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.

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”.

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).

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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.

Fig. 2.

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

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Fig. 3.

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

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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.

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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

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.

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.