Suicide in Hong Kong during the COVID-19 pandemic: an observational study

Abstract

Introduction
The COVID-19 pandemic has exacerbated suicide risk factors in Hong Kong, which faces economic shocks and strict travel restrictions due to its unique economic structure and geographical location. However, there is a scarcity of reliable empirical evidence regarding the relationship between the pandemic and suicide mortality. This study examines whether changes in the suicide rate align with COVID-19 situations and anti-COVID-19 policy events in Hong Kong, focusing on vulnerable population groups based on demographic and socioeconomic characteristics.

Methods
Suicide data spanning 1 January 2019 to 31 December 2022 were sourced from the Hong Kong Suicide Press Database. Case-level data were aggregated monthly by district. Population-weighted Poisson regression with district-level fixed effects was employed to analyse suicide patterns and their association with COVID-19 developments. Robustness checks and demographic-based heterogeneity analysis were conducted, distinguishing suicide risk among different population groups.

Results
A total of 4061 suicide cases were analysed, encompassing deaths and attempts. The first wave of the pandemic saw a 30% decline in suicide cases compared with the 2019 average, while the second and fifth waves witnessed increases of 33% and 51% in suicide rates, respectively. Older adults and individuals with lower socioeconomic status were particularly susceptible to the adverse effects, as evidenced by a significant rise in suicides during the fifth wave.

Conclusions
The findings underscore the importance of targeted interventions to address the mental health needs of vulnerable populations during pandemics, highlighting the impact of COVID-19 situations and antipandemic policies on the suicide rate.

Full text

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BaiA, etal. BMJ Public Health 2024;2:e001125. doi:10.1136/bmjph-2024-001125
Suicide in Hong Kong during the
COVID- 19 pandemic: an observational
study
Anying Bai ,1 Jinjian Li,2 Yuhang Pan,3 Yu Jiang4
Original research
To cite: BaiA, LiJ, PanY, etal.
Suicide in Hong Kong during
the COVID- 19 pandemic: an
observational
study. BMJ Public Health
2024;2:e001125. doi:10.1136/
bmjph-2024-001125
►Additional supplemental
material is published online only.
To view, please visit the journal
online (https:// doi. org/ 10. 1136/
bmjph- 2024- 001125).
AB and JL are joint rst authors.
Received 4 March 2024
Accepted 29 May 2024
1School of Population Medicine
and Public Health, Chinese
Academy of Medical Sciences &
Peking Union Medical College,
Beijing, China
2The Hong Kong University of
Science and Technology, Hong
Kong, Hong Kong SAR
3Institute for Global Health and
Development, Peking University,
Beijing, China
4School of Health Policy and
Management, Chinese Academy
of Medical Science & Peking
Union Medical College, Beijing,
China
Correspondence to
Professor Yu Jiang;
jiangyu@ pumc. edu. cn and
Professor Yuhang Pan;
yhpan@ pku. edu. cn
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY- NC.
Published by BMJ.
ABSTRACT
Introduction The COVID- 19 pandemic has exacerbated
suicide risk factors in Hong Kong, which faces economic
shocks and strict travel restrictions due to its unique
economic structure and geographical location. However,
there is a scarcity of reliable empirical evidence
regarding the relationship between the pandemic and
suicide mortality. This study examines whether changes
in the suicide rate align with COVID- 19 situations and
anti- COVID- 19 policy events in Hong Kong, focusing on
vulnerable population groups based on demographic and
socioeconomic characteristics.
Methods Suicide data spanning 1 January 2019 to 31
December 2022 were sourced from the Hong Kong Suicide
Press Database. Case- level data were aggregated monthly
by district. Population- weighted Poisson regression with
district- level xed effects was employed to analyse
suicide patterns and their association with COVID- 19
developments. Robustness checks and demographic-
based heterogeneity analysis were conducted,
distinguishing suicide risk among different population
groups.
Results A total of 4061 suicide cases were analysed,
encompassing deaths and attempts. The rst wave of the
pandemic saw a 30% decline in suicide cases compared
with the 2019 average, while the second and fth waves
witnessed increases of 33% and 51% in suicide rates,
respectively. Older adults and individuals with lower
socioeconomic status were particularly susceptible to
the adverse effects, as evidenced by a signicant rise in
suicides during the fth wave.
Conclusions The ndings underscore the importance of
targeted interventions to address the mental health needs
of vulnerable populations during pandemics, highlighting
the impact of COVID- 19 situations and antipandemic
policies on the suicide rate.
INTRODUCTION
The global impact of the COVID- 19 pandemic
has had far- reaching consequences, including
a concerning rise in suicide rates (SR).
According to the World Bank, the pandemic
has caused a contraction of economic activity
in nearly 90% of countries, surpassing the
declines witnessed during World Wars and
the Great Depression.1 This economic
downturn has significantly impacted house-
holds, with surveys indicating that over a
third of respondents have ceased working
due to the pandemic and 64% of house-
holds have experienced income reductions.
The unprecedented changes and restrictions
associated with the pandemic have contrib-
uted to heightened levels of stress, isolation
and uncertainty, thereby elevating the risk
of suicide. Studies examining the impact of
WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒Limited studies on suicide risk during COVID- 19 out-
break, with only three previous relevant studies, two
conducted in Taiwan and Japan.
⇒No research examined the link between the
COVID- 19 pandemic and suicide behaviours in Hong
Kong using real- world data.
⇒This study addresses the gap by focusing on the
suicide pattern in a relatively isolated city during
COVID- 19, providing large- scale evidence from
2020 to 2022.
WHAT THIS STUDY ADDS
⇒Notable changes in the suicide rate corresponding
to COVID- 19 situations and anti- COVID- 19 policy
events, especially quarantine requirements and the
Consumption Voucher Scheme.
⇒Effects of the pandemic not evenly distributed; sui-
cide rates more likely to increase in low- income
population and elderly groups.
HOW THIS STUDY MIGHT AFFECT RESEARCH,
PRACTICE OR POLICY
⇒Hong Kong’s proactive policy response succeeded in
curtailing the spread of COVID- 19 and effectively al-
leviated associated adverse outcomes, such as eco-
nomic distress and a potential rise in suicide cases.
⇒Governments and agencies should promote mental
well- being, targeting determinants of poor mental
health exacerbated by the pandemic, especially
among specic subgroups.
⇒Ongoing close monitoring of suicide risks and imple-
mentation of corresponding public policies remain
a priority globally due to the recurring nature of the
COVID- 19 epidemic.
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2BaiA, etal. BMJ Public Health 2024;2:e001125. doi:10.1136/bmjph-2024-001125
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COVID- 19 on suicide mortality have yielded mixed find-
ings. Some research has suggested an increase in SR
during the pandemic, potentially attributed to factors
such as economic stress, social isolation and disruptions
to mental health.2 Conversely, other sources have indi-
cated that there is no definitive evidence of a change in
SR since the onset of the pandemic.3 4
Hong Kong, a prosperous metropolis located in the
southeast of China, is an autonomous region with a
heavily externally oriented economy. Hong Kong was
greatly impacted by the COVID- 19 pandemic. Specifi-
cally, the overall excess mortality per 100 000 popula-
tion was 25 in 2020,5 and the unemployment rate hit
7.2% in December 2020, the highest value in 16 years.6
Daily arrivals into the city dramatically declined after
the Chinese New Year holidays at the end of January
2020, and further plummeted following the imple-
mentation of home quarantine arrangements for all
arrivals from mainland China on 8 February 2020.7
Furthermore, Hong Kong experienced a relatively
high COVID- 19 fatality rate, as evidenced by the case
fatality rate during the Omicron outbreak, which was
significantly higher than that of Singapore, standing
at 0.53% compared with 0.06%.8 The prolonged stress
and uncertainty caused by the pandemic can lead
to profound risks of mental health issues in the city.
Particularly, one research conducted in the aftermath
of the 2003 SARS outbreak in Hong Kong revealed a
notable increase in the SR among the elderly popula-
tion.9 Considering Hong Kong’s ageing population and
the more severe nature of COVID- 19, the risk of suicide
may be even higher than what was observed during the
2003 SARS outbreak.
However, reliable empirical evidence establishing
a clear link between the COVID- 19 pandemic and
suicide mortality remains scarce, and conclusions
drawn from previous research on whether the SR will
rise as the pandemic spreads have been inconsistent.
Some evidence suggests that deaths by suicide have
increased, and mental health has deteriorated during
the pandemic.2 10 Nevertheless, several previous reviews
propose that although SR may sometimes increase
following public health emergencies, these changes
may not necessarily occur immediately and there may
even be an initial reduction in risk.11 In contrast, a
comprehensive international study encompassing data
from 33 countries revealed that the majority of these
nations did not experience an increase in suicide cases
(SC).12 Other studies have also demonstrated no signifi-
cant increases or even decreases in suicide deaths, espe-
cially during the initial months of the pandemic.13 The
impact of the pandemic on suicide outcomes can vary
depending on factors such as a country’s public health
control measures, sociocultural and demographic struc-
tures, availability of digital alternatives to face- to- face
consultation and existing support systems.11 Compared
with other regions and countries examined in similar
studies, Hong Kong may have suffered more severe
economic shocks and stricter travel restrictions during
the pandemic due to its unique economic structure
and geographical location. To the best of our knowl-
edge, this paper represents the first focused investiga-
tion into the suicide pattern in Hong Kong during the
COVID- 19 pandemic.
This study provides large- scale evidence examining
the association between the COVID- 19 pandemic and
changes in the SR in Hong Kong from 2020 to 2022. To
achieve this, we aggregated individual SC at the district-
month level and tested two hypotheses in this paper.
First, we hypothesised that there was a corresponding
change in the SR following the evolving trends of
COVID- 19 situations and anti- COVID- 19 policy events.
Second, taking into account demographic and socio-
economic characteristics, we posited that certain popu-
lation groups were more susceptible to the adverse
effects of the pandemic.
MATERIALS AND METHODS
Data sources
The data on suicide are obtained from the Hong Kong
Suicide Press Database, which records each media-
reported suicide death case (SDC) or attempted SC
from 1 January 2019 to 31 December 2022. Media-
reported suicide data are an important measure of
self- harm in Hong Kong, covering the whole city’s 7.5
million citizens.14 15 The advantage of using media-
reported SC is that we can know the number of suicide
deaths and explore the changes in suicide attempts
during the COVID- 19 pandemic. In online supple-
mental figure S2, we formally compare our data with
the aggregated statistics by the Coroner’s Court in
Hong Kong. We found that the two datasets share
similar magnitudes and patterns in various dimensions.
Data on COVID- 19 infections were obtained from the
Hong Kong Department of Health. Each district’s soci-
oeconomic statistics during the research period were
obtained from the Hong Kong Census and Statistics
Department. The data include numbers of domestic
households, average domestic household size, propor-
tions of owner- occupiers and median monthly house-
hold income statistics for each district, which are all
provided in online supplemental table S2. Details of the
study population inclusion process were provided in
online supplemental figure S1. In this study, we analysed
the characteristics of suicides during the COVID- 19
pandemic, not of suicides caused by COVID- 19 infec-
tion, as data on individuals affected by COVID- 19 who
engaged in suicidal behaviour were unavailable.
Measure of SC
Suicide is defined as death caused by self- directed injurious
behaviour with the intent to die as a result of the behav-
iour, and a suicide attempt is a self- initiated sequence
of behaviours by an individual who, at the time of initia-
tion, expected that the set of actions would lead to their
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BaiA, etal. BMJ Public Health 2024;2:e001125. doi:10.1136/bmjph-2024-001125 3
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own death.16 For each case, the geographical location,
date, time and demographics of the suicide person have
been recorded. During our research period, a combined
total of 4061 SCs, encompassing both suicide deaths and
attempts, were reported across Hong Kong’s 18 districts.
Among these cases, 3004 persons were recorded as having
died by suicide, resulting in an average monthly SR of 8.34
per million population. The methods of suicide were also
recorded, including jumping, hanging, charcoal burning,
drowning, bleeding and others (eg, firearms, poisoning,
self- immolation, overdose with prescription and non-
prescription medications, traffic, gas, liquid and suffoca-
tion). Jumping accounted for the largest proportion of
suicides from 2019 to 2022, comprising over 55% of all SCs.
Hanging consistently ranked as the second most prevalent
method of suicide across all years (see online supplemental
figure S3).
Pandemic onset and study period
Based on the epidemiological investigation of commu-
nity outbreaks and the predominant virus strains, Hong
Kong experienced five distinct waves of COVID- 19 from
2020 to 2022 (online supplemental table S4).17 The first
8 weeks in 2020 were defined as pandemic wave 1; weeks
9–16 and weeks 25–36 in 2020 were defined as pandemic
waves 2 and 3, respectively; weeks 41 (November 2020)
to 64 (April 2021) were classified as pandemic wave 4.
Finally, wave 5 commenced in the fourth week of 2022
and extended until December 2022.
The Hong Kong government has implemented a series
of significant COVID- 19- related policies, encompassing
mandatory quarantine requirements for all travellers
and the phased implementation of the Consumption
Voucher Scheme (CVS). Details of these policies could
be found in the online supplemental materials.
Patient and public involvement
Patients or the public were not involved in the design,
or conduct, or reporting, or dissemination plans of our
research.
Statistical analysis
In practice, we aggregated the case- level data to the
district by month level. The statistical analysis was done in
three phases (full analysis model described in the online
supplemental materials). First, employing population-
weighted Poisson regression with district- level fixed
effects, we examined the pattern of suicide incidence
and its association with local COVID- 19 developments.
Our baseline model estimated the incidence rate ratios
(IRR) for each year- month from 2020 to 2022 with 95%
CIs, taking the year 2019 as the reference group. Second,
we performed multiple robustness checks to validate the
relationship between changes in SC and major events
during the pandemic, such as the surge in COVID- 19
cases and the implementation of the government’s
CVS. Third, through heterogeneity analysis based on
demographic characteristics, we further distinguished
the suicide risk among different population groups.
Our focus was on two outcomes of suicide: SCs, which
combine both suicide deaths and attempted SC, and
SDC. The main text primarily demonstrates the results
on SC, and results on SDC are presented in the online
supplemental materials.
RESULTS
Main results
Figure 1 depicts the yearly average of combined cases of
suicide deaths and suicide attempts per 100 000 popula-
tion in each district in Hong Kong from 2019 to 2022. We
found the majority of districts witnessed an elevated SR
during the COVID- 19 period. Comparable trends were
also observed in SDC (online supplemental figure S4).
Furthermore, online supplemental table S3 demonstrates
that districts with lower proportions of owner- occupiers
exhibited higher SR. However, the income level, number
of local households and average household size did not
exhibit statistically significant associations with local SR.
Figure 2 presents the monthly SC in Hong Kong from
2019 to 2022, highlighting the pandemic situation. The
y- axis demonstrates the number of monthly SC and SDC.
The implementations of key COVID- 19- related policies
are marked in dotted lines. A steadily increasing trend
in both SC and SDC was identified in waves 1 and 2
(figure 2). After that, SC and SDC declined substantially
between waves 2 and 3. However, SC increased again
significantly during wave 3 in May 2020, coinciding with
the implementation of quarantine requirements for
all travellers. Following a slight decrease in SC during
wave 4, SC and SDC dropped remarkably in October
and December 2021, attributed to the CVS 2021 by the
government. Wave 5 exhibited the highest increase in SC
(March and May 2022), although the impact was miti-
gated by the introduction of the CVS in 2022.
Figure 3 reports the estimated IRR of SC for each
month from 2020 to 2022 relative to the corresponding
months in the year 2019 (see online supplemental
methods and table S1). The estimates, accounting for
district- specific effects, revealed a 30% decline in the
overall SR (IRR=0.70, 95% CI 0.56 to 0.87) during the
initial COVID- 19 outbreak compared with previous years.
In contrast, the SR increased by 33% (IRR=1.33, 95% CI
1.02 to 1.74) during wave 2 and 51% (IRR=1.51, 95% CI
1.09 to 2.09) during wave 5 (online supplemental table
S1 and figure 3). A declining suicide trend was apparent
during the third wave, with a 37% decrease in October
2021 and a 23% decrease in November 2021. In online
supplemental figures S4 and S5, we test the robustness
of these results. Online supplemental figure S5 exam-
ined the change in IRR of SDC. Online supplemental
figure S6 used ordinary least squares regression instead
of Poisson regression to test the fluctuation of suicide
incidence patterns with local COVID- 19 developments.
All the results remained similar to the baseline pattern.
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4BaiA, etal. BMJ Public Health 2024;2:e001125. doi:10.1136/bmjph-2024-001125
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Figure 1 Yearly suicide incident cases per 100 000 population in Hong Kong from 2019 to 2022. (A) Suicide incident cases
per 100 000 population in each district of Hong Kong in 2019. (B) Suicide incident cases per 100 000 population in each district
of Hong Kong in 2020. (C) Suicide incident cases per 100 000 population in each district of Hong Kong in 2021. (D) Suicide
incident cases per 100 000 population in each district of Hong Kong in 2022.
Figure 2 Monthly suicide cases in Hong Kong from 2019 to 2022. The dotted lines indicate the implementation of important
antipandemic policies. CVS, Consumption Voucher Scheme.
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Figure 4 Cumulative suicide cases in the entire population and in different gender and age groups in Hong Kong from 2019 to
2022. (A) Results of the cumulative number of suicide cases among the whole population from 2019 to 2022. (B, C) Results of
comparing cumulative number of suicide cases among males (B) and females (C). (D–F) Results for different age groups: under
25 years (D), 25 - 65 years (E) and ≥65 years (F).
Figure 3 Changes in suicide incidence rate ratio (IRR) for each month from 2020 to 2022, relative to the corresponding
months in the year 2019.
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Heterogeneity across subgroups
Figure 4 describes the cumulative SC in Hong Kong
from 2019 to 2020 in the entire population and across
different gender and age groups. Notably, a significant
rise in cumulative SC was observed among the elderly
population (65+ years old), while the total number of
cases remained relatively stable among children and
adolescents. In 2019, the cumulative SCs among elders
aged over 65 years were 318, while this number reached
410 in 2022, bringing about 92 excess SC during the
pandemic. Similar patterns were observed for SDC, as
depicted in online supplemental figure S7.
We then formally and separately investigated the IRR
across different gender groups (figure 5A,B), age groups
Figure 5 Changes in suicide incidence rate ratio (IRR) in heterogeneous population groups from 2020 to 2022. (A- B) Results
of comparing cumulative number of suicide cases among males (A) and females (B). C–F) Results for different age groups:
below 25 years (C), 25–45 years (D), 45–65 years (E) and ≥65 years (F). (G, H) Results among population groups residing in
different housing conditions: cases from private houses (G), cases from public houses (H).
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(figure 5C–F) and economic status groups (figure 5G,H).
These analyses revealed notable heterogeneous effects
of the pandemic among these population groups.
Figure 5A,B investigate the impacts across different
gender groups. We did not observe a significant differ-
ence in the SR between females and males during waves
1–4. However, the SR increased dramatically among
the female population in March 2022 (IRR=1.77, 95%
CI 1.04 to 3.02) and May 2022 (IRR=1.67, 95% CI 1.13
to 2.46) during wave 5 (online supplemental table S5).
By contrast, the SR for males only increased by 35% in
March 2022 (IRR=1.35, 95% CI 0.95 to 1.92).
Figure 5C–F explore the impacts across different age
groups. We found that SR declined consistently among
younger adults (individuals aged 25–45 years). For
adults below 25 years old, the most significant decrease
occurred in August 2020 (IRR=0.38, 95% CI 0.16 to 0.91)
and February 2022 (IRR=0.22, 95% CI 0.05 to 0.95). For
adults aged 25–45 years, a more pronounced decline in
SR was observed in February 2020 (IRR=0.39, 95% CI
0.15 to 1.05) and December 2021 (IRR=0.53, 95% CI 0.29
to 0.96). In contrast, SR increased markedly among older
adults (aged over 65 years) during wave 5, with the most
pronounced elevation observed in March 2022 by 127%
(IRR=2.27, 95% CI 1.50 to 3.42) and in May 2022 by 47%
(IRR=1.47, 95% CI 1.03 to 2.09).
Figure 5G,H examine the heterogeneous pattern of SC
among population groups residing in different housing
conditions. In Hong Kong, living in public houses typi-
cally represents a relatively lower household socioeco-
nomic status (SES). Due to the lack of specific population
data for these two population groups in each district, the
outcome variable in figure 5G,H presents the number
of SC at the district- year- month level. We observed a
substantial increase in the SR among the population
with lower SES in March 2022 (IRR=1.19, 95% CI 0.10
to 2.27), while no significant increase in SR was observed
among the population living in private houses.
DISCUSSION
This study investigated the suicide patterns in Hong
Kong during the COVID- 19 pandemic from 2020 to
2022. There was a noticeable corresponding change in
the SR with the trends of COVID- 19 situations and the
anti- COVID- 19 policy events, particularly the policies of
quarantine requirements for all travellers and the govern-
ment’s CVS. Moreover, we highlighted that the impacts
of the pandemic were not evenly distributed among
different population groups, with distinct differences
observed based on demographic and socioeconomic
characteristics. Specifically, the SRs were more likely to
increase among the elderly groups and the low- income
population.
Consistent with previous research findings, our study
observed a trend of increasing suicides during and after
pandemics.18 19 During the COVID- 19 pandemic, the
number of SCs in Hong Kong increased steadily from
waves 1–2 to wave 4, followed by a dramatic surge during
wave 5, primarily attributed to the Omicron outbreak.
Several factors may have influenced these SRs, including
pre- existing health inequalities related to gender, age,
economic status and underlying health conditions. Addi-
tionally, the implementation of strict measures such as
isolating infected individuals, mandatory quarantine
requirements, travel restrictions, school closures, mask
mandates and compulsory social distancing would
also burden the population’s mental health, leading to
heightened emotional distress and an increased risk of
subsequent psychiatric symptoms.20
Considering the discrepancy in gender identity and
social norms, the suicide patterns between males and
females might be different. In this study, we observed
that the SR of the female population increased dramati-
cally in March 2022 (IRR=1.77, 95% CI 1.04 to 3.02) and
May 2022 (IRR=1.67, 95% CI 1.13 to 2.46). Compara-
tively, SC among males only increased by 35% in March
2022 (IRR=1.35, 95% CI 0.95 to 1.92) and did not show a
noticeable growth in May 2022. Females are known to be
more likely to bear the brunt of the social and economic
consequences of the pandemic,21 and can consequently
develop various forms of mental disorders, including
depression, anxiety, post- traumatic stress disorder and
stress.22 During the studied pandemic period, females
experienced greater psychological distress due to their
over- representation in industries negatively impacted
by COVID- 19, such as retail, service and healthcare. In
addition to the disproportionate effects of employment
disruptions on females, several research studies also indi-
cate that females may have a higher prevalence of certain
mental disorders due to differential neurobiological
responses to stressors.23
The downsizing of the economy and the overwhelming
focus of the medical system on the COVID- 19 pandemic
can potentially lead to unintended long- term conse-
quences for vulnerable groups on the fringes of society.
Individuals with chronic diseases and a history of medical
or psychiatric illnesses showed more symptoms of anxiety
and stress, consequently having an increased SR under
the strict quarantine measures, travel restrictions, physical
distancing protocols and lockdown policies implemented
during the pandemic.24 The pre- existing conditions
rendered them susceptible to infection and heightened
the risk of mortality, with certain illnesses even compro-
mising their immune systems, such as systemic lupus
erythematosus.25 In Hong Kong, where over 18% of the
population is aged over 65 years, only 3.6% of them reside
in residential institutions or nursing homes. Compared
with children and adolescents, older adults may possess
inadequate resources to effectively cope with the stress
brought about by the COVID- 19 crisis. This may include
material (eg, lack of access to digital devices and the
internet), social (eg, limited family or social support),
cognitive (eg, limited exposure to health- related infor-
mation and knowledge) and biological (eg, pre- existing
chronic diseases or the inability to engage in physical
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exercise) resources.26 Several reports also reveal substan-
tially higher mortality rates among patients with diabetes,
hypertension and other coronary heart diseases, yet
the exact causes remain unknown,27 leaving those with
these common chronic conditions in a state of fear and
uncertainty.
In response to the crisis, the Hong Kong government
initiated the CVS, which aimed to alleviate economic
distress and potentially contribute to the decline in
SC during the pandemic waves 4 and 5. The impact of
this policy might be particularly noteworthy among the
population with low household SES. In our subgroup
analysis, we indeed observed a significant increase in
the SR exclusively among the population residing in
public houses (IRR=1.19, 95% CI 0.10 to 2.27) during
wave 5. Conversely, we consistently observed a decline in
SR among the population living in private houses from
wave 1 to wave 5. It is important to note that in Hong
Kong, only people with lower SES are eligible to apply
for public housing. The pandemic has exacerbated the
financial pressure for low SES families, making it more
challenging to maintain a quality life and increasing job
insecurity. Consequently, the low SES population may
need to work longer hours to secure employment and
meet daily necessities for their families,28 resulting in
feelings of helplessness, fear and anxiety. Our findings
were generally consistent with previous large- scale local
surveys that have demonstrated a few significant differ-
ences in negative impacts on mental health between
populations at the higher and lower ends of the SES
spectrum, as well as between populations with higher and
lower levels of depressive symptoms prior to the onset of
the COVID- 19 pandemic.29
Finally, it is important to acknowledge the limitations
of this study. First, the accuracy of the media- reported
suicide data may be compromised, as there is a possibility
that some suicide deaths or attempts were not discov-
ered or were reported with some delay. Previous studies
have highlighted the inadequate precision of suicide risk
factor reporting by the mass media in Hong Kong, poten-
tially resulting in under- reporting of SR city- wide and
throughout the pandemic.30 To address this concern,
we performed a sensitivity analysis comparing our data
with the aggregated statistics from the Coroner’s Court in
Hong Kong. The findings from both datasets were consis-
tent, providing reassurance regarding the reliability of
our main results. Second, we used 1 year of prepandemic
data from 2019 due to availability. This approach may
introduce some instability when estimating the impact
of COVID- 19 on SR by juxtaposing 2019 data with post-
pandemic data spanning 2020–2022. Future studies
incorporating a longer prepandemic period would yield
more robust estimates of the pandemic’s influence on
SR. Third, given that this study was conducted within the
specific context of Hong Kong, caution must be exercised
when extrapolating our conclusions to other regions
with differing socioeconomic, cultural and healthcare
landscapes, particularly in light of varying anti- COVID- 19
policy measures. Prior investigations have underscored
the presence of heterogeneous pandemic effects on SR
across diverse demographic contexts.4 31 Consequently,
future research endeavours should strive to encompass a
more representative sample spanning multiple countries
or regions to enhance the generalisability of findings.
The COVID- 19 pandemic has presented numerous
unprecedented challenges for health research, service
provision and public health policies. While the impact
of the pandemic and government responses on suicide-
related consequences is not entirely new, pre- existing
inequalities have the potential to deepen, making it even
more challenging to address these issues, particularly in a
relatively isolated city during this period. In Hong Kong,
suicides increased during the pandemic period, espe-
cially among the elderly population and those with low
SES. Some policy responses in Hong Kong have demon-
strated their effectiveness in controlling the spread of
COVID- 19 and in mitigating some of the adverse effects
of the pandemic, such as the alleviation of economic
distress and the decline in SC. Nevertheless, it is crucial
for governments and other agencies to remain atten-
tive to mental well- being and target the determinants of
poor mental health that have been exacerbated by the
pandemic, especially among specific subgroups of the
population during and after the pandemic. Since the
infectious disease- induced epidemic is still happening
worldwide, continued vigilance and close monitoring of
the mental health of vulnerable populations remain a
priority.
Contributors The study was conceptualised by YP and YJ. Project administration
was managed by YJ and YP. Data collection was supervised and conducted in
part by AB and YP. Data analysis was performed by AB and YP, with assistance
and inputs by JL and YJ. The rst draft of the manuscript was written by AB, JL,
and YP. All authors reviewed and approved the nal manuscript. YP and YJ accept
responsibility as the guarantor of this publication.
Funding This research is funded by Research on the Construction of a New Public
Health Science System and Talent Training Model (No. 201920102401) .
Map disclaimer The depiction of boundaries on this map does not imply the
expression of any opinion whatsoever on the part of BMJ (or any member of its
group) concerning the legal status of any country, territory, jurisdiction or area or of
its authorities. This map is provided without any warranty of any kind, either express
or implied.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available in a public, open access
repository. The codes and data used in this study are available at https://zenodo.
org/records/12589670.
Supplemental material This content has been supplied by the author(s). It
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
been peer- reviewed. Any opinions or recommendations discussed are solely
those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability
and responsibility arising from any reliance placed on the content. Where the
content includes any translated material, BMJ does not warrant the accuracy and
reliability of the translations (including but not limited to local regulations, clinical
guidelines, terminology, drug names and drug dosages), and is not responsible
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BaiA, etal. BMJ Public Health 2024;2:e001125. doi:10.1136/bmjph-2024-001125 9
BMJ Public Health
for any error and/or omissions arising from translation and adaptation or
otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
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use is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
AnyingBai http://orcid.org/0000-0002-3121-1228
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