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Perfil de las personas con conducta suicida y con enfermedades de salud
mental preexistentes antes de la pandemia por COVID-19 y durante los 6
primeros meses de la pandemia: Estudio comparativo por períodos
temporales y por género
Profile of people with suicidal behavior and pre-existing mental health
illnesses before the COVID-19 pandemic and during the first 6 months of
pandemic: Comparative study by time periods and by gender
Liliana Mahulea 1, Marta Domínguez García1,2,3* , María Millán Taratil1,2,3, María Ruiz
Herrero1,2,3, Mª Jesús Serrano Ripoll4,5,6 .
1 Servicio Aragonés de Salud. España.
2 Instituto de Investigación Sanitaria de Aragón.
3 Grupo Aragonés de Investigación en Atención Primaria
4 Instituto de Investigación Sanitaria de las Islas Baleares. España.
5 Unidad de Investigación en Atención Primaria de Mallorca, Servicio de Salud de las Islas Baleares,
Palma de Mallorca, España.
6 Red de Investigación en cronicidad, Atención Primaria y Servicios Sanitarios (RICAPPS). Instituto de
Salud Carlos III, Madrid, España.
*Autor de correspondencia: mardoga5@gmail.com
Recibido: 29-08-2023. Aceptado: 25-10-2023
Resumen
El objetivo de este estudio es analizar y comparar el perfil de las personas con conducta suicida 6
meses antes de la pandemia y durante los 6 meses posteriores al inicio de la pandemia en una
cohorte de pacientes con enfermedades de salud mental previas de alta prevalencia, utilizando para
ello los registros de Atención Primaria de la Salud (APS).
Metodología: Estudio retrospectivo, longitudinal y comparativo. Se recogieron datos
sociodemográficos, enfermedades de salud mental prexistente o nuevos diagnósticos, infección por
COVID-19, utilización de los recursos sanitarios durante el período del estudio donde se produjo el
intento autolítico o el suicidio. Se realizó un análisis bivariante comparando por género y por periodo
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de tiempo donde se produjo la conducta suicida, y un análisis multivariante de regresión logística.
Resultados: En Aragón (España), 173 personas tuvieron conducta suicida durante los 6 meses previos
a la pandemia, y 153 personas durante los 6 meses posteriores al inicio de la pandemia, sin que haya
habido cambios en el perfil sociodemográfico. Este perfil es el de una mujer, y está relacionado con
la preexistencia de un episodio de depresión y/o ansiedad mayoritariamente. La ausencia de
contacto con el sistema sanitario, especialmente con el trabajador/a social del centro de salud y los
servicios de atención continuada ha incrementado el riesgo de suicidio durante la pandemia.
Conclusiones: Es importante el contacto con el sistema sanitario en futuras pandemias para la
prevención de las conductas suicidas.
Palabras clave: Suicidio; pandemia; COVID-19; enfermedad mental preexistente; servicios sanitarios
y sociales
Abstract
The aim of this study is to analyze and compare the profile of people with suicidal behavior 6 months
before the pandemic and during the first 6 months after its onset, in a cohort of patients with
previous high prevalence mental health illnesses, using Primary Health Care (PHC) records.
Methodology: A retrospective, longitudinal and comparative study. We collected data on
sociodemographic, pre-existing mental health illnesses or new diagnoses, COVID-19 infection, use of
health resources during the study period where the suicide attempt or suicide occurred. A bivariate
analysis was performed comparing by gender and by the time period during which the suicidal
behavior occurred, as well as a multivariate logistic regression analysis.
Results: In Aragón (Spain), 173 persons were reported with suicidal behavior during the 6 months
prior to the onset of the pandemic, and 153 persons during the 6 months after, with no changes in
the sociodemographic profile.The participant profile was that of a woman, with a preexisting
episode of depression and/or anxiety. Lack of contact with the health system, especially with the
health center social worker and the continuing care services increased the risk of suicide during the
pandemic.
Conclusions: Contact with the health care system in future pandemics is important for the
prevention of suicidal behavior.
Keywords: Suicide; pandemic; COVID-19; pre-existing mental illness; health and social services.
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INTRODUCTION
According to the World Health Organization (WHO), suicide can be defined as the set of behaviors
that include thinking about suicide or suicidal ideation, planning, attempted suicide, and suicide
itself (WHO, 2014). In addition, suicidal behavior has been associated with emotional states of
depression and hopelessness (Beck et al., 1990; Ribeiro et al., 2018). Suicide is the second leading
cause of death among people aged 15-29 years, thus has become a health and social priority
worldwide, being the leading cause of unnatural death since 2012 in Spain (Instituto Nacional de
Estadística, 2020). There are 800,000 deaths by suicide every year, and for every death, it is
estimated that there are 20 suicide attempts (World Health Organization, 2016). In 2020, there was
an increase in the number of suicides, coinciding with a global pandemic produced by COVID-19,
which was a very stressful situation for the population due to measures to control the spread of the
virus, including home confinements and limited mobility measures, with the consequent economic,
social, physical and mental health consequences (Valdés-Florido et al., 2020). Numerous studies
have analyzed the psychological consequences of the pandemic and confinement in the Spanish
population (Ayuso-Mateos et al., 2021; Villanueva-Silvestre, Vázquez-Martínez, Isorna-Folgar, &
Villanueva-Blasco, 2022), concluding that the COVID-19 pandemic increased mental health problems
in the population, especially anxiety, depression and sleep disorders, as observed in other countries
(Luo et al., 2020; Nochaiwong et al., 2020; Salari et al., 2020; Wu et al., 2021). Regarding suicidal
behaviors, data published in Spain showed that in 2020 there was an increase of 7.4% over the
previous year (Fundación Española para la Prevención del Suicidio, 2021). Furthermore, one aspect
that the COVID-19 pandemic has evidenced is the close relationship between mental health and
social determinants (Lear-Claveras, Aguilar-Latorre, Oliván-Blázquez, Couso-Viana, & Clavería-
Fontán, 2022), and more specifically with socioeconomic conditions (Lorant et al., 2007; Weich,
Nazareth, Morgan, & King, 2007).
People with pre-existing mental disorders were particularly vulnerable to these stressors
experienced during the pandemic (Sheridan Rains et al., 2021). Having depression, anxiety or —even
more— comorbidity between the two, are considered important risk factors for suicidal behavior
(Moitra et al., 2021).
Primary health care (PHC) is the gateway to the health system and the place where main mental
health problems are managed (Kennedy et al., 2003; Roca et al., 2009). The collapse of health
services and especially PHC during the COVID-19 pandemic disrupted health services for these
patients (Kozloff et al., 2020). According to the results of the pulse survey conducted by the WHO in
105 countries, most of them (90%) experienced interruptions in essential health services from the
beginning of the pandemic, with the consequent impact on health, especially in vulnerable
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population sectors (WHO, 2020). Similarly, fear of contagion may have reduced demand on health
facilities (WHO, 2020), leading to expected psychopathological imbalances and increased demand
downstream (Kozloff et al., 2020).
Research efforts have focused on curbing suicide deaths by trying to predict their occurrence. One
strategy of this predictive approach is risk assessment, analyzing risk factors and establishing models
and profiles of people at increased risk of suicide (Forte et al., 2021; Large, 2018). Therefore, the
aim of this study was to analyze and compare the profile and health resources utilization of persons
with previous high prevalence mental health illnesses who attempted or committed suicide 6
months before the pandemic and during the 6 months after its onset, using PHC (specifically family
medicine) registries for this purpose. A secondary objective of the study was the comparison by
gender of individuals with previous chronic mental illness with suicidal behavior before or after the
onset of the pandemic.
METHOD
Design
A retrospective, longitudinal and comparative study in an autonomous community in northern Spain
(Aragón) was performed, in which data were collected on all persons over 16 years of age, with a
diagnosis of mental illness with a prevalence of more than 5% (depression, anxiety, smoking,
alcoholism, previous suicidal behavior) registered in their medical records, and who had attempted
or committed suicide in the 6 months before or after the onset of the pandemic. The criterion of
including people from the age of 16 is because at this age the health system transfers them from
pediatrics to family medicine.
Aragón is an autonomous community, located in the north of Spain, with 1,328,753 inhabitants. Its
territory occupies 47,719 km2 and has a population density of 28.20 inhabitants/km2. It has an aging
population concentrated in rural areas, while the main cities have a younger demographic structure.
The regional capital (Zaragoza) accounts for half of the total population, with rural areas (with less
than 2,000 inhabitants) representing 16.8%. These characteristics of aging and population
dispersion in rural areas are similar to those in other parts of Europe.
Participants
The participants in this study were all men and women with an open medical record in the
Aragonese Health Service with electronic access, with a suicide attempt or completed suicide
registered in their medical record (code P98 according to CIAP-2 - International Classification of
Primary Care. International Classification Committee of ©Wonca) in the 6 month-period preceding
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the pandemic (from September 14, 2019, to March 14, 2020, when the state of alarm was initiated
in Spain) or during the 6 months after its onset, that is after strict confinement (May 3, 2020 to
November 3, 2020). These individuals had to have been diagnosed prior to September 14, 2019,
with any chronic mental illness with a prevalence greater than 5% (depression, anxiety, smoking,
sleep disorder, alcoholism) (Calderón-Larrañaga et al., 2017), or to have had a previous suicide
attempt.
Due to the universal nature of the healthcare system and the lack of other PHC providers, the data
obtained in this research was considered representative of the studied population.
The period of strict confinement was excluded because there are few records during this time,
either because of saturation of the health system or because they were not recorded, and
statistically the comparison cannot be made.
The exclusion criteria were records with inconsistencies in the clinical history.
The population that met the inclusion criteria was 326 persons.
Variables and Instruments
Data were collected on sociodemographic variables, chronic diseases, COVID-19 infection, and use
of health care resources during the study period where the suicide or self-harm attempt occurred.
Sociodemographic variables that are associated with the etiopathogenesis of depression and could
be collected through the PHC registry were sex, age, pharmaceutical benefit, which was linked to
the annual income of individuals (less or more than 18,000 €/year), and residence in a rural or urban
area (the latter is defined as having more than 10,000 inhabitants).
- Chronic or new mental health diagnoses in the period of suicidal behavior with prevalence above
5% (Calderón-Larrañaga et al., 2017): smoking, alcoholism, insomnia, depression and/or anxiety.
- Individuals infected with COVID-19 in the sample that attempted or completed suicide6 months
after the start of the pandemic, recorded as yes/no.
- Patient’s use of healthcare resources was assessed by the number of visits in the time period in
which suicide was attempted or completed. Specifically, we recorded the following types of visit: to
the family physician or nurse at the health center, either in regular consultation or in continuing
care (including telephone or face-to-face visits, but without distinguishing between them); to the
health center social worker; to the specialist in first or follow-up visits; and to the hospital
emergency room.
These variables were collected from the PHC records (electronic medical records and the
interactions that patients have with the health care system, which are recorded). The use of these
records allowed us to analyze sociodemographic variables, health diagnoses, and accessed health
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resources, which may indicate a change in the patient's mental health status. Professionals from the
public health network of Aragón, with appropriate qualifications and training, completed these
records.
Data analysis
The sample size allowed the use of parametric methods because, although the data do not follow a
normal distribution, the statistics tend towards normality in large samples such as this one (Lubin
Pigouche P, Maciá Antón MA, 2005). First, a descriptive analysis of the sample was performed for
the study variables, using frequencies and percentages for categorical variables, and means and
standard deviation (SD) for continuous variables. For the comparison by gender, the chi-square
statistic was used to compare categorical variables and Student's t-test for continuous ones.
Subsequently, a bivariate analysis was performed, using Chi-square when analyzing categorical
variables, and Student's t-test to compare the use of health care resources according to the time of
attempted or completed suicide (6 months before or after the start of the pandemic). Finally, a
multivariate logistic regression analysis was performed, introducing suicide or attempted suicide in
the first 6 months of the pandemic as a dependent variable in the model. The variables that had
showed a significant difference in the bivariate analysis were entered as independent variables.
These refer to the visit to the health center social worker and the number of visits in ordinary care
to the family doctor. The variables of sex and age of the patients were also introduced into the
analysis.
Statistical analysis was performed using IBM SPSS version 26 and R 4.0.5. [60] and a result was
considered significant when the p-value was equal to or less than 0.05.
RESULTS
In Aragón, 326 persons with previous high prevalence mental illness attempted or completed
suicide in the 6 months prior to or after the onset of the pandemic. Of these, 173 had a suicidal
behavior in the pre-pandemic period and 153 in the post-pandemic period. As can be seen in Table
1, 63.5% were women, with a mean age of 47.97 years (SD: 18.42, range between 16 and 92 years),
86.8% had an income of less than 18,000 Euros per year, and 83.4% had a previous diagnosis of
depression. In the comparison by gender, there were significant differences in the previous
diagnoses of smoking and alcoholism, being higher in men, as well as in the previous diagnoses of
depression and/or anxiety, which was significantly higher in women. Regarding the use of health
services according to gender, women made significantly more use of the health center's continuing
care service to receive care from family medicine, as well as follow-up visits by specialized medicine.
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Table 1
Description of the sample in the study variables and comparison by gender
VARIABLES
TOTAL SAMPLE
N=326
MEN
N= 119
WOMEN
N=207
P-VALUE
Sex
Female
Male
207 (63.5%)
119 (36.5%)
Age*
Age ranges
Under 40
Between 40 and 59
60 and over
47.97 (18.42)
123 (34.0%)
147 (40.6%)
92 (25.4%)
49.50 (20.05)
39 (32.8%)
45 (37.8%)
35 (29.4%)
47.10 (17.40)
71 (34.3%)
92 (44.4%)
44 (21.3%)
0.276
0.233
Income level
Less than 18,000 per year
More than 18,000 Euros/year
283 (86.8%)
43 (13.2%)
104 (87.4%)
15 (12.6%)
179 (86.5%)
28 (13.5%)
0.813
Geographic setting
Urban
Rural
149 (45.7%)
177 (54.3%)
54 (45.4%)
65 (54.6%)
95 (45.9%)
112 (54.1%)
0.928
Previous mental illness (yes %)
Smoking
Alcoholism
Insomnia
Depression and/or anxiety
Suicide attempt
123 (37.7%)
35 (10.7%)
74 (22.7%)
272 (83.4%)
1 (0.3%)
55 (46.2%)
18 (15.1%)
31 (26.1%)
84 (70.6%)
0 (0%)
68 (32.85%)
17 (8.2%)
43 (20.8%)
188 (90.82%)
1 (0.5%)
0.017
0.053
0.273
<0.001
0.048
New mental health diagnoses (yes %)
Smoking
Alcoholism
Insomnia
Depression and/or anxiety
8 (2.4%)
4 (1.2%)
10 (2.9%)
49 (15%)
3 (2.5%)
2 (1.7%)
5 (4.2%)
20 (16.8%)
5 (2.4%)
2 (1%)
5 (2.4%)
29 (14%)
0.953
0.573
0.368
0.496
COVID-19 infection (yes %)
13 (4%)
7 (5.88%)
6 (2.89%)
0.185
Use of health resources*
No. of visits to ordinary C
No. of visits to continuing FM
No. of ordinary nursing visits
No. of visits to continuing nursing
No. of visits to social worker
No. of 1st visits to specialist
No. of successive visits to specialist
No. of visits to hospital ER
10.28 (8.11)
2.84 (3.30)
2.12 (3.55)
2.33 (2.04)
3.00 (2.42)
1.62 (1.01)
3.46 (3.46)
2.64 (3.25)
10.13 (8.72)
2.00 (1.42)
3.52 (3.89)
1.97 (1.53)
3.11 (2.29)
1.28 (0.61)
2.80 (2.48)
2.90 (4.25)
10.37 (7.76)
3.50 (4.10)
3.79 (4.12)
2.59 (2.32)
2.90 (2.58)
1.84 (1.15)
3.80 (3.84)
2.50 (2.54)
0.811
0.002
0.762
0.111
0.795
0.388
0.014
0.069
Categorical variables, shown in frequency and percentage, and Chi-square statistic is used except in * Continuous
variables, shown in means and standard deviations, and Student's t-statistic is used. No.: Number, FM: Family Medicine,
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Continuing: Continuing Care, ER: Emergency Room.
In the bivariate analysis, when comparing the individuals who attempted or committed suicide
during the two time periods —6 months prior to the onset of the pandemic or 6 months after it, as
can be seen in Table 2— we found significant differences in the variables among people who used
the social work and family medicine services. Among those who were suicidal during the first 6
months of the pandemic, a lower percentage visited the social services of the health center. On the
other hand, among those who visited their family physician, they did so significantly more
frequently.
Table 2
Comparison of individuals with suicidal behavior (attempted or completed suicide) 6 months before the pandemic and 6
months after the pandemic.
VARIABLES
PERSONS WITH SUICIDAL
BEHAVIOR 6 MONTHS
BEFORE THE PANDEMIC
N= 173
PERSONS WITH SUICIDAL
BEHAVIOR 6 MONTHS AFTER
THE PANDEMIC
N= 153
P-VALUE
Sex
Female
Male
109 (63%)
64 (37%)
98 (64.1%)
55 (35.9%)
0.845
Age*
47.23 (18.36)
48.81 (18.51)
0.441
Income level
Less than 18,000 per year
More than 18,000 Euros/year
151 (87.3%)
22 (12.7%)
132 (86.3%)
21 (13.7%)
0.788
Geographic setting
Urban
Rural
82 (47.4%)
91 (52.6%)
67 (43.8%)
86 (56.2%)
0.514
Previous mental illness (yes %)
Smoking
Alcoholism
Insomnia
Depression and/or anxiety
Suicide attempt
65 (37.6%)
15 (8.7%)
40 (23.1%)
149 (86.1%)
1 (0.6%)
58 (37.9%)
20 (13.1%)
34 (22.2%)
123 (80.4%)
0 (0%)
0.950
0.201
0.847
0.165
0.347
New mental health diagnoses (yes %)
Smoking
Alcoholism
Insomnia
Depression and/or anxiety
5 (2.9%)
2 (1.2%)
7 (4%)
26 (15%)
3 2%)
2 (1.3%)
3 (2%)
23 (15%)
0.588
0.902
0.276
0.999
Use of health resources (yes %)
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Persons visiting ordinary FM
Persons visiting continuing FM
Persons visiting ordinary nursing
Persons visiting continuing nursing
Persons visiting social worker
Persons1st visiting specialist
Persons successively visiting specialist
Persons visiting hospital ER
168 (97.1%)
80 (46.2%)
89 (51.4%)
59 (34.1%)
28 (16.2%)
31 (17.9%)
71 (41%)
156 (90.2%)
149 (97.4%)
79 (51.6%)
98 (64.1%)
42 (27.5%)
12 (7.8%)
33 (21.6%)
64 (41.8%)
133 (86.9%)
0.879
0.331
0.202
0.195
0.022
0.408
0.885
0.357
Use of health resources*
No. of visits to ordinary MF
No. of visits to continuing MF
No. of ordinary nursing visits
No. of visits to continuing nursing
No. of visits to social worker
No. of 1st visits to specialist
No. of successive visits to specialist
No. of visits to hospital ER
9.18 (7.49)
2.86 (3.08)
3.76 (3.79)
2.37 (2.19)
3.03 (2.44)
1.74 (1.12)
3.36 (3.55)
2.50 (3.37)
11.52 (8.62)
2.83 (3.53)
3.63 (4.25)
2.28 (1.83)
2.91 (2.50)
1.51 (0.90)
3.57 (3.38)
2.81 (3.12)
0.011
0.959
0.824
0.829
0.891
0.380
0.724
0.404
Categorical variables, shown in frequency and percentage, and Chi-square statistic is used except in * Continuous
variables, shown in means and standard deviations, and Student's t-statistic is used for hypothesis contrasting. No.:
Number, FM: Family Medicine, Continuing: Continuing Care, ER: Emergency Room.
Regarding the multivariate logistic regression analysis —on factors related to attempted or
committed suicide comparing both the first 6 months after and before the onset of the pandemic—
a significant model was obtained (value= 0.008), with a Cox and Snell R squared of 0.043, and a
Nagelkerke R squared of 0.057. As can be seen on Table 3, variables related to attempted or
committed suicide during the first 6 months of pandemic included not having visited the health
center social worker, and having more frequently visited the family physician. This means that
people who did not visit the social worker (odds ratio 2.529, value 0.013) and who visited the family
medicine professional more often (odds ratio 1.041, value 0.007) had a higher risk of suicide or
attempted suicide. The factor of greatest importance is not visiting the health center social worker,
with an Odds ratio of 2.378, that is, the risk of suicidal behavior is 2.378 higher.
Table 3.
Multivariate logistic regression of factors associated with suicidal behavior during the first 6 months of the pandemic
compared to the 6 months prior it
B
Exp (B)
Odds ratio
95% Confidence Interval
for Exp(B)
p-value
Intersection
-1.601
0.002
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FM: Family Medicine,Continuing: Continuing Care.
DISCUSSION
The aim of this study was to analyze and compare the profile of persons who committed suicide or
made a suicide attempt 6 months before the pandemic and during the 6 months after its onset, from
a cohort of patients with previous high prevalence mental health illnesses using Primary Health Care
records. It can be affirmed that the sociodemographic profile of persons who attempted or
completed suicide did not change when comparing the cases from 6 months before and 6 months
after the pandemic, since no significant differences were found in the variables of sex, age,
economic income, and rural or urban setting. In our research, the profile of people who have self-
injure behaviors tends to be female, with an income of less than 18,000 Euros per year, with a
previous or new diagnosis of depression and/or anxiety. These results endorse the relationship
between suicidal behavior and the presence of depression and anxiety (Beck et al., 1990; Gouin et
al., 2023; Hu et al., 2023; Laghaei et al., 2023; Nawaz et al., 2023; Ribeiro et al., 2018; Souza et al.,
2023; Wilk et al., 2023; Zhang et al., 2022), as well as with other social determinants of health.
In the sample of this study, 63.5% of individuals were women, which also indicates us the
relationship between being female and suffering depressive episodes (Girgus & Yang, 2015;
Grigoriadis & Robinson, 2007; Hyde et al., 2008; Hyde & Mezulis, 2020; Kuehner, 2003; Lin et al.,
2021a, 2021b; Parker & Brotchie, 2010; Salk et al., 2017; Smith et al., 2007), and therefore a higher
risk of suicidal behavior. On the other hand, there is abundant literature linking financial stress or
low socioeconomic status and suffering from depression (King et al., 2008; Lorant et al., 2007; Weich
et al., 2007; Weich & Lewis, 1998) and/or suicidal behavior (Choi et al., 2021; Mathieu et al., 2022).
The comparative bivariate analysis by gender of people who attempted or completed suicide shows
that women who commit suicide or have a suicide attempt have mostly (90.82%) a diagnosis of
depression and/or anxiety. It should be noted that the gender difference regarding depression not
only has a multifactorial etiology (Hyde et al., 2008; Hyde & Mezulis, 2020), but also has to do with a
developmental context (Salk et al., 2017), since there are vital moments in which there may be a
greater vulnerability or stressors that appear to produce this gender difference. The gender
Not visiting the health center social
worker
0.928
2.529
1.216 5.258
0.013
Visiting the social worker
0b
Ref
.
No. of visits to continuing FM
0.040
1.041
1.011 1.071
0.007
Male
-0.019
0.981
0.613 1.569
0.937
Female
0b
Ref
.
Age
0.005
1.005
0.993 1.018
0.384
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difference in treatment is also noteworthy, i.e., men are referred less frequently or receive a lower
follow-up by psychiatric services.
On the other hand, both the multivariate and the comparative bivariate analyses between persons
who had attempted or committed suicide in the 6 months prior to the pandemic and those who had
attempted or committed suicide in the 6 months after its start, reflect the importance of the health
care system for suicide prevention. Not only those who did not visit the social worker at the health
center, but also those who consulted their family physician and yet—either because it was a
telephone consultation or because of saturation—did not receive adequate care had a higher risk of
self-inflicted suicide attempts. Contact with the health care system and appropriate response may
be crucial in suicide prevention (Myhre et al., 2023).
With respect to visits to the health center social worker, several studies have found that during the
first year of the pandemic there was a negative impact on the life quality of users at the physical,
psychological, social and economic levels (Algamdi, 2021; Hossain et al., 2020), as well as an increase
in distress in households (Shah et al., 2021). The impact of the pandemic at the economic and social
levels has been devastating and has generated highly stressful situations for individuals. Social work
professionals have tools both to minimize the effects of the social determinants of health and to
promote prevention and complement psychosocial treatment of addictions or other mental health
pathologies (Burke & Clapp, 1997; Wells et al., 2013).
This study focuses on the consequences of the COVID-19 pandemic on suicidal behavior (attempted
or completed suicide) in people with a previous diagnosis of mental illness of high prevalence
(prevalence greater than 5%) such as depression and anxiety, smoking, alcoholism and sleep
disorders. This population sector is vulnerable to the situations experienced during the COVID-19
pandemic (Lear-Claveras et al., 2022).
This investigation has strengths and limitations. Among the strengths, we can highlight the use of
primary care records in Spain which, given the universal nature of primary care, make these data
representative of practically the entire population. Moreover, PHC is the gateway for most citizens
to the health system, since it represents the level closest to them. Strength is that this study aims to
delve into the consequences of the pandemic in a vulnerable population group such as people with
previous mental illness. The consequences of COVID-19 on the well-being of general population have
been extensively studied, but there is not much research of the kind presented here. On another
note, the first limitation would be the length of the study, which could be extended to further
explores the long-term consequences of the pandemic in relation to suicidal behavior in people with
pre-existing mental illness. The second limitation is that the source of information consulted was
data from clinical records and the health system, but although they allow us to develop studies from
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an ecological perspective, we cannot deepen factors that are not systematically recorded, such as
personality factors, social support, etc. In addition, by using data from clinical records, people in
social exclusion have been left out of the analysis, although suicide attempts generally end up in the
health system. The third limitation is that remote assistance was used in primary care during the
pandemic, and it is not possible to differentiate whether the visit was made in person, online or by
telephone. The fourth and final limitation is the scope of the study. It corresponds to a single
autonomous community in Spain which, although its population and geographical characteristics
make it representative of other areas of Spain and Europe (Llorente et al, 2018), it would be
interesting to replicate this study in other communities or countries to widen the external validity of
the results.
The implications of this study would indicate that, in future situations similar to those experienced
during the COVID-19pandemic, it is greatly important that people at higher risk of suicide due to
previous psychiatric illnesses are not alienated from the health system, or that the health system is
more proactive in approaching these people.
CONCLUSIONS
In the first 6 months after strict confinement, the sociodemographic profile of people with suicidal
behaviors did not change. This profile is usually female, and it is related to the preexistence of an
episode of depression and/or anxiety. On the other hand, a higher risk of suicidal behavior during
the pandemic has been found in people who did not have contact with the health system, especially
with the social worker at the health center and the continuing care services.
AVAILABILITY OF DATA AND MATERIALS
Data supporting the findings of this study are available, upon reasoned request, from the
corresponding author.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
FUNDING
This study has been funded by the Department for Science, Universities and the Knowledge Society
of the Government of Aragon (Spain), through the DGACovid-01 project. The B21_20R Research
Group of the Department of Research, Innovation and Universities of the Aragon Regional Authority
(Spain); and the European Regional Development Fund (ERDF) “A way to make Europe” also funds it.
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AUTHOR CONTRIBUTIONS
LM, MDG and MªJSR were responsible for the following contributions: conceptualization, data
duration, formal analysis, drafting-original manuscript, and editing. MMT and MRH were responsible
for the following contributions: writing, editing, and revising the manuscript.
ACKNOWLEDGMENTS
The authors would like to thank Selene Fernández and the Association of Depressive Disorders of
Aragon (AFDA), their workers and associates for their collaboration in the development of this study.
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