COVID-19, young people, and suicidal behaviour

The COVID-19 pandemic and its effects on mental health continue to preoccupy researchers, clinicians, and policy makers alike. Evidence for its effects on suicidal behaviours remains relatively sparse but data suggest no increase, or even decrease, in suicide and hospital presentations for self-harm.1Pirkis J John A Shin S et al.Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries.Lancet Psychiatry. 2021; 8: 579-588Summary Full Text Full Text PDF PubMed Scopus (352) Google Scholar, 2Steeg S John A Gunnell DJ et al.The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review.Br J Psychiatry. 2022; 221: 603-612Crossref PubMed Scopus (9) Google Scholar Young people (ie, those 18 years and younger) have been a particular concern, with some evidence that children and young people's mental health deteriorated following the pandemic. Sheri Madigan and colleagues'3Madigan S Korczak DJ Vaillancourt T et al.Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.Lancet Psychiatry. 2023; 10: 342-351Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar systematic review aimed to plug an important gap in the literature by comparing paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the pandemic. What should we make of their findings? We would argue that they are not as straightforward as they seem. The study reports “good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08–1·37)”.3Madigan S Korczak DJ Vaillancourt T et al.Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.Lancet Psychiatry. 2023; 10: 342-351Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Is it really the case that a rate ratio indicating a possible 20% increase in risk with a lower limit for the 90% (not 95%) CI of 1·08 is good evidence? It is according to the thresholds the authors used (appendix p 8), but good evidence in these statistical terms does not necessarily equate to good evidence in real-world clinical settings or good evidence to guide policy makers. The thresholds do not appear to be linked to the quality of the studies from which the estimates were derived or the clinical meaningfulness of their findings. On the basis of the authors' own criteria, the magnitude of the changes were described as slight to small in the main text of the paper. No “predefined thresholds”, either for categorising magnitude of changes or for interpreting 90% CI limits, can adequately account for the quality of the evidence on which pooled estimates are based, or the different health settings represented. Terminology in suicidal behaviour is contentious but the authors have made interpretation more challenging by examining suicide attempts and self-harm separately, finding an overall reduction for one but not the other. There is strong rationale for avoiding the dubious distinction between acts of harm with and without suicidal intent.4Kapur N Cooper J O'Connor RC Hawton K Non-suicidal self-injury v attempted suicide: new diagnosis or false dichotomy?.Br J Psychiatry. 2013; 202: 326-328Crossref PubMed Scopus (268) Google Scholar This categorisation is highly likely to have led to the inclusion of episodes labelled as self-harm in the suicide attempt group and vice versa. For example, in our study,5Steeg S Bojanic L Tilston G et al.Temporal trends in primary care-recorded self-harm during and beyond the first year of the COVID-19 pandemic: time series analysis of electronic healthcare records for 2·8 million patients in the Greater Manchester Care Record.eClinicalMedicine. 2021; 41101175Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar self-harm describes episodes with and without suicidal intent and those with fluctuating intent. The authors estimated statistical heterogeneity, observing “substantial heterogeneity in the changes in rates”.3Madigan S Korczak DJ Vaillancourt T et al.Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.Lancet Psychiatry. 2023; 10: 342-351Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar However, the health settings in which there was evidence of an increase, decrease, or no change in rates are not reported, which is surprising given the markedly different health systems and varied provision of self-harm services across settings. In addition, the study states it examined emergency department visits, yet in our study of primary care-recorded self-harm,5Steeg S Bojanic L Tilston G et al.Temporal trends in primary care-recorded self-harm during and beyond the first year of the COVID-19 pandemic: time series analysis of electronic healthcare records for 2·8 million patients in the Greater Manchester Care Record.eClinicalMedicine. 2021; 41101175Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar only a minority of patients presented at an emergency department. The narrative of the COVID-19 pandemic worsening mental health has been a powerful and generally accepted one. The story of the effect on our young people is arguably even more important to get right. Our interpretation of the research to date suggests we should be mindful about possible rises in self-harm in young people2Steeg S John A Gunnell DJ et al.The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review.Br J Psychiatry. 2022; 221: 603-612Crossref PubMed Scopus (9) Google Scholar but we do not agree with Madigan and colleagues' assertion that the evidence is good. In the end though, suicidal behaviour in young people was a concern before the pandemic and will continue to be a concern as we move beyond the pandemic. Developing and providing evidence-based interventions remains the overwhelming priority. NK reports research grants and fees related his research and implementation work in self-harm and suicide prevention from the Department of Health and Social Care, the National Institute for Health and Care Research, the Healthcare Quality Improvement Partnership, and the National Institute for Health and Care Excellence (NICE). NK does not receive industry funding for research. NK is a member of England's National Suicide Prevention Strategy Advisory Group and is supported by Greater Manchester Mental Health NHS Foundation Trust. NK chaired the NICE guideline development group for the NICE depression in adults' guideline and was a topic expert member for the NICE suicide prevention guideline. NK chaired the guideline development group for the NICE guidelines on the longer-term management of self-harm and was a topic advisor on the 2022 NICE guideline on self-harm. JW has conducted research into COVID-19, supported by funding through the National Core Study PROTECT programme, managed by the Health and Safety Executive on behalf of the UK Government. JW has conducted research into COVID-19, supported by funding from The Office for National Statistics (PU-22-0205). SS and RTW declare no competing interests. Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countriesThis is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold. Full-Text PDF COVID-19, young people, and suicidal behaviourSheri Madigan and colleagues'1 systematic review evaluates whether the COVID-19 pandemic has affected paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation. They report that the combined rate of emergency department visits for attempted suicide and suicidal ideation increased among girls (rate ratio 1·39, 90% CI 1·04–1·88), whereas there was no significant change among boys (1·06, 0·92–1·24).1 We were interested in this difference between the sexes because the COVID-19 pandemic appears to have had a greater impact on the behaviour of girls than boys in Japan. Full-Text PDF COVID-19, young people, and suicidal behaviour – Authors' replyIn their Correspondence about our meta-analysis on changes in paediatric emergency department visits during the COVID-19 pandemic,1 Sarah Steeg and colleagues assert that our evidence for a substantial increase does not equate to good evidence in clinical settings. We disagree. Our predefined threshold for substantial was intended to be clinically meaningful: an extra one in every ten emergency department visits to a health setting for a given pathology (eg, suicide attempt) attributable to COVID-19. Full-Text PDF