Can real-time surveillance systems of suspected suicide accurately reflect national suicide rates? Age-specific and sex-specific findings from the first two years of the COVID-19 pandemic in England: an observational study
Introduction ‘Real-time surveillance’ (RTS) systems of suspected suicide showed no overall rise in the early COVID-19 pandemic several months before official statistics reported the same. There has to date been no national examination of suicide recorded by RTS systems by sex or age group during the COVID-19 pandemic.
Methods We used data from established RTS systems of suspected suicides in England, in 10 areas covering a total population ~13 million, to examine overall suicide numbers and rates from the pre-pandemic months of January–March 2020, to the end of 2021, by sex and by age group, through different phases of the pandemic.
Results From January 2020 to December 2021, there were 2923 suspected suicides recorded by RTS systems in the 10 areas providing data. Using the pre-pandemic period as the baseline, we found a lower rate of suicide in the remainder of 2020 compared with the pre-pandemic period (0.80–0.99). This fall reflected lower numbers of deaths in men aged 25–44 between April and December 2020. Though there was no significant fall in 2021, there were lower rates in people aged 45–64 during this time. A month-by-month breakdown showed no change during periods of lockdown or social restrictions.
Conclusions Our findings demonstrate the viability of RTS to provide timely information on suicide rates at a national level and were later confirmed by official statistics. While suicide rates have not increased, continued vigilance is needed given ongoing effects of the pandemic in the context of current economic pressures. Early data on suspected suicides collected by local systems can be instrumental in reflecting national trends, and in aiding a rapid response in times of crisis.
What is already known on this topic
Internationally, most countries (the majority of which are high and upper-middle-income) reported no rise in numbers or rates of suicide deaths from January 2020 up to the end of June 2021, both overall, and by sex and age group. There were some exceptions, particularly within areas in lower-income and middle-income countries, and in countries that had the longest follow-up time periods. Official statistics for suicide for England and Wales published by the Office for National Statistics (ONS) in April 2023, covering the period to end December 2021 show no evidence that suicide increased since the COVID-19 pandemic. ONS reports a decrease in suicide in men aged 30–39 between April and December 2020, and lower rates for both men and women at different points during 2021. We previously combined evidence from real-time surveillance (RTS) systems to report no rise in suicide during the early pandemic, later corroborated by these official statistics.
What this study adds
This paper extends available data on suspected suicide deaths from RTS systems since the beginning of the COVID-19 pandemic in England, from January 2020 until the end of December 2021. We found that suicide rates did not rise in England during the COVID-19 pandemic to the end of December 2021, extending international evidence from real-time data. We report a fall in suicide rates in 2020 compared with the pre-pandemic period; this decrease was driven by men, particularly those aged 25–44 years. These findings were later corroborated by official statistics, which are available several months after death and are affected by the time taken to inquest.
How this study might affect research, practice or policy
Our findings support RTS systems of suspected suicide deaths as a viable and timely method of monitoring suicide numbers, as the figures reflect national trends. This is particularly important given that monitoring local suicide rates is a public health responsibility in England and developing RTS is a commitment for the Office for Health Improvement and Disparities in the 2023 national suicide prevention strategy. Continued vigilance in suicide prevention is needed as we navigate the ongoing impacts of the pandemic, including the effects of disruption to education and family, psychological distress that may have begun during the pandemic, and long COVID. Alignment of findings from combined local RTS systems with national official statistics demonstrates the efficacy of these early systems of data collection. These systems can provide rates of suicide deaths a year or more earlier than official statistics and offer timely information in times of crisis.
Introduction
In recent years, many areas in England have established ‘real-time surveillance’ (RTS) systems of suspected suicide deaths, collecting data from police and coronial systems soon after a death has occurred.1 2 Evaluations of individual RTS systems have identified commonalities of aims; to provide timely data to inform local action in suicide prevention and to offer support to bereaved families.1
Official suicide statistics from the Office for National Statistics (ONS)—commonly used in suicide research and in reporting suicide rates—are based on suicide conclusions determined at coroner’s inquest and include some ‘narrative conclusions’ and deaths from ‘undetermined’ cause. The median time from death to conclusion at inquest and subsequent registration of death is 5–6 months, with some cases taking more than a year to reach inquest.3 The COVID-19 pandemic demonstrated a need for information on suicide rates at a national level, at a time of potentially harmful media speculation, and registration delays inherent in official statistics were additionally impacted by social restrictions.3 4
We previously combined data from RTS systems of suspected suicide deaths in England covering a population of around 13 million to report suicide figures between January 2020 and October 2020.5 We showed that suicide rates in England remained broadly stable during the early months of the pandemic, despite evidence of increased distress.5 6 These findings from RTS systems in England were published in April 2021 (following the publication of early figures in October 2020), and later corroborated by Official Statistics published in April 2022.7
Internationally, RTS systems have reported suicide rates remaining at expected or lower-than-expected numbers in the majority of countries (mostly high or upper-middle-income countries) where data were available during the first 15 months of the pandemic.8 9 There is an indication that the pattern of stable or decreasing suicide rates may change, as there were more exceptions—i.e., countries with greater than expected numbers of suicides—towards the end of the 15-month period than in the first 9 months of the pandemic.9 Additionally, there were increases in some groups (men or women) in some countries, suggesting that data should be disaggregated where possible to identify differential effects in different populations. Time trend analysis from Japan to the end of December 2021 has indicated an increase in suicide in some groups after June 2020; particularly for women and young age groups.10
In this study, our aim was to further examine the efficacy of utilising combined data from local RTS systems to report on national rates. We previously reported total suicide figures from January 2020 to October 2020. We now present figures from January 2020 to end December 2021, in total, by sex and by age group.
Methods
We obtained anonymised, aggregate RTS-recorded suspected suicide figures from 10 areas in England (National Health Service regional structures at the time of initial data collection, known as Sustainability and Transformation Plan footprints—STPs) to examine changes since the beginning of the pandemic and restriction measures (April 2020) to the end of December 2021. We examined suicide rates overall, by sex and by age group (age groups consisted of under 25, 25–44, 45–64 and 65 years or over) for April–December 2020 and January–December 2021 in comparison to the pre-pandemic period (January–March 2020). The areas providing data (figure 1) have a combined population of approximately 13 million, around a quarter of the population in England. All areas had established systems of RTS data collection of suspected suicide deaths, and all met the following criteria: (1) availability of RTS-recorded monthly suicide data for January 2020–December 2021, (2) figures available for the whole STP, to eliminate reporting bias from partial data and (3) figures available by sex and by age group. One of the areas did not provide data by age group, therefore, they were excluded from the age-specific results. For this reason, we also did a sensitivity analysis examining overall and sex-specific suicide rates excluding the area with missing data.
Map highlighting 10 National Health Service (NHS) Sustainability and Transformation Partnerships (STPs)* with ‘real-time surveillance’ suicide data in the study. *STPs = NHS regional structure at the time of initial data collection.
The areas were concentrated in the North and South-West of the country, where suicides have been consistently higher in recent years pre-pandemic.11 12 The majority of the participating areas had police led RTS systems with coroner involvement in some areas. We ran a comparison of figures from 2019 with equivalent figures from April-October 2020; this comparison was less valid due to uncertainty of how comprehensive early data were for RTS systems that begun in April 2019, and missing data in one area for the period April–September 2019. Further detail on the participating areas and their RTS systems of data collection has been previously published with findings from these systems to end October 2020.5 Since the publication of our initial analysis, some areas include additional data sources as contributors to their RTS systems. In these instances, we sought updates to the figures previously provided and incorporated these into the current analysis.
Statistical analysis
We examined the suicide rates (expressed as per 100 000 population) from RTS at three time periods in England using Poisson regression. For the purposes of this analysis, the periods were defined as 3 months before the pandemic (January–March 2020), the remaining months of 2020 following the beginning of restrictions (April–December 2020) and the entire year of 2021.13 We tested the regression models for overdispersion (where variation is higher than expected in a Poisson model) and fitted negative binomial regression models where overdispersion was evident. Using these models, we calculated incidence rate ratios (IRR) with 95% confidence intervals (CI), estimated using robust standard errors to account for any clustering effects across the STPs. Denominator data were population estimates of people aged 10 and over in 2020 and 2021. Population estimates in 2021 using Census data were not available by STPs, therefore, they were linearly interpolated for individual areas using previous population estimates from the ONS between 2018-2020, to account for a steady increase in mid-year population estimates between 2016 and 2020.14 The yearly estimates obtained were equally divided by 12 months and adjusted for the number of days in the month to account for the fewer days in February and the 30-day months. Data were not available by age group for one of the areas; for sensitivity analyses, we also examined the overall suicide rates using Poisson regression after excluding this area.
Monthly RTS-recorded suspected suicide data were not available consistently for all areas prior to 2020. In our previous study of suspected suicide deaths from January to October 2020, we explored the effect of recurring temporal (‘seasonal’) variation using coroner-confirmed suicide data and found no differences in temporal patterns between coroner-confirmed and RTS-recorded suicide deaths for that period.2 All analyses were performed by using STATA 16.1 software for Windows.
Results
From January 2020 to December 2021, there were 2923 people who died by suspected suicide recorded by RTS systems in the 10 areas providing data, 2132 men and 786 women (5 missing). Overall and sex-specific RTS-recorded suspected suicide rates per 100 000 population in 2020–2021 are shown in figure 2. The number of RTS-recorded suspected suicides in the pre-pandemic months (January–March 2020) was 134 per month, and this was lower in the rest of the year (April–December 2020) at 121 per month, an absolute fall of 10% (−10%; 95% CI −25% to 8%; p=0.15). The number of suicides in 2021 averaged 120 per month, an absolute fall of 10% (−10%; 95% CI −26% to 7%; p=0.11) compared with the pre-pandemic period (further detail on suicide numbers by month in online supplemental table 1).
Total and sex-specific RTS suicide rates in 10 STPs: January 2020–December 2021. RTS, real-time surveillance; STPs, Sustainability and Transformation Partnerships.
In men and boys, pre-pandemic suicide numbers were 100 per month, and they were lower in the subsequent periods at 85 per month between April-December 2020 and 89 per month in 2021. For women and girls, suicide numbers before the pandemic were 34 per month, and they were similar between April and December 2020 (35 per month) and lower in 2021 (31 per month). There was a fall in the RTS-recorded suspected suicide rates in April–December 2020 (IRR 0.89 (95% CI 0.80 to 0.99)) and in 2021 (0.89 (95% CI 0.75 to 1.06)) compared to the pre-pandemic period (table 1). The fall in 2020 was caused by a fall in suicide by men and boys (IRR 0.84 (95% CI 0.75 to 0.94)) when compared with men and boys in the pre-pandemic period. There was no difference in RTS-recorded suspected suicide rates in women and girls after April 2020 (IRR 1.02 (95% CI 0.84 to 1.23)) or in 2021 (0.90 (95% CI 0.69 to 1.17)).
Table 1
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Negative binomial regression models comparing IRRs in the months pre-pandemic (January–March 2020), the rest of the months of 2020 and the whole of 2021; total and by sex
Figure 3 shows RTS-recorded suicide rates between 2020 and 2012 by age groups. The highest rates of suicide were found in the month of July 2020 in 45–64 year-olds (21.6 (95% CI 16.6 to 27.6)) and June 2021 in 25–44 year-olds (21.0 (95% CI 15.8 to 27.3)). Overall, there was no significant increase in suicide rates in April–December 2020 and in 2021 compared with the pre-pandemic period across age groups (table 2). Rates were lower in April–December 2020 in 25–44 year-olds (IRR 0.85 (95% CI 0.75 to 0.97)) and in 2021 in 45–64 year-olds (0.78 (95% CI 0.63 to 0.98)) compared with the pre-pandemic period. Further details on suicide numbers by month and age group are shown in online supplemental table 2.
Age-specific RTS suicide rates based on 9 STPs: January 2020–December 2021 (1 area excluded as data by age were not available). RTS, real-time surveillance; STPs, Sustainability and Transformation Partnerships.
Table 2
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Negative binomial regression models comparing IRRs in the months pre-pandemic, the rest of the months of 2020 and the whole of 2021 by age group
Data were available to combine sex and age groups for nine of the areas. As in the disaggregated sex and age group analysis, we found no significant increase in suicide rates in any sex and age group in April–December 2020 and in 2021 compared with the pre-pandemic period across age groups. Rates were lower in April–December 2020 in men aged 25–44 years (IRR 0.76 (95% CI 0.59 to 0.98)). This was the only combined sex and age group with a significant difference in suicide rates compared with the pre-pandemic period.
Discussion
Main findings
This paper reports on suicide deaths since COVID-19 restrictions began in England in April 2020 to the end of December 2021, as recorded by RTS systems covering around a quarter of the country. We found an absolute fall of 10% in suicide rates during the pandemic in 2020 in comparison to the pre-lockdown period; this fall was driven by lower numbers in men. These findings from RTS systems align with official statistics following coroner’s inquests, as published by ONS in April 2023, which also reported lower rates in men between April and December 2020.3 Rates from RTS systems were lower in 25–44 year-olds in April–December 2020,7 and in 45–64 year-olds during 2021,3 in comparison to the pre-lockdown period. ONS—using narrower age bands—reported lower rates in those aged 30–39 from April to December 2020.7 They did not report changes by age group for 2021.3 When we combined sex and age group where these data were available, the only significant difference in suicide rates in comparison to the pre-pandemic period was a lower rate in men aged 25–44 in April–December 2020. Overall, our findings have been broadly corroborated by official statistics following coroner’s inquests, and extend existing reports from RTS systems on suicide during the pandemic, both in England and most countries internationally.5 8 9
Methodological limitations
There are caveats and limitations to this data collection. First, while we selected areas with RTS systems that had been established pre-pandemic, they are still relatively new and only allow for comparison with a baseline period from January to March 2020. Second, it is likely that the real-time data collection differed between areas and may introduce bias as to how a suspected suicide death is determined for inclusion in the figures, though we would presume any difference between areas would remain consistent over time. Third, these collated figures may mask differences in population groups or geographical areas. There are signals in the literature that the impact of COVID-19 on suicide has varied by ethnicity and socioeconomic status.15 While we have reported on differences by sex and by age group—and combined where the data were available—we have been unable to explore any further subgroups. Data on ethnicity and socioeconomic status were not routinely collected across the areas providing data, and where these data were collected, recording was not consistent between the areas. Fourth, these data will not reflect the ongoing impact of the COVID-19 pandemic, and as such it is still too soon to examine some longer-term effects from disruption to education and jobs, increased risks from alcohol, or domestic violence, the physical effects of long COVID and differential effects in different groups and areas. There may be biases in the areas included in the analysis, though these areas had higher pre-COVID-19 suicide risk, and so are likely to be serving vulnerable populations.11 12 Fifth, and finally, we have made comparisons between the collated RTS-collected data, and the conclusions published about official suicide figures for the equivalent period. We have not performed a direct statistical comparison of RTS-collected suspected suicide deaths and postinquest deaths for the 10 areas that provided data.
Interpretation of findings
This paper presents further evidence that RTS systems of early data collection of suspected suicide deaths are likely to be an early indication of suicide rates nationally, showing no rise during the pandemic from April 2020 to December 2021, in line with official statistics. In fact, we found an absolute fall of 10% from April to December 2020, driven by a decrease in suicide by men. As we posited in our previous study, it may be that the earlier days of the national crisis led to an increase in social coherence, or greater protections for some groups in the form of social supports and a lack of access to some suicide methods. There were considerable financial supports available to individuals and businesses in the UK during the pandemic, which may have offered a temporary mitigation against economic pressures, though most of these supports ended in late 2021.16 There is a suggestion from the international literature that this lack of an increase in suicide may not last, especially in young people and women. While increases in suicide following the pandemic are the exception, over time there are more countries with increases in suicide than there were in the early pandemic months.8 9
Given future pandemic-related risks from long COVID, psychological distress that began during the pandemic, educational and family disruption, and loss of care at crucial early stages of illness for some, the suicide prevention question now is what supports need to be in place to prevent a potential future rise? While people may have experienced some social and financial protections during the pandemic, the current global cost of living crisis has seen increases in food and energy prices beyond what many can afford.17 18 Historically and internationally, there is evidence of an association between economic downturns and suicide deaths, particularly for men.19–21 It is essential that support agencies and debt charities are aware of the mental health impact inferred by economic pressures. Similarly, mental health services should ask about financial adversity, and work with financial advice agencies to support vulnerable patients. While it is too soon to examine the relationship between long COVID and suicide rates, we do know that physical illness in general carries an increased risk of suicide and suicidal thoughts, and that this may be related to the impact of limitations on activity.22 23 Clinicians working in physical and mental health specialities must remain vigilant to the impact that physical illness has on suicide risk, and how this specifically affects a person’s daily life. Crucially, having timely access to suicide figures via RTS systems and the ability to monitor any changes in numbers and rates is likely to form an essential component of future suicide prevention.
Conclusion
Our analysis of data from RTS systems covering approximately a quarter of England shows that suicide rates have not increased in England since April 2020 to the end of 2021. We found an absolute fall of 10% in 2020 compared with pre-pandemic figures, driven by a decrease in the number of men dying by suicide; this is in line with official suicide statistics that are published several months after death.3 With the current cost of living crisis and the unknown effects of long COVID, education and job disruption, domestic violence and alcohol use, our suicide prevention priority now must be to maintain protections for vulnerable groups, and to offer support via government policy, and health and community services. In England, monitoring local suicide rates is a public health responsibility. Furthermore, the development of RTS is a commitment for the Office for Health Improvement and Disparities in the 2023 national suicide prevention strategy. Our analysis suggests that RTS data collection of suspected suicide deaths has a vital role to play in the monitoring of suicide rates, allowing for a timely response in times of crisis.
