Suicide Research, Prevention, and COVID-19.

Abstract

Open AccessSuicide Research, Prevention, and COVID-19Towards a Global Response and the Establishment of an International Research CollaborationThomas Niederkrotenthaler, David Gunnell, Ella Arensman, Jane Pirkis, Louis Appleby, Keith Hawton, Ann John, Nav Kapur, Murad Khan, Rory C. O'Connor, Steve Platt, and The International COVID-19 Suicide Prevention Research CollaborationThomas NiederkrotenthalerUnit Suicide Research and Mental Health Promotion, Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, AustriaSearch for more papers by this author, David GunnellNational Institute of Health Research Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and the University of Bristol, UKSearch for more papers by this author, Ella ArensmanSchool of Public Health and National Suicide Research Foundation, College of Medicine and Health, University College Cork, Republic of IrelandSearch for more papers by this author, Jane PirkisMelbourne School of Population and Global Health, University of Melbourne, VIC, AustraliaSearch for more papers by this author, Louis ApplebyCentre for Mental Health & Safety, The University of Manchester, UKSearch for more papers by this author, Keith HawtonCentre for Suicide Research, Department of Psychiatry, Warneford Hospital, University of Oxford, UKSearch for more papers by this author, Ann JohnPopulation Psychiatry, Suicide and Informatics, Medical School, Swansea University, UKSearch for more papers by this author, Nav KapurCentre for Mental Health and Safety & Greater Manchester NIHR Patient Safety Translational Research Centre, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UKSearch for more papers by this author, Murad KhanDepartment of Psychiatry, Aga Khan University, Karachi, PakistanSearch for more papers by this author, Rory C. O'ConnorSuicidal Behaviour Research Laboratory, Institute of Health & Wellbeing, University of Glasgow, UKSearch for more papers by this author, Steve PlattUsher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, UKSearch for more papers by this author, and The International COVID-19 Suicide Prevention Research CollaborationPablo Analuisa, Louis Appleby, Ella Arensman, Jose Luis Ayuso-Mateos, Jason Bantjes, Jose Bertolote, Eric Caine, Lai Fong Chan, Shu-Sen Chang, Ying-Yeh Chen, Helen Christensen, Rakhi Dandona, Diego De Leo, Michael Eddleston, Annette Erlangsen, David Gunnell, Jill Harkavy-Friedman, Keith Hawton, Ann John, Fabrice Jollant, Nav Kapur, Murad Khan, Olivia J. Kirtley, Duleeka Knipe, Kairi Kolves, Flemming Konradsen, Shiwei Liu, Sally McManus, Lars Mehlum, Matt Miller, Ellenor Mittendorfer-Rutz, Paul Moran, Jacqui Morrissey, Christine Moutier, Thomas Niederkrotenthaler, Emma Nielsen, Merete Nordentoft, Rory O’Connor, Siobhan O’Neill, Maria Oquendo, Joseph Osafo, Andrew Page, Michael R. Phillips, Jane Pirkis, Steve Platt, Boris Polozhy, Maurizio Pompili, Ping Qin, Thilini Rajapakse, Mohsen Rezaeian, Barbara Schneider, Morton M. Silverman, Mark Sinyor, Steven Stack, Ellen Townsend, Gustavo Turecki, Michiko Ueda, Lakshmi Vijayakumar, Paul Yip, Gil ZalsmanSearch for more papers by this authorPublished Online:July 27, 2020https://doi.org/10.1027/0227-5910/a000731PDFSupplemental Material ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreThe COVID-19 pandemic of 2020 is a major global health challenge. At the time of writing, over 11.6 million people around the world had been registered as infected and 538,000 had died (Worldometers, 2020, accessed July 7, 2020). Public health responses to COVID-19 need to balance direct efforts to control the disease and its impact on health systems, infected people, and their families with the impacts from associated mitigating interventions. Such impacts include social isolation, school closure, health service disruption stemming from reconfiguring health systems, and diminished economic activity. The primary focus of both the United Nations (UN) and the World Health Organization (WHO) has been on addressing COVID-19 as a physical health crisis, but the need to strengthen mental health action, including suicide prevention, is increasingly recognized, as is the need for mental health research to be an integral part of the recovery plan (UN, 2020a). The impacts of the pandemic on physical and mental health will unfold differently over time and will vary depending on the duration and fluctuating intensity of the disease. Research is needed to help ensure that decision-making regarding all aspects of health, including mental health (Holmes et al., 2020), is informed by the best quality data at each stage of the pandemic.The pandemic poses a prolonged and unique challenge to public mental health, with major implications for suicide and suicide prevention (Gunnell et al., 2020; Reger, Stanley, & Joiner, 2020). A rise in suicide deaths in the wake of the pandemic is not inevitable. There is consensus, however, that the mitigation of risk will be contingent upon a proactive and effective response involving collaborative work between the state, NGOs, academia, and local governments and coordinated leadership across government ministries, including health, education, security, social services, welfare, and finance. Countries have responded in different ways to the pandemic, effectively creating a series of natural experiments. Thus, regions of the world affected later in the pandemic can draw on lessons from countries, such as China and Italy, affected in its early phase. Likewise, lessons learned early in the pandemic (e.g., on the impact of lockdown and physical distancing measures) can be used to inform responses to any future surges in the incidence of COVID-19.Although there are important parallels between countries in the course of the pandemic, some stressors, responses, and priorities are likely to differ between high- and low–middle-income countries and between cultures and regions. As COVID-19 appears to be disproportionately affecting Black, Asian, and minority ethnic communities, the response – and suicide prevention research carried out to inform the response – needs to be sufficiently granular and account for the complexity of risks in these groups (O'Connor et al., 2020).Throughout this editorial, when we refer to suicide and suicidal behavior, we mean to include both fatal and nonfatal suicidal behaviors and self-harm.The Need for Evidence-Based Suicide Prevention Responses Suicide is the most extreme outcome of a mental health crisis and should therefore be a key priority in any broader mental health response to the pandemic (Gunnell et al., 2020; Reger et al., 2020). Suicide prevention responses need to be informed by research that is as specific as possible to the current situation and takes account of the many mechanisms that have an impact on suicide, as they may vary during the different phases of the pandemic. At the same time, given the risks involved, strategic development of policy and implementation responses cannot wait until all aspects of the epidemiology and consequences of the disease on mental health and risk of suicide are understood. The dilemma here is that few studies have investigated the impact of previous pandemics – or even epidemics – on suicide (Cheung, Chau, & Yip, 2008; Wasserman, 1992; Zortea et al., 2020), and none has evaluated suicide prevention measures in the current context. An analysis of the impact of the Spanish Flu epidemic (1918–1920) in the United States indicated that it resulted in a small rise in suicides (Wasserman, 1992). Cheung and colleagues (2008) reported a rise in suicide among older people during the 2003 SARS epidemic in Hong Kong. Similarly, what can be learned from other types of public health emergencies is limited. Much of the related research comes from one-off events, such as terrorist attacks and natural disasters (e.g., earthquakes). Findings from such events might not be applicable to the current situation (Devitt, 2020).Early Research Findings Relevant to Assessing the Impact of COVID-19 on Mental Health Early publications relevant to the COVID-19 response have largely come from literature reviews, small selective surveys or case reports, often using indirect measures of suicide risk or from modeling approaches to predict the impact of the pandemic. These have addressed issues such as the impact of quarantine (Brooks et al, 2020), highlighted possible high-risk groups (Yao, Chen, & Xu, 2020), and assessed mental health service disruption (Royal College of Psychiatrists, 2020). Physical distancing and related measures, which have been at the forefront of the public health response, carry a strong risk of increasing isolation, particularly in vulnerable populations such as older people and people who have been bereaved (Brooks et al., 2020; De Leo & Trabucchi, 2020; Wand, Zhong, Chiu, Draper, & De Leo, 2020; Yip & Chau, 2020). Physical distancing measures may also lead to increases in household stress levels, domestic violence, and alcohol misuse and affect the accessibility of mental health services (Brooks et al., 2020; Reger et al., 2020). The stresses of lockdown may be worse in low- and middle-income countries where extended families tend to live together with limited housing space. Concerns have been expressed about increases in demand for psychiatric emergency care (Royal College of Psychiatrists, 2020). In the context of overwhelmed health-care systems and shortages of resources to treat people with COVID-19 in healthcare settings, qualitative findings from China indicate that the intensity of work during the pandemic drained health-care workers physically and emotionally (Liu et al., 2020). In the United Kingdom, the British Medical Association well-being support services have seen a 40% increase in use after the onset of the pandemic (Torjesen, 2020). Positive effects of the pandemic on the public, such as increased prosocial behavior (e.g., donating and volunteering) and the strengthening of community ties, may help to mitigate detrimental impacts of physical distancing (Van Bavel et al., 2020). The move of some health and third-sector services into online settings may also have long-lasting benefits in improving service accessibility, particularly to those who find face-to-face consultation difficult. The effect on people with mental illness of replacing face-to-face treatment with remote delivery of care, however, remains unclear. Moreover, in low- and middle-income countries the technology to support remote assessment is limited (De Sousa, Mohandas, & Javed, 2020; UN, 2020a). In these, and other settings, where there is limited access to specialist mental health services, community and peer support becomes extremely important. The potential for the COVID-19 virus to affect the brain and to cause long-lasting physical morbidity means it might become relevant as a risk factor for mental illness and suicide in the future (Holmes et al., 2020; Rogers et al., 2020; Wu et al. 2020). Review findings indicate that the incidence of psychosis, a major risk factor for suicide and suicidal behavior, appeared to be high in people following SARS, MERS, and H1N1 infection (Rogers et al., 2020). Given emerging evidence that the virus can have severe effects on different organ systems including kidney and liver function (Zhang, Shi, & Wang, 2020), the physical consequences of infections might include a prolonged reduction in functional capacity and disability in some patients, all of which might have potential implications for suicide risk and prevention. However, longer-term risks for suicide are likely most closely related to the economic consequences of the pandemic, including financial strain and unemployment. In a study based on suicide data from 54 countries, the recession of 2008 was associated with a 3.3% increase in suicides in men (but not women) in the following year and more prolonged increases in several countries (Chang, Stuckler, Yip, & Gunnell, 2013). The increase varied depending on the regional depth of the recession and the specifics of the social insurance systems (e.g., regulations for unemployment benefits or payed sick leave; Chang et al., 2013; Norström & Grönqvist, 2015). The economic downturn associated with the COVID-19 pandemic may be more rapid in onset than the 2008 recession and may push an estimated 500 million people, particularly in low- and middle-income countries, below the poverty line (UN, 2020b). Early Research Findings Relevant to Assessing the Impact of COVID-19 on Suicide and Suicidal Behavior There is, as yet, no direct evidence of the impact of the pandemic on suicidal behavior. While a number of news stories from Japan, New Zealand, and Germany report a decrease in suicides in the period around the time of lockdown (Deutsche Welle, 2020; New Zealand Herald, 2020; The Guardian, 2020), these are all based on preliminary data/anecdotal reports and unsubstantiated by peer-reviewed publications. General population survey findings from the United Kingdom have shown no clear evidence of a rise in reported self-harm during the weeks following lockdown (after March 23), but no pre-lockdown data are available (Fancourt, Bu, Mak, & Steptoe, 2020). Many surveys have been carried out in the wake of the pandemic, these often use convenience samples, which are prone to selection bias (Pierce et al., 2020). In addition, there have been multiple case reports from some low- and middle-income countries highlighting occurrences of suicide thought to be related to COVID-19 (De Sousa et al., 2020; Mamun & Ullah, 2020). These reports must, however, be interpreted with great caution – and even more so when they are based on mass media reports, which are unlikely to have been validated. Some researchers have attempted to model the possible pandemic-associated increase in suicides, largely based on predicted rises in unemployment (Kawohl & Nordt, 2020; McIntyre & Lee, 2020; Moser, Glaus, Frangou, & Schechter, 2020). Risk estimates vary widely, from a 1% increase in global suicides (Kawohl & Nordt, 2020) to a doubling of national suicides in a Swiss study, using prison incarceration as a questionable proxy for modeling the social distancing effects of lockdown (Moser et al., 2020). These discrepancies are partly due to differences in modeling assumptions, which are associated with considerable uncertainty and may be very misleading. Given the uncertainty of the baseline assumptions about how events will unfold, the results of these tentative projections can at best provide a guide as to where action should be directed but are largely unhelpful for accurate quantifications of future suicidal behavior and suicide. In this regard, access to real-time suicide mortality data is a key priority (Gunnell et al., 2020). Further, active surveillance systems for suicide attempts are warranted (WHO, 2016).In the absence of direct evidence about trends in suicide, some researchers have used search behavior on Google Trends for terms related to suicide, as a proxy for suicide risk (Knipe, Evans, Marchant, Gunnell, & John, 2020; Sinyor, Spittal, & Niederkrotenthaler, 2020). Their findings indicate that, although relative search volumes for financial and work-related concerns have increased (Knipe et al., 2020), searches for suicide and suicide methods have not (Knipe et al, 2020; Sinyor et al., 2020). The potential limitations of Google search data for surveillance are well recognized and include uncertainty about the algorithms used and issues with the stability of findings provided by Google Trends, as well of inconsistent associations with suicide (Tran et al., 2017).Gaps in knowledge about the epidemiology of suicide and suicidal behavior during COVID-19 and the effectiveness of intervention and prevention measures underline the need for a strategic approach to suicide research and prevention at a global level. The uncertainties regarding the direct and indirect effects of COVID-19 on suicide can only be addressed with good-quality tailored research. Furthermore, suicide prevention in the age of COVID-19 needs to build on what we know about the effectiveness of various measures, but also needs to take account of the unique challenges posed by the situation in order to develop novel approaches. Our knowledge is currently still very limited and building the evidence base on suicide prevention is crucial. Research Considerations During COVID-19 There are several considerations in relation to suicide prevention research carried out during crisis situations and in the present global pandemic (Table 1). These include ensuring the safety of research participants and researchers as well as the need for research to focus on low- and middle-income settings as well as high-income countries, keeping in mind that findings from one setting may not generalize to another. We expand on a few specific issues in the following section. First, the limited research conducted thus far on suicide and its prevention during COVID-19 has focused mostly on high-income countries. While complementary research in this area in low- and middle-income countries should be prioritized, the poor quality of routine mortality and hospital attendance data as well as the limited availability of resources to carry out research in many of these settings present very real challenges. In 2014 the WHO considered that only just over one third of member states had good-quality suicide registration data, and such data were largely absent in low- and middle-income countries (WHO, 2014). The establishment of sentinel sites to gather as accurate data on suicidal behavior as possible to supplement those that already exist would be one way forward (WHO, 2016). Table 1 Considerations for suicide and suicidal behavior research during the COVID-19 pandemicResearch considerationsThe COVID-19 suicide research response should be truly multidisciplinary. This will foster research that addresses the different aspects and layers of risk and resilience relating to the health consequences of COVID-19, including suicide and suicidal behavior. It will also foster research that informs prevention efforts by taking a range of perspectives.People with lived experience of suicide should be involved at all stages of the research process.Researchers should ensure that key risk groups that are often under-represented in suicide research are represented appropriately in studies.The safety and well-being of participants should remain at the forefront of research design considerations.Researchers' safety must not be compromised if they are carrying out field work in situations where they may be at increased risk of infection.Researchers should embrace Open Science research practices, such as registering research questions in advance and sharing data, wherever possible.To ensure research findings inform practice, researchers should consider the potential real-world impact of their studies during the design phase and develop a clear, a priori dissemination strategy.Research findings, particularly those making bold statements about risk or about effective treatments, should be peer reviewed prior to dissemination. If researchers decide that early dissemination is warranted, outputs should clearly state the preliminary status of the research and that it is yet to be peer reviewed. In this case, conclusions should be stated cautiously, in a manner that is consistent with the preliminary nature of findings.When talking about research findings with the media, researchers should remain vigilant about not increasing risk for people who are already vulnerable. They should take care not to contribute to sensationalist headlines, should not make monocausal attributions of suicide to COVID-19, and should not use stigmatizing language (e.g., COVID-19 suicides). Researchers should recommend that media professionals use COVID-19-specific media reporting guidelines (see IASP, 2020b).Research teams should be supported, particularly because some team members will be working in difficult home circumstances and many will be personally affected by concerns about the pandemic and its consequences.Table 1 Considerations for suicide and suicidal behavior research during the COVID-19 pandemicView as image HTML Second, as a result of the pandemic, mental health services have had to develop new ways of working to deliver care to suicidal individuals, including new care pathways, the mass roll-out of remote consultation, and increased use of digital interventions. These new ways of working require real-time evaluation and ongoing adaptation in response to findings. Traditional evaluation approaches, such as randomized trials, may need to be adapted in a manner that is still consistent with making robust inferences about their effectiveness.Third, with school and university closures in place in a number of countries, the traditional setting for carrying out research into children and young people's health is no longer available. Given current concerns about the impact of the pandemic on young people, mental health researchers will need to find alternative routes to studying the impact of the pandemic on this potentially vulnerable group. Fourth, for all studies it is vital that those with lived experience of suicide are involved in shaping the research at all stages – from developing the research questions to data collection and dissemination of the findings. Fifth, all research needs to comply with ethical standards. Researchers who do not normally work in the area of mental health and suicide prevention but who are now shaping conversations on suicide prevention need to obtain necessary training and background information on how to conduct suicide research, including the need to follow established research protocols and safety considerations that are specific to the field (Townsend, Nielsen, Allister, & Cassidy, 2020). Sixth, it is important that research resources (i.e., staff, funding) are rapidly mobilized to ensure timely research evidence is available. However, this presents tensions between the time researchers have available to write robust funding applications, time-scales for the grant review by funding bodies, and, if funded, the availability of high-quality fieldworkers and analysts as these are likely to be already committed to other projects. Flexibility and clear communication with funders about project delays and re-allocation of resources should help ameliorate these challenges. There is a distinct possibility that research funding may be adversely affected by a post-pandemic recession. Seventh, any proposed research should have a clear pathway to impact to ensure that clinicians and policy-makers can implement the findings of research in their work.Lastly, traditional models of research publication, with the need for peer review, introduce delays between article submission and on-line publication, reducing the speed with which evidence is disseminated and recommendations implemented. One solution is the fast-track review processes for selected papers – these were already in place before COVID-19, but have been extended and adopted by more journals since the beginning of the outbreak. Another solution is open science publication models that involve on-line publication of articles while they await peer review, although there is a danger of low-quality research findings being disseminated and acted upon precipitously, without scrutiny of their validity (Armstrong, 2020). In order to mitigate this risk, researchers need to label their findings as preliminary and implement a communications strategy that addresses the preliminary nature of findings. The International COVID-19 Suicide Prevention Research Collaboration High-quality timely research to understand the suicide-related consequences of COVID-19 and to determine how best to mitigate the risk stemming from these consequences is now needed. The UN highlights the need for "rapid knowledge acquisition," establishing research priorities, coordinating research efforts, open-data sharing, and funding (UN, 2020a). In response to widespread concerns about the impact of the COVID-19 pandemic on suicide and suicidal behavior, a