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Original Article
Temporal Changes in Suicide Mortality Rates Before and During the COVID-19 Pandemic in Colombia. A Joint Point Regression Model
Cambios temporales en las tasas de mortalidad por suicidios antes y durante la pandemia por COVID-19 en Colombia. Un modelo de regresión joint point
Julio Ricardo Zuluaga Peñaa,
Corresponding author
julio.zuluagap@gmail.com

Corresponding author.
, Juan P. Zuluaga Peñab, Ángela P. Vega Landaetac, Eugenio Ferrod, Alejandro Lopera Maríne, Diana R. Chávez Bejaranoe, Julián Enrique Barrera Lópeze
a Pontificia Universidad Javeriana, Bogotá, Colombia
b Odds Epidemiology SAS, Bogotá, Colombia
c Departamento Administrativo Nacional de Estadística (DANE), Bogotá, Colombia
d Instituto Colombiano del Sistema Nervioso, Clínica Montserrat, Bogotá, Colombia
e Odds Epidemiology, Bogotá, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Suicidal behaviors are complex phenomena that threaten life and can negatively affect people&#39;s health and the emotional state of families and the community&#46; They comprise various degrees and types such as suicidal ideation&#44; suicide attempt&#44; and actual suicide occurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Being a global public health concern&#44; the World Health Organization &#40;WHO&#41; set a worldwide mental health goal to reduce by 10&#37; the mortality rate from suicide by 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">During the last century&#44; there have been viral infectious outbreaks that have increased the overall mortality rates and the incidence of mental illness&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> In March 2020&#44; the WHO declared the coronavirus disease 2019 &#40;COVID-19&#41; pandemic&#59; this infection mainly affects the respiratory system&#44; and displayed high mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Furthermore&#44; extrapulmonary manifestations of the COVID-19 infection have been described&#44; including neurological conditions caused by the overexpression of immunoglobulin G &#40;IgG&#41; and angiotensin-converting enzyme 2 &#40;ACE2&#41; receptor in the brain endothelium &#40;which allows viral entry&#41;&#44; and the invasion of peripheral nerves that can cause disorientation&#44; confusion&#44; delirium&#44; hallucinations&#44; and suicidal behaviors&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#8211;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical symptoms such as fear and anxiety associated with COVID-19 &#40;including the possibility of dying from it&#41;&#44; led to prolonged states of anxiety that increased the risk of major psychiatric disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> In addition&#44; public policies implemented by governments such as social isolation&#44; the use of face masks&#44; frequent hand washing&#44; and cleaning of contact surfaces&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#8211;13</span></a> increased rates of distress manifested as dysphoria&#44; anxiety&#44; insomnia&#44; traumatic stress disorders&#44; and suicidal ideation&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> The economic crisis&#44; temporary and overall unemployment due to quarantines&#44; decrease in wages&#44; and rising debts could be associated to increased anxiety and depression&#44; that in turn would increase suicide ideation and suicidal behaviors&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Suicidal ideation during the COVID-19 pandemic has been associated with loneliness&#44; anxiety&#44; depression&#44; insomnia&#44; impaired family functioning&#44; history of mental health disease&#44; alcohol abuse&#44; COVID-19-related stress symptoms&#44; marital status&#44; financial pressure&#44; unemployment&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">18&#8211;23</span></a> However&#44; the existing evidence on the impact of the COVID-19 pandemic on suicide attempts is scant&#46; Thus&#44; there is an evidence gap &#8211; with important public health implications &#8211; regarding the potential impact of the COVID-19 pandemic&#44; and no estimates on how rates might change when pandemic-related social restrictions are reduced or removed&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Worldwide&#44; cases of people who died by suicide have linked to fear of COVID-19&#44; of transmitting the virus to others&#44; of isolation&#44; anxiety about COVID-19&#44; and lack of knowledge&#46; Other triggers that have been identified for pandemic-related suicides include xenophobia&#44; stigma&#44; social boycott related to the virus&#44; financial insecurities&#44; and uncertainty about the future&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">25&#44;26</span></a> Few observational studies have analyzed the effect of the pandemic on suicidal behavior&#46; Existing studies are restricted to the early phases of the pandemic&#44; and thus may not capture the impact of massive and prolonged social trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In Colombia&#44; Colombian National Administrative Department of Statistics &#40;DANE&#41; indicated that in the first quarter of 2021&#44; 709 cases of suicide were registered &#8211; an increase of 161 cases compared to the same period in 2020&#46; Likewise&#44; an increase was reported between 2019 and 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a> However&#44; there are few studies that compare the suicide situation before and during the COVID-19 pandemic&#46; Therefore&#44; the objective of this research was to describe and analyze the changes in temporal trends of suicide mortality rates between 2008 and 2020 in Colombia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">The main data source for this study was the DANE registry of vital statistics of births and deaths &#40;deaths due to intentional self-inflicted injuries by year&#44; sex&#44; department of occurrence&#44; and educational level 2008&#8211;2020&#41;&#46; To obtain mortality rates by type of affiliation to health system &#40;2008&#8211;2020&#41;&#44; we used the national annual series of affiliation in the period 1995&#8211;2020 published by the Ministry of Health and Social Protection&#44; whose sources correspond to the subsidized regime affiliation history&#44; compensated affiliation history&#44; insurance bulletin &#40;2016&#41;&#44; and the Single Affiliate Database &#8211; Solidarity and Guarantee Fund&#46; Records of active affiliates to the contributory&#44; subsidized&#44; and exception health regime by department prepared by the Administrator of the Resources of the General System of Social Security in Health in Colombia &#40;2008&#8211;2020&#41;&#44; were also included&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Mortality rates by educational level were retrieved from the statistical information on the number of students enrolled in basic secondary and middle school by grades and sector &#40;2008&#8211;2019&#41;&#44; the reports published by the Integrated System of Enrollment of the Ministry of Education of Colombia&#44; and the data in the Technical Document ISP&#47;DT No&#46; 033-19 of the Institute of Public Health of Pontificia Universidad Javeriana on the demand for higher education in Colombia&#44; projections 2019&#8211;2040 published in December 2019&#46; Finally&#44; to analyze mortality rates against each variable included in the study&#44; the 2005&#8211;2017 and 2018&#8211;2050 departmental population projections reported by DANE were used&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All the information retrieved was sorted in a single database under the following variables&#58; sex&#44; age&#44; type of affiliation to health system &#40;contributory&#44; subsidized&#44; especial&#47;exception&#44; uninsured&#44; or without information&#41;&#44; educational level &#40;preschool&#44; primary school&#44; secondary school&#44; technical education&#44; high school&#44; technological education&#44; postgraduate&#44; university&#41;&#44; region &#40;by department&#41;&#44; and suicide method&#46; Using the R Studio statistical program&#44; we performed the 2008&#8211;2020 descriptive statistical analysis for each variable&#44; and calculated the disaggregated crude annual mortality rate per variable&#44; the age-adjusted mortality rate &#40;according to the five-year standard WHO reference&#41;&#44; and the crude average suicide mortality rates by region between 2008 and 2020&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The joint point regression program 3&#46;4&#46;4 software developed by the National Cancer Institute of the United States was used to estimate changes in temporal trends of suicide mortality rates in Colombia before and during the COVID-19 pandemic by age &#40;five-year groups&#41;&#44; sex&#44; region&#44; educational level&#44; and type of affiliation to the health system&#46; Annual percentage changes &#40;APC&#41; were estimated at a significance level of 0&#46;05&#46; Finally&#44; using the statistical program QGIS&#44; a choropleth map of Colombia was made&#44; illustrating the crude average mortality rates due to suicide by departments in Colombia between 2008 and 2020&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical considerations</span><p id="par0055" class="elsevierStylePara elsevierViewall">In accordance with the scientific and technical standards of resolution No&#46; 8430 of 1993 of the Ministry of Health of Colombia&#44; this study is considered a risk-free investigation&#46; Data was stored securely and in compliance with the principles stipulated in the Declaration of Helsinki regarding data access&#44; management&#44; confidentiality&#44; anonymity&#44; integrity&#44; and documentation&#46; Statistical analysis was impartial and responsible&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The crude mortality rate due to suicide in Colombia in 2020 was 5&#46;4 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46; This was lower than that reported in the previous three years&#44; where rates of 5&#46;7 &#40;2017&#41;&#44; 5&#46;9 &#40;2018&#41;&#44; and 5&#46;9 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants &#40;2019&#41; were reported&#46; The average mortality rate estimated due to suicide in Colombia &#40;2008&#8211;2020&#41; ranged between 1&#46;9 and 33&#46;6 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Between 2008 and 2020&#44; the region with the highest average suicide mortality rate was Vaup&#233;s &#40;33&#46;6 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41;&#44; followed by Amazonas and Arauca &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The regions with the lowest rates were Archipelago of San Andr&#233;s&#44; Providencia and Santa Catalina&#44; and Choc&#243;&#46; It was estimated that 81&#37; of the cases were males&#46; The age groups in which more cases of suicide were registered were the groups from 20 to 24&#44; 15 to 19&#44; and 25 to 29 years old&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The educational levels with the highest number of events were primary and secondary school&#46; The most common suicide methods were intentionally self-inflicted injury by hanging&#44; strangulation&#44; or suffocation &#40;55&#46;12&#37;&#41;&#44; followed by intentional self-inflicted poisoning&#44; and intentional self-inflicted injury by gunshot&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Estimates of change in temporal trends of suicide mortality rates in Colombia between 2008 and 2020 by sex showed two statistically significant decreases of &#8722;3&#46;32 annual percentage change &#40;APC&#41; &#40;2008&#8211;2013&#41; and &#8722;5&#46;28 APC &#40;2018 and 2020&#41; for men &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In women&#44; between 2011 and 2020&#44; there was a statistically significant increase in the temporal trend of 3&#46;75 APC &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">When estimating changes in temporal trends based on age by five-year groups&#44; a statistically significant APC increase was determined between 2012 and 2020 in people in the 15&#8211;19 age group&#46; A decrease in the trend between 2008 and 2015 in people in the 20&#8211;24 age group was also found&#46; In the 35&#8211;39 age group&#44; there was a statistically significant decrease in the trend between 2008 and 2013&#44; and there was an increase in the trend between 2013 and 2018&#46; In the 40&#8211;44 age group&#44; a positive and statistically significant trend was found &#40;without a change in the temporal trend throughout the period of time analyzed&#41;&#46; Between 2012 and 2018&#44; there was a statistically significant positive change in the 45&#8211;49 age group&#46; There were statistically significant increasing trends in suicide mortality rates between 2008 and 2020 in the 50&#8211;54&#44; 55&#8211;59&#44; 60&#8211;64&#44; and 65&#8211;69 age groups&#46; Finally&#44; between 2011 and 2020 there was a statistically significant increase in the trend in the 75&#8211;79 age group &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding the educational level&#44; a statistically significant APC increase in the temporal trend between 2013 and 2019 was estimated in people who were enrolled in basic secondary school&#46; An increase in the trend of the suicide rate in people enrolled at the technical level was also estimated for the period 2014&#8211;2019&#44; with a reported APC of 42&#46;64&#46; In this same period&#44; people in the high school group had a statistically significant increase in the suicide trend&#46; Finally&#44; between 2015 and 2019&#44; there was a statistically significant APC increase in people enrolled at the university level &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">According to the affiliation type to the health system&#44; statistically significant decreases in suicide trends were estimated between 2016 and 2020 for those affiliated to especial and exception health regimens &#40;&#8722;58&#46;45 APC&#41;&#44; and between 2015 and 2020 for those uninsured &#40;&#8722;53&#46;49 APC&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is the first study in Colombia that evaluates changes in temporal trends of suicide mortality between 2008 and 2020&#46; Social&#44; psychological&#44; clinical&#44; and economic risk factors are associated with anxiety and depression of communities&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> Suicides and suicidal behaviors are major public health concerns worldwide&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> and the COVID-19 pandemic is being associated with an increase in their morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> Despite the above&#44; pathways which correlate COVID-19 and suicide remain unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> In our study&#44; sex&#44; age&#44; educational level&#44; and health insurance affiliation were collected in different periods between 2008 and 2020&#46; However&#44; we did not find significant differences between the suicide rates between 2019 and 2020 &#40;pandemic start&#41;&#46; This could be attributed&#44; among other reasons&#44; to the scarce in data collected which may have led to underestimate the effect of the pandemic&#44; also impacting our results due to residual confounding&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> Factors related to stigma&#44; economic status&#44; social isolation&#44; healthcare access&#44; and social and geographical conditions should be further studied to estimate the effect of the pandemic in countries like Colombia&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">It has been published that at early stages of the pandemic the prevalence of suicides remained stable or fell&#44; especially in vulnerable populations such as women&#44; ethnic minorities&#44; younger age groups&#44; and low and middle income countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8&#44;31&#44;32</span></a> This could be explained by the success of health policies&#44; lockdowns&#44; vaccine development and vaccination access&#44; suicide prevention strategies&#44; new ways to interact with each other&#44; reduction of conflicts&#44; and a survival collective feeling&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8&#44;31</span></a> Our results contribute to expanding the evidence on changes in suicide trends over time by comparing the period before the start of the COVID-19 pandemic with the first year of the pandemic in Colombia&#46; These results are consistent with those of other recently published studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">31&#44;33&#8211;35</span></a> which also indicate that there was no increase in the annual rate or a growing trend in suicide mortality in times of pandemic&#46; This would suggest that the start of the pandemic did not significantly affect overall suicide trends&#44; meaning that the interaction between COVID-19 and the time of monitoring and evaluation of the impact of the pandemic is not significant&#44; but changes could occur in the medium and long term&#46; Further investigation&#44; specific analyses&#44; and predictive models are needed to estimate the effect of the pandemic in latter stages of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">29&#44;36</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">On the other hand&#44; most of the studies that have evaluated the impact of the COVID-19 outbreak on suicide rates have analyzed general rates &#8211; not by age strata or subgroups like ours&#46; In the study published by Chen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> through an interrupted time series analysis&#44; trends stratified by age &#40;&#60;25&#44; 25&#8211;44&#44; 45&#8211;64&#44; &#8805;65&#41; were modeled in the rates of suicide before &#40;January 1&#44; 2017&#44; to December 31&#44; 2019&#41; and after &#40;January 1&#44; 2020 to December 31&#44; 2020&#41; in Taiwan&#46; They found a slight decrease in the overall suicide rates after the outbreak&#59; and in the analysis by age&#44; suicide rates increased in the youngest &#40;&#60;25 years&#41; and decreased in the middle-aged group &#40;25&#8211;64 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> Similarly&#44; our estimation showed a suicide rate increase in people between 15 and 19 years old&#46; The increase in the suicide rate before and after the pandemic in young population reflects the global concern regarding deterioration of mental health in this group&#44; which may be caused by internet addiction&#44; substance abuse&#44; and the lack of family support&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Joint point regression analyses have been used to estimate changes in mortality rates from cancer and traffic accidents in different time series&#46; One of its strengths is being able to identify the moment in which the rate trend changes&#46; The use of this method has increased in recent years &#40;especially in ecological studies&#41; to understand population dynamics and epidemiological changes&#46; This statistical analysis model was identified in the study carried out by P&#233;rez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> in which suicidal thoughts&#44; behaviors&#44; and tendencies were examined in 2020 in relation to 2019&#44; as an approach to the impact of the pandemic on the suicidal behavior and death in the general population of Catalonia&#44; Spain&#46; Results showed a substantial decrease in rates of suicidal thoughts and behaviors with a monthly percentage change &#40;MPC&#41; of &#8722;22&#46;1 &#40;95&#37; CI&#58; &#8722;41&#46;1 to 2&#46;9&#41; from January to April 2020&#44; followed by a similar increase from April to July 2020 &#40;MPC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#46;7&#59; 95&#37; CI&#58; &#8722;5&#46;9 to 65&#46;2&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> Likewise&#44; the number of suicide-related events registered in the Catalan Suicide Risk Code &#40;CSRC&#41; was 5&#37; lower than it was in 2019&#59; similar to that presented in our study &#40;6&#46;90&#37;&#41;&#46; Suicidal behavior and mortality should continue to be monitored to better understand the medium and long-term impact of COVID-19 on suicide trends&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; another strength of our study &#40;unlike other studies with similar objectives&#41; is the evaluation of suicide trends over a broader period of time and not just the comparison between 2020 and the year before the pandemic&#46; Only one study has compared the risk of suicide during the COVID-19 pandemic against data from other years &#40;2010&#8211;2019&#41; using an interrupted time series analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> The period of time evaluated in our study is longer &#40;12 years&#41;&#46; This work provides a starting point for future research that can establish the causal effect of the COVID-19 pandemic on the incidence of mortality from suicide in Colombia&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">This is the first epidemiological study to evaluate temporal trend changes in suicide mortality rates in Colombia before and during the COVID-19 pandemic&#46; The crude suicide mortality rate in 2020 decreased compared to the rates reported in the previous 3 years&#46; Although changes were found in the temporal trends of suicide mortality rates in different periods for all variables&#44; no significant increases were identified between 2019 and 2020&#46; Multiple clinical&#44; epidemiological&#44; and socioeconomic risk factors have been associated with COVID-19 infection&#59; therefore&#44; further investigation is required to determine the effect of the pandemic on suicide mortality in Colombia&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have declared that no conflicting interests exist&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The coronavirus disease &#40;COVID-19&#41; pandemic was declared in March 2020&#46; This disease affects the respiratory system&#44; and shown high rates of morbidity and mortality during 2020 and 2021&#46; Neurological compromise and increased rates of depression&#44; anxiety&#44; insomnia&#44; and substance abuse have also been described&#46; Public health policies to prevent COVID-19 infection&#44; decrease in control and monitoring of mental illness&#44; and social and economic impact may have contributed to the increase in suicidal ideation and suicides&#46; It is not yet clear if there have been changes in suicide mortality rates in Colombia before and during the pandemic&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe and analyze the changes in the temporal trends of suicide mortality rates in Colombia between 2008 and 2020&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on national records&#44; suicide mortality rates observed in Colombia during the COVID-19 pandemic were calculated and compared with those reported in previous years &#40;2008&#8211;2019&#41;&#46; Mortality rates were analyzed by age&#44; sex&#44; educational level&#44; type of affiliation to health system&#44; region&#44; and etiology of death by suicide&#46; Using the joint point regression software 3&#46;4&#46;4&#44; changes in time trends in suicide mortality rates were estimated for each mentioned variable&#46; Annual percentage changes &#40;APC&#41; were estimated&#44; and their statistical significance was calculated&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The crude suicide mortality rate in Colombia in 2020 &#40;5&#46;4 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41; decreased compared to those reported in the previous 3 years&#46; Estimates of changes in time trends in suicide mortality rates between 2008 and 2020 showed a decrease in men of &#8722;5&#46;28 &#40;APC&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; between 2018 and 2020&#44; and an increase in women of 3&#46;75 &#40;APC&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; between 2011 and 2020&#46; Regarding age &#40;by five-year periods&#41;&#44; an increase of 3&#46;87 &#40;APC&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; was determined in people between 15 and 19 years old between 2012 and 2020&#46; According to health system affiliation regimen&#44; decreases were estimated between 2016 and 2020 &#40;&#8722;58&#46;45 CPA&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; for people affiliated to especial and exceptional health regimes&#59; and between 2015 and 2020 &#40;&#8722;53&#46;49 CPA&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; for the uninsured&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The crude suicide mortality rate during the COVID-19 pandemic in Colombia decreased compared to what was reported in the previous years&#46; Although significant changes were found in the temporal trends of suicide mortality rates in different periods for all variables&#44; no significant increases were identified between 2019 and 2020&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La pandemia por coronavirus &#40;COVID-19&#41; se declar&#243; en marzo de 2020&#46; Esta enfermedad afecta el sistema respiratorio&#44; y mostr&#243; altas tasas de morbimortalidad durante los a&#241;os 2020 y 2021&#46; Tambi&#233;n se ha descrito compromiso neurol&#243;gico e incremento en las tasas de depresi&#243;n&#44; ansiedad&#44; insomnio y abuso de sustancias&#46; Las pol&#237;ticas de salud p&#250;blica para prevenir la infecci&#243;n por COVID-19&#44; la disminuci&#243;n del control y del seguimiento de patolog&#237;as mentales&#44; as&#237; como el impacto social y econ&#243;mico&#44; pueden haber contribuido al incremento en ideaci&#243;n suicida y suicidios consumados&#46; A&#250;n no est&#225; claro si se han presentado cambios en las tasas de mortalidad por suicidio en Colombia antes y durante la pandemia&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir y analizar los cambios en las tendencias temporales de las tasas de mortalidad por suicidio en Colombia entre 2008 y 2020&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Con base en registros nacionales&#44; se calcularon y compararon las tasas de mortalidad por suicidio observadas en Colombia durante la pandemia por COVID-19 con las reportadas en a&#241;os anteriores &#40;2008-2019&#41;&#46; Las tasas de mortalidad se analizaron con respecto a edad&#44; sexo&#44; nivel educativo&#44; tipo de afiliaci&#243;n al sistema de salud&#44; regi&#243;n y m&#233;todo empleado en la muerte por suicidio&#46; Mediante el software del programa de regresi&#243;n <span class="elsevierStyleItalic">joint point</span> 3&#46;4&#46;4 se estimaron los cambios en las tendencias temporales de las tasas de mortalidad por suicidio para cada variable&#46; Se estimaron los cambios porcentuales anuales &#40;CPA&#41; y se calcul&#243; su significancia estad&#237;stica&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La tasa cruda de mortalidad por suicidio en Colombia en el a&#241;o 2020 &#40;5&#44;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#46;000 habitantes&#41; disminuy&#243; con respecto a las tasas reportadas en los 3 a&#241;os anteriores&#46; Las estimaciones de los cambios en las tendencias temporales de las tasas de mortalidad por suicidio entre 2008 y 2020 mostraron una disminuci&#243;n en los hombres de &#8722;5&#44;28 &#40;CPA&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; entre 2018 y 2020&#44; y un aumento en las mujeres de 3&#44;75 &#40;CPA&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; entre 2011 y 2020&#46; Con respecto a la edad por quinquenios&#44; se determin&#243; un aumento de 3&#44;87 &#40;CPA&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; en personas entre 15 y 19 a&#241;os entre 2012 y 2020&#46; Tambi&#233;n se estimaron disminuciones en las tendencias temporales por suicidios entre 2016 y 2020 de &#8722;58&#44;45 &#40;CPA&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; para las personas afiliadas a reg&#237;menes especiales y excepcionales de salud&#44; y de &#8722;53&#44;49 &#40;CPA&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; entre 2015 y 2020 para los no asegurados&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La tasa cruda de mortalidad por suicidio durante la pandemia de COVID-19 en Colombia disminuy&#243; con respecto a lo reportado en a&#241;os anteriores&#46; Aunque se encontraron cambios significativos en las tendencias temporales de las tasas de mortalidad por suicidio en diferentes per&#237;odos para todas las variables&#44; no se identificaron incrementos significativos entre 2019 y 2020&#46;</p></span>"
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                  \t\t\t\t">2008&#8211;2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="3" align="left" valign="\n
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                  \t\t\t\t">30&#8211;34</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2008&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;3&#46;78&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2014&#8211;2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#46;63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2018&#8211;2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;10&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2008&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;5&#46;17&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2013&#8211;2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2018&#8211;2020&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;9&#46;62&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40&#8211;44&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2008&#8211;2020&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2011&#8211;2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2008&#8211;2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Suicide mortality temporal trends by age &#40;five-year groups&#41; in Colombia &#40;2008&#8211;2020&#41;&#46; Joint point analysis&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">APC&#58; annual percentage change&#59; NS&#58; no statistical significance&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Statistical significance&#40;<span class="elsevierStyleItalic">p</span> value&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preschool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;1&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Primary school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary school</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;1&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2013&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Technical education</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2014&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High school</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2014&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Technological education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postgraduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">University</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&#8211;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&#8211;2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Period&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Statistical significance&#40;<span class="elsevierStyleItalic">p</span> value&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Contributory&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Suicide mortality temporal trends by type of affiliation to the health system in Colombia &#40;2008&#8211;2020&#41;&#46; Joint point analysis&#46;</p>"
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