Suicide prevention and COVID-19: the role of primary care during the pandemic and beyond
TL;DR: In this paper, the authors outline the current evidence for impact of the COVID-19 pandemic on self-harm and suicide rates, and consider how primary care can contribute to suicide prevention during the crisis.
Abstract: The COVID-19 pandemic has brought with it multiple threats to mental wellbeing — the possibility or reality of serious physical illness; complex COVID-related bereavement; lockdowns that cause isolation and inhibit social contact, or that can increase exposure to abuse in the family; caring for children unable to go to school; and precarious employment and redundancy, failing businesses, and financial insecurity. The pandemic has exacerbated the longstanding pressure on resources and underinvestment in both statutory mental health and wider community services. Against this background we outline the current evidence for impact of COVID-19 on self-harm and suicide rates, and we consider how primary care can contribute to suicide prevention during COVID-19 and after the acute crisis has passed.
There is international evidence of raised prevalence of anxiety disorder, post-traumatic stress disorder, and depression symptoms, especially during lockdowns implemented to contain COVID-19, and particularly in young people and those living with children.1,2 Those with pre-existing mental and chronic illness may be at higher risk.3 These increases in prevalence of symptoms of mental illness are important in their own right, and may also increase suicide risk.
Self-harm is the strongest risk factor for suicide. Although thoughts of self-harm and suicide are common accompaniments of adversity and poor mental health, evidence to date has not indicated increased rates of self-harm during the UK’s COVID-19 epoch.4 Data from electronic health records in UK general practice identified substantial reductions in recorded incident diagnoses of anxiety disorders, depression, and self-harm episodes during April 2020 compared to previous years.5 Although these rates had returned to expected levels in England by mid-September 2020, we do not yet know the impact of the subsequent stringent regional restrictions and two successive …
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TL;DR: The authors investigated suicidal ideation in relation to COVID-19 related stress, including material and social stress, in a predominantly low-SES ethno-racially diverse sample in New York City during a peak in COVID19 cases in April 2020.
Abstract: The link between large-scale disasters and population-level risk of suicide remains unclear. The present study sought to investigate suicidal ideation (SI) in relation to COVID-19 related stress, including material and social stress, in a predominantly low-SES ethno-racially diverse sample in New York City during a peak in COVID-19 cases in April 2020. Using binary logistic regressions of data collected with self-report surveys, we found that individuals who identified as Asian, as well as those with high total, material, and social stress levels, and persons without access to primary care providers had significantly higher adjusted odds of SI. These results indicate the specific burden faced by Asian participants due to increases in targeted racism, the importance of cumulative stress and specific stressor type, as well as the role of healthcare access on SI during the pandemic. Such findings suggest the need for specific interventions that target individuals who may be at higher risk of suicide after large-scale traumatic events and during the ongoing pandemic.
9 citations
TL;DR: In this paper , the authors describe the sociodemographic characteristics and identify antecedents in middle-aged males who recently consulted a GP before dying by suicide and identify clinical factors associated with having a last GP consultation close to suicide.
Abstract: Reducing suicide risk in middle-aged males (40-54 years) is a national priority. People have often presented to their GP within 3 months before suicide thus highlighting an opportunity for early intervention.To describe the sociodemographic characteristics and identify antecedents in middle-aged males who recently consulted a GP before dying by suicide.This study was a descriptive examination of suicide in a national consecutive sample of middle-aged males in 2017 in England, Scotland, and Wales.General population mortality data were obtained from the Office for National Statistics and National Records of Scotland. Information was collected about antecedents considered relevant to suicide from data sources. Logistic regression examined associations with final recent GP consultation. Males with lived experience were consulted during the study.In 2017, a quarter (n = 1516) of all suicide deaths were in middle-aged males. Data were attained on 242 males: 43% had their last GP consultation within 3 months of suicide; and a third of these males were unemployed and nearly half were living alone. Males who saw a GP recently before suicide were more likely to have had recent self-harm and work-related problems than males who had not. Having a current major physical illness, recent self-harm, presenting with a mental health problem, and recent work-related issues were associated with having a last GP consultation close to suicide.Clinical factors were identified that GPs should be alert to when assessing middle-aged males. Personalised holistic management may have a role in preventing suicide in these individuals.
2 citations
TL;DR: Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self-harm.
Abstract: Abstract Objectives This study aimed to (1) examine barriers and enablers to General Practitioners’ (GP) use of National Institute for Health and Care Excellence (NICE) guidelines for self‐harm and (2) recommend potential intervention strategies to improve implementation of them in primary care. Design: Qualitative interview study. Methods Twenty‐one telephone interviews, semi‐structured around the capabilities, opportunities and motivations model of behaviour change (COM‐B), were conducted with GPs in the United Kingdom. The Theoretical Domains Framework was employed as an analytical framework. Using the Behaviour Change Wheel, Behaviour Change Techniques (BCTs), intervention functions and exemplar interventions were identified. Results GPs valued additional knowledge about self‐harm risk assessments (knowledge), and communication skills were considered to be fundamental to high‐pressure consultations (cognitive and interpersonal skills). GPs did not engage with the guidelines due to concerns that they would be a distraction from patient cues about risk during consultations (memory, attention and decision processes), and perceptions that following the guidance is difficult due to time pressures and lack of access to mental health referrals (environmental context and resources). Clinical uncertainty surrounding longer term care for people that self‐harm, particularly patients that are waiting for or cannot access a referral, drives GPs to rely on their professional judgement over the guidance (beliefs about capabilities). Conclusions Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self‐harm. Five intervention functions and ten BCT groups were identified as potential avenues for intervention design.
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TL;DR: In this article , the authors evaluated the impact of the COVID-19 pandemic on suicidal acts using hospital data and found that suicidal patients and GPs have adapted by improving the expression of suicidal ideas.
Abstract: Background Most studies published to date have investigated the impact of the COVID-19 pandemic on suicidal acts using hospital data. Trends from primary care in a country such as France are crucial, as individuals may not consult hospital services after suicide attempts (SAs) but rather see their general practitioner (GP). Objectives We aimed to evaluate whether the incidence and characteristics of SAs and completed suicides (CSs) reported to French GPs were different during the COVID-19 pandemic than those of before. Methods and findings We conducted a retrospective observational study using data from a nationwide monitoring system, the French Sentinel Network (FSN). All SAs and CSs reported by GPs to the FSN from January 1, 2010, to March 10, 2022 were included. The annual incidence rates (IRs) and the characteristics of SAs and CSs during the pandemic (March 11, 2020, to March 10, 2022) were compared to those of before. In total, 687 SAs and 169 CSs were included. The IRs remained stable for SAs and CSs before and during the pandemic (overlap in confidence intervals). The mean IRs were 52 (95%CI = 44; 57) per 100,000 inhabitants for SAs during the pandemic versus 47 [36; 57] during the pre-pandemic period (p = 0.49), and 5 (95%CI = 2; 9) for CSs versus 11 [6; 16] (p = 0.30). During the pandemic, SA were slightly different from those before in terms of age and occupational status (young/students and older/retirees over-represented), history of consultation and expression of suicidal ideas to GP (more frequent), and CS in terms of occupational status (students over-represented) (p<0.05). Conclusion The COVID-19 pandemic had no major effect on the overall incidence of SAs and CSs reported to French GPs. However, more suicidal acts were reported among younger and older individuals. Suicidal patients and GPs have adapted by improving the expression of suicidal ideas.
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TL;DR: The COVID-19 pandemic is associated with highly significant levels of psychological distress that, in many cases, would meet the threshold for clinical relevance.
3,011 citations
TL;DR: Mental health in the UK had deteriorated compared with pre-COVID-19 trends by late April, 2020, and policies emphasising the needs of women, young people and those with preschool aged children are likely to play an important part in preventing future mental illness.
1,636 citations
TL;DR: Subgroup analyses showed that women, young people, those from more socially disadvantaged backgrounds and those with pre-existing mental health problems have worse mental health outcomes during the pandemic across most factors.
Abstract: Background
The effects of coronavirus disease 2019 (COVID-19) on the population's mental health and well-being are likely to be profound and long lasting.
Aims
To investigate the trajectory of mental health and well-being during the first 6 weeks of lockdown in adults in the UK.
Method
A quota survey design and a sampling frame that permitted recruitment of a national sample was employed. Findings for waves 1 (31 March to 9 April 2020), 2 (10 April to 27 April 2020) and 3 (28 April to 11 May 2020) are reported here. A range of mental health factors was assessed: pre-existing mental health problems, suicide attempts and self-harm, suicidal ideation, depression, anxiety, defeat, entrapment, mental well-being and loneliness.
Results
A total of 3077 adults in the UK completed the survey at wave 1. Suicidal ideation increased over time. Symptoms of anxiety, and levels of defeat and entrapment decreased across waves whereas levels of depressive symptoms did not change significantly. Positive well-being also increased. Levels of loneliness did not change significantly over waves. Subgroup analyses showed that women, young people (18–29 years), those from more socially disadvantaged backgrounds and those with pre-existing mental health problems have worse mental health outcomes during the pandemic across most factors.
Conclusions
The mental health and well-being of the UK adult population appears to have been affected in the initial phase of the COVID-19 pandemic. The increasing rates of suicidal thoughts across waves, especially among young adults, are concerning.
702 citations
TL;DR: The first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm found no scales have sufficient evidence to support their use and are unlikely to be of much practical use.
Abstract: Background People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex. Aims To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm. Method We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable. Results Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the meta-analysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38–2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91–3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16–3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70–2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%. Conclusions The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.
341 citations
TL;DR: In this article, the authors used difference-in-difference estimation to assess whether suicide mortality changed during the COVID-19 pandemic and found that monthly suicide rates decreased by 14% during the first 5 months of the pandemic (February to June 2020).
Abstract: There is increasing concern that the coronavirus disease 2019 (COVID-19) pandemic could harm psychological health and exacerbate suicide risk. Here, based on month-level records of suicides covering the entire Japanese population in 1,848 administrative units, we assessed whether suicide mortality changed during the pandemic. Using difference-in-difference estimation, we found that monthly suicide rates declined by 14% during the first 5 months of the pandemic (February to June 2020). This could be due to a number of complex reasons, including the government's generous subsidies, reduced working hours and school closure. By contrast, monthly suicide rates increased by 16% during the second wave (July to October 2020), with a larger increase among females (37%) and children and adolescents (49%). Although adverse impacts of the COVID-19 pandemic may remain in the long term, its modifiers (such as government subsidies) may not be sustained. Thus, effective suicide prevention-particularly among vulnerable populations-should be an important public health consideration.
328 citations