1. Background
Suicide is an important global problem, with the World Health Organization (WHO) reporting that one person dies by suicide every 40 seconds. According to the WHO, suicide is the act of deliberately killing oneself. Mental illness, including depression and neurological problems, cancer, and human immunodeficiency virus (HIV) infection, are significant risk factors for suicide. Nearly one million individuals every year commit complete suicide, with low- and middle-income nations accounting for 86% of these deaths. Suicide accounts for 10-20% of deaths in women up to one year postpartum and is one of the top three causes of death in young individuals under 25 years (1). The estimated lifetime prevalence of suicidal ideation in the general population is approximately 4% (2). In the Fars province of southern Iran, within 2011 and 2018, a study measuring the years of life lost as a result of completed suicides showed an increasing trend in successful suicide attempts. About 58669 years were calculated to be the total number of years of life lost (14.71 per 1000 individuals), and the most years of life lost due to suicide were among individuals aged 15 to 29 years (3). Therefore, suicide should be considered a significant public health concern, especially in cases of crises, such as the coronavirus disease 2019 (COVID-19) pandemic.
The COVID-19 pandemic’s potential effects on suicide rates are still unknown (4). Studies have shown that there is a two-way relationship between mental health disorders and the COVID-19 pandemic; therefore, not only individuals with a history of mental disorders are susceptible to COVID-19, but having COVID-19 itself could increase the risk of mental disorders (5). An increased probability of mental disorders during the COVID-19 pandemic might lead to the occurrence of suicidal behavior and ultimately increase the rate of suicide among individuals (6-8).
In recent years, numerous studies have been conducted on the relationship between the risk factors for suicide attempts in the COVID-19 pandemic (9-11). Feeling lonely due to social distancing, sleep disorders, underlying mental disorders, alcohol or drug abuse, anxiety and stress related to COVID-19, domestic violence, economic recession, and temporary changes in the health system’s structure might increase the rate of suicide (12-14). Although numerous studies have reported that suicide rates have increased both in past epidemics and in the COVID-19 pandemic (15-18), there is no consensus in this regard. A reduction or no change in the suicide rate has also been reported in some other studies (19-22).
2. Objectives
To the best of our knowledge, reports and definitive evidence about the contribution of risk factors for suicide attempts during the COVID-19 pandemic, such as age, gender, occupation, marital status, educational level, death of a family member due to contracting COVID-19, a history of mental disorders, and a history of suicide attempts, are very limited. By studying the risk factors related to suicide during the COVID-19 pandemic, it is possible to identify at-risk individuals and thereby prevent committing suicide during crises similar to the COVID-19 pandemic as much as possible. Therefore, this study examined and compared the risk factors for committing suicide before and after the pandemic.
3. Methods
3.1. Study Design and Participants
The study protocol was approved by the Research Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran, with the ethics code REC: IR.SBMU.RETECH.REC.1400.443. In this case-control study, patients were divided into two groups: 160 individuals who committed suicide during the pandemic period, within October 1, 2021, to August 30, 2022 (the case group) and 160 individuals who committed suicide before the pandemic period, within March 11, 2019, to March 11, 2020 (the control group).
3.2. Sample Size and Sampling Method
The sample size was arrived at through the following equation, where n is the sample size, Z is the statistic corresponding to the level of confidence, P is the expected prevalence (that can be obtained from the same studies or a pilot study conducted by the researchers), and d is precision (corresponding to effect size):
With a 95% confidence interval (CI), Z is equal to 1.96. In a pilot study, the expected prevalence of suicide among poisoned patients admitted to Loghman Hakim hospital, Tehran, Iran, was estimated to be 11.5%. With a prevalence of the disease between 10% and 90%, it is recommended to select a precision of 5%. By placing the values in the above-mentioned equation, the final sample size arrived at 156 and was rounded off to 160. Sampling was random and included the patients admitted to Loghman Hakim hospital due to suicide attempts during the COVID-19 pandemic and one year before.
3.3. Data Collection
The data on the demographic characteristics, mental-psychological status, and socioeconomic status (SES) of the patients were obtained based on a pre-designed questionnaire. A semi-structured questionnaire was prepared based on the review of the previous research and experts’ opinions. Patients with ages less than 12 years and patients with prominent intellectual disabilities or cognitive disorders were excluded from the study. Moreover, the patients who had incomplete medical records or provided incomplete information during the face-to-face or telephone interview were excluded from the study. The patients in the case group were orally interviewed by trained study staff under the supervision of a clinical psychiatrist. The patients were asked about their demographic characteristics, mental-psychological status, and SES before and after the COVID-19 pandemic. The data for the control group were obtained by retrospectively reviewing electronic medical records and conducting a telephone interview. Each participant was explained in detail about the study, and informed consent was obtained from the participant prior to the commencement of data collection.
3.4. Data Analyses
The statistical analysis of the collected data was performed using SPSS software and appropriate statistical tests. The Student’s t-test and chi-square test were used to compare quantitative and qualitative variables between the two groups, respectively. Missing data were less than 5% and addressed using listwise deletion. The Wilcoxon signed-rank test was used to compare the mental-psychological and SES of the patients in the case group before and after the pandemic. Finally, a multivariable logistic regression test was used to determine the risk factors predicting suicide attempts during the COVID-19 pandemic. Quantitative variables were reported as mean (± standard deviation [SD]) and qualitative variables as number (percentage). Differences were considered significant if P-values were less than 0.05.
4. Results
4.1. Demographic Data
In the case group, there were 43 (26.9%) and 117 (73.1%) male and female patients, respectively. In the control group, there were 56 (35%) and 104 (65%) male and female patients, respectively. There was no significant difference between the case and control groups in terms of gender distribution. The average age of patients in the case group was 27.03 with an SD of 8.9, and the average age of the patients in the control group was 29.66 with an SD of 9.6, which was significantly higher than the case group (P = 0.01). Based on clinical history, the patients were classified as having mental disorders if they had received at least one of the medications related to mental disorders (including antidepressants, antipsychotics, or mood stabilizers) under the physician’s prescription. The results showed that mental disorders were more frequent among patients in the case group than in the control group (73.1% vs. 61.9%, respectively; P = 0.032) (Table 1).
Table 1.
Demographic Characteristics, Mental-psychological Status, and Socioeconomic Status of Case and Control Groups a
| Variables | Control (N = 160) | Case (N = 160) | P-Value |
|---|---|---|---|
| Age | 29.66 (9.6) | 27.03 (8.9) | 0.01* |
| Gender | 0.116 | ||
| Male | 56 (35) | 43 (26.9) | - |
| Female | 104 (65) | 117 (73.1) | - |
| Occupational status | 0.104 | ||
| Employed | 52 (32.5) | 37 (23.1) | - |
| Student | 28 (17.5) | 25 (15.6) | - |
| Unemployed | 80 (50.0) | 98 (61.3) | - |
| Marital status | 0.163 | ||
| Married | 56 (35.0) | 75 (46.9) | - |
| Single | 86 (53.8) | 68 (42.5) | - |
| Divorced | 12 (7.5) | 10 (6.3) | - |
| Widow | 6 (3.8) | 7 (4.4) | - |
| Educational level | 0.556 | ||
| Illiterate | 10 (6.3) | 12 (7.5) | - |
| Elementary | 28 (17.5) | 21 (13.1) | - |
| High school | 47 (29.4) | 56 (35) | - |
| Academic | 75 (46.9) | 71 (44.4) | - |
| Socioeconomic status | 0.689 | ||
| Low | 36 (22.5) | 35 (21.9) | - |
| Middle | 97 (60.6) | 92 (57.5) | - |
| High | 27 (16.9) | 33 (20.6) | - |
| Underlying mental disorders | 0.032* | ||
| Yes | 99 (61.9) | 117 (73.1) | - |
| No | 61 (38.1) | 43 (26.9) | - |
| Underlying disease | 0.221 | ||
| Yes | 39 (24.4) | 30 (18.8) | - |
| No | 121 (75.6) | 130 (81.3) | - |
| Close friend | 0.048* | ||
| Yes | 49 (30.6) | 66 (41.3) | - |
| No | 111 (69.4) | 94 (58.8) | - |
| Parental relationship | 0.001*** | ||
| Good | 98 (61.3) | 71 (44.4) | - |
| Bad | 17 (10.6) | 40 (25.0) | - |
| Divorced | 18 (11.3) | 29 (18.1) | - |
| Died | 27 (16.9) | 20 (12.5) | - |
| Cigarette smoking | 0.138 | ||
| Yes | 89 (55.6) | 102 (63.7) | - |
| No | 71 (44.4) | 58 (36.3) | - |
| Alcohol drinking | 0.367 | ||
| Yes | 95 (59.4) | 87 (54.4) | - |
| No | 65 (40.6) | 73 (45.6) | - |
| Family suicide history | 0.211 | ||
| Yes | 28 (17.5) | 37 (23.1) | - |
| No | 132 (82.5) | 123 (76.9) | - |
| Friends suicide history | 0.243 | ||
| Yes | 35 (21.9) | 44 (27.5) | - |
| No | 125 (78.1) | 116 (72.5) | - |
| Planning for suicide | 0.002** | ||
| Yes | 79 (49.4) | 107 (66.9) | - |
| No | 81 (50.6) | 53 (33.1) | - |
| Suicide history | 0.174 | ||
| None | 101 (63.1) | 87 (54.4) | - |
| Once | 45 (28.1) | 50 (31.3) | - |
| Several times | 14 (8.8) | 23 (14.4) | - |
| Sleep disorder due to worry | 0.032* | ||
| Rarely | 61 (38.1) | 43 (26.9) | - |
| Often | 99 (61.9) | 117 (73.1) | - |
| Feeling loneliness | 0.023* | ||
| Rarely | 75 (46.9) | 55 (34.4) | - |
| Often | 85 (53.1) | 105 (65.6) | - |
| Domestic violence | 0.004** | ||
| Yes | 39 (24.4) | 63 (39.4) | |
| No | 121 (75.6) | 97 (60.6) | |
| Physical fight | 0.508 | ||
| Yes | 23 (14.4) | 19 (11.9) | |
| No | 137 (85.6) | 141 (88.1) | |
| Losing job | 0.562 | ||
| Yes | 27 (16.9) | 31 (19.4) | |
| No | 133 (83.1) | 129 (80.6) | |
| Debt | 0.052 | ||
| Yes | 47 (29.4) | 32 (20) | |
| No | 113 (70.6) | 128 (80) |
a Values are presented as No. (%) or mean ± SD.
b Significant levels are * P < 0.05, ** P < 0.01, *** P < 0.001.
Some other variables were also different between the two groups, which were mostly related to the mental and psychological status of the patients (Table 1). The results revealed that, compared to the control group, a higher percentage of the patients in the case group had at least one close friend. According to the results, 66 (41.3%) and 49 (30.6%) patients in the case and control groups had at least one close friend, respectively (P = 0.048). The relationship between the parents of patients who committed suicide during the pandemic period was worse than that between those who committed suicide before the pandemic. In the case group, compared to the control group, the prevalence of patients whose parents had a bad relationship (25% vs. 10.6%) or got divorced (18.1% vs. 11.3%) was higher (P = 0.001).
The patients with suicidal ideation who had previously planned to commit suicide were more prevalent among patients in the case group than in the control group (66.9% vs. 49.4%, respectively; P = 0.002). According to the data, a high percentage of patients who committed suicide during the pandemic had sleep disorders, and their frequency was significantly higher in the case group than in the control group (73.1% vs. 61.9%, respectively; P = 0.032). The feeling of loneliness was also higher among patients in the case group who committed suicide during the pandemic than in the control group (65.6% vs. 53.1%, respectively; P = 0.023). Finally, data analysis showed that domestic violence was higher among patients who committed suicide during the pandemic (the case group) than the patients who committed suicide before the pandemic (the control group). In the case and control groups, 63 (39.4%) and 39 (24.4%) patients, respectively, reported that they were victims of domestic violence, and the observed difference was statistically significant (P = 0.004).
4.2. Comparison of the Mental, Psychological, and Socioeconomic Status of Patients in the Case Group Before and After the Start of the COVID-19 Pandemic
The patients who committed suicide during the pandemic period (the case group) were asked about their mental-psychological and SES before and after the pandemic period. The results showed that during the pandemic period, these patients had sleep disorders and suicidal ideation more often than in the pre-pandemic period (P = 0.046 and P = 0.025, respectively). In addition, the parental relationship worsened during the pandemic period (P < 0.001), and the experience of domestic violence with these patients during the COVID-19 pandemic was significantly higher than in the previous years (P = 0.008) (Table 2).
Table 2.
Comparison of Mental-psychological and Socioeconomic Status and Family Relationships of Patients Before and After the Start of the Pandemic
| Variables | Negative Ranks | Positive Ranks | Test Statistics | ||||||
|---|---|---|---|---|---|---|---|---|---|
| N | Mean Rank | Sum of Ranks | N | Mean Rank | Sum of Ranks | Ties | Z | P-Value | |
| Parental relationship | 28 | 15.16 | 424.5 | 1 | 10.5 | 10.5 | 131 | 4.7 a | < 0.001 c |
| Cigarette smoking | 1 | 4 | 4 | 6 | 4 | 24 | 153 | 1.9 b | 0.059 |
| Alcohol drinking | 0 | 0 | 0 | 3 | 2 | 6 | 157 | 1.7 b | 0.083 |
| Suicide planning | 0 | 0 | 0 | 5 | 3 | 15 | 155 | 2.2 b | 0.025 c |
| Sleep disorder | 4 | 2.5 | 10 | 0 | 0.00 | 0.00 | 156 | 2.0 a | 0.046 c |
| Feeling loneliness | 2 | 1.5 | 3.0 | 0 | 0.00 | 0.00 | 158 | 1.4 a | 0.157 |
| Domestic violence | 0 | 0 | 0 | 7 | 4 | 28 | 153 | 2.6b | 0.008 c |
| Physical fight | 3 | 2 | 6 | 0 | 0 | 0 | 157 | 1.7 a | 0.083 |
a Based on positive ranks.
b Based on negative ranks.
c Indicates a statistically significant change.
4.3. Predicting the Risk Factors for Suicide Attempts During the Pandemic Period
The multivariable logistic regression model for committing suicide during the COVID-19 pandemic is shown in Table 3. The independent predictors of committing suicide during the COVID-19 pandemic were as follows:
Good economic status (odds ratio [OR] = 1.68; 95% CI: 1.08 - 2.6; P = 0.022), having a close friend (OR = 0.28; 95% CI: 0.14 - 0.57; P < 0.001), a bad relationship between parents (OR = 1.82; 95% CI: 1.34 - 2.46; P < 0.001), suicide planning (OR = 0.15; 95% CI: 0.06 - 0.34; P < 0.001), domestic violence (OR = 0.3; 95% CI: 0.16 - 0.59; P < 0.001), and job loss (OR = 0.42; 95% CI: 0.18 - 0.99; P = 0.047).
Table 3.
Risk Factors Predicting Suicide Attempts During the Pandemic Period
| Variables | B | S.E. | Wald | Sig. | Exp (B) | 95% CI for Exp (B) | |
|---|---|---|---|---|---|---|---|
| Lower | Upper | ||||||
| Socioeconomic status | 0.518 | 0.226 | 5.255 | 0.022 | 1.679 | 1.078 | 2.615 |
| Close friend | - 1.271 | 0.364 | 12.196 | < 0.001 | 0.280 | 0.137 | 0.572 |
| Parental relationship | 0.597 | 0.156 | 14.717 | < 0.001 | 1.817 | 1.339 | 2.465 |
| Plan for committing suicide | - 1.916 | 0.433 | 19.560 | < 0.001 | 0.147 | 0.063 | 0.344 |
| Domestic violence | - 1.198 | 0.338 | 12.546 | < 0.001 | 0.302 | 0.155 | 0.586 |
| Job loss | - 0.876 | 0.440 | 3.959 | 0.047 | 0.416 | 0.176 | 0.987 |
Abbreviation: CI, confidence interval.
5. Discussion
Although numerous studies have investigated the relationship between suicide risk factors during the COVID-19 pandemic, the results are still challenging in this regard. As a result, the present study examined and compared the risk factors effective in suicide attempts during the COVID-19 pandemic and one year before to demonstrate how effective these risk factors were in suicidal attempts during the COVID-19 pandemic. The results of this study showed that during the COVID-19 pandemic, the probability of committing suicide increased in younger individuals with an underlying mental illness who had suicidal ideation and suffered from sleep disorders or a feeling of loneliness. In agreement with the aforementioned finding, it was reported that during the COVID-19 pandemic, the suicide rate among younger individuals (under 25 years) increased, and among middle-aged individuals (25 to 64 years) decreased (23).
Numerous studies have shown that individuals with underlying mental disorders were more likely to commit suicide in the COVID-19 pandemic (9, 24). In addition, a study reported that there is a bidirectional association between mental disorders and COVID-19 contraction; accordingly, individuals with mental disorders were more likely to contract COVID-19 and vice versa (5). Studies showed that during the COVID-19 pandemic or other previous global public health crises, feeling lonely and sleep disturbance were common (25, 26). It was also suggested that feeling lonely might be a risk factor for insomnia (27). It was also reported that there is a close association between sleep disturbances and a heightened sense of loneliness with suicidal ideation and attempts (28-31).
It is interesting to note that, according to the results, having a close friend increases the probability of committing suicide during the pandemic. Previous studies revealed that worrying about close friends or family members being infected with COVID-19 is associated with an increased likelihood of suicidal ideation during the COVID-19 pandemic (32). Moreover, sudden and unexpected loss of connection with close friends following social distancing measures had destructive effects on mental health in individuals with a sociable lifestyle (33, 34). Poor family bonds, poor relationships between parents, and frequent family conflict lead to post-traumatic stress disorder, depression, and other mental illnesses that increase the risk of suicidal ideation or attempts (35).
Given that family functioning was affected by the COVID-19 pandemic (36), it is important to consider the quality of relationships between parents as a risk factor for perpetrating suicide during the COVID-19 pandemic. Domestic violence was also reported to be among the identified risk factors for suicidal attempts during the COVID-19 pandemic (37). The results of this study, which indicate that poor parental relationships and domestic violence were associated with an increased likelihood of suicide attempts during the COVID-19 pandemic, are in line with these reports. According to the results of logistic regression, in addition to the discussed variables, job loss and high SES were two other variables that could predict the risk of suicide attempts during the COVID-19 pandemic. Previous studies also reported that belonging to a higher socioeconomic class and job loss were associated with a higher likelihood of suicide during the COVID-19 pandemic (38, 39).
The multivariable logistic regression analysis revealed that high SES, having a close friend, relationships between parents, having suicidal ideation and planning for it, experiencing domestic violence, and job loss are independent. Some other studies have also investigated the predictors of suicide attempts during the COVID-19 pandemic. For instance, Liu et al. reported that job or income loss, feelings of loneliness, and experiencing stressful or traumatic events were associated with a higher likelihood of suicidal thoughts during the COVID-19 pandemic (40). In another study conducted in Norway, authors reported that lower age, daily alcohol use, considering oneself to be in the risk group, and having economic concerns were associated with increased suicidal ideation during the COVID-19 pandemic (41).
Moreover, a statistically significant relationship between anxiety and depressive symptoms with age, educational level, occupation, financial difficulties, COVID-19 infection, health status, suicidal thoughts, and abuse or domestic violence was observed through logistic regression analysis. With the exception of age, educational attainment, and occupational status, the results of the regression analysis showed a statistically significant correlation between insomnia and all other study factors (42). In one study, it was reported that the monthly suicide rate decreased by 14% during the first five months of the COVID-19 pandemic; however, several months later, during the second wave, it increased by 16%. Although the COVID-19 pandemic’s negative effects might last for a while, its moderators (e.g., government subsidies) might not. Effective suicide prevention should, therefore, be a key public health concern, especially for vulnerable groups (43).
For the first time, the current study evaluated the pre- and post-pandemic psychological and SES of patients who committed suicide during the COVID-19 pandemic. In addition, the findings were compared to those of patients who committed suicide before the inception of the COVID-19 pandemic. However, there are some limitations in this study, including the small sample size, failure to evaluate patients who died due to suicide during the COVID-19 pandemic, possible dishonesty of the patients in the interview, and incomplete electronic medical records. In addition, the differences in the number of patients in the two groups in terms of some factors of demographic characteristics, mental-psychological status, and SES can create bias in the study results.
5.1. Conclusions
According to the present study’s findings, COVID-19 or the death of relatives due to COVID-19 did not play a role in the suicide attempts of the patients; however, the mental and socioeconomic conditions resulting from the COVID-19 pandemic led to an increase in the suicide attempt rate, especially among those who had suicidal ideation. As a result, in times of crises, such as the COVID-19 pandemic, it is critical to identify the vulnerable population in society and provide them with more effective psychological and economic support. However, it seems that there is a mutual relationship between different variables predicting suicide attempts during the COVID-19 pandemic. Further investigations are needed to unravel this complex connection in order to precisely detect the root predictors of suicide attempts during crises similar to the COVID-19 pandemic.
