This study reveals that the prevalence of multiple adverse mental health and behavioral issues, namely suicidal ideation, problematic use of alcohol and cannabis, among a sample of Saskatchewan residents is relatively high during the second year of the COVID-19 pandemic. We found that among people with problematic use of alcohol and cannabis, suicidal ideation was 26%, meaning that among this group one in four had thoughts of ending their lives during the pandemic. Suicidal ideation was more common among respondents who had problem with alcohol use than among people with problematic cannabis use. Younger respondents (16–34 years) and those reported other coping behaviors that were not particularly adaptive or helpful (e.g. use of other psychoactive drugs) were independent factors that were associated with the common experience of suicide ideation, problematic cannabis and alcohol use.
Some factors were associated with one outcome but not all three. Having a diagnosis of mental health disorders either before or during the pandemic, and the perceived inability to bounce back after the pandemic (low resilience) are strong correlates of suicidal ideation. Those who lived alone, between 35 and 55 years of age were more likely to report problematic alcohol use. Those who reported coping strategies that were deemed more adaptive (such as physical and relaxation activities, and connection with social networks), who reported pandemic stress, and declared a LGBTQIA2S + identity had higher probability of problematic cannabis use.
The prevalence of problematic use of alcohol or cannabis during the COVID-19 pandemic reported here are comparable with the national prevalence of 14% and 8%, respectively (data not shown). Two years into the pandemic, in March 2022, 6.2% of Saskatchewan respondents have contemplated suicide compared to 3.3% in 2019—an increase of 87.9%—and 5.6% in Spring 2021, an increase of 10.7%.22
Although, there is generally an increasing trend in suicidal ideation in Canada,22 the Saskatchewan prevalence is lower than the national prevalence of 8.1%. The Saskatchewan suicide rates have been consistently declining since 2018, reducing by 14% from 2018 to 2019 (20.7 deaths per 100,000 population to 17.8 deaths per 100,000 population).8 Moreover, the suicide rate has been documented to further drop by 22% from the 2019 to 2021 (13.8 deaths per 100,000 people in 2021).8 The reason the suicide rate in Saskatchewan showed improvement, while suicidal ideation did not, is not clear. A plausible explanation for this finding is that suicidal ideation varies in intensity, and duration; a few people might have proceeded with their suicide intentions and plans after the initial suicidal thoughts (passive suicidal ideation). However, it should be noted that regardless of whether a suicidal thought is followed up by an attempt or not, it is still a mental health emergency because it is an early precursor to later attempted suicide (especially in the face of elevated rates of anxiety and depression). Given that active suicidal ideation (suicidal thoughts with plans to ending one’s life) is a more severe form of suicidal ideation than passive suicidal ideation (suicidal thoughts with no plans to end one’s life), this study could not delineate suicidal ideation by types. Further research is recommended to specifically estimate the magnitude and progression of suicidal ideation by types, and whether accessibility to social support and suicidal prevention programmes somehow reduce suicide rates.
While prevention efforts are unlikely to result in immediate changes in suicide rates, provincial efforts to increase prevention activities may be lowering the intensity of suicidal ideation from active to passive. The prevention activities were developed within the provincial sociocultural context, while leveraging community needs and strengths, as emphasized in the 2020 Saskatchewan Suicide Prevention Plan, commonly known as the “Pillars for Life” plan.34 This plan aligns with the Saskatchewan’s Mental Health and Addictions Action Plan, and both plans recognize the importance of community driven and culturally responsive multisectoral collaborations.34,35 Through the continuous implementation of community-led initiatives such as the “Roots of Hope programmes” by the community gatekeepers in La Ronge, Meadow Lake, and Buffalo Narrows, public health awareness about suicide prevention, drug safety, and other mental health services are delivered in the communities.35 In addition, crisis services, community recovery teams, police and crisis teams (PCT), and mental health capacity-building initiatives are being expanded within the province.35 Despite the recent progress achieved in reducing suicide rates, the high rates of suicidal ideation are concerning. Also, there have been mixed reactions due to the recent budget cut for suicide prevention programmes by the government of Saskatchewan.36
Consistent with other studies, suicidal ideation and problematic alcohol use are interrelated problems.37–39 Alcohol and cannabis misuse coexist,40 as well, thus interventions aimed at improving problematic alcohol use are more likely to have reciprocal effects on both suicidal ideation and problematic cannabis use, and vice versa. Somewhat paradoxically but consistent with the findings of Zhang et al.,41 and Price et al.,18 we found no significant relationship between problematic cannabis use and suicidal ideation after adjusting for confounding effects of the selected covariables. Further studies are needed to clarify the association between problematic cannabis use and suicidal ideation.
In this study, the respondents who said they were having suicidal thoughts and problematic cannabis and alcohol use tend to be younger (16–34 years old) and were more likely to use other illicit and psychotropic substances, as indicative of their reported use of other maladaptive coping strategies. These findings are in line with shifting trends that were exacerbated by the pandemic. Before the pandemic, there was clustering of suicidal ideation at older age (≥ 65 years).42,43 A longitudinal study conducted during the early months of the pandemic in the United States had established that young people were disproportionately affected by suicidal ideation partly because of substance misuse.44 Also, more recent studies have noted the demographic shift in suicidal ideation from older population to younger population.22,45 The relationship between suicidal ideation, and experience with alcohol or cannabis use has been linked to other negative coping behaviors such as polysubstance use.11
This study found evidence that problematic alcohol use decreases with increasing age. Judging by the current data, this finding might indicate that young people used substances as part of the measures taken to ease pains and losses arising from the pandemic. For example, in our further analysis, we observed that more young people lost their jobs than other age groups (16–34 years old: 4%, 35–54 years old: 1% and ≥ 55 years old: 2%), which could have possibly increased economic hardship and solitude (data not shown).
We also observed substance-specific correlates of problematic alcohol and cannabis use. Living arrangements have been shown to increase the risk of alcohol misuse.46 According to Joutsenniemi et al.,46 living with other people (social capital) promotes healthy lifestyle such as abstinence or low alcohol consumption by bolstering social cohesion and support. This association is broadly in line with our findings which shows that people who lived with others are less likely to misuse alcohol. Alternatively, people who excessively drink alcohol may have problems maintaining relationships with other people. However, in line with the ideas of Canham et al.,47 and Rosenquist et al.,48 it is important to note the residual effects of shared ideologies among social groups on drinking behaviors of the respondents as some individuals might not drink alcohol because their friends did not, while others would drink due to interpersonal influence or pressure.
Consistent with literature,49–51 this study highlights a higher susceptibility of respondents who declared as LGBTQIA2S+, and who reported links between pandemic-related stress and problematic cannabis use. In this study, most of the respondents reported unstable financial situation (20%) as their biggest source of COVID-19 related stress. While some people might have consumed cannabis recreationally, according to the sexual minority stress theory,49–51 LGBTQIA2S + often experience higher level of stress, conflicts within household, social stigma, prejudice and social isolation which, in turn, could have triggered cannabis use as a coping strategy. These experiences by the sexual minority groups could have been aggravated by the pandemic or persistent homophobic and transphobic culture in Canada.52–54 Cannabis use has been shown to ameliorate HIV symptoms such as nausea, diarrhoea, and neuropathic pain among this vulnerable group.55–57
Another important finding of this study is the elevated probability of suicidal ideation among individuals who reported they would have a difficult time bouncing back from the pandemic (low resiliency) and those diagnosed with mental health disorders, being stronger when diagnosed during the pandemic. Although it is still unclear whether a causal relationship exists, there continues to be growing body of evidence that mental health disorders (especially psychological distress and depression) are among the common risk factors of suicidality.58 Early identification and treatment of mental health disorders can prevent suicidal ideation. While it is encouraging that 76% of the respondents reported their ability to bounce back after the pandemic, the probability of having suicidal thoughts was 87% higher among the respondents who assessed their resilience as low. This suggests that perceived resilience can be protective against suicide during the pandemic.59–61 In the midst of the crisis, helping people to build resilience through social support and teaching them about positive coping skills may reduce pandemic-related stress and suicidal behavior, and therefore should be an integral part of suicide prevention measures.
This study contributes by advancing our understanding of the interplay between suicidal ideation, problematic use of alcohol, and cannabis use in the second year of the COVID-19 pandemic, and establishing the roles of sociodemographic, triggers and adaptability factors. Using separate models, previous studies have failed to address the correlation between the three outcome variables, with a possibility of introducing type-1 errors (i.e., concluding that results are statistically significant when they are not). To address the correlation structure and generate unbiased estimates, this study utilized trivariate probit regression to simultaneously predict the outcomes of interest.
There are some potential limitations to consider. First, participants’ responses were self-reported and might be subject to recall bias. Using validated and calibrated tools might have reduced this risk. Second, non-probabilistic sampling (quota sampling) was employed, so not every Saskatchewan adult had an equal chance of being recruited into the study. However, considering that sampling was done based on geographic distribution, age, gender, immigration status and ethnicity, the composition of study sample is representative of the Saskatchewan adult population. Lastly, causal inferences can not be made because of the cross-sectional nature of the study. Our findings should therefore be interpreted in the light of associations.
In summary, suicidality among Saskatchewan adults is not occurring in isolation but occur simultaneously with alcohol misuse. This finding suggests that recognition of early warning signs and treatment of individuals with problematic alcohol use are important for suicide prevention. Also, those who reported problematic alcohol use are more likely to experience problematic cannabis use, although cannabis use did not have an independent association with suicidal ideation. This study also provides a motivation for implementing age-responsive interventions and public education on coping strategies because these factors are shared among people living with suicidal ideation, problematic alcohol, and cannabis use. The distinct roles of mental health disorder and resilience in reducing suicidality during crisis (as was the case in this study, COVID-19 pandemic) deserve attention by the stakeholders. Mental health supports should be intensified in the communities. Also, treatment and prevention of cannabis dependence and its attendant problems among LGBTQIA2S + and other people affected by the pandemic is recommended and considered as good use of public health resources. Given the extent to which people who lived alone were at risk of alcohol misuse, these groups should be prioritized. As the pandemic persists, it is necessary to deliver screening and educational interventions to the high-risk individuals identified in this study.