Keywords
COVID-19, Living systematic review, Suicide, Attempted suicide, Self-harm, Suicidal thoughts
-
Views
-
Downloads
How to cite this article
John A, Eyles E, McGuinness LA et al. The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2020, 9:644 (https://doi.org/10.12688/f1000research.24274.1)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Export Citation
Sciwheel
EndNote
Ref. Manager
Bibtex
ProCite
Sente
▬
✚
Study Protocol
The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review
[version 1; peer review: 1 approved, 1 approved with reservations]
PUBLISHED 25 Jun 2020
OPEN PEER REVIEW
REVIEWER STATUS
This article is included in the Emerging Diseases and Outbreaks gateway.
This article is included in the Living Evidence collection.
This article is included in the Coronavirus collection.
Abstract
Corresponding author:
Ann John
Competing interests:
DG: member of the Department of Health and Social Care (England) National Suicide Prevention Strategy Advisory Group. DG has grants from the National Institute for Health Research (NIHR) outside the submitted work and is a member of Samaritans Policy and Research Committee and Movember’s Global Advisory Committee.
AJ: chair of the National Advisory Group on Suicide and Self-harm Prevention to Welsh Government and is national lead on suicide prevention for Public Health Wales.
KH: member of the Department of Health and Social Care (England) National Suicide Prevention Strategy Advisory Group.
NK is a member of the Department of Health and Social Care (England) National Suicide Prevention Strategy Advisory Group and sits on committees for the National Institute for Health and Care Excellence to develop clinical guidelines for depression and self-harm. He reports grants outside the submitted work from NIHR, DHSC, and the Health Care Quality Improvement Partnership.
Grant information:
This work was supported by Swansea University and the University of Bristol.
DG, BKO, JPTH are supported by the NIHR Bristol Biomedical Research Centre [IS-BRC-1215-20011].
JPTH and EE are suported by the NIHR Applied Research Collaboration West.
LAMcG is by the NIHR through a NIHR Doctoral Research Fellowship [DRF-2018-11-ST2-048].
LS is supported by the NIHR through a NIHR Systematic Reviews Fellowship [RM-SR-2017-09-028].
AJ and CO are supported by the Swansea University Cochrane Satellite for Suicide and Self-Harm Prevention.
NK and RW are supported by the NIHR Greater Manchester Patient Safety Translational Research Centre.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2020 John A et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: John A, Eyles E, McGuinness LA et al. The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2020, 9:644 (https://doi.org/10.12688/f1000research.24274.1)
First published: 25 Jun 2020, 9:644 (https://doi.org/10.12688/f1000research.24274.1)
Latest published: 25 Jun 2020, 9:644 (https://doi.org/10.12688/f1000research.24274.1)
DG, BKO, JPTH are supported by the NIHR Bristol Biomedical Research Centre [IS-BRC-1215-20011].
JPTH and EE are suported by the NIHR Applied Research Collaboration West.
LAMcG is by the NIHR through a NIHR Doctoral Research Fellowship [DRF-2018-11-ST2-048].
LS is supported by the NIHR through a NIHR Systematic Reviews Fellowship [RM-SR-2017-09-028].
AJ and CO are supported by the Swansea University Cochrane Satellite for Suicide and Self-Harm Prevention.
NK and RW are supported by the NIHR Greater Manchester Patient Safety Translational Research Centre.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
The COVID-19 pandemic is causing widespread disruption and loss of life globally. By mid-May 2020 over 4.4 million people had been infected and 300,000 had died [https://www.worldometers.info/coronavirus/]. There are concerns about the impact of the pandemic on population mental health (Holmes et al., 2020). These stem from the impact of the virus itself on the people infected, as well as front line workers caring for them (Kisely et al., 2020), and from the public health measures to minimise spread of the virus – in particular physical distancing, leading to social isolation, disruption of work, businesses and education. Physical distancing measures have resulted in substantial rises in unemployment, falls in GDP and concerns that many nations will enter a period of deep economic recession.
There are concerns that suicide and self-harm rates may rise during and in the aftermath of the pandemic (Gunnell et al., 2020; Reger et al., 2020). Time-series modelling indicated that the 1918–20 Spanish Flu Pandemic, which caused well over 20 million deaths worldwide, led to a modest rise in the national suicide rate in the USA (Johnson & Mueller, 2002; Wasserman, 1992). Likewise, there is evidence that suicide rates increased briefly amongst people aged over 65 in Hong Kong during the 2003 SARS epidemic, predominantly amongst those with more severe physical illness and physical dependency (Cheung et al., 2008).
The current context is, however, very different from previous epidemics and pandemics. The 2003 SARS epidemic was restricted to relatively few countries. Furthermore, in the time since the 1918–20 influenza pandemic, global and national health systems have improved, international travel and the speed of communication of information (and disinformation) have increased, antibiotics are available to treat secondary infection, and national economies have become more inter-dependent. The availability of the internet and technology for communication has made it easier for people to communicate and engage in home working and home schooling. However, there are huge inequalities in relation to access to technology and ability to stay safe and continue to work, within and between countries. Public health policies and responses, and the degree of access to technology to facilitate online clinical assessments and treatments differ greatly between countries.
Key concerns in relation to suicide prevention include: uncertainty regarding how best to assess and support people with suicidal thoughts and behaviours, whilst maintaining physical distancing; people who have attempted suicide may not attend hospitals because they are worried about contracting COVID-19 or being a burden on the healthcare system at this time; the uncertain impact on mental health and risk of suicide in the general population of physical distancing; an economic recession may adversely impact on suicide rates (Chang et al., 2013; Stuckler et al., 2009). There may be an increase in prevalence of suicide risk factors such as mental illness, domestic violence, alcohol misuse and bereavement (Turecki et al., 2019); the insensitive or irresponsible media reporting of suicide deaths associated with COVID-19 may be harmful; and in some countries access to highly lethal suicide methods such as firearms and pesticides may rise (Gunnell et al., 2020).
In the context of the COVID-19 pandemic there is likely to be a rapidly expanding research evidence base on its impact on suicide rates, and how best to mitigate such effects. It is therefore important that the best available knowledge is made rapidly available to policymakers, public health specialists and clinicians. To facilitate this, we plan to conduct a living systematic review focusing on suicide prevention in relation to COVID-19. Living systematic reviews are high-quality, up-to-date online summaries of research that are regularly updated, using efficient, often semi-automated, systems of production (Elliott et al., 2014).
Aim
The overarching aim of the review is to identify and appraise any newly published evidence from around the world that assesses the impact of the COVID-19 pandemic on suicide deaths, suicidal behaviours, self-harm and suicidal thoughts, or that assesses the effectiveness of strategies to reduce the risk of suicide deaths, suicidal behaviours, self-harm and suicidal thoughts, resulting from the COVID-19 pandemic.
Methods
We will undertake a living systematic review (Figure 1) following published guidance for such reviews and for how expediated ‘living’ recommendations should be formed where relevant (Akl et al., 2017; Elliott et al., 2017). The review was prospectively registered (PROSPERO ID CRD42020183326; registered on 1 May 2020). This protocol is reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline (Moher et al., 2015).
Eligibility criteria
Study participants may be adults or children of any ethnicities living in any country. Outcomes of interest are:
1. Deaths by suicide
2. Self-harm (intentional self-injury or self-poisoning regardless of motivation and intent) or attempted suicide (including hospital attendance and/or admission for these reasons)
3. Suicidal thoughts/ideation
Studies must address one of the following research questions:
(i) What is the prevalence/incidence?
Prevalence/incidence of each outcome during pandemic (including modelling studies to predict incidence / prevalence)
(ii) What is the comparative prevalence/incidence?
(iii) What are the effects of interventions?
Effects of public health measures to combat COVID-19 (including physical distancing, school closures, interventions to address loss of income, interventions to tackle domestic violence) on each outcome
Effects of changed and new approaches to clinical management of (perceived) elevated risk of self-harm or suicide risk on each outcome (any type of intervention is relevant)
(iv) What are the effects of other exposures?
• Impact of media portrayal of each outcome and misinformation attributed to the pandemic on each outcome
• Impact of bereavement from COVID-19 on each outcome
• Impact of any COVID-19 related behaviour changes (domestic violence, alcohol, cyberbullying) on each outcome
• Impact of COVID-19-related workload on crisis lines on each outcome
• Impact of infection with COVID-19 (self or family member) on each outcome
• Impact of increased availability of analgesics, firearms and pesticides on each outcome (method-specific and overall suicide rates)
• Impact of COVID-19 related socio-economic exposures (recession/depression: unemployment, debt, deprivation at the person-, family- or small-area level) on each outcome
• Impact on health and social care professionals: the stigma of working with COVID-19 patients or the (perceived) risk of infection/being a ‘carrier’, as well as work-related stress on each outcome
• Impact of changes in/reduced intensity of treatment for patients with mental health conditions, in particular those with severe psychiatric disorders.
• Impact of any other relevant exposure on our outcomes of interest.
Qualitative research. We will include any qualitative research addressing perceptions or experiences around each outcome in relation to the COVID-19 pandemic (e.g. stigma of infection, isolation measures, complicated bereavement, media reporting, experience of remote methods of self-harm / suicide risk assessment or provision of treatment; experience of seeking help for individuals in suicidal crisis); narratives provided for precipitating factors for each outcome.
No restrictions will be placed on the types of study design eligible for inclusion, with the exception of single case reports. Pre-prints will be assessed at the time of publication. There will be no restriction on language of publication. We will draw on a combination of internet-based translation systems and network of colleagues to translate evidence in a language other than English.
Figure 1. Workflow for updating the living review.
The process will be supported using automation technology and in three-month intervals reviewers will decide on extracting new data and updating the review.
Identification of eligible studies
We will search the following electronic databases: PubMed; Scopus; medRxiv, bioRxiv; the COVID-19 Open Research Dataset (CORD-19) by Semantic Scholar and the Allen Institute for AI, includes relevant records from Microsoft Academic, Elsevier, arXiv and PMC); and the WHO COVID-19 database. A sample search strategy (for PubMed) appears in Box 1. We have developed a workflow that automates daily searches of these databases, and the code supporting this process can be found at https://github.com/mcguinlu/COVID_suicide_living (McGuinness & Schmidt, 2020)). Searches are conducted daily via PubMed and Scopus application program interface and the bioRxiv and medRxiv RSS feeds. Conversion scripts for the daily updated WHO and the weekly updated CORD-19 corpus are used to collect information from the remaining sources. The software includes a systematic search function based on regular expressions to search results retrieved from the WHO, CORD-19 and preprint repositories (search strategy available as extended data (John et al., 2020)). We will investigate the use of other databases to capture papers made available prior to peer review and assess eligibility and review internally.
A two-stage screening process will be undertaken to identify studies meeting the eligibility criteria. First, two authors (either CO or EE) will assess citations from the searches and identify potentially relevant titles and abstracts. Second, either DG, AJ or RW will assess the full texts of potentially eligible studies to identify studies to be included in the review. This process was managed via a custom-built online platform (Shiny web app, supported by a MongoDB database). The platform also allows for data extraction via a built-in form (extended data (John et al., 2020)). At the time of writing we are processing new records virtually every working day. Regularity of this task may reduce over time though it will be done at least monthly. We have the resources to display the current state of the review and screening process publicly on a regular basis.
Box 1. Search terms for PubMed
((selfharm*[TIAB] OR self-harm*[TIAB] OR selfinjur*[TIAB] OR self-injur*[TIAB] OR selfmutilat*[TIAB] OR self-mutilat*[TIAB] OR suicid*[TIAB] OR parasuicid*[TIAB) OR (suicide[TIAB] OR suicidal ideation[TIAB] OR attempted suicide[TIAB]) OR (drug overdose[TIAB] OR self?poisoning[TIAB]) OR (self-injurious behavio?r[TIAB] OR self?mutilation[TIAB] OR automutilation[TIAB] OR suicidal behavio?r[TIAB] OR self?destructive behavio?r[TIAB] OR self?immolation[TIAB])) OR (cutt*[TIAB] OR head?bang[TIAB] OR overdose[TIAB] OR self?immolat*[TIAB] OR self?inflict*[TIAB]))) AND ((coronavirus disease?19[TIAB] OR sars?cov?2[TIAB] OR mers?cov[TIAB]) OR (19?ncov[TIAB] OR 2019?ncov[TIAB] OR n?cov[TIAB]) OR ("severe acute respiratory syndrome coronavirus 2" [Supplementary Concept] OR "COVID-19" [Supplementary Concept] OR COVID-19 [tw] OR coronavirus [tw] OR nCoV[TIAB] OR HCoV[TIAB] OR ((virus*[Title] OR coronavirus[Title] OR nCoV[Title] OR infectious[Title] OR HCoV[Title] OR novel[Title])AND (Wuhan[Title] OR China[Title] OR Chinese[Title] OR 2019[Title] OR 19[Title] OR COVID*[Title] OR SARS-Cov-2[Title] OR NCP*[Title]) OR “Coronavirus”[MeSH]))))
Data collection and assessment of risk of bias
One author (DG, AJ or RW) will extract data from each included study using a piloted data extraction form (extended data (John et al., 2020)), and the extracted data will be checked by one other author. Disagreements will be resolved in the first instance through discussion, and where this fails, by referral to a third reviewer (KH or NK). Irrespective of study design, data source and outcome measure examined, the following basic data will be extracted: citation; study aims and objectives; country/setting; characteristics of participants; methods; outcome measures (related to suicidal behaviour and COVID-19); key findings; strengths and limitations; reviewer’s notes. For articles where causal inferences are made i.e. randomized or non-randomized studies examining the effects of interventions or aetiological epidemiological studies of the effects of exposures, we will use a suitable version of the ROBINS-I or ROBINS-E tool to assess risk of bias as appropriate based on the research question and study design (Morgan et al., 2017; Sterne et al., 2016).
Data synthesis
We will synthesise studies according to themes based on research questions, using tables and narrative. Results will be synthesised separately for studies in the general population, in health and social care staff and other at-risk occupations, and in vulnerable populations (e.g. people of older age or those with underlying conditions that predispose them to becoming severely ill or dying after contracting Covid-19). Where multiple studies address the same research questions, we will assess whether meta-analysis is appropriate and conduct it where suitable following standard guidance available in the Cochrane Handbook (Deeks et al., 2019).
Living mode of the review, and transition to a static state
We plan to maintain the review in living mode for at least 12 months, from publication of the protocol. We will undertake monthly screening and consider full updates considered at least every 3 months, if sufficient relevant evidence is published, although these are likely to happen monthly in the first instance. We will extend the living mode at 6-monthly intervals if evidence is still being published regularly. We anticipate an end to the living phase of the review at most 24 months after initiation, at which point we plan to publish the cumulated evidence in the form of a standard systematic review. Our decision to update the review will depend on the likely impact of the new evidence on the conclusions of the review. Impactful evidence may be (i) evidence that affects policy and/ or (ii) substantial, high-quality research studies (e.g. a randomised trial or population-based observational cohort study).
When a decision is made to move to from a living review to a static publication, two reviewers will independently assess 10% of all citations screened to determine whether any records were likely to have been missed, with further independent screening in the case of concerns. In addition, all extracted data will be checked against each relevant paper by an additional reviewer.
Justification for a living method
In the context of the COVID-19 pandemic there is a high level of uncertainty relating to its impact on suicide rates and how best to mitigate such effects and there is likely to be a rapidly emerging research evidence base to address this (Gunnell et al., 2020; Holmes et al., 2020; Reger et al., 2020). It is therefore important that the best available knowledge is made rapidly available to policymakers, public health specialists and clinicians to inform their practice.
Dissemination of information
This living review, along with further updates, will be published via F1000Research. This review was registered on PROSPERO, with ID CRD42020183326. All further data are publicly available via our Harvard Dataverse repository including all results of the continuous evidence surveillance and screening. Findings from the review will be widely disseminated through conference presentations, policy briefings, peer-reviewed publications, a project website, and traditional and social media outlets. Many of the co-authors are members of the International Covid-19 suicide prevention research collaboration (IPCSPRC), we will also use this network and its partnership with the International Association for Suicide Prevention to disseminate findings.
Data availability
Extended data
Harvard Dataverse: Underlying data for: The impact of the Covid-19 pandemic on suicidal behaviour: a living systematic review protocol. https://doi.org/10.7910/DVN/9JYHLS (John et al., 2020)
This project contains the following extended data:
Search.docx (additional information about the searches, including full search strategies)
data_extraction_form.docx (Data extraction sheet/study report)
lsr_fig1.png (Figure 1 from protocol)
PROSPERO_registration.pdf (Prospero registration)
Reporting guidelines
Harvard Dataverse: PRISMA-P checklist for ‘The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review’ https://doi.org/10.7910/DVN/9JYHLS (John et al., 2020)
Software availability
The development version of the software for automated searching is available from Github: https://github.com/mcguinlu/COVID_suicide_living.
Archived source code at time of publication: http://doi.org/10.5281/zenodo.3871366 (McGuinness & Schmidt, 2020)
License: MIT
Download
Export To
metrics
| Views | Downloads | |
|---|---|---|
| F1000Research | - | - |
|
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Citations
CITE
how to cite this article
John A, Eyles E, McGuinness LA et al. The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations] F1000Research 2020, 9:644 (https://doi.org/10.12688/f1000research.24274.1)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.
Open Peer Review
Current Reviewer Status:
Key to Reviewer Statuses
VIEW
HIDE
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 25 Jun 2020
Views
29
How to cite this report:
Duncan EAS. Reviewer Report For: The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2020, 9:644 (https://doi.org/10.5256/f1000research.26781.r65519)
The direct URL for this report is:
https://f1000research.com/articles/9-644/v1#referee-response-65519
https://f1000research.com/articles/9-644/v1#referee-response-65519
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 29 Jul 2020
Approved
VIEWS 29
This paper presents a protocol for a living systematic review on the impact of COVID-19 pandemic on self-harm and suicidal behaviour. This is an important and timely review.
Suicidal and self-harm behaviours have increased during previous epidemics and pandemics and ... Continue reading
Suicidal and self-harm behaviours have increased during previous epidemics and pandemics and ... Continue reading
CITE
HOW TO CITE THIS REPORT
Duncan EAS. Reviewer Report For: The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2020, 9:644 (https://doi.org/10.5256/f1000research.26781.r65519)
The direct URL for this report is:
https://f1000research.com/articles/9-644/v1#referee-response-65519
https://f1000research.com/articles/9-644/v1#referee-response-65519
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
31
How to cite this report:
Turner T. Reviewer Report For: The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2020, 9:644 (https://doi.org/10.5256/f1000research.26781.r65517)
The direct URL for this report is:
https://f1000research.com/articles/9-644/v1#referee-response-65517
https://f1000research.com/articles/9-644/v1#referee-response-65517
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 02 Jul 2020
Tari Turner, Monash University, Melbourne, Australia
Approved with Reservations
VIEWS 31
This is a clear and well written protocol for a living systematic review of evidence on the impact of the COVID-19 pandemic on self-harm and suicidal behaviour. This is an important topic, a living systematic review approach is clearly useful
... Continue reading
CITE
HOW TO CITE THIS REPORT
Turner T. Reviewer Report For: The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: protocol for a living systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2020, 9:644 (https://doi.org/10.5256/f1000research.26781.r65517)
The direct URL for this report is:
https://f1000research.com/articles/9-644/v1#referee-response-65517
https://f1000research.com/articles/9-644/v1#referee-response-65517
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Comments on this article Comments (0)