Abstract

This article aims to analyze the factors associated with suicidal ideation in the COVID-19 pandemic. A cross-sectional home-based survey, with three-stage cluster sampling, was conducted with 4,203 adults from ten municipalities in the Mato Grosso, Brazil. The data collection was carried households to assessment of sociodemographic characteristics, substance use and behavior in the pandemic. The Level 1 Symptom Cross Scale was used to identify suicidal ideation and aspects of mental health (somatic symptoms, sleep disturbances, dissociation, depression, anger, mania, anxiety, thoughts, substance use and memory). Chemiluminescence was used to detect IgG anti-SARS-CoV-2 antibodies. The prevalence of suicidal ideation was 19.2%, and the associated with increased consumption of alcohol (RP=1.16), smoking (RP=1.30), COVID-19 symptoms (RP=1.03), having one’s life affected (RP=1.04), mental illness (RP=1.09) somatic symptoms (RP=1.15), sleep disturbance (RP=1.30), dissociation (RP=1.24), depression (RP=1.24), anger (RP=1.11), anxiety (RP=1.26), substance use (RP=1.19), drug prescription use (RP=1.18) and memory (RP=1.87). Highlights the high prevalence of suicidal ideation related to COVID-19 symptoms, changes in behavior post-pandemic and mental health factors.

Key words:
SARS-CoV-2; Epidemiological surveys; Mental health; Suicidal ideation

Resumo

O objetivo deste artigo é analisar fatores associados a ideação suicida durante a pandemia da COVID-19. Inquérito de base populacional conduzido com 4.203 adultos de dez municípios mato-grossenses, Brasil. A coleta de dados foi realizada no domicílio, com avaliação de características sociodemográficas, uso de substâncias e comportamentos durante a pandemia. A Escala Transversal de Sintomas de Nível 1 do DSM-5 foi utilizada na identificação dos aspectos da saúde mental (sintomas somáticos, distúrbios do sono, dissociação, depressão, raiva, mania, ansiedade, pensamentos, uso de substâncias e memória) e utilizou-se quimioluminescência para detecção de anticorpos IgG anti-SARS-CoV-2. A prevalência de ideação suicida foi de 19,2%, e associou-se ao aumento do consumo de álcool (RP=1,16) e tabagismo (RP=1,30), sintomas de COVID-19 (RP=1,03), ter a vida muito afetada (RP=1,04), doença mental (RP=1,09), sintomas somáticos (RP=1,15), distúrbio do sono (RP=1,30), dissociação (RP=1,24), depressão (RP=1,24), raiva (RP=1,11), ansiedade (RP=1,26), uso de substâncias (RP=1,19), uso de medicamentos (RP=1,18) e memória (RP=1,87). Destacou-se a alta prevalência de ideação suicida e sua associação à sintomas de COVID-19, mudanças de comportamento pós-pandemia e fatores de saúde mental.

Palavras-chave:
SARS-CoV-2; Inquéritos epidemiológicos; Saúde mental; Ideação suicida

Introduction

With the advent and rapid expansion of the new coronavirus (SARS-CoV-2) worldwide¹1 Wang C, Horby PW, Hayden FG, Gao G. A novel coronavirus outbreak of global health concern. Lancet 2020; 395(10223):470-473., social isolation measures were adopted, and they proved to be highly effective in controlling viral spread²2 Chinazzi M, Davis JT, Ajelli M, Gioannini C, Litvinova M, Merler S, Pastore Y Piontti A, Mu K, Rossi L, Sun K, Viboud C, Xiong X, Yu H, Halloran ME, Longini IM, Vespignani A. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science 2020; 368(6489):395-400.. However, the mental health of the population, which before the pandemic was already impacted in a multifactorial way, with emphasis on factors inherent to the individual and the other biopsychosocial dimensions had negative repercussions due to the long periods of social isolation³3 Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, Ho RC. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health 2020; 17(5):1729.^,44 Lima CKT, Carvalho PMM, Lima IAAS, Nunes JVAO, Saraiva JS, de Souza RI, da Silva CGL, Neto MLR. The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatry Res 2020; 287:112915..

There was a negative effect on the quality of the population’s mental well-being, an increase in the levels of anxiety, depression and alcohol abuse⁵5 Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, McKyer ELJ, Ahmed HU, Ma P. Epidemiology of mental health problems in COVID-19: a review. F1000Res 2020; 23(9):636., and an increase in cases of depression⁵5 Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, McKyer ELJ, Ahmed HU, Ma P. Epidemiology of mental health problems in COVID-19: a review. F1000Res 2020; 23(9):636.

6 Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020; 7(4):300-302.

7 Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020; 395(10228):945-947.^-88 Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7(4):e19., anxiety⁵5 Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, McKyer ELJ, Ahmed HU, Ma P. Epidemiology of mental health problems in COVID-19: a review. F1000Res 2020; 23(9):636.

6 Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020; 7(4):300-302.

7 Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020; 395(10228):945-947.^-88 Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7(4):e19., stress⁶6 Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020; 7(4):300-302.

7 Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020; 395(10228):945-947.^-88 Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7(4):e19., panic disorder³3 Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, Ho RC. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health 2020; 17(5):1729., insomnia⁸8 Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7(4):e19., fear⁴4 Lima CKT, Carvalho PMM, Lima IAAS, Nunes JVAO, Saraiva JS, de Souza RI, da Silva CGL, Neto MLR. The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatry Res 2020; 287:112915.^,77 Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020; 395(10228):945-947.^,88 Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7(4):e19. and anger⁵5 Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, McKyer ELJ, Ahmed HU, Ma P. Epidemiology of mental health problems in COVID-19: a review. F1000Res 2020; 23(9):636. in different populations. The financial losses in this pandemic episode were an additional factor to the psychosocial risk⁹9 Liu T, Nakajima T, Hamori S. The impact of economic uncertainty caused by COVID-19 on renewable energy stocks. Empir Econ 2021; 27:1-21.^,1010 Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, Ballard C, Christensen H, Cohen Silver R, Everall I, Ford T, John A, Kabir T, King K, Michie S, Przybylski AK, Shafran R, Sweeney A, Worthman CM, Yardley L, Cowan K, Cope C, Hotopf M, Bullmore E. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry 2020; 7(6):547-560.; in particular, suicide rates increased in proportion to a rise in unemployment in Canada¹¹11 McIntyre RS, Lee Y. Projected increases in suicide in Canada as a consequence of COVID-19. Psychiatry Res 2020; 290:113104., a relationship already described in Brazil in the pre-pandemic period¹²12 Vieira FS. Crise econômica, austeridade fiscal e saúde: que lições podem ser aprendidas? Brasília: Ipea; 2016..

Suicidal behaviour is a complex phenomenon and involves different aspects that include planning and carrying out the suicide attempt¹³13 World Health Organization (WHO). National suicide prevention strategies: progress, examples and indicators. Geneva: WHO; 2018. and also suicidal ideation, which is characterized by passing thoughts or permeated by detailed plans on how to take one’s own life.

It is evident that before the COVID-19 pandemic, suicide was already considered to be an impacting health problem, accounting for 1.4% of premature deaths worldwide¹⁴14 Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016; 387:1227-1239.^,1515 Hoertel N, Franco S, Wall MM, Oquendo MA, Kerridge BT, Limosin F, Blanco C. Mental disorders and risk of suicide attempt: a national prospective study. Mol Psychiatry 2015; 20(6):718-726. in 2019, the rate of suicide deaths in the world was 9/100,000, while in Brazil it reached 6.4/100,000¹⁶16 World Health Organization (WHO). Suicide worldwide in 2019: global health estimates. Geneva: WHO; 2021. and Mato Grosso 7.9/100,000¹⁷17 Fórum Brasileiro de Segurança Pública. Anuário Brasileiro de Segurança Pública [Internet]. 2021 [acessado 2020 mar 18]. Disponível em: https://forumseguranca.org.br/anuario-brasileiro-seguranca-publica/.
https://forumseguranca.org.br/anuario-br... . During the pandemic, a meta-analysis with 308,596 participants from 54 international surveys¹⁸18 Dubé JP, Smith MM, Sherry SB, Hewitt PL, Stewart SH. Suicide behaviors during the COVID-19 pandemic: A meta-analysis of 54 studies. Psychiatry Res 2021; 301:113998. identified high rates of suicidal ideation (10.8%), which indicates an important risk for the occurrence of suicide.

A study conducted in the first weeks of social distance in April 2020, suggested that suicidal ideation remained stable in the American population¹⁹19 Bryan CJ, Bryan AO, Baker JC. Associations among state-level physical distancing measures and suicidal thoughts and behaviors among U.S. adults during the early COVID-19 pandemic. Suicide Life Threat Behav 2020; 50(6):1223-1229.. However, in the subsequent months, there was a tendency for an increase in suicidal ideation, and it was in those in social isolation²⁰20 Killgore WDS, Cloonan SA, Taylor EC, Allbright MC, Dailey NS. Trends in suicidal ideation over the first three months of COVID-19 lockdowns. Psychiatry Res 2020; 293:113390..

There are still many factors to be unveiled about suicidal ideation in Brazil during the pandemic, especially in the Legal Amazon region, whose geographic conditions have particular effects on the organization of the health care network and the distribution of resources, these were neglected in the pre-pandemic period and with the increase in demand tends to worsen the scenario. In addition, there are no population-based studies in the region that investigate mental health. In this context, this study aimed to analyze the factors associated with suicidal ideation in the COVID-19 pandemic in a population of the Brazilian Legal Amazon.

Methods

A cross-sectional home-based survey was carried out in the state of Mato Grosso, in the Brazilian Legal Amazon region, namely Cuiabá, Várzea Grande, Cáceres, Rondonópolis, Barra do Garças, Tangará da Serra, Alta Floresta, Água Boa, Juína and Sinop (Figure 1). These municipalities are considered to be hubs, owing to their urban structure and intensity of flows of people in the existing health networks. They are cities whose population varies from 30,000 to 600,000 inhabitants, located in 3 of the main Brazilian biomes (Cerrado [5 cities], Pantanal [1 city] and Amazonia [3 cities]). Except for 2 cities that make up the metropolitan region of the capital Cuiabá, where the service sector is the main economic source. from 0.0 to 1.0 of the FIRJAN Municipal Development Index, a national index that considers the dimensions “employment and income”, “education” and “health”²¹21 Federação das Indústrias do Estado do Rio de Janeiro (FIRJAN). Índice FIRJAN de Desenvolvimento Municipal (IFDM):Consulta. Rio de Janeiro: FIRJAN; 2013.. The main connections of regional integration are also considered, and it was possibly based on them that the hierarchical diffusion process of COVID-19 occurred in this region²²22 Mato Grosso. Secretaria do Estado de Sáude. Painel Informativo COVID-19 em Mato Grosso. Mato Grosso: Secretaria do Estado de Sáude; 2021.. This study integrates the matrix project “Endemic and epidemic diseases in Mato Grosso”.

This study used a probabilistic design with three-stage cluster sampling: census sector (selected with probability proportional to the number of permanent households according to 2010 census data); household (selected from a systematic sampling); resident over the age of 18 (one randomly selected resident). The sample was estimated at 4,530 individuals, proportionally distributed according to the population size of the municipalities (25,000 to 65,000 inhabitants; 65,000 to 150,000; 150,000 to 300,000; >300,000).

Sample calculation was performed using the 2019 population estimate for the 10 selected municipalities (sample space: 1,650,643 inhabitants in the 10 municipalities in the study), considering a confidence level of 95%, design effect equal to 1.5, the prevalence of 3%²³23 Hallal PC, Horta BL, Barros AJD, Dellagostin OA, Hartwig FP, Pellanda LC, Struchiner CJ, Burattini MN, Silveira MF, Menezes AMB, Barros FC, Victora CG. Evolução da prevalência de infecção por COVID-19 no Rio Grande do Sul, Brasil: inquéritos sorológicos seriados. Cien Saude Colet 2020; 25(1):2395-2401. and accuracy of 0.65%. The sample size was calculated using OpenEpi21²⁴24 Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health [Internet]. 2013 [cited 2020 mar 18]. Available from: https://www.openepi.com/Menu/OE_Menu.htm.
https://www.openepi.com/Menu/OE_Menu.htm... . A percentage of 13% of recomposition was added to the sample size, considering the anticipated losses arising from refusals and the existence of closed households during the visit. The sampling weight of each selected unit (census sector, household and individual) was calculated separately for each municipality, considering the inverse of the probability of selection according to the proposed sampling plan, and including calibrations for adjustments to known population totals. Medium-sized municipalities, census sectors in urban areas and residents over 18 years of age were included and were excluded municipalities with less than 25,000 inhabitants, census sectors that encompassed rural areas and indigenous reserves and unconscious bedridden residents.

Data collection took place between September and October 2020 by professionals and students of health degree. Previous training was given in August 2020 to standardize the interviews, blood collection and conduction of a pilot test. The pilot test was carried out in a census sector not selected for sampling, and its data were not included in the analysis. During data collection, the selected census sector was covered following a systematic approach for selecting households by “jumps” determined for each sector. If the selected household was currently empty or the selected resident did not agree to participate in the survey, the next box on the left was taken as a replacement.

At home, a resident over 18 years of age was randomly selected to answer the questionnaires, which was applied through Epi InfoTM on Smartphones, which was also used to capture geographic coordinates. Fieldwork was carried out by a coordinator in each selected municipality.

The instrument applied in the individual interview included (i) sociodemographic data, (ii) behavioral information, and (iii) the assessment of mental health (DSM-5).

The DSM-5 scale proved to be clinically useful and with good reliability in the DSM-5 field trials that were conducted on adult clinical samples in the United States and Canada. In Brazil, the DSM-5 manual provides a translation of this instrument for use as screening and diagnostic evaluation²⁵25 American Psychiatric Association (APA). Manual Diagnóstico e Estatístico de Transtornos Mentais-DSM-V. Virginia: APA; 2013.. Because it is a self-administered scale, which allows the monitoring of changes in mental symptoms over time, and because it contributes to the diagnosis and significant impact on treatment, these were some of the motivations that led us to use this scale²⁵25 American Psychiatric Association (APA). Manual Diagnóstico e Estatístico de Transtornos Mentais-DSM-V. Virginia: APA; 2013..

Statistical analysis

All analyses were performed using the Stata software version 14, particularly the “svy” module, which allows the addition of weighting factors and takes into account the complex design of the sample.

The suicidal ideation variable was considered as a dependent variable and all sociodemographic variables (gender, age, race, schooling and family income), substance use after the onset of the pandemic, behaviors experienced during the COVID-19 pandemic period, and mental health (DSM-5 domains) were considered as co-variables.

Variables with p-values less than 0.20 (p<0.20) were tested in the multiple Poisson regression model with robust variance in the bivariate analysis between the dependent and independent variables, considering the prevalence ratio adjusted by the method. Prevalence ratios (PR) and their respective 95% confidence intervals (95%CI) were calculated by the model mentioned above. Variables that presented p values less than 0.20 (p <0.20) in the bivariate analysis were included in the multiple model and variables with p-values below 0.05 (p<0.05) by the stepwise forward method remained in the final model.

Ethics aspects

This study respected all ethical aspects, by Resolution 466/2012 of the National Health Council (NHC). The research project was approved by the Ethics Committee of the University of the State of Mato Grosso (Opinion: 3.986.293/2020). All participants signed an Informed Consent Form and were treated at their homes following strict biosafety protocols. Actions to mitigate risks to participants from the research were implemented in data collection, with guidance on support networks and access to mental health promotion services on demand.

Results

A total of 4,203 individuals were analyzed (92.8% of the initial sample); most of them were aged between 18 and 93 years and predominantly aged between 30 and 49 years (41.4%), females (64.8%), brown (55.2%), whose family income ranged from one to less than three minimum wages (59.2%) and who had completed elementary school (34.6%). It was found that 24.3% of the individuals reported having signs and symptoms potentially related to COVID-19 in the last 14 days before data collection, with a 12.0% seroprevalence of antibodies against SARS-CoV-2, ranging from 7.0% to 24.3% among the ten study municipalities. The risk classification for suicidal ideation was present in 19.2%.

In the bivariate analysis, suicidal ideation was associated with low income, increased alcohol consumption, alcohol consumption almost every day of the week, increased smoking, not working at the onset of the pandemic, considering oneself neutral as to being affected by the pandemic and having COVID-19 self-reported symptoms (Table 1).

Regarding mental health aspects (DSM-5), it was found in the bivariate analysis that somatic symptoms, sleep disturbance, dissociation, depression, anger, mania, anxiety, psychosis, repetitive thoughts and behaviors, substance use, drug use and memory were associated with statistically significant values with suicidal ideation during the COVID-19 pandemic in the Mato Grosso population (Table 2).

Table 3 shows the final model adjusted by Poisson multiple regression with robust variance between the variables suicidal ideation and sociodemographic information, lifestyle after the onset of the pandemic, behaviors while experiencing the pandemic and mental health aspects, with their respective adjusted prevalence values and confidence intervals. Most of the variables that were significant in the bivariate analysis were maintained for the multiple analysis, except for the variables: age in age groups, sex, education and mania.

In the multiple analysis, suicidal ideation was associated with variables increased consumption of alcohol (RP=1,16 IC=1,07;1,25, p<0,001) and smoking (RP=1,30, IC=1,15;1,47, p<0,001) after the pandemic, COVID-19 self-reported symptoms (RP=1,03, IC=1,01;1,07, p=0,024), having one’s life severely affected by the pandemic (RP=1,04, IC=1,01;1,07, p=0,019) self-reported mental illness (RP=1,09, IC=1,03;1,16, p=0,005), somatic symptoms (RP=1,15, IC=1,08;1,22, p<0,001), sleep disturbance (RP=1,30, IC=1,11;1,54, p=0,002), dissociation (RP=1,24, IC=1,03;1,49, p=0,022), depression (RP=1,24, IC=1,06;1,46, p=0,008), anger (RP=1,11, IC=1,03;1,20, p=0,006), anxiety (RP=1,26, IC=1,06;1,50, p=0,007), substance use (RP=1,19, IC=1,08;1,30, p<0,001), drug prescription use (RP=1,18, IC=1,08;1,29, p<0,001) and memory (RP=1,87, IC=1,35;2,58, p<0,001). In this analysis, most variables are a risk factor for suicidal ideation, with the exception of psychosis, repetitive thoughts and behaviors and the interaction between depression and anxiety, which were negatively associated (Table 3).

Discussion

This research presented an unprecedented prevalence of suicidal ideation in a probabilistic sample of 10 municipalities in the state of Mato Grosso, in Brazil, during the COVID-19 pandemic. It was found that 19.2% of the population was classified as having suicidal ideation. Among the study factors, it was associated with the use of substances after the onset of the pandemic (increased consumption of alcohol and smoking), behaviors in the experience of the pandemic (COVID-19 self-reported symptoms, and having one’s life severely affected by the pandemic) and to mental health factors (self-reported mental illness, somatic symptoms, sleep disturbance, dissociation, anger, anxiety, substance use, drug prescription use and memory). In this analysis, most variables are a risk factor for suicidal ideation, except for psychosis, repetitive thoughts and behaviors and the interaction between depression and anxiety, which were negatively associated.

The prevalence of suicidal ideation was higher than as reported in a recent meta-analysis, covering 54 international surveys¹⁸18 Dubé JP, Smith MM, Sherry SB, Hewitt PL, Stewart SH. Suicide behaviors during the COVID-19 pandemic: A meta-analysis of 54 studies. Psychiatry Res 2021; 301:113998.. Niederkrotenthaler et al.²⁷27 Niederkrotenthaler T, Gunnell D, Arensman E, Pirkis J, Appleby L, Hawton K, John A, Kapur N, Khan M, O'Connor RC, Platt S. International COVID-19 Suicide Prevention Research Collaboration. Suicide Research, Prevention, and COVID-19. Crisis 2020; 41(5):321-330. suggested a strategic approach to research on and prevention of suicide at a global level, as there are numerous uncertainties related to the direct and indirect effects of COVID-19 on suicide. In both, Brazil and Mato Grosso, studies on the prevalence of suicidal ideation in the general population are scarce, even with high rates of suicide deaths recorded in the country²⁰20 Killgore WDS, Cloonan SA, Taylor EC, Allbright MC, Dailey NS. Trends in suicidal ideation over the first three months of COVID-19 lockdowns. Psychiatry Res 2020; 293:113390.. However, some studies on suicidal ideation with Brazilian populations, such as a systematic review with children and adolescents in the COVID-19 pandemic, found a prevalence that ranged from 29 to 31.3%²⁸28 Oliveira JMD, Butini L, Pauletto P, Lehmkuhl KM, Stefani CM, Bolan M, Guerra E, Dick B, De Luca Canto G, Massignan C. Mental health effects prevalence in children and adolescents during the COVID-19 pandemic: A systematic review. Worldviews Evid Based Nurs 2022; 00:1-8., and another study with Brazilian undergraduate students in the area of health was 26.33%²⁶26 Sousa GS, Ramos BMD, Tonaco LAB, Reinaldo AMDS, Pereira MO, Botti NCL. Factors associated with suicide ideation of healthcare university students. Rev Bras Enferm 2021; 26(75):e20200982..

In the present study, we identify the association of suicidal ideation and increased alcohol consumption almost every day of the week, increased smoking, substance and drug prescription use. A study found that 15.1% of the US adult population reported increased substance use, and 11.9% reported suicidal ideation during the COVID-19 pandemic²⁹29 Czeisler MÉ, Lane RI, Wiley JF, Czeisler CA, Howard ME, Rajaratnam SMW. Follow-up Survey of US Adult Reports of Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, September 2020. JAMA Netw Open 2021; 4(2):e2037665..

In previous pandemics, there have been negative impacts of social distancing, and in the case of the SARS-CoV virus, it was reported that this viral spread mitigation strategy contributed to an increase in the suicide rate during the SARS epidemic in 2003 in Hong Kong³⁰30 Yip PS, Cheung YT, Chau PH, Law YW. The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong. Crisis 2010; 31:86-92.. However, there is still no evidence of whether or not, in the current pandemic, the fact of being infected and/or becoming ill increases suicidal ideation. In the present study, this association was not found, as the difficulties arising from social distancing, economic crisis, fear of illness and grief may be at the heart of this process. Suicidal ideation can be, independent of the infection itself.

On the other hand, there was an association between COVID-19 self-reported symptoms and suicidal ideation, which encourages reflection on the possible impact of social boycott and discrimination on suicide, as described by Mamun et al.³¹31 Mamun MA, Griffiths MD. First COVID-19 suicide case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies. Asian J Psychiatr 2020; 51:102073. in the report of the first case of suicide by COVID -19 in Bangladesh, where a young man committed suicide owing to social evasion by neighbors and fear of transmitting the virus to his community.

A longitudinal study analyzed aspects of social distancing and the feeling of being alone, and there was an association with suicidal ideation³²32 Domènech-Abella J, Mundó J, Haro JM, Rubio-Valera M. Anxiety, depression, loneliness and social network in the elderly: Longitudinal associations from The Irish Longitudinal Study on Ageing (TILDA). J Affect Disord 2019; 246:82-88.. In descriptions post-pandemic, it was reported that social isolation, anxiety, fear of contagion, uncertainty, chronic stress and economic difficulties can contribute to the development or exacerbation of stress-related illnesses and suicide³³33 Sher L. COVID-19, anxiety, sleep disturbances and suicide. Sleep Med 2020; 70:124.. In Poland and Lithuania, it was found that high levels of adjustment problems, loneliness and staying longer at home during the COVID-19 pandemic were significantly associated with suicidal ideation³⁴34 Gelezelyte O, Dragan M, Grajewski P, Kvedaraite M, Lotzin A, Skrodzka M, Nomeikaite A, Kazlauskas E. Factors Associated with Suicide Ideation in Lithuania and Poland Amid the COVID-19 Pandemic. Crisis 2021 Aug 31. DOI: 10.1027/0227-5910/a000814. Epub ahead of print.
https://doi.org/10.1027/0227-5910/a00081... .

A study with the Japanese adult population, focusing on the profile of people with suicidal ideation during the COVID-19 pandemic, found that young people, who worked in unstable jobs, had no children, had a low income and who received psychiatric care were those with the highest levels of this impact on their mental health³⁵35 Sueki H, Ueda M. Short-Term Effect of the COVID-19 Pandemic on Suicidal Ideation. Crisis 2021 Jun 15. DOI: 10.1027/0227-5910/a000797. Epub ahead of print.
https://doi.org/10.1027/0227-5910/a00079... . This finding is similar to the profile of the population in the present study.

Even though it did not remain in the statistical modeling used in the present study, it should be noted that in the bivariate analysis, low income and the fact of not working in the first wave of the pandemic were associated with suicidal ideation. The association of unemployment, precarious jobs and low income were described as responsible for the higher risk of suicidal behavior³⁶36 Iemmi V, Bantjes J, Coast E, Channer K, Leone T, McDaid D, Palfreyman A, Stephens B, Lund C. Suicide and poverty in low-income and middle-income countries: a systematic review. Lancet Psychiatry 2016; 3(8):774-783.^,3737 Min KB, Park SG, Hwang SH, Min JY. Precarious employment and the risk of suicidal ideation and suicide attempts. Prev Med 2015; 71:72-76.. In a predictive study published in May 2020³⁸38 Kawohl W, Nordt C. COVID-19, unemployment, and suicide. Lancet Psychiatry 2020; 7(5):389-390., it was reported that in a scenario with high numbers of COVID-19, the world unemployment rate would increase from 4.9% to 5.6%, increasing suicides annually to about 9,570 per year.

Uncertainties, especially economic ones, were associated with factors related to mental illness and suicide³⁹39 Vandoros S, Avendano M, Kawachi I. The association between economic uncertainty and suicide in the short-run. Soc Sci Med 2019; 220:403-410.. This finding can encourage the population to reflect on how the pandemic affects their lives, as shown in our study when the respondents considered that life was greatly affected; it was associated with suicidal ideation in the population of Mato Grosso. High unemployment rates, in addition to being associated with suicide, were also related to a higher prevalence of depression, alcohol consumption and other substance use disorders⁴⁰40 Martin-Carrasco M, Evans-Lacko S, Dom G, Christodoulou NG, Samochowiec J, González-Fraile E, Bienkowski P, Gómez-Beneyto M, Dos Santos MJ, Wasserman D. EPA guidance on mental health and economic crises in Europe. Eur Arch Psychiatry Clin Neurosci 2016; 266(2):89-124..

It is known that, worldwide, 90% of individuals who committed suicide had some type of psychiatric disorder¹⁴14 Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016; 387:1227-1239., and that the warning about the increased risk of developing suicidal ideation in people with preexisting mental disorders was issued by psychiatry authorities at the onset of the COVID-19⁴¹41 Unützer J, Kimmel RJ, Snowden M. Psychiatry in the age of COVID-19. World Psychiatry 2020; 19(2):130-131. pandemic. Thus, the present study sought to analyze the other domains proposed by the DSM-5, in addition to the presence of self-reported mental illness, and an association was found between these risk factors in the multivariate analysis: somatic symptoms, sleep disturbance, dissociation, depression, anger, anxiety, substance use, drug prescription use and memory.

The increase in somatic symptoms during the COVID-19 pandemic, such as hypochondria, somatization and chronic pain, has been related to impotence arising from the uncertainties of pandemic lifestyle changes⁴²42 Gracino YLL, Louveira MH, Gaudioso CE, Souza JC. Transtornos somatoformes durante a pandemia de COVID-19. RSD 2020; 9(9):e902998019.. This growth of somatic symptoms in the population raises concern, as there is reported that somatic symptoms can be predictors of suicidal ideas⁴³43 Torres ME, Löwe B, Schmitz S, Pienta JN, Van Der Feltz-Cornelis C, Fiedorowicz JG. Suicide and suicidality in somatic symptom and related disorders: A systematic review. J Psychosom Res 2021; 140:110290..

The prolonged experience of social distancing can directly impact the quality of sleep and memory. This mixed of feelings has already been described as a point of concern that can cause various mental symptoms and lead to the development of anxiety disorders, depression and sleep disorders⁴⁴44 Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM 2020; 113(10):707-712.. In a study conducted by Killgore et al.⁴⁵45 Killgore WDS, Cloonan SA, Taylor EC, Fernandez F, Grandner MA, Dailey NS. Suicidal ideation during the COVID-19 pandemic: The role of insomnia. Psychiatry Res 2020; 290:113134., insomnia was found to be the major trigger for fear of the pandemic and suicidal thoughts, a finding that is corroborated in the descriptions by Sher³³33 Sher L. COVID-19, anxiety, sleep disturbances and suicide. Sleep Med 2020; 70:124., who argued that sleep abnormalities are an autonomous risk factor for suicidal ideation and its consequences.

The relationships between insomnia, depression and anxiety can be considered bidirectional, as insomnia contributes to symptoms of depression and anxiety, while depression and anxiety disturb sleep, and this complex process is described as a risk factor for suicidal behavior⁴⁶46 Mason EC, Harvey AG. Insomnia before and after treatment for anxiety and depression. J Affect Disord 2014; 168:415-421.. A study indicated that loneliness and sensitivity to anxiety are important correlates of suicidal ideation⁴⁷47 Allan NP, Volarov M, Koscinski B, Pizzonia KL, Potter K, Accorso C, Saulnier KG, Ashrafioun L, Suhr J, Allan DM. Lonely, anxious, and uncertain: Critical risk factors for suicidal desire during the COVID-19 pandemic. Psychiatry Res 2021; 304:114144..

Using different instruments, studies conducted during the COVID-19 pandemic showed high anxiety rates (14.1% and 20.8%) in the population⁴⁸48 Papadopoulou A, Efstathiou V, Yotsidi V, Pomini V, Michopoulos I, Markopoulou E, Papadopoulou M, Tsigkaropoulou E, Kalemi G, Tournikioti K, Douzenis A, Gournellis R. Suicidal ideation during COVID-19 lockdown in Greece: Prevalence in the community, risk and protective factors. Psychiatry Res 2021; 297:113713.^,4949 Iob E, Steptoe A, Fancourt D. Abuse, self-harm and suicidal ideation in the UK during the COVID-19 pandemic. Br J Psychiatry 2020; 217(4):543-546.. A particular study showed an increase in anxiety symptoms⁵⁰50 Kaparounaki CK, Patsali ME, Mousa DV, Papadopoulou EVK, Papadopoulou KKK, Fountoulakis KN. University students' mental health amidst the COVID-19 quarantine in Greece. Psychiatry Res 2020; 290:113111.. In another study, 33% of the sample had symptoms of anxiety or depression, which were related to suicidal ideation⁵¹51 Czeisler MÉ, Wiley JF, Facer-Childs ER, Robbins R, Weaver MD, Barger LK, Czeisler CA, Howard ME, Rajaratnam SMW. Mental health, substance use, and suicidal ideation during a prolonged COVID-19-related lockdown in a region with low SARS-CoV-2 prevalence. J Psychiatr Res 2021; 140:533-544..

In the present study, depression and anxiety were associated with suicidal ideation when analyzed on their own. Depression is included among the mental and neurological manifestations of COVID-19⁵²52 Adhanom Ghebreyesus T. Addressing mental health needs: an integral part of COVID-19 response. World Psychiatry 2020; 19(2):129-130., and important rates were found in the populations of the UK (29.5%)⁴⁹49 Iob E, Steptoe A, Fancourt D. Abuse, self-harm and suicidal ideation in the UK during the COVID-19 pandemic. Br J Psychiatry 2020; 217(4):543-546. and the USA (19.5%)⁵³53 Bryan CJ, Bryan AO, Baker JC. Associations among state-level physical distancing measures and suicidal thoughts and behaviors among U.S. adults during the early COVID-19 pandemic. Suicide Life Threat Behav 2020; 50(6):1223-1229.. In addition, there were potential chances for anxiety and depression among those with suicidal ideation in Greece⁴⁸48 Papadopoulou A, Efstathiou V, Yotsidi V, Pomini V, Michopoulos I, Markopoulou E, Papadopoulou M, Tsigkaropoulou E, Kalemi G, Tournikioti K, Douzenis A, Gournellis R. Suicidal ideation during COVID-19 lockdown in Greece: Prevalence in the community, risk and protective factors. Psychiatry Res 2021; 297:113713..

In dissociation, it can be seen, in more severe ways, that a defense can be instituted by the subject when feeling unprotected in response to the invasion of pain and real trauma⁵⁴54 Moskowitz A. Schizophrenia, trauma, dissociation, and scientific revolutions. J Trauma Dissociation 2011; 12(4):347-357.. This is a plausible situation in the current moments imposed by the COVID-19 pandemic, and they can potentiate other problems previously described, such as dissociative amnesia, sexual dysfunction, eating disorders, post-traumatic stress and suicide attempts⁵⁵55 Spiegel D. Dissociative identity disorder. Merck Manuals. Merck & Co; 2015..

Anger-related disorders may be related to suicidal ideation, especially when there is a loss of control in the face of limiting situations, further enhanced by stress, fears and anguish arising from social distancing²2 Chinazzi M, Davis JT, Ajelli M, Gioannini C, Litvinova M, Merler S, Pastore Y Piontti A, Mu K, Rossi L, Sun K, Viboud C, Xiong X, Yu H, Halloran ME, Longini IM, Vespignani A. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science 2020; 368(6489):395-400.. A study with psychoactive substance dependents found that behavioral and emotional changes such as increased expression of anger may be closely related to suicidal behavior⁵⁶56 Almeida RMM, Flores ACS, Scheffer M. Ideação suicida, resolução de problemas, expressão de raiva e impulsividade em dependentes de substâncias psicoativas. Psicol Reflex Crit 2013; 26(1):1-9..

Psychosis, repetitive thoughts and behaviors were statistically associated as protective factors. In contrast, verbal and auditory hallucinations increased the chances of a suicide attempt in adolescents with suicidal ideation⁵⁷57 Fujita J, Takahashi Y, Nishida A, Okumura Y, Ando S, Kawano M, Toyohara K, Sho N, Minami T, Arai T. Auditory verbal hallucinations increase the risk for suicide attempts in adolescents with suicidal ideation. Schizophr Res 2015; 168(1-2):209-212., and the incidence of psychosis is an important risk factor for suicidal behavior in people who have experienced infections by SARS, MERS and H1N⁵⁸58 Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, Zandi MS, Lewis G, David AS. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020; 7(7):611-627.. The same occurred in the analyses by Benatti et al.⁵⁹59 Benatti B, Albert U, Maina G, Fiorillo A, Celebre L, Girone N, Fineberg N, Bramante S, Rigardetto S, Dell'Osso B. What Happened to Patients with Obsessive Compulsive Disorder During the COVID-19 Pandemic? A Multicentre Report from Tertiary Clinics in Northern Italy. Front 2020; 11:720., who found an increase in suicidal ideation in patients with repetitive thoughts and behavior disorders in Italy.

In our study, there was also an association between suicidal ideation and substance use and use of medication, also evidenced in other studies, such as Czeisler et al.⁵¹51 Czeisler MÉ, Wiley JF, Facer-Childs ER, Robbins R, Weaver MD, Barger LK, Czeisler CA, Howard ME, Rajaratnam SMW. Mental health, substance use, and suicidal ideation during a prolonged COVID-19-related lockdown in a region with low SARS-CoV-2 prevalence. J Psychiatr Res 2021; 140:533-544. that observed in Australian population the start of using new substances or increased their consumption to dealing with of the pandemic. Drug abuse and prolonged drug use were also associated with suicidal behavior among Brazilian men⁶⁰60 Roglio VS, Borges EN, Rabelo-da-Ponte FD, Ornell F, Scherer JN, Schuch JB, Passos IC, Sanvicente-Vieira B, Grassi-Oliveira R, von Diemen L, Pechansky F, Kessler FHP. Prediction of attempted suicide in men and women with crack-cocaine use disorder in Brazil. PLoS One 2020; 15(5):e0232242..

Memory was also associated with suicidal ideation in the population studied in Mato Grosso, as well as in a North American study before the pandemic in which deficits in specific components of attention control and memory were associated with suicidal behavior and depression⁶¹61 Keilp JG, Gorlyn M, Russell M, Oquendo MA, Burke AK, Harkavy-Friedman J, Mann JJ. Função neuropsicológica e comportamento suicida: controle da atenção, memória e disfunção executiva na tentativa de suicídio. Psicol Med 2013; 43(3):539-551..

The major limitation of the present study is that its design does not allow causal conclusions between predictors and suicidal ideation; however, it explores the relationship between the variables, with consistent results such as those found in longitudinal studies. Additionally, there was still the risk of interviewer bias and to minimize it, previous training of interviewers and field supervision were carried out, memory bias and desirability bias related to mental health issues (answers from socially accepted standards) can also be cited regarding the participants, and to mitigate them, the interview was carried out in a reserved place, ensuring all the time necessary, in addition to emphasizing anonymity of your answers.

Conclusion

Factors associated with suicidal ideation during the COVID-19 pandemic in a region of the Legal Amazon were: self-reported mental illness, somatic symptoms, sleep disturbance, dissociation, depression, anger, anxiety, memory changes, and increased alcohol consumption. and smoking. These factors, in addition to acting in suicidal ideation, are part of an important group of clinical conditions, which can be easily detected and treated in Primary Health Care (PHC) in the Brazilian National Health System, before presenting characteristics for referral to reference services. However, the aggravation of such factors, either by silencing those who are more vulnerable or by the lack of recognition of professionals and services in welcoming these psycho-emotional demands in the community, potentiate the occurrence of suicidal ideation, and its repercussions harm the quality of life of the person/family when they can even cost their lives.

Suicidal ideation as a moment/step that precedes completed suicide, and which can be worked on without requiring large financial and technological investments, should be included in the list of health education topics of family health teams, and be part of the identified aspects in routine consultations, since many diseases, prevalent in daily care in PHC, have risk factors that predispose to mild to severe mental disorders.

The identification of factors associated with suicidal ideation in this region can collaborate with new care strategies, from those designed in the training scope of future professionals to continuing education programs, by signaling profiles of people who are susceptible to suicidal ideation and strengthening actions surveillance, for the promotion of life and well-being.

Acknowledgments

The authors are grateful to everyone who agreed to participate in the research and to those who worked in the municipalities of Várzea Grande, Cáceres, Rondonópolis, Barra do Garças, Tangará da Serra, Alta Floresta, Água Boa, Juína and Sinop in partnership with academics in the field of health from the UFMT, UNEMAT, Multiprofessional Residency in Health at the UFR and in Biomedicine at the UNIC.

References

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