Winner is announced for the Zero Suicide Alliance (ZSA) Essay Competition 2021

Have rates of self-harm and suicide increased during the COVID-19 lockdowns and pandemic, in the UK and globally, and how might we explain these findings?

Chloe Morris

Suicide is a serious problem globally, with more than 700,000 deaths every year (WHO, 2021); and suicide is the second leading cause of death for individuals aged 15-24 years old (Drapeau & McIntosh, 2020). In 2019 it was reported that 11 in 100,000 people within the population of England and Wales died by suicide (Office for National Statistics, 2020a). Both self-harm and suicide are prominent issues in the UK (Iob et al., 2020), with self-harm often preceding suicide (Kapur et al., 2021). Self-harm, in the UK, refers to any act of self-poisoning or self-injury, regardless of motive (NICE, 2011), therefore all mention of self-harm discussed in this essay will be in line with the UK definition.

COVID-19 was officially announced as a pandemic on the 12^th of March 2020, with over 20,000 confirmed cases (WHO, 2020) and the first UK lockdown (i.e., the first wave) following this on March 16^th 2020. The challenges of the COVID-19 pandemic on health and society were immense (Hawton et al., 2021c), with the extreme threat of COVID-19 potentially causing psychological responses such as fear, stress and worry (Foutoulakis et al., 2021). Considering this, and the steps taken to reduce the spread of COVID (e.g., social distancing), the potential for increased self-harm and suicide risk was high (Appleby, 2021; Reger et al., 2020; Robillard et al., 2021). This is evidenced by Hawton and colleagues (2021b) who found that 46.9% of those who had engaged in self-harm in their study were influenced by COVID-19 and the lockdown. This essay will highlight the relevant literature regarding the UK and global rates of self-harm and suicide in the context of the COVID-19 pandemic. Literature drawing on the Interpersonal Theory (IPTS; Van Orden et al., 2010), Three-Step-Theory (3ST; Klonsky & May, 2015), and Integrated Motivational-Volitional Model (IMV; O’Connor & Kirtley, 2018) will be discussed to address these findings.

Whilst it may be thought that the rates of suicide would increase during the COVID-19 pandemic, data from the initial months of the pandemic does not reflect this, despite the complexity of the COVID-19 pandemic on suicide (Sinyor et al., 2021). Rates of suicide and self-harm decreased compared to past data according to the Office for National Statistics, (2020a; 2021), however some research has documented increased rates of self-harm (e.g., Iob et al., 2020; Teismann et al., 2020; Sáiz et al., 2020). In addition, in previous epidemics, such as the SARS outbreak in 2003, suicide rates among the elderly dramatically increased (Cheung et al., 2008; Yip et al., 2010). Taking into account the potential detrimental impact of COVID-19 on mental health outcomes (e.g., Feng et al., 2020; Fountoulakis et al., 2021; Nam et al., 2021), the same might be expected in the current pandemic. This is emphasised by the mental health of adults in the UK seemingly being affected by the first wave of COVID-19 (O’Connor et al., 2021).

Still, any claims that suicide rates have increased due to the pandemic are thought to be unsubstantiated (Moutier, 2021). Early observational data from April 2020 to October 2020 using real time surveillance methods showed no statistically significant difference in suicide rates for April-October in 2020 (637) compared to the same months in 2019 in England (633; Appleby et al., 2021), whilst research across twenty-one countries suggests a decrease in suicides since the beginning of the pandemic (Pirkis et al., 2021). For example, it was found that there was a five percent decrease in suicide rates during 2020 in Japan (Seposo et al., 2021). The multifactorial nature of suicide risk (e.g., mental health deterioration, financial loss, increased alcohol consumption) can help us understand why rates may not necessarily have risen during the pandemic. Moreover, variation in reported rates of suicide across studies may result from the many factors (e.g., ineffective data systems, stigma and systemic factors) which impact the accuracy of documenting suicide (Moutier, 2021).

While suicidal ideation and self-harm might be linked to COVID-19 (e.g., Ammerman et al., 2021; Bruffaerts et al., 2021; Caballero-Domíguez et al., 2020; Tasnim et al., 2020) it has not necessarily caused an increase in rates of self-harm or suicide. For example, there was a significant reduction in the number of self-harm presentations to hospital emergency departments, with a greater decrease among females than males (Hawton et al., 2021a; 2021b). Statistics from the Greater Manchester Care Record mirror this reduction, with 33,444 instances of self-harm by 13,148 individuals from 1^st January 2019 to 31^st May 2021; although a larger proportion of reductions in self-harm occurred among men and those living in deprived areas rather than in females (Steeg et al., 2021). Likewise, official statistics within England and Wales show a statistically significant decrease in suicide, particularly among men in the early months of COVID-19 (Office for National Statistics, 2021), a trend which continued later into the pandemic (Office for National Statistics, 2020a). Similarly, global suicide rates show a decrease across several countries (Pirkis et al., 2021). These statistics are likely to have a number of plausible explanations, however to sufficiently encompass the complexity of suicide it is necessary to first explore the factors already contributing to suicide and self-harm, alongside COVID-19 related factors. Thus, the following paragraphs will illustrate the risk factors associated with suicide and self-harm.

There is a vast amount of research that has identified common risk factors of both suicide and self-harm. Consistently, a history of a mental health disorder such as anxiety or depression poses a prominent risk for suicide and self-harm behaviour (Sáiz et al., 2020; WHO, 2021). In addition, factors such as being male, of low socioeconomic status (Sáiz et al., 2020), high stress and stressful life events (Macrynikola et al., 2018; WHO, 2021), low self-esteem (Eades et al., 2018), previous suicide attempt and self-harm (Hawton & Heeringen, 2009) and family conflict and abuse (Kapoor et al., 2018; Van Orden et al., 2010) have all been identified as increasing the risk of suicide and self-harm.

Additional factors related to COVID-19 have also been explored. COVID-19 related stress has been associated with self-harm (Robillard et al., 2021), a reduction of services for mental health treatment (Hawton et al., 2021a), isolation (Hawton et al., 2021b; Reger et al., 2020), disruption to routine, lack of contact, loneliness (Hawton et al., 2021b) and anxiety around safety (Feng et al., 2020). Moreover, although, the working environment within professional healthcare during the first wave COVID-19 pandemic in Belgium was not associated with suicidal ideation and death wish, lifetime and current mental health disorders were during this time (Bruffaerts et al., 2021). Additional factors including homelessness, unemployment, reduced income and financial debt that have been identified in previous literature as contributing to suicide (e.g., Stack, 2021) have been exacerbated by the pandemic (Elbogen et al., 2021; Ettman et al., 2020). This has resulted in an economic crisis requiring global cooperation (Susskind & Vines, 2020) which may affect individuals’ mental health further, making it a prominent issue to be addressed in interventions.

The interventions put into place to support those who have attempted suicide include social problem-solving (Walker et al., 2017). Research suggests difficulties surrounding problem solving in individuals who have attempted suicide (Brüden et al., 2015), highlighting the effectiveness social problem-solving interventions would have. What is more, resilience is a protective factor of suicide and self-harm (Xiao et al., 2020), in particular it is linked to adaptive coping strategies (Fuller & Huseth-Zosel, 2021). The implementation of effective coping strategies may increase resilience and address the emotion regulation difficulties often found in those who deliberately self-harm (Robillard et al., 2021) to promote more positive outcomes.

Suicidal ideation, suicide attempts and self-harm are typically high among specific subgroups in society, these include: gender non-conforming youths (Surace et al., 2021), ethnic minorities (Cervantes et al., 2014) and sexual minority youth (Fitzgerald & Curtis, 2017; Taliaferro & Muehlenkamp, 2016) . A typical commonality between these subgroups is that they are not accepted by others and are socially rejected, often facing discrimination (WHO, 2021). A major protective factor for suicide and self-harm is social connectedness (Van Orden et al., 2010) or in other words a sense of belonging (Levi-Belz & Feigelman, 2021). This falls in with several theoretical perspectives in regards to what causes suicide, namely IPTS (Van Orden et al., 2010), 3ST (Klonsky & May, 2015) and IMV (O’Connor & Kirtley, 2018). Therefore, as rejection – alongside defeat – is thought to play a major role in mental pain (Brüden et al., 2015), and a strong and reliable predictor of suicide being social isolation (Van Orden et al., 2010), individuals from these subgroups may not have the protective buffer social connectedness offers, leading to higher rates of suicide and self-harm.

The foundation of IPTS (Van Orden et al., 2010) is based on the assumption that people can and want to end their life. However, to get to this point, three constructs are necessary. The perceived hopelessness associated with two interpersonal concepts: thwarted belongingness (i.e., the idea that you do not belong) and perceived burdensomeness (i.e., that you are a burden to those around you) simultaneously leads to passive suicidal ideation. This, accompanied by the third construct of acquired capability (i.e., where individuals gain the capacity to end their life through the loss of fear associated with suicidal behaviour) serves a condition where an individual will move away from suicidal ideation to suicidal intent.

The IPTS highlights the importance of social support and connectedness in the prevention of suicide, including accounting for risk factors such as self-esteem, which was found to be negatively associated with suicidal ideation, thwarted belongingness and perceived burdensomeness (Eades et al., 2018). Additionally, the IPTS accounts for practical factors such as a reduced access to means in order to carry out suicide due to lockdown restrictions, thereby decreasing the capability for suicide. However, mixed findings have been found regarding the efficacy of IPTS in explaining suicide. When IPTS was applied to veterans, who typically experience higher levels of suicide, support for the IPTS was not found (Compton et al., 2021). Yet, other studies have found empirical support for this theory, particularly in the context of adolescents (e.g., Calear et al., 2021; Hunt et al., 2021). These mixed findings signify a limitation in the explanatory power of the IPTS, and so this theory may be less useful in explaining the decrease in suicide rates within the pandemic. Therefore, alternative theories will be discussed below.

Building on IPTS, Klonsky and May (2015) developed the 3ST which posits that the combination of hopelessness and pain results in suicidal ideation and action. Pain, psychological or emotional, in combination with hopelessness causes suicidal ideation – which is the first step of this theory. The 3ST underscores the protective contribution of connectedness in reducing suicidal ideation, making the lack of social connectedness the next step leading to suicide. Finally, the third step is the capability for suicide, this comes from three distinct categories: dispositional (e.g., genetic factors such as reduced pain sensitivity), acquired (e.g., habituation to experiences involving death and pain) and practical (e.g., knowledge and access to means used for suicide). All three stages together result in suicidal action.

The clinical and empirical applications of both IPTS and 3ST are notable, support has been found for pain and hopelessness being strong predictors of suicidal ideation, with connectedness protecting against this (Tsai et al., 2021). This signifies the potential explanatory validity the 3ST has in explaining the reduced rates of suicide during the pandemic. The precise nature of the 3ST in explaining suicidal action is limited by poor measurement of suicide capability due to a lack of valid measures, alongside a lack of longitudinal data to support the concept, which challenges the theory (Klonsky et al., 2021). For example, ideal measures for suicide capability involve longitudinal assessments when an individual has a strong desire to attempt to end their life and strong capability to do this, resulting in suicide attempts during this time, but not at other times such as when capability is low (Klonsky et al., 2021). This means, that the 3ST’s utility in explaining suicide rates in the context of the pandemic is reduced.

The final theory discussed is a three-phase biopsychosocial framework referred to as the IMV (O’Connor & Kirtley, 2018). In the pre-motivational phase, meaning before suicidal ideation has occurred, there are several biopsychosocial vulnerability factors and events which lead to suicidal ideation. Feelings of defeat and entrapment, emerging from these background factors, drive suicidal ideation and volitional moderators (VMs) facilitate or impede the transition from ideation to action. VMs account for factors that both increase (e.g., fearlessness about death, impulsivity, past suicidal behaviour) and reduce the likelihood of suicide (e.g., social connectedness).

The IMV has particular application in understanding the rates of suicide among individuals in the pandemic and in general . Not only does the IMV encompass the social connectedness aspect of suicide prevention, which is predominant in literature, but it also incorporates additional factors mentioned previously. It accounts for the aspects of people’s lives that may have led to suicidal ideation before the pandemic and also has the potential to include novel facets relevant to this time period, in terms of background factors and VMs. However, this theory views each suicide attempt in the same way, as distinct events, without considering the cyclical nature of suicide (O’Connor & Kirtley, 2018). The complex nature of suicide may not be fully captured by the linearity of the IMV, for example, new suicidal behaviour may not present in the same way as previous suicide attempts (O’Connor & Kirtley, 2018). Still, the IMV has great efficacy in terms of prevention and treatment activities as these can be tailored to the individual by drawing on factors and VMs which apply to them depending on the phase they are in (O’Connor & Kirtley, 2018). The IMV considers individual differences and allows for a personalised formulation for each person.

Further, the moderation effect of the VMs effectively accounts for the novelty of COVID-19, as potential background components for ideation (e.g., lack of support for mental health difficulties) and VMs (e.g., social connectedness) unique to COVID-19 contexts can be incorporated, meaning it has added value in the current climate. For example, an individual may have vulnerabilities increasing their suicidal ideation but the increased social connectedness due to COVID-19 social support may impede suicidal behaviour. This means the IMV has particular utility as it can explain why some research suggests ideation and self-harm rates may have increased (Iob et al., 2020; Teismann et al., 2020; Sáiz et al., 2020), and why suicide rates appear to have decreased (Office for National Statistics, 2020; 2021).

A major protective factor, which can act as a VM, highlighted in literature is social connectedness, which has been implicated in preventing suicidal ideation becoming suicidal action. The high amount of social connectedness stemming from collectively being ‘in it together’ in COVID-19 prevents individuals from acting on their ideation. The promotion of a sense of connectedness to others due to a common threat it poses (Moutier, 2021; Wasserman et al., 2020), is in line with the pulling-together effect seen after a period of natural disaster where suicide rates are low, in which individuals who undergo a shared experience strengthens their social connectedness (Reger et al., 2020). In the context of the COVID-19 pandemic, whilst physical socialising was reduced, a sense of community and social cohesion was high (e.g., Moutier, 2021) thereby decreasing the chance of suicide action. Many areas of life could be contributing to social connectedness in the pandemic.

Parent connectedness has been established as a robust protective factor for self-harm, particularly in groups such as sexual minorities (Taliaferro & Muehlenkamp, 2016) where rates are higher. Due to stay-at-home orders during lockdown periods, the sense of parental connectedness could have increased as families were able to spend more time with each other, therefore buffering potential adverse mental health outcomes leading to self-harm behaviour. Not only does parental connectedness have a huge impact on mental health, but so does community connectedness. Community connectedness is associated with less social anxiety, in particular, family and school connectedness potentially protecting against the risk of suicide and self-harm in young people (Foster et al., 2017). Thus, the sense of connectedness that individuals found during the COVID lockdowns can account for statistics that show significant reduction in suicide for younger populations (e.g., ages 10-24; Office of National Statistics, 2021).

Nevertheless, while this may be the case for many, stay-at-home orders may have had the opposite and adverse effect due to increased time spent with families and this needs to be taken into consideration. Rates of domestic violence have increased during the pandemic, but it is expected that there are still numerous unreported incidences (Kofman & Garfin, 2020). Further, the extended periods of time family members have spent together may have caused negative outcomes with increased tension (e.g., Liu et al., 2021; Zeiler et al., 2021). This could have lowered the protective nature of social connectedness by creating adverse environments which raise familial conflict, this has been implicated in increasing the risk of suicide and self-harm (Adrian et al., 2019; Orlins et al., 2021). This could explain any potential increase in rates of self-harm seen during the pandemic that have been identified in some but not all studies (e.g., Iob et al., 2020; Teismann et al., 2020; Sáiz et al., 2020), however it reduces the ability of social connectedness in explaining why suicide did not take place as it would not be a protective factor here.

Additionally, the statistics regarding suicide and self-harm rates may not be entirely accurate. The collection of data regarding suicides can be challenging due to the extensive investigation needed, meaning caution regarding the decrease in suicide rates is warranted as the difference may not be as large as suggested (Kapur et al., 2021). The lack of face-to-face services may have hindered individuals from being identified as attempting suicide or self-harming, alongside reduced capacity to reach out for help due to limited opportunity, for example the closing of schools preventing the chance for safeguarding of children at risk of self-harm and suicide. Also, it was stated that the delays in death registrations because of the pandemic may account for the decrease in suicides (Office for National Statistics, 2020a). Thus, the data may not actually represent a decrease, instead it may be due to the delay in reporting of incidences. Equally, data regarding mental health in the pandemic is based on cross-sectional research (e.g., Feng et al., 2020 Robillard et al., 2021; Sáiz et al., 2021), therefore the scarcity of longitudinal data means the long-term impacts are still unknown (Kapur et al., 2021). The need for high quality surveillance surrounding self-harm has been stated, largely due to the limited predictive capacity for current findings on future levels of self-harm (Hawton et al., 2021c).

Moreover, as society starts to return to normal, with lockdowns and restriction easing, it is likely that the sense of social cohesion and connectedness that was reported throughout the pandemic will also reduce. Thus, it is essential that focus remains on observing the rates of suicide and self-harm. While it is necessary to consider that the protective factor of social connectedness may not have impeded suicidal activity in everyone and that data may not be entirely accurate, statistics do imply a reduction in suicide rates compared to previous years, meaning the protective factors brought about by COVID-19 are still noteworthy. Further, there could be a future increase in suicide rates once the protective factors brought about by COVID-19, such as social connectedness, are reduced as life returns to normal. As well as potential adverse economic impact of COVID-19 (Office for National Statistics, 2020b) which may impact mental health and suicide rates.

Overall, it is clear that the general consensus points towards a potential reduction, rather than an increase, in suicide and self-harm rates in the UK and globally, although the data are still being analysed and conclusions could potentially change. Research across the globe, such as in the U.S (Reger et al., 2020) and Colombia (Caballero-Domíguez et al., 2020), mirror the idea that while suicidal ideation may have indeed increased throughout the pandemic, this did not proceed to individuals acting on these thoughts. It was proposed that this is because of the increase in social connection in line with the pulling-together effect seen in similar situations of national and global distress (e.g., Reger et al., 2020). This is supported by the IMV which stipulates VMs either facilitate or impede the transition from ideation to enaction (O’Connor & Kirtley, 2018), with social connectedness protecting against suicide attempt (Macrynikola et al., 2018). However, as we start to come out of the pandemic, it is expected that the social connectedness seen will decrease, thus reducing its protective impact on suicide and self-harm. This means it is still vital to monitor the rates of suicide and self-harm, and to develop interventions, which mitigate the impact of the pandemic, and policies aimed at prevention and clinical practice in the context of COVID-19 (Zortea et al., 2020); including addressing factors such as job loss, homelessness and pandemic-related stress (Elbogen et al., 2021).

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During the Covid-19 pandemic there has been much attention given to both the rates of suicide and self-harm, so what does the evidence tell us? It is this very question we invite you to answer in our first annual ZSA competition. The aim of this competition is to encourage quality research and writing on suicide and self-harm, to engage people in a creative way, and to share knowledge and expertise.

Question: Have the rates of self-harm and suicide increased during the covid-19 lockdowns and pandemic, in the UK and globally, and how might we explain these findings?

• Win a first prize of £500
• Prize winner’s presentation by the ZSA.
• This is an academic style of essay. Competition entries will be judged by a panel of members from the Suicide and Self-Harm Research North West (SSHaRe NoW) network and the Zero Suicide Alliance on the extent to which their essay shows good knowledge of the topic area and supporting empirical evidence, cogency of argument, originality and independence of thought, clarity of expression, and overall ability to articulate explanations for trends in the evidence.
• Essays should be no longer than 3,000 words and contain a reference list at the end of essay to support the ideas, claims, and concepts in the essay. The reference list is not included in the word count and can be formatted in any style, but must include all those references that appear within the text. In-text citations should include only the author surname and date.
• Essay published on the University of Central Lancashire, ZSA, and the SSHaRe NoW website which is hosted by the University of Manchester.
• We encourage entries from students, practitioners, experience-by-experience and members of the public with a shared interested in suicide and self-harm, from across the UK and internationally.