Risk factors for poor mental health and suicidal behaviour have increased during the pandemic, due to factors such as the implementation of social restrictions, economic uncertainty, high levels of bereavement, and the long-term effects of infection with the virus.
Most research shows no increase in suicide mortality in the early months of the pandemic. The largest study to date gathered data from 21 countries (16 high-income countries, five middle-income countries) and examined suicide trends up to July 2020. The study showed that the number of suicides was no higher than expected during this initial period, with 12 countries, including Ecuador, reporting fewer than expected suicides. Even when extending the analysis to October 2020, increases in suicides were only observed in three regions – Vienna (Austria), Puerto Rico, and Japan, while Ecuador still reported fewer than expected suicides.
showed initial decreases in deaths by suicide during periods of lockdown. But other LMICs showed an increase in suicides. Borges and colleagues
reported an increase in suicides in Mexico during the first eight months of the pandemic. In Nepal, there was an increase in males and females when examined up to June 2021.
Similarly, in India there was a rise in suicides in 2020 compared to 2019, although the rise pre-dated the onset of the pandemic.
To investigate the impact of the pandemic and the associated socio-economic changes on suicides in Ecuador, we analysed suicide reports from national police records during the first 16 months of the COVID-19 pandemic (March 1, 2020–June 30, 2021) making a comparison with the January 2015–February 2020 period.
and b) men, as previous studies indicate that male suicide rates may increase during economic downturns.
We conducted a time series study to examine suicide trends from January 1, 2015 to June 30, 2021, for the total population and stratified analyses by sex and age groups. Subsequent to this, we undertook a case-series study, comparing changes in the characteristics of suicides between the pre-pandemic period and the pandemic period.
Once police are notified of a violent death, an investigation team – composed of a minimum of two police officers with training in the investigation of such deaths – attend and secure the scene, identify the victim, examine the incident location, conduct interviews with witnesses and people close to the deceased, and identify information about the likely cause of death. Police officers collect information including methods used, the presence of alcohol on the breath, apparent motivation for the suicide and verify whether the deceased had a recorded disability as registered in identifying documentation from the Ministry of Health. This information is recorded in a single computerised system.
Based on the police report, DINASED requests the regional forensic centre conduct an autopsy. Findings from the autopsy supplement the police investigation and contribute to DINASED’s final classification of cause of death as homicide, suicide, or external death of undetermined intent. Every step is registered in the computerised system and linked using the individual’s National identification number with sociodemographic data (marital status, occupation, date of birth, age, sex, ethnicity, disability) from the civil registry. The system records deaths by suicide from 2015 onwards.
Our primary outcome was monthly suicide counts. Suicide was determined from the police investigation and autopsy described above. We adjusted for the population size using official projections from the 2010 Census data of the National Institute of Census and Statistics (for the population aged ≥5 years).
Secondary outcomes included changes in the following characteristics of the deceased as recorded in the linked data: location (urban/rural and region where the death occurred), suicide methods used, civil status, ethnicity, presence of a disability, possible motives/triggers as identified in the police record and possible recent alcohol consumption. The police obtain additional details such as education and occupation from the Civil Registry, but due to high levels of missing data these were not included in our analysis.
To estimate the baseline trend, we used time-series analysis to identify the best fitting model in each series. We did this using Poisson regressions with a scale term to account for overdispersion and an offset term to account for population size. We considered two possible models: (1) a model with a predictor for linear time trends only; or (2) a model with a predictor for a linear time trend and predictors capturing seasonality trends. (More complex models fitting non-linear time trends were not considered because of the low numbers of suicides in some series.) The linear time trend was fit to the data by including a variable coded 1, 2, …t representing each month and year of the study. Seasonality effects were estimated with Fourier terms (pairs of sine and cosine functions) entered into the models. We chose the best model on the basis of goodness of fit and assessed using the AIC statistic.
We chose these categories to distinguish children from young adults and to divide adults into working-aged and retired, as we considered the social and economic impacts of the pandemic might differ in these groups.
For the risk factor data, we calculated risk ratios and risk differences and their 95% confidence intervals and two-sided exact p-values in Stata for the pre-COVID-19 and COVID-19 periods.
We analysed data in Stata, version 16·1. We are unable to provide the dataset as it was provided for exclusive use and not allowed to be shared.
Ethics committee approval
This study reports on anonymised and unidentifiable data available to the public upon request from the National Police. Following the Helsinki Declaration, international and national guidelines of good practice, we used this anonymous database to report on suicide trends ensuring that no harm was caused, or confidentiality breached. At the time this study was conducted, ethical approval was not required, given that we used an anonymous de-identified database.
Role of the funding source
There was no specific funding for this study. All authors had full access to all the data in the study and all had responsibility for the decision to submit for publication.
Table 1Number of suicides and rate (per 100,000 person-years) overall and by sex and age-group in the 62-month pre-pandemic period (January 2015–February 2020) vs. the first 16 months of the pandemic (March 2020–June 2021) with estimated rate ratios during the pandemic based on pre-pandemic trends from time-series analyses.
*Note: Note the differences in rates per 100,000 person-years do not correspond with the rate ratios as the latter are derived from time series models which compare observed vs. predicted rates based on trends in rates between January 2015 and February 2020, rather than a crude comparison of rates over this period.
Table 2Proportion of suicides by risk factors in the 62-month pre-pandemic period (January 2015–February 2020) vs. the first 16 months of the pandemic (March 2020–June 2021).
*Two-sided Fisher’s exact p value.
+The police did not report data from the Insular region (Galapagos).
Table 3Methods used for suicide in the 62-month pre-pandemic period (January 2015–February 2020) vs. the first 16 months of the pandemic (March 2020–June 2021).
*Two-sided Fisher’s exact p value.
The findings from our study suggest there was no evidence of an overall change in suicide rates nationwide in Ecuador in the first 16 months of the COVID-19 pandemic from March 2020 to June 2021, compared to predicted levels based on pre-pandemic trends. There was, however, some evidence of fewer than expected male suicides.
especially in vulnerable groups such as children and adolescents. In Ecuador, education shifted online between March 2020 and June 2021 with very few schools delivering face-to-face teaching. Furthermore, families with children may have been particularly affected by decreases in income, crowded housing conditions, and domestic violence.
and because of physical distancing measures and the fear of COVID-19, many older adults were confined to their homes, losing social connections and having limited access to online support.
Data from the SARS outbreak in 2003 in Hong Kong indicated that older people were at a greater risk of suicide during that epidemic,
however our study found no evidence of this in people aged over 60 years.
There were fewer than expected suicides amongst males, despite the fact that they may have been particularly vulnerable to the economic consequences of the pandemic. Many Ecuadorians live in close-knit family groups, where the permanent presence of others could have helped prevent suicide.
As for the impact of the pandemic across Ecuador’s regions, evidence shows the Coast was the worst affected area, with the highest excess mortality of all regions
; patients with diagnosed or suspected COVID-19 from the Coast also had higher levels of anxiety and depression than in other regions.
It could be hypothesised that the impact of the COVID-19 pandemic on the inhabitants of coastal areas may have influenced the increase in the proportion of suicides. However, studies that address this issue in greater depth are needed.
and in suffocation (largely hanging) in the US.
However, our findings that suicide by poisoning declined are consistent with US findings.
It is possible that self-poisoning may be more difficult to implement if others are at home due to stay-at-home orders; likewise, the suicide attempt may be discovered earlier, leading to prompt hospital treatment saving the life of the person who attempted to take his own life.
and these groups had higher overall mortality during the pandemic.
Ethnic disparities in the impact of the pandemic on suicide rates have been reported in studies from the United States.
Our finding of a decrease in the proportion of suicides by indigenous people is consistent with the decreases observed in the suicide rates of Native Hawaiian people in the US.
However, Ehlman et al.
also reported nonsignificant increases in American Indian or Alaska Native suicides and, in keeping with our study, increases in people of mixed race. It is possible that associations may depend on whether a specific ethnic group is a minority or a majority population in the geographical region they inhabit. The lower proportion of deaths by suicide among indigenous people in Ecuador could be related to social factors, such as community union in face of adversity. However, given that indigenous suicide is an extremely complex and under-researched issue, further research is needed to understand contributing factors as these may be informative for future suicide prevention initiatives.
Our study indicates that in the year since the pandemic began, lower proportions of suicide victims were reported by police to smell of alcohol. Banning the sale of alcohol, closure of bars and pubs, and the physical distancing measures to prevent the spread of the virus (e.g., restrictions on social gatherings and stay-at-home orders) may have contributed towards reducing alcohol consumption in vulnerable people and the fall in male suicides (see above). There is, to our knowledge, no representative study on alcohol use in Ecuador, however, a survey conducted by the Pan-American Health Organization in several Andean countries, including Ecuador, showed that the prevalence of self-reported episodic heavy episodic alcohol consumption decreased from 51% in 2019 to 24% in 2020, suggesting that restrictive policies may have reduced harmful alcohol consumption. The Internal Revenue Service reported a 25% reduction in sales of alcoholic beverages between 2019 and 2020.
Servicio de Rentas Internas. Sistema de identificación, marcación, autentificación, rastreo y trazabilidad fiscal de bebidas alcohólicas, cervezas y cigarrillos de producción nacional. https://www.sri.gob.ec/simar. [cited 25 March 2022]
This could possibly have led to a reduction of men psychologically vulnerable to suicide exposed to harmful alcohol use in Ecuador. Our findings are consistent with other data showing alcohol regulations are associated with falls in suicide.
Therefore (re)-implementation of laws and regulations, such as taxation, and sales restrictions on certain hours or days may be a cost-effective public health policy to reduce suicide as well as other alcohol-related mortality.
but also on the availability of health services support for mental illness – health services were already understaffed before the pandemic and suffered significant human losses during the pandemic.
The lack of an increase in the proportion of suicides amongst those with disabilities is surprising as disabled people may have experienced increased difficulties with their health, worries about their vulnerability to infection, and difficulties in accessing care during the pandemic.
Adversities shared by whole communities may foster a sense of togetherness, as was observed in the aftermath of the 2016 Ecuadorian earthquake. While adolescents who had stayed in shelters for over nine months after the disaster showed higher levels of anxiety and depression than those who were less affected, their suicide ideation was lower.
Strengths and limitations
To our knowledge, our study is one of the first national studies of suicide rates by age group and sex in a LMIC, which compares the contribution of different suicide risk factors before and during the pandemic. The police database includes several variables such as possible motives for the suicide, presence of a disability, and the possible contribution of alcohol to the suicide. This information provides important insights into changes in patterns of risk factors for suicide.
Nevertheless, there are several potential limitations to our findings. First, police investigations into suicides may have been hampered because of COVID-19 restrictions and concerns about their own risk of becoming infected. Second, the quality and completeness of the suicide data may vary from region to region and across time, depending on the degree of disruption caused by the pandemic and variations in the quality of police data collection due to staff capacity and training. For example, during the period when the most deaths occurred in the city of Guayaquil (April–May 2020), the police force investigating deaths by suicide was also responsible for collecting the bodies of people who died from COVID-19 and other causes in this area. With a large increase in deaths during the early months of the pandemic, fewer resources would have been available for investigating suicides, which could lead to lower data quality and underreporting.
Third, some risk factor variables (e.g., motivation for suicide, presence of alcohol) are potentially difficult to record reliably. Data on motives for suicide were collected by police officers, but not using the more rigorous psychological autopsy-based approaches used in many studies of suicide. Furthermore, the smell of alcohol on the breath is a subjective measure that may depend on when this is assessed. Blood alcohol levels would provide a more reliable assessment but are not currently included in the police dataset. Other data, such as disability and marital status, which the police obtain from social registers and the Ministry of Health may have been out of date due to recording delays during the first year of the pandemic. Lastly, we did not have data on key areas of concern such as domestic violence or difficulty accessing mental health services, both of which may have influenced suicide rates during the pandemic.
but not others. The possibility that alcohol sales restrictions may have contributed to the decline in male suicides requires further investigation.