No evidence of a significant increase in risk of suicide in first months of the pandemic, but continued monitoring needed

A new observational study is the first to examine suicides occurring during the early phase of the COVID-19 pandemic in multiple countries and finds that suicide numbers largely remained unchanged or declined in the pandemic’s early months. The study, led by an international team including University of Bristol researchers, is published in The Lancet Psychiatry journal.

• First study to examine suicides occurring around the world during the COVID-19 pandemic finds that – in high-income and upper-middle-income countries – suicide numbers have remained largely unchanged or have declined in the early months of the pandemic, compared with expected levels.
• However, the authors stress that governments must remain vigilant as the longer-term mental health and economic effects of the pandemic unfold and be poised to respond if the situation changes.
• Study looked at numbers of suicides in 21 countries between 1 April and 31 July 2020 and compared these with trends in the previous one to four years.

The authors note that – while their study provides the best available evidence on the pandemic’s effects on suicide so far – it only provides a snapshot of the first few months of the pandemic and effects on suicide might not necessarily occur immediately.

Lead author, Professor Jane Pirkis, Director of the Centre for Mental Health at the University of Melbourne, Australia, says:

“We need to continue to monitor the data and be alert to any increases in suicide, particularly as the pandemic’s full economic consequences emerge. Policymakers should recognise the importance of high-quality, timely data to support suicide prevention efforts, and should work to mitigate suicide risk factors associated with COVID-19, such as the heightened levels of stress and financial difficulties that some people may experience as a result of the pandemic. Increasing mental health services and suicide prevention programmes, and providing financial safety nets may help to prevent the possible longer-term detrimental effects of the pandemic on suicide.”

Professor Pirkis also stresses:

“We know that many people have had their lives changed dramatically by the pandemic, and the journey for some of them is ongoing. We need to recognise that suicide is not the only indicator of the negative mental health effects of the pandemic – levels of community distress are high, and we need to ensure that people are supported.”

It is likely that mental health effects of the pandemic will vary between and within countries, and over time, depending on factors such as the extent of the pandemic, the public health measures used to control it, the capacity of existing mental health services and suicide prevention programmes, and the strength of the economy and relief measures to support those whose livelihoods are affected by the pandemic.

Few studies have examined the effects of any widespread infectious disease outbreaks on suicide. The new study included around 70 authors from 30 countries who are members of the International COVID-19 Suicide Prevention Research Collaboration (ICSPRC), which came together to share knowledge about the impact of the pandemic on suicide and suicidal behaviour, and advise on ways to mitigate any risks.

The study used real-time suicide data obtained from official government sources to determine whether trends in monthly suicide counts changed after the pandemic began. They compared numbers of monthly suicides before COVID-19 (estimated using modelling of available data from at least 1 January 2019 to 31 March 2020, and in some cases ranging from 1 January 2016) with numbers observed in the early months of the pandemic (from 1 April 2020 to 31 July 2020) to determine how suicide trends changed during the pandemic. The study included 21 countries and regions (16 high-income, andfive5 upper-middle-income), including whole-country data in 10 countries and data for 25 specific areas in 11 countries.

The authors found no evidence of an increase in suicide numbers in the early months of the pandemic in any of the countries included. In 12 areas there was evidence of a decrease in suicide, compared to the expected numbers.

The authors note that their findings could be explained by some of the steps that governments took in the various countries. For example, in many countries mental health services were increased or adapted to mitigate the potential impact of lockdown measures on mental health and suicide. Similarly, fiscal measures were put in place to buffer the financial hardship experienced by people who lost jobs or had to close their businesses as a result of stay at home orders. They also note that the pandemic might have heightened some factors that are known to protect against suicide (such as community support of vulnerable individuals, new ways of connecting with others online, and strengthened relationships through households spending more time together), a beneficial collective feeling of ‘being in it together’, as well as a reduction in everyday stresses for some people.

Professor Pirkis says:

“Many countries in our study put in place additional mental health supports and financial safety nets, both of which might have buffered any early adverse effects of the pandemic. There is a need to ensure that efforts that might have kept suicide rates down until now are continued, and to remain vigilant as the longer-term mental health and economic consequences of the pandemic unfold. The effect of the pandemic on suicide might vary over time and be different for different groups in the population.”

The authors note that their study did not include low or lower-middle-income countries, which account for 46 per cent of the world’s suicides and might have been particularly hard hit by the pandemic. They say that there are some concerning signs that the pandemic might be adversely affecting suicide rates in these countries, but that it is difficult to verify as very few of these countries have good quality death registration systems and fewer collect real-time suicide data. In addition, they note that data quality for all countries may have been less reliable if the pandemic disrupted data collection processes, but that sensitivity analyses to test for this in their study yielded similar results.

They also highlight that their data does not explore the association between the pandemic and suicide in different age groups, for males versus females, or for people of different ethnicities. It also does not explore the effects of various public health measures to contain the pandemic or economic support packages on suicide patterns. The authors have plans to study this in future research.

Writing in a linked Comment, Dr Stella Botchway and Professor Seena Fazel, University of Oxford, UK, say:

“[…] despite this initial snapshot, governments and services need to remain vigilant for a possible delayed increase in suicides as a result of the pandemic. Suicide can be a lagging indicator of psychosocial difficulties, influenced by medium-term and longer-term disruptions to civic life and the economy. Other work has shown that suicides can increase following economic recession, and such increases can be sustained for several years. Without counter-measures, ongoing reductions in economic activity can translate into individual financial and personal problems, such as job losses, reduced social status, housing instability, and relationship breakdowns. Alongside social isolation and disruption of normal routines, these factors can, in turn, increase the incidence of suicide through rises in mental health conditions such as depression as well as drug and alcohol misuse. Similar mechanisms might be relevant during the COVID-19 pandemic and its aftershocks.”

They continue:

“Reducing the global impact on mental health of the COVID-19 pandemic will involve continued monitoring alongside early intervention and investment into mental health services. Local, regional, and national strategies should not overlook at-risk groups, including those that might be hidden from view, such as people who are homeless, living in prison, or in abusive relationships. These strategies will be informed by consortia, such as the International COVID-19 Suicide Prevention Research Collaboration, allowing for ongoing surveillance, particularly of populations at higher risk. This collaboration can also lead to more consistent collection of high-quality suicide data across different countries. Pirkis and colleagues’ results are reassuring in that there has not been an initial clear increase in suicide deaths, but will need to be followed up across a wider set of countries over the next few years to investigate whether suicide will be one of the health-related aftershocks of the pandemic.”

Read the paper

‘Suicide trends in the early months of the COVID-19 pandemic: interrupted time series analysis of preliminary data from 21 countries‘ by J Pirkis et al in the Lancet Psychiatry