As a consequence of COVID-19 societal lockdown, we introduced a case of four expatriate workers who felt isolated, had major financial troubles, and could not travel home to support their families who were sick with COVID. They attempted suicide, all were saved, and three were evacuated home.
COVID-19 is an airborne virus that affects mainly the respiratory system and is transmitted primarily by droplet infection and direct contact. In response to the rapid spread of the virus, most governments have responded rapidly with social distancing, isolation, staying home recommendations, and societal lockdown to minimize the spread of the infection. Additionally, most governments had to close most of the international borders and delay the issuing of visas. Certainly, these measures helped in minimizing the pressure on the health care system and limited the spread of the virus, and lowered the rate of mortalities that could be directly due to the virus. However, these sudden and repressive regulations are not free of negative consequences. They increased anxiety, stress, depression as well as the risk of suicide4,8. The four cases in our series were typical examples who were negatively affected by the pandemic lockdown. They felt isolated and guilty as could not travel to help their loved family members who were sick with COVID-19 and also faced possible death. Social isolation contributes to the pathophysiology of psychiatric disorders and suicidal behavior. Also living alone gives rise to subjective feeling of depression which are strongly associated with suicide and that was reported in a large systematic review which included 40 articles9.
The lockdown affected the whole structure of the economy and mostly affected more non-governmental sectors, small businesses and self-employed, and those drawing a daily wage. Despite the different jobs that were presented in our study, all had experienced major financial crises because of the lockdown and the subsequent effects on their daily income. The link between unemployment and financial troubles is known and was reported in many published articles10. Although Hempstead et al reported that hanging is the most common method of suicide due to financial troubles, only one subject in our series attempted suicide by hanging while the other three used knives11. This could be explained by the younger age range in our cases and this is in agreement with Hempstead et al who reported that the number of suicides using suffocation was 59.5% among those aged 40-64 years compared with 18.0% for those aged 15-39 years11.
The data obtained from the deleterious effect of 2008 World global economic crisis is a good example to justify the reported cases of suicide in Oman and other countries. In a study that included 54 countries, Chang et al reported 4,884 excess suicide cases in 2009 compared with the number expected based on previous trends (2000-07)12. He concluded that after the 2008 economic crisis, rates of suicide increased in European and American countries respectively particularly in men and in countries with higher levels of job losses. Similarly, the four cases in our series were male and all lost their jobs.
The recent studies from different parts of the World on 2019 COVID pandemic showed similar findings. Initial reports from China by Wang et al evaluated 1,210 people from different cities in China and found that 16% had symptoms indicative of moderate to severe depression8. In subsequent studies in the US conducted by Google search, results that included the recent additions of words, phrases, and blogs that indicated depression and suicide, phrases such as: I lost my job, laid off, unemployment, help dramatically increasesd4. COVID-19 may have caused an increase in suicide risk factors that could yield long-term increase in suicidality and suicide rate4.
To date, a few case reports were published in the US, UK, Bangladesh, and India. Those cases presented findings based on the number of people who had committed suicide due to the combined factors of xenophobia, COVID-19, and negative media coverage. The reports illustrated the use of different terminology in relation to the chosen method of suicide: gunshot13, hanging5, knife6. In our series, hanging was used in one case, and the others used knives. It must be noted that it is difficult to access guns in Oman. Alleviating stress, anxiety, feeling alone can be achieved by social media campaigns. Telephone calls, texts, and web chats can be used for this purpose even in cases of societal lockdown. RUOK (Are you OK) is a non-profit suicide preventive charity organization that was launched in Australia14. It aimed to access people affected by COVID-19 and provide help to those at-risk of suicide.
We hope that this research paper increases public awareness of the major and negative consequences of COVID-19 lockdown. This is crucial because it was reported that the risk of suicide is not only evident during the pandemic, but also, the rate may persist after its eradication7. The World Health Organization (WHO) announced that the pandemic may take a couple of years to control and the complete eradication of the virus will not be achieved without the development of an effective vaccine. The health care sector has to contact those patients and who are known to have psychiatric diseases who are at risk for suicide. Also, the government and the media have to encourage charity foundations to access those most badly affected and to provide help and support. All those strategic measures could minimize suicide.