Background

The COVID-19 pandemic began in China around the end of 2019. Its prevalence increased dramatically all across the world. Hundreds and thousands of individuals died as a result of the millions of infections that were documented. Nothing in the twenty-first century can come close to the havoc wrought by the COVID-19 pandemic. The last pandemic crisis that unfolded in a similar manner was the Spanish Flu in 1918–19, which infected roughly one-third of the world's population. Millions of people became infected and hundreds of thousands died [1]. The Spanish Flu virus infected approximately 500 million people or one-third of the world’s population. In addition to disease-related deaths, Spanish Flu was associated with suicidal deaths. This led to the conclusion that a decrease in social integration and communications during a pandemic and widespread fear can lead to an increase in suicidal cases [2]. The COVID-19 pandemic had an impact on mental health, escalating the risk of suicides globally. Despair and feelings of loneliness became pervasive [3]. There was misinformation about the virus spread. Global dispersion, number of infections, and mortality increased people's feelings of insecurity and anxiety [4].

Most of the world’s population lives in low- and middle-income countries (LMICs) which have inadequate mental health resources in place [5]. COVID-19 spread rapidly in many of these countries. There is extensive literature on the health implications of COVID-19 in high-income countries. But low- and middle-income countries which have 83% of the global population have very little research [6]. There is evidence to show that the COVID-19 pandemic had profound psychological and social effects with psychological sequelae which persisted for months and years. Social isolation, anxiety, despair, chronic stress, and economic difficulties led to an exacerbation of depression, anxiety, stress, mass panic, substance and drug use, and other psychiatric disorders. These problems are contributing to a rise in suicides, a most concerning but preventable loss [7].

The COVID-19 pandemic disintegrated human lifestyles with mental health at the core of this concern. More than ever before, suicide became a serious public health problem worldwide. Suicide is the termination of a psychologically susceptible, vulnerable person’s life. As the COVID-19 pandemic had profound mental health consequences, there was a concern that it could lead to an increase in suicide cases during and even after the pandemic. There is a pervasive sense of uncertainty about the future as we know that the pandemic is far from over. Most mental health consequences of the COVID-19 crisis, including suicidal behavior, are likely to remain for a long time and peak later than the actual pandemic [8]. The spread of the coronavirus disease may not have a direct effect on the increase in suicides. However, its implications on a broad range of socio-economic and psychological factors evidently perpetuate a chronic increase in risk Suicides are preventable. Therefore, there is an urgent need to design socio-culturally tailored interventions. Frontline workers, migrants, homeless, the unemployed and impoverished, and those with a pre-existing history of mental disorders are at a higher risk of suicide. According to research, fear of being infected, fear of becoming a burden to the family, generalized anxiety, social distancing and isolation, and mental distress were factors that increased suicidal risk during the pandemic.

Since COVID-19 disproportionately affected various countries, ethnicities, and groups, studies on suicides need to be sensitive to the socio-cultural context [9]. It is important to note that a dual vulnerability was created with the convergence of suicidal risk factors and the impact of the pandemic. Studies published after the pandemic was declared in March 2020, estimate that the number of suicides will escalate globally [10]. The WHO estimates that for each adult suicide, there are more than 20 others attempting suicide and that suicide is much more frequent in individuals who previously attempted suicide. Suicide prevention in times of COVID-19 has become a global priority, not only due to increased mortality and morbidity, but also due to the exacerbation of risk factors including economic security, poor health facilities and basic amenities, and a social disconnect.

The United Nations has prioritized suicide prevention as an integral part of mental health interventions. To promote overall wellbeing, concerns of stress, fears, anxiety, and loneliness must be overcome in the general population. According to an advocacy statement released by the Indian Psychiatric Society (IPS), the pandemic crisis has increased the need for multi-disciplinary action to protect mental health. In this regard, an essential component of any public health intervention is suicide prevention, mental health management, and research [11]. Since COVID-19 is much more than a public health crisis and has serious socio-economic impacts, active outreach is necessary through traditional and tech-based media campaigns to promote mental health. To design effective interventions, there is a need for research to understand how mental health consequences can be mitigated during and after the COVID-19 pandemic. The pandemic has revealed the profoundly interconnected nature of global health and has generated knowledge to inform a mental health response. In this chapter, the authors examine the mental health implications of the COVID-19 pandemic especially in low- and middle-income countries (LMICs); assess changes in suicide trends during the pandemic; various triggers; prevention strategies and approaches taken by governments and institutions; and challenges encountered in designing and implementing mental health programs. The authors provide an overview of what is known about this topic, highlights gaps in the literature, and make recommendations for future research.

Impact of COVID-19 on Mental Health in Low- and Middle-Income Countries

A review of available secondary data shows that research on the impact of COVID-19 on mental health and suicides and on designing intervention strategies is largely limited to developed countries like Australia, North America, and Europe. There is a lack of research in LMICs.

The COVID-19 pandemic exposed a huge gap in the mental health infrastructure of LMICs and drew attention to the need to examine the intersection of mental healthcare with existing health systems. Given the challenges of scarce resources, low workforce capacity, inequitable access to interventions, and lack of verifiable information, it is speculated that the consequences of mental health are more severe in impoverished and vulnerable regions of the world [12,13,14]. As compared to high-income countries, there are higher rates of comorbidities among individuals with lower educational attainment in LMICs. In general, about 75% of suicides occur in low- and middle-income countries where poverty rates are high. The relationship between economic variables and suicidal behavior highlights serious concerns [15]. The ripple effects of the pandemic affected the livelihood of the poor, especially those with inadequate safety nets and resources to support them during financially trying times. Following the COVID-19 crisis, global economic growth is expected to contract pushing millions into poverty [16]. This is expected to exacerbate suicidal behaviors. Furthermore, vulnerable groups such as people with disabilities, the elderly, patients in hospitals, and people experiencing violence and abuse are at greater risk of psychological distress due to the pandemic. Thus, there are a host of risk factors that need to be assessed in the context of COVID-19 to address the problem of suicidal behavior.

Assessing the socio-economic determinants of suicidal behavior is essential in aiding policy-makers to develop appropriate population-level interventions. Effective suicide prevention interventions among those with mental health concerns cannot be possible without a thorough understanding of the social and economic factors involved. In comparison to the psychiatrists per 100,000 population in high-income countries, LMICs have much lower numbers of psychiatrists per 100,000 population, which highlights the greater need to address suicidal behaviors from the angle of social determinants of health more than just a psychiatric diagnosis [15].

Variety of Risk Factors that Trigger Suicidal Attempts

Hawton and Van Heeringern note that suicide is the tenth leading cause of death globally and the fourth leading cause of death among 15 to 19 year old persons [15, 17]. It is estimated that every year more than 700,000 people die due to suicide. For every suicide, there are many more suicidal attempts. In 2001, Wasserman estimated that the rates of non-fatal suicidal behavior are 20 to 30 times more common than completed suicides which have increased since the start of the pandemic [18]. Over 77% of global suicides occur in LMICs which have less resources and high levels of poverty. It is, therefore, important to understand the relationship between poverty and suicide for suicide prevention in LMICs. The WHO Suicide Report in 2020 refers to the entire spectrum of suicidal phenomena: “suicidal behavior refers to a range of behaviors that include thinking about suicide (or ideation), planning for suicide, attempting suicide, and suicide itself”. Suicidal ideation, plan, and attempts are the stages involved before a suicide occurs [19, 20]. According to an estimate by WHO, for every successful completion of suicide, there are at least 20 suicide attempts [21]. The risk of suicidal ideation increased 13.810, 6.454, and 9.530 times for those who suffered from depression, anxiety, and stress, respectively during the COVID-19 pandemic [22, 23].

COVID-19 resulted in isolation, dread, depression, and vulnerability which along with biological (disposition, family background of self-destruction, prior mental issues, and substance abuse) and psychosocial factors (financial constraints, loss of livelihood, old age, and others) has increased the risk of mental health problems and suicidal tendencies.

Table 1 shows some of the risk factors and contributors for suicide during the COVID-19 pandemic. It shows how the pandemic is increasing mental health risks because of social inequities, and economic and socio-cultural characteristics including age, religion, economic fall-out, abuse, violence, marginalization, fear, isolation, and other factors. In high-income countries, low educational levels and social disadvantages such as homelessness, unemployment, and social isolation are major risk factors for contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [24, 25]. In low- and middle-income countries, poverty and socio-economic inequities are more prominent. They enhance vulnerability to mental health problems. A prevalence of 33% of depression and 5% of suicidal ideation was reported through an online study of more than 10,000 individuals in Bangladesh [26]. In Brazil, this pattern was apparent in the poorest communities in the country as they had a greater risk of disease transmission and mental health consequences [27]. The COVID-19 pandemic impacted the economic and social determinants of health worldwide. According to a study on the Global Burden of Diseases, mental health conditions had a negative influence on the social determinants of health, which in turn impacted overall wellbeing [28]. In the case of the COVID-19 pandemic, disruption destabilized the social determinants of health globally and as a consequence, impacted the mental health of populations as well as the nations’ wellbeing.

Table 1 Risk factors and contributors for suicide during the COVID-19 pandemic
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McDaid and Kennelly noted that suicide was associated with economic inequalities and shocks [29]. In the wake of the global economic crises, the impact of unemployment in high-income countries were investigated extensively. Following the 2006–2008 economic crisis, higher suicide rates were reported [30]. A similar association between suicide and unemployment was observed during the Asian economic crisis with GDP contractions in Japan, South Korea, and Hong Kong but not in Taiwan and Singapore [31]. Higher risk was observed in the poorest sections of society. It was hypothesized that even after the economic recovery post-crisis, these countries will continue to suffer which will result in more suicides.

With increased exposure to known risk factors, the pandemic is laying the foundation for an increase in suicides worldwide. The risk factors are social isolation, unemployment, job insecurity, economic stress, inaccessible community support, difficulties in accessing mental treatment, and physical ailments especially among the elderly [32,33,34]. A model that combines data from multiple countries, including high-income and low- and middle-income countries, suggested that job losses from COVID-19 could result in upto 9,570 excess suicides annually across the globe [34]. Models assessing the pandemic regression trend in the US estimated that if the rate of unemployment is managed, economic recession would result in 3,235 additional suicides in the next two years (3.3% increase per year). They also estimated an excess of 8,164 suicides over two years (increase of 8.4% per year) if the rate of unemployment was not moderated [35]. It is important to note that pre-existing failures to prevent human rights violations is further complicating the mental health impact of the pandemic [36].

Studies on the COVID-19 pandemic forecasted an increase in the suicide rate based on rising unemployment rates [37]. In 2018, in the US, the suicide rate was 14.8 per 100,000. It was predicted to increase from 16.2 to 17.4 per 100,000 in 2021 [35]. Similarly, the rate of suicide mortality increased in developing countries. Based on a report by the Asian Development Bank, around nine million people will be unemployed due to the COVID-19 pandemic, which could result in an approximate loss of USD 3 billion in gross domestic product (GDP) [38]. As a result of these massive financial losses, large numbers of people would be pressurized and forced into mental breakdowns leading to suicidal behavior. Within the first three weeks of COVID-19 being declared a pandemic, nine COVID-19 associated suicides were reported in Bangladesh; a few of them were associated with sudden unemployment and financial breakdown [39]. Similar mental health consequences leading to suicides were reported in other countries.

Factors that trigger suicidal behaviors are: (1) socio-demographic factors such as gender, marital status, education, and employment; (2) behavioral and health-related factors such as abnormality in sleep, alcohol consumption, smoking, substance use, and lack of physical exercise; (3) COVID-19 pandemic-related factors such as lack of knowledge and lack of preventive measures, economic losses, and deaths of acquaintances; and (4) psychopathological factors such as depression, anxiety, history of suicidal thoughts, and suicide attempts. People with low awareness and lack of knowledge about preventive behaviors and/or higher level of fear of the infection are at a higher risk of suicidal ideation [40]. Suicide risk was 1.347 times higher for people living in high COVID-19 exposure areas and 1.299 times higher for people with economic losses due to the pandemic. About 700,000 people take their own life every year and every suicide is counted as a tragedy that affects families, communities, and even entire countries. There is a long-lasting effect on people who are left behind. With the COVID-19 pandemic, suicide has become a serious public health problem that needs to be addressed with timely, evidence-based, low-cost interventions.

While suicide has wide-ranging and diverse socio-economic triggers that vary with each context, it is important to examine the experience of key population groups.

Impact of COVID-19 on Key Populations

  1. 1.

    Students and working populations: Extended closure of educational institutions is expected to have a deep impact on the mental health of young adults, adolescents, and children across the globe [41]. Schools not only benefit children academically, but also provide a well-defined and moderated space for socio-emotional development and social support, and offer protection from high-risk situations and behaviors like exploitative labor, drug abuse, early marriage and early pregnancy. In addition, public schools are often the main entry point for children's meals in many LMICs to ensure adequate nutrition through school feeding programs [42, 43]. Therefore, school closure in response to the pandemic could have the unintended consequence of increasing food insecurity among children, which negatively affects mental health [44]. In addition to school children, college going students and graduates also suffered from a sense of isolation and uncertainty due to the lack of social interaction and increased dependence on technology. Restriction in mobility and work-from-home lifestyles impacted the mental health of a large group of the working population who had to increasingly deal with ‘burn-out’ and mental exhaustion, not to mention the dual burden of working women in the household.

  2. 2.

    Impact on frontline workers: Frontline workers were the backbone of a country’s fight against the spread of COVID-19 infection. Due to increased work pressure and responsibility, they were most vulnerable to the physical and psychological risks posed by the pandemic. With continuous exposure, they were in constant threat of infection and lived in fear of spreading the disease to their families and loved ones. Significant research has been undertaken on mental health care, especially on frontline workers. Their increased frustration, absenteeism, depression, and suicidality are attributed to growing work pressure, morbidity, chronic stress, and isolation [45]. In addition to disease exposure, health workers also faced the additional burden of a lack of personal protective equipment (PPE) kits, lack of flexibility in work hours or increased hours of work, and inadequate health and insurance facilities, especially in LMICs [46].

  3. 3.

    Impact on the elderly: During the COVID-19 pandemic, age and ageism were special concerns. Age predisposes an individual to psychological vulnerability. Studies have found that quarantine and isolation causes profound loneliness, depression, and suicidality in the elderly [47]. Autonomy, decision-making, dignity, and mobility which are the vital signs of good health, may be compromised at some point during the pandemic [48]. In many cases, the elderly were stranded and pushed to self-neglect when lockdowns deterred their access to home help and essential resources. Suicidality is regularly under-recognized among seniors and their despair manifests in different forms, sometimes leading to suicide [49].

  4. 4.

    Impact on the homeless and migrants: The world shelters around 1.5 billion homeless people. They are mostly from South Asian and African countries [50]. They live in overcrowded and impoverished shelters with no possibility of social distancing and other preventive practices. Hence, they are at an increased risk of infection. They have poor access to testing facilities and inadequate knowledge about the infection. In addition to the vulnerability that accompanies infection, substance abuse and mental health issues that come with socio-economic stress contribute to suicidal risk. Post-lockdown, especially in countries like India, large numbers of migrants were stranded on the streets and at railway stations with no means of survival. They were tormented by starvation. They welcomed death as their living condition were harsher than the virus itself [51].

  5. 5.

    Impact on victims of abuse and violence: The pandemic witnessed a significant increase in intimate partner violence and domestic abuse, especially in families already dealing with marital conflict, interpersonal violence, and substance abuse. There was an increase in the number of registered complaints reported in the United Kingdom’s domestic abuse helpline. Some expressed their death wish while registering their complaints [52]. This entrapment of families during the lockdown due to the unprecedented COVID-19 crisis had never been seen before. Tertiary mental healthcare helplines recorded continuous incoming calls for complaints. These calls were majorly of domestic violence associated with feelings of suicidality as the latter was considered an easy escape. This is preventable but due to underreporting, fear of legal hassles, acceptance, and untreated depression, suicides continue to occur.

Extent of Reporting

Currently, there are no standard models for reporting mental health issues in low- and middle-income countries. However, given that LMICs carried most of the world's suicide burden and were greatly hit by the economic consequences of the pandemic, it is possible for suicide rates to significantly increase in these countries [52]. A review on COVID-19 and suicide by Indian media supports this speculation. In many LMICs, suicides are often under-reported or are reported as having different reasons for death due to stigma, cultural, and religious factors associated with them [53, 54]. These inconsistencies with reporting and the lack of an international database suggest that data on the socio-economic determinants of non-fatal suicidal behavior remains limited in LMICs. In the years between 2001 and 2007, as part of the WHO World Mental Health Surveys, data from 21 countries showed that low-income level and unemployment were major risk factors for non-fatal suicidal behaviors in both high-income and LMICs [55].

Therefore, to fully understand the impact of the pandemic, taking note of the regional difference in suicide rates and strategies implemented to address differing risk factors, it is vital to build transparent and rigorous suicide reporting and monitoring mechanisms. For instance, there is recorded evidence that substance use and disorders, which have led to an increase in suicidal rates in financially affected communities, were the major cause of mortality associated with previous global recessions [56]. Table 2 shows the preferred ways of reporting suicides and practices to be avoided by the media.

Table 2 Reporting of suicides by the media in a responsible manner
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Due to increasing vulnerability in LMICs and rise in mental health concerns, resource-limited. LMICs were compelled to develop nation-wide policies to address the consequences. Using the guidance from psychosocial programs of the World Health Organization (WHO), some LMICs developed their own model programs to address the population’s mental health needs and strengthen support systems [57]. Based on the demand for mental healthcare, systems need to be established in remote regions, WHO created the Ensuring Quality in Psychological Support (EQUIP) platform to provide supervision and counseling to people with mental health concerns and to support them [58]. This platform enables men and women in remote outlying areas to address issues related to their mental health and deal with suicidality [59].

Prevention Strategies and Approaches Taken by Government and Other Institutions

In a report by WHO, suicide was highlighted as a global public mental health concern. In 2014, to make suicide prevention a high priority in the global health agenda, WHO published the first World Suicide Report “Preventing a suicide: A global imperative”. This report aimed to increase the awareness and the public health significance of suicide and suicide attempts. It also aimed to encourage and support countries to develop and strengthen prevention strategies through a multi-sectoral approach. Through the WHO Mental Health Action Plan 2013–2030, member states committed to work towards reducing their suicide rates by one-third by 2030. The suicide mortality rate is an indicator of target 3.4 of the Sustainable Development Goals (SDGs) to reduce mortality rate and promote mental health and wellbeing (WHO) [60].

In June 2020, a study in the U.S. suggested a notable increase in mental health concerns related to COVID-19. Groups like young adults, racial and ethnic minorities, frontline workers, and caregivers for the elderly experienced disproportionately worse mental health outcomes, increased substance use, and suicidal ideation. The study cited several reasons for the lack of evidence on the impact of mental health programs. While the pandemic was still advancing in many countries, most health programs were carried out with a sense of urgency with limited time and resources for comprehensive assessments. The study examined initiatives undertaken and capacity of governments in low- and middle-income countries to develop COVID-19 mental health plans. It highlighted the diversity and innovative capacity of these programs. It acknowledged that while a variety of programs sought to address population groups, cater to individual needs, and provide lessons on implementation, they were yet to be effectively carried out. This underscores the importance of assessing program implementation and outcomes for developing a comprehensive mental health response during emergencies.

Workers in the health system, ranging from community health workers to mental health experts, were trained in several countries to identify individuals suffering from mental health issues and distress (Fig. 1). Kerala, a state in India, organized phone based programs to identify and refer people in need of mental healthcare, while Pakistan and Uganda implemented face-to-face initiatives [61, 62]. In China, mental health consequences were recognized by artificial intelligence programs and mental health materials were disseminated through online applications like WeChat, Weibo, and TikTok, Turkey built apps to allow access to mental health counselors [63]. In South Africa, films were developed for people and healthcare professionals highlighting signs of stress, anxiety, and depression and showcasing tools for those seeking assistance. In the Honduras, Médecins Sans Frontières (MSF) offered phone based psychological care to patients and survivors of violence. It also established a mental health phone helpline. Similarly, virtual online resources were offered for education and information in Nicaragua, Serbia, Liberia, Costa Rica, and other developed and developing countries.

Fig. 1
A world map lists the responses of people from low, lower-middle, upper-middle, and high-income countries on mental health and how to cope with COVID.

Source Lancet

Mental health responses to COVID-19 in low- and middle-income countries.

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Based on past humanitarian emergency experience and the specific needs of the COVID-19 pandemic, many LMICs quickly developed National Mental Health and Psychosocial Support (MHPSS) response plans for COVID-19. The National Health Commission of China developed guidelines for psychological crisis intervention in emergencies emphasizing the importance of mental health services and the need to organize at the city, community, and province levels including psychological counseling teams and hotlines [64]. Lebanon published a government action plan for a MHPSS response in March 2020 outlining the promotion of mental health and associated risk factors related to COVID-19, support for the quarantined and frontline workers, and ensuring continuity of services for patients with pre-existing psychiatric conditions [65]. Similar national action plans were released in South Africa, Kenya, Uganda, the Maldives, and India. Regional responses within countries preceded national plans in some cases [66,67,68]. For example, in February 2020, the Kerala state government formed a multi-disciplinary team that integrated the efforts of various sectors and established a state hotline [69].

Materials were evolved in many LMICs to promote mental health and wellbeing during the COVID-19 pandemic. The WHO published an illustrated manual to showcase evolving stress during the COVID-19 crisis [70]. In India, Firework, a short 30-s decentralized video platform was launched in 2019. It released #sparkthejoy, a social effect promotional marketing campaign to encourage individuals to conduct an ‘act of good’[71]. During the lockdown in India from the start of March 2020 to the end of May 2020, the platform’s usage increased to more than double [72]. The Mental Health Innovation Network and WHO provided stories from the field for the purpose of providing mental health and psychosocial help during the pandemic crisis [73]. Material for information, mentoring, and communication highlighting mental health and stigma globally. For example, a collection of videos on grief and mental health, as a part of the Regional Psychosocial Support Initiative, was developed for South African youngsters and teenagers.

The WHO and the U.S. Centers for Disease Control and Prevention (CDC) published a series of psychosocial and mental health recommendations in 2020 [74, 75].

Government actions: Encourage multi-disciplinary mental health teams to play an active role at the national, state, and municipal levels; provide training in stress management, trauma, depression, and relative risk protocols; standardize and make available psychotropic drugs; ensure adequate resources and infrastructure for mental health services; ensure that clinical and mental healthcare is accessible to the population; develop psychoeducational materials and make them widely available to the population; and provide official channels for the public to receive up-to-date information; provide alternative service channels (apps, websites, and phone calls); monitor and disprove fake news; promote scientific research; take into account and respect cultural diversity when developing public policies; and collect epidemiological data to support future prevention and mental health policies.

Individual recommendations: Take care of yourself and others by staying in touch with friends and family and making time for recreational activities; adhere to the WHO and government health agency recommendations and guidelines; pay attention to your own needs, feelings, and thoughts; limit physical contact with others while maintaining emotional proximity; limit exposure to pandemic-related news because too much information can trigger mental health problems and cause anxiety disorders; monitor dysphoric mental states such as irritability, mood swings, and aggression; share or tell your peers if you experience symptoms of sadness or anxiety; as much as is possible, assist people in high-risk groups and widely disseminate contamination prevention information and instructions [3].

This was in line with longitudinal data from the WHO demonstrating that psychological factors are directly associated with the causes of morbidity and mortality [74]. Thus, increased investment in research and strategic actions for mental health is urgently needed worldwide, especially during such outbreaks.

Challenges Encountered in Devising and Implementing Mental Health Programs

Governments, healthcare providers, and other establishments in many LMICs responded to demanding situations by not only imposing lockdowns, restricting mobility, and strengthening clinical response to the virus, but also by devising a range of suicide and mental health helplines and promoting the public’s psychological wellbeing through billboards and other traditional and non-traditional media channels. Nevertheless, the prevention of suicide has not been adequately addressed due to the lack of awareness and stigma associated with discussing mental health in many conservative societies, especially in LMICs. Many people thinking of taking their own life and those attempting suicide do not seek help due to the major stigma surrounding mental health and suicide disorders. It is important for governments to break down this taboo and raise community awareness through a range of interventions in order to make progress in preventing suicides. There is also the question of prioritizing available resources to manage situations like this public health emergency. For national responses to be effective, a comprehensive multi-sectoral prevention strategy for suicides is needed. To date, only a few countries have included suicide prevention among their health priorities and only 38 countries report having a national suicide prevention strategy [17].

Limitations

Most of the available evidence comes from high and upper-middle-income countries with very few studies from low-income countries. Most studies focus on poverty, joblessness, and the increasing economic crisis. Dimensions such as debt, interest on payments, poverty, and the support of systems have been neglected, especially during the COVID-19 pandemic. Most studies were carried out within a risk factor paradigm and used descriptive statistics, thus providing very little useful information. Stronger evidence is needed in this area with studies focusing on a broader range of dimensions and using better statistical methods. The chapter, therefore, presents a partial picture of the associated risks because it is based on the available literature.

Concluding Comments

The COVID-19 pandemic has disrupted almost every aspect of life in all countries simultaneously. This global phenomenon is unlike any other in human history. Emerging evidence indicates that mental health consequences will be significant and long-lasting. The impact is greatest in under-resourced or low-resourced settings and among disadvantaged populations. Because of the lockdown and constraints associated with public health measures, a growing number of individuals are struggling psychologically and economically which exacerbates mental health problems and eventually leads to suicide. Suicide itself is considered to be a pandemic. Suicide prevention by early detection of risk is an important strategy. It is a collective responsibility. Given its strong socio-economic determinants, an increase in suicide rate is not surprising. Niederkrotenthaler et al. in 2020, in their paper ‘Suicide Research, Prevention, and COVID-19’ note that there is a pressing need for impartial and authenticated information regarding the determinants of population-based suicidal behavior for designing viable strategies for suicide prevention [76].

Even though suicides are preventable, we are losing lives every day. To prevent suicides, a number of measures can be taken at the population, sub-population, and individual levels. In 2018, WHO recommended the following interventions based on its approach of ‘Live Life’ to prevent suicide: (1) limit access to the means of suicides such as pesticides, drugs and medications, and firearms; (2) report responsibly through appropriate media interaction; (3) foster socio-emotional life skills, especially in adolescents; and (4) identify early, manage, and follow-up people with suicidal behaviors [17]. Prevention of suicide requires collaborative and coordinated efforts among multiple sectors of society such as health, education, agriculture, media, law and justice, politics, and other sectors. These efforts need to go hand-in-hand with the foundational pillars of multi-sectoral collaboration, raising awareness, building capacity, regular surveillance, and monitoring and evaluation. All these efforts must be integrated for maximum impact on this most complex problem.

The world stands at a difficult juncture. High quality registration data is vital especially in low- and middle-income countries, as the majority of suicides are predicted to occur in these countries. Enhancing surveillance mechanisms to monitor suicides is crucial to aid the planning and evaluation of intervention strategies in LMICs and to precisely evaluate progress towards global suicide mortality targets.

The International COVID-19 Suicide Prevention Research Collaboration (ICSPRC) requested for a worldwide representation, risk assessment and for employing preventive and control measures. This collaborative community focuses on the moral aspect while systematically studying the duration during the early stages of the pandemic, emphasizing the need for sharing high quality suicide studies, designing and developing appropriate evaluation tools and platforms, and harmonizing information from diverse settings [77].

Every country dealing with suicide has a distinct public health infrastructure, socio-cultural environment, and demographic framework. Therefore, in addition to global collaboration through public health organizations like the WHO and CDC, there is a need for providing additional insights from these countries to advance strategies for suicide prevention during pandemics [78].