ABSTRACT

Objective: To present the characteristics of adolescent suicide, during the period of confinement due to pandemic in 2020 in Ecuador, in order to satisfy the mental health needs of this age group with their knowledge. Method: Observational, descriptive, cut-off study It was carried out. Cross-sectional retrospective, with information from the database of violent deaths of the Ministry of Government, from March 17 to September 13, which lasted the state of emergency. The analysis was carried out by province, sex, age, suicide method and frequency in days after the occurrence of the event. The suicide mortality rate (per 100,000 inhabitants) was estimated for each province. All of these results were compared to 2019 statistics for the same time period. Results: During the confinement due to a state of exception in 2020 in Ecuador, 97 suicides were registered in adolescents between 10 and 19 years old. The highest number was estimated in males between 15 and 19 years of age, with the most frequent age being 19. The most frequent day of removal of corpses was Monday and the preferred form of suicide was hanging with 81 reported cases. followed by much by intoxication and poisoning. Conclusions: Adolescent suicide deserves special attention in our environment, as it is a public health problem, influenced by various psychological and emotional factors, which can be neglected in a context of pandemic and isolation. They are, therefore, essential psychosocial interventions aimed at mitigating the mental effects of the pandemic and confinement, as well as promoting prevention and mental health programs in the adolescent population.

Keywords: COVID-19, public health, suicide, quarantine, adolescent, isolation (Source: MeSH NLM).

RESUMEN

Objetivo: Presentar las características del suicidio adolescente, durante el periodo de confinamiento por pandemia en el año 2020 en el Ecuador, para con su conocimiento atender las necesidades de salud mental en este grupo etario Método: Se realizó un estudio observacional, descriptivo, de corte transversal retrospectivo, con la información de la base de datos de muertes violentas del Ministerio de Gobierno, desde el 17 de marzo al 13 de septiembre que duró el estado de excepción. El análisis se llevó a cabo por provincia, sexo, edad, método de suicidio y frecuencia en días de ocurrido el evento. Se estimó la tasa de mortalidad de suicidio (por 100 000 habitantes) para cada provincia. Todos estos resultados se compararon con estadísticas del 2019 durante el mismo periodo de tiempo. Resultados: Durante el confinamiento por estado de excepción en el año 2020 en el Ecuador, se registraron 97 suicidios en adolescentes de entre 10 a 19 años de edad. Se estimó el número más alto en varones de 15 a 19 años, siendo la edad más frecuente a los 19. El día con más frecuencia de levantamiento de cadáveres fueron los lunes, y el modo preferido de suicidio fue la ahorcadura con 81 casos reportados, seguido con diferencia de la intoxicación y envenenamiento. Conclusiones: Las características del suicidio adolescente durante la pandemia por COVID-19 en Ecuador indican que merece una atención especial en nuestro medio, al tratarse de un problema de salud pública.

Palabras Clave: COVID-19, salud pública, suicidio, cuarentena, adolescente, aislamiento (Fuente: DeCS BIREME).

Introduction

Data reported by the World Health Organization, indicate that since 2012 an average of 804,000 annual suicides exist, which represent a rate of 11.4 suicidal deaths per every 100,000 inhabitants. Furthermore, the same report indicates that for each accomplished suicide, there are 20 unsuccessful attempts, numbers that historically have been higher among the masculine sex with a proportion of 15 men per every 8 women.⁽¹⁾ On their part, the Pan American Health Organization, in their 2014 regional report on mortality by suicide in the Americas, indicates that Latin America has suicidal rates lower than the world average in all these years.⁽²⁾

Suicide is a public health problem, even more among vulnerable groups such as adolescents, where it has been evidenced a gradual increase of this phenomenon lately, to the point of being considered the most frequent second cause of mortality among adolescents 12 to 19 years of age, ⁽³⁾ and at the same time among the five main causes of death between 15 to 19 years of age. ⁽⁴⁾ While in the adolescent population, suicide attempts have a lower fatality than in young adults, ⁽⁵⁾ determinants of age change exist which should be studied. The majority of suicidal thoughts and actions are associated to social isolation and loneliness, situations that have exacerbated with the health emergency since suicidal risk increases as people lack connections with others. Adolescence is a difficult period of social and personal adaptation, on its own, and in times of health contingency, closure of educational institutions, cancellation of public activities, restrictive measures of communication and social interaction have made them lose youth-related moments that influence in the proper development of psychological stability in young people. ⁽⁶⁾

In COVID-19 pandemic situations, there has been evidence of exacerbation of psychological disorders such as anxiety and depression, as wel as high levels of emotional stress and post-traumatic symptoms, factors directly proportional to the appearance of suicidal ideas ⁽⁷⁾. Strict security measures such as social isolation have had negative repercussions not only on physical health, but mainly on the mental health of vulnerable groups such as children and adolescents ⁽⁸⁾. At the national level, the problem of adolescent suicide has manifested itself even before the pandemic, having between 2001 and 2014 a total of 4885 suicides in this age group, with the highest risk being in males over 15 years of age and residents in Amazonin provinces; with a second place in provinces of the Ecuadorian highlands. Similarly, the literature indicates that the most common method of suicide has been hanging, followed by poisoning by pesticides ⁽⁹⁾. Suicides in pandemic period have not been well described so far, however local report indicate that far from reducing, they have remained constant, for example the Consejo de Protección de los Derechos de Quito, reported in 2020, a total of 10 suicides in minor, including a child of 9 years ⁽¹⁰⁾. Therefore, the objective of this study is to present the characteristics of adolescent suicide during the period of pandemic confinement in the year 2020 in Ecuador, according to the databases of violent deaths of Ministry of Goverment.

Methods

Design and Area of Study

For the present article, we chose to conduct an observational, descriptive, cross-sectional, retrospective study, which collected the statistical data concerning deaths of suicidal etiology ocurred nationwide, during the state of emergency in 2020, which lasted 181 days, from March 17 to September 13.

Population and sample

The information was obtained directly from the database of violent deaths of the Directorate of Security Studies, belonging to the Ministry of Government of the Republic. The inclusion criteria were all deaths due to suicidal etiology in the period of time described, between 10 and 19 years of age, with a total of 97 cases. Exclusion criteria were deaths with inconsistencies in diagnosis and cases with incomplete information.

Variables and instruments

For age, measures of central tendency such as mean, median and mode were obtained. The data were also divided into two groups, 10 to 14 years, and 15 to 19 years, following the ranges as stated in the Modelo de Atenci6n Integral del Sistema Nacional de Salud Familiar, Comunitario e lntercultural (MAIS- FCI), and by sex, male and female. Data on the total population of adolescents by province was obtained from the lnstituto Nacional de Estadfsticas y Censos (INEC), projection by age, provinces and national 2010-2020, which in turn made it possible to calculate the provincial suicide rate per 100,000 inhabitants. Of the 24 provinces in Ecuadorian territory, four had no cases of suicides during the "state of emergency". Finally, the Frequency of suicide cases is measured, according to the method used by the adolescents to commit the act, and the frequency of the days on which the reported act occurred, with the respective removal of the corpse.

Procedures

The suicide rate was determined according to international parameters established by the WHO. All figures and statistical data were contrasted with those obtained during the same period of time (March 17 to September 13) in the year 2019, in order to make a pre-pandemic and post-pandemic comparison. Although the database of violent deaths does not contain a detailed autopsy report that would allow a chronological determination of the death, in order to know if the day of death is the same day of the removal or prior to it, it was considered relevant to include the frequency of the days when the body was removed, Statistical analysis

The statistical analysis carried out was the description through frequencies and percentages of the characteristics evaluated.

Statistical analysis

Regarding age, we obtained the measures of central tendency, such as mean, median and mode. Data were also divided in two groups, from 10 to 14 years, and 15 to 19, following the range as noted in the Modelo de Atención Integral del Sistema Nacional de Salud Familiar, Comunitario e Intercultural (MAIS- FCI), and for the sex variable, men and women. In turn, the variables regarding the total adolescent population per province, was obtained from the Proyección por edades, provincias y nacional 2010-2020, from the Instituto Nacional de Estadísticas y Censos (INEC), which allowed the calculation of the rate of suicides in provinces per every 100,000 inhabitants. It should be emphasized that out of the 24 provinces in the Ecuadorian territory, four did not present cases of suicidal deaths, which is why they were not included in the description. Finally, the frequency of suicide cases according to the method applied by adolescents to carry out this act, and the frequency of days in which this reported incident occurred, with their respective corpse removal. Chi squared tests and Fischer exact teste were performed accordingly to carry out some comparisons of frequencies.

Ethical aspects

Since this was a study from which information was collected from a database without data allowing patient identification, it was not necessary for the study to pass through an ethics committee.

Results

Suicide etiology by sex and age. - The database of violent deaths 2020 reports a total of 97 deaths of suicidal etiology in the period established for the study, of which the majority, i.e. 59, correspond to the male sex, distributed in 19 cases for adolescents aged 10 to 14 years, and 40 cases for adolescents aged 15 to 19 years. Meanwhile, in the female sex, with a total of 39 suicides, 11 correspond to the age range of 10 to 14 years, and 27 to 15 to 19 years, a male prevalence that has been present since before the pandemic. (Figure 1) There is a male predominance over female in this type of deaths, with 61% in the first case, compared to 38% in the second, and it is even more evident the superiority of deaths registered after 15 years of age with 67% in balance with those before that age, with 30% of the cases. Compared to the pre-pandemic counterpart figures of 103 for the year 2019 versus 97 cases for the year 2020, showing a slight increase of 3 cases in males aged 10to 14years (Table 1).

On the other hand, the measures of central tendency for the year 2020 showed the following results : The mean of the total number of suicides recorded was 15.91 years, and the median was 16 years. In terms of mode, the most repeated age among the deceased adolescents was 19 years of age.

Provincial statistics. - Ecuador has 24 provinces within its political division, of which, during the period under stud y, four had no cases of adolescent suicide: Canar, Galapagos, Bolivar and Pastaza. The rest of the provinces described vary in number, with Pichincha and Azuay in 2020 leading with 14 cases each, followed by Guayas with 1O cases. Orellana was found to have the highest rate with 13.73 deaths per 100,000 inhabitants, followed by Azuay with 8.84 and Cotopaxi with 7.07 respectively.

These statistics contrast with the homologous period of 2019, where the Province of Orellana did not present any cases, as well as Santo Domingo, Galapagos and Santa Elena. It should be noted that Azuay is in second place both pre-pandemic and during the state of emergency. ( Table 2)

Suicide method. - Of the total number of deaths registered, hanging is the method chosen by far the most in both periods desc ribed, with a total of81 cases, divided into 51 for males and 30 for females during the year 2020. Next in frequency is poisoning/poisoning with 10 reports, with females being slightly more likely to choose this method, a similar comparison during the pre-pandemic period, and it seems to be a constant in the method chosen according to sex.They are followed with a low frequency by deaths produced by firearms, precipitation, submersion and suffocation No suicides with sharps in adolescents were reported during the 2020 period, as there were during 2019. ( Table 3)

Frequency of corpse removal by day. - The daily frequency of corpses resulting from suicide in adolescents is described, with the highest prevalence during the state of emergency being on Monday, with 21.65%, in relation to the other days of the week ( Table 4). In comparison with the dates included in 2019, a tendency to decrease as the week passes, while pre-pandemic, increased as the weekend approached . (Figure 2)

Discussion

Recent studies indicate that there have been no statistically significant increases in the suicide rate worldwide, at least during the first months of the pandemic; even in several countries there is evidence of a decrease in cases⁽¹¹⁾. In our study, reports have been maintained with little variability in the expected rate, at least during the most problematic time as was the state of emergency in 2020, where we noted a slight reduction in total cases. According to INEC and the MSP, the national suicide rate had increased by 380% in ages 10-14 as of 2017, and an increase of 36% among 15-19 year olds⁽¹²⁾.

Although our statistics show an evident male predominance, in line with worldwide figures (of about 79% of all suicide death⁽¹³⁾ ), authors point out that, in age groups from 10 to 19 years of age, this difference is not significant, in contrast to data reported in young adults, where the difference ratio is as high as 4.3:1 in favor of the male sex⁽¹⁴⁾. It has also been described in the literature that, although completed suicide is higher in males, suicidal ideation and attempted suicide are much more frequent in females ⁽¹⁵⁾. Although the numbers of suicides by province have varied during the pandemic, it is interesting to note that the province of Azuay remains in second place in frequency, both before and during the pandemic, being necessary in the future to study the determinants for such prevalence. In both periods of time, we note the hegemony of the hanging method followed by poisoning, the latter more frequent in women. Finally, it is necessary to note that in 2019 suicidal deaths had a tendency to increase as the days of the week progressed, being more frequent on Sunday, while, in the confinement of2020, it becamemorefrequenton Mondays with a tendency to decrease in the rest of the week. This difference is not so marked, perhaps due to the confinement condition itself, where most people saw the time pass indistinctly, without any variation between days.

The psychosocial determinants of adolescent suicide are a separate issue, which must be analyzed in order to address them in a comprehensive manner. The context of COVID-19 has increased the burden of psychological distress, situations such as fear of infection, anxiety, stress, depression, loss of family or friends, which may lead adolescents to think about suicide ⁽¹⁶⁾. Evidence suggests that, to counteract the statistics of self­ inflicted deaths in times of Pandemic, they should be correctly identified in the ideation phase ⁽¹⁷⁾. An important factor in suicidal ideation is the subjective or objective feeling of isolation and loneliness, which should be intervened to recognize and avoid the inherent risk ⁽¹⁸⁾. The actions and public policies that should be taken to safeguard the health of the population in general, and of adolescents based on their special needs, should not only focus on the infectious disease, but also on improving the individual and collective mental state of a population that has been hard hit by the pandemic ⁽¹⁹⁾

The present study was limited by the fact that secondary data were handled that were not designed to answer a research question as such; however, the data are useful to describe an important reality. On the other hand, as they were only reported cases, there could be an underreporting, nevertheless, we consider that the information is useful because it serves to characterize this problem, which is the objective of the study.

CONCLUSIONS

In Ecuador, there was a slight total decrease in deaths due to suicidal etiology in adolescents, during the period called "state of emergency" that comprised 181 days from March 17 to September 13, 2020, this if we compare it with the same period of days in 2019 as a pre-pandemic reference, we note that, during both periods, the trend is Adolescent suicide deserves special attention in our environment, as it is a public health problem, influenced by several psychological and emotional factors, which can be neglected in a context of pandemic and isolation, Psychosocial interventions aimed at mitigating the mental effects of the pandemic and confinement are therefore indispensable, as well as promoting prevention and mental health programs in the adolescent population.

Acknowledgments

To Richard Milton Carvajal Salazar, security information analyst at the Ministry of Government of the Republic of Ecuador, who kindly provided the data on violent deaths for the year 2020, information necessary to carry out this study.

---

---