Impact of immediate post SARS-CoV-2 lockdown on suicide in northern Tunisia

doi:10.21203/rs.3.rs-4172500/v1

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Impact of immediate post SARS-CoV-2 lockdown on suicide in northern Tunisia

https://doi.org/10.21203/rs.3.rs-4172500/v1

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Suicide is a multifactorial phenomenon influenced by pre-existing mental disorders and by the occurrence of detrimental societal changes. The stress related to the SARS-CoV-2 pandemic as well as the health prevention measures had a negative psychological impact on certain vulnerable populations. Our aim was to investigate suicidal trends and to compare suicide decedent’s profile before and after the lockdown. A descriptive and analytical cross-sectional study was conducted including all suicides that occurred in the north of Tunisia during the study period. Suicidal trends, were studied using an interrupted time series analysis while suicide decedent’s profile was compared between the study period from 24/05/2020 to 31/08/2020 and this same period of the previous five years. Interrupted Time Series Analysis showed a sporadic variation without significant peaks while the comparative study showed a significant increase, among suicide decedents after the lockdown, of individuals with a history of psychiatric disorders particularly mood disorders, suicidal attempts, alcohol and cannabis use and professional instability. We also observed an increase in suicides by hanging and precipitation against a decrease in immolations and intoxications. Our study highlights the importance of mental health promotion during health crises and of prevention especially among vulnerable people.

Suicide

Interrupted Time Series Analysis

Sars-Cov-2

mood disorder

Suicide is a global health issue. According to the World Health Organization (WHO), about 700,000 people die by suicide each year. Seventy-seven percent of these suicide cases are recorded in low- or middle-income countries ¹. Throughout history, two distinct representations of suicide have been discussed. The sociological interpretation by Durkheim views the act of suicide as a social fact ², while the psychological interpretation identifies individual biological vulnerability factors³. Emile Durkheim's analysis describes suicide as a phenomenon shaped by societal stability and changes, introducing classifications based on dysfunctions in social integration and regulation. Historical evidence demonstrate that traumatic societal events are associated with increasing suicide rate ⁴. Notably, periods following economic recessions ^5–7, natural and nuclear disasters ^8,9, major health crises, including the 1918 Spanish Flu ¹⁰ and the SARS outbreak in Hong Kong ^11,12 have shown elevated suicide rate largely due to factors like uncertainty, anxiety, social isolation, and economic impacts ^13,14.

In Tunisia, limited research has explored the impact of social disturbance on suicidal trends. Since December 2010, the country underwent a significant political and social transition following the revolution initiated by Mohammed Bouazizi's highly publicized self-immolation, becoming a symbol of social protest. Post-revolution studies conducted by the forensic medicine department at Charles Nicole Hospital showed 1.7 times increase in recorded suicides compared to pre-revolution figures and a shift in suicidal method with a threefold increase in self-immolations becoming the second most prevalent method ^15,16.

Since its emergence in Wuhan, the SARS-CoV-2 pandemic had a profound impact leading to many deaths accompanied by a global economic recession and social suffering. The preventive measures such as general lockdown recommended by WHO and implemented by many governments have had a significant psychological impact ¹³.The post-lockdown period is also critical, potentially having a significant psychological impact, with returning to work and job loss being the main stress factors during this time¹⁷.

Our study aims to investigate the variation in suicidal trends and the profile of suicide decedents, in northern Tunisia, during the fourteen weeks following the lifting of general lockdown and to compare it to the same period over the last five years.

We conducted a cross-sectional study with a retrospective review. Our study was related to the immediate post lockdown period defined by the period between the first release after the lockdown with partial measures until all restrictions have been lifted. This period lasted fourteen weeks from May 24, 2020, to August 31, 2020. We compared the results with this same period of the year over the five years preceding the pandemic.

2.1. The study population

All cases of suicide autopsied in the forensic medicine departments of northern Tunisia were collected during the study period. According to the official figures from the National Institute of Statistics in July 2019, the northern region of Tunisia counts 5,698,985 inhabitants, representing nearly half of the country’s total population ¹⁸.

We didn’t include in this study: suicides autopsied in the mentioned forensic medicine department but occurring in other governorates, cases where the self-inflicted nature of the death was not confirmed and deaths resulting from other manners of death.

We distinguished two groups. The first group (Group 1) includes suicide decedents during the period from May 24 to August 31, 2020 representing the “study group” who has experienced the psychosocial consequences of lockdown and the resumption following this measure. The second group (Group 2) includes suicide decedents during the same period in the five previous years (from 2015 to 2019). This group did not experience the SARS-CoV-2 pandemic.

Data was collected using a standardized form, which collected information from forensic autopsy files, family-reported narratives, hospitalized individuals' medical records and judicial police reports. Variables were categorized into two types: sociodemographic variables and the circumstances related to the suicide.

2.2. Statistical analysis

Data was analyzed using SPSS v26.0 software for Windows. A univariate analysis was conducted, calculating minimum and maximum values means and standard deviations for quantitative variables. For qualitative variables, absolute frequencies and percentages were calculated. Normal distribution of variables was checked by the Shapiro-Wilk statistical test. For the statistical analysis we used the following tests: For percentage comparison we used Pearson's Chi-square and Fisher's exact tests and in case of non-applicability the Mann-Whitney U and Kruskal-Wallis tests for independent samples. For means comparison we used Student t-test. Simple linear correlation analysis was performed using Spearman's non parametric test. The intensity and direction of the relationship were measured by Spearman's rho correlation coefficient.

Suicidal trends were studied through interrupted time series analysis, based on the number of cases per month and including all suicides between January 2015 and December 2020. Trend lines were plotted with calculation of the determination coefficient r². A correlation was considered moderate for an r² between 0.5 and 0.75 and significant for an r² > 0.75.

A total of 284 suicide decedents was included and divided in two groups. The study group (Group 1, n = 45), (group 2, n = 239) the comparison group. Suicides that occurred outside the northern region of Tunisia but were autopsied in the study’s forensic medicine services (n = 22) and deaths where the self-inflicted nature was not confirmed (n = 5).

3.1. Suicidal trends analysis before and after the SARS-CoV-2 pandemic

The interrupted time series analysis revealed sporadic variation with no peak between January 2015 and December 2020 (Fig. 1) and no trend towards an increase during the study period (p = 0.938) with a correlation coefficient r² = 0.00011.

3.2. Comparing immediate post-lockdown outcomes with those from the past five years

3.2.1. Sociodemographic characteristics

The sociodemographic characteristics of the population are presented in Table 1. During the immediate post-lockdown period, the mean age of suicide cases was 46.09 ± 5.29 years [11–81 y-o] The mean age was significantly lower during the same period of the year in the previous five years 39,47 ± 2,23[9–90 y-o] (p = 0,003). We observed a significant rise from 24.9–54% in the percentage of suicides among "Laborers" compared to other professions. Conversely, there was a decline of the “Unemployed” categories (p = 0,001).

Table 1

Sociodemographic characteristics of the population before and after the lockdown
Sociodemographic characteristics		Group 1 (Study group) n = 45	Group 2 n = 239	p
Age (Mean)		46,09 ± 5,29	39,47 ± 2,23	p = 0,003
Sex	Male	82,5%	72%	p = 0.128
Sex	Female	17,5%	28%	p = 0.128
Marital status	Single	41.8%	51.6%	p = 0.121
	Married	54,4%	36.8%
	Others	3.8%	88.4%
Occupational categories	Unemployed	22%	50.2%	p = 0.001
	Student	8%	9.7%
	Laborers	54%	24.9%
	Employee	2%	6%
	Manager	2%	1.8%
	Retired	12%	7.4%

3.2.2. Clinical characteristics

Clinical characteristics are presented in Table 2. Regarding substance use, we observed an increase of alcohol and cannabis use among suicide decedents during the post-pandemic period, with respective rates of 53,7% and 36.1% (p < 0.0001). However, there was no significant change in the rate of smokers. Post-pandemic, we noticed a significant increase of the rate of suicide decedents with psychiatric disorders from 35.7–51.7% (p = 0.034). Our study identified also a significant difference in the distribution of psychiatric disorder. There was a predominance of mood disorder after the pandemic (76.9%) while it was nearly equal schizophrenia before pandemic with respective rates of 47.5% and 50.8% (p = 0.001). We also observed a statistically significant increase in individuals with a history of suicide attempts were suicide occurred in post-lockdown (p = 0.007).

Table 2

Clinical characteristics of the population before and after the lockdown
Clinical characteristics		Group 1 (Study group) n = 45	Group 2 n = 239	p
Substance use	Tobacco	62,8%	42,7%	p = 0.062
	Alcohol	53,7%	18,4%	p < 0.0001
	Cannabis	36,1%	4,6%	p < 0.0001
Medical history		22,8%	19,2%	p = 0.578
Psychiatric history		51,7%	35,7%	p = 0,034
Psychiatric disorders N = 87	Mood disorder n = 49	76.9%	47.5%	p = 0.001
	Schizophrenia n = 35	15.4%	50.8%
	Anxious disorder n = 2	3.8%	1.6%
	Others n = 1	3.8%	0.1%
History of suicide attempts		29.3%	14%	p = 0.007

3.2.3. Suicide methods

Results are presented in Table 3. There was a significant change in the suicide methods. An increase in the method of hanging and defenestration and a decrease in the method of self-immolation, drowning and drug ingestion was noticed (p = 0.007).

Table 3

Suicide methods before and after the lockdown
Suicide methods	Group 1 (Study group) n = 45	Group 2 n = 239	p
Hanging	70.7%	49.8%	p = 0.007
Self-immolation	6.9%	23.1%
Drowning	1.7%	6.7%
Drug ingestion	8.6%	12.9%
Defenestration	10.3%	3.1%
Others	1.8%	4.4%

Our study focused on suicide trends and comparing suicide decedent’s profiles in northern Tunisia during the fourteen weeks following the lockdown from March 20 to May 24, 2020, with the same period of the year in the five years preceding the pandemic. Results showed no significant peaks but highlighted changes in suicide characteristics post-lockdown, with a significant increase in the average age, and higher instances among individuals with a history of psychiatric disorders, particularly mood disorders and previous suicide attempts. There was also a rise in alcohol and cannabis use among the suicide decedents. Suicide methods shifted towards more lethal and violent ones.

4.1. Suicidal trends analysis before and after the SARS-CoV-2 pandemic

Since the emergence of SARS-CoV-2 in Wuhan in November 2019, many deaths have been reported worldwide. Public health measures recommended by the World Health Organization such as social distancing, mask-wearing, hand washing, lockdowns, quarantine and curfews, have been implemented by countries to curb the spread of the virus. These measures alongside the prevailing uncertainty and increased social media exposure, have had a significant psychological impact ¹⁹. Meta-analyses highlighted increased rates of depression, anxiety, sleep disorders, and Post-Traumatic Stress Disorder. Women, nurses, lower socioeconomic status, and individuals facing high exposure risks were particularly affected ^13,20. Additionally, The pandemic also altered substance use patterns leading to increased use of alcohol, cannabis and anxiolytics during lockdowns^21,22.

In Tunisia, limited research has assessed the pandemic's psychological impact. Studies revealed high rates of severe depression and anxiety among general population and specific groups, notably medical residents and women, who also faced increased violence during lockdown ^23–25.

The psychological impact of the pandemic was anticipated from the outset, with multiple studies highlighting the need for psychological support to prevent suicide.

A study from the US involving 3,120 participants, revealed that suicidal ideation doubled among individuals who experienced pandemic restrictions while those unaffected showed no change ²⁶. Subsequent meta-analyses across 21 varied countries in 2021 showed increases in self-harm and suicidal ideation, yet another systematic review showed no significant rise in actual suicide rates ^27,28. However, preliminary suicide trends revealed a decreased rate in Milan ²⁹. Meanwhile, two studies from Japan, using interrupted time series analysis, showed increased suicide rates, particularly among young adults and the elderly in 2021 ^30,31. Our research, using this same statistical method, showed only sporadic shifts in suicide rates without notable rises. This result may be attributable to several factors. These include the relatively limited health impact of the first wave of SARS-CoV-2 with a total of 1051 cases, including 48 deaths by May 25, 2020, as reported by the National Observatory of New and Emerging Diseases ³², the rapid relaxation of sanitary measures, the governmental financial assistance and the establishment of psychological support unit with a helpline accessible on the national level ³³.

4.2. Comparing suicide decedents profile before and after the lockdown period:

In our study, we observed a statistically significant increase in the average age after the pandemic. A potential hypothesis to explain this finding is that this population includes active working-age adults with familial and social responsibilities, who experienced a psycho-social crisis triggered by financial difficulties due to lockdown such as job loss, insecurity, etc... This contrasts with reports from the United States and Taiwan, where the most affected subjects were predominantly younger individuals ^34,35. In the other hand, we did not show any significant difference between sexes before and after the lockdown. The only study we found revealing such result was in Japan. A significant increase was observed among women starting from July 2020. This was linked to the worsening of the unstable financial situation of Japanese women after the pandemic ³¹. We also did not find any significant changes based on marital status. Very few studies have explored this aspect following the lockdown. Additionally, our findings showed that, among suicide cases, laborers increased significantly from 24.9–54%. In Tunisia laborers are individuals employed on an irregular basis and without social security. They are particularly vulnerable to economic instability. A meta-analysis spanning 63 countries, from 2000 to 2011, established a positive correlation between unemployment rise and increasing suicide rates ³⁶. As job loss is a significant risk factor for suicide, a study in Canada predicted an increase in the suicide rate following the rise in unemployment rates due to the pandemic ³⁷.

Regarding substance use our observations revealed a significant increase in alcohol and cannabis consumption among suicide decedents following the lockdown period. Amid suicide cases, the percentage of individuals consuming alcohol rose from 18.4% before the pandemic to 53.7% after the lockdown, and cannabis use increased by 31.5% post-lockdown. Several studies reported an increase in alcohol consumption during the SARS-CoV-2 ^38,39. The main factors contributing to this change were age, gender, education level, depression scores, and loneliness ^40,41. Regarding cannabis use, different results were reported. A meta-analysis found increases in some studies with non-representative samples ²². Half of the cannabis-using individuals increased their consumption during the lockdown in the Netherlands ⁴². In France an increase in cannabis use linked with lower or middle education levels was reported ⁴³. The increase in consumption after the lockdown period could have facilitated the act of suicide, as alcohol and cannabis are known as suicidal risk factors which can explain our findings ^44,45. Further studies within the Tunisian context are needed to investigate this phenomenon.

Our research revealed a significant increase in suicide rates among individuals with psychiatric history after the pandemic, representing 51.7% of post-lockdown cases. The lack of psychological autopsies and the underdiagnosis of psychiatric disorders might explain this difference with the literature’s data where mental health disorders represent 70 to 80% of suicide cases ⁴⁶. Prior to the pandemic onset, the prevalent mental health conditions identified were schizophrenia and mood disorders accounting respectively for 50.8% and 47.5%. After the SARS-CoV-2 lockdown, we observed a distinct surge in the rate of suicide decedent with mood disorders increasing to 76.9%.

Psychiatric disorders are a significant risk factor for suicide. Mood disorders, schizophrenia and substance use disorders are the most frequently reported ^47,48. In March 2021, a longitudinal study showed that patients with psychiatric disorders were disproportionally impacted by the stress related to the pandemic and its preventive measures, compared to control group ⁴⁹. This impact, observed by many other studies, could be linked not only to obstacles in accessing consistent care and monitoring during health crises but also to these patient’s vulnerability to stressful events ^50,51. A Tunisian study exploring suicidal behavior in patient treated for type 1 bipolar disorder published on October 2021 revealed that factors as frequency of depressive relapses, presence of subsyndromal symptoms, impulsivity and job instability were positively correlated to suicidal behaviors ⁵². Regarding suicide decedents with a history of suicidal attempts, our study revealed an increase of 15.3% after lockdown. Studies showed that 19% of individuals with a history of suicide attempts tried suicide again within the two years after the initial attempts and that concentrated self-harm thoughts and behavior significantly increased suicide risk ^53,54. Uncertainty and health restrictions may have impacted these individuals increasing the likelihood of acting on suicidal impulses ⁵⁵. Our findings confirmed these projections.

Our study showed a shift in suicidal methods. After the lockdown, hanging and defenestration increased respectively by 20.9% et 7.2%. As a counterpart, self-immolation’s rate decreased significantly from 23.1–6.9%. This statistically significant change suggests a transition towards more lethal methods with a high level of intention. Since the Tunisian revolution in 2010, we observed a radical shift in the suicidal means as the self-immolation became a symbol of social protest after Mohamed Bouazizi’s suicide ⁵⁶. Tunisian researches showed that self-immolation became the second most used method of suicide ^15,57. During the SARS-CoV-2 pandemic, few studies exploring the suicidal act have been conducted. We found two studies in Nepal and India where the most used methods were: hanging, drug ingestion and the use of firearms ^58,59. These findings match ours regarding the hanging method. The unavailability of firearms in Tunisia accounts for their infrequent use while increased defenestration may reflect a strong suicidal intent that transcends more social protest.

4.3. Strengths and limitations:

We were unable to conduct a nationwide study, which might be more representative, due to logistical problems. Meanwhile, the representativeness of our study was notable since the northern Tunisia’s population accounts for about 50% of the general population. Moreover, the anthropological aspect was missing in our study as we could not conduct a qualitative study with psychological autopsies to gain a better understanding of the phenomenon in all its dimensions. Finally, the retrospective approach to data collection led to some missing information.

However, our study draws its significance from the relevance and originality of the subject, due to the lack of similar researches on the national level and the limited findings within the international literature to this point.

In conclusion, while our study did not show an overall raise in suicide rates, after the lockdown, it highlighted certain vulnerable populations. History of psychiatric disorders especially mood disorders, history of suicidal attempts, cannabis and alcohol use and job instability were the main vulnerability factors. A tailored biopsychosocial management with a better identification of these factors are necessary during crises. Additionally, our research revealed a significant increase in the average age of suicide. Despite predictions of a worldwide rise in suicide rates at the pandemic's start, only sporadic variations without clear trends were observed in most places including Tunisia. These findings should not be reassuring as the medical and socio-economic consequences of the pandemic are ongoing.

A comprehensive multidisciplinary prevention approach is crucial involving government backing for vulnerable groups, enhanced mental healthcare system organization, restricted access to suicide means and psychoactive substances and conscientious media communication. Healthcare professionals and mental health specialists play a vital role in promoting mental health and fighting stigma, offering stress management techniques and adapted coping methods, identifying high-risk individuals and offering them tailored healthcare services.

Our study highlighted the importance of mental health promotion during health crises either in health facilities or remotely and adapted mental healthcare services, focusing on vulnerable individuals.

Finding:

None.

Conflict of interest:

The authors have no conflicts of interest to declare.

Author Contribution

S.M. Conceived and designed the analysis, collected the data, performed the analysis and wrote the paperN.B. Conceived and designed the analysis and reviewed the manuscriptH.H. Contributed dataK.B. Contributed dataF.C. Contributed data and reviewed the manuscriptM.H. Contributed dataR.L. Conceived and designed the analysisM.B. Conceived and designed the analysis, contributed data, performed the analysis and reviewed the manuscript

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Impact of immediate post SARS-CoV-2 lockdown on suicide in northern Tunisia

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Abstract

Figures

1. Introduction

2. Methods

2.1. The study population

2.2. Statistical analysis

3. Results

3.1. Suicidal trends analysis before and after the SARS-CoV-2 pandemic

3.2. Comparing immediate post-lockdown outcomes with those from the past five years

3.2.1. Sociodemographic characteristics

3.2.2. Clinical characteristics

3.2.3. Suicide methods

4. Discussion

4.1. Suicidal trends analysis before and after the SARS-CoV-2 pandemic

4.2. Comparing suicide decedents profile before and after the lockdown period:

4.3. Strengths and limitations:

5. Conclusion

Declarations

Finding:

Conflict of interest:

Author Contribution

References

Additional Declarations

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