key: cord-0870322-rb9be621
authors: Barberis, Nadia; Cannavò, Marco; Cuzzocrea, Francesca; Verrastro, Valeria
title: Suicidal Behaviours During Covid-19 Pandemic: A Review
date: 2022-04-03
journal: Clinical neuropsychiatry
DOI: 10.36131/cnfioritieditore20220202
sha: e9ad17df6ccacf17d4cb562717f006d417e5a5fc
doc_id: 870322
cord_uid: rb9be621

OBJECTIVE: Novel COVID-19 disease has become a major concern worldwide, and a recent line of research warned that the context of the COVID-19 pandemic may be a major risk factor for developing severe suicidal behaviors. A broad systematic review is needed to cover the studies that have already assessed the potential underlying factors for suicidal behaviors in the context of the COVID-19 outbreak. METHOD: A total of 52 studies met the inclusion criteria, and data were then described according to the subsequent categories: (1) countries where the studies were carried out; (2) factors impacting suicidal behaviors during the COVID-19 outbreak; and (3) examination of the observed populations. RESULTS: Findings of the current systematic review suggest that there is a certain amount of heterogeneity in factors impacting suicidal behaviors during the COVID-19 outbreak, with economic downturn, psychiatric vulnerability, isolation and quarantine, health concerns, and relational difficulties being the most prominent reasons for developing suicidal behaviors during the COVID-19 outbreak. CONCLUSIONS: Timely interventions are needed to prevent suicidal behaviors in both the clinical and general populations, and in this regard, the creation of standard procedures may speed up the process.

Suicidal behaviors are increasing sharply as causes of mortality and relevant socioeconomic burden (Chen et al., 2012; Arensman et al., 2020) Recently, more than one million people have attempted suicide in Western countries (Piscopo et al., 2016) and nearly 800 000 individuals perish each year because of it (WHO, 2019) . Therefore, there is a widespread consensus regarding the public relevance of suicidal behaviors (Arensman et al., 2020; Chen et al., 2020; O'Connor et al., 2018) . Suicidal behaviors encompass a broad range of behaviors that may potentially end a person's life (Hemming et al., 2019) . They may include self-harming behaviors, suicide attempts, completed suicides, planning, and ideation (Silverman et al., 2007; Turecki & Brent, 2016) .

It is thought that stressors may foster risk of suicidal behaviors (Bøe et al., 2021; Chu et al., 2017) , and in this regard, changes caused by the newly appeared COVID-19 disease may be considered as stressors that can severely affect individuals' psychosocial functioning (Fardin, 2020; Kontoangelos et al., 2020) because of the relevant economic and interpersonal problems that occur during the pandemic (Abbiati et al., 2020; Casale & Flett, 2020; Sher, 2020) . Studies of previous pandemics have shown that the changes caused by them are significantly associated with increased odds of suicidal behaviors (Cheung et al., 2008; Hawryluck et al., 2004; Reynolds et al., 2007; Wasserman, 1992) due to a decrease in social encounters and difficulties adjusting to the context (Wasserman, 1992) . For instance, findings stemming from observations of the 2003 severe acute respiratory syndrome (SARS) outbreak suggested fears of contagion, perceived burden, general anxiety, social isolation, and psychological distress as relevant predictors of suicide rates. In a similar vein, Cheung et al. (2008) found an increase in suicide rates following the SARS epidemic and suggested that perceived interpersonal burden during the epidemic was a motive for suicide in many individuals. Parallel to previous outbreaks, changes due to COVID-19 may have an impact on the physical and mental health of the public, and therefore increased suicide rates may be likely to occur (Zalsman et al., 2020) .

In this regard, a line of studies emphasized the role of COVID-19 as a risk factor for higher levels of suicidal behaviors (Caballero-Domínguez et al., 2020; Que et al., 2020; Joiner et al., 2020; Zalsman et al., 2020) . Specifically, Gratz et al. (2020) highlighted that both environmental and personal factors such as thwarted belongingness and perceived burdensomeness

The screening procedure is described in figure  1 . A first group of 254 papers was identified by using the aforementioned keywords and then a total of 52 studies were finally included for the purposes of the current review. Specifically, the search first identified 254 publications, of which 48 were excluded because were duplicates. In addition, titles and abstracts of the remaining articles were screened for eligibility, and two more publications were excluded, one because it had no full text in English and one because it was a retracted article, while 70 were excluded because they were commentaries, letter to editors, case reports, brief reports, or reviews. A further 47 were excluded after fulltext assessment because they were not in accordance with the inclusion criteria previously described.

This review focuses on: (1) countries where the studies were carried out; (2) factors impacting suicidal behaviors during the COVID-19 outbreak; and (3) examination of the observed populations.

Analysis of the studies analyzed for the purposes of this review showed that the American continent was the most represented, with 15 studies being conducted in the United States of America, one in Canada, one in Colombia, and one in Argentina. A robust line of research was developed on the Asian continent, with China being the most represented country with five studies, while three were carried out in Japan and three in India. In are particularly predictive of increased odds of suicidal behaviors, whilst Winkler et al. (2020) suggested that higher levels of suicide risk during the COVID-19 outbreak occur when individuals experience strong health concerns. In addition, Zhou et al. (2020) emphasized that healthcare workers are likely to suffer from suicide risk in the presence of excessive outbreakrelated workload pressure.

The pandemic not only impacts individuals' physical and mental health but also has a severe impact on the economic dimension because of financial strain, unemployment, and bankruptcies. Such adverse consequences, in turn, may elicit psychosocial stress which may increase the possibility of suicide (Que et al., 2020) . Indeed, studies of past economic downturns have observed how they exacerbated suicidal behaviors (Reeves et al., 2014; Tapia Granados & Diez Roux, 2009; Värnik, 1991) , and in this regard, previous findings suggest an increased risk of suicidal behaviors during the Great Depression (Tapia Granados & Diez Roux, 2009 ) and that suicidality peaked when unemployment was at its highest during the 2008-2010 recession in Europe (Reeves et al., 2014) . In the context of economic strain inducted by COVID-19, Inoue et al. (2020) argued that economic hardship like decreasing salary growth rates and increasing unemployment may lead to increased rates of suicidal behaviors, whilst Vuorio and Bor (2020) argued they may increase due to prolonged economic downturn occurring as a consequence of the social, economic, employment, and personal challenges of COVID-19. In addition, Mamun and Ullah (2020) highlighted that suicidal behavior occurs due to the economic recession taking place in response to containment measures.

COVID-19-related suicidal behaviors are increasing sharply worldwide (Aquila et al., 2020; Caballero-Domínguez et al., 2020; Mamun & Griffiths, 2020) , and this phenomenon may become a major clinical concern in both Eastern and Western countries. Hence, it is extremely relevant to understand the factors that draw individuals toward suicidal behaviors in the context of the COVID-19 outbreak to prevent these kinds of attitudes and to provide a broad perspective regarding such symptoms to provide better interventions in clinical practice. In this regard, past research aimed to provide an overview regarding the interplay between suicidal behaviors and the COVID-19 outbreak.

Therefore, the current research sought to carry out a comprehensive investigation of suicide risk factors during the current COVID-19 pandemic. Specifically, the goals of the current systematic review are to (i) understand and summarize the major causes of and factors related to the risk of suicidal behaviors due to the COVID-19 pandemic, examining the studies present, to date, in the literature, and (ii) provide a systematic synthesis of the studies present in the literature.

The present systematic review focuses on qualitative and quantitative studies that describe suicidal behaviors in the context of the COVID-19 outbreak. For the purpose of this study, the PRISMA statement for reporting systematic reviews was used (Liberati et al., 2009) , and no registration was previously undertaken. Inclusion criteria were coded by all the authors by reaching an agreement regarding the coding process (Liberati et al., 2009) Interpersonal Psychological Theory of Suicide (ITS; Van Orden et al., 2010) . These theoretical differences preclude analysis and comparison across different studies.

It is worth noticing that different studies observed different dimensions of suicidal behaviors. Specifically, suicide ideation, that is, a persistent intention to commit suicide (Tasnim et al., 2020) , was the most represented suicide-related dimension, with 25 studies addressing this dimension Caballero-Domínguez et al., 2020; Elbogen et al., 2021; Every-Palmer et al., 2020; Fountoulakis et al., 2021; Halford et al., 2020; Han et al., 2021; Hao et al., 2020; Hill et al., 2021; Jiang et al., 2020; Khosravani et al., 2021; López Steinmetz et al., 2020; Louie et al., 2021; Monteleone et al., 2021; Murata et al., 2020; Na et al., 2021; Nomura et al., 2021; O'Connor et al., 2020; Shi et al., 2021; Tasnim et al., 2020; Tsai et al., 2021; Winkler et al., 2020; Zhou et al., 2020; Zwickl et al., 2021) . In addition, suicidal thoughts and planning, namely, considering taking one's life and working out a plan to do it (Mortier et al., 2021; Posner et al., 2011) , were reported by a robust line of study (Ambrosetti et al., 2021; Ammerman et al., 2021; Anestis & Brian, 2021; Caballero-Domínguez et al., 2020; Crasta et al., 2020; Evans et al., 2020; Fayaz & Albarracín, 2021;  addition, four studies were conducted in Bangladesh, one in South Korea, and one in Iran. Furthermore, the results showed that four studies were conducted in countries on the Oceania continent, specifically three in Australia and one in New Zealand. In addition, 13 studies were carried out on the European continent, with two being conducted in Switzerland, two in Spain, one in the United Kingdom, one in the Czech Republic, one in Greece, one in France, one in England, one in Wales, one in North Ireland, one in Italy, and one in Germany (table 1).

With regard to potential factors impacting suicidal behaviors during the COVID-19 pandemic, the results of the current review showed that a combination of several risk factors for more severe suicidal attitudes are present.

Although this review comprises 52 studies, a paucity of studies used a theory-driven approach to deepen the construct of suicidal behaviors in the context of the COVID-19 pandemic. For instance, Gratz et al. (2020) used the well-established theoretical framework of Results support an association between several COVID-19 related experiences (i.e., general distress, fear of physical harm, effects of social distancing policies). Exploratory analyses highlighted a potential additional link between COVID-19 and suicidal behavior, suggesting that a portion of individuals may use exposure to COVID-19 virus as means to kill themselves Cross-Sectional General Population

Individuals who purchased a firearm during COVID-19 more frequently reported lifetime, past-year, and past-month suicidal ideation than non-firearm owners and firearm owners who did not make a purchase during COVID-19

Individuals intending to purchase firearms were also more likely to have experienced suicidal ideation in the past year and to experience greater intolerance to uncertainty Appleby et al., 2021 Real Time Surveillance

No rise in suicide rates in England in the months after the first national lockdown began in 2020 was observed, despite evidence of greater distress Caballero-Domínguez et al. 2020

High suicide risk was associated with high perceived stress related to COVID-19, risk of depressive episode, and poorer quality of sleep Crasta et al., 2020 Cross-Sectional General Population

Suicide risk during the pandemic was related to perceived burdensomeness to others and psychological inflexibility Elbogen et al., 2021 Cross-Sectional General Population

Multivariable logistic regression showed that loneliness and financial strain due to COVID-19 outbreak were associated with suicidal behaviours in a nationally representative sample Evans et al., 2020 Qualitative General Population Australia

Families reported divergent themes regarding the pandemic, namely "Boredom, depression and suicide: A spectrum of emotion" "Families are missing the things that keep them healthy" "Changing family relationships: The push pull of intimacy," "The unprecedented demands of parenthood" 

The COVID-19 outbreak is related with increased rates of clinically significant psychiatric symptoms and loneliness was a major risk factor for more severe suicidal behaviours across populations Na et al., 2021 Longitudinal Army Veterans concern which is very difficult to handle Evans et al., 2020; Fitzpatrick et al., 2020; Knowles et al., 2021) . This suggests that financial, housing, and food insecurity may trigger a crisis of increased suicide/ self harm behaviors related to COVID-19 (Ettman et al., 2020).

A robust line consisting of 16 studies highlighted that changes due to the COVID-19 outbreak may lead to the onset of psychiatric symptomatology, exacerbating stress and vulnerability to suicidal behaviors (Caballero-Dominguez et al., 2020; Every-Palmer et al., 2020; Fitzpatrick et al., 2020; Fountoulakis et al., 2021; Han et al., 2021; Hill et al., 2021; Manzar et al., 2021; López Steinmetz et al., 2020; Murata et al., 2020; Na et al., 2021; Nomura et al., 2021; Radeloff et al., 2021; Shi et al., 2021; Zwickl et al., 2021; Jiang et al., 2020; O'Connor et al., 2020) . The studies in this review showed that a wide range of symptoms appeared during the COVID-19 pandemic. Most of the studies reported the onset of stress, depression, and anxiety symptomatology (Caballero-Dominguez et al., 2020; Every-Palmer et al., 2020; Fitzpatrick et al., 2020; Fountoulakis et al., 2021; Han et al., 2021; Murata et al., 2020; Na et al., 2021; Nomura et al., 2021; O'Connor et al., 2020; Shi et al., 2021) . Some studies also reported higher levels of the onset of PTSD symptomatology Murata et al., 2020; Na et al., 2021) .

One noteworthy finding is that 11 studies suggested that the pandemic scenario worsened pre-existing psychiatric conditions (Fountoulakis et al., 2021; Hao et al., 2020; Khosravani et al., 2021; Louie et al., 2021; López Steinmetz et al., 2020; Monteleone et al., 2021; Mortier et al., 2021; Na et al., 2021; Tasnim et al., 2020; Tsai et al., 2021) . In particular, the studies observed in the current review reported more severe levels of mood disorders and anxious symptomatology (Hao et al., 2020; Mortier et al., 2021; Na et al., 2021; Tasnim et al., 2020; Tsai et al., 2021) , obsessive-compulsive disorder (Khosravani et al., 2021) , eating disorders Fitzpatrick et al., 2020; Gratz et al., 2020; Knowles et al., 2021; López Steinmetz et al., 2020; Mortier et al., 2021; Winkler et al., 2020; Zhou et al., 2020; Zwickl et al., 2021) .

Another interesting suicide-related dimension observed from the included studies was that of suicide rates. Although suicide rates were generally found to peak during the COVID-19 outbreak (Isumi et al., 2020; Jahan et al., 2021; McIntyre & Lee, 2020; Prados-Ojeda et al., 2021; Radeloff et al., 2021; Sripad et al., 2021; Tanaka & Okamoto, 2021) , two studies found no significant change in suicide rates during the COVID-19 outbreak (Appleby et al., 2021; Leske et al., 2021) .

Furthermore, suicide attempts were observed as well (Ambrosetti et al., 2021; Every-Palmer et al., 2020; Fitzpatrick et al., 2020; Gil-Jardiné et al., 2021; Holland et al., 2021; Manzar et al., 2021; Moser et al., 2020; Murata et al., 2020; Panigrahi et al., 2021) . In addition, being unmarried/single or separated/ divorced was identified as increasing the risk of more suicidal behaviors during the COVID-19 outbreak as per Ambrosetti et al. (2021) .

A total of 16 studies Evans et al., 2020; Fitzpatrick et al., 2020; Halford et al., 2020; Holland et al., 2021; Kar et al., 2021; Knowles et al., 2021; Manzar et al., 2021; Na et al., 2021; Nomura et al., 2021; Radeloff et al., 2021; Shi et al., 2021; Tanaka & Okamoto, 2021; Winkler et al., 2020; Zwickl et al., 2021; O'Connor et al., 2020) emphasized the role of economic distress in fostering higher levels of suicidal behaviors. The financial impact of COVID-19 has been significant: a noticeable number of individuals are facing financial strain and experiencing housing insecurity (US Census Bureau, 2020). Taken together, the results show the role of financial strain, loss of employment, and fear of losing housing in determining different levels of suicidal behaviors.

In addition, the observation of the aforementioned studies has highlighted how other types of economic distress such as food insecurity are currently a major Shi et al., 2021 Cross-Sectional

Containment measures, loss of employement and increased psychological stress during the pandemic were related with an increased risk of suicidal ideation and its severity Sripad et al., 2021 Cross-Sectional

Higher levels of suicidal behaviors were observed among males and those with positive/suspected COVID infection within the first week, while receiving treatment in COVID care centres. 

Indeed, many studies have suggested that the psychological impact of COVID-19 may be different across cohorts. In the studies included in this review, suicidal behaviors were observed in different populations. Most of the studies (n = 32) addressed the impact of suicidal behaviors in the general population (Ambrosetti et al., 2021; Ammerman et al., 2021; Anestis & Brian, 2021; Appleby et al., 2021; Caballero-Domínguez et al., 2020; Crasta et al., 2020; Evans et al., 2020; Every-Palmer et al., 2020; Fayaz & Albarracín, 2021; Fountoulakis et al., 2021; Gil-Jardiné et al., 2021; Gratz et al., 2020; Halford et al., 2020; Han et al., 2021; Jiang et al., 2020; Sher, 2020; Kar et al., 2021; Knowles et al., 2021; Leske et al., 2021; López Steinmetz et al., 2020; McIntyre & Lee, 2020; Mortier et al., 2021; Moser et al., 2020; O'Connor et al., 2020; Panigrahi et al., 2021; Pirkis et al., 2021; Radeloff et al., 2021; Shi et al., 2021; Sripad et al., 2021; Tanaka & Okamoto, 2021; Tsai et al., 2021; Winkler et al., 2020) .

Concerning the general population, financial problems were the most frequently described risk factor Fitzpatrick et al., 2020; Gratz et al., 2020; Knowles et al., 2021; O'Connor et al., 2020; Shi et al., 2021; Tanaka & Okamoto, 2021; Winkler et al., 2020) . Physical symptoms and fear of physical harm were also reported as risk factors (Ammerman et al., 2021; Anestis & Brian, 2021; Fitzpatrick et al., 2020; Sripad et al., 2021; Winkler et al., 2020) . Connected to the previous point, fear of testing positive for COVID-19 was reported as closely linked to suicidal behaviors (Sripad et al., 2021) .

Another noteworthy dimension related to suicidal behaviors in the general population was general distress (Ammerman et al., 2021; Caballero-Domínguez et al., 2020; Evans et al., 2020; Every-Palmer et al., 2020; Fountoulakis et al., 2021; Tsai et al., 2021) . In addition, depressive and anxious symptomatology (Caballero-Domínguez et al., 2020; Fitzpatrick et al., 2020; Murata et al., 2020; Shi et al., 2021; Tsai et al., 2021) and PTSD were identified as increasing the risk of suicidal behaviors. In one study, insomnia was linked with higher risk of suicidal behaviors as well (Caballero-Domínguez et al., 2020) .

Furthermore, the contributing role of social distancing in levels of suicidal behaviors reported by general populations was assessed in many studies (Ammerman et al., 2021; Gratz et al., 2020; López Steinmetz et al., 2020; Shi et al., 2021; Tanaka & Okamoto, 2021) . Similarly, higher levels of suicidal behaviors were linked to loneliness Gratz et al., 2020; Murata et al., 2020) , whilst one study emphasized the role of domestic abuse and relational difficulties (Knowles et al., 2021) . In addition, having maladapting thinking patterns, such as exaggerated threat expectancies and low tolerance of uncertainty (Anestis & Brian, 2021) , psychological inflexibility (Crasta et al., 2020) , and perceived burdensomeness (Crasta et al., 2020; Gratz et al., 2020) were identified as increasing the risk of suicidal behaviors during the COVID-19 outbreak.

From the analyses of the included studies, the observation of different vulnerable populations emerged, with emergency department inpatients (n = 4) and psychiatric populations (n = 4) and individuals undergoing surgical treatment (n = 1) being the most frequently represented subjects (Ambrosetti et al., 2021; Hao et al., 2020; Hill et al., 2021; Holland et al., 2021; Khosravani et al., 2021; Monteleone et al., 2021; Prados-Ojeda et al., 2021; (Monteleone et al., 2021) , and alcohol overuse . Interestingly, some of the insights observed in the studies addressed the potential intervening role of trauma (Tasnim et al., 2020) and the onset of different levels of burnout symptomatology (Mortier et al., 2021; Zhou et al., 2020) .

Ten studies emphasized the role of mitigation policies and social isolation in determining different levels of suicidal behaviors (Ambrosetti et al., 2021; Ammerman et al., 2021; Elbogen et al., 2021; Fountoulakis et al., 2021; Holland et al., 2021; Knowles et al., 2021; Murata et al., 2020; Panigrahi et al., 2021; Shi et al., 2021; Tanaka & Okamoto, 2021) .

Specifically, Gratz et al. (2020) argued that longstanding experience of being alienated from meaningful relationships with others increased suicide risk during the current pandemic, whilst Elbogen et al. (2021) emphasized how social isolation was associated with suicidal behaviors during the early months of the pandemic because of social alienation and a lack of connection with others. The observation of the studies mentioned above supports concerns that social distancing measures and isolation stemming from mitigation policies aimed at hindering the spread of the virus may diminish important social connections, which may potentially foster higher levels of suicidal ideation and thoughts of self-harm (Hagerty & Williams, 2020; Reger et al., 2020; Torales et al., 2020) .

Ten studies (Ammerman et al., 2021; Anestis & Brian, 2021; Holland et al., 2021; Kar et al., 2021; Manzar et al., 2021; Na et al., 2021; Panigrahi et al., 2021; Shi et al., 2021; Sripad et al., 2021; Tanaka & Okamoto, 2021) reported that suicidal behaviors were higher when health concerns were higher, for instance, the fear of being infected with COVID-19 (Sripad et al., 2021) . As highlighted by Tanaka and Okamoto (2021) , fear caused by the threat of the disease may cause restricted access to healthcare services, thereby inducing higher levels of psychiatric symptomatology and increased suicidal behaviors. Sripad et al. (2021) also reported that the majority of suicides occurred in the first week of COVID-19-positive status and individuals had expressed either a fear of death or stigma related to COVID-19 infection. In addition, Kar et al. (2021) suggested that feelings of shame and frustration in response to testing positive for COVID-19 test were a major risk factor. Moreover, further insights highlighted a potential additional link between COVID-19 and suicidal behavior, suggesting that a portion of individuals may use exposure to COVID-19 virus as means to kill themselves (Ammerman et al., 2021) .

Five studies highlighted the role of relational difficulties in determining individual differences in suicidal behaviors (Crasta et al., 2020; Evans et al., 2020; Gratz et al., 2020; Han et al., 2021; Knowles et al., 2021) .

Specifically, the observed studies highlighted that the presence of maltreatment and violence (Knowles et al., 2021) , perceptions of being a burden to others, feelings of social detachment, and lack of relevant social bonds (Crasta et al., 2020; Gratz et al., 2020) , and strained relationships (Evans et al., 2020; Han et al., 2021) were closely related to higher levels of suicidal behaviors during the COVID-19 outbreak.

The goal of the current study was to systematically review the studies addressing major causes of and factors related to the risk of suicidal behaviors or suicidal ideation due to the COVID-19 pandemic. Identification of factors that are associated with a higher risk of suicidal behaviors is valuable for prevention purposes. The current results are parallel to previous findings (Wasserman, 1992; Yip et al., 2010) which concluded that past epidemics such as the Spanish flu and SARS created major risk factors for increased suicidal behaviors.

The pandemic and related societal and economic changes created a cascade of modifications in daily life that are mainly characterized by the presence of changes in interpersonal and contextual dimensions (Cannavò et al., in press; Mucci et al., 2020; Presti et al., 2020; Sher, 2020) . A variety of factors were thus associated with a higher risk of suicidal behaviors. Among the most commonly described causes of increased suicidal behaviors in the setting of the COVID-19 pandemic, both individual and contextual factors have been described, with financial difficulties and psychiatric vulnerabilities being the most frequently represented. This is in line with theoretical explanations of suicide positing that the etiology of such behaviors may be explained by the interplay of proximal, medial, and distal factors (Turecki & Brent, 2016) . As far as individual factors are concerned, our results extend those of previous studies suggesting that psychiatric vulnerability and perceived social isolation have a strong effect on the general population (Que et al., 2020; Sher, 2020; Zalsman et al., 2020) and also on healthcare workers (Zhou et al., 2020) .

These results confirm previous studies from SARS outbreaks (Liu et al., 2012) in which authors found that individuals seemed to be more prone to suicidal behaviors because of psychiatric vulnerability. For instance, Que et al. (2020) argued that the increased presence of symptomatology in psychiatric patients during the pandemic could be due to difficulty accessing mental health care providers and healthcare resources, which during the pandemic are used to contain the spread of COVID-19 and for the management of infected patients. As Hawryluck et al. (2004) argued, exposure to a life-threatening illness increases the prevalence of severe psychological and emotional problems, and therefore an increased mental health burden may be likely to follow (Secor et al., 2020) .

It is noteworthy that the number of studies on the impact of factors related to the COVID-19 outbreak and suicidal behaviors is rather well distributed between Western and Eastern countries, but it appears that developing countries have not produced a sufficient number of papers on the subject, thus highlighting the need for this topic to be further deepened to verify whether the same characteristics are maintained in more countries and cultures. In this regard, suicidal behaviors related to the consequences of the COVID-19 pandemic should be further deepened from a crosscultural perspective, as cultural factors may have a role in offsetting or alternatively enhancing suicide risk.

Moreover, the results of this study showed that suicidal behaviors are particularly prevalent in both the general and psychiatric populations during the COVID-19 outbreak. Overall, a diverse range of psychiatric disorders (e.g., mood disorders, eating disorders) are affected by changes due to the COVID-19 Zwickl et al., 2021) .

With regard to emergency department inpatients, studies included in the current review identified a number of factors that may foster suicidal behaviors. Specifically, having a pre-existing history of suicide attempts (Prados-Ojeda et al., 2021) , substance abuse (Holland et al., 2021; Prados-Ojeda et al., 2021) , social distancing , and higher levels of loneliness (Ambrosetti et al., 2021) were identified as increasing the risk of suicidal behaviors during the COVID-19 outbreak. Concerning the psychiatric population, it was generally found that more severe psychiatric symptomatology may worsen suicidal behaviors (Hao et al., 2020; Khosravani et al, 2021; , although one study suggested that the severity of both specific and general psychopathology increased during lockdown and the rise in general symptoms was maintained during the reopening phase, except for suicide ideation (Monteleone et al., 2021) .

Other interesting factors related to suicidal behavior during the COVID-19 outbreak were clinically significant rates of depression and thoughts of self-harm in individuals undergoing gender-affirming surgery as per Zwickl et al. (2021) .

In addition, two lines of research have been developed that address the impact of suicidal behaviors in the context of COVID-19 outbreak in specific populations. Specifically, a line of studies observed suicidal behaviors in certain age groups, such as children and adolescents (Isumi et al., 2020; Manzar et al., 2021; Murata et al., 2020) and the elderly population (Louie et al., 2021) , whilst the other line addressed specific working populations, such as healthcare professionals (Jahan et al., 2021; Mortier et al., 2021; Murata et al., 2020; Zhou et al., 2020) , college students (Nomura et al., 2021; Tasnim et al., 2020) , and former military personnel (Na et al., 2021) .

With regard to children and adolescents, mental health problems such as depression, loneliness, psychological distress (Manzar et al., 2021; Murata et al., 2020; Tasnim et al., 2020) , and even greater exposure to COVID-19-related news (Murata et al., 2020) were identified as increasing suicidal behaviors. Concerning the elderly population, one of the included studies identified that individuals with pre-existing psychiatric histories were at a higher risk of suicidal behaviors (Louie et al., 2021) . Regarding college students, several risk factors were emphasized, namely substance abuse, impaired quality of sleep, personal and family history of suicidal behaviors, and internalizing symptoms (Nomura et al., 2021; Tasnim et al., 2020) .

With regard to healthcare providers, the included studies identified several factors contributing to higher levels of suicidal behaviors in the context of the COVID-19 pandemic scenario. Specifically, perceived lack of coordination, communication, personnel, or supervision at work, financial stress, and work-related stress were reported (Jahan et al., 2021; Mortier et al., 2021) . Fear of infection and fear related to COVID-19 infection/transmission were also reported as being closely linked to suicidal behaviors in healthcare workers. In one study, a significant part of healthcare providers and the general population showed COVID-19-related suicidal behaviors , whilst another suggested that healthcare providers were significantly less likely to show suicidal behaviors (Murata et al., 2020) .

Overall, observation of the results of the current review suggests that several populations are affected by the COVID-19 pandemic scenario, which may indicate that changes due to the pandemic are widespread. carried out in the very early phases of the pandemic and therefore replication studies are needed to substantiate the findings.

The findings of the current systematic review should be considered in the light of the limitations of each included study. In addition, no unpublished material was included, and this could be particularly relevant as the COVID-19 pandemic is still ongoing and several researches that may potentially be investigating its potential impact on the psychological dimension may still be ongoing. Therefore, a publication bias is likely to occur. Furthermore, this systematic review is only descriptive and explorative in nature and therefore did not assess the quality of any of the studies.

The findings of this systematic review provide evidence that the COVID-19 pandemic is significantly associated with more severe suicidal behaviors. Therefore, it is crucial to create targeted interventions aimed at fostering good mental health in the general population, maintaining active healthcare services for psychiatric populations, and preserving at-risk professions. The validation of international procedures, standard protocols, and guidelines for the management of suicidal behaviors may help in the creation of specific interventions and an effective diagnostic process.

outbreak and anti-pandemic measures, which in turn may have triggered increased suicide risk (Que et al., 2020) . Therefore, within the diagnostic process usually provided in the context of the pandemic, additional assessment of the psychological dimensions, particularly of suicidal behaviors, may also be desirable.

In addition, the findings of the current systematic review provide evidence that the psychological impact of COVID-19 on the general population and vulnerable groups is severe. Hence, the implementation of targeted interventions aimed at improving mental health during pandemics is essential. National and international boards should therefore create a large-scale safety plan aimed at preventing suicidal behaviors in the general population. In this regard, the implementation of tailored interventions aimed at fostering emotional intelligence and emotional regulation may have a favorable role, as robust lines of research highlighted that such constructs may hinder suicidal dynamics (Barberis et al., 2020; Domínguez-García & Fernández-Berrocal, 2018; Neacsiu et al., 2017) .

It is of note that a paucity of studies addressed the role of the current outbreak in specific application contexts, such as working environments. This is of particular interest, as some specific occupational contexts may be particularly prone to fostering poor wellbeing in relation to COVID-19 (Zhou et al., 2020) . In this regard, past research has already warned that certain professions are at greater risk of developing maladjustment during the outbreak (Conversano et al., 2020; Ruiz & Gibson, 2020; Vuorio & Bor, 2020) . Specifically, Zhou et al. (2020) observed healthcare providers during the pandemic, highlighting how the observation of specific populations may be a relevant component for deepening the understanding of the harmful impact of COVID-19 on individuals' everyday life. It is important to note that there have been cases of suicides among healthcare workers globally during the COVID-19 outbreak (Goyal et al., 2020; Jahan et al., 2021; Montemurro, 2020; Mukhtar, 2020) and therefore organizations may want to provide physicians, nurses, and allied professionals with screening services for suicidal behaviors as much as possible. In addition, future studies should replicate these findings in different working populations to obtain a broader perspective regarding COVID-19 in working environments.

Interestingly, a small number of studies suggested that COVID-19 had little or no effect on the observed participants (Fayaz & Albarracín, 2021; Gil-Jardiné et al., 2021; Isumi et al., 2020; Leske et al., 2021; Prados-Ojeda et al., 2021; Pirkis et al., 2021; Appleby et al., 2021) . For instance, one study addressing children and adolescents (Isumi et al., 2020) and one assessing the general population (Leske et al., 2021) suggested that the first wave of the pandemic had no harmful effects on the participants, in contrast to other researches that showed a significant increase in social and psychological distress even during the first wave (Iob et al., 2020; Singh, 2020) . On the other hand, other findings suggested that after a decline during the first wave of the pandemic, suicides increased during the second (Tanaka & Okamoto, 2021) , thus revealing a need for the dynamics and the effects of the current COVID-19 outbreak to be further investigated in several application contexts and social environments (e.g. family, romantic relationships, friendships).

Despite the robust contribution provided to the understanding of the interplay between psychological variables and the current pandemic, it should be noted that the studies included in the current review were

COVID-19 -A short-review of the pandemic's mental health impact, personality traits, economics, eating disorder, homeless and education

Impact of the COVID-19 Pandemic on Psychiatric Admissions to a Large Swiss Emergency Department: An Observational Study

Preliminary investigation of the association between COVID-19 and suicidal thoughts and behaviours in the U

Threat perceptions and the intention to acquire firearms

Suicidal Ideation Among Individuals Who Have Purchased Firearms During COVID-19

Suicide in England in the COVID-19 pandemic: Early observational data from real time surveillance. The Lancet Regional Health -Europe, 4

The role of the COVID-19 pandemic as a risk factor for suicide: What is its impact on the public mental health state today?

From "It Has Stopped Our Lives" to "Spending More Time Together Has Strengthened Bonds": The Varied Experiences of Australian Families During COVID-19

Psychological distress, anxiety, family violence, suicidality, and wellbeing in New Zealand during the COVID-19 lockdown: A cross-sectional study

COVID-19 and Anxiety: A Review of Psychological Impacts of Infectious Disease Outbreaks. Archives of Clinical Infectious Diseases

Insights on the implications of COVID-19 mitigation measures for mental health

How bad is it? Suicidality in the middle of the COVID-19 pandemic. Suicide and Life-Threatening Behaviour

Self-reported changes in anxiety, depression and suicidality during the COVID-19 lockdown in Greece

Trends in reasons for emergency calls during the COVID-19 crisis in the department of Gironde, France using artificial neural network for natural language classification

Fear of COVID 2019: First suicidal case in India !

Thwarted belongingness and perceived burdensomeness explain the associations of COVID-19 social and economic consequences to suicide risk

The impact of COVID-19 on mental health: The interactive roles of brain biotypes and human connection

Google searches for suicide and suicide risk factors in the early stages of the COVID-19 pandemic

Investigating how individual differences influence responses to the COVID-19 crisis: The role of maladaptive and five-factor personality traits

Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry

Suicide and Suicide Prevention From a Global Perspective

Suicidal ideation and psychological control in emerging adults: The role of trait EI. Maltrattamento e abuso all'infanzia

Financial difficulties and student health: Results from a National Cross-Sectional Survey of Norwegian college and university students

The relationship between Trait Emotional Intelligence and emotion recognition in the context of COVID-19 pandemic

Interpersonally-based fears during the COVID-19 pandemic: Reflections on the fear of missing out and the fear of not mattering constructs

Suicide in Asia: Opportunities and Challenges

Predicting suicide attempt or suicide death following a visit to psychiatric specialty care: A machine learning study using Swedish national registry data

A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong

The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research

Psychological distress among healthcare professionals involved in the Covid-19 emergency: vulnerability and resilience factors

Modeling suicide risk among parents during the COVID-19 pandemic: Psychological inflexibility exacerbates the impact of COVID-19 stressors on interpersonal risk factors for suicide

The Association Between Emotional Intelligence and Suicidal Behaviour: A Systematic Review

Suicidal ideation and thoughts of self-harm during the COVID-19 pandemic: The role of COVID-19-related stress, social isolation, and financial strain

Real-time suicide mortality data from police reports in Queensland, Australia, during the COVID-19 pandemic: an interrupted time-series analysis

The PRISMA statement for reporting systematic reviews and metaanalyses of studies that evaluate health care interventions: explanation and elaboration

Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic

Levels and predictors of depression, anxiety, and suicidal risk during COVID-19 pandemic in Argentina: the impacts of quarantine extensions on mental health state

Suicidal Risk in Older Patients with Depression During COVID-19 Pandemic: a Case-Control Study

First COVID-19 suicide case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies

COVID-19 suicides in Pakistan, dying off not COVID-19 fear but poverty? -The forthcoming economic challenges for a developing country

Prevalence and risk factors of COVID-19 suicidal behaviour in Bangladeshi population: are healthcare professionals at greater risk

Suicide among adolescents and youths during the COVID-19 pandemic lockdowns: A press media reports based exploratory study

Projected increases in suicide in Canada as a consequence of COVID-19

COVID-19 and its effect on emergency presentations to a tertiary hospital with self-harm in Ireland

The impact of COVID-19 lockdown and of the following "re-opening" period on specific and general psychopathology in people with Eating Disorders: the emergent role of internalizing symptoms

The emotional impact of COVID-19: From medical staff to common people

A systematic review and meta-analysis of the association between alexithymia and suicide ideation and behaviour

Suicide Ideation and Attempts in a Pediatric Emergency Department Before and During COVID-19

Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic

Risk of an Increase in Suicide Rates Associated With Economic Downturn due to COVID-19 Pandemic

Abuse, self-harm and suicidal ideation in the UK during the COVID-19 pandemic

Do suicide rates in children and adolescents change during school closure in Japan? The acute effect of the first wave of COVID-19 pandemic on child and adolescent mental health

COVID-19 suicide and its causative factors among the healthcare professionals: Case study evidence from press reports

A Network Analysis of Post-traumatic Stress Disorder Symptoms and Correlates During the COVID-19 Pandemic

Might the COVID-19 pandemic spur increased murder-suicide

Impact of COVID-19 pandemic related lockdown on Suicide: Analysis of newspaper reports during pre-lockdown and lockdown period in Bangladesh and India

The associations of obsessive-compulsive symptom dimensions and general severity with suicidal ideation in patients with obsessive-compulsive disorder: The role of specific stress responses to COVID-19

The Role of Hope and Resilience in Protecting Against Suicidal thoughts and Behaviours During the COVID-19 Pandemic

Mental Health Effects of COVID-19 Pandemia: A and internal consistency findings from three multisite studies with adolescents and adults

Suicide Presentations to an Emergency Department Pre and During the COVID Lockdown

The Dynamics of Fear at the Time of COVID-19: A Contextual Behavioural Science Perspective

Raising awareness of suicide prevention during the COVID-19 pandemic

Trends in suicide rates during the COVID-19 pandemic restrictions in a major German city. Epidemiology and Psychiatric Sciences

Economic suicides in the Great Recession in Europe and North America

Suicide mortality and coronavirus disease 2019-a perfect storm

Understanding, compliance and psychological impact of the SARS quarantine experience

Emotional impact of the COVID-19 pandemic on U.S. health care workers: A gathering storm

Mental health among Ebola survivors in Liberia, Sierra Leone and Guinea: results from a cross-sectional study

The impact of the COVID-19 pandemic on suicide rates

Prevalence and correlates of suicidal ideation among the general population in China during the COVID-19 pandemic

Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviours Part 2: Suicide-Related Ideations

Lockdown and 3 Waves of Suicide in India During the COVID-19 Pandemic. The Primary Care Companion For CNS Disorders

Suicide in the context of COVID-19 diagnosis in India: Insights and implications from online print media reports

Thirty-day suicidal thoughts and behaviours among hospital workers during the first wave of the Spain COVID-19 outbreak

Years of life lost due to the psychosocial consequences of COVID-19 mitigation strategies based on Swiss data

Lockdown and isolation: psychological aspects of COVID-19 pandemic in the general population

Mental health and emotional impact of COVID-19: Applying Health Belief Model for medical staff to general public of Pakistan

The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers

Prevalence, risk and protective factors associated with suicidal ideation during the COVID-19 pandemic in U.S. military veterans with pre-existing psychiatric conditions

Suicidal Behaviour and Problems with Emotion Regulation. Suicide and Life-Threatening Behaviour

Cross-sectional survey of depressive symptoms and suicide-related ideation at a Japanese national university during the COVID-19 stay-home order

Suicidal ideation in the perinatal period: A systematic review

Mental health and well-being during the COVID-19 pandemic: longitudinal analyses of adults in the UK COVID-19 Mental Health & Wellbeing study

COVID-19 and suicides in India: A pilot study of reports in the media and scientific literature

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

Suicidal Thoughts and Behavior Among Adults: Results from the 2015 National Survey on Drug Use and Health

Black Swan Pandemic and the Risk of Pilot Suicide. Frontiers in Public Health

The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920

Increase in prevalence of current mental disorders in the context of COVID-19: analysis of repeated nationwide cross-sectional surveys

The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong

Suicide in the Time of COVID-19: Review and Recommendations

The prevalence and risk factors of psychological disturbances of frontline medical staff in china under the COVID-19 epidemic: Workload should be concerned

The impact of the first three months of the COVID-19 pandemic on the Australian trans community

Increase in suicide following an initial decline during the COVID-19 pandemic in Japan

Life and death during the Great Depression

Suicidal ideation among Bangladeshi university students early during the COVID-19 pandemic: Prevalence estimates and correlates

The outbreak of COVID-19 coronavirus and its impact on global mental health

Psychological distress and alcohol use disorder during the COVID-19 era among middle-and low-income U.S. adults

Suicide and suicidal behaviour

Household Pulse Survey

Suicide in Estonia

The interpersonal theory of suicide