Suicide attempt risks among hotline callers with and without the coronavirus disease 2019 related psychological distress: a case-control study

The coronavirus disease 2019 (COVID-19) outbreak began in December 2019 and has struck worldwide. Numerous studies reported that mental health symptoms were commonly reported among people during the COVID-19 pandemic [1‐6]. Moreover, during the COVID-19 pandemic, suicide risk has been theorized to increase in the context of increased social isolation, economic stress, and barriers to treatment of mental illness, among other factors [7, 8]. Although we await definitive evidence of increased suicide rates during the pandemic [7, 9, 10], available data suggest that more patients presented to hospitals due to self-harm after the COVID-19 outbreak [11]. Previous online surveys of community samples reported that, during the pandemic, 5% of respondents reported a recent episode of self-harm [12], 7.6% of respondents were classified as high suicidal risk [13], and 8.8 to 25% reported a suicidal thought in the last week [14, 15]. Although these surveys did not include control groups, the high prevalence rates suggest elevated suicidal thoughts and acts (including suicide attempt and suicide death) during the COVID-19 pandemic. Moreover, the risk of self-harm or suicidal ideation has been shown to be associated with concerns about the pandemic and associated psychological distress [16, 17]. Although psychological distress and other suicide related risk factors appear to be increased during the COVID-19 pandemic, it remains unclear whether COVID-19 related distress is associated with increased risk for suicidal acts per se.

Due to the variety of measures employed to combat the COVID-19 pandemic such as lock-down, containment, community and school closure, internet and hotline resources have been widely used to collect data for mental health surveys and to deliver psychological interventions [18‐20]. Google searches for distress helpline were remarkably elevated [21]. In China, the Guideline for Psychological Support Hotline was issued by the National Health Commission to standardize procedures and improve service quality of the hotline-based psychological intervention during the COVID-19 pandemic [22].

The Beijing Psychological Support Hotline provided psychological services to more than 169,000 callers in the first half-year of 2020. For each call made during the COVID-19 outbreak in China, the hotline operators were trained to classify it as a COVID-19 related call or non-COVID-19 related call (the criteria are described in detail in the Methods section). As a regular workflow, detailed information on suicide attempts and several common suicide risk factors were also assessed by the operator. In the present study, we compared the two groups of callers (COVID-19 and non-COVID-19) on demographic variables and common risk factors. We also examined risk for a recent suicide attempt (within 2 weeks of the index call) associated with COVID-19 related distress and common risk factors. Finally, we examined the potential moderating influence of COVID-19 related distress on the strength of association of these variables with risk for a recent suicide attempt. The results can inform the broader understanding of the role of COVID-19 related distress in suicide attempt as guide more specific telephone-delivered psychological intervention techniques and training.

The detailed process of enrolling and screening hotline callers is shown in Fig. 1. Among 13,263 calls from January 25th to June 15th, 2020, 5070 calls were excluded. Among remained 8193 enrolled calls, 1299 were classified as COVID-19 calls and the other 6894 of them were non-COVID-19 calls. After 47 and 809 repeated calls of the two groups were excluded respectively, 7337 callers were included in the final data analysis. Seventy-three (5.8%) of the 1252 COVID-19 callers and 498 (8.2%) of the 6085 non-COVID-19 callers reported a suicide attempt within 2 weeks of the call (i.e., recent attempt).

The non-COVID-19 callers were statistically significantly younger than the COVID-19 callers ([22.1 ± 8.1] years vs [26.8 ± 11.4] years, t = 13.59, P < 0.001). As shown in the Table 1, the non-COVID-19 callers were more likely to attempt suicide in the last 2 weeks (8.2% vs 5.8%, P = 0.005) and to have a prior history of suicide attempt(s) (25.5% vs 21.0%, P < 0.001) than the COVID-19 callers. Furthermore, the non-COVID-19 callers were more likely to have severe depressive symptoms and psychological distress than the COVID-19 callers. Compared with non-COVID-19 callers, COVID-19 callers were more likely to be married, employed, and had higher education levels, were less likely to fear being attacked or having a history of being abused, and were more likely to score high on hopefulness.

The Table 2 listed the risk of recent suicide attempt conveyed by different psychological and social factors among Chinese hotline callers with and without COVID-19 related distress. After adjusted for demographic variables, moderate or severe depressive symptoms, severe psychological distress, acute life events, substance misuse, and the caller’s suicide-attempt history increased the risk of recent suicide attempt, and high hopefulness reduced the risk of a recent suicide attempt to both groups of hotline callers. When interaction terms were added into the logistic regression model, the interaction of acute life events by COVID-19 reached statistical significance (P = 0.021), and the interaction of history of suicide attempt by COVID-19 was only a trend of statistical significance (P = 0.063). It implied that acute life events conferred a lower risk of recent suicide attempt to the COVID-19 callers than that to the non-COVID-19 callers, and the history of suicide attempts tended to confer a higher risk of a recent suicide attempt to the COVID-19 callers than that to the non-COVID-19 callers (see Fig. 2).

High rates of psychological distress during the COVID-19 pandemic is well-documented [1‐6]. Adding to this corpus, the present study provides novel data on whether or not COVID-19 related distress is associated with risk for a recent suicide attempt in Chinese hotline callers, as well as how such distress may moderate (i.e., increase or decrease) suicide attempt risk associated with other with other predictors. Our results show that 17% (1252/7337) of non-repeat calls for psychological distress to the largest crisis hotline in China concerned COVID-19 related distress (COVID-19 callers), further evidence that online or hotline psychological services provide a critical outlet for individuals affected by the pandemic to receive support and intervention [18‐21]. Indeed, more than one in 20 callers (5.8%) with COVID-19 related distress had attempted suicide within the past 2 weeks, underscoring that callers to the crisis line with COVID-19 related distress are a high-risk population. However, contrary to our hypothesis, these callers showed somewhat lower likelihood of suicide attempt within the past 2 weeks than non-COVID-19 callers (8.2%). Moreover, COVID-19 callers showed fewer common risk factors for suicidal acts including lower levels (or lower likelihood) of lifetime suicide attempt(s), depressive symptoms, psychological distress, and abuse history. COVID-19 callers were also more likely to score high on hopefulness and to a have range of demographic characteristics that are protective from attempted suicide including being married, employed, and higher education. The findings indicated that calls prompted by COVID-19 related distress were made by callers at lower risk for suicide attempt than calls that were not prompted by such distress.

Our results showed that individuals making calls to crisis line with COVID-19 related distress had somewhat more protective factors from suicidal acts, lower risk factors for suicidal acts, and were at lower risk for a recent suicide attempt than other callers. A potential explanation is that COVID-19 related distress is protective from suicide attempt, with potential mechanisms including that it may promote a sense of connectedness to others under a common threat including harmony within families [7, 27]. However, on balance this idea seems implausible in light of theorized risks with the COVID-19 pandemic related to social isolation, economic hardship, and other factors [8], along with data in general samples showing elevated rates of psychological distress and suicidal thoughts or behavior during the pandemic [1‐6, 11‐15, 28]. In our view, a more satisfactory explanation is that COVID-19 related distress prompted calls to the crisis line by individuals who are at generally lower risk for suicide attempt than typical hotline callers, a high-risk population who are likely to contact the crisis line in the context of other acute stressors (e.g., interpersonal distress) [29, 30]. In support of this idea, a test of moderation (i.e., statistical two-way interaction) showed that, after demographic variables were adjusted, the strength of association between a recent suicide attempt and experiencing acute life event(s) was weaker in COVID-19 callers than that in non-COVID-19 callers (P = 0.021). The decrease of the association strength might be attributed to the features of acute life events the COVID-19 callers encountered, e.g., transient work or financial problems due to quarantine or lock down which was removed soon.

One other test of moderation also bears discussion, with callers with a history of suicide attempt showing a trend to be more likely to make a recent suicide attempt in the context of COVID-19 related distress (P = 0.063). The current investigation did not attempt to parse out types of COVID-19 related distress, but prior studies suggest that social isolation and limited resources associated with containment efforts may be particularly stress inducing [31, 32], whereas physical distancing in and of itself may not be suicidogenic [16]. Demographic variables, socioeconomic status, and social resources could also moderate the risk for suicidal behavior during the COVID-19 pandemic [12, 14, 17]. Altogether, the results underscore the complex nature of the relationship between COVID-19 related distress and suicidal acts, including the critical importance of considering moderating effects and the population under study. Along these lines, our result of lower risk for suicide attempt among individuals with COVID-19 related distress was identified in a high-risk sample of callers to a suicide hotline and would not expect to be found in a general sample.

There are several limitations in the present study. First, all callers were exposed to the COVID-19 pandemic at some level, and our measure of COVID-19 related psychological distress does not imply the complete absence of exposure. Second, all information, including episodes of suicide attempt, was self-reported and collected via telephone. Third, the participants of our study were hotline callers who seeking help for psychological distress and, as we have discussed, due to the unique demographic characteristics of hotline callers in our study, generalization to other populations is unclear, particularly lower risk samples. Fourth, information on whether or not the callers were infected by COVID-19, were quarantined, or were in contact with confirmed cases were not collected. Fifth, we didn’t detect the changes of the associations at different stages of the pandemic. Sixth, the data missing in most variables might weaken validity of our findings. Finally, the majority of the participants of the present study were recruited in mainland China, where the COVID-19 epidemic was mitigated effectively after about 2 months (February and March), a much shorter period of outbreak than many countries.

To our knowledge, this study of callers to the largest suicide hotline in China during the COVID-19 pandemic is the first study to examine risk for recent suicide attempt associated with COVID-19 related distress in a hotline sample, and the first to explore moderators of the association between COVID-19 related distress and risk for recent suicide attempt. Results suggest that COVID-19 related distress may prompt calls to the crisis line among individuals who are generally at lower risk for suicidal act than typical callers. However, the potential moderation of COVID-19 related distress on associations of suicide attempt and acute life events and history of suicide attempt underscore the importance of outreach and intervention with these vulnerable individuals during the pandemic.