Suicidal behavior in a migrant majority population and impact on trends during the early Covid-19 period: a cross sectional study in Qatar

Background Qatar is a high-income country with 90% of the population being economic migrants from low income countries. Due to this unique population composition, it has been suggested that Qatar may not follow suicide trends of high-income countries. Additionally, there is paucity of information on suicidal trends and rates due to social and cultural reasons. The Covid-19 pandemic has additionally impacted mental health of migrants differently form native Qataris. Objectives This study explores suicidal behavior trends among individuals attending the main Emergency Department in the state of Qatar for mental health emergencies. The study also compared these trends for pre-pandemic period to early post pandemic period. Methods A cross-sectional study of individuals attending the main emergency department of the country from 1st December 2019 to 30th June 2020 was carried out using a composite data collection form. This identified 799 individuals presenting with mental health emergencies. Suicidal behaviors, relevant sociodemographic data, along with factors known to be associated with suicidal behaviors were collected for this group. Results 24.9% (n = 199) of the sample presented with suicidal behaviors. Younger age (31.16 ± 9.497), current hopelessness (70; 54.7%), history of suicidal thoughts (50; 47.2%), history of suicidal attempts (43; 34.7%), history of self-harm thoughts (35; 39.3%), history of self-harm attempts (41; 37.6%) were highly significantly associated with suicidal behavior (p < 0.01). Qataris formed 27% of the group presenting with suicidal behaviors although they constitute only around 10% of the population. There was no significant change in the rate of presenting with suicidal behaviors during the early stages of the Covid-19 pandemic. Conclusions This study reports an annual incidence of suicidal behaviors in Qatar lower than that has been previously reported. The authors surmise that this may be due to improved availability and early intervention of mental health services and decreased stigma around mental health. Supplementary Information The online version contains supplementary material available at 10.1007/s44202-022-00040-8.


Participants
We included all first presentations during the identified period of those people presenting with "suicidal behavior"which was defined as thoughts of suicide (an intent to die), thoughts of deliberate self-harm (no definite intent to die), attempted suicide, and attempted deliberate self-harm to the ED of our main public hospital. We included only new presentations each month, and if those were presented again the following month, those were excluded, as we wanted to see if there has been an increase of new cases following the COVID-19 pandemic. Qatar had a population of about 2.88 million at the time of this study out of which around 89% are expatriates from several countries, and the rest are native Qataris [32]. The ED of the main state-run hospital in Qatar is based in the capital Doha and serves the capital and its suburbs which accounts for over 90% of the population of Qatar. This main ED receives around 3000 new visits each day. The two other state-run Emergency departments are relatively smaller and the private institutions in the country do not have any significant emergency psychiatric facilities. Every visit which mentioned suicidal behavior, as described above, during this period was included in this study. The only exclusion was if the individuals were under 18 years of age.

Measures
We developed a composite data collection form. The first section included demographic characteristics, COVID-19 status, associated physical comorbidities, smoking status, alcohol and substance use history, and past psychiatric history. The second section included information about symptoms that are known to be associated with suicidal behaviors like presence of current mental disorders, documented evidence of hopelessness, worthlessness, acute stressors, followed by a detailed account of current suicidal behavior, past suicidal behavior, and evidence of social isolation/entrapment/ quarantine during the presentation. Initial draft of the questionnaire was piloted on 30 EPR by three researchers to assess feasibility of the questionnaire. Modifications were made to the questionnaire to account for missing or unclear information and a final version was approved after discussion with the wider team. To achieve maximum reliability among the raters, two training sessions about the rating methods and terms were carried out. As a final step, 60 of the modified questionnaires were completed again by the three researchers and we achieved high interrater reliability.

Patient and public involvement
Patients or the public were not involved in the design or conduct of this research or in the dissemination of the research plans.

Data analyses
We analyzed the data using SPSS version 26 software. Initially, we conducted a simple frequency analysis of those presented each month with suicidal behavior using the total presentations as the denominator. We then conducted a univariate analysis comparing those with suicidal behavior and those without using t-tests and chi-square (χ 2 ) tests for comparisons of continuous variables and categorical variables, respectively. Furthermore, we used a binary logistic regression to examine the potential risk factors predicting suicidal behavior, using the enter method after removing variables that had multicollinearity.

Results
From 1 December 2019 to 30 June 2020 (seven months), a total of 799 individuals with mental health issues presented to the ED, which comprised the total sample. Out of these, 199 (24.9%) presented with suicidal behavior. 524 (65.6%) of this sample were males and 275 (34.4%) females. The mean age of this sample was 35.44 ± 12.60 years. Most of the individuals of the total sample were living with family (437; 54.7%), Islam was the cited religion for 357 (44.7%), and a third of the total sample was Qataris (241; 30.2%). More demographic characteristics are shown in Table 1.

Time trends in suicidal behavior
Month-by-month frequency of those with suicidal behavior and those without are shown in Fig. 1 Univariate analysis comparing those with suicidal behavior and those without are shown in Table 4. Younger age (31.16 ± 9.497), being non-married (91; 54.2%), currently smoking (71; 52.6%), using alcohol (43; 28.7%) were highly significantly associated with suicidal behavior compared to those without (p < 0.01). Similarly, experiencing acute The final regression model showed that having thoughts of hopelessness was a significant risk factor in predicting suicidal behavior (Table 5).

Suicidal behavior trends; general epidemiological observations
This study set out to explore presentations to emergency care with suicidal behaviors in Qatar and also whether the Covid-19 pandemic had any impact on these presentations. The main finding of this study, which is a first in almost a decade, was that almost a quarter (24.9%) of the psychiatric presentations to Emergency Department presented with some form of suicidal behaviors. This gave the annual incidence of the suicidal behaviors during this study period, which included the pre-pandemic period, to be at 14.2 per 100,000 of the adult population. Qatari natives formed 27% of the group presenting with suicidal behaviors although they constitute only around 10% of the population. The majority of the manual laborers are from the Indian subcontinent and they constituted 23.3% of the suicidal behavior group. The Asian community comprises around 56% of the population in Qatar [32]. Due to its unique demographic make-up, males in Qatar outnumber females in the ratio of 3:1 [32]. The annual incidence of suicidal behavior for males was at 11.7 per 100,000 adult males and for females, it was significantly higher at 20.8 per 100,000 adult females, (z statistic-5.13 and p < 0.00001).
Overall, these figures are much lower than the only other study [20] exploring the suicidal behaviors presenting to the Emergency Department of the same hospital in Qatar which reported on data that was collected around 10 years ago. There have been no changes in the legal status to reporting suicide since the previous study. However, the population composition and the mental health services in Qatar have undergone significant changes since that time [32][33][34]. The regular mental health services are provided by the state heavily subsidized and free of charge in emergency to all residents irrespective of the nationality status. Additionally, National Mental Health Strategy launched in 2013 focused on promotion and prevention of mental ill health through service integration [33]. We believe that the national focus on early detection and prevention through mental health promotion has led to improvement in service delivery, development of integrated community mental health services, recruitment of experts has contributed to this apparent improvement in suicidal behavior attendance in the emergency department [34]. Finally, changes in social attitudes, including stigma, to mental health and treatment of mental illness have also experienced changes over the recent years in Qatar [35]. This last change may explain the relative increase in the proportion of local Qataris and individuals of ethnic Arab origin seeking help for suicidal behaviors.

Covid-19 suicidal behavior trends
Another main finding of this study is that there was no significant change in the rate of suicidal behaviors seeking emergency care in the immediate post covid-19 pandemic period in Qatar. In fact, there was a drop in the number of cases presenting with suicidal behaviors.

Research
Discover Psychology (2022) 2:28 | https://doi.org/10.1007/s44202-022-00040-8 This is an interesting finding given that there was an increase in number of people seeking help for mental health issues in the same period. The impact of Covid-19 on mental health has been extensively studied [36] and the increase in mental ill health rates in this study follows the trends across the globe. We hypothesize that during the early post pandemic period, the thoughts of getting infected and consequences of the emerging pandemic in a rapidly changing situation did not immediately translate into longer term hopelessness and consequently increased suicidal behaviors. This wasn't just at the individual level but even state policies differed in their response to the pandemic and this was underlined by lack of consensus globally around the nature and severity of the pandemic [37]. It is also possible that fear of infection kept people away from attending hospital emergency departments for non-Covid 19 related issues during these early stages potentially impacting emergency psychiatry attendance rates [38,39]. In fact, studies looking into suicidal behaviors in general population rather than emergency department attendees during the early post pandemic period reported increased rates of suicidal behaviors [40,41]. Qatar was able to implement quick and sweeping changes in delivery of healthcare, including mental health care, to manage the pandemic and its fallout owing to its small size and default centralization of services [42]. This included rapid and easier access to mental health services through tele-psychiatry services and Covid-19 mental health helpline [43]. Taken together these might explain the relative drop in suicidal behavior cases attending the ED during the early post covid-19 lockdown period. The suicidal behavior rates in this study started picking up as the pandemic and its impact on all aspects of life stared becoming clearer and prolonged. a Percentages in parentheses are relative to valid total cases of the respective column (i.e., missing values are excluded from the denominator)

Trends in the migrant population
Finally, it is interesting to note that despite the restrictions on travel and impact on livelihoods, the suicidal behaviors in the economic immigrant population did not vary significantly over this study period. This was despite this subgroup of the population in Qatar having experienced significantly more mental health issues during the pandemic and the self-reported lack of contact with their families as the main contributing factor to their mental distress [28]. Again, we surmise that ease of access to mental health help and the relatively short duration of experience of Covid-19 related restrictions and stresses Covid-19 pandemic could be the possible reasons explaining this finding. We suspect that as our wider study continues to collect data, and with the continued restrictions of this pandemic affecting lives, we will see a change in the observed trends so far.

Conclusion
Despite reported concerns around relatively high suicidal behavior rates in Qatar, particularly among the low paid economic immigrants, our data did not support such claims. Provision of good quality, easily accessible and equitable mental health services during and before the Covid-19 pandemic has helped manage mental ill health and suicidal behaviors among the residents of Qatar. There is a possibility that as the Covid-19 pandemic evolves and persists and its long-term impacts on all aspects of life become clearer, the rates of mental ill health and the associated suicidal behaviors may increase. We expect that mental health services will continue to see elevated rates of mental ill health as the pandemic continues to unfold and will require increased allocation of resources and attention from healthcare policy makers.

Strengths and limitations
While the strength of this study lies in that it presents the most recent data on suicidal behaviors in Qatar during the Covid-19 pandemic, collected by trained psychiatrists however, it does have limitations.
The study relies on retrospective data collected from electronic patient records which do not always capture all the variables we were exploring. Additionally, study only presents findings from the early post pandemic period and may not report actual trends as the pandemic develops and leaves lasting impact on people's lives.
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