19
• epidemiology
• International COVID-19 Suicide Prevention Research Collaboration

The COVID-19 pandemic is among the most disruptive events to global health in living memory. Evidence has emerged of substantial negative mental health consequences, including possible increasing rates of suicidal thoughts (O’Connor et al., 2021; Winkler et al., 2020). Nationwide survey data from the first months of the pandemic in the United States showed increased mental distress, anxiety, depression, substance use, and suicidal thoughts in adults (Czeisler et al., 2020; Twenge & Joiner, 2020). However, our group’s recent study of suicide mortality in 21 high- and upper-middle-income countries during the pandemic’s first four months found no evidence of increased rates of suicide (Pirkis et al., 2021). Indeed, there was evidence of decreases in national or regional suicide rates in nine countries (Australia, Canada, Chile, Ecuador, Germany, Japan, New Zealand, South Korea, United States) and no significant change in rates in the remaining 12 countries (Austria, Brazil, Croatia, England, Estonia, Italy, Mexico, Netherlands, Peru, Poland, Russia, and Spain) (Pirkis et al., 2021). Recently published data from China and India support these findings (Behera, Gupta, Singh, & Balhara, 2021; Zheng et al., 2021). Moreover, rates of outpatient and hospital presentations for self-harm have decreased in many regions during the early phase of the pandemic, suggesting a lower prevalence of medically serious suicidal behavior; though this might partly reflect the generally reduced use of healthcare services (Carr et al., 2021; Jollant et al., 2021; Knipe et al., 2021). However, these findings should be viewed cautiously as they only pertain to the earliest months of the pandemic; it is unclear whether the observed trends will persist. Notably, a sensitivity analysis that incorporated up to seven months of data from 18 of the countries identified increased suicide rates for three locations (Vienna (Austria), Puerto Rico, and Japan) (Pirkis et al., 2021).

How should we interpret these seemingly contradictory findings and what are their implications for suicide prevention going forward? The pandemic’s effects on mental health are complex, simultaneously affecting both risk and protective factors for suicidal behavior (Figure 1). On one hand, the pandemic has caused immense hardship arising from the effects of the disease itself, societal fear and uncertainty, prolonged isolation and physical distancing, disruption to education and school closure, economic hardship, increases in intimate partner/domestic violence, and bereavement. On the other hand, the collective trauma may also have normalized the experience of distress and resulted in a “coming together” phenomenon, as many individuals spend more time with their families and in their local communities. The pandemic has focused the public on survival and the collective hope that modern science will rescue the world with a vaccine. Hope, purpose, and belongingness may all lower the risk of suicide. These nuances may explain the counterintuitive increase in both suicidal thoughts and positive well-being reported in the UK (O’Connor et al., 2021). Furthermore, emerging evidence indicates that the pandemic may disproportionately affect young people including US data showing an increase in emergency presentations for suspected suicide attempts in adolescent girls (O’Connor et al., 2021; Yard et al., 2021); while young people have higher rates of suicide attempts, in high-income countries they generally have substantially lower rates of a suicide death. Such findings might explain rising rates of mental health symptoms and suicidal thoughts without corresponding increases in suicide. It should also be noted that deteriorating mental health has not been observed in all countries. For example, the prevalence of mental disorders and suicidal ideation were unchanged in Norway during the first six months of the pandemic (Knudsen et al., 2021).

FIGURE 1. Potential risk and protective factors that may influence suicide rates during the COVID-19 pandemic.

Data from early phases of the pandemic demonstrate that hardship faced by people worldwide does not inevitably translate into increased suicide deaths, at least in higher-income countries where short-term financial safety nets were put in place often in addition to preexisting national suicide prevention strategies. That is important news which deserves broad attention. But lessons from previous pandemics suggest that we must avoid complacency (Zortea et al., 2021). Mental health effects of the pandemic may increase over time due to prolonged economic stress and underemployment (Kawohl & Nordt, 2020) or post-infection increases in the prevalence of some psychiatric illnesses (Taquet, Luciano, Geddes, & Harrison, 2021). For example, in Japan, decreased suicide rates in the first four months of the pandemic were followed by a period with suicide rates that were higher than historical averages (Ueda, Nordström, & Matsubayashi, 2021). Moreover, in some locations where overall suicide rates were unchanged (or decreasing), there is concern about increased rates among youth, women, and ethnic minorities (Mitchell & Li, 2021; Ueda et al., 2021). There is a clear need for continued monitoring of mental disorders and suicidal behavior during the remainder of the pandemic and the protracted recovery period. This monitoring is especially necessary for low and middle-income countries, given the dearth of existing data. It is also crucial given vaccine shortages that may prolong the pandemic and its impacts in these countries.

Proactive efforts to prevent suicide are, therefore, a current worldwide imperative. Robust, ongoing governmental and societal responses must include: (1) efforts to prevent and mitigate the negative effects of mass unemployment and economic hardship such as expanded unemployment and related social welfare programs; (2) actions to minimize the long-term damage to the career prospects of young people arising from disruptions to their education and to their transition to employment at a time of labor market upheaval, (3) timely access to high quality, evidence-based mental health treatment and suicide prevention interventions, including crisis helplines and services, with attention to the issue of diminished help-seeking during the pandemic; (4) public health and media messaging emphasizing healthy coping, emotional resilience and avoiding presentations of suicide as a common or rational strategy for managing distress or an inevitable consequence of the pandemic; and (5) efforts to promote social cohesion with particular attention to places and times where societal divisions and/or discord may be emerging. A priority for the research community is also to evaluate which approaches have most effectively mitigated the pandemic’s impact on suicide rates to inform future responses to similar events.

Unlike previous pandemics, COVID-19 is occurring in the modern digital world, where video conferencing and virtual healthcare provision are increasingly available. Public health advice based on real-time data and rapid development of vaccines has been demonstrated to be possible as has the potential for internationally coordinated economic mitigation strategies. These conditions may shorten the duration of the pandemic and prevent a substantial number of COVID-19 deaths in many countries. Preventing suicide during the remainder of the pandemic and its aftermath will likewise require robust, comprehensive efforts that address the diverse and rapidly changing conditions affecting risk in populations across the globe.

All of these efforts must include specific steps to address suicide risk in youth, migrants, those with preexisting health and/or socioeconomic challenges, as well as people who have been infected with COVID-19 and professionals experiencing long-term stress (e.g., healthcare workers), since these groups may be particularly vulnerable (Iob, Steptoe, & Fancourt, 2020). Lastly, and perhaps most importantly, the economic and mental health consequences of this pandemic will last well beyond its duration. We, therefore, urge governments and other stakeholders to begin planning immediately, if they have not already done so, for how the strategies above will be maintained in the aftermath of the pandemic and what culturally appropriate steps can be taken to facilitate healing and to promote community togetherness.

AUTHOR NOTES

Mark Sinyor is an Associate Professor of Psychiatry at the University of Toronto and a Psychiatrist at Sunnybrook Health Sciences Centre in Toronto, Canada. His main research focus is population-level strategies for suicide prevention.

Duleeka Knipe is a Vice Chancellor’s Elizabeth Blackwell Institute research fellow at the University of Bristol, UK. She is a mental health epidemiologist with an interest in suicide and self-harm in low and middle income countries and marginalised groups.

Guilherme Borges is a senior researcher and a Professor of epidemiology at the National Institute of Psychology Psychiatry in Mexico City. His main research interest is understanding the determinants of suicide.

Michiko Ueda is an Associate Professor at Waseda University in Tokyo, Japan. Her research interests include socioeconomic factors of suicide and media and suicide.

Jane Pirkis is the Director of the Centre for Mental Health at the University of Melbourne. She has a background in psychology an epidemiology, and she has a particular interest in suicide and the media. She is a past Vice President of the International Association for Suicide Prevention.

Michael R. Phillips is Director of the Suicide Research and Prevention Center of the Shanghai Mental Health Center at Shanghai Jiao Tong University School of Medicine, Executive Director of the WHO Collaborating Center for Research and Training in Suicide Prevention at Beijing Hui Long Guan Hospital, and Clinical Professor of Psychiatry and Epidemiology at Columbia University.

David Gunnell is Professor of Epidemiology at the University of Bristol, UK. He is a public health physician and epidemiologist with a longstanding research interest in the etiology and prevention of suicide. He leads the ICSPRC.

ACKNOWLEDGMENTS

The authors would like to acknowledge the help the International COVID-19 Suicide Prevention Research Collaboration (ICSPRC) has received from the International Association for Suicide Prevention (IASP) in establishing and supporting its activities.

DISCLOSURE STATEMENT

Affiliations of the International COVID-19 Suicide Prevention Research Collaboration are listed in the Supplementary Appendix. MS has received salary support from Academic Scholar Awards from the Departments of Psychiatry at the University of Toronto and Sunnybrook Health Sciences Centre. MS has grants from the American Foundation for Suicide Prevention, the Canadian Institutes of Health Research, the Ontario Ministry of Research and Innovation, Mental Health Research Canada, the Institute for the Advancements in Mental Health, the University of Toronto Miner’s Lamp Innovation Fund, and Telus Canada. DK is supported by the Elizabeth Blackwell Institute for Health Research, University of Bristol and the Wellcome Trust Institutional Strategic Support Fund (ISSF3: 204813/Z/16/Z). MRP is supported in part by the National Natural Science Foundation of China (NSFC, 81761128031). DG is a member of the Department of Health and Social Care (England) National Suicide Prevention Strategy Advisory Group. DG is supported by the NIHR Biomedical Research Centre at University Hospitals Bristoland Weston NHS Foundation Trust and the University of Bristol, UK. DG has grants from the National Institute for Health Research (NIHR) outside the submitted work and is a member of the Samaritans Policy and Research Committee and Movember’s Global Advisory Committee. All other authors declare no competing interests.

Additional information

Funding

The present work was financially supported by the Departments of Psychiatry at the University of Toronto and Sunnybrook Health Sciences Centre.