Introduction

Self-inflicted death, or the act of deliberately taking one’s own life, is a complex phenomenon that is difficult to decide from one moment to the next; it is a process associated with emotional crises that result in despair, existential emptiness and a los solution to them is death. The risk and protection factors for suicide are diverse. In their understanding lies the possibility of designing assertive intervention and prevention strategies, aimed at safeguarding the most valuable thing a human being has, his or her life. This article aims to delve into relevant aspects of suicide and its link with Covid-19.

1. Suicide in the world

Suicide is a public health problem, which has increased significantly in our country and in the world. According to the World Health Organization ⁽¹, ²⁾, every year around 800 thousand people commit suicide; in other words, every 40 seconds a person in the world dies from this cause. The worldwide suicide rate is 10.6 per 100 thousand inhabitants (13.5 in men and 7.7 in women); however, there are significant differences depending on the economic income of nations, since, despite the fact that 79% of self-inflicted deaths occur in low and middle-income countries, the suicide rate is higher in those with high incomes (rate of 10.5 vs. 11.5 respectively). Prevalence according to sex is also influenced by the economic variable. While in developed countries men commit suicide almost three times more than women, in developing countries 1.5 men die from suicide for every woman ⁽³⁾. These data allow us to identify that, in global terms; men commit suicide more than women do. However, there are some exceptions, such as China, where the suicide rate per 100,000 inhabitants is 10.3 in women and 9.1 in men ⁽⁴⁾.

In general, in almost all countries of the world, individuals under 15 years of age commit less suicide and those between 15 and 49 years of age commit more. Adults over 70 years old or more are also represented in this group ⁽⁵⁾. Since 2015, suicide is the second leading cause of death in the world population between 15 and 29 years, after road accidents. In adolescents between 15 and 19 years old, it is the second cause of death in women (after maternal conditions) and the third in men (after deaths from interpersonal violence and traffic accidents) ⁽²⁾.

The methods of suicide depend largely on social and cultural factors, as well as on access to these means. However, globally, hanging is the most common, followed by firearms and voluntary pesticide poisoning (the latter used mostly in rural areas) ⁽¹, ³⁾. In Asian countries such as China, Taiwan, Hong Kong and Japan, for example, high jump and carbon monoxide, hydrogen sulfide, and helium gas poisoning are common suicide methods.

2. The situation in Mexico

If all the regions established by the World Health Organization are considered, Europe has the highest suicide rate (15.4), and of this, the Eastern Mediterranean region (3.9) has the lowest. America has a rate of 13.2 suicides per 100 thousand inhabitants (14.8 in men and 11.7 in women) ⁽²⁾.

With a rate of 6.1 self-inflicted deaths per 100,000 inhabitants, the presence of suicide in Latin America is low compared to other countries in the world. In this area, Mexico has a rate of 5.1 suicides (8.0 for men and 2.3 for women). The number may seem low; however, two fundamental elements must be considered. The first and most important is that all life is valuable and, secondly, that the numbers have increased alarmingly in recent years. Specifically, in the last 37 years there has been a 976% increase in the presence of suicide in our country (in 2017 there were 6,559 suicides). The states with the highest suicide rates in Mexico are Chihuahua (11.4), Yucatan (10.2), Aguascalientes (9.6), Campeche (9.1), Colima (8.5), Guanajuato (7.8), Quintana Roo (7.7), Jalisco (7.2), Baja California Sur (7.1) and Sonora (7.1) ⁽⁶⁾.

Death from this cause follows the world trend, so that it is more frequent in men (80.1% of suicides) than in women (19.9%), which represents a rate of 8.5 suicides per 100,000 men and 2.0 per 100,000 women. In both cases, the main method is hanging, strangulation or suffocation ⁽⁷⁾.

In Mexico, suicide is the third cause of death in adolescents between 15 and 19 years of age and the fifth in children under 15 years of age ⁽⁸⁾. Six out of every 10 deaths by suicide occur in people under 30 years of age,¹ mostly women.² Specifically, it is noteworthy that when one is 29 years old or younger, female suicides represent a higher percentage in our country. However, as age increases, the number of self-inflicted deaths in men is greater, to the point that in persons 65 years of age or older, the percentage distribution of suicides is 7.7 in men and 2.7 in women ⁽⁷⁾.

It is substantial to distinguish the factors that intervene in the behavior of this variable, so that not only are developed strategies of suicide prevention according to age and gender separately, but also intervention maneuvers can be articulated, considering the interposition of both elements, without excluding, of course, the presence of other factors contributing to suicidal behavior.

3. Risk factors in suicide

The interest in identifying the causes of suicide has given rise to multiple investigations that conclude its multifactorial origin and the combination of cognitive and neurobiological elements associated with stressful and/or traumatic life situations ⁽⁹⁾.

Factors such as experiences of trauma in childhood and/or adolescence, family dysfunction, fractured family communication, domestic violence (having lived through it or witnessed it), psychological abuse, physical or sexual violence, bullying, absence of a life project, hopelessness, diminished sense of life, existential emptiness and lack of a social support network are considered to be at risk for suicidal behavior^{3 (10- 17)}.

In the areas of genetics and neurobiology, studies have dealt with the gene and protein expression involved in suicidal behavior and serotonin metabolism, the possible identification of specific genes associated with suicidal behavior, and the brain areas linked to emotional processing, real or imagined perception of pain, suicidal ideation, and suicide attempt ^{(18- 22)}.

The mental disorders primarily underlying suicidal behavior are depressive disorders (particularly major depressive disorder), posttraumatic stress disorder, anxiety disorders (including generalized anxiety, social phobia, and panic disorder), substance use disorders, and personality disorders ^{(23- 29)}. These disorders are involved with suicidal behavior not only because of the symptoms of each disorder or even the comorbidity that may exist between two or more mental and/or personality disorders, but also because of the associated difficulty to effectively tolerate stress, frustration or adverse situations, as well as to implement effective social skills and problem-solving strategies.

Specifically, anxiety disorders have been associated with a greater risk of suicide if accompanied by some depressive disorder, since they seem to form a bridge between suicidal ideation and suicide attempt ⁽³⁰, ³¹⁾. The consumption of substances, including alcohol, is closely related to suicide in all age groups from adolescence onwards ^{(32- 34)}, which is why suicide prevention should include addiction prevention and comprehensive rehabilitation programs.

Although the influence of mental disorders on suicidal behavior is undeniable, it has been emphasized that not all persons who present suicidal ideation, suicide attempts, or even death from self inflicted damage, have some mental and/or personality disorder ⁽³⁵⁾. Recent research points out that suicide is more than a mental health problem, since the motivations for carrying out suicide are also linked to social factors and life crises caused by a decrease in social adjustment, affectation of relationships or interpersonal relationships, unemployment and work or financial stress ⁽³⁶, ³⁷⁾.

4. Suicide and Covid-19

The introduction of Covid-19 brought with it many more challenges than the disease itself. The pandemic has had implications as serious as the death of nearly one million people worldwide ⁽³⁸⁾. The suffering from the loss of a loved one with the concomitant complications of grieving, the economic crisis and unemployment, mental illnesses that have emerged and been exacerbated by confinement in all age groups, access to the means of causing death ⁽³⁹⁾, which have not yet been restricted despite the recommendations of the World Health Organization, and even the polarity in the manifestations of affection towards health workers.

The imminent impact of the factors associated with Covid-19 with suicide, has generated the alert of specialists around the world. They warn of the probable increase in suicidal behavior during the health crisis ^{(39- 45)} and even, once it has been controlled, since it is a fact that, despite the predictions that may be generated about the «wave»⁴ of mental disorders and suicides caused by confinement, we know little about the real impact that it will have on people’s lives.

Although more research is needed, the figures so far indicate an increase in suicidal behavior from December 2019 and January 2020. Suicides linked to the Covid-19 pandemic have been reported in Mexico, and particularly to confinement and its associated elements. During the more than 150 days of social distancing in our country, a greater number of people (a significant percentage of men and young adults) ⁽⁴⁶⁾ have been identified with suicidal gestures, in which fortunately, intervention has been achieved. In some cases, the action has been in real time, but in others, it has been possible to carry out psychological first aid and crisis intervention via telephone or through Whatsapp, provided by workers from government agencies or volunteers from clinical and educational institutions. An increase in calls for psychological help has been observed as the months have progressed. Thus, a greater number of calls were received in July 2020 than in March of the same year ⁽⁴⁷⁾. The requests for psychological support, requested directly by the person who requires it, or by someone close -family or friend- are for feelings of loneliness and isolation, changes in mood, irritability, sadness, stress, fear, anxiety, depression, sleep disorders, addictions, episodes of domestic violence, break-up of relationships, damage to interpersonal relationships, suicidal ideation and suicide attempts ^{(48- 51)}.

With these data, one could say that Covid-19 has had a significant impact on mental health and specifically on self-inflicted death; however, it is worthwhile to delve into each of the factors that could be involved in this association.

One of the main ones recognizes the global economic and labor crisis, which is estimated to be the loss of nearly 25 million jobs, according to the International Labor Organization. If these forecasts come true, working poverty, originally predicted to be 14 million worldwide by 2020, would be between 8.8 and 35 million people ⁽⁵²⁾. Latin America has been more affected than other countries in the Americas, Europe and Asia, with a loss of 18.3% of working hours recorded in the second quarter of 2020, 14% above the global decline in the same; Chile, Brazil, Colombia and Mexico are the most affected countries ⁽⁵³⁾.

In our country, 11.9 million people have been temporarily suspended from work without pay, of which only 42.3% believe they could return to work once the health contingency is over ⁽⁵³⁾. According to the National Institute of Statistics and Geography (INEGI), in nearly 30% of homes a family member lost his or her job because of the pandemic, and in 65.1% of homes income has decreased ^{(53- 57)}. The figures indicate that those most affected by unemployment are women working in the informal sector ⁽⁵⁸⁾, including domestic workers, who continue to be vulnerable despite the fact that, by law, they must be incorporated into Social Security.

The economic and labor crisis, without a doubt, entails altered self-concept and self-esteem, exacerbated stress, emotional destabilization and feelings of shame; guilt, frustration and loss that are associated with ideas about death and suicidal gestures. In the world’s most intense economic crises, there has been a greater number of suicides in both sexes, but mostly in men ^{(59- 62)}.

Confinement, on the other hand, is experienced differently depending on the variables that accompany it; for example, job and economic stability, the type of housing availability, the number of family members with whom one lives, interpersonal relationships, and physical and mental health.

In some cases, confinement is experienced as social distancing. In others as social isolation. It is in this last area where the emotional and psychological implications are greater, and yet in all cases we observe a greater or lesser tendency to interact to a lesser extent with family and friends. This is sometimes perceived as a decrease in the social support network, a change in the routine, eating and sleeping habits, a greater physical and emotional fatigue, which increases if you are responsible for an older adult, a minor or someone at greater risk of complications from Covid-19. Also a feeling of overload in those who work remotely, as it has been identified that 70% of people work more in the home office, with an average of between 9 and 12 working hours per day ⁽⁶³⁾.

Confinement increases the risk of interpersonal problems, mood swings, increased consumption of alcohol and illegal substances, and living with or witnessing domestic violence⁵ and sexual abuse, especially towards women and children ⁽⁶⁴⁾. The increase in stressors goes beyond the defense mechanisms and coping styles that were usually used. These exacerbating the symptoms of those who already had mental disorders⁶ or even generating depression, anxiety, acute stress disorder and post-traumatic stress disorder ⁽⁶⁴, ⁶⁵, ⁶⁸⁾, which together with a feeling of hopelessness and difficulty in projecting oneself into the future, lead to ideation or attempted suicide.

The most vulnerable population consists of older adults and youth ⁽⁷⁰⁾. Older adults who do not live with their children or a relative have had to experience confinement in solitude, in many cases isolated because, not knowing how to use technological tools satisfactorily, they cannot communicate by this means with their children or grandchildren. In the case of young people, they face high levels of tension due to situations related to their studies. For example, the loss of routine and social relations, the closure of schools, concerns about whether they will have the necessary materials to take classes online or, even, if they will be able to continue their studies or these will be interrupted given the economic situation of their parents, in addition to the anxiety they may experience for the health of their relatives ⁽⁶⁴, ⁷⁰, ⁷¹⁾.

Children have also seen their emotional health decline, manifesting significant behavioral changes, anxiety or nervousness, irritability expressed in tantrums, agitation or loneliness. It has also been difficult for them to take classes online, alter their routine, stop seeing their schoolmates and spend extra time with their family. The situation becomes more complex if the child has a disability, lives in overcrowded conditions, or is in conditions of greater social vulnerability, such as living or working on the street ⁽⁶⁴⁾. Another group that has presented important affectations in mental health is those who are in humanitarian or conflict environments, because besides the fact that mental disorders are more frequent in this population ⁽⁶⁴⁾, with the health crisis, stress has been exacerbated and the possibility of medical and psychological care has diminished.

Grief is an element that has changed during the health crisis. Dealing with the loss of a loved one under ordinary conditions is painful and complex enough, but doing so during a pandemic is even more. The death of a close person in times of Covid-19, prevents the realization of funeral rites that allow the assimilation of the loss, not being able to organize a community wake or take children old enough to the funeral rites, or to show condolences in a face-to-face way and with physical demonstrations, has been a challenge, which in many occasions has become a pathological mourning.

The situation is even more unintelligible when the person close to you has died from Covid-19, since in most cases it was not possible to say goodbye physically (in the best of cases there can be a goodbye via telephone or video call). The illness and death happened too quickly, so much so that they could not be processed emotionally; one has the feeling that the sick person was left in a stable state and not with his health so diminished as to conclude in death ⁽⁷²⁾, and one experiences the sensation that something more could have been done. This generally leads to the appearance of feelings of guilt and to states of depression and anxiety.

In various countries around the world and in our country, notes have been circulated of patients who have tested positive for Covid-19 or who were suspected of carrying the virus, and who made some kind of suicide gesture (attempted suicide that was successfully contained by security personnel or suicide, generally occurring by throwing oneself off the roof of hospital institutions). The reports indicate that these patients presented previous depression pictures, or that they did not have emotional alterations before the diagnosis, but that now in which they knew that they could have Covid-19 they manifested anxiety crises.

It is common for those who are sick with this virus to feel intense fear and uncertainty because they do not know how they will evolve and if they will die because of the complications of the disease. In other cases, guilt is added because of the probability of having infected someone else, and even trauma if they were close to a person who died from Covid-19 or, even if this is not the case, if they have been overexposed to news related to the subject.⁷

The isolation required by the disease tends to increase anxiety in patients, so it is important that, as far as possible, they be connected to their families, either by phone or by video call. In the case of minors, the World Health Organization, the European Charter of Children’s Rights and the Mexican Group of Pediatric Psychology, among other organisms, indicate that it is essential that their parents accompany hospitalized children, since an inverse measure would contravene the patient’s integral well-being ⁽⁷³⁾.

5. Suicide and Covid-19 in health care workers

For some years now, the medical profession has been considered one of the professions with the greatest risk of presenting suicidal behavior due to the overload of work, the demands of the job, the tendency to manifest burn out syndrome and the difficulties in having adequate means to carry out the requested activities ⁽⁷⁴⁾. During the pandemic, suicidal ideation and suicide attempts have increased and, unfortunately, so have completed suicides. Among the possible motivations for these events is the requirement, which not only consists of strenuous working hours, but also on many occasions is accompanied by the request to perform tasks other than those of doctors, given the shortage of personnel in hospital institutions.⁸

In addition to poor nutrition and hydration and little rest, health personnel face feelings of frustration and helplessness; fear of infecting family members (and consequently the isolation of the family unit), and the trauma of seeing their colleagues get sick and die, in addition to burn-out syndrome and compassion fatigue, which tend to produce symptoms of depression, anxiety, acute stress disorder and post-traumatic stress disorder.

The daily confrontation with the illness and death of the patients is no longer something habitual and becomes an overwhelming situation, particularly when symptoms of defenselessness prevail due to not having enough supplies for the adequate treatment of the patients, but also not having the personal protection equipment ⁽⁷⁶⁾. According to recent reports, 97,632 health workers have been infected with Covid-19 (42% of infections have occurred in nurses, 27% in doctors and 31% in other workers such as assistants, technicians and cleaning staff). In terms of deaths, Mexico has the highest coronavirus mortality rate among health care workers ⁽⁷⁷⁾. Additionally, health care personnel in our country have had to face discriminatory acts and verbal, physical and psychological violence. Unlike what has happened in other countries, where health workers are valued for the work they do on a daily basis, in Mexico a sector of the population discriminates against them and is violent because of the apparent fear that they may be transmitters of coronavirus.

Despite the social stigma that still exists about mental illness and the request for psychiatric and psychological care, a large number of health workers have approached institutions, that offer specialized mental health services ⁽⁷⁹, ⁸⁰⁾, in order to attend to the psychological conditions that they present, which prevents the chronicity of mental disorders and pays for the prevention of suicidal behavior.

Suicide prevention is for the World Health Organization a categorical imperative for all countries ⁽³⁵⁾. This organization has been emphatic in calling on nations to design strategies that promote mental health, limit access to the means of suicide, decrease risk factors for suicidal behavior, and promote protective factors for suicide. In the current health crisis, the United Nations, the World Health Organization, and the Pan American Health Organization ⁽⁸¹, ⁸²⁾ have recognized the important role of national governments in mitigating the adverse effects of the pandemic on all sectors of the population.

6. Bioethics and suicide

Suicide is far from ceasing to be a worldwide problem, since the insertion of the individual in society is unquestionable; the one who has ended his life breaks the social fabric and leaves an indelible mark. We can assume that the suffering of those who present some suicidal gesture is elevated and that they surely go through emotional problems and life crises that make them question the meaning of their existence. Recognizing these mourners as persons with intrinsic and inalienable dignity is fundamental, but it is also fundamental to attend to their physical and mental health.

Sickness and death remind us of the fragility of human beings, but in many cases also of the social vulnerability faced by a significant population group due to the poverty in which they find themselves, or because of limited access to health services. In this area, that of integral health, at a global level, but above all in Latin America, and particularly in Mexico, there are relevant deficiencies and disregard for the principle of distributive justice, since many vulnerable groups do not have access to quality care to protect their health.

This is the case of people, who suffer from a mental illness and who lack sufficient economic resources to attend a private psychiatric or psychological consultation. People who do not have access to specialty public care institutions, or who have to abandon their pharmacological treatment because they do not have money to pay for it. Failures in distributive justice also refer to human resources, as mental health doctors in our country are concentrated in Mexico City, Monterrey and Guadalajara, so people who cannot be transferred to those cities are less likely to be treated by a specialist. The lack of mental health care does not only affect the health area, but also the academic, labor and social areas.

Despite this urgent need for mental health care, the resources allocated annually to this sector have suffered an average budget cut of 2.7% worldwide ⁽⁶⁴⁾. In our country, the budget percentage of public investment in mental health is much lower than the average of developed countries and even of other nations in Latin America.

The implications for social and community life are high. From this perspective, the responsibility to provide support to those who need it most is not exclusively that of government programs, but also of the members of society themselves, adhering to the principles of sociability and subsidiarity. From the perspective of sociability, all members of a community are committed to collaborating in the pursuit of the good of all; a person is self-realized when he or she favors the realization of the good of others. From the point of view of subsidiarity, society has the responsibility to identify which of its own elements are the promoters of the suicide of one of its members and what actions should be implemented to prevent this type of behavior ⁽⁸⁴⁾. For example, in the reduction of social stigma, in the support of those who are experiencing significant difficulties during confinement, those who manifest emotional crises, or those who risk their lives for the well-being of the population, such as health personnel.

A person with suicidal behavior experiences the emotional process he or she goes through in loneliness and isolation. As they find themselves in a state of emotional numbness with little possibility of effectively identifying different solutions to their problems, they consider that the only alternative they have is to die. It is in those moments when he needs a social support network; a group of people who, from solidarity, understand his suffering; who, from sociability, promote his well-being, and who, from subsidiarity, recognize that he is a person, who requires psychological attention but who, most probably, is not in conditions to seek it by himself.

Conclusions

Suicide is a public health problem that has increased alarmingly in Mexico and the world. The Covid-19 pandemic presents even greater challenges than the disease itself. Confinement has had a great impact on people’s lives, in health, economic, labor and social terms. Specifically in the area of mental health, the ravages of confinement are beginning to be seen; however, it is still too early to clearly identify the impact it will have in the short, medium and long term on the development of mental disorders, life crises and suicidal behavior.

Suicide treatment is multimodal. Intervention efforts must focus on effective care of mental disorders; reduction of social stigma; implementation of preventive programs and the creation of practices for the reduction of alcohol and drug consumption; restriction of access to the means of suicide; resolution of severe problems; and reduction of markers of social disadvantage.

It is cardinal to follow up on the mental illnesses, life crises, ideation and suicide attempts, which are occurring in different sectors of the population because of Covid-19. Nevertheless, promoting a sense of community and the relevance of the common good is transcendental because only with respect to the dignity of the person and the understanding of the principles of sociability, subsidiarity and solidarity can human life be safeguarded.