key: cord-1009281-1crb3kcu
authors: Farooq, Saeed; Tunmore, Jessica; Ali, Wajid; Ayub, Muhammed
title: Suicide, self-harm and suicidal ideation during COVID-19: a systematic review
date: 2021-10-07
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2021.114228
sha: a07352abcbe270f80e83266951b5daecf44c1080
doc_id: 1009281
cord_uid: 1crb3kcu

We aimed to do a systematic review and meta-analysis of studies describing suicidal ideation, suicide attempts and suicide and associated risk factors during COVID-19 pandemic. We searched following electronic databases using relevant search terms: Medline, Embase, PsycInfo and CINAHL and systematically reviewed the evidence following PRISMA guidelines. The meta-analysis of prevalence of suicidal ideation was done using random effect model. The search returned 972 records, we examined 106 in full text and included 38 studies describing 120,076 participants. Nineteen studies described suicide or attempted self-harm, mostly in case reports. Out of 19 studies describing suicidal ideations, 12 provided appropriate data for meta-analysis. The pooled prevalence of suicidal ideation in these studies was 12.1 % (CI 9.3-15.2). Main risk factors for suicidal ideations were: low social support, high physical and mental exhaustion and poorer self-reported physical health in frontline medical workers, sleep disturbances, quarantine and exhaustion, loneliness, and mental health difficulties. We provide first meta-analytic estimate of suicidal ideation based on large sample from different countries and populations. The rate of suicidal ideations during COVID pandemic is higher than that reported in studies on general population prior to pandemic and may result in higher suicide rates in future.

Approximately 86 million cases of COVID-19 have been recorded worldwide (Worldometer, 2021) . Suicide and self-harm resulting from direct and indirect effects of the COVID-19 pandemic are a major public health concern. The measures employed by many countries to slow the spread of COVID-19 have ranged from physical/social distancing to full lockdown of cities.

These strategies have led to major economic downturn.

(International Monetary Fund, 2020). Social, psychological and economic consequences of COVID-19 are likely to affect suicide rates all over the world.

Previous pandemics had significant impact on livelihoods. Reduced food supplies and uncertainty about the future led to increased levels of anxiety in societies (Koh & Goh, 2020; Mak et al., 2009; UNDP, 2015) . During the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, healthcare workers who treated infected patients reported higher levels of burnout, psychological distress, and Post Traumatic Stress Disorder than their peers who did not treat infected patients (Maunder et al., 2006) .

Emerging research points to the mental health consequences of COVID-19 as different from previous pandemics, with symptoms of anxiety, depression and stress being common (Kumar & Nayar, 2020) in general population. The magnitude of global involvements, death toll, and imposition of social distancing policies, lockdown measures and isolation had huge social and economic impact. Unemployment alone can lead to up to three fold increased relative-risk of death by suicide, compared with being employed (Milner, 2013) . Although the links between economic recessions and suicide are well-established, it is not clear how the relationship plays out in the situation of COVID-19. This relationship may be even more pronounced due to other risk factors such as physical distancing, lock-down, the scaling back of non-essential services and limited access to health care. The physical distancing measures and quarantine can be associated with loneliness (Brodeur et al., 2020) which in turn is a risk factor for suicide across many age groups (Daniel & Goldston, 2012; McClelland et al., 2020) .

During this pandemic, self-harm is likely to increase due to limited social interaction and increased feeling of anxiety amongst communities. . Self-harm has been shown to be a risk factor for suicide (Murphy et al., 2012) . Combined with the barriers to effective treatment due to several restrictions on face to face treatment, vulnerable individuals (Yao et al., 2020) Given that COVID-19 is novel for multitude of reasons discussed above, longitudinal data about its impact on suicide is currently unavailable. The primary aim of this review is to systematically review the evidence about suicide, self-harm and suicidal ideation during the COVID-19 pandemic. The secondary aims were to examine the prevalence of suicide or deliberate self-harm assess the quality of studies in this area, and to evaluate the psychological, social, and clinical risk factors for suicide and self-harm during the COVID-19

pandemic. We also aimed to carry out a Metaanalysis of outcome variables where appropriate.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines (Moher et al., 2009) . A protocol defining the key methodological parameters was developed prior to the literature search and was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020187255)

The following electronic databases and platforms were searched from November 2019 to 1 st September 2020; Medline, Embase, PsycInfo and CINAHL. A search of the reference lists of the articles included at full text examination phase was carried out.

A search strategy based on following key search terms were used to identify the relevant literature: -Coronavirus‖ OR Sars-Cov-2" (all variants), -Suicide‖ OR -suicidal ideation‖ (all variants), -suicide attempted/ OR suicide‖ (all variants) "self-injurious behavioural‖ OR -self-mutilation‖ self-harm (all variants, "social distance *" OR "stay at home" , -quarantine‖, "selfisolation" -shield‖ "shelter-in-place". Truncations and related terms were used as appropriate based on individual database procedures (please see appendix-1 for full search strategy).

The search was last updated in September 2020.

We included qualitative, quantitative, mixed methods study designs and case reports. We included all studies that reported individuals in any setting that reported suicidal ideations, suicide or self-harm in relation to the COVID-19 pandemic. We included all studies that described the relationship of suicidal ideations, suicide or self-harm with a COVID-19 related adversity, such as; lockdown, physical distancing, infection with COVID-19, or enduring the COVID-19 pandemic. There were no age restrictions applied. We included individuals of any age who hurt themselves by; cutting, overdoses, gunshot, jumping from height or similar techniques to end their lives. We included studies that; described the measurement of suicidal ideation using a validated measure, explored the prevalence of suicidal ideation in a population of interest, described suicidal attempts or suicide. Studies describing suicidal ideations, suicide or self-harm that was not related to the COVID-19 pandemic were excluded. We included any means of suicide or deliberate self-harm that occurred during the COVID-19 pandemic.

We excluded any studies that were not published in peer-review publications or did not include original data.

After completing the search process and screening for relevant abstracts, examination of full text articles for inclusion and data extraction was completed by two reviewers (JT & WM) independently, as outlined in the protocol (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020187255).

Disagreements regarding study selection were resolved by consensus or, where appropriate, by a third reviewer (SF). References of articles were also manually searched to identify additional relevant articles.

A data extraction sheet was developed based on the pre-specified outcomes. Relevant data was extracted by three reviewers (JT, WM, MA) and cross checked by another reviewer (SF). Relevant data was extracted; author names, year of publication, country of publication, study design, setting, characteristics of participants, number of participants, inclusion/exclusion criteria, comparison group, method of assessing diagnostic criteria, method of assessing treatment outcomes and factors related to suicidal ideations, suicide or self-harm and COVID-19 (physical distancing, quarantine, lockdown, social isolation or adversities associated with COVID exposure).

The quality of the studies was assessed independently by two reviewers (JT & WM), and cross checked by a third reviewer (MA) using appropriate checklists. There were no intervention studies included in the review, and therefore observational studies were assessed for quality using the Newcastle-Ottawa Quality Assessment Scale adapted for cross sectional studies (Modesti et al., 2016) .

We performed a meta-analysis of prevalence of suicidal ideation. The studies provided percentage of participants reporting suicidal ideation. We meta-analysed the data examining the proportions. We reported the pooled prevalence with a 95% confidence interval (CI). If the same data were reported in more than one publication, we selected the publication that had the most complete data.

We expected many sources of heterogeneity in the studies, including assessment methods, settings, and populations studied. We used a random-effect model for meta-analysis because of heterogeneity. We examined the CIs in the forest plot for variability in the studies and we are reporting an I2 statistic as an indicator of heterogeneity.

We used R packages Meta (version 4.15-1) and metafor (version 2.4-0) for analysis. The analysis was performed in R version 3.6.1. In our meta-analysis we considered individual study weights and utilized the inverse variance method with the Freeman-Tukey double arcsine transformation (Barendregt et al., 2013) . As recommended by Schwarzer et al (2019) we performed sensitivity analysis by comparing the results with logit transformations.

We used DerSimonian-Laird estimator for tau^2 (DerSimonian and Laird, 1986) and Jackson method for confidence interval of tau^2 and tau.

The search returned 972 records. After removing duplicates, 575 titles were screened at title phase. We screen 235 records at abstract phase and excluded 129 records. We selected 106 articles for full text examination, 68 records were excluded and we finally included 38 studies. The reasons for exclusion and details of study selection are given in PRISMA diagram (figure 1) The characteristics of included studies are given in table 1 and 2. Table 1 gives the characteristics of included studies describing attempted suicide and suicide Table 1 here Table 2 give the characteristics of studies describing suicidal ideation and self-harm behaviours. Table 2 here

Nineteen studies included 79 cases of suicide and 13 cases of attempted suicide. These were mostly case reports (15 articles) and cases based on news reports (4 articles). These studies included 57 males and 20 females. Suicide cases included members of the community and (n=75) and healthcare and frontline workers (n=10). Eight suicide pacts were described that included a mother-son, and young and elderly couples. The details of suicide and attempted suicide including underlying mental health conditions, means of suicide/ attempted suicide, relationship with COVID-19 and a brief description of cases are given in table 1.

The main concerns related to COVID-19 in cases of suicide and attempted suicide included: fear of being infected or infecting others, shame and guilt, economic recession and financial hardship, stress due to COVID-19 pandemic and lockdown, self-isolation, being unable to access alcohol, lack of access to educational resources and prejudice from communities.

Fear of already being/becoming infected with COVID-19 was prevalent across all cases reported and a significant factor in attempting/completing suicide (n=40). Three patients were awaiting the outcome of their COVID-19 swab result when they took their lives, and the remainder did not know whether they were infected or not, or the information was not given in the studies. Only four cases were actually COVID-19 positive (see table 1 for details).

Two suicides appeared to be due to academic pressures arising from the COVID-19

pandemic. In a suicide pact, a mother and her son ingested poisonous tablets, after an argument with the father/husband related to online schooling issues caused by COVID-19 quarantine and spatial distancing policies (Mamun et al., 2020a) . Lathabhavan et al (2020) describes the case of a 15 years old female student who ended her own life due to lack of available resources to complete home schooling. The girl was classed as ‗gifted' and worried about her academic performance as her family could not afford the equipment to enable her to complete her schooling from home.

Ten cases of suicides and attempted suicides in healthcare workers were described in two articles. Aquila et al. (2020a) reported three Italian nurses working in COVID-19 units who had died by suicide, fearing they had spread the infection, and also reported the suicide of the medical director of an emergency department in Manhattan. In a study based on newspaper reports Rahman and Plummer (2020) describes six cases of suicide in nurses in Italy, England, United States and India. Contributing factors to suicide in these cases were;

fear of being infected with COVID-19, critical shortage of personal protective equipment, working with COVID-19 positive environments, and a positive test result for COVID-19.

Nineteen studies including 119,984 participants provided data on suicidal ideations, selfharm thoughts and associated risk factors. Sixteen studies provided data on prevalence of suicidal ideations or examined relationship between a risk factor related to COVID-19.

Studies investigated a number of risk factors for suicidal ideation. Out of these, 12 studies had data that was suitable for meta-analysis. Details of risk factors is given in Box 1, while table 2 describes methodologies used, outcome measures, population characteristics and instruments used.

Box 1 describes the factors associated with suicidal ideations and attempts.

Twelve studies (Caballero−Dom'nguez et al., 2020; Iob et al., 2020; Byran et al., 2020; Fitzpatrick et al., 2020; Czeisler et al., 2020; Killgore et al., 2020; Cai et al., 2020; Xin et al., 2020; Xiaoming et al., 2020; Hou et al., 2020; Papadopoulou., 2020) had data that was suitable for meta-analysis which is described below.

There were 15 datasets from 12 studies that provided suitable data for meta-analysis. had two groups in their study; frontline health workers and non-frontline health workers. Killgore et al (2020) had separate samples for three consecutive months and we treated those as separate datasets. The total sample size in these studies is 113428.

The pooled prevalence of suicidal ideation in these studies was 12.1 % (CI 9.3-15.2). The logit transformation resulted in prevalence of 11.5 % (CI 9.2-14.3). As the results are close to each other we are only reporting results for Freeman-Tukey double arcsine transformation.

The level of heterogeneity was high as expected (I 2 = 100%, 2 = 0.0077, p = 0). We conducted sensitivity analysis based on country of publication, population studied and the study design, the results are summarised in figures 2, 3, and 4. The pooled prevalence of suicidal ideation for different populations were; general population 11.5% (95CI 7.4-16.5), students 12.3% (95CI 6.5 -41.7), health care workers and first responders 9.5% (6.9-12.3) (Fig -2 ). One longitudinal study by Iob et al (2020) accounted for largest number of participants (= 44775) and suicidal ideation prevalence of 17.8% (95 CI 17.5 -18.2), while case control study had prevalence of 10.4% (95% CI7.6 -13.6). Rest of studies were cross sectional and had pooled prevalence of 11.9%% (95CI 9.1 -15.1) (Fig-3) . The prevalence in different countries was as following: China 13.4% (8.7-18.9), Columbia 7.6% (5.7-9.7), Taiwan 10.8% (9.4-12.2), United Kingdom 17.8% (17.5-18.2), United States 12.5% (7.8-18.2), Greece 5.2 (4.6-5.8) ( 

In a cross sectional survey (Czeisler et al., 2020) found that being a carer for adults was associated with higher risk of suicidal ideations (adjusted OR 95% CI 1.20-7.63 p=.01). (2020) reported that nearly 15 percent of respondents in their study were categorized as high risk, scoring 7+ on the SBQ-R (Suicide Behavior Questionnaire); families with children, unmarried, and younger respondents reported higher SBQ-R scores than their counterparts (p < .000). Those reporting moderate or high levels of food insecurity were four times more likely to be in the high SBQ-R category compared to those reporting no or low food insecurity (p < .000). In a cross sectional survey of hospital workers in China, Xiaoming et al (2020) showed that the need of psychological assistance before and during the pandemic, concern about pandemic, and self-rated health condition were risk factors for high level of suicidal and selfharm ideation.

Cai et al (2020) (2020) found that mandatory quarantine status was moderately or strongly associated with self- (2020) showed a significant indirect relation of stay-at-home order status to suicide risk through thwarted belongingness.

We used Newcastle-Ottawa Quality Assessment Scale (NOQAS) for the observational studies. The NOQAS provides 1-3 stars for each item such as such as description of cohorts, outcome and ascertainment of exposure, and we converted this to a numerical score. The maximum score for a study is 10. Only two studies (Fitzpatrick et al 2020; Bryan et al (2020) scored 8 on NOQAS. Six studies (Killgore et al, 2020; Iob et al., 2020; Hao et al., 2020; Cai et al., 2020; Caballero -Dominguez et al., 2020; Ahorsu et al., 2020 ) scored a total of 7, four studies had a score of 6 (Xiaoming et al., 2020; Hamm et al., 2020; Gratz et al., 2020; Czeisler et al., 2020) , three studies scored 5 on NOQAS ( Xin et al., 2020; Smalley et al., 2020; Hou et al., 2020) , three studies scored a total of 4 out of ten (Olding et al., 2020; Papadopoulou et al., 2020) and only scored two.

The main findings are that in relation to COVID pandemic ( Based on these studies it is not possible to comment whether COVID-19 had any effect on suicide rates. A systematic review (Leaune et al., 2020) showed that previous pandemics did not increase the risk of deaths by suicide in people with pre-existing psychiatric disorders but the evidence was limited to only three studies. There is emerging evidence that suicide rates in present pandemic have remained unchanged or declined. Pirkis et al (2021) found that in high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the COVID pandemic. Deisenhammer and Kemmler (2021) found a significant decrease in suicide numbers during the first 6 months of the COVID-19 pandemic compared to the respective periods of the preceding year in Austria. Considering that the present pandemic has had a global effect, this evidence is limited to few high and middle income countries, further evidence is needed to understand the impact of present pandemic on rates of suicide.

The estimates of suicidal ideation prevalence vary depending upon population studied, methods used and the location of study (Biswas et al., 2020) . The pooled prevalence of suicidal ideation for all participants in our meta-analysis was 12.1 %. The pooled prevalence of suicidal ideation for different populations were as following; general population (11.5%), students (12.3%) and health care workers and first responders (9.5%). Sensitivity analysis based on population, country of study and study design showed that only study design accounted for large variation in the prevalence rates. The only longitudinal study by Iob et al 2020), these studies found that COVID-19 lockdown, social distancing measures and stay at home orders were associated with increased suicidal ideation. Studies in previous pandemics (Leaune et al., 2020) and in the infectious diseases such as HIV (Aro et al., 1995) found that fear of being infected by the virus was reported as major reason for suicidal ideations, suicide or self-harm. Social isolation is also considered to be a significant risk factor for deaths by suicide during the 2003 SARS outbreak. Objective social isolation and subjective feelings of loneliness are associated with higher suicidal ideation suicide or self-harm in the general population (Calati et al., 2019 

This is a comprehensive systematic review that covers suicidal ideations, acts and suicides.

We used a robust methodology following PRISMA guidelines, a pre-specified and comprehensive search strategy that captured 38 studies providing information on 119000 participants. A previous systematic review included 28 studies. To the best of our knowledge, this the first study that provides a meta-analysis of the prevalence of suicidal ideations.

The major limitation of this review is the low quality of included studies and poorly reported mental health outcomes. Studies on suicide during the pandemic are particularly scarce.

Almost all included studies had high or unclear risk of bias. Thirteen studies were crosssectional in design. Almost all were based on online interviews and survey questionnaires completed remotely. All studies relied on self-report measures and with the exception of five (Smalley et al., 2020; Olding et al., 2020; Hamm et al., 2020; Gratz et al., 2020) . Only three studies used a specific, validated measure for suicidal ideation and intention (Bryan et al., 2020; Gratz et al., 2020; Fitzpatrick et al., 2020) , the rest relied on suicide or self-harm items of depression scale such as the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001) and the General Anxiety Disorder-7 (GAD-7) (Spitzer et al., 2006) . The long term effects of living through the pandemic, effects of COVID in those who contracted the disease and received highly potent drugs such as steroids or care in Intensive Treatment Units remain largely unknown.

We used a comprehensive search strategy but may have missed some studies from low and middle income (LAMI) countries. It is well known that the major databases such as Medline or EMBASE cover less than 50% of research from LAMI countries, as most journals published in LAMI countries are not indexed in these databases. For example, Pakistan is an LAMI country with over 100 medical journals, however only six of these journals are indexed in PubMed (PakMediNet, 2021) . This may be important considering large population affected by COVID in countries such as India and Brazil. The prevalence of suicidal ideation estimates are based on heterogeneous populations. High risk groups such as clinicians and frontline staff in health care facilities may be more prone to mental health consequences of COVID but there were only two studies from this group. Despite these limitations, we believe we have estimated the prevalence of suicidal ideations and factors that underlie suicidal ideations, suicide or self-harm in a pandemic. We highlight the diagnostic and screening measures that were used in the included studies, which could possibly be used to help design future studies. This information will help to design better epidemiological and intervention studies in future.

Our results highlight the need to perform high quality research on suicide risk and prevention in the current pandemic context. In view of the high prevalence of suicidal ideation, it is important that practitioners should routinely assess for fear of infection during the COVID-19

pandemic to detect people with higher suicide risk. This is important in case of high risk people such as those in nursing homes, the elderly and those in quarantine measures.

Social connection plays a key role in suicide prevention. The prevention of loneliness induced by quarantine measures should be included in public health interventions during the COVID-19 pandemic. Brief contact interventions such as post-discharge telephone contacts; emergency or crisis cards; and postcard or letter contacts may be useful in providing social support and promoting distance-based access to mental health care and have been used to reduce suicide risk (Milner et al., 2016) . It would be important to evaluate these interventions in people facing quarantine and social isolation. were performed in a small number of countries. Suicidal ideations, suicide or self-harm are known to be shaped by cultural and social contexts. Across the globe, a COVID-19 diagnosis and its implications will be different, and this needs to be handled with a degree of skill and expertise. It is important to conduct properly designed studies in different countries, especially in low and middle income countries who are facing a large prevalence of COVID-19 infection.

We would like to acknowledge our information specialist Fiona Rees, who along with the library team, supported us with conducting the search, and providing advice.

We have no conflict of interest to declare 10 Medline (self-harm OR "self harm" OR NSSI OR "non-suicidal self injury" OR self-injur* OR "self injur*" OR "self mutilat*" OR "self inflicted" OR "self immolat*" OR "self destructive" OR "self wounding" OR "nonsuicidal self injury" OR suicide OR suicidal OR cutting).ti,ab 114125 115985

13 Medline ("social distanc*" OR "stay at home" OR quarantin* OR "self isolation" OR shield* OR "shelter-inplace" 27 EMBASE (self-harm OR "self harm" OR NSSI OR "non-suicidal self injury" OR self-injur* OR "self injur*" OR "self mutilat*" OR "self inflicted" OR "self immolat*" OR "self destructive" OR "self wounding" OR "nonsuicidal self injury" OR suicide OR suicidal OR cutting 44 PsycINFO (self-harm OR "self harm" OR NSSI OR "non-suicidal self injury" OR self-injur* OR "self injur*" OR "self mutilat*" OR "self inflicted" OR "self immolat*" OR "self destructive" OR "self wounding" OR "nonsuicidal self injury" OR suicide OR suicidal OR cutting 60 CINAHL (self-harm OR "self harm" OR NSSI OR "non-suicidal self injury" OR self-injur* OR "self injur*" OR "self mutilat*" OR "self inflicted" OR "self immolat*" OR "self destructive" OR "self wounding" OR "nonsuicidal self injury" OR suicide OR suicidal OR cutting Figure 2 shows the pooled prevalence of suicidal ideation for different populations. 

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Figure legend: Figure 1 denotes the PRISMA diagram which shows search process that was carried out in selecting texts for final review