key: cord-0950228-xqyec5tb authors: Radeloff, D.; Papsdorf, R.; Uhlig, K.; Vasilache, A.; Putnam, K.; von Klitzing, K. title: Trends in suicide rates during the COVID-19 pandemic restrictions in a major German city date: 2020-10-23 journal: nan DOI: 10.1101/2020.10.21.20187419 sha: f4bb17ca9665f94455abb35fc7229aff86c7f7be doc_id: 950228 cord_uid: xqyec5tb Background It remains unclear whether the COVID-19 pandemic is having an impact on suicide rates. Social distancing, economic insecurity and increasing prevalence rates of mental disorders may cause an increase in risk factors for suicide. Methods Data on suicide events in a major city in Germany, and the corresponding life years 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 in suicide risk, data from 2020 were compared to data from 2010 to 2019. Outcomes A total of 333 suicides were registered and 2,791,131 life years (LY) were spent between 2010 and 2020. Of these, 42 suicides and 300,834 LY accounted for the year 2020. In 2020, suicide rates (SR, suicides per 100,000 LY) were lower in periods with moderate (SR = 8.5, X^2 = 4.374, p = 0.037) or severe COVID-19 restrictions (SR = 7.0, X^2 = 3.999, p = 0.046) compared with periods without restrictions (SR = 18.0). A comparison with preceding years showed that differences cannot be attributed to seasonal variations. No age- or gender differences were found. Interpretation SR decreased during the COVID-19 restrictions; we expect SR to rise in the medium term. Careful monitoring of SR in the further course of the COVID-19 crisis is therefore urgently needed. The findings have regional reference and should not be over-generalized. Funding This study was conducted without external funding. In 2020, suicide rates (SR, suicides per 100,000 LY) were lower in periods with 43 moderate (SR = 8.5, χ 2 = 4.374, p = 0.037) or severe COVID-19 restrictions (SR = 44 7.0, χ 2 = 3.999, p = 0.046) compared with periods without restrictions (SR = 18.0). 45 A comparison with preceding years showed that differences cannot be attributed to 46 seasonal variations. No age-or gender differences were found. 47 48 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. ; https://doi.org/10.1101/2020.10.21.20187419 doi: medRxiv preprint Introduction 62 It remains unclear whether the COVID-19 pandemic is having an impact on suicide 63 rates. Some predict that suicide rates will rise, since actions to contain COVID-19, 64 such as social distancing, economic lockdown, or the temporary restructuring of the 65 health system, could cause risk factors for suicide to increase 1-5 . Indeed, analyses 66 of previous economic crises have shown that an increase in unemployment was 67 associated with an increase in suicide rates 6-10 ; and according to leading theories of 68 suicide prevention, the loss of social inclusion is a major risk factor for suicide 11 . 69 In Germany, a significant restriction of the free movement of persons was agreed 71 upon in March 2020, with the strongest restrictions coming into force in April and 72 May. German borders were virtually closed for travel from 16 March onwards 12-14 . 73 On 22 March 2020, the German Federal Government and the Länder agreed on a 74 comprehensive restriction of social contacts, which required people to reduce 75 contacts with others (except for members of one's own household) to an absolute 76 minimum 15 . In the Free State of Saxony, further restrictions on going out, and a ban 77 on visiting care homes, were adopted on 1 April 2020 16 . While the restrictions on 78 going out were eased on 4 May, the restrictions on visiting care homes remained 17 . 79 Following a meeting by the EU interior ministers on 15 June, extensive freedom of 80 movement within the EU's Schengen Area was gradually restored, but differentiated 81 travel warnings and quarantine regulations following travel remained in place for 82 parts of it. The German Federal Foreign Office also maintained the existing travel 83 warnings for 160 countries until 31 August 2020 18 . 84 85 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Sample and data acquisition 106 The data on suicides are based on the City of Leipzig's cause of death statistics, and 107 were provided by the responsible health authority for the years 2010 to 2020. Data 108 were obtained for age ranges 0-4, 5-9, 10-14, …, 75-79, 80-84, 85+ and for both 109 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. The analysis included suicides from the first six months of each of the years studied. 117 For the year 2020, months without restrictions on freedom of movement or social 118 contact were aggregated as period nR_2020 (January, February), those with 119 moderate restriction as period R1_2020 (travel restrictions; March to June), and 120 those with severe restrictions as period R2_2020 (restrictions on travel, going out 121 and social contact; April, May). To compare suicide mortality in 2020 before and 122 during the COVID-19 restrictions, suicide cases were assigned to group nR_2020, 123 R1_2020 and R2_2020. Corresponding life-years were calculated, according to the 124 length of the periods examined. 125 126 Life years (LY) and events were used to calculate the Risk Ratios (RR) with 127 Incidence Rate Ratios (IRR). Differences in suicide risk between nR_2020 and the 128 risk groups R1_2020 and R2_2020 were conducted using Chi-Square tests. In order 129 to exclude biases due to seasonal fluctuations in the suicide risk, Mantel-Haenszel 130 statistics (MH, Test for Heterogeneity) were performed to examine the risk of suicide 131 within the 2020 restriction periods and with the paired periods for years 2010-2019. 132 The Test for Heterogeneity examines whether the IRR of n 2x2 tables differ. Post-133 hoc, Chi-Square tests were used to examine differences for each pair (nR_2020 vs 134 nR_2010/19; R1_2020 vs R1_2010/19; R2_2020 vs R2_2010/19). 135 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. ; https://doi.org/10.1101/2020.10.21.20187419 doi: medRxiv preprint 136 In order to examine age-related and gender-related differences within the 2020 137 restriction periods, suicide risk in nR_2020, R1_2020 and R2_2020 were compared 138 between senior age (70+) vs age group 0-69 and between genders using the MH. The difference for nR compared to R1 and R2 also remained in a comparison with 158 the previous years 2010 to 2019 (Test for Heterogeneity; periods nR vs R1: Q [df = 1] 159 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. ; https://doi.org/10.1101/2020.10.21.20187419 doi: medRxiv preprint = 12.233, p < 0.001; periods nR vs R2: Q [df = 1] = 13.974, p < 0.001). The post hoc 160 analysis showed that the described difference was due to high suicide rates in 161 nR_2020 compared to nR_2010/19. The periods R1_2020 and R2_2020 were not 162 different compared to the previous years. inhabitants, respectively 24 . The regional shut-down was much less restrictive than in 181 other European countries, i.e. United Kingdom, France, Spain or Italy. At an early 182 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. ; https://doi.org/10.1101/2020.10.21.20187419 doi: medRxiv preprint stage of the pandemic, the German government committed to support measures to 183 prevent insolvencies and unemployment. Accordingly, results should be evaluated 184 under these external conditions. Regional differences in the COVID-19 pandemic 185 may produce regional differences in the mental health situation, economic crises and 186 suicide rates. The findings of this study should not, therefore, be extrapolated 187 uncritically to other regions or countries. It should not be assumed either that the 188 trend described will remain stable. This study only provides a first regional snapshot. For instance, online surveys showed a decrease in suicidal thoughts and intention 206 during the pandemic; presentation at emergency departments due to suicidal ideation 207 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The findings have led us to change our initial hypothesis. We predict the pandemic 214 will see the following course of suicide rates; this will need to be verified in future 215 studies: In an initial phase, the pandemic was perceived as an incalculable new 216 threat without any social countermeasures being taken. In this phase of individual 217 disorientation, suicide rates were unusually high. 218 In a second phase, with the COVID-19 restrictions, a social response to the threat 219 was given. Rules were established to protect the most vulnerable individuals and to 220 slow down the spread of the virus. The omnipresent concern for the well-being of 221 fellow human beings led to an increased sense of social belonging despite physical 222 distance. According to Durkheim's theory, a temporary increase of social integration 223 and cohesion results in a reduction in suicide rates 42 . Some findings observed during 224 the Second World War and the 9/11 terror attacks support this hypothesis, but it 225 remains controversial [43] [44] [45] . 226 In a third phase, the pandemic could be perceived as more predictable and less 227 threatening. The feeling of belonging may once again be increasingly determined by 228 the quality and quantity of everyday contacts, which could continue to be reduced 229 depending on the regulations. A rise in loneliness, unemployment and mental 230 disorders may lead to a delayed increase in the suicide rates in the medium term. As 231 other authors have stressed, it is important to distinguish between physical distance 232 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. We would like to thank the Leipzig Health Authority for their support and fast 254 provision of relevant data sets. We would also like to thank Monica Buckland for her 255 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Gesetz-und Verordnungsblatt 02.05.2020: § 10 (1). 320 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 23, 2020. ; https://doi.org/10.1101/2020.10.21.20187419 doi: medRxiv preprint Außenminister Maas zum Kabinetsbeschluss über die 321 Verlängerung der weltweiten reisewarnung bis zum 31.08. press release Age-Related Morbidity and Mortality among Patients with COVID-19 Federal Statistical Office (Destatis) Germany. Cause of death statistics R: A Language and Environment for Statistical Computing. Vienna, 328 Austria: R Foundation for Statistical Computing, 2016. 329 22 IBM Corp. IBM SPSS Statistics for Windows On heterogeneity tests based on efficient scores Coronavirus SARS-CoV-2. Daily situation reports in German and 333 English Hospital suicide due to non-treatment by 336 healthcare staff fearing COVID-19 infection in Bangladesh? 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