COVID‐19‐related self‐harm and suicidality among individuals with mental disorders

To the editor,

The coronavirus disease (COVID‐19) pandemic has created an unprecedented public health emergency. Extraordinary measures have been implemented to reduce the spread of the virus, including mass quarantines and social distancing. However, these preventive measures come at a price. Economic stress, social isolation, decreased access to community activities, etc., are the new reality for a large part of the global community and may have detrimental effects on mental health. In their recent paper in Acta Psychiatrica Scandinavica, Madsen et al. describe how the COVID‐19 pandemic may affect mental health and psychiatric care, and predict that suicide rates may increase because of the pandemic. ¹ Indeed, an increase in suicide rates was observed in the wake of the severe acute respiratory syndrome (SARS) epidemic in Hong Kong. ² Although the COVID‐19 pandemic may affect the risk of suicide in populations at large, individuals living with a mental disorder may be at particularly elevated risk. ³ Should Madsen et al. be right in their dire prediction, we may expect to see a rise in self‐harm and suicidality among individuals with mental disorders as one of the first manifestations. ⁴

We previously reported on COVID‐19‐related psychiatric symptoms among adult patients from the psychiatric services of the Central Denmark Region (CDR: catchment area: 1.3 million people). Specifically, we extracted all clinical notes from the adult psychiatric services in the CDR from February 1, 2020, to March 23, 2020, and screened them for pandemic‐related psychiatric symptoms. We then labeled all included notes by their dominant psychopathology. A detailed description of the methods and the results of this effort are published elsewhere. ⁵ One of the most severe manifestations of pandemic‐related psychopathology was self‐harm/suicidality, which was described in 102 clinical notes from 74 patients. ⁵ Here, we provide a more thorough characterization of this phenomenon. In brief, all 102 clinical notes describing thoughts of/completed self‐harm or suicidality were re‐assessed independently by OHJ and CR, and divided into five different categories: (i) thoughts of self‐harm, (ii) completed self‐harm, (iii) passive wish to die of COVID‐19, (iv) suicidal thoughts, or (v) suicide attempts. This effort was approved by the Chief Medical Officer of Psychiatry in the CDR as part of a quality development project (‘COVID‐19 and mental disorders’) aiming at optimizing the detection and care of patients with pandemic‐related psychopathology.

The 74 patients displaying pandemic‐related self‐harm/suicidality had a median age of 29.8 years (interquartile range: 24.3‐37.2 years) and 77% were females. While suicidal ideation was the most prevalent manifestations (see Table 1A), there were also several cases of thoughts of/completed self‐harm, suicide attempts, and patients with a passive wish to die of COVID‐19. The diagnostic distribution of the patient sample is shown in Table 1B and clearly illustrates that it is the known ‘high risk’ groups for self‐harm and suicidality (psychotic disorders, mood disorders, stress‐related and adjustment disorders, and personality disorders), which appear to respond to the stress associated with the COVID‐19 pandemic with these symptoms/behaviours. ³

Table 1.

Types of pandemic‐related self‐harm/suicidality (A) and the diagnoses of the patients displaying pandemic‐related self‐harm/suicidality (B)

A.
Symptom	Number of clinical notes	Number of patients*
Thoughts of self‐harm	16	14
Completed self‐harm	11	10
Passive wish to die of COVID‐19	15	13
Suicidal thoughts	46	34
Suicide attempts	14	10
Total	102	74

B.
ICD‐10	Diagnosis	Number of patients
DF2x	Schizophrenia and other psychotic disorders	12
DF3x	Mood disorders	10
DF43.x	Stress‐related and adjustment disorders	13
DF60‐61	Personality disorders	14
DF84	Autism	5
	Other diagnosis	15
	No diagnosis	5

^*The sum of the number of patients with different symptoms column does not add up to the total number of patients (n = 74), as some patients are represented in more than one symptom category (with different clinical notes).

Although we have no knowledge of the counterfactual (how these patients would have fared without the pandemic), our results seem compatible with the COVID‐19 crisis leading to increased self‐harm/suicidality in individuals with mental disorders, thereby corroborating the concern expressed by Madsen et al. ² Importantly, as the patients were not systematically assessed for pandemic‐related psychopathology, the prevalence of self‐harm/suicidality related to the ongoing crisis is probably highly underestimated in our data. For these reasons, we advise our colleagues worldwide to pay extra attention to the risk of self‐harm and suicide during—and in the aftermath of—the COVID‐19 pandemic.

Funding

This project is supported by an unconditional grant from the Novo Nordisk Foundation (Grant Number: NNF20SA0062874).

Conflict of interest

None.

Peer Review

The peer review history for this article is available at https://publons.com/publon/10.1111/acps.13214.

Jefsen OH, Rohde C, Nørremark B, Østergaard SD. COVID-19-related self-harm and suicidality among individuals with mental disorders.