Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries.

BACKGROUND: The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world. METHODS: We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries' ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms "suicide" and "cause of death", before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis). FINDINGS: We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72-0·91]); Alberta, Canada (0·80 [0·68-0·93]); British Columbia, Canada (0·76 [0·66-0·87]); Chile (0·85 [0·78-0·94]); Leipzig, Germany (0·49 [0·32-0·74]); Japan (0·94 [0·91-0·96]); New Zealand (0·79 [0·68-0·91]); South Korea (0·94 [0·92-0·97]); California, USA (0·90 [0·85-0·95]); Illinois (Cook County), USA (0·79 [0·67-0·93]); Texas (four counties), USA (0·82 [0·68-0·98]); and Ecuador (0·74 [0·67-0·82]). INTERPRETATION: This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold. FUNDING: None.

Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study.

BACKGROUND: Attempted suicide is a strong risk factor for subsequent suicidal behaviors. Innovative strategies to deal with people who have attempted suicide are needed, particularly in resource-poor settings. AIMS: To evaluate a brief educational intervention and periodic follow-up contacts (BIC) for suicide attempters in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, People's Republic of China) as part of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS). METHODS: Among the 1,867 suicide attempters enrolled in the emergency departments of the participating sites, 922 (49.4%) were randomly assigned to a brief intervention and contact (BIC) group and 945 (50.6%) to a treatment as usual (TAU) group. Repeated suicide attempts over the 18 months following the index attempt - the secondary outcome measure presented in this paper - were identified by follow-up calls or visits. Subsequent completed suicide - the primary outcome measure - has been reported in a previous paper. RESULTS: Overall, the proportion of subjects with repeated suicide attempts was similar in the BIC and TAU groups (7.6% vs. 7.5%, chi(2) = 0.013; p = .909), but there were differences in rates across the five sites. CONCLUSIONS: This study from five low- and middle-income countries does not confirm the effectiveness of brief educational intervention and follow-up contacts for suicide attempters in reducing subsequent repetition of suicide attempts up to 18 months after discharge from emergency departments.

Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study.

This cross-cultural study investigates whether religiosity assessed in three dimensions has a protective effect against attempted suicide. Community controls (n = 5484) were more likely than suicide attempters (n = 2819) to report religious denomination in Estonia (OR = 0.5) and subjective religiosity in four countries: Brazil (OR = 0.2), Estonia (OR = 0.5), Islamic Republic of Iran (OR = 0.6), and Sri Lanka (OR = 0.4). In South Africa, the effect was exceptional both for religious denomination (OR = 5.9) and subjective religiosity (OR = 2.7). No effects were found in India and Vietnam. Organizational religiosity gave controversial results. In particular, subjective religiosity (considering him/herself as religious person) may serve as a protective factor against non-fatal suicidal behavior in some cultures.

Epidemiology of suicide attempters resorting to emergency departments in Karaj, Iran, 2003.

BACKGROUND AND OBJECTIVES: This cross-sectional study was conducted as a part of the Multisite Intervention Study on Suicidal Behaviors, a WHO multinational project, and aimed at determining demographic and clinical characteristics of suicide attempters seen at emergency care departments (EDs) in Karaj, Iran. METHODS: The population under study comprised all suicide attempters seen at EDs of hospitals in Karaj from 2002 to 2003. In total, 632 suicide attempters agreed to participate in the study. Information about demographic and clinical variables; the method, time and place of the suicide attempt; earlier attempts; the use of health services, etc was collected by examining hospital records and by interviewing patients. Data were analyzed with SPSS software. RESULTS: Most of the suicide attempters were women (62.5%), single (53.6%), and had a high-school education (52.8%). The mean age was 24.5 (+/-9) years. Many of the male suicide attempters were unemployed (29.8%) and the majority of female attempters were housewives (67.5%). A positive history of suicide among relatives was observed in 15.4% of the attempters. A total of 28% of the participants had previously attempted suicide. A total of 23.7% reported poor physical health in the 3 months before the attempt. CONCLUSION: The suicide attempters seen at the EDs typically were unemployed men, high-school students, women, and housewives.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries.

OBJECTIVE: To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries. METHODS: Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up. FINDINGS: Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001). CONCLUSION: This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Community study of suicidal behaviors and risk factors among Iranian adults.

The present study is part of the WHO/SUPRE-MISS conducted in Iran. The aim of the study was to determine the lifetime prevalence of suicide behaviors in a community sample of Iranian adults. Five hundred and four families were selected randomly according to electricity bills in Karaj, 45 km from the capital city, represented the catchment area for this investigation. The SUPRE-MISS questionnaires used in this study compromised a variety of aspects of suicidal behaviors. Lifetime prevalence rates for suicidal ideation, planning and attempts were 14%, 6.6%, and 4.1% respectively. Tobacco users and long-term mental and physical disabilities were significantly higher among subjects with a history of suicidal attempts. Younger ages, tobacco abuse, and long-term mental or physical disabilities could be considered risk factors for attempting suicide.

Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey.

BACKGROUND: The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community. METHOD: The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys. RESULTS: Suicide attempts (0.4-4.2%), plans (1.1-15.6%), and ideation (2.6-25.4%) varied by a factor of 10-14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts. CONCLUSIONS: The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.

Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries.

BACKGROUND: The objective was to describe patients presenting themselves at emergency-care settings following a suicide attempt in eight culturally different sites [Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Viet Nam), Karaj (Iran), Tallinn (Estonia), and Yuncheng, (China)]. METHOD: Subjects seen for suicide attempts, as identified by the medical staff in the emergency units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview administered by trained health personnel after the patient was medically stable. RESULTS: Self-poisoning was the main method of attempting suicide in all eight sites. Self-poisoning by pesticides played a particularly important role in Yuncheng (71.6% females, 61.5% males), in Colombo (43.2% males, 19.6% females), and in Chennai (33.8% males, 23.8% females). The suicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai (over 65%). In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care. CONCLUSIONS: Action for the prevention of suicide attempts can be started immediately in the sites investigated by addressing the one most important method of attempted suicide, namely self-poisoning. Regulations for the access to drugs, medicaments, pesticides, and other toxic substances need to be improved and revised regulations must be implemented by integrating the efforts of different sectors, such as health, agriculture, education, and justice. The care of patients who attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic referral to professional services after discharge.

Suicide prevention: at what level does it work?

This paper reviews the prevention of suicide according to programme evaluation, risk and protective factors, type of intervention, level of intervention and the interface between clinical and public health levels. From nearly a century of experience, a few but important lessons have been learned: since suicide is affected by sociocultural factors, there is no safe indication that what has worked somewhere will work elsewhere; in order to acquire any public health importance, suicide prevention programmes must clearly spell out their objectives and targets; isolated actions have a much lesser probability of yielding significant population outcome results than more articulated approaches that integrate public health measures and individual care with appropriate follow-up and social support.

Saúde mental e cuidados primários no sistema penitenciário / Mental health and primary care in penitentiary system

Os autores descrevem a organização do Sistema Penitenciário do Rio Grande do Sul, que compreende 11.000 detentos. Tem um Manicômio Judiciário com finalidade de atender prisioneiros com doenças mentais à época do delito ou que vieram a surgir durante o cumprimento de pena (superveniência de doença mental - SDM). Apontam os efeitos sobre o número de internações por SDM após a criação de um serviço de psiquiatria junto à maior penitenciária do Estado, o Presídio Central de Porto Alegre (PCPA). Constataram que, no período em estudo, houve aumento de 11 por cento tanto da população carcerária total do Estado, quanto da do PCPA, porém o número de internações no Manicômio Judiciário, por SDM, cresceu 40 por cento. Observaram, porém, diminuição significativa no número de internações por SDM de prisioneiros oriundos do PCPA (de 23,06/10.000 para 14,64/10.000, com redução de 36,51 por cento), o que demonstra a efetividade do novo serviço psiquiátrico

Saude mental e cuidados primarios no sistema penitenciario

Os autores descrevem a organizacao do Sistema Penitenciario do Rio Grande do Sul, que compreende 11.000 detentos. Tem um Manicomio Judiciario com finalidade de atender prisioneiros com doencas mentais a epoca do delito ou que vieram a surgir durante o cumprimento de pena (superveniencia de doenca mental - SDM). Apontam os efeitos sobre o numero de internacoes por SDM apos a criacao de um servico de psiquiatria junto a maior penitenciaria do Estado, o Presidio Central de Porto Alegre (PCPA). Constatam que, no periodo em estudo, houve aumento de 11 por cento tanto da populacao carceraria total do Estado, quanto da do PCPA, porem o numero de internacao no Manicomio Judiciario, por SDM, cresceu 40 por cento. Observaram, porem, diminuicao significativa no numero de internacoes por SDM de prisioneiros oriundos do PCPA (de 23.06/10.000 para 14.64/10.000, com reducao de 36,51 por cento), o que demonstra a efetividade do novo servico psiquiatrico.

Legislaçäo relativa á saúde mental: revisäo de algumas experiências internacionais / Mental health legislation: a review of some international experience

Apresenta-se atualizaçäo das principais áreas de interesse atual sobre a legislaçäo relativa à saúde mental, a saber: direitos dos doentes mentais (direito à assistência e direitos humanos); qualidade da assistência; utilizaçäo da via administrativa e do controle orçamentário; e a participaçäo dos usuários na organizaçäo e administraçäo dos serviços de saúde mental. Com base em exemplos atualizados de modelos legislativos em várias jurisdiçöes em alguns países, descreve-se a evoluçäo da legislaçäo internacional referente às pessoas acometidas de doenças mentais, indica as tendências atuais e aponta alternativas para a melhoria da situaçäo dos direitos humanos dos doentes mentais e da qualidade da assistência que lhes é oferecida