Trends in medically serious suicide attempts before and after the COVID-19: a four-year retrospective analysis (2018-2022)

doi:10.21203/rs.3.rs-3093002/v1

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Trends in medically serious suicide attempts before and after the COVID-19: a four-year retrospective analysis (2018-2022)

https://doi.org/10.21203/rs.3.rs-3093002/v1

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Background

Suicide has become a first-order public health concern after the negative impact of COVID-19 on the general population’s mental health. Several studies have analyzed the trends in suicide attempts (SA) before and after the onset of the pandemic, but few studies focus on the impact of the pandemic on medically serious suicide attempts (MSSA).

Methods

Participants were 396 hospitalized individuals ≥ 16 years old who made MSSA identified retrospectively through a review of e-medical records between 2018 and 2022 ("pre-COVID-19" and “COVID” periods). The two groups were compared on sociodemographic and clinical variables using Chi-square or Exact Fisher’s tests for categorical variables and a Mann-Whitney test for continuous variables. To study the variation in MSSA over time, MSSA were aggregated monthly. Joinpoint regression analyses were used to assess time trends.

Results

A sample of 161 MSSA patients, 80 women and 81 men, were selected from 396 admissions after a suicide attempt (SA) in the four years (n = 169 pre-COVID period vs. n = 199 COVID period). Sixty-eight patients with MSSA were admitted during the first period, and 93 during the COVID period. MSSA patients were more likely to be admitted to an intensive care unit during the COVID period than during the pre-COVID period (OR = 3.4620; CI 95%=1.7305–6.9260).

Conclusions

This study highlights the need for research on suicide risk during and after crisis periods, such as the COVID-19 pandemic. It provides valuable knowledge on the incidence of SA needing hospitalization, MSSA, and highly severe MSSA for four years before and after the pandemic onset.

Medically serious suicide attempt

COVID-19

consultation-liaison

psychopathology

Epidemiology

Suicide and self-harm resulting from the direct and indirect effects of the COVID-19 pandemic have become major public health concerns (1). During the COVID-19 pandemic, there has been a significant increase in the number of consultations for suicidal ideation, suicide attempts, and deaths by suicide (2). The long-term impact of the crisis on people’s mental health and, in turn, on society should not be overlooked.

Exposure to adverse events is a well-established risk factor for short- and long-term mental health problems (3, 4). When crises affect people’s lives and communities, high-stress levels are expected to arise. Research on past epidemics has highlighted the negative impact of pandemics on people’s mental health, as reported by Zürcher et al.⁵ in their review, which finds a relationship between the pandemic and the increase in the prevalence of anxiety, depression, and post-traumatic stress disorders.

The few studies in the field are cross-sectional and from mono-source designs, with a lack of national databases, as well as heterogeneous outcomes and measures (i.e. suicide ideation, suicide attempt, MSSA, deaths by suicide), thus yielding contradictory results. Banerjee, Kosagisharaf and Sathyanarayana Rao⁶ reviewed suicide rates during the bubonic plague, Spanish Flu, SARS-COV-1, MERS, and Ebola and showed an increase in the incidence of suicidal behaviors shortly after the pandemics that were maintained over time. However, another study found different results, pointing to a weak relationship between the epidemic apogee and increased suicidal thoughts or death by suicide but a significant boost in the mid-long term (7). Leaune et al.⁸ and Ruck, Borycz, and Bentley⁹ explained these findings as a delayed effect on suicidal behavior after an initial period of reduced risk. Resulting from the 2008 economic crisis, a rise in “deaths of despair” was recorded (10). Farooq et al.¹ systematically reviewed studies (N = 38) on COVID-19 and suicide and found higher suicidal ideation during the COVID period in the general population than before it. Pompili¹¹ studied the loss of hope due to the lack of employment and rising inequality, and found that suicide and substance-use-related mortality accounted for most of these deaths. Otherwise, the United Nations¹² hypothesized that, as the economic burden of COVID-19 rises, a similar toll on people’s mental health may be triggered, with a major impact on individuals, families, and wider society.

In Catalonia, an autonomous region of Spain with approximately 7.5 million inhabitants, the first case of COVID-19 was detected on February 25, 2020. The most severe restrictions were put in place from March 14 to June 21 of that year, with measures that included a nearly complete lockdown, prohibition of social and religious gatherings, and closure of schools/universities, bars, restaurants, sports facilities, and non-essential shops. Some of these restrictions were removed or softened in phases after May 2020. Pérez et al.¹³, based on the data obtained from the Risk Suicide Code register, a system used in the National Health System of Catalonia¹⁴ to report suicide risk, and the regional police department of Catalonia, found that suicidal thoughts and behaviors significantly decreased during the lockdown restrictions (from March to May 2020) compared to 2019. However, deaths by suicide slightly increased in 2020 (n = 556) and 2021 (n = 576) compared to 2018 (n = 522) and 2019 (n = 535) (14).

Medically serious suicide attempts

Medically serious suicide attempts (MSSAs) represent a subgroup of clinically heterogeneous suicidal behaviors very close to deaths by suicide (15, 16). MSSAs include those attempts needing hospitalization resulting from the medical severity of the attempt (15, 17–19). Beautrais¹⁵ defined MSSA as an attempt that requires hospitalization in the emergency department for more than 24 hours and also meets the following criteria: a) treatment at specialized medical units; b) surgery under general anesthesia; c) extensive medical treatment; or, d) used a highly lethal method (i.e., precipitation, hanging, or drowning) despite not needing specialized or extensive medical or surgical treatment (15, 18, 19). Studying this type of attempt is highly valuable from a clinical perspective, as MSSA and deaths by suicide may represent an overlapping population with common predictors, such as the presence of psychiatric pathology, previous SA, social deficiencies, and recent exposure to life stressors (15).

Beautrais¹⁹ found that 90% of MSSAs met the criteria for a mental disorder at the time of the attempt. The most common diagnoses were affective disorders, substance use disorders, antisocial behaviors, and psychotic disorders. Comorbidity was also elevated, with more than half of MSSA patients having two or more comorbid Axis I mental disorders and Axis II personality disorders (16, 18). Patients who attempted suicide were more likely to be older and male and had a higher prevalence of nonaffective psychosis (15, 19). In contrast, anxiety disorders and social isolation predominated among patients with MSSA (19). Quesada-Franco et al.²⁰ compared the MSSA’s features requiring admission to an Intensive Care Unit

(ICU) to less severe MSSA (considering only those hospitalized ≥ 48 hours after the attempt). They found that the former reported recent stressful life events more frequently, were more likely to have at least one prior SA and a history of mental disorders, and their current attempt was predominantly non-planned compared to the other group. Affective and personality disorders were also more frequent among them. Focusing on MSSA needing ICU treatment is more valuable, from a clinical point of view, as they can be comparable to attempts resulting in suicide.

Conversely, a prospective study found that 37% of MSSA patients had attempted suicide during their 5-year follow-up, and 7% had died by suicide (21). Both suicidal behaviors were more common in the first 18 months. Factors associated with further SA after an MSSA were a history of previous suicidal ideation, admissions to mental health units, and a high score on despair. They combined these three factors, which modestly predict ideational suicide (15).

However, few studies focus on the impact of the COVID-19 pandemic on MSSA beyond the first months of the pandemic (22–25). A study on the impact of COVID-19 on suicide attempts (SA) found a significantly higher proportion of SA in all patients admitted to the trauma resuscitation room during the lockdown period in 2020 compared to the same 2-month time period in the pooled previous four years (22). García-Ullán et al.²³ reported the incidence of high-lethality SA after the declaration of the state of alarm in Salamanca, a province of Spain. They compared three periods (before, during, and after the first state of alarm declared on March 14, 2020) from January 1 to July 31, 2020, and found an increase in the lethality of the attempts after the declaration of the state of alarm. They defined high-lethal attempts as those using different methods than drug poisoning, stabbing, and other chemical poisonings. However, their definition does not include the need for hospitalization after the attempt resulting from the medical consequences of the MSSA (15, 16, 20).

Fushimi²⁴ theorized through his results about the COVID-19 pandemic as an influence on the group previously most likely to be suicide attempters becoming suicide completers. Similar results were found by Lee et al.²⁶, where an association between the COVID-19 pandemic and low-rescue SAs was shown. This study aims to analyze the trends of MSSA patients admitted to the largest general hospital in Catalonia two years before and two years after the pandemic onset (March 2020). Within the pandemic, the study aims to analyze the trends in admissions after COVID-19 and the start of the vaccination campaign. MSSA patients needing admission to an Intensive Care Unit for treatment (hereinafter, MSSA-ICU subgroup), will be compared to those needing other types of treatment. According to the evidence, the number of admissions during the COVID period is expected to be positively correlated both to the number of MSSA and MSSA-ICU compared to the pre-COVID period (1, 26–29). However, the number of MSSA during the COVID period is expected to be inversely correlated to the number of hospitalizations for COVID during that period.

Study design

This is an observational and retrospective study examining 396 e-medical records of individuals admitted to Vall d’Hebron University Hospital (HUVH) between 2018 and 2022 after an MSSA. Within this interval, two periods concerning the COVID-19 pandemic onset were defined: 1) the “pre-COVID-19” period, from March 13, 2018, to March 12, 2020; and 2) the “COVID” period from March 13, 2020, to March 13, 2022. The turning point was the first state of alarm declared in Spain (03-13-2020).

Setting

HUVH is a public hospital of the Hospital Network of the Catalan Health Institute in Spain, and the referral center in the comprehensive healthcare area of the north of the city of Barcelona, with a total population of more than 480,000 inhabitants. However, HUVH is also a tertiary care hospital, the biggest in Catalonia and one of the biggest in Spain, receiving patients from all over Catalonia (30).

Procedure

All SA data were extracted from the HUVH electronic record systems, and those cases which met the criteria for MSSA were selected through clinical consensus. Only patients older than 16 years were included in the study. Within the interval of study, two groups of patients were compared based on their admission period: the “pre-COVID” period (from March 2018 to February 2020) and the “COVID” period (from March 2020 to February 2022). Approval for conducting the study was obtained from Vall d’Hebron University Hospital Ethics Committee (PR(AG)51/2022). Informed consent was waived by Vall d’Hebron University Hospital Ethical Research Committee PR(AG)51/2022.

Study variables

MSSA was defined, following Beautrais’ criteria (15, 19), as SA that required hospitalization after the attempt and meeting one of the following treatment criteria: a) Treatment in specialized units (Intensive Care Unit, Hyperbaric Unit, Burns Unit); b) Surgery under general anesthesia (superficial cuts that did not require surgical repair were excluded); and c) Extensive medical treatment (beyond gastric lavage, activated charcoal, or routine neurological observations) including antidotes for drug overdose telemetry, or repeated tests or investigations. Individuals who attempted suicide by methods with a high risk of fatality (i.e. hanging), more than 24 hours but did not meet the preceding treatment criteria, were also included. For this study, the timing of MSSA was conceptualized as hospitalization in non-psychiatric wards for a self-inflicted injury of more than 48 hours, thus expanding the 24-hour criterion for MSSA of Beautrais^15,19. The number of COVID-19 cases was defined as the number of patients hospitalized for COVID-19 at HUVH. Patients hospitalized after MSSA and MSSA-ICU were analyzed for the main outcomes in both periods, pre-COVID and COVID.

Socio-demographic variables included sex, age, marital status, unemployment, and having children. Clinical variables included the need for intensive care treatment, suicide method, alcohol use during the attempt, having a prior SA, history of psychiatric and/or psychological treatment, and main diagnosis registered in the medical record following DSM-IV-TR criteria (31).

Statistical analyses

Association between the two groups and categorical variables was assessed using a Chi-square test or Odds Ratios (ORs) with a 95% confidence interval (CI). When statistically significant differences were found for categorical variables calculated by Chi-square, post hoc pairwise comparisons using Bonferroni correction were performed. Mann-Whitney test was conducted for continuous non-normally distributed variables. The hypothesis tests were two-tailed and conducted with an alpha of 0.05.

MSSA cases were aggregated monthly to study the variation in MSSA over time.

A sample of 161 MSSA patients, 80 women and 81 men, was selected from a total of 396 hospital admissions after an SA in the four years (n = 169 pre-COVID period vs. n = 199 COVID period). During the pre-COVID period, 68 patients were admitted with MSSA and 93 during the COVID period (OR = 1.37; CI 95%=1.0003–1.8698; p < 0.05). MSSA patients were more likely to need admission to an ICU during the COVID period than the pre-COVID period (OR = 3.4620; CI 95%=1.7305–6.9260; p < 0.001).

**********Table 1***************

Table 1 shows the characteristics of patients admitted for MSSA in each period. No statistically significant differences in sex, marital status, unemployment, or having children were found between the groups. However, there was a statistically significant difference in the age group distribution between the two periods (p < 0.05). A post hoc comparison revealed that the difference between periods lay in the 36–50 group, which increased from 19% in pre-COVID patients to 41% in COVID patients (p < 0.01). When statistically significant differences were found for categorical variables, post hoc pairwise comparisons using Bonferroni correction were performed.

No statistically significant differences were found between the groups regarding main Axis I and Axis II diagnoses. The most frequent diagnoses were affective disorders (25.9% pre-COVID vs. 33.3% COVID), cluster B personality disorders (25.93% vs. 33.8%, respectively), and substance use disorders (18.52% vs. 17.24%, respectively).

Regarding suicidal variables, both groups were similar when comparing the frequency of previous SA (44.6% in both subsamples), alcohol use during the attempt (19.4% vs. 28.2%), and type of lethal method, medical overdose being the most frequent (58.8% vs. 61.5%).

Trends in MSSA and COVID admissions before and after the pandemic onset

Figure 1 depicts the relationship between the number of admissions for COVID-19 and MSSA before and after the pandemic. Figure 2 shows the evolution of MSSA admissions that required and did not require ICU admission, where there is a separation of both curves after the pandemic onset. The trends of MSSA in our study showed an increase at the beginning of 2019, reaching the peak after the lockdown, when the restrictions were relaxed, and decreasing after the beginning of the vaccination campaign. We observed a decrease of MSSA during the lockdown and an increase after the COVID-19 wave.

**********Figure1***************

**********Figure2***************

Our results confirm the evidence found in other studies comparing SA before and after the pandemic onset. The number of SA patients who needed hospitalization during the COVID period doubled the incidence with respect to the pre-COVID period. Both MSSA and MSSA-ICU as a subgroup of highest severity were also more frequent during the COVID period. MSSA were more frequent in the 36-50-year-old group during the COVID period but no other differences in either the sociodemographic or the clinical variables were found between groups.

In our findings, individuals who made an MSSA consumed more alcohol in COVID (28.2%) than in the pre-COVID (19.4%) period, even though this increase was not significant. Varin et al.³² found an association between suicide ideation and increased alcohol use in the general population during the COVID-19, and Kim et al.²⁹ found a significant increase in alcohol consumption at the time of the SA among adult patients after COVID-19. The increase in alcohol consumption during the COVID-19 period indicates the possibility of an increase in the incidence of alcohol use disorder, at the same time being a risk factor for SA and MSSA.

Concerning age, our data concurred with Corbé et al.²⁷ who found a higher number of caseloads represented in the age group from 25–55 years old (27). Despite that, the literature reported an increase in SA in the elderly during the COVID period, associated with more vulnerability, lower economic inputs, and isolation (33, 34). Moreover, gender was reported as a risk factor for SA, higher rates being found in women and girls during the COVID-19 period (35). Our findings show equity between genders in MSSA cases. This result can be explained because MSSA can be studied as a subgroup, which differs from SA, not only because of the high lethality but also in view of the differential sociodemographic characteristics (36–38). Moreover, these data agree with Corbé et al.²⁷, who found that women represent half of MSSA cases out of a total sample of 81,959. Previous SA is the only predictive factor of suicide found (38), with Ammerman et al.³³ stressing the need to implement suicidal risk screening in order to identify those who are at risk of suicide.

Our study is in line with two meta-analyses and reviews on the relationship between the COVID-19 pandemic and suicide rates. Dubé et al.²⁸ included 54 studies and 308,596 participants, and found that suicide ideation, SA, and self-harm increased during the COVID-19 pandemic. A meta-analysis aiming to objectivize whether infectious epidemics were related with variations in suicide incidence found little robust evidence sustaining this relationship. They noted a lack of up-to-date statistic monitoring changes due to the pandemic (7). The study by O’Connor et al.⁴⁰ reported that rates of suicidal ideation increased over time, with respondents at wave 2 (9.2%; OR = 1.17, 95% CI 1.01–1.34) and wave 3 (9.8%; OR = 1.24, 95% CI 1.07–1.44) reporting higher levels than at wave 1 (8.2%). However, this study was conducted from April to May 2020, only providing insight into the short-term consequences of the pandemic.

García-Ullán et al.²³ studied the incidence of high-lethality SA, which is defined by the method, specifically gas poisoning, pesticide, or herbicide, drowning, stabbing, or jumping, finding that the number of consultations related to suicidality in the emergency room remained constant in the pre-COVID period. However, the lethality of the means employed increased (23, 41). Also, all patients needing ICU admission, regardless of their medical diagnosis, have more risk of suicide after discharge than other types of inpatients (42). Lethality can be defined by different criteria. For example, Lim, Lee and Park⁴¹ differentiate high and low lethality depending on the method, and Beautrais^15,19 uses criteria linked to the consequences of the SA, such as time of hospitalization needed, or medical treatments required. However, few studies have analyzed the trends in MSSA after the COVID period using a definition based on time hospitalized after the attempt (i.e., > 24 hours for Beautrais¹⁵; and < 48 hours for Quesada-Franco et al.¹⁶. This criterion helps identify those SA with more severe medical consequences, regardless of their psychiatric severity and the type of lethal method.

Our MSSA trends were similar to those reported by Dubé et al.²⁸ and Rogers et al.⁷ in their meta-analysis, and agreed with García-Ullán et al.²³ in the increase of lethality and low-rescue SA in the COVID period compared with pre-COVID. Also, Carlin et al.²² revealed an increase in SA. Despite that, our results differed from Maleitzke et al.²⁵, Appleby et al.⁴³, and Leske et al.⁴⁴, who found no differences between COVID and pre-COVID periods. Potential explanations for the discrepancy could be the shortness of the studies, which analyze from 3 to 12 months after the start of the COVID pandemic. To our knowledge, this is the first study focusing on the effects of the COVID pandemic on suicidal behavior, particularly on MSSA with an extended period of time comparison (2 years before and after the COVID state alarm declaration).

Disasters like pandemics may result in higher rates of suicide because of stress, uncertainty, social isolation, and aggravation of previous mental health disorders (7, 45). Besides, looking at the most reliable and potent predictors of death by suicide across the lifespan, having a previous suicide attempt (SA) (46–49), mental health and behavioral problems, serious economic difficulties, and multiple psychosocial stressors associated with the COVID-19 pandemic may increase the incidence of all types of suicidal behavior (50, 51).

Strengths and limitations

This study provides a novel insight into the hospitalization trends after SA by expanding the studied period to four years, two before and two after the pandemic onset. Moreover, SAs needing hospitalization in Spain are predominantly referred to public resources, and our data were obtained from the largest public hospital in Barcelona. Using a more restrictive definition of MSSA and analyzing MSSA-ICU as a higher severity subgroup (i.e., based on the hospitalization time after the attempt) helps identify SA that are similar to deaths by suicide. Finally, these results may be generalizable and portable to other comparable environments, on being obtained from a real-world study.

The main limitations of the study are 1) the sample size, as it limits the statistical significance of some differences found between groups. However, this is the largest sample studied on MSSA in a period of 4 years; 2) retrospective data obtained from medical records; and 3) the clinical diagnosis with the lack of structured interviews. Although, all inpatients were attended through a structured psychiatric and psychological intervention.

This study highlights the need for research on mental health consequences during and after crisis periods, particularly on suicide risk and suicide behavior in the COVID-19 context. More specifically, it provides valuable knowledge on the incidence of SA needing hospitalization, MSSA, and highly severe MSSA during four years, two years before and two years after the pandemic onset. Suicide is an urgent public health problem, and specific clinical and social interventions to mitigate the impact of economic, social, and health crises is a vital requirement.

MSSA

Medically Serious Suicide Attempts

Suicide Attempts

ICU

Intensive Care Unit

Acknowledgements

The authors wish to thank all the researchers for their kind collaboration, and La Marató de TV3 for the funding and support.

Funding

Mª Dolores Braquehais, Marta Quesada-Franco, Luis Marte, Rosa Ramos and Anna Beneria are funded by a grant from La Marató de TV3 (202208-30-31 funds).

Ethics approval and consent to participate

The study was approved by Vall d’Hebron University Hospital Ethical Research Committee PR(AG)51/2022. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was waived by Vall d’Hebron University Hospital Ethical Research Committee PR(AG)51/2022.

Consent for publication

Not applicable.

Competing interests

Josep Antoni Ramos-Quiroga received the grants: BGaze, Ferrer, Fundación F.C. Barcelona, Fundación PROBITAS, Instituto Carlos III-EU FP7-H2020, Janssen, Lundbeck, Oryzon, Psious, Nesplora, Roche, Rubió and Shire-Takeda. He is honorary member of Rubió, Janssen-Cilag, Novartis, Shire, Takeda, Bial, Shionogi, Sincrolab, Novartis, BMS, Medice, Uriach, Technofarma and Raffo. He is advisory board of BGaze, Biogen, Ferrer, Instituto Carlos III-EU FP7-H2020, Janssen, Medice, Novartis, Rubió, Shire-Takeda, and Sincrolab.

Anna Beneria is funded as a research collaborator by Instituto de Salud Carlos III (PI22-0618 funds).

Authorship and contributions

A.B. and L.M. performed the data search from the e-medical records. S.G.G., D.R., C.P. and A.B. reached clinical consensus to select the final sample in view of the inclusion/exclusion criteria. L.M. performed the statistical analysis. L.M. and A.B. interpreted the analysis. M.D.B. and A.B. wrote the first draft of the manuscript. O.S., M.Q.F, R.R., J.A.R.Q., and M.D.B. contributed to the design of the study, participated in the consensus process, and critically revised the manuscript. All authors contributed to and approved the final manuscript.

Data availability statement

The datasets generated during and analyzed during the current study are not publicly available due to contain personal, clinical and high sensitivity data but are available from the corresponding author on reasonable request. Clinical data are a specially protected data group according to Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016.

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Table 1 is available in the Supplementary Files section.

Competing interest reported. Josep Antoni Ramos-Quiroga received the grants: BGaze, Ferrer, Fundación F.C. Barcelona, Fundación PROBITAS, Instituto Carlos III-EU FP7-H2020, Janssen, Lundbeck, Oryzon, Psious, Nesplora, Roche, Rubió and Shire-Takeda. He is honorary member of Rubió, Janssen-Cilag, Novartis, Shire, Takeda, Bial, Shionogi, Sincrolab, Novartis, BMS, Medice, Uriach, Technofarma and Raffo. He is advisory board of BGaze, Biogen, Ferrer, Instituto Carlos III-EU FP7-H2020, Janssen, Medice, Novartis, Rubió, Shire-Takeda, and Sincrolab.

Anna Beneria is funded as a research collaborator by Instituto de Salud Carlos III (PI22-0618 funds).

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Trends in medically serious suicide attempts before and after the COVID-19: a four-year retrospective analysis (2018-2022)

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Abstract

Background

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Background

Epidemiology

Medically serious suicide attempts

Methods

Study design

Setting

Procedure

Study variables

Statistical analyses

Results

Trends in MSSA and COVID admissions before and after the pandemic onset

Discussion

Strengths and limitations

Conclusions

Abbreviations

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Supplementary Files

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