National academic response to COVID-19-related suicide prevention
In April 2020, we extended our national suicide prevention support role to include responding to local area’s concerns specific to the pandemic. Our support included:
- providing local areas with quality-assured publications regarding COVID-19 and mental health/suicide prevention;
- discussing challenges and providing advice on suicide prevention concerns via email contact and virtual interactive webinars;
- facilitating shared learning by linking mental health providers/local areas together.
This support has now been embedded within our quality improvement and patient safety project.
We also adapted our core data collection methods in mental health services in England to collect brief “real-time” data from clinicians on people who died by suspected suicide under the recent care of mental health services during the COVID-19 pandemic. We present brief findings from deaths reported to us between 23rd March 2020 and 1st March 2022 in our Annual Report 2022.
Out pilot real-time data collection of suspected suicide deaths in England is paused. We are developing a new model of real-time data collection for patients whose deaths occurred in closest proximity to services: in-patients and those recently discharged from in-patient care. This will launch towards the end of 2022.
Suicide in England since the COVID-19 pandemic
We continue to work with several local areas in England to collate numbers of deaths from real-time surveillance (RTS) of suspected suicides. These are probable suicides as they have not been confirmed by inquest, which means they give us a more immediate picture of any change.
We present findings for suicide that occurred before and after the onset of the COVID-19 pandemic in the resources listed below. We found no rise in the number of suspected suicides in the general population in these areas in the months after March 2020. However, we need to be cautious about this finding as there could be higher figures in some local areas or in some demographic subgroups, and because it is too early to examine the long term impact of the pandemic on mental health and suicide. We are continuing to work with local areas to collate their real-time data and will publish updated findings in late 2022.
Read our paper published in The Lancet Regional Health – Europe here
Evidence and guidance around COVID-19 and suicide prevention
We have drawn together evidence and guidelines specific to COVID-19 and suicide prevention, grouped into themes reflecting areas of concern raised by clinicians and during our webinars.
Bereavement support resources have been adapted to offer advice specific to physical distancing and lockdown restrictions. Information about practical arrangements in addition to available financial and bereavement support:
- What to do when someone dies during the COVID-19 pandemic (Cabinet Office)
The National Bereavement Partnership also has a helpline and webchat for anyone seeking support, practical advice and information:
THRIVE LDN have developed a resource for people who have been bereaved during the pandemic:
Advice from bereavement charities for people who have been bereaved during the pandemic:
- Coronavirus, bereavement and grief (Cruse Bereavement Support)
- Bereaved during the pandemic? (At A Loss)
- COVID-19 bereavement (Sudden)
- Help and hope in one place (The Good Grief Trust)
A guide to support those who have been bereaved or affected by suicide:
- Finding the words (Support After Suicide Partnership)
Information is provided for managers running bereavement services:
- COVID-19: information for bereavement service managers & practitioners (National Bereavement Alliance)
How mental health services adapted in response to COVID-19
COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity, in this study of referrals and presentations to a provider of mental health and community health service in the UK:
- The early impact of COVID-19 on mental health and community physical health services and their patients’ mortality in Cambridgeshire and Peterborough, UK (Journal of Psychiatric Research)
A study evaluating the impact of the COVID-19 ‘lockdown’ policy in the UK on mortality and mental health service activity provision found sizeable disruption to mental health care during the first national lockdown:
- Changes in daily mental health service use and mortality at the commencement
and lifting of COVID-19 ‘lockdown’ policy in 10 UK sites: a regression discontinuity in time design (BMJ Open)
A WHO survey of 130 countries worldwide reports 93% had their critical mental health services disrupted or halted by the COVID-19 pandemic. Many (70%) countries adapted their services to overcome disruptions but there are significant disparities:
- The impact of COVID-19 on mental, neurological and substance use services (World Health Organisation)
A survey examining UK mental health staff’s views of the impact of the pandemic on mental health care and mental health service users suggests directions for service development:
- Impact on mental health care and on mental health service users of the COVID-19 pandemic: a mixed methods survey of UK mental health care staff (Social Psychiatry and Psychiatric Epidemiology)
Healthcare workers reported a change in mindset regarding technology that may become permanent:
A briefing provides key information on the impact of COVID-19 on mental health trusts, including how they responded to the challenges faced:
- The impact of COVID-19 on mental health trusts in the NHS (PDF) (NHS Providers)
A position paper describes how mental health care delivery was adapted to the demands of COVID-19:
- How mental health care should change as a consequence of the COVID-19 pandemic (Lancet Psychiatry)
A learning resource for healthcare staff who work with people who may be distressed or suicidal:
Guidance for people requiring mental health care
People who are experiencing a mental health crisis are recommended to seek immediate help, irrespective of whether services seem busy:
Staff training and support
Suicide prevention training is available to anyone, including NHS volunteers:
- Training (Zero Suicide Alliance)
There is limited robust evidence for suicide prevention within nursing homes, although gatekeeper training for staff and peer support could be effective:
- Suicide prevention interventions for older people in nursing homes and long-term care facilities: a systematic review (Journal of Geriatric Psychiatry and Neurology).
High risk groups
We now know there are likely to have been specific groups particularly vulnerable and a source of concern during the COVID-19 pandemic. In the NCISH 2022 Annual Report although data is from deaths occurring between 2009 and 2019, most of the themed findings relate to some of these groups: patients with economic difficulties, those who have experienced domestic violence, and those with comorbid physical illness.
Public health responses to help mitigate suicide risk associated with the pandemic have also included financial issues, domestic violence and increased alcohol consumption (see Suicide risk and prevention during the COVID-19 pandemic (The Lancet)).
Financial problems including unemployment and debt have been significant worries, particularly for men, during the pandemic (see Coronavirus policy brief: middle-aged men (Samaritans)), and also for people with pre-existing mental health conditions, alongside access to mental health support and engagement with social security services (see Coronavirus policy brief: people with pre-existing mental health conditions (Samaritans)).
The mental health of people newly reliant on benefits and financial support during the pandemic has been reported to have worsened since the beginning of COVID-19:
- Society Watch 2021 (NatCen Social Research)
The social legacies of the pandemic on different communities are a focus of NatCen’s third annual Society Watch:
- Society Watch 2022 (NatCen Social Research)
Early studies of population mental health from before the COVID-19 pandemic and into the subsequent lockdown period found an increase in mental distress in the UK, particularly in young people, women and those with preschool aged children (see Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population (The Lancet Psychiatry)). By October 2020, however, the mental health of most UK adults had returned to pre-pandemic levels (see Mental health responses to the COVID-19 pandemic: a latent class trajectory analysis using longitudinal UK data (The Lancet Psychiatry)).
What impact has the pandemic had on offender mental health?
Measures to decrease the consequences of COVID-19 to mental health in offender populations:
- Effects of the COVID-19 pandemic on the mental health of prisoners (The Lancet Psychiatry)
GPs can assist in risk reduction generally by improving treatment of depression and recognising risks associated with domestic violence:
- Homicide-suicide and the role of mental disorder: a national consecutive case series (Social Psychiatry and Psychiatric Epidemiology)
What impact has the pandemic had on people who gamble?
- The impact of COVID-19 on gambling behaviour and associated harms: a rapid review (Public Health England)
What impact has the COVID-19 pandemic had on women’s mental well-being?
The COVID-19 pandemic has negatively impacted mental well-being, particularly among women:
- The gender gap in mental well-being during the COVID-19 outbreak: Evidence from the UK (Institute for Social and Economic Research, University of Essex)
Women, young people, those from socially disadvantaged backgrounds and with pre-existing mental health problems reported worse mental health outcomes in the initial phase of the COVID-19 pandemic:
- Mental health and well-being during the COVID-19 pandemic: longitudinal analyses of adults in the UK COVID-19 Mental Health and Well-Being study (The British Journal of Psychiatry)
Being a woman and younger, having lower educational attainment, lower income, pre-existing mental health conditions or living alone or with children were all risk factors for higher levels of anxiety and depression at the start of lockdown:
- Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study (The Lancet Psychiatry)
What impact has the COVID-19 pandemic had on LGBT communities?
The LGBT Foundation have published a report on the impact of the COVID-19 pandemic on LGBT communities. The report details findings from an online survey, existing research on LGBT health inequalities and unpublished service user data:
Information about mental health support is provided for people who are lesbian, gay, bisexual, trans, intersex, non-binary, queer or questioning (LGBTIQ+):
- LGBTIQ+ mental health (Mind)
Resources from LGBT-inclusive organisations and support services for those who are experiencing mental health problems or need practical support:
Changes in modes of access for help
How individuals accessed mental health support for self-harm and suicidal ideation during the pandemic appears to have changed.
How has service access changed?
A&E frontline workers anecdotally reported a reduction in self-harm attendance to A&E. Although A&E presentations for self-harm may have decreased, self-harm in itself may not have reduced.
In the 12 weeks after lockdown restrictions were implemented, there was a marked reduction in hospital presentations for self-harm, particularly for females:
- Self-harm during the early period of the COVID-19 pandemic in England: comparative trend analysis of hospital presentations (Journal of Affective Disorders)
People who self-harm may not have sought help or may have received support from elsewhere, because of perceptions of burdensomeness, stigma, or fear of contracting COVID-19 in a hospital or GP setting:
In contrast, there were reports of an increase in mental health presentations and expression of suicidal ideation in the community through police callouts and crisis helplines, as individuals turned to remote support where social support was unavailable.
The Samaritans reported an increase in calls to their helpline, with coronavirus concerns present in 1 in 5 calls:
Pandemic-related stressors and suicide prevention
It is important to remember that many of the key priorities for suicide prevention remain during this pandemic (see Preventing suicide in England: Fifth progress report of the cross-government outcomes strategy to save lives (PDF)).
- reducing risk in men;
- preventing and responding to self-harm;
- mental health of children and young people;
- treatment of depression in primary care;
- acute mental health care;
- tackling high-frequency locations;
- reducing isolation;
- bereavement support.
In addition, economic and psychosocial pandemic-related stressors should be addressed for effective suicide prevention during and beyond the COVID-19 pandemic. There may have also been some protective factors during the lockdown.
The impact of the pandemic on risk and protective factors for suicide has been summarised including recommendations for suicide prevention:
- Suicide prevention during and after the COVID-19 pandemic: Evidence-based recommendations (The World Psychiatry Association)
There is evidence that suicide rates increased post-recession globally and across England, and more so in men and in countries and regions with greater job losses:
- Impact of 2008 global economic crisis on suicide: time trend study in 54 countries (BMJ)
- Suicides associated with the 2008-10 economic recession in England: time trend analysis (BMJ)
- Recession, recovery and suicide in mental health patients in England: time trend analysis (British Journal of Psychiatry)
Sustained welfare spending, spending on active labour market programmes and high levels of social capital were found to reduce the risk of suicide during a recession:
- Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors (International Journal of Social Psychiatry)
- Suicide risk and prevention during the COVID-19 pandemic (Lancet)
- Economic shocks, resilience and male suicides in the Great Recession: cross-national analysis of 20 EU countries (European Journal of Public Health)
Financial experiences during the pandemic have been found to be associated with changes in mental health:
Previous epidemics are associated with an increased risk of suicide-related outcomes, particularly in older women, individuals with more severe illnesses and those dependent on others:
- The impact of infectious disease-related public health emergencies on suicide, suicidal behaviour, and suicidal thoughts: a systematic review (Crisis)
The SARS epidemic was associated with a higher number of suicides in females aged over 65:
- Elderly suicide and the 2003 SARS epidemic in Hong Kong (International Journal of Geriatric Psychiatry)
Prevention and intervention strategies should focus on the mental health of vulnerable groups such as the elderly, who may experience higher levels of fear about the disease, with self-isolation potentially increasing mental distress and loneliness:
- The impact of epidemic outbreak: the case of SARS and suicide among older adults in Hong Kong (Crisis)
- Psychological impact of the response to the coronavirus/COVID-19 on older people (PDF) (BPS)
How to address mental health and psychosocial aspects of the COVID-19 pandemic in general and specifically for vulnerable groups:
- Addressing mental health and psychosocial aspects of COVID-19 outbreak (PDF) (Inter-Agency Standing Committee)
A recent rapid review of the psychological impact of quarantine found negative psychological outcomes may be long lasting, and recommendations to mitigate these outcomes are provided:
Protective factors that have arisen from lockdown
There has been limited research into protective factors from the lockdown.
Anecdotally, these could include:
- reduction in usual life pressures (school attendance, work issues, peer relationships);
- increased social connection;
- a greater awareness of supporting each other’s mental health.
Mental health in the community
Guidance is available on how to support mental wellbeing during the COVID-19 pandemic and beyond. Suicide prevention training can help with increasing confidence to ask questions about suicide and responding in a helpful way.
A Public Health England report draws on real time data and evidence to examine the mental health and wellbeing of the population in England during the pandemic:
- COVID-19: Mental health and wellbeing surveillance report (Public Health England)
Data from the UK Household Longitudinal Study has revealed that, although most people either remained resilient or reacted and recovered within the first 6 months of the pandemic, those experiencing deterioration or consistently poor mental health were more likely to be Asian, Black or Mixed ethnicity, younger, and living in deprived neighbourhoods:
- Mental health responses to the COVID-19 pandemic: a latent class trajectory analysis using longitudinal UK data (The Lancet Psychiatry)
Delivering suicide prevention training remotely
Online suicide awareness training:
- Training (Zero Suicide Alliance)
E-learning modules on suicide and self-harm for adults working with children and young people:
E-learning tool to help volunteers and health professionals spot early warning signs of suicide:
- We need to talk about suicide (Health Education England)
Training in a group webinar format:
- Connecting with People mental health training programmes (4 Mental Health)
Online resources for supporting people who may be thinking of suicide:
- Online learning options (Grassroots)
The National Suicide Prevention Alliance’s discussions have generated ideas on how to deliver virtual suicide prevention training:
Occupational concerns and support
What are the concerns about healthcare staff?
Evidence has previously highlighted the increased risk of mental ill-health, self-harm and suicide in healthcare staff. Female health professionals, particularly nurses, are reported to be at an increased risk of suicide:
- Why do some occupations have a high risk of suicide? (Office for National Statistics)
- Suicide by female nurses: a brief report (NCISH)
Anecdotal reports from healthcare professionals suggest there is stigma surrounding disclosing mental health problems, resulting in a reluctance to seek help.
Another barrier to help-seeking among health professionals is the perceived supportiveness of managers:
- Exploring experiences of and attitudes towards mental illness and disclosure amongst health care professionals: a qualitative study (Journal of Mental Health)
The COVID-19 pandemic may exacerbate trauma and anxieties in frontline staff:
- Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic (JAMA Network)
Beyond the clinical environment, healthcare staff working from home may also be experiencing increased levels of stress and anxiety.
There is emerging evidence the pandemic has negatively affected the mental health and well-being of NHS staff:
- Mental health impact of COVID-19 on NHS healthcare staff (UK Parliament)
What support is available for healthcare staff?
Providing help at a range of levels is required. Approaches should be flexible and tailored to individual needs.
Samaritans have launched support lines for health and social care workers and volunteers in England and Wales:
Guidance on protecting the psychological needs of healthcare staff:
- The psychological needs of healthcare staff as a result of the coronavirus pandemic (PDF) (British Psychological Society)
Measures healthcare managers should implement to protect the mental health of their staff:
Four key elements in an evidence-based staff NHS recovery plan:
- How might the NHS protect the mental health of health-care workers after the COVID-19 crisis? (The Lancet Psychiatry)
Guidance to inform managers and team leaders of the psychological and organisational processes to help support staff:
- Guidance for planners of the psychosocial response to stress experienced by hospital staff associated with COVID: early interventions (PDF) (COVID Trauma Response Working Group)
- COVID-19: Workforce (Royal College of Psychiatrists)
A resource for frontline staff containing advice and tips from a large panel of international experts:
- Coronavirus Staff Resilience Hub (MindEd)
A resource for people working in health and social care in Scotland:
- National Wellbeing Hub (PROMIS)
Support for Greater Manchester key health and care workers and their families who have been impacted by COVID-19:
- Greater Manchester Resilience Hub – coronavirus support (Pennine Care NHS Foundation Trust)
Is ethnicity data recorded at death registration?
Data on an individual’s ethnicity is not collected at death registration:
- Suicide rates by ethnicity (Office for National Statistics)
Consequently, our understanding of suicide prevention for ethnic minority groups is limited.
The Office of National Statistics published, for the first time, in August 2021 experimental statistics on national suicide rates for different ethnic groups. For most ethnic groups, rates are low compared to the white population. The exception, with high rates, is people of mixed ethnicity:
- Mortality from leading causes of death by ethnic group, England and Wales, 2012 to 2019 (Office for National Statistics)
Public Health England (now the Office for Health Improvement and Disparities) have reported that ethnic minority groups are more likely to be diagnosed with COVID-19, and death rates for COVID-19 are highest for people from ethnic minority groups:
There is a need for more comprehensive recording of ethnicity data to understand health inequalities. The Office for National Statistics emphasises the complexity of collecting data on ethnicity:
The NHS Race and Health Observatory, a new research centre, is a good step forward, as it will explore the impact of ethnicity on an individual’s health:
- NHS England and NHS Confederation launch expert research centre on health inequalities (NHS England)
What mental health issues are found in ethnic minority groups?
The reported frequency of self-harm and thoughts of suicide is higher among ethnic minority groups according to a study using data from the COVID-19 Social Study:
- Abuse, self-harm and suicidal ideation in the UK during the COVID-19 pandemic (British Journal of Psychiatry)
Evidence suggests an increase in the proportion of young people from ethnic minority groups presenting with thoughts of suicide and anxiety/stress compared to white young people.
Children and young people from ethnic minority groups may also be experiencing the pandemic differently.
- How is COVID-19 affecting children and young people in BAME communities? (Royal College of Paediatrics and Child Health)
Patients from ethnic minority groups accessing mental healthcare face a negative pathway compared to White patients:
- Black mental health matters: Time to eradicate long-standing ethnic inequalities in mental healthcare (Policy@Manchester Blogs)
Black men are more likely to experience a psychotic disorder compared to White men:
- Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014 (NHS Digital)
Young Black women are at greatest risk of self-harm, although less likely to receive psychiatric care:
- Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study (British Journal of Psychiatry)
Among in-patients, Black African men have the highest rates of suicide compared to White British men:
- Ethnicity and its influence on suicide rates and risk (Ethnicity & Health)
Older South Asian women are at an elevated risk for suicide:
- Suicide rates in people of South Asian origin in England and Wales: 1993-2003 (British Journal of Psychiatry)
How should services meet the needs of ethnic minority groups?
Social stigma around mental health is a perceived barrier for help-seeking among people from ethnic minority groups:
- Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England (BMJ)
Community delivered mental health awareness workshops may help to reduce stigma:
- Community conversation: addressing mental health stigma with ethnic minority communities (Social Psychiatry and Psychiatric Epidemiology)
NCISH suggests effective approaches to suicide prevention might differ between minority ethnic groups and recommend clinicians and the services in which they work should be aware of the distinct needs of minority ethnic patients with mental illness:
- Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales (The Lancet Psychiatry)
A literature and evidence review outlines what mental health support can be effective for ethnic minority groups:
- Racial disparities in mental health (PDF) (Race Equality Foundation)
Guidance on risk mitigation for staff from ethnic minority groups in mental healthcare settings:
- Impact of COVID-19 on BAME staff in mental healthcare settings: assessment and management of risk (Royal College of Psychiatrists)
Students and older people
What impact has the COVID-19 pandemic had on student’s mental health?
The proportion of students reporting a worsening in their mental health and well-being has increased as of March 2022, compared to late 2021:
- Coronavirus and higher education students: England, 25 February to 7 March 2022 (Office for National Statistics)
A survey by MIND found 73% of students reported their mental health declined during the lockdown:
What impact has the COVID-19 pandemic had on older people’s mental health?
Concerns about the potential adverse physical and mental health outcomes of lockdown measures in older people have been raised:
However, interventions to counter suicide risk factors in vulnerable groups have been suggested:
The Inter-Agency Standing Committee suggests interventions to support older adults during the pandemic:
- Briefing note on addressing mental health and psychosocial aspects of COVID-19 outbreak: Version 1.1 (PDF)
Suggestions, including cognitive-behavioural strategies, for how clinicians can help older patients maintain social connectedness during social distancing restrictions have also been addressed:
- Strategies to promote social connectedness among older adults during social distancing restrictions (The American Journal of Geriatric Psychiatry)
Older people with pre-existing mental health conditions (and their friends and families) have self-reported an increase in symptom severity:
Older people with physical disability might be at particular risk for emotional distress, poor quality of life, and low well-being during the COVID-19 pandemic:
- Mental health and social interactions of older people with physical disabilities in England during the COVID-19 pandemic: a longitudinal cohort study (The Lancet Public Health)
This article outlines how COVID ageism can negatively affect the mental health of older adults through worry and fear about the virus itself and a feeling of burdensomeness on society and healthcare services:
- COVID ageism as a public mental health concern (The Lancet Healthy Longevity)
Older adults in the US have reported higher depression and greater loneliness following the onset of the pandemic:
- The Impact of Sheltering in Place During the COVID-19 Pandemic on Older Adults’ Social and Mental Well-Being (The Journals of Gerontology: Series B)
Suicide data and statistics
How have suicide rates changed over time?
Suicide statistics are based on the National Statistics definition of suicide; including all deaths from intentional self-harm (ages 10 and over), and deaths caused by injury or poisoning where intent was undetermined (ages 15 and over):
- Suicide rate in the UK QMI (Office for National Statistics)
Since 1981 suicide rates have been on a general downward trend in England, with a record low seen in 2007, followed by a post-recession rise.
Males aged 10 to 24 years have consistently had the lowest suicide rates. However, in 2018 the suicide rate increased significantly to 8.2 deaths per 100,000 males in this group, and remained the same in 2019. In 2020, rates for all age groups were lower than 2019 – there were 7.0 deaths per 100,000 males in this age group. Before 2012, males aged 25 to 44 years had the highest suicide rates however since 2013 the highest suicide rates are seen in males aged 45 to 64 years.
Suicide rates increased by 93.8% in females aged 10 to 24 years from 1.6 deaths per 100,000 females in 2012 to 3.1 in 2019. However, in 2020 the suicide rate for females aged 10-24 fell to 2.5 deaths per 100,000 females. Since 1981 suicide rates in females aged 45 years and over have reduced significantly, although those aged 45 to 64 years still have the highest rates overall.
The Office for National Statistics urge caution in the interpretation of any decrease in the suicide rate in 2020, due to death registration delays during the COVID-19 pandemic:
- Suicides in England and Wales: 2020 registrations (Office for National Statistics)
How will the change in burden of proof affect suicide rates?
The change in the standard of proof for suicide at inquests may well lead to some increase in deaths recorded as suicide, although it is important to remember there are other factors which could contribute as well. We should also bear in mind that the increase reported in 2018 began even before the change in coroners’ practice:
An investigation by the Office for National Statistics found the change in the burden of proof did not result in any significant change in the reported suicide rate in England and Wales – the increase began before the standard of proof was lowered:
- Change in the standard of proof used by coroners and the impact on suicide death registrations data in England and Wales (ONS)
What is a Real Time Surveillance (RTS) system?
A RTS system for suicide has two major purposes: (i) to track local suicide trends and (ii) to provide timely bereavement support. A multi-agency approach is important and it can be specially important to involve the police and coroners:
- Local suicide prevention planning (Public Health England)
In addition to collecting suicide data, it is useful to collect data on self-harm, an important predictor of suicide. The “iceberg model” refers to three levels of self-harm: (i) the tip is fatal self-harm (i.e. suicide); (ii) the middle section is self-harm resulting in presentation to services; and (iii) the largest submerged part is self-harm that occurs in the community:
- Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study (The Lancet)
Data on self-harm typically captures the middle section of the iceberg and is collected in general hospitals. The Multicentre Study of Self-harm in England collates data from three centres across five hospitals. We are also working with selected sites to provide timely data on self-harm for the period of the pandemic:
- The Multicentre Study of Self-harm in England (Department of Health)
Collecting self-harm and suicide data can also reveal other risk factors, such as domestic abuse:
- Prevalence and correlates of domestic violence among people seeking treatment for self-harm: data from a regional self-harm register (Emergency Medicine Journal)
- Intimate partner abuse and suicidality: a systematic review (Clinical Psychology Review)
Data on community episodes of self-harm are also available:
- Suicide and self-harm in Britain: researching risk and resilience using UK surveys (NatCen)
- Abuse, self-harm and suicidal ideation in the UK during the COVID-19 pandemic (British Journal of Psychiatry)
- COVID-19 Social Study (UCL)
What impact has the COVID-19 pandemic had on self-harm and suicidal behaviour?
Our examination of suicide figures from established RTS systems in several parts of England found no rise in suicide after lockdown:
- Suicide in England in the COVID-19 pandemic: early observational data from real time surveillance (The Lancet Regional Health – Europe)
Figures from the Office for National Statistics on suicide rates in the early months of the pandemic (April to July 2020), the first based on the coroner system, also show no rise in suicide rates:
- Deaths from suicide that occurred in England and Wales: April to July 2020 (Office of National Statistics)
The evidence so far also does not show an increase in self-harm rates in the UK, but important caveats apply:
- Effects of the COVID-19 pandemic on self-harm (The Lancet Psychiatry)
A living systematic review, which reviews all studies of COVID-related suicide prevention, concludes there is currently not sufficient evidence of an increase in suicide or self-harm associated with the pandemic:
- The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review (F1000 Research)
This is not unique to England, several countries are showing no rise in suicides in the early months or first year (where data is available) of the pandemic:
- Suicide trends in the early months of the COVID-19 pandemic: an interrupted time series analysis of preliminary data from 21 countries (The Lancet Psychiatry)
- Trends in suicide during the COVID-19 pandemic (The BMJ)
- Suicide deaths during the COVID-19 Stay-At-Home advisory in Massachusetts, March to May 2020 (JAMA Network Open)
- Prevalence of mental disorders, suicidal ideation and suicides in the general population before and during the COVID-19 pandemic in Norway: A population-based repeated cross-sectional analysis (The Lancet Regional Health – Europe)
- The leading causes of death in the US for 2020 (JAMA)
- COVID-19 as a context in suicide: early insights from Victoria, Australia (Australian and New Zealand Journal of Public Health)
- Suicide reduction in Canada during the COVID-19 pandemic: lessons information national prevention strategies for suicide reduction (Journal of the Royal Society of Medicine)
In Japan, however, suicide fell during the first 5 months of the pandemic but then rose with a larger increase among women and children and adolescents:
- Increase in suicide following an initial decline during the COVID-19 pandemic in Japan (Nature Human Behaviour)
National data from Japan also show a rise in the suicide rate in October-November 2020 for men and July-November 2020 for women, particularly in younger men and women (under 30):
- Assessment of suicide in Japan during the COVID-19 pandemic vs previous years (JAMA Network Open)
A study using well-established monitoring systems reports a reduction in the number of self-harm presentations to hospital early in the pandemic:
- Self-harm during the early period of the COVID-19 pandemic in England: comparative trend analysis of hospital presentations (Journal of Affective Disorders)
GP presentations for mental illness and self-harm were also lower than expected for the period April to June 2020:
- Effects of the COVID-19 pandemic on primary care-recorded mental illness and self-harm episodes in the UK: a population-based cohort study (The Lancet Public Health)
In the US, there is some evidence that ED visits for mental health issues and self-harm were higher during the COVID-19 pandemic (up to October 2020) compared with 2019:
- Trends in US Emergency Department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic (JAMA Psychiatry)
Whilst self-harm does not appear to have risen during the pandemic, COVID-related factors have played a part in A&E attendances for self-harm during the first lockdown (March-May 2020) including loneliness and disruption to usual care:
- Self-harm and the COVID-19 pandemic: a study of factors contributing to self-harm during lockdown restrictions (Journal of Psychiatric Research)
Our Professor Louis Appleby summarises the current evidence on the effect of COVID-19 on suicide rates:
From the US, this Special Communication provides evidence-based strategies for clinicians and health care delivery systems, along with national and local policy and educational initiatives tailored to the COVID-19 environment:
Responsible media reporting of suicide and self-harm
The careful and accurate reporting of suicide is vital, even more so during the COVID-19 pandemic.
- Media guidelines on reporting death by suicide (Samaritans)
- The Suicide Reporting Toolkit
- Reporting on suicide during the COVID-19 pandemic (PDF) (International Association for Suicide Prevention and Suicide Awareness Voices of Education)
- Reporting on suicidal behaviour and COVID-19 – need for caution (The Lancet Psychiatry)
- Researchers must contribute to responsible reporting of suicide (The BMJ)
The media covering positive coping stories in difficult situations could have protective effects:
- Role of media reports in completed and prevented suicide: Werther v. Papageno effects (The British Journal of Psychiatry)
Talking about suicide in the right way can reduce suicidal ideation in treatment-seeking populations:
Children and young people
What are the concerns about children and young people?
A follow up report to the Mental Health of Children and Young People (MHCYP) survey 2017 found rates of mental disorder in children aged 5 to 16 have increased since 2017:
- Mental health of children and young people in England, 2020: Wave 1 follow up to the 2017 survey (NHS Digital)
The clinical and policy implications of the 2020 MHCYP survey are considered in this article:
- Child mental health in England before and during the COVID-19 lockdown (The Lancet Psychiatry)
Future uncertainty, loneliness, and loss of coping mechanisms are concerns for young people during the pandemic:
Anxiety and depression is reported to have increased slightly in adolescents in Norway between 2019 and 2020. However, this change appears to have been driven by age rather than any pandemic-related measures:
- Adolescents’ symptoms of anxiety and depression before and during the Covid-19 outbreak – A prospective population-based study of teenagers in Norway (The Lancet Regional Health – Europe)
Can suicide happen without warning?
In our NCISH study examining suicide in children and young people, 30% had no known history of suicidal ideas or self-harm. This group also had low rates of other risk factors for suicide. This may be because some young people hid their distress or signs of emerging risk were missed. It could also be due to rapid escalation in suicidal feelings in response to adverse events:
- Suicide in children and young people: can it happen without warning? (Journal of Affective Disorders)
60% of 10-19 year olds who died by suicide had been in contact with specialist children’s services, most often with mental health services.
- Children and young people who die by suicide: childhood-related antecedents, gender differences and service contact (BJPsych Open)
Is there any evidence for suicide in young people with autism spectrum disorder during the pandemic?
The National Child Mortality Database (NCMD) have developed a real-time surveillance system on likely child suicide rates during the COVID-19 pandemic in England. There is limited evidence of increased suicide risk in children with ASD or Attention Deficit Hyperactivity Disorder (ADHD) – 6 (25%) children who died by suspected suicide had a diagnosis of ASD and/or ADHD. Findings indicate a possible increase in child suicide deaths during the initial 56 days of lockdown. However, these findings should be interpreted with caution due to small numbers and suicide risk remains low:
What are the risk factors for suicide and self-harm in children and young people?
A thematic report from the National Child Mortality Database (NCMD) shows how varied the circumstances and factors that contribute to suicide in children and young people can be:
- Suicide in children and young people: National Child Mortality Database Programme thematic report (NCMD)
There is some evidence that absence from school is as a risk factor for self-harm and thoughts of suicide:
- School absenteeism as a risk factor for self-harm and suicidal ideation in children and adolescents: a systematic review and meta-analysis (European Child & Adolescent Psychiatry)
There are several antecedents to suicide in young people, particularly girls, including bullying, self-harm, bereavement, and academic pressures, which are important in a multiagency approach to prevention:
- Children and young people who die by suicide: childhood-related antecedents, gender differences and service contact (BJPsych Open)
The National Society for the Prevention of Cruelty to Children (NSPCC) have guidance regarding online safety during the COVID-19 pandemic, including how to talk to children about online safety:
- Online safety during coronavirus (NSPCC)
How can the mental wellbeing of young people be supported?
The NHS Long Term Plan (2019) sets out the aim for a further 345,000 children and young people aged up to 25 years to be able to access NHS mental health services, and mental health support teams in schools or colleges by 2023/24:
- NHS Long Term Plan (NHS)
The closure of schools and universities interrupted the education of young people. It is important for academic institutions to continue to provide teaching during the pandemic and, where required, for the government to provide funds to assist with this:
- Suicide risk and prevention during the COVID-19 pandemic (The Lancet Psychiatry)
Time to Change have a number of resources to help teachers with talking to students about mental health such as ideas for school assemblies:
- Mental health resources for teachers (Time to Change)
Many mental health services are continuing to offer support via the telephone and online, including for young people. Information for parents supporting their child(ren) during the pandemic are available from YoungMinds, including how to access routine and urgent mental health care:
Dialectical behaviour therapy was found to be effective in decreasing repeat suicide attempts in adolescents in one study but the evidence base for interventions for self-harm in young people remains patchy:
- Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide. A Randomized Clinical Trial (JAMA Psychiatry)
Beyond the pandemic
As the pandemic continues to evolve and as lockdown restrictions ease, some research has moved towards reflecting on the short and long-term consequences of the pandemic on mental health and mental health support:
- Looking back to move forward: reflections on the strengths and challenges of the COVID-19 UK mental health research response (Frontiers in Psychiatry)
Including how primary care can contribute to suicide prevention after the acute crisis has passed:
- Suicide prevention and COVID-19: the role of primary care during the pandemic and beyond (British Journal of General Practice)
The Government have published an action plan outlining the objectives for COVID-19 recovery in relation to mental health and wellbeing:
- COVID-19 mental health and wellbeing recovery action plan (HM Government)
A UK Parliament POST paper outlines the impact of COVID-19 on adults in the UK, highlights those groups most affected and their mental health outcomes, and the limitations of current knowledge. The paper also discusses policy approaches to protect mental health and how healthcare services can adapt to improve outcomes:
- Mental health impacts of the COVID-19 pandemic on adults (UK Parliament POSTNOTE)
The Royal College of Psychiatrists (RCPsych) have brought together the current professional guidance on managing post-COVID-19 syndrome and ‘long-COVID’ and the symptoms associated with it:
We have worked with experts in quality improvement at the National Collaborating Centre for Mental Health (NCCMH) to provide interactive webinars for sharing ideas and learning how to respond to local areas’ concerns over the impact of COVID-19 on suicide and self-harm prevention.
Upcoming interactive webinars
Details of upcoming webinars will be published here when available.
Suicide prevention in the COVID-era: recent findings from NCISH
Tuesday 18 January 2022, 1-2pm
This webinar discussed what is known about suicide risk during the COVID-19 pandemic, how the impact of COVID-19 on self-harm and suicide rates is being measured and reported, the future risks following the pandemic (economic adversity, isolation, long COVID, young people and mental health patients), and what recovery from the pandemic means for suicide prevention; the webinar was chaired by Professor Katherine Berry (Professor in Clinical Psychology, University of Manchester).
- Recording available on YouTube: Suicide prevention in the COVID era
Suicide prevention for children and young people
Wednesday 22 July 2020, 10-11am
This webinar discussed what is known about suicide risk in children and young people during the COVID-19 pandemic, how the impact of COVID-19 on self-harm and suicide rates is being measured and reported, and how mental health services are continuing to adapt; we were joined by Lara Ferguson (Researcher and Lived Experience campaigner).
- Recording available on YouTube: Suicide prevention for children and young people
Suicide prevention and changing mental health services
Wednesday 3 June 2020
This webinar discussed the challenges mental health services are facing during the COVID-19 pandemic, particularly how we manage the mental health of healthcare workers and suicide prevention in Black, Asian and Minority Ethnic (BAME) groups; we were joined by Ananta Dave (Medical Director, Lincolnshire Partnership NHS Trust).
- Recording available on YouTube: Suicide prevention and changing mental health services
How has COVID-19 changed suicide prevention?
Wednesday 6 May 2020
This webinar discussed the impact of COVID-19 on suicide and self-harm prevention, and emerging priorities for prevention; we were joined by Caroline Harroe (CEO of Harmless).
- Recording available on YouTube: How has COVID-19 changed suicide prevention?