Suicidal attempt and suicidal ideation during the COVID-19 pandemic compared to previous years

Abstract

Introduction

Since the COVID-19 pandemic began, warnings have been made about the impact on the mental health of the population and as occurred in previous pandemics, an increase in suicide rates had been anticipated. To date, studies differ with regard to whether suicide rates are being affected during the COVID pandemic.

Material and methods

All individuals registered for suicidal ideation or suicidal attempt in the Suicide Risk Code (SRC) from the City of Barcelona from January 1, 2018 to June 30, 2021 have been included. A bivariate analysis has been carried out between the 2018 and 2019 period and the pandemic period. The percentage increase in the monthly incidence of SRC cases has been calculated, using the average monthly incidence for the 2018–2019 period as a reference.

Results

A total of 3 388 consultations for suicide ideation or suicidal attempt were registered. There has been an increase of 43.20% in the monthly incidence of suicidal ideation and suicidal attempts during the pandemic compared to the 2018–2019 period, reaching a maximum increase of 573.8% in young people under 18 years in the month of May 2021.

Conclusions

During the COVID-19 pandemic period, consultations for suicidal ideation and suicidal attempts have increased compared to the previous 2 years in the City of Barcelona. It should be noted that this growth has been occurred especially in young people under the age of 18 years.

Introduction

Suicide is a major public health problem. It is estimated that around 800,000 people worldwide die by suicide each year, and a previous suicide attempt is the main risk factor. However, it should be borne in mind that statistics only reflect deaths and not suicide attempts or suicidal ideation, which are estimated to be 20 times more frequent.¹ In this context, the Suicide Risk Code (SRC) was launched in Catalonia in 2015. The SRC consists of a set of protocolised care and preventive actions aimed at those people who at the time of contacting the health services present a risk for suicide, either because they have made a suicide attempt or because they have suicidal ideation. Thus, when a person who has made a suicide attempt or presents suicidal ideation is detected in the health system, the attending physician is obliged to record the details of the episode and refer them to the corresponding care centre, if required, which is obliged to visit them in less than 15 days, if they are an adult, and less than seven days if they are a minor.²

Since the start of the 2019 coronavirus pandemic (COVID-19), several studies have predicted an increase in suicide rates due to the socio-economic problems arising from the different restrictions, as occurred in 1918-1919 with the Spanish flu and in 2003 in Hong Kong with severe acute respiratory syndrome (SARS).^3–5

Studies to date differ on whether suicide rates were affected during the pandemic. An Australian study shows no increase in suicide rates,⁶ while another US study describes a decrease in suicidal ideation,⁷ and another in Germany⁸ also describes a decrease during the tighter restrictions put in place to control the pandemic. Another US study also describes an overall decrease in suicide rates during lockdown, although with increases in certain social classes.⁹ Other studies, however, did detect an increase in suicidal ideation in relation to adjustment problems, loneliness, and overload due to having to spend more time at home under the lockdown.^10,11

During the pandemic, severe restrictions were imposed in Spain to contain COVID-19, especially during the first wave. The measures started on 14 March 2020. Initially, retail premises and establishments were closed, with the exception of retail food, drinks, essential goods and products, pharmaceutical, medical, optical, and orthopaedic establishments, hygiene products, newspapers and stationery, automotive fuel, tobacconists, technological and telecommunications equipment, pet food, internet, telephone and mail orders, dry cleaners, and laundries.¹²

On 28 April, Spain's plan to ease lockdown was announced, which consisted of four phases¹³ until achieving the “new normality”.¹⁴ In the particular case of Barcelona, this new normality started on 21 June 2020.

The main objective of the study is to assess whether the situation under the COVID-19 pandemic had any influence on suicidal ideation and suicide attempts in the city of Barcelona compared to previous years.

Methods

All individuals registered in the SRC in the city of Barcelona from 1 January 2018 to 30 June 2021 were included. The SRC registry collects information on all suicidal ideation and suicide attempts seen in psychiatric emergency departments. The data collected for each case includes the date of the visit, sex, age, whether it was an episode of suicidal ideation or attempted suicide, the type of suicide attempt separated into five categories: “ingestion of solids or liquids”, “hanging”, “sharp instruments”, “precipitation” and “other”; and finally, the Spanish version of the suicide subscale of the Mini-International Neuropsychiatric Interview (MINI) 5.0.0,¹⁵ administered at discharge. This scale gives as a final result a suicide risk level (SRL) that can be “no risk”, “low risk”, “moderate risk”, and “high risk”.

Ethical aspects

The project was approved by the ethics committee of Parc de Salut Mar (CEIC-PSMAR), and the national and international guidelines of the code of ethics and the Declaration of Helsinki were followed, as well as the legal regulations on data confidentiality, in accordance with the provisions of “Organic Law 3/2018, of 5 December, on Protection of Personal Data and Guarantee of Digital Rights, and Regulation (EU) N° 2016/679 of the European Parliament and of the Council of 27 April 2016 on Data Protection (GDPR)”.

Statistical analysis

This is an observational and retrospective study. Initially, a univariate analysis of the sample was performed, including the number of episodes recorded, monthly incidence, mean age, gender, number of episodes due to suicide ideation and suicide attempts, type of suicide attempt and SRL at discharge.

A bivariate comparative analysis was then performed between the pre Covid-19 pandemic period from January 2018 to December 2019 and the pandemic period. The latter was separated into three groups, “total pandemic”, which runs from 14 March 2020 to 30 June 2021, “lockdown” for the period of lockdown from 14 March to 21 June 2020 and “post-lockdown” for the period after lockdown from 22 June 2020 to 30 June 2021. Differences in age, gender, suicide ideation and attempt, type of suicide attempt, and SRL at discharge were assessed in this analysis. The Student's t-test was used for quantitative variables and the χ² test for qualitative variables; Fisher's exact test was used for analysis of the type of attempt between the 2018-2019 period vs. the period of lockdown.

Finally, the percentage growth of the monthly incidence of SRC cases registered in the city of Barcelona from January 2020 to June 2021 was calculated for both minors and adults. For this purpose, the average monthly incidence for the 2018-2019 period of SRC data was taken as a reference, which was 59.50 cases of suicide ideation or attempt each month for adults and 8.46 for minors.

Data were analysed using the SPSS 25.0 statistical package (IBM Corp., Armonk, NY, USA).

Results

From 1 January 2018 to 30 June 2021 a total of 3,388 consultations for suicidal ideation or suicide attempts were registered in the city of Barcelona. In 2018, 629 cases were registered, 1,003 cases in 2019, 1,018 cases in 2020 and from 1 January 2021 to 30 June 2021, 738 cases. Figure 1 shows the monthly incidence of cases from January 2020 to June 2021 for the total sample, for minors and for adults (≥ 18 years). The mean age of the sample was 37.9 years (standard deviation (SD): 17.78), 509 (15.02%) were minors and 2,879 (84.98%) were adults, 1,115 (32.91%) males and 2,273 (67.09%) females. A total of 1,689 (49.91%) consulted for suicidal ideation and a total of 1,699 (50.09%) consulted for suicide attempts. Of those who made suicide attempts 1,389 (82.24%) were by ingestion of solids or liquids, 26 (1.54%) by hanging, 166 (9.83%) with sharp instruments, 46 (2.72%) by precipitation, and 62 (3.67%) for other reasons. The SRL at discharge was “no risk” in 551 (16.26%) cases, “low risk” in 2,278 (67.24%), “moderate risk” in 523 (15.44%) and “high risk” in 36 (1.06%) cases.

Fig. 1.

Number of Suicide Risk Code cases recorded each month from January 2020 to June 2021 (n = 1,756).

Table 1 shows the bivariate analysis between the period 2018-2019 and the pandemic period (total pandemic, lockdown, and post-lockdown). Figures 2 and 3 show the graphical distribution of different types of suicide attempts and SRL at discharge, respectively, for the 2018-2019 lockdown and post-lockdown periods.

Table 1.

Bivariate analysis between the period 2018-2019 and the pandemic period (total pandemic period, lockdown period and post-lockdown period) (n = 3,155).

	Period 2018-2019		Lockdown			Post-lockdown			Total pandemic
	n	%	n	%	p*	n	%	p*	n	%	p*
Total number of SRC	1,632	51.73	153	4.85		1,370	43.42		1,523	48.27
Age (mean SD)	39.28	17,814	39.77	18,248	.744	36.45	17,592	.000	36.78	17.681	.000
Sex					.802			.529			.602
Male	549	33.64	53	34.64		446	32.55		499	32.76
Female	1,083	66.36	100	65.36		924	67.45		1,024	67.24
Type of episode					.051			.004			.032
Ideation	795	48.77	62	40.52		738	53.94		800	47.41
Attempt	837	51.23	91	59.48		632	46.06		723	52.59
Attempt type					.676**			.839			.885
Ingestion of solids or liquids	683	81.92	74	82.22		513	82.1		587	82.12
Hanging	16	1.92	1	1.11		8	1.3		9	1.26
Sharp instruments	82	9.82	11	12.22		60	9.6		71	9.92
Precipitation	22	2.63	3	3.33		16	2.6		19	2.65
Other	31	3.71	1	1.11		28	4.5		29	4.05
SRL					.987			.000			.000
No risk	245	15.01	22	14.38		235	17.15		257	16.87
Low risk	1,077	65.99	101	66.01		946	69.05		1,047	68.75
Moderate risk	284	17.4	28	18.3		181	13.21		209	13.72
High risk	26	1.59	2	1.31		8	.58		10	.66

SD: Standard Deviation; SRC: Suicide risk code; SRL: Suicide risk level at discharge.

*

Student's t-test for the quantitative variable “age”; χ² for qualitative variables.

**

Fisher's exact test.

Fig. 2.

Distribution of the different types of suicide attempt for each period of time (n = 3,155).

Fig. 3.

Distribution of the suicide risk level at discharge for each period of time (n = 3,155).

Figure 4 shows the percentage growth in the monthly incidence of episodes recorded in the SRC relative to the average for the 2018-2019 period; the average percentage increase from March 2020 to June 2021 was 43.20%.

Fig. 4.

Percentage growth in the monthly incidence of episodes recorded in the Suicide Risk Code in relation to the average for the period 2018-2019.

Discussion

Suicidal behaviour during the COVID-19 pandemic period increased compared to the previous two years. Overall, the data show a decrease in suicidal ideation and suicide attempts detected during the period of lockdown and a progressive increase in the period after lockdown, notably higher among minors.

Compared to the previous two years taken as a baseline, despite the increase in recorded cases of SRC during the COVID-19 pandemic, the data point to lower severity of episodes, with the proportion of suicide ideation to suicide attempts having significantly increased and the SRL score at discharge also being significantly lower than during the 2018-2019 period. As previously described in other papers,¹⁶ the proportion of women making suicide attempts is higher than that of men. In our sample, twice as many episodes were recorded by women than men; however, this proportion remained stable over time and no differences were found during the pandemic compared to the previous two years. There were also no differences in the different ways suicide attempts were made compared to previous years, with the most frequent method being the ingestion of solids or liquids.

Several studies describe a decrease in the use of emergency services during the pandemic restrictions.^17,18This is probably the reason that the results of this study show a decrease in the detection of episodes of suicide attempts and suicidal ideation in Barcelona during the lockdown, both in minors and adults. This decrease has been described in different countries.¹⁹ The desire to maintain social distancing and avoid contact with infected persons may be the reason for the decrease in emergency department consultations¹⁸ and the decrease in detection, given that during the lockdown an increase in irritability, anxiety,²⁰ and suicidal ideation²¹ was reported especially among the younger population.

After the lockdown, but still in a pandemic situation and with some restrictions in place that fluctuated according to the epidemiological situation, there was a progressive increase in episodes of suicidal ideation and attempts, more significant in the last months. Lifestyle changes and alcohol consumption during the pandemic have been linked to an increased risk of mental health symptoms such as low mood, anxiety, insomnia, and suicidal behaviour.²² This growth is striking, especially in minors, resulting in a statistically significant decrease in the average age in the post-pandemic period, reaching a maximum increase of 573.8% in May 2021, compared to the average for the pre-pandemic period of 2018-2019. This increase in suicidal ideation and suicide attempts in minors has also been observed in other studies,^23,24 in which it also seems to correspond to periods of greater intensification of restrictive measures to control the pandemic. Some studies point to increased screen time and social media use as risk factors for depression, anxiety, and suicide risk during the COVID-19 pandemic among young people,^25,26while a recent systematic review of longitudinal studies concludes that their impact on mental health may be small or non-existent.²⁷ It does seem clear, however, that the isolation and loneliness produced by the lockdown and restrictive measures may increase clinical depression and possibly also anxiety among young people.^28,29

Limitations

The study has several limitations. One of the main limitations is that only suicide attempts and suicidal ideation are reflected in the study, but not completed suicides, since these, as they do not entail hospital intervention, are not detected by the SRC. Another important limitation is that the SRC is not registered automatically, but rather it is the professional who must enter the data into a specific online platform, and although it is obligatory, this could lead to cases that have not been registered.

Conclusions

In conclusion, despite the aforementioned limitations, this study provides relevant data on suicidal behaviour during the COVID-19 pandemic, being the first study in our setting to evaluate it. The data obtained indicate that during the period of the COVID-19 pandemic there was an increase in consultations for suicidal ideation and attempts compared to the previous two years, although with a decrease in the severity of these episodes. This increase is noteworthy, especially in minors, reaching a maximum increase of 573.8% in May 2021. Further studies are needed to assess the impact of the COVID-19 pandemic on suicidal behaviour.