key: cord-0861086-lxfcxa6h
authors: Manzar, Md. Dilshad; Albougami, Abdulrhman; Usman, Norina; Mamun, Mohammed A.
title: Suicide among adolescents and youths during the COVID‐19 pandemic lockdowns: A press media reports‐based exploratory study
date: 2021-04-03
journal: J Child Adolesc Psychiatr Nurs
DOI: 10.1111/jcap.12313
sha: 26d8190ec7e969cdf8c12ddcc1111c694005a92d
doc_id: 861086
cord_uid: lxfcxa6h

PROBLEM: Suicide incidences among adolescents and youths during the Coronavirus Disease 2019 (COVID‐19) lockdowns have been reported across the world. However, no studies have been carried out to investigate cumulative nature, patterns, and causative factors of such suicide incidences. METHODS: A purposive sampling of Google news between 15 February and 6 July was performed. After excluding duplicate reports, the final list comprised a total of 37‐suicide cases across 11 countries. FINDINGS: More male suicides were reported (21‐cases, i.e., 56.76%), and the mean age of the total victims was 16.6 ± 2.7 years (out of a total of 29 cases). About two‐thirds of the suicides were from three countries named India (11‐cases), UK (8‐cases), and the USA (6‐cases). Out of 23‐student victims, 14 were school‐going students. Hanging was the most common suicide method accounting in 51.4% of cases. The most common suicide causalities were related to mental sufferings such as depression, loneliness, psychological distress, and so forth, whereas either online schooling or overwhelming academic distress was placed as the second most suicide stressors followed by TikTok addiction‐related psychological distress, and tested with the COVID‐19. CONCLUSIONS: The finding of the temporal distribution of suicides concerning lockdowns may help in exploring and evolving public measures to prevent/decrease pandemic‐related suicides in young people.

The Coronavirus Disease 2019 , since its start and following massive global transmission spread has shaped several challenges for the healthcare workers and the general people across the world (Jahan et al., 2021; Mamun, Bodrud-Doza, et al., 2020) . The pandemic is expected to lead to a substantial degree of mental health crisis along with other aspects of the quality of life (Hossain et al., 2020; Khan et al., 2020; Pedrosa et al., 2020) . Hence, the World Health Organization (2020) has issued brief messages related to psychological and mental health considerations and has emphasized the execution of psychological first aid. The publics' mounting concern about the spread of infection from the alleged/suspected COVID-19 positive individuals has twisted a psychological panic mode in the society, although this may be advocated for suppressing the infection rate (World Health Organization, 2020). However, this has also led to a substantial increase in anxiety or fear of COVID-19, whereas extreme fear and worry aggravates psychological instabilities (Pedrosa et al., 2020) . As a consequence, suicide occurrences are being reported because of COVID-19-related fear (Dsouza et al., 2020; Mamun & Griffiths, 2020a) Globally suicide death rate is increasing day-by-day; for instance, a 30% increment is observed in the United States between 2000 and 2016 (Miron et al., 2019) . As reported by the World Health Organization (2014), nearly 800,000 people commit suicide every year throughout the entire world, which was projected to be nearly 1.5 million by the year 2020; and of the total suicides, about 80% occur in the low-and middle-income countries (LMICs) (Bilsen, 2018) . The same report also claimed, suicide as the second most leading cause of mortality after the unintentional injury-related deaths among the age groups of 15-19 years (World Health Organization, 2014) . The suicide incidence rates in the younger age group are higher than the kids' (i.e., 15.3 and 11.2 per 100,000 and 0.9 and 1.0 per 100,000 among males and females respectively for the 15-29 years and 5-14 years older, respectively; Bilsen, 2018) . In the United States, adolescents aged between 15 and 19 years, there were no significant suicide incidence changes within 2000-2007 (i.e., 8 per 100,000 people), although a 3.1% and 10.0% increment rate is observed in the years of 2014 and 2017, respectively (Miron et al., 2019 ). There are a few possible factors that signify the suicide rate among adolescents and youths compared with other age groups, particularly an increase in relationship problems, educational distress, social media use, depression, anxiety, trauma, and so forth (Bilsen, 2018; Miron et al., 2019) .

Traumatic events like the current COVID-19 pandemic, undoubtedly affect all demographics including children and adolescents. The common behavioral and emotional changes such as-(i) sleep problems and nightmares, (ii) development of unfounded fears, (iii) increase drugs, alcohol, or tobacco use, (iv) become isolated from others, (v) lose interest in funny activities, (vi) be angry or resentful easily, (vii) be disruptive or disrespectful or behave destructively, and so forth, are prevalent (Erbacher, 2020; National Institute of Mental Health, 2020) . These indicators manifest clearly that adolescents and young people are highly prone to suffer from mental health problems during the pandemic. The preventive strategies of lockdowns, social distancing, and so forth, decrease social interactions while aiming to suppress virus transmission. In addition, mental distresses that are already common due to the pandemic, may be heavily exaggerated if less family support is available (Dsouza et al., 2020; Mamun, 2020; Pedrosa et al., 2020) . Besides, remote schooling, potential sickness, economic shutdown, and so forth, play a role in their mental sufferings, which frequently mediates the suicidality risk (Erbacher, 2020) . For instance, Mamun, Chandrima, et al. (2020) recently reported that online schooling related problems leading mother and son suicide-pact in Bangladesh.

As the schools are employing virtual teaching methods, wherein, teachers are supposed to communicate with the adolescents online, so, becoming aware of any behavioral fluctuations is somewhat challenging (Erbacher, 2020) . Thus, parents may find themselves to play the additional role of a teacher or counselor especially for the adolescents who may be showing signs of depression. But they may not be well informed of such sudden changes in their adolescents' behaviors which frequently leads them to mental instabilities as well as suicide risk (Erbacher, 2020; National Institute of Mental Health, 2020) . Social workers, school counselors, psychologists, psychiatric professionals, and advanced practice psychiatric nurses offer accessibility through telehealth. However, access to such services is limited, and targeted delivery may be compromised because of paucity in the available information about adolescents' suicide-related risky behaviors. As there is a paradigm shift in suicide nature and risk factors due to the ongoing pandemic; hence, exploring specific cohorts to understand suicide nature is warranted in adolescents. In this circumstance, the present study attempted to understand the adolescents' suicide risk and pattern for the first time across the world.

As there is almost no updated information available on suicide in the national surveillance systems across the world (especially in the lower-and middle-income countries) because of governments' focus on combating the physical issues of the ongoing pandemic; hence, the present study utilizes the press media reports of suicide cases (Mamun & Griffiths, 2020b) . Research-based on detailed and aggregated analysis of press reports of suicides is a well-established method for retrospective studies in those countries where no functional national suicide databases exist (Mamun & Griffiths, 2020b) .

Moreover, in the context of the COVID-19 pandemic, the methods have been often used to perform suicide research works (e.g., Dsouza et al., 2020; Jahan et al., 2021; Panigrahi et al., 2021; Sripad et al., 2021; Syed & Griffiths, 2020) .

A purposive sampling method via Google news search was used to collect the press media reporting of suicide cases. The news was searched using keywords combinations (in English and other languages) are as follows-(i) suicide, adolescent, COVID-19;

(ii) suicide, adolescent, COVID-19, lockdown; (iii) suicide, teen, lockdown; (iv) 

The suicide news reports between 15 February and 6 July were utilized and duplicated reports were screened and excluded. The final list comprised a total of 37 suicide cases across 11 countries.

About three-thirds of the suicides (73%) were reported in the months of April-May, 2020. More male suicides were reported (21 cases, i.e., 56.76%), and mean age of the total victims was 16.6 ± 2.7 (calculated for 29 cases for which exact age was available, ages were not reported in 8 cases) (Figure 1 ). Almost two-thirds of the victims were from three countries namely India (11 cases), UK (8 cases), and the United States (6 cases). A total of 23 victims were students, of which 14 were school students. The most common method of suicide was reported to be hanging (19 out of a total of 26 reported cases, i.e., 73.07%). No exact stressors for suicide was reported in a total of 10 cases although, most of the suicide causalities were almost the same, which is related to mental instabilities such as depression, loneliness, psychological distress, etc. In addition, five victims were reported to have issues related to either online schooling or overwhelming academic distress, where two cases were reported for TikTok addiction-related psychological distress and were tested for the COVID-19 (Table 1) .

This finding that most cases of suicides in the young people happened after a month of the implementation of lockdown and its various forms across countries of the world do indicate that public health policy needs to evolve to prevent such deaths in future pandemics. Previous epidemics have also shown that people are distressed by preventive measures of lockdown and quarantines. For instance, the quarantine time was reported to be enormously troublesome to some individuals, as stated in 15% of the severe acute respiratory syndrome quarantined persons in Toronto, who did not feel the necessity of quarantine (Hawryluck et al., 2004) . The experience from previous epidemics and the COVID-19-related suicides in young people do necessitate exploration and implementation of strategies and methods to reduce lockdown-related distress, especially in vulnerable groups. If such measures are not implemented then this may lead to double-faced public health concerns during pandemics. One in which affected individuals may put their own life at risk (suicides are one expression). Second, folks escaping from these preventive measures can create a conflict because quarantine is essential to slow down the chances of virus transmission (Dsouza et al., 2020; Pedrosa et al., 2020) . Besides, quarantine time without expressive and determined resolve may cause life-threatening conditions in these cases (Hawryluck et al., 2004) .

As aforementioned, for suppressing the virus transmission rate, preventive approaches like lockdown and social distancing for the general people, and isolation and quarantine for the suspected and confirmed cases are being applied throughout the entire world (Dsouza et al., 2020) . But the implementation of lockdowns in the absence of a consensus and proper guidelines may cause unexpected problems that have been highlighted by many researchers (see Manzar et al. [2020] for details). However, these measures led to restricted movements and decreased social interactions with others, which may be extremely burdensome in some of the people. Such isolation and lack of social interaction influence people psychologically and emotionally, leading to a higher level of loneliness, anxiety, fear, stress, depression, tediousness, and so forth (Hossain et al., 2020; Islam et al., 2020; Pedrosa et al., 2020) . As a result of unstable mental health, circumstances may easily lead the individual to suicidality increases, especially among teenagers . This is because teenagers are more emotional, impulsive, and therefore, unable to cope with stressful situations. Therefore, they are more prone to take extreme steps. A recent review suggested that several suicide cofounders are common in youths, therefore, it is likely that suicide incidences can surge among the youths (Bilsen, 2018) . For instance, these factors include-(i) mental disorders, (ii) previous suicide attempts, (iii) specific personality characteristics, (iv) genetic loading and family processes in combination with triggering psychosocial stressors, (vi) exposure to inspiring models, and (vii) availability of means of committing suicide (Bilsen, 2018) . Therefore, it is not very surprising that this study identified suicide occurrences related to the lockdown-related distress, movement restriction, not being able to socialize with friends, colleagues, and lovers, which makes them psychologically vulnerable. Although the present findings cannot verify all factors rather than stressful lockdown-related mental instabilities, such information that is presented here may carry the appeal of the initial information for early detection of children and youths who may be vulnerable to suicide.

In children and adolescents, life events before suicidal behavior are usually academic stressors (including exam stress or bullying), family conflicts, disturbance, and other stressful life events (Erbacher, 2020) . In this study, we found that the second most common reason attributed to suicides in these young people was stress related to studies, exams, grades, and difficulties in attending Dsouza et al., [2020] for one of the largest press media reporting suicide study). Similarly, the present findings about major causative factors of suicide differed from the studies conducted in the general population in Bangladesh (Bhuiyan et al., 2020; Mamun & Griffiths, 2020a) , Pakistan , as well as the global context . In contrast, PUBG-gaming related three suicide cases among adolescents and youths are alleged in Pakistan (Mamun et al., 2020c) , which alludes to the present finding of TikTok related suicidality. All these shows that there are age-specific differences in perceived factor involved in the causality of suicides during the lockdowns.

One of the disturbing trends was that one-third of suicides was in school going teens. The subject of suicides in teens during a pandemic is less understood and continuously developing. This may be a multifaceted topic, and public policymakers, psychiatrists, mental health services need to work in a concerted and tandem manner to prevent such deaths. Apart from the problems of age at which children cannot fully recognize the outcome of their actions, there are frequently familial issues involved in suicides in this age group. These familial issues may often go unnoticed and underreported. Suicides in the very young are often termed accidents on death inquiries, apparently due to these issues (Zainum & Cohen, 2017 

The study can be partially limited because of extracting suicide causalities from press media, although the method has been applied by previous research on pandemic-related suicide studies (e.g., Dsouza et al., 2020; Jahan et al., 2021; Panigrahi et al., 2021; Sripad et al., 2021; Syed & Griffiths, 2020) . Besides, the suicide risk factors reported herein has limited face value of taking as factual because psychological autopsies were not performed. Despite the limitation, this is the first study to investigate suicide-related trends in adolescent and youth people during the COVID-19 pandemic. Some of the important trends from the study were (i) most of these suicides happened in the months of April-May, that is, after a month of lockdowns, (ii) suicides were reported from both developing and developed parts of the world, (iii) about one-third of suicides were in school going teens-an alarming trend, (iv) hanging was the most common mode, and (v) lockdown-related distress and stress of exams, studies, grades, etc., were two most common stressors attributed to these suicides.

The present findings may help in suicide prevention actions, increasing awareness of suicidal behavior, and familiarization of warning signs. The age-specific causative factors of suicides in adolescents and youths may be explored further to develop a strategy to screen, and identify youths with suicidal behavior during epidemics.

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Suicide among adolescents and youths during the COVID-19 pandemic lockdowns: A press media reports-based exploratory study

The authors extend their appreciation to the Deanship of Scientific Research at Majmaah University for funding this study under Project Number No (R-2021-67).

The data that support the findings of this study are available from the corresponding author upon reasonable request.

https://orcid.org/0000-0002-5571-3310Mohammed A. Mamun http://orcid.org/0000-0002-1728-8966