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. 2023 Mar 12;323:115164. doi: 10.1016/j.psychres.2023.115164

Increased suicidal ideation and suicide attempts in COVID-19 patients in the United States: Statistics from a large national insurance billing database

Michael Reinke a,⁎, Chloe Falke a, Ken Cohen b, David Anderson b, Kathryn R Cullen a,1, Jessica L Nielson a,c,1
PMCID: PMC10008142  NIHMSID: NIHMS1884505  PMID: 36948017

Abstract

Emerging research suggests suicidality may have increased during the COVID-19 pandemic. This cross-sectional study aimed to advance understanding of suicide risk during the pandemic through novel use of a large insurance database. Using logistic regression across time-points, we estimated the effect of exposure to SARS-CoV-2 infection on rates of suicidal ideation and suicide attempts in infected individuals versus uninfected controls during the pandemic (March 2020 - September 2021). In uninfected individuals, we estimated the effect of exposure to the pandemic period versus the pre-pandemic control period (January 2017 to February 2020) on suicidality rates. We also investigated within-pandemic temporal patterns of suicidality. All patients with data in the UnitedHealth Group claims during those intervals were included. ICD-10 codes defined suicidality measures. There were 525,312,717 (62.3% over age 45, 57.7% female) included encounters. From the pandemic subsample (32.8%), 1.7% were COVID+. Adjusted odds ratios showed that COVID+ patients were significantly more likely to have suicidal ideation and suicide attempts than COVID- patients. Among COVID- patients, adjusted odds of suicidality were significantly lower during versus prior to the pandemic. Results were unfortunately limited by the absence of data on deaths by suicide. Further research should examine how SARS-CoV-2 infection may influence suicidality.

Keywords: SARS-CoV-2, Suicide, Suicidal, Ideation, Attempt

1. Introduction

Previous coronavirus pandemics have been associated with the possibility of temporary but notable adverse mental health outcomes in a subset of patients who contracted SARS1 or MERS (Rogers et al., 2020). A similar pattern may be unfolding with the Coronavirus Disease 2019 (COVID-19). During the recent COVID-19 pandemic, associations with psychiatric illness have been found in infected individuals both acutely (Deng et al., 2021) and as long-term sequelae (Daugherty et al., 2021; Taquet et al., 2021). Additionally, within the context of large-scale lockdowns and heightened public stress, there have been reports of declining mental health of the global population at large (Nochaiwong et al., 2021). Suicide is a leading cause of death in the United States and is the cause of 1.4% of premature deaths worldwide (Bachmann, 2018). Suicide is strongly associated with mental illness (Bachmann, 2018) and with feeling disconnected from others (Van Orden et al., 2010). Taken together, these factors suggest a potentially higher risk of suicidal thoughts and behavior during the COVID-19 pandemic. A recent systematic review reported pandemic-associated increases in suicidal ideation and called for more high-quality studies to determine pandemic-related suicidality outcomes (Farooq et al., 2021).

Within the United States, initial results have raised concern. An early survey identified increased levels of suicidal ideation early in the pandemic (Czeisler et al., 2020), and rates continued to be elevated three months after that (Czeisler et al., 2021). In parallel to suicidal ideation, suicide attempts may have also increased during the pandemic. A retrospective analysis of emergency room visits in the United States demonstrated a slight increase in the mean and median overall number of patients presenting for suicide attempts in 2020 compared to 2019 (Holland et al., 2021).

The purpose of the present study is to advance current understanding about suicidality in the context of the COVID-19 pandemic by analyzing billing codes from a large medical claims database in the United States. First, to understand the direct role of SARS-CoV-2 infection on suicidality, we examined the risk of suicidal ideation and suicide attempts in COVID+ versus COVID- patients in the database. Based on prior reports of increased rates of depression and anxiety following SARS-CoV-2 infection, we predicted that compared to COVID- patients, patients who were COVID+ would have demonstrated greater rates of suicidal thoughts and behaviors. Second, to test the impact of the broader societal factors of living through COVID-19 pandemic (separate from SARS-CoV-2 infection per se), we focused on COVID- patients, and compared rates of pre-pandemic suicidal thoughts and behaviors pre-pandemic versus during the pandemic. Based on prior work suggesting a pandemic-related increase in suicidal thoughts and attempts, we predicted that suicidality would increase during the pandemic, even among those who have not been infected. Third, we examined within-pandemic temporal effects on rates of suicidality. We hypothesized that due to mounting stressors over time such as accumulated toll of isolation, economic fallout, and unmet mental health needs, the overall burden of the pandemic would be associated with an increase in suicidal ideation and attempts over the course of the pandemic.

2. Methods

2.1. Data sources

Data were sourced from the UnitedHealth Group's research datamart, a large claims database that contains deidentified information from over 525 million encounters from fully insured, administrative-only, and Medicare patients in the United States. The study was approved by the institutional review board (IRB) at University of Minnesota (UMN IRB # STUDY00013093).

2.2. Study population and measures

Patients from all ages, genders and clinical encounter types (e.g., inpatient, outpatient, lab diagnosis) were included if they were insured and had an encounter in the healthcare system between January 2017 to September 2021. Due to the nature of the database, each participant who had one or more visits in a given month would generate one encounter data point during that month. International Classification of Disease (ICD)-10 codes up to and including the 10th position was cross-referenced using structured query language (SQL) for SARS-CoV-2 infection (U071) or SARS-CoV-2 pneumonia (J12.82). Suicidal ideation (R45.581), and suicide attempts (T14.91, T36-T65, T71, X71-X83) codes were used, based on the recommendations from the Centers for Disease Control and Prevention and other expert recommendations (Hedegaard et al., 2018). For the purposes of designating whether a patient had a positive COVID-19 diagnosis, we relied on ICD-10 billing codes. We did not include encounters from testing centers which only involved a COVID-19 test, since these did not include a clinical assessment that would have been able to identify presence or absence of suicidality. Given the likelihood that a history of psychiatric comorbidities may impact the incidence of suicidality in this population, we included a variable for psychiatric history. (See Supplementary Table 1 for full list of ICD-10 codes for psychiatric diagnoses and suicidality presentations). Patients’ ages were binned into 7 groups, starting with ages 0-14, followed by increments of fifteen years until the final group for ages 90-104. We included the CDC/ATSDR Social Vulnerability Index of the patient's home county. The Social Vulnerability Index is a measure that reflects a community's vulnerability to disasters, including infectious disease. An aggregate score is assigned based on input of 15 census variables that represent four major themes: socioeconomic status, household composition and disability, minority status and language, as well as housing and transportation (Flanagan et al., 2018). In the present study, counties were divided into three groups based on Social Vulnerability Index scores: those in the lowest 14%, those in the top 14%, and those in the middle 15 to 85%. Data were aggregated for each month of the study period. A summary of the study population in our pre-pandemic period (January 2017 to February 2020) compared to our pandemic period (March 2020 to September 2021) as well as a comparison of the COVID + and COVID – study observations are provided in Table 1 .

Table 1.

Descriptive statistics of the sample population of encounters with the United Health Group claims datamart.

Pre-pandemic period vs Pandemic period
Pre-pandemic Pandemic p-value
Total Observations 353,199,118 172,113,599
Age 45 or over, n (%) 216,439,843 (61.280%) 110,800,133 (64.376%) <0.001
Female, n (%) 203,866,874 (57.720%) 99,028,073 (57.536%) <0.001
SI, n (%) 330,080 (0.092%) 160,320 (0.093%) 0.2802
SA, n (%) 44,675 (0.013%) 19,719 (0.011%) <0.001
Covid+ vs Covid- patients in Pandemic period
Covid - Covid + p-value
Total Observations 169,214,196 2,899,403
Age 45 or over, n (%) 108,984,999 (64.407%) 1,815,134 (62.604%) <0.001
Female, n (%) 97,457,589 (57.594%) 1,570,484 (54.166%) <0.001
SI, n (%) 155,977 (0.092%) 4,343 (0.150%) <0.001
SA, n (%) 19,110 (0.011%) 609 (0.021%) <0.001
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Note: SI = suicidal ideation, SA = suicide attempt.

Pre-pandemic: January 2017 to February 2020, Pandemic: March 2020 to September 2021.

P-values calculated from chi-square test.

2.3. Statistical analyses

We first used a logistic regression to examine the relative risk of suicidal ideation by SARS-CoV-2 infection status with an adjusted odds ratio (with odds >1.0 indicating increased suicidal behavior). This regression analysis pooled data from the 19 months of our pandemic period and included an indicator for SARS-CoV-2 infection status as our primary predictor, as well as demographic covariates, and separate intercepts for each month, to allow for seasonal fluctuations (Coimbra et al., 2016) in overall rates of suicidal thoughts and behavior. logit(P(SIi))=InfectionStatusi+Monthi+Agei+Genderi+SVIi+MentalIllnessHistoryi

We then repeated the analysis for the relative risk of suicide attempt by SARS-CoV-2 infection status.

Second, we examined the relative risk of suicidal ideation and attempts in uninfected individuals in the pre-pandemic period compared to the pandemic period. Again we estimated the relative risk as a common odds ratio using logistic regressions with indicators for demographic covariates, and separate intercepts for each month of the year to allow for seasonality of suicidal behavior, as shown in the model below, and repeated the analysis for suicide attempts.

logit(P(SIi))=Pandemici+Monthi+Agei+Genderi+SVIi+MentalIllnessHistoryi

Third, to test whether the overall rate of suicidality increased throughout the pandemic period, we conducted logistic regressions of suicidal ideation and on suicide attempt against the number of months since March 2020, while controlling for demographic covariates and SARS-CoV-2 infection status.

logit(P(SIi))=Monthssince2020i+InfectionStatusi+Agei+Genderi+SVIi+MentalIllnessHistoryi

Finally, we repeated all of our analyses controlling for COVID-19 Community Vulnerability Index instead of CDC/ATSDR Social Vulnerability Index. Similar to the Social Vulnerability Index, the COVID-19 Community Vulnerability Index combines multiple variables to predict risk within communities that was designed specifically to assess vulnerability to COVID-19 (https://precisionforcovid.org/ccvi). As shown in the regression models, all analyses controlled for demographic covariates defined above: sex, age group, history of mental illness, and home county social vulnerability. Two-tailed p-values and 95% confidence intervals were calculated for each statistic of interest, with p-values less than 0.05 considered statistically significant. All analyses were conducted using R version 4.0.2.

3. Results

The study population included all patients who had a patient encounter in the UHG system from January 2017 to September 2021. Total counts of patients in the system that had ICD billing codes indicating presence of a COVID-19 diagnosis, suicide attempt, and/or suicidal ideation, or none of these, are presented in Supplementary Table 2. For example, of the over 25 million (25,322,917) individuals who had coverage within the system in July 2020, just over 9 million (8,914,321) had a clinical encounter and are included in our dataset for that month.

The overall incidence of COVID-19 across all encounters between March 2020-September 2021 shows two distinct peaks in December 2020 and August 2021 (Fig. 1A ).

Fig. 1.

Fig 1

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Temporal incidence trends from over 525 million clinical encounters from the UnitedHealth Group (UHG) claims datamart between January 2017 – September 2021 in the United States. Prevalence of COVID-19 infection during the pandemic from March 2020 – September 2021 (A). Overall incidence of suicidal ideation (SI) and suicide attempts (SA) before and during the COVID-19 pandemic in the general population (B), and patterns of suicidal ideation (C), and suicide attempts (D) in the United States general population during the pandemic (March 2020 - September 2021) revealed a significant increase in the incidence of both suicidal ideation and suicide attempts in patients who tested positive for COVID-19.

The logistic regression investigating the effect of SARS-CoV-2 infection on suicidality outcomes revealed a significant effect. Specifically, the adjusted odds ratio for SARS-CoV-2 infection on suicidal ideation was 1.742 (95% confidence interval, 1.690 to 1.796; p<0.001) when controlling for month and demographic covariates (Fig. 1C). The adjusted odds ratio for SARS-CoV-2 infection on suicide attempts was 2.000 (95% confidence interval, 1.844 to 2.169; p<0.001) (Fig. 1D). See Supplementary Table 3 for full regression results.

Contrary to predictions, among those without evidence of SARS-CoV-2 infection, results indicated that pandemic-period rates of suicidality were lower in comparison to the pre-pandemic period (Fig. 1B). Specifically, the adjusted odds ratio for the pandemic period on suicidal ideation was 0.948 (95% confidence interval, 0.942 to 0.954; p<0.001) compared to the pre-pandemic period when controlling for month and demographic covariates. The change in rates of suicide attempts for the pandemic period had an odds ratio of 0.853 (95% confidence interval, 0.838 to 0.868; p<0.001) compared to the pre-pandemic period. See Supplementary Table 4 for full regression results.

Next, we investigated temporal patterns within the pandemic, across all patients in the database. While we expected to find temporal trends showing increased suicidality as the pandemic wore on and stressors mounted, we instead found that overall rates of suicidal thoughts and suicide attempts in both COVID+ and COVID- patients decreased slightly as time passed during the pandemic. The adjusted odds ratio for month-to-month change in suicidal thoughts was 0.999 (95% confidence interval, 0.998 to 1.000; p=0.031) while controlling for SARS-CoV-2 infection status and demographic covariates. The adjusted odds ratio for month-to-month change in suicide attempts was 0.993 (95% confidence interval, 0.990 to 0.996; p<0.001). See Supplementary Table 5 for full regression results.

Finally, we repeated all analyses using COVID-19 Community Vulnerability Index as our measure of social vulnerability instead of Social Vulnerability Index and the results were replicated. See Supplementary Table 6 for COVID-19 Community Vulnerability Index controlled estimates.

4. Discussion

The goal of the present study was to characterize suicidality within the context of the COVID-19 pandemic using patient encounter data from a large medical claims database. Key findings included (1) rates of suicide ideation and attempts were greater in patients who were positive for SARS-CoV-2 infection versus those who were not, (2) rates of suicide attempts in uninfected individuals decreased during the pandemic, and (3) within-pandemic temporal trends revealed that overall rates of suicidal ideation and attempts decreased as the pandemic months wore on from 2020-2021. Strengths of the study included the large, representative national sample, the ability to control for certain demographic variables (age, gender, and social vulnerability as reflected by the Social Vulnerability Index or COVID-19 Community Vulnerability Index), and the ability to examine changes over time across the evolving COVID-19 pandemic.

As hypothesized, suicidality was more prevalent in those with an active SARS-CoV-2 infection compared to those without. Results indicated that having a SARS-CoV-2 infection substantially increased risk for suicidal ideation and suicide attempts. Our findings build upon previous data associating SARS-CoV-2 infection with suicidal ideation (Shi et al., 2021). However, it should be considered that suicidality was rare within the study population (approximately 1 in 1000) so these trends only describe a small, but important, minority of susceptible individuals in the database. While the study design does not allow us to infer causality, these results could reflect numerous factors. One early study from China identified increased rates of depression, anxiety, and PTSD symptoms among patients quarantined for COVID-19 as well as subjective reports of feeling stigmatized (Guo et al., 2020). It is also possible that individuals with COVID-19 uniquely experience shame and guilt, and it has recently been suggested that these experiences are implicated in one's affective response to infection (Hamama and Levin-Dagan, 2022). Furthermore, strong feelings of shame and guilt have generally been theorized to contribute to suicidal ideation (Kealy et al., 2021). Another possibility is that certain individual differences such as lower socioeconomic status, (Karmakar et al., 2021) medical comorbidities, (Chadeau-Hyam et al., 2020) or increased rates of pre-existing psychiatric illness may predispose particular populations both to SARS-CoV-2 infection and to suicide risk (Ceban et al., 2021; Taquet and Harrison, 2021). Further research investigating the biological and psychosocial links between SARS-CoV-2 infection and suicide risk is greatly needed.

Contrary to our predictions, among COVID- insured patients, rates of suicidality in patient clinical encounters slightly decreased during the pandemic compared to pre-pandemic times. These results differ from previous findings reporting increased suicidal ideation based on survey data within the United States (Czeisler et al., 2021, 2020). While an early UK web-based survey data also indicated that regions affected by lockdowns demonstrated both increased mental health symptoms and suicidal ideation (Pierce et al., 2020), such survey results may have been influenced by response biases. However, our findings mirror observed trends in actual deaths by suicide reported so far in the United States (Faust et al., 2021; Pirkis et al., 2021). While it is not entirely clear why suicidality may have decreased in our sample despite early reports of declining mental health during the pandemic, we cautiously offer a couple potential explanations that could have contributed to this finding. First, our sample draws from clinical encounters, which inherently misses suicidal ideation and attempts experienced by individuals who are not presenting for care. Second, it is possible that mental health for some individuals may have improved in the context of shutdowns due to having more free time, experiencing relief from the usual stressors (e.g. school), and having an opportunity to re-think one's priorities or path in life. Third, despite reduced healthcare interactions that were observed earlier in the pandemic (Anderson et al., 2021), it is possible that the proliferation of telemedicine may have helped some obtain mental health treatment as time progressed. Telemedicine may reduce barriers to access for mental health care (Fletcher et al., 2018) and is associated with fewer missed psychotherapy appointments during the pandemic (Silver et al., 2020). Finally, the pandemic may also have motivated people to help others in need, and such altruistic community actions have been associated with increases in well-being (Bowe et al., 2021).

Interestingly, despite the seemingly strong reasons for increased suicidality and reports of increased suicide attempts and suicidal ideation, initial data from both the United States (Faust et al., 2021; Pirkis et al., 2021) and many other nations around the world (Appleby et al., 2021; Clapperton et al., 2021; Jeremy S Faust et al., 2021; Knudsen et al., 2021; Pirkis et al., 2021) have suggested that the overall number of deaths by suicide remained stable or slightly reduced through much of the pandemic. Speculatively, this may reflect that many people adjusted well to pandemic circumstances after an initial period characterized by fear and perceived loss of quality of life. However, there remains cause for concern that deaths by suicide may at some point increase, as was previously observed in a Japanese cohort after a similar period of stability (Nomura et al., 2021; Sakamoto et al., 2021). More work is needed to continue to monitor suicidal behavior and its associated risk factors over time as the pandemic continues to unfold.

4.1. Study Limitations

While sourcing data from insurance claims has many advantages, for example access to large numbers of patients and the ability to examine multiple clinical factors that were objectively assessed, this approach also has several notable limitations. First, billing codes could be subject to human error, either due to the clinician misdiagnosing the patient, or due to incorrectly entering the code into the medical record. As a more specific concern, it is possible that mild or incidentally discovered cases of COVID-19 may have been less likely to receive a code reflective of SARS-CoV-2 infection. Second, representation of mild cases of COVID-19 may have been further reduced by absence of complete clinical assessment at testing site visits, leading to omission of those data. Third, since the data are limited to clinical encounters, they do not reflect all instances of suicidality in the broader community. Fourth, claims data frequently do not capture deaths due to suicide, as in such cases individuals may not present for care. Finally, the sample may not be fully representative of the general care-seeking population. Although some demographic variables were controlled for in the analyses, including Social Vulnerability Index which is in part reflective of minority and socioeconomic status, the dataset is limited to insured patient encounters in the United States. This is a concern since suicidality rates likely vary across populations, time, and location. For instance, in Japan, as the pandemic went on, increased suicide rates were observed only in women first (Nomura et al., 2021), and rates in men did not increase until later (Sakamoto et al., 2021). Likewise, data from emergency rooms have reported increased suicide attempts specifically in women and younger individuals (Hill et al., 2021; Shrestha et al., 2021; Yard et al., 2021). In contrast, one Australian study reported an increase in suicide among young men (Clapperton et al., 2021). Racial disparities in the way the COVID-19 pandemic has affected suicidal behavior were identified in the state of Maryland in the United States, where a simultaneous increase in suicides in white individuals and a decrease in suicides in black individuals were observed (Bray et al., 2021). These examples highlight how vital information may be missed by only paying attention to overall rates of suicidal behavior. Additionally, it is possible that there could be misclassification bias of suicide codes that aren't factored into the analysis without comparing to rates of positive predictive value of suicidal thoughts and behaviors and actual deaths by suicide (Swain et al., 2019). We also acknowledge that regarding COVID-19 patients, there is a possibility in differences in how suicidality was assessed in those presenting for mental health concerns vs other primary concerns for an encounter in the system where this was then detected secondarily. However, without a full chart review for these patients, this cannot be determined.

In conclusion, although the vast majority of the study population in any group showed low rates of suicidality, our results suggest that infection with SARS-CoV-2 appears to be a substantial risk factor for suicidality with increased incidence of suicidal thoughts and behaviors noted among those testing positive for the virus. Given the seriousness of suicidality, this result may be of great importance for the minority that were affected. However, among those who have not been infected, rates of suicide attempts in the United States may have slightly decreased with the onset of the COVID-19 pandemic. This would suggest that generalized pandemic stress has not increased suicidality across the general population. Future work is needed to elucidate the cause of the association between SARS-CoV-2 infection and suicidality; this information will be critical to guide intervention and prevention strategies aimed at reducing suffering and deaths by suicide.

Data sharing statement

Deidentified participant data will be made available to researchers whose proposed use of the data has been approved for a specific purpose, with a signed data access agreement made with Optum Labs. Contact ken.cohen@optum.com to inquire about data access.

Declarations of Competing Interest

Ken Cohen and David Anderson were both working for UnitedHealth Group at the time that this work was completed. We have no other declarations of interest.

CRediT authorship contribution statement

Michael Reinke: Writing – original draft, Writing – review & editing. Chloe Falke: Formal analysis, Methodology. Ken Cohen: Writing – review & editing. David Anderson: Writing – original draft, Resources, Data curation. Kathryn R. Cullen: Writing – original draft, Supervision, Conceptualization. Jessica L. Nielson: Supervision, Visualization, Writing – original draft, Conceptualization, Project administration.

Acknowledgements

This work was supported by National Institute of Mental Health R01 MH116156 (Nielson), and donations from UnitedHealth Group to the University of Minnesota Foundation to support the effort of the authors.

Footnotes

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2023.115164.

Appendix. Supplementary materials

mmc1.docx (36KB, docx)
mmc2.csv (2.7KB, csv)

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