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Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries

Authors:
M J Spittal
M J Spittal
M J Spittal
Article

Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries

Abstract and Figures

Summary Background The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world. Methods We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries’ ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms “suicide” and “cause of death”, before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis). Findings We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72–0·91]); Alberta, Canada (0·80 [0·68–0·93]); British Columbia, Canada (0·76 [0·66–0·87]); Chile (0·85 [0·78–0·94]); Leipzig, Germany (0·49 [0·32–0·74]); Japan (0·94 [0·91–0·96]); New Zealand (0·79 [0·68–0·91]); South Korea (0·94 [0·92–0·97]); California, USA (0·90 [0·85–0·95]); Illinois (Cook County), USA (0·79 [0·67–0·93]); Texas (four counties), USA (0·82 [0·68–0·98]); and Ecuador (0·74 [0·67–0·82]). Interpretation This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold.
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www.thelancet.com/psychiatry Published online April 13, 2021 https://doi.org/10.1016/S2215-0366(21)00091-2
1
Articles
Lancet Psychiatry 2021
Published Online
April 13, 2021
https://doi.org/10.1016/
S2215-0366(21)00091-2
See Online/Comment
https://doi.org/10.1016/
S2215-0366(21)00117-6
*Joint last authors
Centre for Mental Health,
Melbourne School of
Population and Global Health,
University of Melbourne,
Melbourne, VIC, Australia
(Prof J Pirkis PhD, S Shin MPH,
V Arya MRes, J Dwyer PhD,
M J Spittal PhD); Swansea
University Medical School,
Swansea, UK (Prof A John MD,
M DelPozo-Banos PhD);
Translational Health Research
Institute, Western Sydney
University, Campbelltown,
NSW, Australia (V Arya);
Ministry of Public Health,
Department of Health
Promotion, Quito, Ecuador
(P Analuisa-Aguilar MPH);
National Confidential Inquiry
into Suicide and Safety in
Mental Health
(Prof L Appleby FRCPsych) and
Centre for Mental Health and
Safety and National Institute
for Health Research Patient
Safety Translational Research
Centre (Prof N Kapur FRCPsych,
Prof R T Webb PhD), University
of Manchester, Manchester,
UK; School of Public Health,
National Suicide Research
Foundation, University College
Cork, Cork, Ireland
(Prof E Arensman PhD);
Australian Institute for Suicide
Research and Prevention,
School of Applied Psychology,
Griffith University, Brisbane,
Suicide trends in the early months of the COVID-19
pandemic: an interrupted time-series analysis of preliminary
data from 21 countries
Jane Pirkis, Ann John, Sangsoo Shin, Marcos DelPozo-Banos, Vikas Arya, Pablo Analuisa-Aguilar, Louis Appleby, Ella Arensman, Jason Bantjes,
Anna Baran, Jose M Bertolote, Guilherme Borges, Petrana Brečić, Eric Caine, Giulio Castelpietra, Shu-Sen Chang, David Colchester,
David Crompton, Marko Curkovic, Eberhard A Deisenhammer, Chengan Du, Jeremy Dwyer, Annette Erlangsen, Jeremy S Faust, Sarah Fortune,
Andrew Garrett, Devin George, Rebekka Gerstner, Renske Gilissen, Madelyn Gould, Keith Hawton, Joseph Kanter, Navneet Kapur, Murad Khan,
Olivia J Kirtley, Duleeka Knipe, Kairi Kolves, Stuart Leske, Kedar Marahatta, Ellenor Mittendorfer-Rutz, Nikolay Neznanov,
Thomas Niederkrotenthaler, Emma Nielsen, Merete Nordentoft, Herwig Oberlerchner, Rory C O’Connor, Melissa Pearson, Michael R Phillips,
Steve Platt, Paul L Plener, Georg Psota, Ping Qin, Daniel Radeloff, Christa Rados, Andreas Reif, Christine Reif-Leonhard, Vsevolod Rozanov,
Christiane Schlang, Barbara Schneider, Natalia Semenova, Mark Sinyor, Ellen Townsend, Michiko Ueda, Lakshmi Vijayakumar, Roger T Webb,
Manjula Weerasinghe, Gil Zalsman, David Gunnell*, Matthew J Spittal*
Summary
Background The COVID-19 pandemic is having profound mental health consequences for many people. Concerns
have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We
aimed to assess the early eect of the COVID-19 pandemic on suicide rates around the world.
Methods We sourced real-time suicide data from countries or areas within countries through a systematic internet
search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the
ocial websites of these countries’ ministries of health, police agencies, and government-run statistics agencies or
equivalents, using the translated search terms “suicide” and “cause of death”, before broadening the search in an
attempt to identify data through other public sources. Data were included from a given country or area if they came
from an ocial government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020.
Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we
relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be
included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in
monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a
country, comparing the expected number of suicides derived from the model with the observed number of suicides in
the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis).
Findings We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including
whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based
on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide
since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared
with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72–0·91]);
Alberta, Canada (0·80 [0·68–0·93]); British Columbia, Canada (0·76 [0·66–0·87]); Chile (0·85 [0·78–0·94]); Leipzig,
Germany (0·49 [0·32–0·74]); Japan (0·94 [0·91–0·96]); New Zealand (0·79 [0·68–0·91]); South Korea (0·94
[0·92–0·97]); California, USA (0·90 [0·85–0·95]); Illinois (Cook County), USA (0·79 [0·67–0·93]); Texas
(four counties), USA (0·82 [0·68–0·98]); and Ecuador (0·74 [0·67–0·82]).
Interpretation This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in
multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely
unchanged or declined in the early months of the pandemic compared with the expected levels based on the
pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term
mental health and economic eects of the pandemic unfold.
Funding None.
Copyright © 2021 Elsevier Ltd. All rights reserved.
Introduction
The COVID-19 pandemic has had profound mental
health consequences1 and there are concerns that it could
lead to increases in suicide rates.2 However, few studies
have examined the eects of previous widespread disease
outbreaks on suicide. Two systematic reviews collectively
Articles
2
www.thelancet.com/psychiatry Published online April 13, 2021 https://doi.org/10.1016/S2215-0366(21)00091-2
QLD, Australia
(Prof E Arensman,
Prof D Crompton FRANZCP,
K Kolves PhD, S Leske PhD);
Institute for Life Course Health
Research, Department of
Global Health, Stellenbosch
University, Stellenbosch, South
Africa (Prof J Bantjes PhD);
Working Group on Prevention
of Suicide and Depression at
Public Health Council, Warsaw,
Poland (A Baran PhD);
Department of Psychiatry,
Blekinge Hospital, Karlshamn,
Sweden (A Baran); Botucatu
Medical School, Universidade
Estadual Paulista, São Paulo,
Brazil (Prof J M Bertolote MD);
Instituto Nacional de
Psiquiatría Ramon de la Fuente
Muñiz, Mexico City, Mexico
(Prof G Borges PhD);
Department for Medical Ethics
(Prof M Curkovic MD) and
Department for Psychiatry
(Prof P Brečić MD), University
Psychiatric Hospital Vrapče,
School of Medicine, University
of Zagreb, Zagreb, Croatia;
University of Rochester
Medical Center, Rochester,
NY, USA (Prof E Caine MD);
Region Friuli Venezia Giulia,
Central Health Directorate,
Outpatient and Inpatient Care
Service, Trieste, Italy
(G Castelpietra PhD);
Department of Medicine,
University of Udine, Trieste,
Italy (G Castelpietra); Institute
of Health Behaviors and
Community Sciences, College
of Public Health, National
Taiwan University, Taipei,
Taiwan (S-S Chang PhD);
Thames Valley Local Criminal
Justice Board, Bicester, UK
(D Colchester BTech);
Department of Psychiatry,
Psychotherapy and
Psychosomatics, Medical
University of Innsbruck,
Innsbruck, Austria
(E A Deisenhammer MD); Center
for Outcomes Research and
Evaluation, Yale School of
Medicine, New Haven, CT, USA
(C Du PhD); Coroners Court of
Victoria, Melbourne, VIC,
Australia (J Dwyer); Danish
Research Institute for Suicide
Prevention, Copenhagen,
Denmark (A Erlangsen PhD);
Department of Mental Health,
Johns Hopkins School of Public
Health, Baltimore, MD, USA
(A Erlangsen); Centre for Mental
Health Research, Australian
National University, Canberra,
ACT, Australia (A Erlangsen);
identified ten studies, focusing on epidemics or
pandemics of influenza (1889–93 [UK]; 1918–19 [USA];
2009–13 [USA]), severe acute respiratory syndrome (2003
[Hong Kong and Taiwan]), and Ebola virus (2013–16
[Guinea]).3,4 These reviews suggested that, although
suicide rates might sometimes increase following these
sorts of public health emergencies, the changes might
not necessarily occur immediately, and that the risk
might actually be reduced initially.
We established the International COVID-19 Suicide
Prevention Research Collaboration (ICSPRC) to monitor
the global eect of COVID-19 on suicide. We have tracked
studies specific to COVID-19 and suicide through a living
systematic review,5 and found that most studies have had
methodological limitations. Some have relied on data
from unconfirmed sources, including reports from
Nepal and Thailand based on newspaper articles citing
data from the police6,7 and a secondary source,8 res-
pectively. These reports indicated increases in suicide
after the COVID-19 pandemic began.
Other studies have used ocial suicide statistics for
the months since the pandemic began but have made
comparisons to equivalent periods without accounting
for underlying trends. Studies of this kind in Norway,9
Sweden,10 South Korea,11 Tyrol in Austria,12 Leipzig in
Germany,13 and Connecticut in the USA14 showed
decreases in suicides, and one in the Evros region of
Greece found no change.15 Three separate studies used a
similar approach to analyse Japanese suicide statistics:
one considered children and adolescents only and found
no evidence of an increase;16 and the other two considered
all age groups and identified a decrease in the pandemic’s
early stages,17 but highlighted an upswing in July, 2020.17,18
Only five studies—from Greece,19 Queensland in
Australia,20 Massachusetts in the USA,21 Peru,22 and
Japan23—have used ocial data and accounted for
temporal trends. The studies in Greece, Queensland, and
Massachusetts found that the observed and expected
numbers of suicides did not dier after pandemic
responses were introduced.19–21 The Peruvian study
reported a decrease in suicides following stay-at-home
orders.22 The Japanese study confirmed fluctuations in
suicides and identified a positive association between
pandemic-induced employment shocks and suicides.23
The evidence so far is insucient to indicate what the
eect of COVID-19 on suicides has been or will be. It is
Research in context
Evidence before this study
Evidence on the relationship between the COVID-19 pandemic
and suicide before this study predominantly came from studies
that relied on unofficial data sources or did not account for
pre-existing trends. We have been conducting a living
systematic review since the onset of the pandemic, searching
the literature (including preprints) on a daily basis via PubMed,
Scopus, medRxiv, bioRxiv, the COVID-19 Open Research
Dataset by Semantic Scholar and the Allen Institute for AI,
and the WHO COVID-19 database. We used over 20 search
terms for suicide (eg, “suicid*”), suicidal behaviour
(eg, “attempted suicide”), and self-harm (eg, “self-harm*”),
in combination with a range of terms for COVID-19
(eg, “coronavirus” OR “COVID*” or “SARS-CoV-2”). Databases
were searched from Jan 1, 2020, with no language restrictions.
As of Dec 8, 2020, we had identified 21 reports but only five of
these accounted for temporal trends in suicides (eg, by using
time-series analyses). Three of these studies found no change in
suicide numbers in Greece, Queensland (Australia),
and Massachusetts (USA), and the fourth identified a decrease
in Peru. The fifth highlighted a decrease followed by an increase
in Japan, which appeared to be related to pandemic-induced
employment shocks.
Added value of this study
This study drew on data from 21 countries and used an
analytical approach that controlled for pre-existing trends to
assess whether patterns of suicide have changed since the
COVID-19 pandemic was declared. It is the first study to explore
the potential suicide-related effects of COVID-19 at this scale.
The results of the primary analysis showed that, in general,
there does not appear to have been an increase in suicides since
the pandemic began, at least in high-income and upper-
middle-income countries. Our study adds value because
previous studies have reported findings from single countries
or regions and their estimates of effect have often not taken
account of trends in suicide before the pandemic.
Implications of all the available evidence
Policy responses to prevent the spread of COVID-19 need to
balance the benefits of physical distancing, school and workplace
closures, and other restrictions against the possible adverse
impact of these measures on population mental health and
suicide. Our early findings provide some reassurance (at least for
high-income and upper-middle-income countries) that COVID-19
risk mitigation measures have not led to population-level
increases in suicide rates. Many countries put in place additional
mental health supports and financial safety nets, both of which
might have buffered any early adverse effects of the pandemic.
There is a need to ensure that efforts that might have kept suicide
rates down until now are continued, and to remain vigilant as the
longer-term mental health and economic consequences of the
pandemic unfold. There are some concerning signals that the
pandemic might be adversely affecting suicide rates in
low-income and lower-middle-income countries, although data
are only available in a small minority of these countries and tend
to be of suboptimal quality. Even in high-income and upper-
middle-income countries, the effect of the pandemic on suicide
might vary over time and be different for different subgroups in
the population.
Articles
www.thelancet.com/psychiatry Published online April 13, 2021 https://doi.org/10.1016/S2215-0366(21)00091-2
3
Brigham and Women’s Hospital
Department of Emergency
Medicine, Boston, MA, USA
(J S Faust MD); School of
Population Health, University
of Auckland, Auckland,
New Zealand (S Fortune PhD);
Magistrates Court of Tasmania
(Coronial Division), Hobart,
TAS, Australia (A Garrett PhD);
Bureau of Vital Records and
Statistics, Louisiana Office of
Public Health, Baton Rouge,
LA, USA (D George MPPA);
Ministry of Public Health,
Undersecretary of Health
Services, Quito, Ecuador
(R Gerstner MPH); Research
Department, 113 Suicide
Prevention, Amsterdam,
Netherlands (R Gilissen PhD);
Departments of Psychiatry and
Epidemiology, Columbia
University Medical Center/
New York State Psychiatric
Institute, New York, NY, USA
(Prof M Gould PhD); Centre for
Suicide Research, University of
Oxford, Oxford, UK
(Prof K Hawton FMedSci);
Louisiana Department of
Health, Baton Rouge, LA, USA
(J Kanter MD); Greater
Manchester Mental Health NHS
Foundation Trust, Manchester,
UK (Prof N Kapur); Department
of Psychiatry, Aga Khan
University, Karachi, Pakistan
(Prof M Khan PhD); KU Leuven,
Center for Contextual
Psychiatry, Leuven, Belgium
(O J Kirtley PhD); Population
Health Sciences, Bristol Medical
School, University of Bristol,
likely that any eect will vary between and within
countries, and over time, depending on factors such as
the extent of the pandemic, the public health measures
instituted to control it, the capacity of existing mental
health services and suicide prevention programmes, and
the strength of the economy and relief measures to
support those whose livelihoods are aected by the
pandemic. There are also multiple other population-level
influences on suicide (eg, political unrest, economic
challenges, and availability of lethal means) that might
operate independently of the pandemic or be exacerbated
by it, and these factors might dier across countries.
We did this ICSPRC study to gain a broader
understanding of suicide patterns, which we believe is
crucial for mitigating the risk of any pandemic-related
increases. Specifically we aimed to assess the early eect
of the COVID-19 pandemic on suicide rates around the
world.
Methods
Overview
Using real-time suicide data from multiple countries and
areas within countries, we did an interrupted time-series
analysis to ascertain whether trends in monthly suicide
counts changed after the pandemic began. Given the
importance of questions about COVID-19 and suicide,
we believed that it was crucial to provide evidence from
the best available real-time data sources. In many
countries, there is a time-lag in ocial suicide data being
released because of the way in which suicide deaths are
identified and recorded in vital statistics collections. In
these countries, suspected suicides are investigated by a
coroner, medical examiner, or other ocial to confirm
the cause and manner of death, with or without an
autopsy. The investigation process can be lengthy,
resulting in data that are not suciently timely to guide
suicide prevention actions. Consequently, some countries
and areas within countries have developed methods for
initial death classification while the investigation is
ongoing to produce real-time suicide data. Typically,
although not always, these approaches rely on police
reports or death certificates as their primary source
of evidence for the preliminary classification. These
alternative or preliminary data sources are crucial for
identifying and responding to any changes in patterns of
suicide that might be associated with external events.
Our approach followed the Guidelines for Accurate
and Transparent Health Estimates Reporting (GATHER;
appendix p 1).24 We received approval from the Swansea
University Medical School Research Ethics Sub-Committee
(2020-0054).
Data inputs
We sought real-time data on suicides from countries as
well as from areas within countries to maximise the
number of places that could contribute to the overall
picture. Establishing real-time suicide data collection
systems is dicult, especially on a national level, so
restricting our eorts to whole countries would have
limited the conclusions we could draw. Real-time suicide
data were identified through internet searches, recourse
to the scientific literature, and contact with our networks.
We did internet searches between Sept 1 and Nov 1, 2020,
to identify relevant data in World Bank countries and
economies with more than 3 million residents (n=135).25
We first searched the ocial websites of these countries
ministries of health, police agencies, and government-run
statistics agencies or equivalents, using the translated
search terms “suicide” and “cause of death”. If this search
did not yield results, we did a more general internet
search using the translated search terms “suicide”,
“[name of country]”, “pandemic”, “COVID” and “corona”
for publicly reported information (eg, in news reports and
on the websites of suicide prevention organisations) that
might indicate whether relevant data existed and, if so,
how they might be traced.
We also searched the academic literature for studies
reporting on suicides before and after the pandemic
began through our living review.5 We extracted data from
the publications or their cited sources and contacted the
authors. We also drew on the knowledge of ICSPRC
members (representing 40 countries) and our contacts at
WHO and the International Association for Suicide
Prevention (IASP).
Publicly available data were accessed online and data
that were not publicly available were provided by data
custodians.
Data inclusion and exclusion criteria
To be included, data from a given country or area had
to come from an ocial government source (eg, a
government department, agency responsible for collating
Figure 1: Pre-COVID-19 and COVID-19 periods as defined in the primary analysis and the two sensitivity
analyses
Primary analysis
Sensitivity analysis 1
Sensitivity analysis 2
Jan 1, 2016
Jan 1, 2020
April 1, 2020
Jan 1, 2019
July 31, 2020
Jan 1, 2016
Jan 1, 2020
April 1, 2020
Jan 1, 2019
July 31, 2020
Oct 31, 2020
Jan 1, 2016
Jan 1, 2020
March 1, 2020
Jan 1, 2019
July 31, 2020
Pre-COVID-19 period (where data were available) Pre-COVID-19 period
COVID-19 period COVID-19 period (where data were available)
Articles
4
www.thelancet.com/psychiatry Published online April 13, 2021 https://doi.org/10.1016/S2215-0366(21)00091-2
Bristol, UK (D Knipe PhD); South
Asian Clinical Toxicology
Research Collaboration, Faculty
of Medicine, University of
Peradeniya, Peradeniya,
Sri Lanka (D Knipe); World
Health Organization, Country
Office for Nepal, Kathmandu,
Nepal (K Marahatta MD);
Karolinska Institutet,
Stockholm, Sweden
(Prof E Mittendorfer-Rutz PhD);
Bekhterev National Medical
Research Center of Psychiatry
and Neurology, Pavlov First
Saint Petersburg State Medical
University, Saint Petersburg,
Russia (Prof N Neznanov PhD);
Unit Suicide Research and
Mental Health Promotion,
Department of Social and
Preventive Medicine, Center for
Public Health
(T Niederkrotenthaler PhD) and
Department of Child and
Adolescent Psychiatry
(Prof P L Plener MD), Medical
University of Vienna, Vienna,
Austria; School of Psychology
(E Nielsen PhD) and Self-Harm
Research Group, School of
Psychology
(Prof E Townsend PhD),
University of Nottingham,
Nottingham, UK; Mental
Health Centre Copenhagen,
Copenhagen, Denmark
(Prof M Nordentoft DrMSc);
Department of Psychiatry and
Psychotherapy, Klinikum
Klagenfurt am Wörthersee,
Klagenfurt, Austria
(H Oberlerchner Dr med);
Suicidal Behaviour Research
Lab, University of Glasgow,
Glasgow, UK
(Prof R C O’Connor PhD);
Preventing Deaths from
Poisoning Research Group
(M Pearson PhD) and Usher
Institute (Prof S Platt PhD),
University of Edinburgh,
Edinburgh, UK; Suicide
Research and Prevention
Center, Shanghai Mental
Health Center, Shanghai Jiao
Tong University School of
Medicine, Shanghai, China
(Prof M R Phillips MD);
Departments of Psychiatry and
Epidemiology, Columbia
University, New York, NY, USA
(Prof M R Phillips); Department
of Child and Adolescent
Psychiatry and Psychotherapy,
University of Ulm, Ulm,
Germany (Prof P L Plener);
Psychosocial Services in
Vienna, Vienna, Austria
(G Psota MD); National Centre
for Suicide Research and
national statistics, coroners’ court, medical examiners
oce, police department, or university), and be available
at a monthly level from at least Jan 1, 2019, to July 31, 2020
(and potentially from as far back as Jan 1, 2016, until as
recently as Oct 31, 2020). Our internet searches were
restricted to countries with more than 3 million residents
for pragmatic reasons, but we relaxed this rule for
countries identified through the literature and our
networks. Areas within countries could also be included
with populations of 3 million residents or fewer.
Data storage and management
We aggregated all data to the monthly level. Data were
housed in a safe, secure, password-protected database
held at Swansea University using Secure eResearch
Platform technology (Adolescent Mental Health Data
Platform [ADP]). Per the platform’s data protection
protocols, access to the data was limited and only made
available to JP, AJ, SS, MDPB, VA, DGu, and MJS.
Data analysis
We used interrupted time-series analysis to model the
trends in monthly suicides before COVID-19 in each
country or area within country, accounting for time trends
and seasonality wherever possible. Models were fitted
with use of Poisson regression and accounted for possible
over-dispersion using a scale parameter set to the
model’s χ² value divided by the residual degrees of
freedom. We modelled the eect of time as a non-linear
predictor, unless this oered no improvement beyond a
linear model, in which case we used the linear model
instead. Non-linear time trends were estimated by
selecting the best fitting model from a series of fractional
polynomial models. Seasonality was accounted for with
Fourier terms (pairs of sine and cosine functions). We
then used each country or area’s model to forecast what
the trend in suicides from the beginning of the COVID-19
period would have been had COVID-19 not occurred,
calculating the expected number of suicides, which
represented the counterfactual. We compared this
expected number with the observed number of suicides
in the same period by calculating rate ratios (RRs) and
95% CIs. In a small number of countries or areas, it was
Population in 2020 Beginning of initial
stay-at-home period
in country26*
High-income countries
Australia 25 500 000 March 24, 2020
New South Wales 8 157 700 ··
Queensland 5 160 000 ··
Victoria 6 689 400 ··
Austria 8 900 000 March 16, 2020
Carinthia 560 900 ··
Tyrol 757 600 ··
Vienna 1 911 200 ··
Canada 37 700 000 March 14, 2020
Alberta 4 421 900 ··
British Columbia 5 147 700 ··
Manitoba 1 380 000 ··
Chile 19 100 000 March 25, 2020
Croatia 4 100 000 March 23, 2020
England, UK 56 300 000 March 24, 2020†
Thames Valley 2 400 000 ··
Estonia 1 300 000 March 9, 2020
Germany 83 800 000 March 9, 2020
Cologne and
Leverkusen
1 285 500 ··
Frankfurt 753 000 ··
Leipzig 591 000 ··
Italy 60 500 000 March 5, 2020†
Udine and
Pordenone
841 300 ··
Japan 126 500 000 April 7, 2020
Netherlands 17 100 000 March 6, 2020
New Zealand 4 800 000 March 21, 2020
Poland 37 800 000 March 31, 2020
South Korea 51 200 000 Feb 23, 2020
Spain 46 800 000 March 14, 2020
Las Palmas 1 109 000 ··
USA 331 000 000 March 15, 2020
California 39 747 300 ··
Illinois (Cook
County)
5 106 780 ··
Louisiana 4 649 000 ··
New Jersey 8 936 600 ··
Texas (Denton,
Johnson, Parker,
Tarrant Counties)
3 374 000 ··
Puerto Rico‡ 3 032 200 ··
(Table continues in next column)
Population in 2020 Beginning of initial
stay-at-home period
in country26*
(Continued from previous column)
Upper-middle-income countries
Brazil 212 600 000 March 14, 2020
Botucatu 140 000 ··
Maceió 1 020 000 ··
Ecuador 17 600 000 March 17, 2020
Mexico 128 900 000 March 30, 2020
Mexico City 9 000 000 ··
Peru 33 000 000 March 15, 2020
Russia 146 000 000 March 5, 2020
Saint Petersburg 5 468 000 ··
Countries are categorised according to World Bank income classifications. NA=not
applicable. *Date when stay-at-home orders were first applied anywhere in the
given country; dates for areas within countries might differ from this.
†Date amended by local author(s). ‡Unincorporated territory of the USA.
Table: Details of countries and areas within countries included in the
study
Articles
www.thelancet.com/psychiatry Published online April 13, 2021 https://doi.org/10.1016/S2215-0366(21)00091-2
5
not possible to account for seasonality in the model
because we only had pre-COVID-19 data for a single year
(Jan 1, 2019, onwards). For these countries, we fitted a
model with a linear predictor for time only. Further details
of the modelling strategy are provided in the
appendix (pp 2–10).
We did a primary analysis and two sensitivity analyses
(figure 1). In each analysis, we included data from all
available months in each country or area in the pre-
COVID-19 period. In the primary analysis, we treated
April 1, 2020, as the start of the COVID-19 period and
censored the data beyond July 31, 2020, in order to
maximise data quality, in recognition that there might
have been under-enumeration of suicides in the later
months with figures being subsequently updated. In the
first sensitivity analysis, we retained April 1, 2020, as the
start of the COVID-19 period but relaxed the end date to
include all data available in the COVID-19 period for each
country or area up to Oct 31, 2020. In the second sensitivity
analysis, we changed the start of the COVID-19 period to
March 1, 2020, and used the original censoring date of
July 31, 2020, as the end of the COVID-19 period,
recognising that the onset of COVID-19 and associated
public health measures varied.
We also did two supplementary analyses. In the first,
we repeated the primary analysis using the same
methods and date cutos, but inflated the number of
suicides in each country and area in the months of the
COVID-19 period by 5%. In the second, we used data
from the Australian state of Tasmania that were
aggregated to 3 months (rather than 1 month) but
otherwise met our inclusion criteria. In this analysis, we
used data from Jan 1, 2019, to Sept 30, 2020, and treated
April 1, 2020, as the beginning of the COVID-19 period.
All analyses were done on the Swansea University ADP
Secure eResearch Platform using Stata software
(version 16.1). The Stata code is available in the
appendix (pp 11–17).
Role of the funding source
There was no funding source for this study.
Results
We sourced data from 21 countries (16 high-income
countries and five upper-middle-income countries), of
which ten had data available for the whole country and
11 had data for a specific area or areas within the country.
The table summarises the populations of the countries
and areas as well as the dates on which the first stay-at-
home orders were implemented.26 The appendix contains
details of the source and nature of the data for each country
and area (pp 18–23) as well as the raw data (pp 24–28).
The observed and expected number of suicides for
April 1 to July 31, 2020, and the RRs based on these
numbers are shown in figure 2 (see appendix pp 4–10 for
the coecients and standard errors of the models
underlying the expected number of suicides). The 95% CIs
Figure 2: Observed and expected numbers of suicides in the COVID-19 period based on trends in
pre-COVID-19 period by country or area in the primary analysis
The COVID-19 period was defined as April 1 to July 31, 2020, and the pre-COVID-19 period as at least Jan 1, 2019 to
March 31, 2020 (with data included from Jan 1, 2016, if available). *Predictor for linear time trend only. †Predictors
for linear time trends and seasonality. ‡Predictors for non-linear time trends and seasonality. §Unincorporated
territory of the USA.
High-income countries
Australia
New South Wales*
Queensland†
Victoria†
Austria
Carinthia†
Tyrol†
Vienna*
Canada
Alberta†
British Columbia†
Manitoba*
Chile†
Croatia‡
England, UK
Thames Valley*
Estonia†
Germany
Cologne and Leverkusen*
Frankfurt*
Leipzig*
Italy
Udine and Pordenone†
Japan‡
Netherlands†
New Zealand†
Poland‡
South Korea‡
Spain
Las Palmas†
USA
California‡
Illinois (Cook County)‡
Louisiana†
New Jersey‡
Texas (four counties)†
Puerto Rico‡§
Upper-middle-income countries
Brazil
Botucatu*
Maceió*
Ecuador‡
Mexico
Mexico City*
Peru‡
Russia
Saint Petersburg†
286
237
221
36
33
48
157
189
65
471
190
68
64
49
22
22
26
6504
594
190
1841
4502
36
1280
142
258
245
120
54
6
11
384
182
176
119
Observed
354
241
247
30
41
45
197
250
80
551
178
77
77
44
32
45
29
6947
588
241
1932
4778
47
1429
180
256
217
147
42
3
14
521
199
178
114
Expected
0·81 (0·72−0·91)
0·98 (0·87−1·12)
0·89 (0·78−1·02)
1·21 (0·87−1·67)
0·80 (0·57−1·13)
1·07 (0·80−1·41)
0·80 (0·68−0·93)
0·76 (0·66−0·87)
0·81 (0·64−1·03)
0·85 (0·78−0·94)
1·07 (0·92−1·23)
0·88 (0·69−1·12)
0·83 (0·65−1·06)
1·12 (0·84−1·48)
0·68 (0·45−1·03)
0·49 (0·32−0·74)
0·91 (0·62−1·33)
0·94 (0·91−0·96)
1·01 (0·93−1·09)
0·79 (0·68−0·91)
0·95 (0·91−1·00)
0·94 (0·92−0·97)
0·77 (0·56−1·07)
0·90 (0·85−0·95)
0·79 (0·67−0·93)
1·01 (0·89−1·14)
1·13 (0·99−1·28)
0·82 (0·68−0·98)
1·27 (0·98−1·66)
1·78 (0·80−3·97)
0·77 (0·42−1·38)
0·74 (0·67−0·82)
0·91 (0·79−1·06)
0·99 (0·85−1·14)
1·05 (0·87−1·25)
Rate ratio (95% CI)
0·20 0·35 0·60 1·00 1·80 3·10
Number of suicides
Articles
6
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surrounding the RR for each country or area either
include the null value of 1·00 or fall below the null value,
indicating that there was no evidence of an increase in
suicides relative to the expected number during the
COVID-19 period in any country or area. There was
statistical evidence of a decrease in suicides in 12 countries
or areas: New South Wales, Australia (RR 0·81 [95% CI
0·72–0·91]); Alberta, Canada (0·80 [0·68–0·93]); British
Columbia, Canada (0·76 [0·66–0·87]); Chile (0·85
[0·78–0·94]); Leipzig, Germany (0·49 [0·32–0·74]); Japan
(0·94 [0·91–0·96]); New Zealand (0·79 [0·68–0·91]);
South Korea (0·94 [0·92–0·97]); California, USA
(0·90 [0·85–0·95]); Illinois (Cook County), USA (0·79
[0·67–0·93]); Texas (four counties), USA (0·82
[0·68–0·98]); and Ecuador (0·74 [0·67–0·82]).
Incorporating data up until the latest month available
(to Oct 31, 2020) made little dierence to the results from
most countries or areas (figure 3), with most 95% CIs
for the RR estimates below or including 1·00. Victoria,
Australia (0·89 [0·80−0·99]); Thames Valley, England,
UK (0·82 [0·68−0·98]); and Mexico City, Mexico (0·86
[0·77−0·97]) showed significant decreases that were not
seen in the primary analysis. There were three exceptions
to the picture of no change or decreases in suicides:
Vienna showed statistical evidence of an increase in
suicides (1·31 [1·08–1·59]) relative to the expected
number when the additional months were included, as
did Japan (1·05 [1·04–1·07]) and Puerto Rico (1·29
[1·05–1·58]). In each case, the latest month for which
data were available was October.
The results of the second sensitivity analysis, in which
the pandemic’s first day was defined as March 1 rather
than April 1, 2020 (figure 4), were also similar to those
from our primary analysis. Again, there was evidence
of a decreased risk of suicide in several additional
countries or areas over and above those observed in our
primary analysis: Manitoba, Canada (0·60 [0·48−0·76]);
Poland (0·94 [0·90−0·98]); Las Palmas, Spain (0·69
[0·51−0·94]); and Peru (0·73 [0·64−0·83]). There was no
evidence of any increase in suicides relative to the
expected number during this COVID-19 period for any
country or area except Puerto Rico (1·36 [1·07–1·72]).
Our two supplementary analyses also showed consistent
findings. Inflating the suicide numbers in the COVID-19
period by 5% made little dierence to the results (appendix
p 29), with only two areas showing statistical evidence of
an increase in suicides where this had not been the case
previously: New Jersey, USA (RR 1·18 [95% CI 1·05–1·34])
and Puerto Rico (1·34 [1·03–1·74]). When we analysed the
3-monthly data from Tasmania, the findings were similar
to those from the other Australian states, with no evidence
of any increase in suicides in the COVID-19 period
(RR 0·74 [95% CI 0·53–1·02]).
Discussion
In general, based on the primary analysis, there does not
appear to have been an increase in risk of suicide during
Figure 3: Observed and expected numbers of suicides in COVID-19 period based on trends in pre-COVID-19
period by country or area in the first sensitivity analysis
The COVID-19 period was defined as April 1 to at least July 31, 2020 (with data included up to Oct 31, 2020,
if available), and the pre-COVID-19 period as at least Jan 1, 2019, to March 31, 2020 (with data included from
Jan 1, 2016 if available). *Predictor for linear time trend only. †Predictors for linear time trends and seasonality.
‡Predictors for non-linear time trends and seasonality. §Unincorporated territory of the USA.
440
413
331
43
58
101
174
237
122
859
334
112
115
84
40
22
26
12 421
594
344
3176
6603
69
1790
265
258
389
203
90
6
13
668
305
264
119
537
448
372
36
65
77
246
314
142
1046
307
137
108
76
49
45
29
11 789
588
427
3234
7060
82
2144
312
256
364
255
70
5
22
986
353
257
114
0·82 (0·75−0·90)
0·92 (0·84−1·01)
0·89 (0·80−0·99)
1·19 (0·88−1·61)
0·89 (0·68−1·15)
1·31 (1·08−1·59)
0·71 (0·61−0·82)
0·75 (0·66−0·86)
0·86 (0·72−1·03)
0·82 (0·77−0·88)
1·09 (0·98−1·21)
0·82 (0·68−0·98)
1·06 (0·88−1·27)
1·11 (0·89−1·37)
0·81 (0·59−1·10)
0·49 (0·32−0·74)
0·91 (0·62−1·33)
1·05 (1·04−1·07)
1·01 (0·93−1·09)
0·81 (0·72−0·90)
0·98 (0·95−1·02)
0·94 (0·91−0·96)
0·84 (0·66−1·06)
0·83 (0·80−0·87)
0·85 (0·75−0·96)
1·01 (0·89−1·14)
1·07 (0·97−1·18)
0·80 (0·69−0·91)
1·29 (1·05−1·58)
1·21 (0·54−2·69)
0·60 (0·35−1·03)
0·68 (0·63−0·73)
0·86 (0·77−0·97)
1·03 (0·91−1·16)
1·05 (0·87−1·25)
0·20 0·35 0·60 1·00 1·80 3·10
High-income countries
Australia
New South Wales*
Queensland†
Victoria†
Austria
Carinthia†
Tyrol†
Vienna*
Canada
Alberta†
British Columbia†
Manitoba*
Chile†
Croatia‡
England, UK
Thames Valley*
Estonia†
Germany
Cologne and Leverkusen*
Frankfurt*
Leipzig*
Italy
Udine and Pordenone†
Japan‡
Netherlands†
New Zealand†
Poland‡
South Korea‡
Spain
Las Palmas†
USA
California‡
Illinois (Cook County)‡
Louisiana†
New Jersey‡
Texas (four counties)†
Puerto Rico‡§
Upper-middle-income countries
Brazil
Botucatu*
Maceió*
Ecuador‡
Mexico
Mexico City*
Peru‡
Russia
Saint Petersburg†
Observed
Rate ratio (95% CI)Number of suicides
Expected
Articles
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7
the pandemic’s early months in the 21 countries for
which we had data, and a number of countries or areas
appear to have seen fewer suicides relative to the expected
number.
Our findings align with those of other published
studies from high-income and upper-middle-income
countries, in which there were either decreases or
no changes in suicide rates as a function of the
pandemic.9–15,19–22 Our findings are also consistent with
emerging reports in the grey literature from various
countries (eg, England).27 In some cases, this consistency
is not surprising because we used the same data sources,
but the fact that we found similar patterns in many other
countries increases our confidence in this finding.
The lack of increase in suicides since the pandemic
began could be attributed to various factors. First, there
was an early emphasis on the potential adverse eects of
stay-at-home orders, school closures, and business shut
downs. Empirical evidence began to emerge from some
countries that self-reported levels of depression, anxiety,
and suicidal thinking were heightened during the initial
stay-at-home periods,1 but this does not appear to have
translated into increases in suicides, at least in the
countries in our study. In some countries, governments
responded rapidly to the threat to mental health,
implementing recommended approaches such as
bolstering mental health services.28 Maintaining this
emphasis on accessible, high-quality mental health care
is crucial.
Second, certain protective factors might have been
operating in the pandemic’s early months. Communities
might have actively tried to support at-risk individuals,
people might have connected in new ways, and some
relationships might have been strengthened by house-
holds spending more time with each other.28 For some
people, everyday stresses might have been reduced
during stay-at-home periods, and for others the collective
feeling of “we’re all in this together” might have been
beneficial.
Finally, many countries rapidly enacted fiscal support
initiatives to buer the pandemic’s economic con-
sequences. In many cases, this support is now being
reduced or withdrawn. As it lapses, previously protected
populations might face increasing stress. Suicide rates
can rise during times of economic recession,29 so it is
possible that the pandemic’s potential suicide-related
eects are yet to occur.
Vienna, Japan, and Puerto Rico were outliers in parts of
our analysis. Although they showed no evidence of an
increased risk of suicide in our primary analysis, we
observed a significantly increased risk in all three when
we extended the observation period to Oct 31, 2020, and
in Puerto Rico we noted an increase when we brought
forward the pandemic’s start date from April 1 to
March 1, 2020. Additional contextual factors might have
operated in these countries—for example, in Japan,
several widely reported celebrity suicides that occurred
Figure 4: Observed and expected numbers of suicides in COVID-19 period based on trends in pre-COVID-19
period by country or area in the second sensitivity analysis
The COVID-19 period was defined as March 1 to July 31, 2020, and the pre-COVID-19 period as at least Jan 1, 2019,
to Feb 29, 2020 (with data included from Jan 1, 2016, if available). *Predictor for linear time trend only. †Predictors
for linear time trends and seasonality. ‡Predictors for non-linear time trends and seasonality. §Unincorporated
territory of the USA.
374
305
294
40
46
62
201
239
74
627
230
93
76
59
31
27
33
8253
740
241
2234
5622
42
1629
182
315
288
151
69
7
14
485
245
221
143
435
309
306
40
49
53
252
325
123
688
221
84
96
57
38
69
36
8688
741
298
2372
6191
61
1731
226
313
289
186
51
4
19
652
220
304
142
0·86 (0·78−0·95)
0·99 (0·88−1·10)
0·96 (0·86−1·08)
1·01 (0·74−1·38)
0·93 (0·70−1·25)
1·18 (0·92−1·51)
0·80 (0·69−0·91)
0·74 (0·65−0·84)
0·60 (0·48−0·76)
0·91 (0·84−0·99)
1·04 (0·91−1·18)
1·11 (0·91−1·36)
0·80 (0·64−1·00)
1·03 (0·80−1·33)
0·81 (0·57−1·15)
0·39 (0·27−0·57)
0·92 (0·65−1·30)
0·95 (0·93−0·97)
1·00 (0·93−1·07)
0·81 (0·71−0·92)
0·94 (0·90−0·98)
0·91 (0·88−0·93)
0·69 (0·51−0·94)
0·94 (0·90−0·99)
0·80 (0·70−0·93)
1·01 (0·90−1·12)
1·00 (0·89−1·12)
0·81 (0·69−0·95)
1·36 (1·07−1·72)
1·73 (0·83−3·63)
0·74 (0·44−1·25)
0·74 (0·68−0·81)
1·11 (0·98−1·26)
0·73 (0·64−0·83)
1·01 (0·85−1·18)
0·20 0·35 0·60 1·00 1·80 3·10
High-income countries
Australia
New South Wales*
Queensland†
Victoria†
Austria
Carinthia†
Tyrol†
Vienna*
Canada
Alberta†
British Columbia†
Manitoba*
Chile†
Croatia‡
England, UK
Thames Valley*
Estonia†
Germany
Cologne and Leverkusen*
Frankfurt*
Leipzig*
Italy
Udine and Pordenone†
Japan‡
Netherlands†
New Zealand†
Poland‡
South Korea‡
Spain
Las Palmas†
USA
California‡
Illinois (Cook County)‡
Louisiana†
New Jersey‡
Texas (four counties)†
Puerto Rico‡§
Upper-middle-income countries
Brazil
Botucatu*
Maceió*
Ecuador‡
Mexico
Mexico City*
Peru‡
Russia
Saint Petersburg†
Observed
Rate ratio (95% CI)Number of suicides
Expected
Articles
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during the pandemic might have exerted an influence;
and Puerto Rico has been in a deep recession since 2006,
so pre-existing high levels of poverty might have
exacerbated the pandemic’s economic eects.
To our knowledge, this study is the first to combine data
from multiple countries to examine the early eects of
COVID-19 on suicide, taking account of underlying
trends. The study involved a systematic search process
and overcame the delays inherent in vital statistic
collection by using real-time data from numerous ocial
sources. However, it did not represent low-income or
lower-middle-income countries, which account for 46% of
the world’s suicides and might have been hit particularly
hard by the pandemic. Very few of these countries have
good-quality vital registration systems and still fewer
collect real-time suicide data.30 In our search, we identified
unocial real-time data from two lower-middle-income
countries (Myanmar and Tunisia) and one low-income
country (Malawi) that could not be disaggregated to the
monthly level. We were unable to verify or use these data
in our analyses, but they were concerning for two of
these countries. In Malawi, there was reportedly a
57% increase in January–August, 2020, compared with
January–August, 2019, and in Tunisia there was a
5% increase in March–May, 2020, compared with
March–May, 2019. By contrast, in Myanmar, there was a
2% decrease in January–June, 2020, compared with
January–June, 2019.
Another limitation is that data quality might have been
an issue in the countries and areas in our study. Data
from the most recent months in any given country or
area might have been the least reliable and the most
likely to represent undercounts, especially if COVID-19
disrupted data-collection processes. We attempted to
overcome this problem by using July 31, 2020, as the end
date in our primary analysis, and only using more recent
months (to Oct 31, 2020) in the first sensitivity analysis.
If the data in the later months were artificially low, we
might have expected to see countries or areas that showed
no dierence in suicides in the primary analysis
recording a decrease in this sensitivity analysis, but this
only occurred in Victoria, Australia; Thames Valley,
England, UK; and Mexico City, Mexico. Similarly,
inflating the number of suicides in each month of the
COVID-19 period by 5% (which might be the typical
magnitude of any increase if later figures were updated)
made little dierence. Only two areas showed statistical
evidence of an increase in suicides where this had not
been the case previously: New Jersey (USA) and Puerto
Rico.
In addition, various factors might have influenced the
power and precision of our models. In particular, low
numbers of timepoints and low numbers of monthly
suicides in given countries or areas might have resulted
in models with relatively poorer power and precision,
with the eect of biasing the findings to the null and
suggesting that there was no change in the number of
monthly suicides from the pre-COVID-19 period to the
COVID-19 period when in fact there might have been
an increase or a decrease. Only five areas had both
the minimum number of pre-COVID-19 timepoints
(January, 2019, to March, 2020) and low numbers of
monthly suicides and showed no change in suicide risk
in our primary analysis: Vienna, Austria; Cologne and
Leverkusen, Germany; Frankfurt, Germany; Botucatu,
Brazil; and Maceio, Brazil. The findings from these five
areas should be inter preted with caution.
We were unable to stratify the data by age, sex, or
ethnicity, and the pandemic might have a dierential
eect on suicides in certain demographic groups
(eg, women and girls,17,18 children and adolescents,17 and
ethnic minorities14). We were also unable to explore any
temporal changes in suicide methods. Additionally, we
could not consider external factors that might have
influenced suicide patterns in dierent countries or
areas, including varying public health measures or
economic support packages. We are planning future
studies to address these questions.
We relied on area-within-country data for 11 countries.
We included these data to ensure representation from as
many countries as possible and to avoid generating a
picture that was biased towards better-resourced
countries. We deliberately did not extrapolate from these
areas to whole countries because we were aware that they
were sometimes small and might have had unique
suicide profiles. However, some of these areas would
have been expected to account for a large proportion of
the suicides in the given country, based on their
population size and their historical suicide statistics
(eg, suicides in New South Wales, Queensland, and
Victoria typically represent 75% of all suicides in
Australia)31 and others had larger populations than some
of the other included countries (eg, California had a
population of 39·7 million people). Additionally, data
from the areas within these countries showed similar
patterns to those from relevant areas studied elsewhere.
For example, studies done in Massachusetts and
Connecticut, USA, showed no increase in suicide
numbers after the pandemic began,14,21 which is in line
with our findings from the US jurisdictions for which we
had data. Similarly, the 3-monthly data from Tasmania
that we analysed separately showed no increase in
suicides, consistent with the findings from the other
Australian states.
We used the same date in a given analysis to distinguish
the pre-COVID-19 period from the COVID-19 period for
all countries (April 1 or March 1, 2020), potentially
underestimating any eect of COVID-19 in countries or
areas with an earlier onset of the pandemic or public
health protection measures. We considered using the
date of the initial stay-at-home order to distinguish the
pre-COVID-19 and COVID-19 periods, but areas within a
given country might have introduced stay-at-home orders
at dierent times. Additionally, because we had monthly
Prevention, Institute of Clinical
Medicine, University of Oslo,
Oslo, Norway (Prof P Qin PhD);
Department of Child and
Adolescent Psychiatry,
Psychotherapy and
Psychosomatics, University
Hospital Leipzig, Leipzig,
Germany (D Radeloff Dr med);
Department of Psychiatry and
Psychotherapeutic Medicine,
Landeskrankenhaus Villach,
Villach, Austria
(C Rados Dr med); Department
of Psychiatry, Psychosomatic
Medicine and Psychotherapy,
University Hospital Frankfurt,
Frankfurt am Main, Germany
(Prof A Reif MD,
C Reif-Leonhard MD);
Department of Borderline
Disorders and Psychotherapy,
Bekhterev National Medical
Research Center of Psychiatry
and Neurology, Saint
Petersburg State University,
Saint Petersburg, Russia
(Prof V Rozanov PhD);
Department of Psychiatry,
Health Authority Frankfurt
am Main, Frankfurt, Germany
(C Schlang Dr med);
Department of Addictive
Disorders, Psychiatry and
Psychotherapy, LVR-Klinik
Köln, Cologne, Germany
(Prof B Schneider Dr med habil);
Department of Psychiatry,
Psychosomatic Medicine and
Psychotherapy, Goethe-
University, Frankfurt am Main,
Germany (Prof B Schneider);
Organizational-Scientific
Department, Bekhterev
National Medical Research
Center of Psychiatry and
Neurology, Saint Petersburg,
Russia (N Semenova PhD);
Department of Psychiatry,
University of Toronto, Toronto,
ON, Canada (M Sinyor MD);
Department of Psychiatry,
Sunnybrook Health Sciences
Centre, Toronto, ON, Canada
(M Sinyor); Waseda University,
Faculty of Political Science and
Economics, Tokyo, Japan
(M Ueda PhD); Sneha—Suicide
Prevention Centre, Voluntary
Health Services, Chennai, India
(L Vijayakumar PhD);
Department of Community
Medicine, Faculty of Medicine
and Allied Sciences, Rajarata
University of Sri Lanka,
Anuradhapura, Sri Lanka
(M Weerasinghe PhD);
Department of Psychiatry,
Sackler School of Medicine,
Tel Aviv University and Geha
Mental Health Center, Tel Aviv,
Articles
www.thelancet.com/psychiatry Published online April 13, 2021 https://doi.org/10.1016/S2215-0366(21)00091-2
9
Israel (Prof G Zalsman MD);
Division of Molecular Imaging
and Neuropathology, New York
State Psychiatric Institute and
Department of Psychiatry,
Columbia University, New York,
USA (Prof G Zalsman); National
Institute of Health Research
Biomedical Research Centre,
University Hospitals Bristol
and Weston NHS Foundation
Trust, University of Bristol,
Bristol, UK
(Prof D Gunnell FMedSci)
Correspondence to:
Prof Jane Pirkis, Centre for
Mental Health, Melbourne
School of Population and Global
Health, University of Melbourne,
Melbourne, VIC 3065, Australia
j.pirkis@unimelb.edu.au
suicide counts, we would have had to convert the date of
the initial stay-at-home order to the beginning of the
month in question or the next month. These dates fell
between Feb 23 and April 7, so between them the analyses
covered all periods.
Our study is the first to examine suicides occurring in
the COVID-19 context in multiple countries. It oers a
broadly consistent picture, albeit from high-income and
upper-middle-income countries, of suicide numbers
remaining unchanged or declining in the pandemic’s
early months. This picture is neither complete nor final,
but serves as the best available evidence on the
pandemic’s eects on suicide so far.
We need to continue to monitor real-time data and be
alert to any increases in suicide, particularly as the
pandemic’s full economic consequences emerge. We
need to understand what has kept suicide numbers down
during the pandemic’s early months, and what drives any
increases if they do occur. We also need to recognise that
suicide is not the only indicator of the negative mental
health eects of the pandemic; levels of community
distress are high and we need to ensure that people are
supported. We need to redouble our eorts to understand
the pandemic’s eects on suicides in low-income and
lower-middle-income countries, and we need to make
sure that we communicate our findings to governments
and communities in safe, non-sensationalist ways.32
Policy makers should heed the value of high-quality,
timely suicide data in suicide prevention eorts, and
should prioritise mitigation of suicide risk factors
associated with COVID-19 and take decisive action (eg, by
resourcing mental health services and providing financial
safety nets) to prevent the possible longer-term det-
rimental eects of the pandemic on suicide.
Contributors
JP, AJ, and DGu conceptualised, designed and led the study, with
assistance from MJS. SS, MDP-B, and VA conducted the internet
searches for data and JP, AJ, and DGu followed up leads through the
ICSPRC and IASP networks, assisted by MJS and TN. Additional data
were sourced or provided by the following authors: PA-A, AB, JMB, PB,
GC, MC, DCo, DCr, CD, EAD, JD, MDP-B, JSF, SF, AG, DGe, RGe, RGi,
DGu, KH, AJ, JK, KK, SL, EM-R, NN, HO, GP, PLP, PQ, AR, CR, DR,
CR-L, VR, BS, CS, MS, NS, MU, and RTW. JP, SS, MDP-B and VA were
responsible for data verification, management and storage. MJS did the
analysis. JP prepared the first draft of the manuscript with input from
AJ, DGu, and MJS. All authors interpreted data and made critical
intellectual revisions to the manuscript. Access to the data were limited
for data protection reasons and only made available to JP, AJ, SS,
MDP-B, VA, DGu, and MJS.
Declaration of interests
We declare no competing interests.
Data sharing
The statistical code and raw data are available in the appendix (pp 18–25).
Acknowledgments
We acknowledge the help that the ICSPRC has received from IASP in
establishing and supporting its activities. This study was supported by
the ADP, which is funded by MQ Mental Health Research Charity (grant
reference MQBF/3 ADP). ADP and the authors acknowledge the data
providers who supplied the datasets enabling this study. The views
expressed are entirely those of the authors and should not be assumed to
be the same as those of ADP or MQ Mental Health Research Charity.
The authors acknowledge the Queensland Mental Health Commission
for funding the Queensland Suicide Register from 2013 to the present
day and Queensland Health for funding the register from 1990–2013.
The authors acknowledge the Coroners Court of Queensland and the
Victorian Department of Justice and Community Safety as the source
organisations of data, and the National Coronial Information System as
the database source of data. The authors also acknowledge Queensland
Police Service sta for sending police reports of suspected suicides.
The authors would also like to thank the team working on the living
systematic review of COVID-19 and suicidal behaviour: Emily Eyles,
Luke McGuinness, Babatunde K Olorisade, Lena Schmidt,
Catherine MacLeod Hall, and Julian Higgins (University of Bristol),
and Chukwudi Okolie and Dana Dekel (University of Swansea). JP is
funded by a National Health and Medical Research Council Investigator
Grant (GNT1173126). AJ is funded by MQ (MQBF/3) and the Medical
Research Council (MC_PC_17211). MDP-B is funded by Health and Care
Research Wales (CA04). VA is supported by Australian Government
Research Training Program Scholarship. EA is supported by the Health
Research Board Ireland (IRRL-2015-1586). AB is supported by the EU
Erasmus+ Strategic Partnership Programme (2019-1-SE01-KA203-060571).
NK is supported by the University of Manchester, Greater Manchester
Mental Health NHS Foundation Trust, and the National Institute for
Health Research (NIHR) Greater Manchester Patient Safety Translational
Research Centre. OJK is supported by a Senior Postdoctoral Fellowship
from Research Foundation Flanders (FWO 1257821N). DK is funded by
the Elizabeth Blackwell Institute for Health Research, University of
Bristol, and the Wellcome Trust Institutional Strategic Support Fund.
TN has been supported by the Vienna Science and Technology Fund
through project COV20-027. RCO’C reports grants from Samaritans,
Scottish Association for Mental Health, Mindstep Foundation, NIHR,
Medical Research Foundation, Scottish Government, and NHS Health
Scotland/Public Health Scotland. MRP is supported in part by a grant
from the Global Alliance of Chronic Diseases and the Chinese National
Natural Science Foundation of China (81371502). PLP is an employee of
the Medical University of Vienna, Austria. AR, CR-L, and CS are
responsible for Frankfurter Projekt zur Prävention von Suiziden mittels
Evidenz-basierten Maßnahem (FraPPE; Frankfurt Project to prevent
suicides using evidence-based measures), which is funded by the
German Ministry. MS is supported by Academic Scholar Awards from
the Departments of Psychiatry at Sunnybrook Health Sciences Centre
and the University of Toronto. MW is funded by a Focus Grant from
American Foundation for Suicide Prevention (IIG-0-002-17). DGu is
supported by the NIHR Biomedical Research Centre at University
Hospitals Bristol NHS Foundation Trust and the University of Bristol.
MJS is a recipient of an Australian Research Council Future Fellowship
(FT180100075).
Editorial note
The Lancet Group takes a neutral position with respect to territorial
claims in published tables, figures, and institutional aliations.
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... Manisa's crude death rate (3.58 per 1000) in 2020 during the pandemic period did not differ significantly from the crude death rate in 2019 during the pre-pandemic period. Similarly, one of the USbased studies where seven countries were compared in terms of completed suicide rates also did not find any significant difference between the crude death rates before and during the pandemic periods 16 . In parallel, in a study conducted in England, there was no significant increase in completed suicide rates during the pandemic period compared to the prepandemic period 17 . ...
... However, the study stressed that suicidal thoughts do not always result in suicide 18 . In addition, in a meta-analysis by Pirkis et al. 16 , in which 21 countries were compared in terms of completed suicides, there was a significant increase in the number of completed suicides that occurred during the pandemic period compared to the pandemic period in Germany, the U.S., South Korea, Sweden, and Norway, contrary to Greece. Furthermore, in a systematic analysis conducted by Mamun et al. in Pakistan in 2021, which focused on the economic consequences of the pandemic, it was demonstrated that the number of completed suicides increased in Pakistan during the pandemic period compared to the pre-pandemic period. ...
... This finding was attributed to the social distancing and quarantine measures by the authors of the said study. In light of the above information, it can be concluded that the crosssectional studies do not provide concrete and generalized outcomes about the definitive effects of the COVID-19 pandemic on the completed suicide rates 16,[22][23][24][25] . ...
Article
Full-text available
Purpose: This study aims to compare the completed suicides in the early period of the COVID-19 pandemic with the completed suicides in the same time interval immediately before the pandemic in the Manisa Province of Turkey and to investigate whether there are pandemic-specific completed suicide trends. Materials and Methods: The study sample consisted of 162 completed suicides that occurred between January 2019-February 2020 (pre-pandemic period) and March 2020-June 2021 (pandemic period) in Manisa Province. Completed suicides were compared in terms of sociodemographic and clinical characteristics. Results: The number of completed suicides before and during the pandemic was 84 and 78, respectively. There was no statistically significant difference between the pre-pandemic and pandemic periods in the number of completed suicides. In terms of sociodemographic characteristics, marital status, contrary to gender, age, employment status, and educational level, caused a significant difference in the number of suicides before and during the pandemic period. Additionally, the season when the completed suicide occurred and the type of place of residence of the individuals with completed suicide, caused a significant difference in the number of suicides Conclusion: The study's findings indicated that the pandemic period was not a factor in general in completed suicides. Specifically, however, it is noteworthy that suicide by hanging was more common during the pandemic period, in the spring season, among individuals who were married, employed, resided in urban areas, had a low educational level, and had a history of psychiatric diseases such as mood disorders.
... More interesting, the authors observed a larger increase in suicides in females as well as in children and adolescents, indicating differential adverse impact of the pandemic on potentially vulnerable subgroups. A recent study analyzing suicide data from 21 countries found either a decrease or unchanged suicide rates in the early months of the pandemic in high-income and upper-middle-income countries (Pirkis et al., 2021). Unfortunately, the data could not be stratified by age or gender. ...
... Looking at the group as a whole, the results of the present study are in agreement with previous studies (Leske et al., 2021;Olie et al., 2021;Pirkis et al., 2021;Radeloff et al., 2021) and extend them by the observation of nonsignificant negative long-term effects of the COVID-19 pandemic and associated measures on suicidal behavior. Suicide and suicide attempts are complex and multifaceted behaviors. ...
Article
Background The COVID-19 pandemic and public life restrictions may have a negative impact on people's mental health. Therefore, we analyzed whether this condition affected the occurrence of suicide attempts (SA) over 20 months during the pandemic period. Methods We included patient records according to DSM-5 criteria for suicidal behavior disorders (n = 825) between Jan 1, 2017, and Dec 31, 2021. We applied interrupted time-series Poisson regression models to investigate the effect of the pandemic on SA occurrence, time trends, and seasonal patterns in the whole group of patients as well as stratified by age and gender. Results There was no significant effect of the pandemic on the occurrence of SA in the overall group. However, we observed a significant impact of the pandemic on the seasonal pattern of SA, also the variance differed significantly (pre-pandemic mean ± variance: 13.33 ± 15.75, pandemic: mean ± variance: 13.86 ± 7.26), indicating less periodic variation in SA during the pandemic. Male patients and young adults mainly contributed to this overall effect. Subgroup analysis revealed a significant difference in SA trends during the pandemic in older adults (>55 years) compared with younger adults (18–35 years); SA numbers increased in older adults and decreased in younger adults as the pandemic progressed. Limitations A few patients may have received initial care in an emergency department after SA without being referred to psychiatry. Conclusions In general, the COVID-19 pandemic and related measures did not significantly affect the occurrence of SA but did significantly affect the dynamics. In addition, the pandemic appeared to affect suicidal behavior differently across age groups as it progressed. Particularly for the older adult group, negative long-term effects of the pandemic on suicidal behavior can be derived from the present results, indicating the need to strengthen suicide prevention for the elderly.
... Despite concerns regarding a potential increase in suicide rates during the early stages of the COVID-19 pandemic, a recent study suggested that suicide rates remained constant. 21 Our results are consistent with this finding. The number of patients who visited the emergency department of our hospital after a suicide attempt during the pandemic period was slightly smaller than those who visited for the same reason during the pre-pandemic period. ...
... One study reported that the suicide rate increased during the pandemic, 26 whereas another reported that it did not. 21 Negative factors in the external environment that threaten mental health and positive factors that increase concern and awareness of mental health threats coexist. Additional studies are required to verify this relationship. ...
Article
Full-text available
Background The COVID-19 pandemic poses a major threat to mental health and is associated with an increased risk of suicide. An understanding of suicidal behaviours during the pandemic is necessary for establishing policies to prevent suicides in such social conditions. Aims We aimed to investigate vulnerable individuals and the characteristics of changes in suicidal behaviour during the COVID-19 pandemic. Method We retrospectively reviewed the medical records of patients with suicide attempts who visited the emergency department from February 2019 to January 2021. We analysed the demographic and clinical characteristics, risk factors and rescue factors of patients, and compared the findings between the pre-pandemic and pandemic periods. Results In total, 519 patients were included. During the pre-pandemic and pandemic periods, 303 and 270 patients visited the emergency department after a suicide attempt, respectively. The proportion of suicide attempts by women (60.1% v . 69.3%, P = 0.035) and patients with a previous psychiatric illness (63.4% v . 72.9%, P = 0.006) increased during the COVID-19 pandemic. In addition, patients’ rescue scores during the pandemic were lower than those during the pre-pandemic period (12 (interquartile range: 11–13) v . 13 (interquartile range: 12–14), P < 0.001). Conclusions Women and people with previous psychiatric illnesses were more vulnerable to suicide attempts during the COVID-19 pandemic. Suicide prevention policies, such as continuous monitoring and staying in touch with vulnerable individuals, are necessary to cope with suicide risk.
... A study focusing on suicidal ideation in the general population of the UK found elevated levels, which increased over the first three infection waves of the pandemic [13]. Yet, studies examining suicide death rates have found no overall difference or a decline compared to pre-pandemic times [14][15][16], only one study in Germany reported an increase of suicidality in the subgroup of elderly women [17]. ...
... Predictions of increased suicides during the current pandemic were made based on models extrapolating suicide rates from unemployment and suicide rates of previous economic crises [60]. However, until now, studies examining suicide deaths found no overall change in suicide rates during the pandemic [16,17,61]. A rise in suicides may be specific to certain subgroups, e.g. in elderly women in Germany [17]. ...
Article
Full-text available
Psychiatric patients are prone to mental health deterioration during the Covid-19 pandemic. Little is known about suicidality in psychiatric patients during the Covid-19 pandemic. This study is a retrospective chart review of psychiatric emergency department (pED) presentations with present or absent suicidality (5634 pED attendances, 4110 patients) in an academic pED in Berlin, Germany. Poisson regression analysis was performed on the effect of Covid-19 period on suicidality (suicidal ideation (SI), suicide plans (SP) or suicide attempt (SA)) during the first (3/2/2020–5/24/2020 “first-wave”) and second (9/15/2020–3/1/2021 “second-wave”) wave of the Covid-19 pandemic compared to the same periods one year earlier. During the first-wave the number of pED visits per person with SI, SP and SA was higher compared to one year earlier (SI RR = 1.614; p = 0.016; SP RR = 2.900; p = 0.004; SA RR = 9.862; p = 0.003). SI and SP were predicted by interaction between substance use disorder (SUD) and second-wave (SI RR = 1.305, p = 0.043; SP RR = 1.645, p = 0.018), SA was predicted by interaction between borderline personality disorder (BPD) and second-wave (RR = 7.128; p = 0.012). Suicidality increased during the first-wave of Covid-19 pandemic in our sample. In the second-wave this was found in patients with SUD and BPD. These patients may be at particular risk of suicidality during the Covid-19 pandemic.
... The COVID-19 pandemic initially raised concerns about increased suicides, particularly due to stressors such as unemployment, financial strain, and social disconnectedness, however data from the earliest months of the pandemic generally showed no increases, including in three Canadian provinces (Alberta, British Columbia, Manitoba) (see Supplemental file). 1,2 Experts have recommended cautious media reporting about the pandemic's potential effects on suicides, 3 as suicide-related media discussions can influence populationlevel behavior. 4 Specifically, reporters have been advised against presenting unbalanced, pessimistic statements about the pandemic's impact on suicides, as such messages may increase suicide risk. ...
... His explanation is that individuals are united around major national issues that rekindle the sense of belonging to a community. Indeed, data from 21 countries or areas show that there was no increase in suicide in the early months of the COVID-19 pandemic, and even a decrease in 12 of them (Pirkis et al., 2021). 16 One could also think of a purely seasonal effect, as the SHARE Corona Survey was conducted in summer 2020. ...
Article
Full-text available
Did the first wave of the COVID-19 epidemic and the various lockdown measures taken by European governments in the spring of 2020 impact individuals aged 50 and over differently according to their living arrangements and housing conditions? Focusing on three indicators of mental well-being, depression, loneliness and trouble sleeping, this paper answers the question using data on Europeans interviewed in the SHARE Corona Survey, fielded right after the first wave of the pandemic in summer 2020, linked longitudinally with two previous waves of SHARE (2013 and 2015). We find that the first wave of the pandemic changed the association between mental health and living arrangements and housing conditions. New to this pandemic period, the mental well-being of those who lived only with a spouse declined relative to the general population aged 50+. Relatedly, there was a protective impact for parents of having (adult) children in the same building as opposed to children, however close, who were not co-residing. Finally, living in cities and in multi-unit housing also led to a decrease in mental well-being relative to the general population aged 50+.
... 1 These adverse effects of the pandemic on youths' mental health might be exacerbated by fear of contagion, deaths of friends or family members, self-isolation, and physical distancing. 2 Thus, suicide among youth has become a topic of concern as the pandemic continues to affect the general population, 3 especially in Japan, where suicide has been the number one cause of death for young populations. 4 Studies have extensively investigated the trends in suicide during the pandemic among the general population in Japan 5−8 and abroad, 9,10 which found that suicide rates initially decreased compared to previous years 5 but subsequently increased into 2021. Of note, two studies provided robust evidence that suicide rates among younger populations in Japan increased later into the pandemic in 2020, after accounting for time trends and seasonality. ...
Article
Full-text available
Background The COVID-19 pandemic posed many mental health challenges to youth through unprecedented infection control measures such as nationwide school closures. Despite this, few studies have investigated trends in suicide among youth during the pandemic, let alone their reasons. Methods Population-level data on crude monthly suicide rates (2016–2021) and reasons of suicide (2018–2020) among youth aged 10-19 years were obtained from the Japanese Ministry of Health, Labour and Welfare and the National Police Agency, respectively. Using an event study design (with a Poisson regression model to calculate changes-in-changes (CiC) estimates) and interrupted time series analysis, we investigated changes in monthly suicide rates during the first 12 months of the pandemic (May 2020 to April 2021) compared to pre-pandemic levels (May 2016 to March 2020). Additionally, we investigated the changes in reasons of suicide (family-related, mental illness, social concerns, and academic concerns). Findings In the event study analysis, suicide rates among youth increased during the pandemic relative to pre-pandemic levels, especially between August-November 2020 (e.g., ratio of the suicide rate in November 2020 relative to previous years, 1.86; 95% confidence interval (CI), 1.30 to 2.66). Though suicide levels returned closer to pre-pandemic levels by December 2020, they remained slightly elevated into 2021. In the interrupted time series analysis, suicide rates increased from May to August 2020 (0.099 cases per 100,000 youth per month; 95% CI, 0.022 to 0.176), followed by a decrease from September to December 2020 (-0.086 cases per 100,000 youth per month; 95% CI, -0.164 to -0.009). We observed elevated suicide rates for all major reasons from summer to autumn 2020, especially suicides attributed to family-related problems and social concerns. Furthermore, rates of suicides attributed to mental illness remained higher than pre-pandemic levels into December 2020. Interpretation Suicide rates among youth remained slightly elevated compared to pre-pandemic levels into 2021. The reasons of the increase in suicide rates were multifactorial, including mental health issues and disruptions in social relationships. During a pandemic, interventions that provide mental support as well as opportunities for regular social interactions to youth may be beneficial. Funding Norwegian Agency for International Cooperation and Quality Enhancement in Higher Education.
Article
Full-text available
Concerns have been raised about early vs. later impacts of the COVID-19 pandemic on suicidal behavior. However, data remain sparse to date. We investigated all calls for intentional drug or other toxic ingestions to the eight Poison Control Centers in France between 1st January 2018 and 31st May 2022. Data were extracted from the French National Database of Poisonings. Calls during the study period were analyzed using time trends and time series analyses with SARIMA models (based on the first two years). Breakpoints were determined using Chow test. These analyses were performed together with examination of age groups (≤ 11, 12–24, 25–64, ≥ 65 years) and gender effects when possible. Over the studied period, 66,589 calls for suicide attempts were received. Overall, there was a downward trend from 2018, which slowed down in October 2019 and was followed by an increase from November 2020. Number of calls observed during the COVID period were above what was expected. However, important differences were found according to age and gender. The increase in calls from mid-2020 was particularly observed in young females, while middle-aged adults showed a persisting decrease. An increase in older-aged people was observed from mid-2019 and persisted during the pandemic. The pandemic may therefore have exacerbated a pre-existing fragile situation in adolescents and old-aged people. This study emphasizes the rapidly evolving situation regarding suicidal behaviour during the pandemic, the possibility of age and gender differences in impact, and the value of having access to real-time information to monitor suicidal acts.
Article
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Aims It remains unclear whether the coronavirus disease 2019 (COVID-19) pandemic is having an impact on suicide rates (SR). Economic insecurity and mental disorders are risk factors for suicide, which may increase during the pandemic. Methods Data on suicide events in a major city in Germany, and the corresponding life years (LY) were provided by the local authorities. For the year 2020, periods without restrictions on freedom of movement and social contact were compared with periods of moderate and severe COVID-19 restrictions. To avoid distortions due to seasonal fluctuations and linear time trends, suicide risk during the COVID-19 pandemic was compared with data from 2010 to 2019 using an interrupted time series analysis. Results A total of 643 suicides were registered and 6 032 690 LY were spent between 2010 and 2020. Of these, 53 suicides and 450 429 LY accounted for the year 2020. In 2020, SR (suicides per 100 000 LY) were lower in periods with severe COVID-19 restrictions (SR = 7.2, χ ² = 4.033, p = 0.045) compared with periods without restrictions (SR = 16.8). A comparison with previous years showed that this difference was caused by unusually high SR before the imposition of restrictions, while SR during the pandemic were within the trend corridor of previous years (expected suicides = 32.3, observed suicides = 35; IRR = 1.084, p = 0.682). Conclusions SR during COVID-19 pandemic are in line with the trend in previous years. Careful monitoring of SR in the further course of the COVID-19 crisis is urgently needed. The findings have regional reference and should not be over-generalised.
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There is increasing concern that the coronavirus disease 2019 (COVID-19) pandemic could harm psychological health and exacerbate suicide risk. Here, based on month-level records of suicides covering the entire Japanese population in 1,848 administrative units, we assessed whether suicide mortality changed during the pandemic. Using difference-in-difference estimation, we found that monthly suicide rates declined by 14% during the first 5 months of the pandemic (February to June 2020). This could be due to a number of complex reasons, including the government’s generous subsidies, reduced working hours and school closure. By contrast, monthly suicide rates increased by 16% during the second wave (July to October 2020), with a larger increase among females (37%) and children and adolescents (49%). Although adverse impacts of the COVID-19 pandemic may remain in the long term, its modifiers (such as government subsidies) may not be sustained. Thus, effective suicide prevention—particularly among vulnerable populations—should be an important public health consideration.
Preprint
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Background Various surveys have documented a negative impact of the COVID-19 pandemic on the population’s mental health. There is widespread concern about a surge of suicides, but evidence supporting a link between global pandemics and suicide is very limited. Using historical data from the three major influenza pandemics of the 20 th century, and recently released data from the first half of 2020, we aimed to investigate whether an association exists between influenza deaths and suicide deaths. Methods Annual data on influenza death rates and suicide rates were extracted from the Statistical Yearbook of Sweden from 1910-1978, covering the three 20 th century pandemics, and from Statistics Sweden for the period from January to June of each year during 2000-2020. COVID-19 death data were available for the first half of 2020. We implemented non-linear autoregressive distributed lag (NARDL) models to explore if there is a short-term and/or long-term effect of increases and decreases in influenza death rates on suicide rates during 1910-1978. Analyses were done separately for men and women. Descriptive analyses were used for the available 2020 data. Findings Between 1910-1978, there was no evidence of either short-term or long-term significant associations between influenza death rates and changes in suicides. The same pattern emerged in separate analyses for men and women. Suicide rates in January-June 2020 revealed a slight decrease compared to the corresponding rates in January-June 2019 (relative decrease by −1.2% among men and −12.8% among women). Interpretation We found no evidence of short or long-term association between influenza death rates and suicide death rates across three 20 th century pandemics or during the first six months of 2020 (when the first wave of COVID-19 occurred). Concerns about a substantial increase of suicides may be exaggerated. The media should be cautious when reporting news about suicides during the current pandemic.
Preprint
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This paper examines whether the COVID-19-induced employment shock has increased suicides and the utilization of means-tested poverty alleviation programs in the first eight months of the COVID-19 crisis. We exploit plausibly exogenous regional variation in the magnitude of the employment shock in Japan and adopt a difference-in-differences (DID) research design to identify the employment-shock impact. Our preferred point estimates suggest that a one-percentage-point decrease in the employment rate in the second quarter of 2020 resulted in an additional 0.14-0.44 male suicides per one hundred thousand male population in June 2020 and an additional 5.3-7.9 Public Assistance recipients per one hundred thousand population in August 2020. The impacts on female suicides and other poverty alleviation programs are not precisely estimated, but there is suggestive evidence that the same employment shock has also increased the caseloads of the other poverty alleviation programs. We also examine the impact of the increase in the unemployment rate and find a positive impact on the poverty alleviation programs but not on suicides.
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