Effect of COVID-19 related national lockdown on suicide in Nepal: A comparative analysis of suicidal reports of major national newspaper

COVID-19 has detrimental effects on suicide globally (Pirkis et al., 2021), not only because of morbidity and mortality due to COVID-19 but also due to strategies implemented for its control including nationwide lockdown and mobility restrictions. Despite lockdown and travel restrictions help in decreasing the rate of COVID-19 transmission and interruption of transmission, such measures lead to obtrusion in normal daily lives heading one to conditions such as loneliness, economic deficit due to loss of employment and/or reduced income; and, these circumstances could trigger a vulnerable individual towards deteriorated mental health (Simon et al., 2021; Singh and Subedi, 2020) leading him/her to commit suicide (Gunnell et al., 2020; Calderon-Anyosa and Kaufman, 2021). Low- and middle-income countries (LMICs) are more receptive to witness increased suicides due to elevated mental health issues and economic hardships (Dsouza et al., 2020). This impact is seen more in people with mental health problems as they get hindered to access appropriate, adequate and timely treatment (Muruganandam et al., 2020). Although, in the early months of COVID-19 pandemic there were scattered narratives in the media that the pandemic affected suicidal behavior among individuals, most comprehensive data-based studies either reported a modest decrease or no significant net increase in suicide rates during the first year of the pandemic (Tandon, 2021).

Nepal, one of the LMICs in South Asia, imposed nationwide lockdown on March 24, 2020 after two confirmed cases of COVID-19 were reported, and later lifted the four months national lockdown on July 21, 2020 when 69.34 % of the infected individuals were recovered from the disease. The World Health Organization (WHO) has estimated age-standardized suicide rate of 9.8 per 100,000 for Nepal in 2019 (WHO, 2021). According to WHO, Nepal ranks seventh in the world and second in South Asia in terms of total number of suicides. Moreover, the incidence of suicide was found to upsurge during the lockdown period in Nepal with more than 1600 cases according to media reports and estimated to have increased by 20 % as compared to pre-lockdown period (Singh et al., 2020). As Nepal lacks suicide database and research related to suicide during COVID-19 pandemic, this is just an approximation based on the cases reported; therefore, true estimates regarding change in suicide rates is hard to calculate to draw inferences regarding association of suicide or suicidal rates and coronavirus lockdown. Suicidal reports in media are one of the major sources of epidemiological information for suicide in countries that lack suicide surveillance system (Shah et al., 2017). Hence, this study aimed to explore the effect of national lockdown on suicide in Nepal based on comparative analysis of major national newspaper reports during pre-lockdown and nationwide lockdown duration. For this, we compared the pattern of suicide between pre-COVID lockdown and national lockdown period in Nepal by carrying out the content analysis of the suicide reports of major four national newspapers and four national online news portals during the first four months of national lockdown during COVID-19 pandemic (March 24, 2020 to July 21, 2020) with the contents of the previous three months of COVID-19 pandemic when there was no lockdown in Nepal (January 1, 2020 to March 23, 2020). During these periods, we retrieved a total of 90 reports of suicides in Nepal. From the retrieved suicidal reports, we extracted data in MS Excel sheet under different variables including date of report, newspaper/news portal’s name, demographic profile of the deceased (age, gender, marital status, and employment status), method of suicide, life events, risk factor, suicide note, presence of mental illness/substance use, suicide pact, and homicide linked with suicide. A cross-checking of the extracted data was made by the first author and ensured to have good inter-rater reliability with Cohen’s Kappa exceeding 0.90. We analyzed data in SPSS version 20 and utilized frequency and percentage to describe magnitude of each variables and calculated odds ratio at 95 % confidence interval to examine their association with pattern of suicide.

Overall analysis indicated, when there were 19 suicidal reports during pre-lockdown, it increased to 71 during the lockdown period, i.e. increment by more than 3.5 times in the lockdown. Although, there was no significant association between the variables of choice and suicidal behavior, the results of the differences in prevalence of suicidal patterns are interesting and may pose important implications for approaches to prevent suicide considering these risks especially during adverse conditions of lockdown. While prevalence of suicide was higher in males during both pre-lockdown and lockdown, the prevalence got higher among those with broken family during lockdown (Table 1 ). Similarly, the prevalence of suicide got doubled among employed and students during lockdown, but was constant among unemployed. These results indicate that loneliness among widow/widower/separated/divorced was higher than those who were married, increased stress among students and employed individuals due to reduced income, disturbed academic activities and isolation with peers, could be linked with suicidal behavior. Hanging was found to be the most preferred mode of suicide during both periods. Similarly, while there was no issues related to finance and health for suicidal act during pre-lockdown, these were prevalent among suicidal cases during lockdown. Additionally, substance use and mental illnesses were found to be linked with suicides during lockdown which was not prevalent during pre-lockdown. There was no report of suicidal pact during the entire period of the study.

Table 1.

Comparison between suicide patterns in Nepal during pre-lockdown and lockdown period of COVID-19 pandemic (N = 90).

Variablesa	Pre-lockdown n (%)	Lockdown n (%)	OR (95 % CI)
Gender	n = 19	n = 67
Male	11 (57.9)	51 (76.1)	0.43 (0.15–1.26)
Female	8 (42.1)	16 (23.9)	Ref
Marital status	n = 4	n = 14
Married	4 (100)	11 (78.6)	Ref
Widow/Widower/Separated/Divorced	0	3 (21.4)	n.c.
Employment status	n = 10	n = 18
Employed	7 (70)	14 (77.8)	Ref
Unemployed	2 (20)	2 (11.1)	0.50 (0.06–4.34)
Others/students	1 (10)	2 (11.1)	1.00 (0.07–13.02)
Method of suicide	n = 17	n = 66
Hanging	11 (64.7)	54 (81.8)	Ref
Firearm	4 (23.5)	7 (10.6)	0.36 (0.09–1.43)
Others (Drowning/poisoning)	2 (11.8)	5 (7.6)	0.51 (0.09–2.97)
Life event	n = 19	n = 71
Present	5 (26.3)	35 (49.3)	0.37 (0.12–1.13)
Absent	14 (73.7)	36 (50.7)	Ref
Risk factor	n = 8	n = 28
Financial stress	0	5 (17.9)	n.c.
Health issue	0	7 (25)	n.c.
Relational issue	2 (25)	8 (28.6)	3.00 (0.46–19.59)
Others	6 (75)	8 (28.6)	Ref
Suicide note	n = 19	n = 71
Recovered	1 (5.3)	5 (7)	0.73 (0.08–6.68)
Not recovered	18 (94.7)	66 (93)	Ref
Substance use	n = 19	n = 71
Present	0	2 (2.8)	n.c.
Not present	19 (100)	69 (97.2)	Ref
Mental illness	n = 19	n = 71
Present	0	6 (8.5)	n.c.
Not present	19 (100)	65 (91.5)	Ref
Suicide pact	n = 19	n = 71
Present	0	0	n.c.
Absent	19 (100)	71 (100)	Ref
Homicide	n = 19	n = 71
Present	3 (15.8)	4 (5.6)	3.14 (0.64–15.45)
Absent	16 (84.2)	67 (94.4)	Ref

Notes: ^a Numbers may differ for various variables because all suicide reports did not mention information for all variables; n.c., not calculated due to small numbers or no reports.

The findings of this study revealed very baseline and preliminary evidence of differences in prevalence of various suicidal patterns between adverse nationwide condition of lockdown and pre-lockdown in Nepal. This result regarding impacts of lockdown on suicidal behavior during the pandemic is found to be similar in other South Asian countries including India and Bangladesh (Kar et al., 2021). The impact on suicide patterns due to the pandemic and travel restrictions could be similar in other low-and-middle income countries with poor resources. Although the results of this study are based on small sample size, they could help in formulating etiological inferences to be statistically explored further through longitudinal studies to provide way out for evidence-based strategies to prevent or reduce epidemics of suicide in Nepal and similar settings. During crisis such as COVID-19 pandemic, it is very important to disseminate real-time accurate data and information of various health issues including suicide in order to enable healthcare and policy decision-making to prevent and control epidemic of suicide in a situation of urgency with substantial uncertainty (Tandon, 2021). Moreover, increase in the rates of suicide documented in the immediate aftermath of an infectious pandemic warrants urgent recognition and controlling strategies (Tandon, 2021). Henceforth, the current scenario of the pandemic urges to make an important call for now, more than ever, to establish population based registry for suicidal behavior that could work as a suicide database for giving real time data on suicide, suicidal acts, trends and seasonality of suicide and their pattern for designing appropriate prevention and control program in poor resource settings like Nepal. Furthermore, in the absence of national database for suicidal surveillance, the quality suicidal media reporting is very important for preventing and controlling outbreaks of suicide.

Funding

The authors did not receive any financial support for this work that could have influenced its outcome.

Declaration of Competing Interest

The authors report no declarations of interest.