Comparison of suicide attempt cases admitted to emergency services during covid-19 and before

Abstract

AimCOVID-19 infection did not remain isolated in China, where it originated, but spread all over the world and caused a pandemic. It is known that people’s mental health may deteriorate in situations such as pandemics that create a global impact. Deterioration in people’s mental health can affect the number and general characteristics of suicide attempt cases admitted to the emergency department. The aim of this study was to compare the number of suicide attempts in the emergency department in two periods before and during COVID-19.MethodsThe study was planned as a retrospective, observational study. Suicide attempt cases admitted to our emergency department 2 years before and 2 years during COVID-19 infection were analyzed. Patients were divided into two groups.ResultsA total of 900 patients were included in the study. The mean age was 41.44 ± 14.97 years. The number of admissions before COVID-19 infection was higher. Statistically significant differences were found between both groups in marital status, previous diagnosis of psychiatric illness, educational status and age.ConclusionThe number of patients admitted to our emergency department with suicide attempts decreased in the 2-year period following the pandemic. Statistically significant changes were found in patient characteristics. Especially patients who were single, unemployed and had a history of depressive mood disorder presented to the emergency department with suicide attempts more frequently during COVID-19. We argue that preventive and preventive health services should be expanded in epidemic situations such as pandemics.

Keywords

Introduction

Suicide, which refers to ending one’s life by one’s own will and whose Latin meaning is “killing oneself” (suicide), is considered a fatal act.¹ According to the World Health Organization, the number of deaths due to suicide is more than 700,000 every year.[available at: Organization WH. Preventing suicide: a global imperative. Luxemburg: World Health Organization. 2014. s. 07-08] Suicidal behavior can be observed in individuals with severe mental disorders as well as in normal individuals reacting to challenging life conditions.²
Durkheim argued in 1897 that suicide should be considered a purely social phenomenon.³ Positive or negative changes in the social structure lead to an increase in suicide rates and a decrease in social peace and welfare. The fact that suicide rates and forms vary from one society to another, and even that the methods and numbers of suicides differ in different segments of the same society, indicates that social phenomena affect suicides.[available at: Odağ C: Suicide. Izmir: Izmir Psychiatry Association Publications. 1995]⁴ Problems related to marriage, unemployment, low socioeconomic level, living alone, migration history and stressful social events can be listed as determinants of suicide rates.^5-6
In December 2019, the COVID-19 outbreak in China caused global concern. All health systems around the world have been helpless in combating the pandemic.⁷ Unpredictable outcomes, uncertainty, and information pollution about COVID-19, especially on social media, can affect people’s mental state and health. Restrictive practices related to the pandemic such as social isolation and quarantine may cause sadness, anxiety, fear, panic, irritability, anger, distress, frustration, guilt, helplessness and loneliness. Such symptoms, which many individuals may experience during or after a crisis, can lead to serious mental problems and suicidal behavior.^8-10
Previous studies have reported an increase in the prevalence of depression, anxiety and sleep disorders and the number of suicide attempts in COVID-19 patients.^11-13 In our study, we aimed to compare the number, demographic characteristics and characteristics of pre-COVID-19 and COVID-19-era suicide attempt cases admitted to our emergency department.

Materials and Methods

Study DesignThis study was designed as a retrospective observational study. After the pandemic was declared, strict health measures were taken in our country as in the whole world. These measures were actually eased approximately 2 years after the onset of the pandemic. For this reason, all patients admitted to the emergency department with suicide attempts or suspicion between March 2018 and March 2022, covering 2 years before and 2 years after the period of March 2020, when COVID-19 infection started, were included in the study. Before starting the study, ethics committee approval was obtained from Izmir Katip Çelebi University Ethics Committee for Non-Invasive Clinical Research dated 16.06.2022 and decision number 0309.Patients and SettingAll patients aged 18 years and older who presented to the emergency department with a suicide attempt or suspicion between the specified dates were included in the study. The records of patients with suicide attempts or suspicion were verified from the hospital data system and psychiatry consultations. Patients with incomplete data and patients referred to an external center were excluded from the study.Data CollectionThe data of the patients who met the study criteria were collected through the hospital data registry system. Age, gender, marital status, occupation, known diagnosis of psychiatric illness, number of suicide attempts, method of suicide attempt, educational status, family history and outcome information were recorded. Patients were divided into two groups: before and during the pandemic. The data obtained were compared between the two groups.Ethical ApprovalEthics Committee approval for the study was obtained. This study was approved by the Non-Invasive Clinical Research Ethics Committee of Izmir Katip Çelebi University (Date: 16.06.2022, Decision No: 0309)Statistical AnalysisData were analyzed using the statistical package program IBM SPSS Statistics Standard Concurrent User V 26 (IBM Corp., Armonk, New York, USA). Descriptive statistics were given as number of units (n), percentage (%), mean ± standard deviation, median, minimum and maximum values. Normal distribution of numerical variables was evaluated by the Shapiro-Wilk normality test. Numerical variables according to the time of diagnosis were compared with independent samples t-test if the data were normally distributed and with the Mann-Whitney U test if the data were not normally distributed. The relationship between categorical variables was evaluated by Pearson’s chi-square and Fisher’s exact test. p<0.05 was considered statistically significant.

Results

A total of 900 patients were included in the study and 426 (47.3) of them were females. The mean age was 41.44 ± 14.97 years. When all patients were divided into two groups before and during the pandemic and compared, there was a statistically significant difference between the categories of marital status, occupation, psychiatric diagnosis, method, educational status, family history and outcome variables (p<0.05).
In the marital status variable, single patients accounted for 55% (305 people) and married patients accounted for 45% (45) before the pandemic. During the pandemic, single patients accounted for 64.3% (222) and married patients accounted for 35.7% (123). Comparison of Suicide Cases Before and During the Pandemic with Categorical Variables is presented in Table 1 and Table 2.
There is a statistically significant difference between the variables of age and number of attempts and suicide cases before and during the pandemic (p<0.05). Regarding the age variable, the mean age of the patients before the pandemic is higher. In the number of interventions variable, the average number of attempts in patients before the pandemic is higher. The Comparison of Suicide Cases Before and During the Pandemic with the Variables of Age and Number of Attempts is presented in Table 3.

Discussion

It is known that pandemics, which cause global effects as a result of epidemic diseases such as the COVID-19 pandemic, have effects on mental health. WHO has predicted an increase in the number of mental health problems due to the pandemic. They brought this situation to the agenda through various messages and publications aimed at mental health awareness and prevention (available at: https://www.who.int/publications-detail-redirect/9789240003927). Suicide attempts are one of the frequent presentations of mental health problems to the emergency room. In this study, we aimed to investigate the effects of mental disorders that occur during the pandemic on suicide attempts in our society. We compared changes in the number of suicide cases and other characteristics of patients who presented with a suicide attempt during the pre-pandemic and 2-year period when the pandemic measures were lifted. Our results show that the number of patients admitted to our hospital with suicide for 2 years during the pandemic has decreased. Some of the studies investigating drug use and deaths related to COVID-19 disease focused on patients using antidepressant drugs. In the study conducted by Bora et al., it was determined that the use of antidepressants reduces mortality.¹⁴ This situation has been associated with the fact that the pituitary hormone balance is affected by pandemic situations such as COVID-19 and the stress hormone levels are high. The difference in the number of suicide attempts admitted to the emergency department before and during COVID-19 may be due to the drug effect. However, we found that there was a statistically significant increase in the rates of patients who were single, unemployed, diagnosed with known depressive disorder and had not completed their basic education, and presented to the emergency service with suicide attempts concurrently with the pandemic (p=0.005, p=0.002, p=0.001, p= 0.001).
When the patients were examined according to their gender, there was no statistically significant difference between the patients who applied to the emergency department with a suicide attempt before and during the COVID-19 outbreak. It was found that the male gender was more common in both periods. In the study conducted by Kang et al. in which suicide cases admitted to the emergency department after the COVID-19 pandemic were examined, no statistically significant difference was found in gender distribution before and during the pandemic.¹⁵ The results are similar to our study, but the gender distribution was predominantly female in both periods. This can be explained by the fact that the studies were conducted in different societies. However, it should be noted that the effect of epidemic situations such as pandemics on patients who applied to the emergency department with a suicide attempt is independent of gender.
Again, in the study by Kang et al. the rate of admission to the emergency department with suicide is higher among those who were single in both periods.¹⁵ In the study by Kang et al., no statistical significance was reported between the two periods in terms of single or other marital status. In our study, it was found that single patients increased statistically during the pandemic, while married patients decreased statistically. Our result may be due to the decrease in social interaction of single patients with the restrictions on staying at home, and the decrease in social communication, which is an important condition in the prevention of mental disorders.
The mean age of patients who attempted suicide during the pandemic was found to be statistically significantly lower. In the study conducted by Shrestra et al., no statistical significance was found between the ages of patients who presented to the emergency department with a suicide attempt in the pre- and post-COVID-19 periods.¹⁶ Their study reported that the average age was 32 years. In our study, while the mean age was 39 years before COVID-19, it was found to be 33 years during COVID-19, and the difference between them is statistically significant.
While the number of suicide attempts with medication and incision decreased statistically significantly, the number of attempts with jumping, hanging and firearms increased statistically. In the study by Kang et al., it was determined that the number of suicide attempts by taking drugs increased statistically significantly after the pandemic. This may be due to social differences and existing comorbid conditions of the patients and the different access to drugs.
While the rates of discharge from the emergency department and mortality rates with the pandemic did not differ statistically significantly, it was found that the rates of hospitalization and referral increased statistically significantly. They reported that mortality rates increased, hospitalization rates increased, and referrals out of hospital decreased during the COVID-19 period. They explained this by the effect of emptying beds as a result of increased mortality. However, in our study, the rates of hospitalization and referral increased, while the rates of mortality and discharge from the emergency room did not change before and during COVID. The decrease in the number of patients in the rooms due to the measures may have been the main reason for out-of-hospital referrals.

Limitations

The study has some limitations. The first limitation is that it was retrospectively reviewed and the accuracy of the information written on the data recording system and in the consultation note was taken as basis. The second limitation is that the study was conducted in a single center. Although it was conducted in a large hospital, the fact that it reflects the population of a single region constitutes a limitation. Since we have a relatively young patient population, it may not be correct to generalize the study results to all age groups. There is a possibility that death after hospitalization and intensive care unit hospitalization may be due to reasons other than suicide and this may also be considered as a limitation.

Conclusion

The results of our study show that although the number of patients admitted with suicide attempts decreased in the 2-year period with the pandemic, the general characteristics of the patients changed. Particular attention should be paid to emergency room admissions of patients who are single, unemployed and have a history of depressive mood disorder. In epidemic situations such as pandemics, it may be useful to expand preventive and preventive health services.

Declarations

References

1. Sadock BJ, Sadock VA, editors. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:1978-1981.
   PubMed · Google Scholar
2. Sayıl I. Crisis Intervention and Suicide Prevention. Ankara: Ankara University Press; 2008:98-105.
   PubMed · Google Scholar
3. Durkheim E, Ozankaya Ö. Suicide. Ankara: İmge Bookstore; 1992:62-67.
   PubMed · Google Scholar
4. Langford RA, Ritchie J, Ritchie J. Suicidal behavior in a bicultural society: a review of gender and cultural differences in adolescents and young persons of Aotearoa/New Zealand. Suicide Life Threat Behav. 1998;28(1):94-106. doi:10.1111/j.1943-278x.1998.tb00629.x
   Article · PubMed · Google Scholar
5. Stack S. Suicide: a 15-year review of the sociological literature. Part II: Modernization and social integration perspectives. Suicide Life Threat Behav. 2000;30(2):163-176. doi:10.1111/j.1943-278x.2000.tb01074.x
   Article · PubMed · Google Scholar
6. Heikkinen A, Aro H, Lönnqvist J. Recent life events, social support and suicide. Acta Psychiatr Scand Suppl. 1994;(377):65-67. doi:10.1111/j.1600-0447.1994.tb05805.x
   Article · PubMed · Google Scholar
7. Zandifar A, Badrfam R. Iranian mental health during the COVID-19 epidemic. Asian J Psychiatr. 2020;51:101990. doi:10.1016/j.ajp.2020.101990
   Article · PubMed · Google Scholar
8. Banerjee D. The COVID-19 outbreak: crucial role the psychiatrists can play. Asian J Psychiatr. 2020;50:102014. doi:10.1016/j.ajp.2020.102014
   Article · PubMed · Google Scholar
9. Peng EY, Lee MB, Tsai ST, et al. Population-based post-crisis psychological distress: an example from the SARS outbreak in Taiwan. J Formos Med Assoc. 2010;109(7):524-532. doi:10.1016/s0929-6646(10)60087-3
   Article · PubMed · Google Scholar
10. Xiang YT, Yang Y, Li W, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-229. doi:10.1016/s2215-0366(20)30046-8
    Article · PubMed · Google Scholar
11. Deng J, Zhou F, Hou W, et al. The prevalence of depression, anxiety, and sleep disturbances in COVID-19 patients: a meta-analysis. Ann N Y Acad Sci. 2021;1486(1):90-111. doi:10.1111/nyas.14506
    Article · PubMed · Google Scholar
12. Sher L. COVID-19, anxiety, sleep disturbances and suicide. Sleep Med. 2020;70:124-130. doi:10.1016/j.sleep.2020.04.019
    Article · PubMed · Google Scholar
13. Dragovic M, Pascu V, Hall T, Ingram J, Waters F. Emergency department mental health presentations before and during the COVID-19 outbreak in Western Australia. Australas Psychiatry. 2020;28(6):627-631. doi:10.1177/1039856220960673
    Article · PubMed · Google Scholar
14. Bora ES, Arıkan C, Yurtsever G, et al. Is it possible that antidepressants protect against COVID-19? Ann Clin Anal Med. 2021;12(9):991-994. doi:10.4328/acam.20549
    Article · PubMed · Google Scholar
15. Kang JH, Lee SW, Ji JG, et al. Changes in the pattern of suicide attempters visiting the emergency room after COVID-19 pandemic: an observational cross-sectional study. BMC Psychiatry. 2021;21(1):571. doi:10.1186/s12888-021-03570-y
    Article · PubMed · Google Scholar
16. Shrestha R, Siwakoti S, Singh S, Shrestha AP. Impact of the COVID-19 pandemic on suicide and self-harm among patients presenting to the emergency department of a teaching hospital in Nepal. PLoS One. 2021;16(4). doi:10.1371/journal.pone.0250706
    Article · PubMed · Google Scholar

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