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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 249-255

Suicidal behavior during the COVID-19 pandemic: A finding of an Indo-Nigerian online survey


1 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Human Nutrition, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria
3 Department of Psychiatry Nursing, KGMU College of Nursing, King Georg's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission11-Sep-2021
Date of Acceptance08-Jul-2022
Date of Web Publication17-Sep-2022

Correspondence Address:
Dr. Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_219_21

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  Abstract 


BACKGROUND: The COVID-19 pandemic has a significant impact on the mental health and is associated with high suicidal behavior. This study is an effort to scrutinize suicidal behavior among general population in two countries, namely India and Nigeria.
METHODS: This was an online survey conducted on 536 adult participants (272 from India and 264 from Nigeria) over a period of six months. It was conducted using a snowball sampling method. The participation in the survey was entirely voluntary. Current suicidality was measured among the participants. Data were collected in two countries only.
RESULTS: Feeling of hopelessness over the past one month was reported by more than one-fifth of Indian as well as Nigerian participants. The differences in suicidal behavior of Indian and Nigerian participants were not statistically significant. Intention to hurt self and passive death wishes in the Indian population was higher than Nigerian participants, which can be explained by significantly higher medical morbidity and past psychiatric illness history in the Indian participants. Suicide attempt was reported in 1.1% of Indian participants and 1.51% of Nigerian participants in the past one month. On the other hand, 5.88% of the Indian participants and 2.65% of the Nigerian participants had suicidal ideation in the past month.
CONCLUSION: High suicidal behavior has been reported during the COVID-19 pandemic among the participants from India and Nigeria.

Keywords: COVID-19 pandemic, general population, India, Nigeria, suicidal behavior


How to cite this article:
Sinha K, Oyetunji TP, Mishra S, Fatima H, Prakash AJ, Singh N, Srinivasan G, Kar SK. Suicidal behavior during the COVID-19 pandemic: A finding of an Indo-Nigerian online survey. Indian J Health Sci Biomed Res 2022;15:249-55

How to cite this URL:
Sinha K, Oyetunji TP, Mishra S, Fatima H, Prakash AJ, Singh N, Srinivasan G, Kar SK. Suicidal behavior during the COVID-19 pandemic: A finding of an Indo-Nigerian online survey. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 29];15:249-55. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/249/356272




  Introduction Top


In December 2019, a highly infectious severe acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) emerged in Wuhan, China. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. Between April and September 2020, there was exponential growth in the number of COVID-19 cases in India (1998 cases on April 1, 2020, to 5,115,893 cases by September 16, 2020) and Nigeria (174 cases on April 1, 2020, to 56,604 cases by September 16, 2020).[1],[2] This exponential growth further continued and, as of April 20, 2022, there were 506,106,457 confirmed cases of COVID-19 globally, including 6,228,373 deaths, and the largest number of cumulative cases were reported from the United States of America followed by India.[3] By April 20, 2022, in India, 43,047,594 cases and 522,006 deaths were reported, whereas in Nigeria, 255,670 cases and 3143 deaths were reported.[3] These data suggest that this pandemic has reached to a level of humanitarian crisis with a negative impact not only on physical health but also a serious impact on the mental health of the people. It has also been seen previously that during the pandemic period when all resources are geared up for the containment of infection, mental health care does not take up much of precedence, further increasing the vulnerability of the public.

The COVID-19 pandemic has led to serious psychological impact due to multifaceted causes, including the fear and stigma associated with the pandemic, inadequate knowledge, lack of resources, lockdown implementation, loss of loved ones, and direct and indirect economic implications.[4] In particular, these effects may render the infected individuals and the general population vulnerable to develop a range of emotional reactions including psychiatric conditions, unhealthy behaviors including excessive substance use and behavioral addictions, and also noncompliance with public health directives.[5] These outcomes will be disproportionately more pronounced in those with preexisting psychiatric illness, migrant workers, health-care workers, and homeless individuals, making the situation more challenging in these groups of vulnerable populations.[4] As the pandemic has evolved, a number of studies have examined the impact of COVID-19 crisis on mental health on the general population, health-care workers, and people with mental illness. It is evident that social isolation and fear of contracting illness has negatively impacted the mental health of the public.[6]

One of the serious mental health concerns as a result of this pandemic is the risk of suicide. It was seen that deaths by suicide increased in the USA after the 1918-1920 Spanish flu pandemic (though there was a dip in the suicide rate during the pandemic from prepandemic period)[7] and among older people in Hong Kong during the 2003 (31.7% increase in suicide rate in comparison to the year 2002) severe acute respiratory syndrome (SARS) epidemic.[8] A wide range of interrelated pandemic reactions can heighten the risk for suicide, and knowledge regarding this will help plan effective preventive measures. The risk factors for suicide during the pandemic include preexisting mental illness, poor access to mental health care, financial stressors, domestic violence, alcohol consumption, isolation and loneliness, entrapment during the lockdown, bereavement, access to means, and irresponsible media reporting.[9] The suicidal behavior resulting from the pandemic can have varied presentation depending on the region's public health control measures, the sociodemographic structure, accessibility to mental health care, and support.[9] These differences in the pattern of suicidal behavior have not been explored much in the general population. This study compares the difference in suicidality (ideation, plan, and attempt) among the general population between Nigeria and India during the pandemic period.


  Methods Top


This was an online, anonymous survey. The sample was gathered using an exponential snowball sampling method as the data were collected via Google Forms. The message was sent to people in groups such as WhatsApp, Facebook, Email, and Twitter. They were then asked to complete the survey and then forward the link to close contacts. The survey began on April 22, 2020, and ended on September 16, 2020. Two nations, India and Nigeria, participated in the survey. The requirements for inclusion age ranged between 18 and 60 years, completed 10 years of formal schooling, and had Internet access. Participation was entirely voluntary. Those who were currently having any psychiatric illness or currently COVID-positive (at the time of participation) were excluded.

Measures

On opening the link of survey, details of the survey and consent to participate in the survey were displayed. As the participation the survey was, voluntary, the individual had right to decline to participate in the survey. The survey questions were displayed only after the participant agreed to consent for the survey. A semistructured pro forma, which includes (voluntary) country, age, sex, education, occupation, marital status, religion, residence and type, whether living alone or with family (demographic and personal characteristics), was used. This survey also explored about the presence of any current medical illness (irrespective of their severity currently including in the past 30 days). A survey also explored about whether or not the participant works in a hospital for the care of patients and whether, the participant has any COVID-19 associated symptoms.

To measure the suicidal behavior in past one month, Suicide module of MINI 6.0.0 was used.[10]

The study proposal was reviewed and approved by the Institutional Ethics Committee of India and Nigeria's study institute (ethics committee of King George's Medical University, Lucknow, India: IIIrd ECM COVID-19 IB/P3; University of Ibadan, Nigeria: AD 13/479/2000B). Descriptive statistics were applied, and statistical analysis was done using the (GraphPad Software, San Diego, California USA) online version. The mean values were compared by unpaired t-test, and the Chi-square test compared the categorical variables. For statistical significance, the P value was considered <0.05.


  Results Top


In this study, the dataset of 543 respondents was analyzed, of which the data of seven respondents were found to be incomplete, hence excluded. The final sample size was 536, consisting of a dataset of 272 and 264 respondents from India and Nigeria, respectively.

The respondents' age ranged between 18 and 60 years, with a mean age of 30.05 ± 8.74 years for Indian participants and 25.98 ± 6.04 years for the Nigerian participants. Furthermore, most of the respondents were male, accounting for as many as 59.93% and 53.41% of the total Indian and Nigerian participants, respectively (NIndia = 163; NNigeria = 141). The mean years of education of the respondents from India and Nigeria were found to be 17.32 ± 5.37 and 13.33 ± 6.75, respectively. The majority of the Nigerian participants were single (80.30%) than the Indian respondents (54.41%). Furthermore, more than half of the Indian participants (64.71%) were employed compared to 44.32% of the Nigerian respondents. About 23.52% of participants from India and 4.54% from Nigeria were employed in the health-care sector.

As shown in [Table 1], about 89.02% of the Nigerian participants belonged to the nuclear family system compared to 66.51% of the Indian participants. The percentage of urban dwellers was almost similar in Indian participants (82.72%) and the Nigerians (82.58%). The majority of the participants from both the nations were living with their families.
Table 1: Comparison of sociodemographic and clinical variables between Indian and Nigerian participants

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The respondents' current state of mood (in the past one week) was measured using a Likert scale of 1 to 10, and the results showed the mean value of 6.92 ± 2.09 and 6.46 ± 2.31 for the Indians and the Nigerians, respectively, and it was found that there was a significant difference (P = 0.016) in the current mood state between the participants of these two nations. Only four and five participants from India and Nigeria, respectively, had reported symptoms related to COVID-19, while most of the participants reported none. Furthermore, the majority of the participants from both the nations did not report any current medical illness. Further, only about 8.8% of respondents from India had a history of psychiatric illness, while the percentage was even less than one (NNigeria = 2) for the Nigerian participants [Table 1]. Thus, Indian participants had significantly higher medical morbidity (P = 0.0021) and past psychiatric illness history (P ≤ 0.0001) than Nigerian participants.

[Table 2] shows the suicidal behavior among the respondents over the past 30 days. About 6.62% of the Indian participants and about 3.79% of the Nigerian participants had a plan or intention to either actively or passively hurt themselves. When asked about the feeling of hopelessness, about 24.26% of the Indians and 21.2% of the Nigerian participants had reported such feelings, and 7.72% of Indian participants and 3.79% of the Nigerian participants had the wish to die at the time of the COVID-19 pandemic.
Table 2: Suicidal behavior among the respondents

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About 6.62% Indian and 14.17% Nigerian participants had thought about hurting or injuring themselves or had mental images of harming themselves, with at least some intent or awareness that they might die as a result. Similarly, 5.88% of the Indian and 2.65% of the Nigerian participants had thought about suicide. Furthermore, about 8.09% and 4.54% of the Indian and Nigerian participants, respectively, have difficulty restarting themselves from acting on these impulses during this pandemic.

In this study, we also found that about 3.31% of Indian participants and 3.03% of the participants from Nigeria had a suicide method in mind, and as much as 4.04% of Indian participants and 2.27% of the Nigerian participants had intended to die as a result of a Suicidal act during the COVID-19 pandemic. Furthermore, within the past 30 days of the study, two participants from each nation had taken active steps to prepare to kill themselves but had not started the suicide attempt. Data regarding the participants who had actively injured themselves on purpose without intending to kill themselves had revealed that as many as 5 Indians (1.84%) and 5 Nigerian participants (1.89%) had responded in affirmation. About 1.10% of Indian and 1.51% of the Nigerian participants had made a suicide attempt within the last 30 days of the study. Results have also revealed that about 1.10% of the Indians and 1.89% of the Nigerian participants had taken any active steps to prepare to injure themselves or to prepare for a suicide attempt in which they had expected or intended to die [Table 2].


  Discussion Top


During the COVID-19 pandemic, several cases of suicide have been documented from various corners of the world, including India.[11],[12] Existing research suggests about the close association of suicide with disasters like COVID-19 pandemic. This study attempted to give an insight to the suicidal behavior during COVID-19 pandemic in India and Nigeria. COVID-19 experience has been enormously stressful for everyone and across countries. Feeling of hopelessness over the past one month was reported by more than one-fifth of Indian and Nigerian participants. Given the novelty of COVID-19, questionable evidence (scheduling the doses, number of doses, safety, duration of protection, effectiveness against various strains of COVID-19) of vaccine, lack of specific treatment for it, and abrupt lifestyle changes can cause to an extent a significant increase in mental disposition.[13] Studies show that major concern during the pandemic is fear of isolation/loneliness, job loss, stress, and financial insecurity.[13],[14] Among our study participants, the slight and insignificant difference from both the countries is apropos to the research expectations that though COVID-19 experience differs in terms of severity, the fear and negative feelings cut across every country. However, hopeless feelings can trigger negative thoughts, which could aggravate suicidal behavior.[15] The challenge of empty feelings and suicide has been documented in past pandemics, triggered by social isolation, fear, and uncertainty.[16],[17] More mental health campaigns should be provided to ameliorate the underlying suicidal factor and its devastating effect. The study reveals that Indian participants have significantly higher medical morbidity and past psychiatric illness history than Nigerian participants. Intention to hurt self and passive death wishes in the Indian population is higher than Nigerian participants, which can be explained by significantly higher medical morbidity and past psychiatric illness history in the Indian population. Similarly, Indian participants have a higher educational level, so academic loss for the participants (which happened during the lockdown and postlockdown period due to closure of academic institutions) can become a matter of concern. Similarly, anticipated fear of unemployment (due to academic loss, lockdown, and uncertainty of the course of pandemic) may be a possible reason for suicidal behavior. Although the Indian population have relatively higher medical morbidity and history of psychiatric illness, they had significantly lesser negative mood state than Nigerian participants. This may be due to difference in the health-care facilities in both the countries, access to health-care facilities, and adequacy of care.

However, there were no significant differences in suicidal behavior reported subjectively in Indian and Nigeria; the diminutive study sample size might be a significant factor for the observation. Moreover, suicidal behavior reporting is subject to underreporting and social desirability bias.[18]

This study revealed a significant difference (P = 0.016) in the current mood state between Indian and Nigerian participants, as subjectively reported. Nigerian participants had a more negative mood state than the Indians, which may be explainable by poor psychosocial support (as most are single) and higher unemployment as revealed in the study demographics-another alternative contribution includes the disparity in socioeconomic status and COVID-19 palliative programs between the countries. Pre-COVID-19 pandemic, India is the fifth biggest global economy,[19] while Nigeria, just out of recession, was struggling with minimal economic growth.[20],[21],[22],[23] COVID-19 could exacerbate the fear of more significant economic hardship, which was revealed in Nigerian citizens' agitation against lockdown measures due to perceived less support to meet daily needs.[22] Evidence also shows the disparity in psychosocial support systems were provided for the citizen during the pandemic between the two countries. According to a scoping review on mental health evidence in Asia and Africa, fewer mental health activities were observed in Nigeria; however, in India, several institutions such as the National Centre for Suicide Research and Prevention of Mental Ill-Health, Centre for Addiction Medicine (NIMHANS), and Drug E-Addiction and Treatment Centre (PGIMER) provided early intervention to curb suicide attempt, initiated an e-Consultation portal for psychoeducation.[23]

In this study, suicide attempt behaviors were slightly higher in Nigeria compared to India. This finding justifies the Global Suicide Report: Nigeria has a suicide mortality rate of 17.3/100,000 population compared to India's 16.5 per 100,000 population. It is documented that for every suicide confirmed, there is likely over 20 cases of suicide attempt.[24] More stringent measures should be placed to monitor the suicidal-triggering factors and activities to avoid worsening the pandemic burden. On the other hand, our finding shows a variation in suicide ideation across Nigerian and Indian participants. It is noteworthy that despite the pandemic situation, suicide ideation was reported by only 2.5% of the Nigerian participants and 5.8% for the Indian participants. As of the time of the study, COVID-19 burden was higher in India than in Nigeria. During the study period, COVID-19 cases in India and Nigeria were 29,435, and 1337, respectively, while the number of deaths in India and Nigeria was 934 and 40, respectively.[25] However, our finding across both the countries is lower than the prevalence observed across previous studies. A study across 17 countries, including Nigeria using WHO World Mental Health (WMH) survey data, reported suicidal ideation at 3.2% for Nigeria. In contrast, 7.28% was observed in a more recent national study.[26]

Similarly, a study among the Indian adult population reported 12.5% suicide ideation prevalence.[27] This study's lower prevalence could be attributed to the smaller sample size, variation in methodologies, and unknown bias. The National Mental Health Survey of India (2015–2016) estimated suicidality among general population in the community (n = 34748) and found the prevalence of suicidality among females to be 6.0% and among males to be 4.1%, respectively.[28] This indicated that the suicidal behavior in general population during the initial phase of pandemic was low. As the participants in these studies are not true representative of the community population and the individuals participated were mostly educated (understanding English), it may be a potential bias to the findings of the study.

Limitations

This online survey included 536 valid respondents from India and Nigeria; hence, the results of this study are restricted due to the small sample size. The data were collected using snowball technique through Google Forms shared via social media platforms; hence, the sample may not be representative of the general population and the results cannot be generalized. The data collection was carried out between April 2020 and September 2020; the COVID situation has been ever-changing and the impact of the pandemic on mental health has also varied over time; hence, the findings may also differ and cannot be generalized for the effect of pandemic as a whole. Self-reported Likert scale was used for measuring the current mood state; however, a better scale for the assessment of mood state might be more useful in future studies.


  Conclusion Top


Suicide attempt has been reported in 1.1% of Indian participants and 1.51% of Nigerian participants in the past one month. On the other hand, 5.88% of Indian participants and 2.65% of the Nigerian participants had suicidal ideation in the past month. There are no significant differences in the suicidal behavior of Indian and Nigerian participants. However, intention to hurt self and passive death wishes in the Indian population is higher than Nigerian participants, which can be explained by significantly higher medical morbidity and past psychiatric illness history in the Indian population. Indians reported less negative mood state than the Nigerians. Hence, the study provided an understanding of the suicidal behavior of general population in India and Nigeria. Further studies, with larger sample size and prospective approach, will be more helpful in inspecting this phenomenon in more detail and will provide useful insights in developing preventive strategies, especially in situation of such crises.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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