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Journal of Affective Disorders 292 (2021) 139–141 Contents lists available at ScienceDirect Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad Correspondence Is the COVID-19 pandemic a risk factor for suicide attempts in adolescent girls? A R T I C L E I N F O A B S T R A C T Keywords Background: The COVID-19 pandemic might increase suicide behaviors. However, results are still limited and Suicide attempt inconclusive, especially in adolescents. COVID-19 Pandemic Methods: To provide a preliminary evidence of the effects of the COVID-19 pandemic on suicide attempts (SA), Adolescent we compared data from the Catalonia Suicide Risk Code (CRSC), during the first 12 months of Spain COVID-19 Mental health pandemic (March 2020 to March 2021) with data of the previous 12 months (March 2019 to March 2020). The CRSC is a well-established population-based registry of suicide attempts (SA) which allows monitoring of the dynamic changes that COVID-19 may produce in a Spanish region. Results: SA among adolescents increased 25% during the COVID-year, whatever, SA among adults decreased 16,5% in the same period. The increase of SA in girls was especially prominent in the starting school period in the COVID-year (September 2020-March 2021), where the increase reached 195%. Limitations: This study did not evaluate other individual risk factors of SA in the context of the COVID-19 pandemic, so is unable to make concrete causal inferences. Conclusions: These finding suggest that SA increased in adolescent girls during the last period of the COVID-19 pandemic, underscoring the need to implement effective preventive measures by public health systems and stakeholders into response during this public health crisis. Detrimental effects of the COVID-19 pandemic on mental health significant decrease of 16.5% in the same period (X2=41.5524, have been identified in multiple reports (Holmes et al., 2020), and are p<0.00001). particularly associated with depression and anxiety in adolescents Pre- and post-pandemic SA changes among adolescents differed by (Nearchou et al., 2020). Secondary consequences of the social changes gender: while SA rates did not change in boys (32.1–32.3/100.000), in due to the COVID-19 pandemic may increase the risk of suicide (Reger girls they increased substantially (from 99.2 to 146.8/100.000). The et al., 2020) however, current evidence is not well established (John increase of SA in girls was especially prominent in the starting school et al., 2020). period, i.e. from September 2020 to March 2021, where the increase Due to the limitations to identify suicide rates in real time, moni­ reached 195% (74.3 to 219.3/100,000 person-years), compared to the toring suicide attempt (SA) rates is an important approach to assess the previous six months. Some increase in girls’ SA was also observed during dynamic changes that COVID-19 may produce on population mental the same period in the pre-pandemic year (March to September 2020), health (Kapur et al., 2020). but just up to 54% (77.9 to 120.5/100,000 person-years). This observed The Catalonia Suicide Risk Code (CRSC) is a secondary suicide pre­ annual increase in SA among girls (Fig. 1) was significantly higher in the vention program established by the Catalan Ministry of Health in 2014, COVID-year than in the pre-COVID-19 year (X2=21.411, p<0.000001). that provides a specialized follow-up care for individuals at a high risk of No statistically significant effect of the COVID-19 year was found for suicide in order to reduce the likelihood of suicide re-attempts. The boys (X2=0.0489, p = 0.824916). strengths of the CSRC include not only a proper acute care and follow-up An increase in suicidality may be due to the interaction of the treatment for high-risk individuals, but also the registration of suicide pandemic with pre-existing risk factors: psychological factors (i.e., attempts including a systematic collection of data related to suicidal depression, anxiety, previous suicide attempt – the strongest predictive behavior, which is the key to develop preventive actions (Perez et al., factor of future suicide attempts-, drug and alcohol use, and other co­ 2020). This well-established population-based registry of suicide at­ morbid psychiatric disorders); stressful life events (i.e., early childhood tempts (SA) allows monitoring of the dynamic changes that COVID-19 traumatic experiences, family problems and academic stressors that act may produce in this Spanish region. as precipitants); personality traits (i.e., neuroticism and impulsivity) and We compared the CRSC data during the first 12 months of Spain a family history of suicide (Carballo et al., 2020). COVID-19 pandemic (March 2020 to March 2021) with data of the The increase of SA among adolescent girls in Catalonia may be due to previous 12 months (March 2019 to March 2020). During the pandemic, an increase in stress levels during the COVID-19 pandemic, especially 690 adolescent SA were registered (12–18 years old), representing a from September 2020 to March 2021. In this period, adolescents have 25% increase in SA when compared to the previous year, when only 552 been exposed to more academic stress in contrast to previous school SA were registered. This contrasts with SA among adults which showed a closed period, added to continue with social isolation due to https://doi.org/10.1016/j.jad.2021.05.044 Received 15 April 2021; Accepted 23 May 2021 Available online 27 May 2021 0165-0327/© 2021 Elsevier B.V. All rights reserved. Correspondence Journal of Affective Disorders 292 (2021) 139–141 ADOLESCENT SUICIDE ATTEMPTS PER MONTH 100 90 80 70 60 50 40 30 20 10 0 girls covid year (March2020-March2021) boys covid year( (March2020-March2021) girls precovid year (March 2019-March2020) boys precovid year (March 2019-March2020) Fig. 1. The increase in SA in girls during the second half of the COVID-19 period is statistically significant X2=21.411, p<0.000001, compared with the pre-COVID period. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) maintenance of social distancing measures. Stress is a risk factor for References internal disorders, which has been proved to be a specific girl suicide factor, as well as emotional problems or peer relationships difficulties Holmes, E.A., O’Connor, R.C., Perry, V.H., Tracey, I., Wessely, S., Arseneault, L., Ballard, C., Christensen, H., Silver, R.C., Everall, I., Ford, T., John, A., Kabir, T., (Miranda-Mendizabal et al., 2019). Furthermore, the loss of protective King, K., Madan, I., Michie, S., Przybylski, A.K., Shafran, R., Sweeney, A., factors (i.e., social support and social activities) added to an increase of Worthman, C.M., Yardley, L., Cowan, K., Cope, C., Hotopf, M., Bullmore, E., 2020. suicide risk factors could explain gender differences in SA registered in Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry 7 (6), 547–560. Catalonia during the COVID-19 pandemic. It may be possible that these Nearchou, F., Flinn, C., Niland, R., Subramaniam, S.S., Hennessy, E., 2020. Exploring the findings related to the COVID-19 pandemic could be given in other Impact of COVID-19 on mental health outcomes in children and adolescents: a western countries. systematic review. Int. J. Environ. Res. Public Health 17 (22), 8479, 16. Reger, M.A., Stanley, I.H., Joiner, T.E., 2020. Suicide mortality and Coronavirus disease Our findings call for the public health system and stakeholders to 2019–a perfect storm? JAMA Psychiatry 77 (11), 1093–109410. implement measures to reduce the risk of suicide in an effective way, John, A., Pirkis, J., Gunnell, D., Appleby, L., Morrissey, J., 2020. Trends in suicide during including a rapid assessment of at-risk youngsters and the development the COVID-19 pandemic. BMJ 371, m4352. Kapur, N., Clement, C., Appleby, L., Hawton, K., Steeg, S., Waters, K., Webb, R., 2020. of adequate policies. The identification of adolescents at high risk for Effects of the COVID-19 pandemic on self-harm. Lancet Psychiatry 10. https://doi. suicidality and their elements of resilience will improve preventive org/10.1016/S2215-0366(20)30528-9. measures in targeted subgroups, especially in the aftermath of the Perez, V., Elices, M., Prat, B., Vieta, E., Blanch, J., Alonso, J., Pifarre, J., Mortier, P., COVID-19 pandemic. Cebria, A.I., Campillo, M.T., Vila-Abad, M., Colom, F., Dolz, M., Molina, C., Palao, D. J., 2020. The Catalonia Suicide Risk Code: a secondary prevention program for in­ dividuals at risk of suicide. J. Affect. Disord. 1 (268), 201–205. Authors’ contributions Carballo, J.J., Llorente, C., Kehrmann, L., Flamarique, I., Zuddas, A., Purper-Ouakil, D., Hoekstra, P.J., Coghill, D., Schulze, U.M.E., Dittmann, R.W., Buitelaar, J.K., Castro- Fornieles, J., Lievesley, K., Santosh, P., Arango, C., Consortium, STOP, 2020. Psy­ RG, MP and DP wrote the first draft with substantial contributions chosocial risk factors for suicidality in children and adolescents. Eur. Child Adolesc. from the other authors. All the authors critically reviewed drafts and Psychiatry 29 (6), 759–776. Miranda-Mendizabal, A., Castellví, P., Parés-Badell, O., Alayo, I., Almenara, J., Alonso, I., approved the final the final manuscript. Blasco, M.J., Cebrià, A., Gabilondo, A., Gili, M., Lagares, C., Piqueras, J.A., Rodrí­ guez-Jiménez, T., Rodríguez-Marín, J., Roca, M., Soto-Sanz, V., Vilagut, G., Alonso, J., 2019. Gender differences in suicidal behavior in Adolescents and young Declaration of Competing Interest adults: systematic review and meta-analysis of longitudinal studies. Int. J. Public Health 64 (2), 265–283. The authors declare that they have no competing interests. Rebeca Graciaa,b, Montse Pamiasa,b,c, Philippe Mortierd,e, Jordi Alonsod,e,f, Víctor Pérezb,c,d,g, Diego Palaoa,b,c,* Role of the Funding Source a Department of Mental Health, Parc Taulí-University Hospital, Unitat Mixta de Neurociència Traslacional I3PT-Autonomous University of The founders had no role in the study. Barcelona, Spain b Department of Psychiatry and Forensic Medicine, Autonomous University Acknowledgements of Barcelona, Spain c CIBERSAM, Madrid, Spain d This work was supported by Spanish Ministry of Science and Inno­ IMIM, Hospital del Mar Medical Research Institute, Barcelona, Spain e vation / ISCIII/FEDER (PI17/00521, PI17/01205 and PI19/01484), CIBERESP, Madrid, Spain f Generalitat de Catalunya (2017 SGR 452) and a Sara Borrell research Department of Health & Experimental Sciences, Pompeu Fabra University, contract awarded by the ISCIII (CD18/00049 to PM). Barcelona, Spain 140 Correspondence Journal of Affective Disorders 292 (2021) 139–141 g * Institut de Neuropsiquiatria i Addiccions, Hospital del Mar, Barcelona, Corresponding author: Diego Palao*, MD PhD, Department of Mental Spain Health. University Hospital Parc Taulí, Sabadell (Barcelona),Spain, Parc Taulí, 1 - 08208-Sabadell (Barcelonna), Spain. E-mail address: dpalao@tauli.cat (D. Palao). 141