Different studies have suggested that psychological, social and economic factors, such as stress due to fear of infection, depression due to isolation and economic crises, such as declining income and unemployment, could contribute to an increase in the suicide rate.1 In situations of previous infection, such as the Spanish flu outbreak or the severe acute respiratory syndrome outbreak in 2003, mortality due to suicide increased.2 That is why the scientific community and political authorities fear an epidemic of suicides secondary to this crisis3 as has already been shown in Spain with an upturn in the number of suicides in 2020, rising to 3941 suicides compared to 3671 in 2019.4

There are multiple studies carried out on the influence of the COVID-19 pandemic on suicidal behavior. A meta-analysis carried out with data from 54 studies with 308,596 participants stands out. Their results suggested higher rates of suicidal ideation events (10.81%), suicide attempts (4.68%), and self-harm (9.63%) during the COVID-19 pandemic when compared to event rates of pre-pandemic studies. The analysis indicated that younger people, women, and people from democratic countries are more susceptible to suicidal ideation during the COVID-19 pandemic.5 Another review involving 12 studies with 120,076 patients reported a prevalence of suicidal ideation of 12.1% (CI 9.3–15.2). The main risk factors for suicidal ideation were: low social support, high physical and mental exhaustion, and self-reported poorer physical health in frontline medical workers, sleep disturbance, quarantine and exhaustion, loneliness, and mental health problems. Thus, it seems confirmed that the rate of suicidal ideation during the COVID pandemic is higher than that reported in studies on the general population before the pandemic and may result in higher suicide rates in the future.6

Although there are projections about the greater probability of suicide and deaths due to despair due to the COVID-19 pandemic,7 it is necessary to carry out local studies according to the care areas that allow a better identification of the situation and care needs. The objective of this study is to evaluate the variables related to suicidal behavior during the two states of alarm and to review if there were sociodemographic or clinical differences with respect to periods prior to the COVID-19 pandemic.

In this sample, unlike other studies that warned of an increase in suicidal behavior,13 we did not find a significant increase in emergency care for suicidal behavior compared to the situation prior to the pandemic. Some studies considering only 2020 reported no difference or reduced emergency department attendances for suicidal behaviour.14 Relative to a similar period in 2019, the number of emergency department attendances for suicide attempts remained stable among American youngs during summer 2020 and winter 2021.15 And lose to our territory under study, a recent study that reviewed suicidal behavior attended to and included in the Barcelona Suicide Risk Code (CRS) platform revealed a 43.20% increase in the monthly incidence of suicidal ideation and suicide attempts during the pandemic compared to the period 2018–2019, reaching a maximum increase of 573.8% in young people under 18 years of age in the month of May 2021.16 It also highlights that, in our province of study, Lérida, there was no increase in suicides compared to the previous year, since that in 2020, 24 suicides were reported and in 2019, 41 deaths were recorded. In the autonomous community of Catalonia, on the other hand, there was an increase in deaths by suicide since 556 people committed suicide in 2020 while in 2019 there were 535 deaths by suicide.4

In this sense, a study that analyzed visits to the emergency room or hospitalizations for suicidal behavior of 1,690,733 adolescents and young adults is relevant, where they showed that a 15-month period of the COVID-19 pandemic was associated with a relative decrease of self-harm or overdose.17 But this information must be interpreted with caution, since preliminary reports on suicide mortality at the beginning of the pandemic indicated that suicide rates would not increase (Massachusetts, USA; Victoria, Australia; England) or would decrease (Japan, Norway) in the first months of the pandemic.13 In Austria, for example, during the first 6 months of the pandemic, there was a relative decrease in suicide among all adults.18 Nevertheless, it must be reiterated that some fatal or non-fatal cases of self-harm or overdose may have been missed due to failure to attend an emergency room, or incomplete recording of any of them as a fatality.17 Any change in suicide risk associated with covid-19 is likely to be dynamic. The 20% decline in Japan at the beginning of the pandemic appeared to reverse in August, when an increase of 7.7%19 was reported. Evidence from previous epidemics suggests that a short-term decline in suicide may initially occur.20

In our work, there are three risk factors associated with suicidal behavior after carrying out logistic regression: female sex, living with relatives and presenting a substance use disorder.

Our results are consistent with others that have already reported more suicide attempts in women, such as a study conducted in Asia in which the number and proportion of emergency care related to suicide attempts increased in 2020 compared to the previous 2 years, especially among women and people from 25 to 49 years old.21

Regarding the nucleus of coexistence, it is surprising that the aspect of living with relatives was a suicidal risk factor since loneliness has been described in multiple works as a high suicidal risk factor.22-24 In fact, a group of French researchers highlighted the need for specific strategies to address loneliness, as well as improve access to care, including telepsychiatry to prevent depression and suicide.25 Specifically, a study carried out in New Zealand reported that living with relatives during confinement was a source of hope for individuals.26

We observed an increased risk of suicide in patients with a history of substance use disorder. It should be noted that up to 40% of patients with substance dependence report a history of previous suicide attempts27 and that this diagnosis has been associated with greater recidivism in suicidal behavior.28

Although not significant in our multivariate logistic regression model, prior suicide attempts were associated with suicidal behavior during the pandemic. The literature that identifies previous suicidal behavior as a high risk factor for subsequent recidivism is robust29,30 which is why secondary prevention has been described as essential in this risk group.31 In terms of suicide attempts lethality, we observed a decrease of general hospital days in the second state of alarm, indicating a decrease of lethality in this period. These results are not supported by previous literature in the acute phase of the pandemic describing low-recue suicide attempts and therefore with greater potential somatic lethality. Moreover, these results also contrast with those observed in more chronic phases of the pandemic1: a recent French study on hospitalizations for suicide in the country revealed that the severity and use of violent methods increased during the second and third quarters of 2020 compared to 2019 and 2018, and this was more evident in those under 60 years of age.32

Paradoxically, in our sample the diagnosis of depression turned out to be protective for suicide attempt. This fact is controversial since classically 10–15% of people with a major depressive disorder commit suicide, and between 60 and 70% of suicide victims suffered a depressive episode.33 This finding of ours is not consistent with the literature, since several studies report that there was a general worsening of mental health throughout the confinement, with prevalence estimates ranging between 9 and 46% among those who report data on symptoms. depressive34,35 and some studies indicate factors such as hopelessness and depression as aspects closely related to suicide attempts during the pandemic.36

Finally, in our study we observed that hospital admissions for suicidal behavior decreased during the pandemic, especially in the second state of alarm. These findings, although not significant, are consistent with the results from France, which indicate that hospital admissions for suicide decreased during the pandemic.32

In our study, we did not observe an increase in emergency care for suicidal behavior during the pandemic and, in fact, in 2020, completed suicides decreased by almost half in our province. Risk factors for suicide attempt were female gender, living with relatives, and having a diagnosis of substance use disorder. Instead, it was a protective factor to have depression.

All authors declare that they have no conflict of interest in relation to the performance of this work.