1. Introduction

Coronavirus disease 2019 (COVID-19) is a disease caused by infection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which first appeared in Wuhan, China in 2019 and is caused global pandemic [1]. This is a pandemic that is unprecedented in history, and has a huge economic impact as well as a health problem internationally [2]. Historically, these disasters and infectious disease epidemics have had various effects on suicide rates. Previously, in addition to study on the association between World War II and suicide rates, studies have also been published that the epidemic of Spanish flu and Severe Acute Respiratory Syndrome (SARS) is also associated with suicide rates [3, 4, 5, 6].

The COVID-19, which has been a pandemic since 2020, has also had a significant impact on mental health such as suicide, anxiety, and depression [7, 8]. This is not only the fear of infection, but also various emotional stresses such as economic problems, social isolation, deprivation, and loneliness [9]. The uncertainty of the COVID-19 pandemic, social distancing, and economic breakdown can exacerbate mental health problems. In particular, it can have an adverse impact on people with pre-existing mental health disorders, and may present difficulties with continuity of treatment [10]. In general, these effects have more long-term effects toward the later stages of the outbreak than the immediate effects at the beginning of the pandemic [8, 9, 11].

Suicide attempt are one of the main symptoms that require visiting emergency department (ED) and psychiatric treatment [12]. These are closely related to the suicide rate due to the high risk of subsequent suicides [13, 14]. Therefore, it is very important to evaluate the suicide attempt patients who come to the ED and take appropriate measures. The effects of COVID-19 on depression, suicide, and suicide attempts have been extensively studied, and previous studies using online surveys reported that stress associated with COVID-19 increases the risk of depressive episodes and suicidal ideations [15, 16]. However, studies examining how COVID-19 affects their motives for suicide are lacking, and there is no study using face-to-face interview records with suicide attempt patients. We thought that this study would help to establish effective suicide prevention measures in the event of a prolonged COVID-19 pandemic or an epidemic of new infectious disease. Therefore, we studied the impact of the pandemic on motives for suicide attempt using face-to-face interview records with suicide attempts patients who visited ED during the COVID-19 pandemic.

2. Materials and methods

3. Results

3.1 Study population

A total of 610 suicide attempts patients visited the ED during the study period. Among them, 108 without interview records were excluded. There were 87 who did not consult a psychiatrist, 18 who refused a psychiatric interview, and 3 who arrived dead. Finally, a total of 502 people were included in the study (Fig. 1). 90 people who mentioned a causal relationship between COVID-19 and suicide attempt in their interview records were classified as a COVID-19 related group, and 412 people who did not were classified as a non-related group.

Fig. 1.Flowchart of study. ED: Emergency department, COVID-19: Coronavirus disease 2019.

4. Discussion

We tried to investigate the effects of the COVID-19 pandemic on suicide attempts and the motives for suicide attempts by reviewing the psychiatric interview records of suicide attempt patients who visited the ED. From February 2020 to January 2021 included in this study period, it can be said that the whole world was dominated by COVID-19 pandemic. Previous studies have shown that the epidemic of these infectious diseases has a greater number of psychiatric affected patients than those infected with the disease [7]. This is thought to be due to various factors including social isolation, financial difficulties, economic uncertainty, and unemployment. These factors may affect differently depending on the patient’s mental disorder, psychiatric history, and personality. Accordingly, we compared the differences in psychiatric history between the COVID-19 related and non-related groups. As a result, more cases with no psychiatric history were observed in the COVID-19 related group than in the non-related group, and there was no difference in the history of major depressive disorder, bipolar disorder, panic disorder, anxiety disorder, schizophrenia and substance use disorder between the two groups. This suggests that COVID-19 pandemic can have a negative impact even on patients who were psychically healthy. Not only the anxiety and stress caused by the COVID-19 pandemic, but also the problems caused by social distancing may have had an impact on this result. Due to the COVID-19 pandemic, the Korea Centers for Disease Control and Prevention (KCDC) has been promoting social distancing policies since 29 February 2020. From then, several workplaces and public institutions have ceased operations, and kindergartens and schools have not been able to operate normally. This is a measure to prevent the spread of COVID-19, and it is a policy to prevent the spread of disease through outside activities and gatherings. However, problems caused by this have often been reported. Emotions such as loneliness, anxiety, depression, and anger due to social distancing also increased problems such as domestic violence and self-harm [19]. In 2003, Toronto, the largest city in Canada, suffered a severe social and economic impact due to the severe acute respiratory syndrome (SARS) epidemic. Hawryluck et al. [20] reported that more than 15,000 people epidemiologically exposed to SARS were ordered to self-isolate, and they experienced significant psychological stress. As a result, various types of psychiatric disorders were shown, especially post-traumatic stress disorder (PTSD) and depression. Although our study was not conducted on self-isolated people, we think that people may have experienced similar stress because outside activities were restricted due to social distancing policies.

In a previous study by Dsouza et al. [21], reported suicide reason was investigated using press media reported COVID-19 related suicide cases in India, and a total of 72 suicide cases were included. Interestingly, fear of COVID-19 infection was reported as the most common causative factor. There were 21 cases of suicide due to fear of COVID-19 infection, and most victims were diagnosed negative for COVID-19 at autopsy. However, in our study, only 3 cases (classified as a health problem) were affected by fear of COVID-19 infection as motives for suicide attempt. It is thought that the difference in the target population has influenced such different results. In India, where their study was conducted, most of the population in the country reside in rural areas. As they mentioned in the discussion, populations living in rural areas have less knowledge about COVID-19 than people living in urban areas, and the resulting fear can make them vulnerable to mental health. However, since the hospital where our study was conducted was located in a metropolitan city and most of the patients were residents of the city, this difference may have been seen. Following fear of COVID-19 infection, financial crisis, loneliness, and pressure to be quarantine were observed as suicide reasons, and similar variables were observed as motives for suicide attempts in our study. Their study investigated the reasons for suicide using press media reported COVID-19 related suicide cases. It differs from our study in that we conducted face-to-face interviews with patients who attempted suicide.

The COVID-19 pandemic has had a huge impact not only on health care, but also on the economy [2, 22]. This impact has also been extended to countries, companies, employers and employed workers. Due to the COVID-19 pandemic, many people have experienced economic instability, and many have lost their jobs [23]. Unemployment more than doubles the risk of suicide for both men and women [24]. This is not simply due to financial stress, but a combination of factors such as deprivation due to unemployment and increased vulnerability to stress. In addition, according to the social distancing policy, normal operation of the company becomes difficult and financial problems may arise for entrepreneurs and small business owners. As a result, many entrepreneurs and employed workers are exposed to severe stress, which can dramatically change their way of life. These stresses and changes can lead to mental health problems, such as substance use disorders and suicide attempts [25]. In our study results, unemployment and financial difficulties were more common among the motives for suicide attempts in the COVID-19 related group, which can be interpreted in the same context. The longer the COVID-19 pandemic continues, the greater the negative economic impact will be, which could cause serious health problems as well as social problems, especially psychiatric problems.

In general, psychiatric problems following an epidemic of an infectious disease such as the COVID-19 pandemic often have long-term effects rather than immediate effects [8, 9, 11]. Some previous studies reported that the suicide rate at the beginning of the epidemic onset rather decreases [26]. In addition, in the Republic of Korea, the suicide rate from January to August 2020, during the early stages of the COVID-19 pandemic, actually decreased [27]. In our study, the proportion of patients in the COVID-19 related group was higher in the late period than in the early period, which can be seen in the same context. In our study, we observed whether the motives for suicide attempts differed according to the period of disease epidemic. Considering that the accumulation of negative emotions and economic difficulties according to the COVID-19 pandemic will be aggravated toward the late period, we expected that it would show a difference according to the epidemic period. Contrary to our expectations, the motives for suicide attempt did not show a statistically significant difference according to the epidemic period. However, in the COVID-19 related group, suicide attempts due to interpersonal problems tended to increase toward the late period. Because of the pandemic prolongs, it is thought that negative emotions including loneliness, anxiety and depression may accumulate and cause more serious interpersonal problems.

In this study, we observed that the COVID-19 pandemic has various effects on motives for suicide attempts. As a result of this study, in the COVID-19 related group, there were more patients who were employers by occupation compared to the non-related group. In addition, unemployment, financial difficulties, and loneliness were more observed as motives for suicide attempts. There have been previous studies that analyzed the psychiatric effects of COVID-19 through online surveys [15, 16, 28]. The strength of this study is that it analyzed the impact of the COVID-19 pandemic on patients who came to the ED for suicide attempts using face-to-face interview records. This is more meaningful in that it was based on direct statements of patients, unlike questionnaires or online surveys targeting the public.

This study has several limitations. First, as this is a retrospective study through review of electronic medical records, there may be errors in patient information or some medical records necessary for the study. However, such errors were minimized by excluding cases where there was no psychiatric interview record. Second, there are limitations in generalizing the results of the study because regional and demographic variables may have effects because the study was conducted on a group of patients who visited a single emergency medical center. Third, the period included in this study was before COVID-19 vaccination began. Therefore, changes after vaccination could not be included. Further research on this will be needed in the future.

5. Conclusions

The COVID-19 pandemic has had various impacts on suicide attempt patients. In the COVID-19 related group, unemployment, financial difficulty, and loneliness were observed as motives for suicide attempts, and it had a great effect on patients with no psychiatric history. In addition, interpersonal problem tended to increase as the motive for suicide attempts toward the late period. If another infectious disease such as COVID-19 spreads in the future, it will be necessary to prepare for suicide attempt patients based on these studies.

Availability of data and materials

The data are contained within this article (and supplementary material).

Author contributions

TKA—designed the study, data collection, wrote original draft. SK—designed the study, analyzed the data, wrote original draft. YHS—analyzed the data, reviewed and edited. JHP—designed the study, supervised, reviewed and edited. SLS—designed the study, supervised, reviewed and edited. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Institutional Review Board of Inha University College of Medicine (IRB No.: 2021-09-037-000). Informed consent was waived owing to the retrospective nature of the study, and the study was conducted in compliance with the principles of the Declaration of Helsinki.

Acknowledgment

Thanks to all the peer reviewers for their opinions and suggestions.

Funding

This research was supported by INHA University Hospital Research Grant.

Conflict of interest

The authors declare no conflict of interest.

Supplementary material

Supplementary material associated with this article can be found, in the online version, at https://oss.signavitae.com/mre-signavitae/article/1699978116168859648/attachment/Supplementary%20material.doc.