Characteristics of suicidal emergency room patients before and during the COVID‐19 pandemic in Japan

Abstract Aim Owing to the stress caused by the behavioral restrictions and lifestyle changes during the COVID‐19 pandemic, suicide rates have increased in Japan, especially among young people. This study aimed to identify the differences in the characteristics of patients hospitalized for suicide attempts in the emergency room, requiring inpatient care before and during the pandemic over 2 years. Methods This study was a retrospective analysis. Data were collected from the electronic medical records. A descriptive survey was conducted to examine changes in the pattern of suicide attempts during the COVID‐19 outbreak. Two‐sample independent t‐tests, Chi‐square tests, and Fisher's exact test were used for data analysis. Results Two hundred one patients were included. No significant differences were found in the number of patients hospitalized for suicide attempts, average age, or sex ratio before and during the pandemic periods. Acute drug intoxication and overmedication in patients increased significantly during the pandemic. The self‐inflicted means of injury with high fatality rates were similar during the two periods. The rate of physical complications significantly increased during the pandemic, while the proportion of unemployed individuals significantly decreased. Conclusions Despite studies predicting an increase in suicides based on past statistics of young people and of women, no significant changes were observed in this survey of the Hanshin‐Awaji region, including Kobe. This may have been owing to the effect of suicide prevention measures and mental health measures implemented by the Japanese government after an increase in suicides and after past natural disasters.

including Kobe, as emergencies and referred to psychiatrists.
We included patients who were admitted to the emergency room and provided with interventions by psychiatrists after they attempted suicide between April 1, 2018 and March 31, 2022. We excluded the following: patients who visited the emergency room for suicide attempts but were sent home because they promised not to reattempt suicide and did not require hospitalization, those with minor or no physical symptoms, those with severe psychiatric symptoms who were referred to psychiatric hospitals, and those who were confirmed dead after emergency transport. The interviews were conducted with verbal consent from a psychiatrist, an initial resident or late-stage psychiatrist, and at least three medical staff members. At least one nonpsychiatrist in liaison team was included in the consultation to avoid bias in information and diagnosis. The interviews were conducted at the patient's bedside or in an interview room in the emergency ward, and there was no specific time limit. Questions were asked, including confirmation of the presence or absence of suicidal thoughts. To maintain the data confidentiality, data accumulation and statistical analysis were performed by a different person than the psychiatrist who examined the patient. An opt-out method was used for inclusion in the study for patients to withdraw at any time; all patients agreed to take part in the study.

| Data collection and analysis
All research procedures complied with institutional practice guidelines, regulations, clinical research standards, and the principles of the Declaration of Helsinki. All data were encrypted, and the study protocol was approved by the Research Ethics Review Board of Kobe City Medical Center General Hospital (number: zn220702).
To compare the severity of comorbidities, we collected the following data from the electronic medical records: sex, age, COVID-19 infection status, admission to a ward with physical complications, psychiatric liaison team intervention, the presence or absence of previous psychiatry visit and diagnosis, prescription history of antipsychotic, antidepressant, anxiolytic, or sleeping medication, the presence of physical complications, and Charlson Comorbidity Index (CCI) score. 16 The CCI score was calculated using records from the Japanese Diagnosis Procedure Combination data. 17 A descriptive survey was conducted to examine changes in the pattern of suicide attempts during the COVID-19 outbreak. In addition, a cross-sectional survey was conducted between the periods during and before the COVID-19 pandemic to examine the number and methods of suicide attempts. All outcome variables were collected, stratified, and compared between the two periods: the "pre-COVID-19 period" and the "COVID-19 period." Two-sample independent t-tests, Chi-square tests, and Fisher's exact test were used for data analysis. Significance was set at 0.05. The study included 201 participants, however, due to the shortage of beds during the pandemic, we cannot rule out the possibility that emergency inpatients were discharged by their attending physicians without a psychiatrist's consultation. Two hundred one patients visited the emergency room and were hospitalized for suicide attempts, met our inclusion criteria and were further analyzed; Table 1 shows the patient characteristics. The number of patients admitted to Kobe City Medical Center General Hospital with COVID-19 was 1368. In both periods, more women visited the emergency room after suicide attempts compared to men. There was no significant difference in patients' mean age before and during the COVID-19 pandemic.

| Patients' characteristics
Physical complication rates before and during the pandemic were significantly different (p < 0.001); however, the CCI score was not (p = 0.054). Acute drug intoxication during the COVID-19 pandemic was significantly more common as compared to before (p = 0.006).
Similarly, overmedication as a means of self-injury was significantly higher during the pandemic compared to before (p = 0.023). Selfinflicted injuries with high fatality rates (suicide by hanging, jumping, diving, cervical stab wounds, abdominal stab wounds, falls, and toxic gas) decreased during the pandemic; however, the difference was not significant (p = 0.227). No significant differences were found between the pre-and post-COVID-19 periods for either psychiatric illnesses on admission at the hospital or previous psychiatric diagnoses. Employment significantly decreased during the pandemic  Table 2.

| DISCUSS ION
The number of people who visited a hospital after a suicide attempt in the COVID-19 period (n = 101) did not change compared with the pre-COVID-19 period (n = 100). No significant differences were found in sex or age. The number of suicide attempts owing to overdoses of prescribed medicines, such as sleeping pills, was higher during the COVID-19 period compared to before. However, the number of all emergency patients, outpatients, and inpatients including suicide visits at the hospital has been decreasing each year at the Kobe City Medical Center General Hospital. 18 The number of emergency patients peaked at 35 244 in FY2017 and has been declining every year. The lowest was 18 330 in FY2020 during the COVID-19 pandemic, which increased slightly to 21 230 in FY2021; however, it remains lower than before the COVID-19 outbreak. These lower rates are likely partly due to hospitals being overwhelmed and reducing services for self-harm and suicide. Especially at the beginning of the outbreak, on April 9, 2020, nosocomial infections occurred among seven inpatients and 29 staff members, and 349 employees were requested to standby at home in quarantine to prevent the spread of infection, 19 which had stopped accepting emergency patients except outpatients of our hospital from April 13, 2020. Thus, the number of patients with suicidal behavior visiting emergency rooms is likely to have increased relatively.
Overdoses exhibited a significant increase during the pandemic compared to before, which may be due to stay-at-home orders in order to prevent the spread of infection. 20 These results contradict similar reported statistics showing a decrease in self-harm during the pandemic period in the United States (March 16, 2020 to October 10, 2020) and Canada (April 1, 2020 to June 30, 2021) when compared to before. 10,11 This may be because, in Japan, the restrictions were not as strict as the lockdowns in the United States and Canada; for example, there were mild requests for self-restraint, and people were allowed to go out if they met the requirements. This is the unique mentality of the Japanese. Japanese people are disposed to be attentive and sympathetic toward their surroundings, and traditionally have a sense of group cohesiveness or group consciousness that distinguishes between insiders and outsiders. 21   If the pandemic is prolonged and affects the public and the economically and socially vulnerable, suicide will become a more pressing issue. It is also possible that domestic violence and alcoholism are becoming increasingly serious, even though they have not yet surfaced. 37 Suicide prevention measures should be implemented.

| Limitations
This study had certain limitations. First, it was based on data from a single institution and an emergency room-based sample data, which is unlikely to be representative of the entire population.
In addition, because this institution accepts all types of patients 24 h a day, 365 days a year, more patients with severe diseases will