Suicide is one of the leading preventable causes of premature mortality globally (Naghavi, 2019). India accounts for around 17% of global deaths due to suicide (Kamalja and Khangar, 2017). Suicidal behavior is shaped by a complex set of risk and protective factors. These include the factors that operate at the individual, familial, and community level. The COVID-19 pandemic is arguably the worst healthcare crisis that the world has witnessed in the past several decades. Both, the concerns related to the pandemic as well as the response to address the same, have contributed to the distress associated with this public health challenge (Sher, 2020).
Rapid transmission of the infection and a limited understanding of the disease coupled with the lack of an approved treatment created an atmosphere of fear and uncertainty leading to increased psychological distress in the population (Grover et al., 2020). This is reflected in a high rate of psychiatric morbidity reported across different sections of population in the recent publications (Luo et al., 2020). Additionally, restrictions imposed as part of the lockdown to contain the spread of the infection across different regions of the world created financial and economic challenges. Limited recreational and socialisation opportunities since the beginning of the pandemic are expected to undermine the coping ability of the population to address the stress posed by the pandemic. This situation is further compounded by the limited availability and accessibility to the mental health support services. This is especially true of the Low- and Middle- income countries that had limited mental health resources even prior to the start of the pandemic. Further, there was a disruption of existing mental health services due to reorganization or diversion of resources for COVID care, and hesitancy among people in visiting treatment facilities due to travel restrictions and fear of acquiring the infection (WHO, 2020).
There have been concerns expressed in news media reports and academic publications about the likely surge in suicide deaths during the COVID-19 pandemic as a result of its direct and indirect effects of the situation consequent to the pandemic on several of the risk factors for suicide (Reger et al., 2020; Srivatava, 2020). Modelling studies predicted a rise in suicides ranging from 1% to 145% across different geographical areas based on the assumptions made for assessing the impact due to the COVID-19 pandemic and the adverse socio-economic effects of subsequent public health measures like lockdown (John et al., 2020a).
However, there are only a few studies that have reported on the actual data while assessing the trend in suicide deaths during the COVID-19 pandemic. The findings of these studies are mixed, with few of them reporting an increase, decrease, or no significant change in suicide rates during the COVID-19 lockdown period (John et al., 2020b). Almost all of these studies are from populations living in western or high-income countries and they are not expected to capture the impact of the pandemic in settings that are socio- economically different. The only published study from a low-and-middle income country from Asia (Nepal) reported a 25% increase in suicides during the lockdown when compared to pre-lockdown period (Pokhrel et al., 2020). However, this study did not report on the suicide rate during the post-lock down period nor did it compare the suicide numbers with that of the past years to rule out other possible variations across the year.
In India, the nationwide lockdown was implemented in four phases (from 25 March 2020 to 31 May 2020). Subsequently, the process of un-lockdown was started in a phased manner (from June 2020- November 2020).
The present study was planned with the aim of assessing the impact of situation consequent to COVID-19 pandemic on the deaths due to suicide in two districts of New Delhi, India. We aimed to explore the changes in deaths due to suicide following the COVID-19 pandemic as compared to the previous year. Additionally, the autopsy profile of deaths due to suicides was examined to explore factors associated with suicide during the study period.
All India Institute of Medical Sciences (AIIMS) is the reporting hospital for all the medicolegal cases from two districts of New Delhi (i.e. south and south-east). All deaths due to suicide from these two districts are reported to the hospital and an autopsy is performed for all such deaths. The data was reviewed for the period from 25 March 2020 to 31 October 2020. The detailed analysis of these cases based on information furnished by the investigating agency in inquest reports, medical records, psychological autopsy data from the relatives of the deceased and the autopsy reports were retrieved. Additionally, we retrieved the data for deaths due to suicide during the same period for the previous year (2019) to explore for variation across the year.
This study has been performed in accordance with the Declaration of Helsinki, and data was extracted anonymously (without any personal identification details) from autopsy records maintained by the Department of Forensic Medicine and Toxicology, AIIMS in accordance with the biomedical research ethical standards. The study was approved by the Institute Ethics Committee vide letter number IEC-12/08.01.2021.
The data were analysed using SPSS version 23.0 (Armonk, NY, IBM Corp). Descriptive statistics using median, inter-quartile range (IQR), frequency and percentage were used to describe the characteristics of the study sample. The data were checked for normality distribution by using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Since, the data were not normally distributed even after attempting logarithmic transformation, non-parametric inferential statistics were used. Mann-Whitney U tests were conducted to examine for differences in number of deaths due to suicide for the four sets of study time-periods. To control for possible inflation of Type I error rate due to multiple comparisons between different time periods, we applied a Bonferroni correction and considered a result significant only if p-value was < 0.0125 (i.e. 0.05/4) for trend analysis. Further, bivariate analysis using Mann-Whitney U test for continuous variables and Chi-square test for categorial variables was conducted. Fisher’s exact test was used when at least one expected value in the contingency table was less than five. A two tailed p-value of < 0.05 was considered significant for bivariate analyses.
A total of 1104 autopsies were conducted during the study period (between 25 March 2020 to 31 October 2020), out of which 321 (29.0%) were for deaths due to suicide. The median age of the persons whose bodies were autopsied was 28.00 (IQR: 22.00–36.50) years, with majority being male (235/321, 73.2%).
Fig. 1 shows the daily number of deaths due to suicides reported during the study period. There was a significant increase in the number of deaths due to suicides registered during the unlock period as compared to the lockdown period (U = 3368.00, p < 0.001). Further, there was a significant decrease in the number of deaths due to suicide registered during the lockdown months as compared to the same months the previous year (61 vs. 105; 41.9% reduction). Hence, the changes in trends for deaths due to suicide observed during the study period were unlikely to be explained by a seasonal pattern (see Table 1 ).
Fig. 1.
Daily variations in the number of deaths due to suicide registered during the COVID-19 Pandemic.
Table 1.
Trends in deaths registered as suicide during the lockdown and unlock period with the deaths by suicide during same time period last year.
| Time periods compared | Median (IQR) suicide deaths | Test statistic (p-value) |
|---|---|---|
| 1 vs. 2 | 1.00 (0.00−1.00) vs. 1.00 (1.00−2.50) | 3368.00a (< 0.001)** |
| 3 vs. 4 | 1.50 (1.00−2.00) vs. 1.00 (0.50−2.00) | 4845.50a (0.40) |
| 1 vs. 3 | 1.00 (0.00−1.00) vs. 1.50 (1.00−2.00) | 1510.50a (< 0.001)** |
| 2 vs. 4 | 1.00 (1.00−2.50) vs. 1.00 (0.50−2.00) | 10583.00a (0.13) |
1: 25 March 2020 to 31 May 2020; 2: 1 June to 31 October 2020; 3; 25 March 2020 to 31 May 2019; 4: 1 June to 31 October 2019. IQR: Inter-quartile range; a Mann Whitney U-test; ** p-value < 0.0125.
Profile of deaths due to suicide during and after the lockdown
There were no significant differences for age (U = 7273.00, p = 0.31) and gender (χ2 = 0.56, p = 0.45) distribution of deaths due to suicide between lockdown and unlock (post-lockdown) period. Table 2 presents the findings from the comparison of the profile of deaths registered as suicide during the lockdown and unlock periods. There was a significantly lesser proportion of deaths due to suicide at residence during the lockdown as compared to unlock period (85.2% vs. 94.2%, p = 0.01). Similarly, a significantly lesser proportion of suicide by hanging method were reported during the lockdown (82.0% vs. 91.1%, p = 0.03). There was a significantly greater proportion of deaths due to suicide attributable to marital problems (10.4% vs. Zero, p = 0.009) during the unlock period.
Table 2.
Comparison of profile of deaths registered as suicides between the lockdown and unlock period.
| Study variable | Lockdown (n = 61) | Unlock (n = 260) | Test statistic (p-value) |
|---|---|---|---|
| Gender: | 0.56b (0.45) | ||
| Male | 47 (77.0%) | 18 (72.3%) | |
| Female | 14 (23.0%) | 72 (27.7%) | |
| Place of death: | 5.76b (0.01) * | ||
| Residence | 52 (85.2%) | 245 (94.2%) | |
| Non-residence | 9 (37.5%) | 15 (5.8%) | |
| Suicide note found: | 3.22c (0.07) | ||
| Yes | 3 (4.9%) | 34 (13.1%) | |
| No | 58 (95.1%) | 226 (86.9%) | |
| H/o suicide attempt: | 0.22c (0.99) | ||
| Yes | 1 (1.6%) | 7 (2.7%) | |
| No | 60 (98.4%) | 253 (97.3%) | |
| H/o current alcohol use | 12.40b (<0.001) * | ||
| Yes | 1 (1.6%) | 53 (20.4%) | |
| No | 60 (98.4%) | 207 (79.6%) | |
| Method of suicide: | |||
| Hanging | 50 (82.0%) | 237 (91.1%) | 4.40b (0.03) * |
| Poisoning | 7 (11.4%) | 13 (5.0%) | 3.54b (0.06) |
| Jumping off height | 2 (3.3%) | 8 (3.1%) | 0.007c (0.99) |
| Other methods | 2 (3.3%) | 2 (0.8%) | 2.52c (0.16) |
| Reason for suicide: | |||
| Financial/Job related | 4 (6.6%) | 24 (9.2%) | 0.44b (0.50) |
| Mental illness | 1 (1.6%) | 32 (12.3%) | 6.09b (0.01) * |
| Alcohol use | 1 (1.6%) | 10 (3.8%) | 0.72c (0.69) |
| Physical health issues | Zero | 14 (5.4%) | 3.43c (0.08) |
| Love affair | 1 (1.6%) | 9 (3.5%) | 0.54c (0.69) |
| Marital problems | Zero | 27 (10.4%) | 6.91b (0.009) * |
| Academic problems | Zero | 1 (0.4%) | 0.23c (0.99) |
| Family problems | Zero | 3 (1.2%) | 0.71c (0.99) |
| Other reasons | Zero | 4 (1.5%) | 0.95c (0.99) |
| Unknown reasons | 53 (86.9%) | 137 (52.7%) | 23.91b (<0.001) * |
b Chi-square test; c Fisher’s exact test; * p-value < 0.05; H/o: History of.
Table 3 compares the profile of deaths registered as suicide on autopsy during the study period for the current year with corresponding months from the past year (331 deaths). The profile of deaths due to suicide was comparable for age (U = 52380.50, p = 0.75) and gender (χ2 = 0.39, p = 0.52) for the two years (2020 vs. 2019). There was a significantly lesser number of deaths due to suicide with past history of suicide attempt in the current as compared to the last year (2.5% vs. 12.4%, p < 0.001). Similarly, a significantly lesser proportion of deaths due to suicide were reported due to academic problems (0.3% vs. 2.4%, p = 0.03) and family problems (0.9% vs. 3.6%, p = 0.02) during the current year.
Table 3.
Comparison of profile of deaths registered as suicides between this year and last year for the duration of study period (25th March to 31st October).
| Study variable | March-October 2020 (n = 321) | March-October 2019 (n = 331) | Test statistic (p-value) |
|---|---|---|---|
| Gender: | 0.39b (0.52) | ||
| Male | 235 (73.2%) | 235 (71.0%) | |
| Female | 86 (26.8%) | 96 (29.0%) | |
| Place of death: | 0.03b (0.85) | ||
| Residence | 297 (92.5%) | 305 (92.1%) | |
| Non-residence | 24 (7.5%) | 26 (7.9%) | |
| Suicide note found: | 2.99b (0.08) | ||
| Yes | 37 (11.5%) | 25 (7.6%) | |
| No | 284 (88.5%) | 306 (92.4%) | |
| H/o suicide attempt: | 22.95b (< 0.001) * | ||
| Yes | 8 (2.5%) | 41 (12.4%) | |
| No | 313 (97.5%) | 290 (87.6%) | |
| H/o current alcohol use | 2.25b (0.13) * | ||
| Yes | 54 (16.8%) | 71 (21.5%) | |
| No | 267 (83.2%) | 260 (78.5%) | |
| Method of suicide: | |||
| Hanging | 287 (89.4%) | 288 (87.0%) | 0.90b (0.34) |
| Poisoning | 20 (6.2%) | 34 (10.3%) | 3.50b (0.06) |
| Jumping off height | 10 (3.1%) | 4 (1.2%) | 2.82b (0.09) |
| Other methods | 4 (1.2%) | 5 (1.5%) | 0.08b (0.99) |
| Reason for suicide: | |||
| Financial/Job related | 28 (8.7%) | 20 (6.0%) | 1.71b (0.19) |
| Mental illness | 33 (10.3%) | 33 (10.0%) | 0.01b (0.89) |
| Alcohol use | 11 (3.4%) | 13 (3.9%) | 0.11b (0.73) |
| Physical health issues | 14 (4.4%) | 13 (3.9%) | 0.07b (0.78) |
| Love affair | 10 (3.1%) | 15 (4.5%) | 0.88b (0.34) |
| Marital problems | 27 (8.4%) | 30 (9.1%) | 0.08b (0.76) |
| Academic problems | 1 (0.3%) | 8 (2.4%) | 5.30c (0.03) * |
| Family problems | 3 (0.9%) | 12 (3.6%) | 5.24b (0.02) * |
| Other reasons | 4 (1.2%) | 9 (2.7%) | 1.80b (0.17)* |
| Unknown reasons | 190 (59.2%) | 180 (54.4%) | 1.53b (0.21) |
b Chi-square test; c Fisher’s exact test; * p-value < 0.05; H/o: History of.
Deaths due to suicide attributable to mental disorders and alcohol use
Psychological autopsy suggested mental disorders to be the underlying cause for suicidal behavior in 10.2% (33 out of 321) cases. There was a significantly greater proportion of deaths due to suicide attributable to mental illness (12.3% vs. 1.6%, p = 0.01) during the unlock period. Current alcohol use was documented in 16.8% (54 out of 321) cases. Current alcohol use was documented in a significantly greater proportion of deaths due to suicide during the unlock period as compared to the lockdown period (20.4% v/s 1.6%; p < .001). However, proportion of deaths due to suicide attributable to current alcohol use was comparable between the lockdown and unlock period.
There was a significant decline in deaths due to suicide during the lockdown period, with more than forty per cent reduction in the number of deaths due to suicide registered during the lockdown period as compared to the corresponding period last year. This finding is in line with the findings from two other previous studies, both of which reported a significant decrease in suicide rate during the initial phase of restrictions following COVID-19 pandemic (Ueda et al., 2020; Radeloff et al., 2020). This observation can be attributed to the “pulling together” phenomenon described in the context of previous natural disasters including the 2003 infectious SARS epidemic (Zortea et al., 2020). It has been postulated that the decrease in suicides during the initial period of a pandemic could be because of the omnipresent sense of threat caused by the spread of COVID-19 pandemic and need to follow the lockdown and other public health advisory guidelines for protection by the entire community, in turn increasing social cohesion or connectedness among people despite physical distancing. Also, in the face of a large-scale crisis like COVID-19 affecting virtually all the members of the society there is likely to be an increase in the social support received by otherwise marginalized or vulnerable groups of the society. This acts as a protective factor and leads to a decreased risk of suicidal behaviours among the population in the short-term future in line with the inter-personal theory of suicide. Further, the most common method of suicide was hanging for the current as well as the last year, and there was a significant decline in suicide deaths occurring at the persons’ residence and by hanging method during the lockdown period when compared to the unlock period. This suggested that decline in suicides observed in the study sample could be partly explained by the effect of restricted access to means and opportunities to engage in suicidal act during the lockdown period with most people staying at their homes with family members or friends. The restriction of access to lethal means has been well documented as an evidence-based strategy for prevention of suicide at the population level (Zalsman et al., 2016).
There was a significant increase in the deaths due to suicide in the unlock period after the restrictions were gradually lifted off. Also, this increase could not be explained by changes in suicide pattern across months upon comparison with data for the past year. A similar pattern of initial decrease in suicide rate followed by subsequent increase over a period of about six-months period following the COVID-19 pandemic has also been reported in a study from Japan. This could be attributable to the increased psychological distress due to several factors such as the prolonged adverse socio-economic consequences of the pandemic, fear of getting COVID-19 infection or death of a loved one with COVID-19, less than expected impact of the lockdowns to contain the COVID-19 pandemic compared to what was anticipated at the beginning of the pandemic, and uncertainty regarding the future due to COVID-19 pandemic. Employment opportunities were reduced, and businesses faced difficulties in the months following the onset of pandemic. This is a cause of particular concern, as the available evidence from previous economic recession periods showed that a rise in unemployment was consistently associated with increased suicide rate (Chang et al., 2013). Additionally, the Werther effect caused by reports of celebrity suicides during the latter part of the pandemic might also have contributed to this increased suicide deaths in the unlock period. An infodemiology study from the country suggested an increase in online search for suicide-seeking behaviours along with media reports of actual copy-cat suicides from different parts of India in the recent months (Ganesh et al., 2020).
Further, a comparison of suicide deaths registered between the lockdown and unlock period revealed significant differences in the apparent reasons for suicide during the two time-periods. There was significant increase in suicide among people with mental illness during the unlock period as compared to lockdown. This suggested that the people with pre-existing mental illness were more vulnerable to the increased stress caused by various factors related to COVID-19 and lockdown, which is in line with the available literature assessing their impact on mental health (Singh et al., 2020a). There is a need to focus specifically on the vulnerable populations by offering targeted mental health interventions aimed at suicide prevention. These include the use of digital technology to provide tele-consultations, online self-help resources to promote healthy life-style to reduce stress and use of positive coping strategies to deal with COVID-19 related disruptions, national mental health counselling tele-helplines to provide support and guidance to people in seeking help during the crisis period. Also, there was a significant association between increased risk of suicide during the unlock period and history of current alcohol use in the study sample. This is in line with the bulk of available literature on the association of problematic alcohol use to be associated with an increased risk of suicidal behavior (Pompili et al., 2010). Further, studies have suggested an increased alcohol use for relieving negative affect states like anxiety, boredom or loneliness during the period of COVID-19 pandemic (Chiappini et al., 2020). The increase in association of alcohol use with deaths due to suicide could be explained in part by the change in availability of alcohol in the country during the lockdown and unlock periods (Singh et al., 2020b). The sale of alcohol was prohibited across the country for a period of about six weeks beginning the lockdown, only to resume after 3rdMay 2020.
Interestingly, there was a significant decrease in suicide attributable to academic problems or family problems during the COVID-19 pandemic than compared to last year. This could be partly due to cancellation of various examinations and students being promoted to next year. Academic examinations are a well-documented source of stress among students in India (Reddy et al., 2018). Further, family members spent much of their time together staying at home during the lockdown and thereafter. This could have resulted in improved communication and inter-personal relationships among them. However, there is a need for conducting further studies exploring the complex relationship and effects of the COVID-19 and subsequent lockdown and closure of academic institutions on the lives of students and family units in India.
The findings of the present study are based on the reported cases of deaths due to suicide from two districts of the capital city of India. Hence, caution should be exercised while interpreting these results. The findings of the study may have limited generalisability owning, in part, to the immense socio- demographic diversities observed across the country. Also, these is a possibility of underestimation due to underreporting and misclassification of suicide in the existing official reporting system for suicides in the country. Lastly, the suicide related information was obtained from the review of autopsy records. These were prepared based on the information available from collateral sources at the time of autopsies. The adequacy and reliability of this information could vary across the cases. Despite of the above-mentioned limitations, this is to the best of our knowledge the first study to have systemically reported the impact of COVID-19 on the number and pattern of deaths due to suicide registered in India. Further, unlike most of the previous studies available from the South-East Asian countries including India that were based on suicide deaths reported in news reports by journalists and being prone to several biases; the present study involved review of records for all the suicides brought for autopsy by the police which is the only agency collecting official suicide data in India. Moreover, the suicide data for the study period was compared with the data from the previous year to assess the possible variation in deaths due to suicide across the different months of the year.
The present study showed an initial decline in suicide rates during the lockdown period followed by increase during the unlock period. Further, the well-established suicide risk factors like mental disorders and alcohol use were associated with increased deaths due to suicide during the COVID-19 pandemic period as well. There is a need to recognize and put in place the strategies to mitigate their negative effects during the pandemic for preventing deaths due to suicide going ahead. In conclusion, the suicide risk appears to be dynamic and needs to be continuously monitored to ensure early identification of any potential surge in deaths due to suicide as we continue to address the challenges posed by COVID- 19. Also, there is a need to further identify and characterize the risk and protective factors, to implement tailored interventions for suicide prevention.
Ethics approval statement
The study was approved by the Institute Ethics Committee vide letter number IEC-12/08.01.2021.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgement
None.
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