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Publications from the Centre

Suicide risk and prevention during the COVID-19 pandemic

The mental health effects of the coronavirus disease 2019 (COVID-19) pandemic might be profound and there are suggestions that suicide rates will rise, although this is not inevitable. Suicide is likely to become a more pressing concern as the pandemic spreads and has longer-term effects on the general population, the economy, and vulnerable groups. Preventing suicide therefore needs urgent consideration. The response must capitalise on, but extend beyond, general mental health policies and practices.
There is some evidence that deaths by suicide increased in the USA during the 1918–19 influenza pandemic and among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) epidemic. The current context is different and evolving. A wide-ranging interdisciplinary response that recognises how the pandemic might heighten risk and applies knowledge about effective suicide prevention approaches is key. Selective, indicated, and universal interventions are required (figure).

The likely adverse effects of the pandemic on people with mental illness, and on population mental health in general, might be exacerbated by fear, self-isolation, and physical distancing.4 Suicide risk might be increased because of stigma towards individuals with COVID-19 and their families. Those with psychiatric disorders might experience worsening symptoms and others might develop new mental health problems, especially depression, anxiety, and post-traumatic stress (all associated with increased suicide risk). These mental health problems will be experienced by the general population and those with high levels of exposure to illness caused by COVID-19, such as frontline health-care workers and those who develop the illness. The consequences for mental health services are already being felt (eg, increased workloads and the need to find new ways of working). Some services are developing expertise in conducting psychiatric assessments and delivering interventions remotely (eg, by telephone or digitally); these new working practices should be implemented more widely, but with consideration that not all patients will feel comfortable with such interactions and they may present implications for privacy. Making evidence-based online resources and interventions freely available at scale could benefit population mental health.
People in suicidal crises require special attention. Some might not seek help, fearing that services are overwhelmed and that attending face-to-face appointments might put them at risk. Others may seek help from voluntary sector crisis helplines which might be stretched beyond capacity due to surges in calls and reductions in volunteers. Mental health services should develop clear remote assessment and care pathways for people who are suicidal, and staff training to support new ways of working. Helplines will require support to maintain or increase their volunteer workforce, and offer more flexible methods of working. Digital training resources would enable those who have not previously worked with people who are suicidal to take active roles in mental health services and helplines. Evidence-based online interventions and applications should be made available to support people who are suicidal.
Loss of employment and financial stressors are well-recognised risk factors for suicide. Governments should provide financial safety nets (eg, food, housing, and unemployment supports). Consideration must be given not only to individuals' current situations but also their futures. For example, many young people have had their education interrupted and are anxious about their prospects. Educational institutions must seek alternative ways to deliver curricula and governments need to be prepared to offer them financial support if necessary. Active labour market programmes will also be crucial.
The pandemic could adversely affect other known precipitants of suicide. For example, domestic violence and alcohol consumption might increase during lockdown. Public health responses must ensure that those facing interpersonal violence are supported and that safe drinking messages are communicated. Social isolation, entrapment, and loneliness contribute to suicide risk and are likely to increase during the pandemic, particularly for bereaved individuals. Providing community support for those living alone and encouraging families and friends to check in is helpful. Easily accessible help for bereaved individuals is crucial.
Access to means is a major risk factor for suicide. In the current environment, certain lethal means (eg, firearms, pesticides, and analgesics) might be more readily available, stockpiled in homes. Retailers selling such products should be especially vigilant when dealing with distressed individuals. Governments and non-governmental organisations should consider temporary sales restrictions and deliver carefully framed messages about reducing access to commonly used and highly lethal suicide means.
Irresponsible media reporting of suicide can lead to spikes in suicides. Repeated exposure to stories about the crisis can increase fear and heighten suicide risk. Media professionals should ensure that reporting follows existing and COVID-19-specific guidelines.
Comprehensive responses should be informed by enhanced surveillance of COVID-19-related risk factors contributing to suicidal behaviours. Some suicide and self-harm registers are now collecting data on COVID-19-related stressors contributing to the episode; summaries of these data will facilitate timely public health responses. Repeat representative cross-sectional and longitudinal surveys will help identify increases in population-level risk, as might anonymised real-time data on caller concerns from helplines. Monitoring demands and capacity of mental health-care providers over the coming months is also essential to ensure resources are directed to those parts of the system under greatest pressure. These efforts need to be appropriately resourced and coordinated.
The suicide-related consequences of the pandemic might vary depending on countries' public health control measures, sociocultural and demographic structures, availability of digital alternatives to face-to-face consultation, and existing supports. The effects might be worse in resource-poor settings where economic adversity is compounded by inadequate welfare supports. Other concerns in these settings include social effects of banning religious gatherings and funerals, interpersonal violence, and vulnerable migrant workers. COVID-19-related stigma and misinformation may be particularly acute in these settings; many of the solutions proposed above will be applicable globally, but additional efforts will be required in resource-poor settings.
These are unprecedented times. The pandemic will cause distress and leave many people vulnerable to mental health problems and suicidal behaviour. Mental health consequences are likely to be present for longer and peak later than the actual pandemic. However, research evidence and the experience of national strategies provide a strong basis for suicide prevention. We should be prepared to take the actions highlighted here, backed by vigilance and international collaboration.
Affiliations of the International COVID-19 Suicide Prevention Research Collaboration are listed in the appendix. The views and recommendations in this Comment are endorsed by the International Association of Suicide Prevention, the American Foundation for Suicide Prevention, and the International Academy of Suicide Research. DG, KH, and NK are members of the Department of Health and Social Care (England) National Suicide Prevention Strategy Advisory Group; LA is the chair. DG has grants from the National Institute for Health Research (NIHR) outside the submitted work, and is a member of Samaritans Policy and Research Committee and Movember's Global Advisory Committee. LA and KH hold grants from the Department of Health and Social Care during the conduct of this work. AJ reports chairing the National Advisory Group on Suicide and Self-harm Prevention to Welsh Government and is national lead on suicide prevention for Public Health Wales. NK reports grants and personal fees from the Department of Health and Social Care, NIHR, National Institute of Health and Care Excellence (NICE), and Healthcare Quality and Improvement Partnership, outside the submitted work, and works with NHS England on national quality improvement. He has chaired NICE guideline committees for self-harm and depression and is currently the topic advisor for the new NICE guidelines for self-harm. RCO'C reports grants from NIHR, Medical Research Foundation, Scottish Government, NHS Health Scotland, and Public Health Scotland, outside the submitted work. He is also co-chair of the Academic Advisory Group to the Scottish Government's National Suicide Prevention Leadership Group, and a member of NICE's guideline development group for the new NICE guidelines for suicide and self-harm. All other authors declare no competing interests.

Are we missing a lifesaving opportunity?

In India, there are around 31 farmer suicides every day, and 948 every month. In addition, 570 non-farmers commit suicide every day causing immense family and community distress. Though much public attention has been focused on farmer and farm-labour suicides, little has been said about possible solutions that aren’t predicated on structural shifts to the agricultural sector, the economy, or combating climate change. After more than a decade of research, the Center for Pesticide Suicide Prevention (CPSP) at The University of Edinburgh suggests that there may be a solution—a quick fix of-sorts—that could mitigate the number of suicide-related deaths in India: banning highly hazardous pesticides (HHPs). Recent policy shifts towards sustainable agriculture, combined with evidence that banning pesticides can reduce suicide-related deaths, presents a unique window of opportunity for us to address this problem.

Understanding the link between pesticides and suicides
Pesticide consumption is one of the three most important forms of suicide in the world, accounting for nearly a fifth of the world’s suicides. Close to 95 percent of pesticide-related suicides take place in rural communities in low and middle income countries. This can be seen as a legacy of the Green Revolution, which exponentially increased the availability and use of highly toxic pesticides in agriculture.
“There are 86 pesticides being used in India that have been banned and/or heavily regulated in other countries”
Currently, there are 86 pesticides being used in India that have been banned and/or are being heavily regulated in other countries. Thirty percent of the pesticides used in India are classified as Class I pesticides by the World Health Organisation (WHO), which means that they are extremely hazardous, and deadly when ingested even in small quantities. Within rural communities, the problem of pesticide-related suicides is not limited to farmers alone. The easy availability and unregulated access to pesticides makes the rate of suicide deaths among non-farmers far higher than among farmers and farm labour.

The reasons for this are manifold:
Easy access: Anyone can buy pesticides since their purchase is unregulated. They are often not stored safely and can be found lying about in homes, making it easy to ingest them either by mistake, or intentionally.
Impulse: According to the WHO, a large number of pesticide related acts of self-harm are impulsive (rather than premeditated). Easy access to lethal pesticides allows people to immediately act on impulsive suicidal thoughts. Without it, the person would have to go out of their way to find a means of attempting suicide, potentially giving them time to reconsider harming themselves.
Low awareness: Limited knowledge regarding proper usage and storage of pesticides also contributes to a number of accidental deaths. In 2015, 7,672 people in India died due to accidentally ingesting pesticides and insecticides. For instance, in Maharashtra, ten people died due to cooking food in the same drum where they had mixed pesticides—deaths that could have been easily prevented.

Pesticides aren’t only a ‘rural problem’
They end up on our plates and are a public health hazard
Poisoning by pesticides—both intentional and accidental—is a major public health issue. Beyond the issue of direct consumption, pesticides also enter into the food and water we consume. A Ministry of Agriculture report shows that Indian food samples have a high level of pesticide residue, exceeding the maximum permissible limit.
The presence of pesticides in food can suppress the immune system, leading to a number of diseases, especially cancer. Cancer levels across districts in Punjab are abnormally high—almost twice the national average—and this has been associated with the overuse of pesticides. Research has also found high concentrations of toxic metals across populations in Punjab.
Pesticide toxicity is a public health emergency, but much like the ongoing climate change crisis, it is conveniently being ignored, since its effects are not visible and immediate.

They have environmental consequences
Not only does the heavy usage of pesticides poison people, it degrades the capacity of land and ground water to grow food and sustain plant and animal life, threatening both biodiversity and the future of food security.
Insects also develop resistance to the pesticides, forcing farmers to either increase the quantity of pesticides they use, and/or their lethality. Pesticides remain in the environment for decades and affect our entire ecological system.
They impact our economy
Due to high levels of pesticides, Indian food imports are often rejected by other countries. Not only do Indian citizens end up consuming pesticide-laced food that other countries won’t even let in, it also reduces the income of farmers, who aren’t always aware of the toxicity of pesticides, and therefore use as much as they can. Rice exports from India have been rejected due to high pesticide residue. Similarly, in 2010, a huge consignment of grapes from Maharashtra was rejected by the European Union because of high levels of chlormequat chloride—a highly toxic chemical used to induce plant growth.
India needs stricter regulations
The current scenario may seem hopeless, but a solution exists. Since pesticide related acts of self-harm are more likely to be impulsive, an important way of preventing them is to restrict access to this lethal means of suicide.
Recognising the harmful effects of pesticides on human life and the environment, the Indian government banned 18 pesticides in 2018. Despite being a step in the right direction, this measure has been under scrutiny for being inadequate since the ban doesn’t include some of the most dangerous pesticides, only partially addressing the issue.
Evidence from Sri Lanka
This focus on tackling the cause rather than the symptoms of pesticide-related suicide is driving the work of the CPSP, which is trying to remove HHPs from agricultural chains through regulation.
Through their work in Sri Lanka, they were able to successfully demonstrate how banning HHPs can bring down suicide rates in agricultural communities. The overall suicide rate reduced by a drastic 70 percent between 1995 and 2015, due to simple government action of identifying the most toxic pesticides and replacing them with less lethal ones. Not only was this massive fall achieved in a relatively short period of time, it was at a low cost and had no effect on agricultural yields—a common argument against the regulation of chemical pesticides.

State governments are realising that there is an urgent need to more effectively regulate pesticides
Individual state governments have started recognising the magnitude of this problem and are taking measures to safeguard their citizens, providing a unique opportunity to take action and influence policy. For instance, Andhra Pradesh has promoted the idea of Zero Budget Natural Farming (ZBNF), which reduces the use of pesticides in agriculture. Kerala, Punjab, and Sikkim have started to limit their pesticide usage, revoked the licences of certain pesticides, and submitted applications to the central government to ban others. In 2019, the Maharashtra government temporarily banned five pesticides in select districts because of an unprecedented rise in poisoning by pesticide inhalation.
However, under the Insecticides Act of 1968, state governments can only temporarily ban pesticides for a period of 60 days, and the power to completely ban them rests with the central government. These disparities in power means that states can’t effectively regulate pesticides. A temporary ban neither encourages the use of safer alternatives, nor does it significantly reduce usage.
Where we need to focus
Due to the sensitive nature of suicides, the extent of the problem is often under-reported and there is a lack of reliable data, particularly data identifying toxins in the pesticides. Every toxin causes different symptoms and requires different treatments. Often, when pesticide-poisoned patients are brought in, doctors do not know which toxins to treat for, since pesticides may be mixed before they are consumed. Identifying chemicals and using this knowledge to build out treatment protocols can help doctors save time and lives.
In Maharashtra, the Medical Education and Drugs Department has partnered with CPSP to collect and generate data around pesticide related suicides in Yavatmal—a region with one of the highest incidences of pesticide poisoning and suicide deaths. The first set of data is to understand how many people attempt suicide using pesticides, how many are saved, and how many are not. The second set of data tries to identify specific toxins and correlate them to pesticide-poisoned patients. The goal here is to help the state government in its legislative decisions around HHPs, and ultimately, show the state government which pesticides need to be removed. The state can then make a case to the central government.
A new Pesticide Management Bill is set to be heard in Parliament this session. While it’s a step in the right direction, it does not yet cover many critical issues such as a complete ban of all Class I pesticides. Unregulated availability of HHPs denies people the right to safe food, clean water, safe working conditions, and a healthy environment. Pesticide management is by no means a panacea for solving India’s agrarian problems. But, by not effectively managing and regulating toxic pesticides, India is missing out on a huge opportunity to address its interrelated issues of health, agriculture, food, and the environment.

Know More
Understand the adverse impacts of pesticides through the United Nations Special Report on Right to Food.
Learn more about pesticide suicides from the Centre for Suicide Prevention’s website, which includes case studies, current projects, and best practices from other parts of the world.
Read the Pesticides Management Bill, 2017 and its review report.
Do More
As a concerned citizen, you can check for latest updates on the Pesticides Management Bill and also spread awareness among your peers about the adverse effects of highly hazardous pesticides on human life and the environment.

WHO publication : Preventing suicide: a resource for pesticide registrars and regulators

There is now a growing body of international evidence indicating that regulations to prohibit the use of highly hazardous pesticides can lead to reductions in national suicide rates.

Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidence

Global public health policy on pesticide suicides has focused on improved storage to prevent deaths over the last decade. This review looks at the evidence for the effectiveness of pesticide regulation to remove highly hazardous pesticides and argues that the evidence indicates that regulation will be much more effective than improve storage

Preventing deaths from pesticide self-poisoning - learning from Sri Lanka's success.

This commentary looks at the remarkable success of Sri Lanka in reducing suicide by regulating pesticides, saving 93,000 lives over 20 years

Effectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trial

Agricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning.