Caution: Some people may find parts of this content confronting or distressing.
Please carefully consider your needs when reading the following information about suicide and self-harm. If this material raises concerns for you contact Lifeline on 13 11 14, or see other ways you can seek help.
The information included here places an emphasis on data, and as such, can appear to depersonalise the pain and loss behind the statistics. The AIHW acknowledges the individuals, families and communities affected by suicide each year in Australia.
Aboriginal and Torres Strait Islander readers are advised that information relating to Indigenous suicide and self-harm is included.
The AIHW supports the use of the Mindframe guidelines on responsible, accurate and safe suicide and self-harm reporting. Please consider these guidelines when reporting on statistics on the monitoring of suicide and self-harm.
While there has been a rise in the use of mental health services and an increase in psychological distress during 2020 there is no evidence to date that COVID-19 has been associated with a rise in suspected deaths by suicide.
Since April 2020, the AIHW has been compiling detailed data on the use of mental health services and the various crisis help lines on a weekly basis (fortnightly in 2021), as part of the National Suicide and Self-harm Monitoring Project. These data are shared within government to inform the mental health response to the COVID-19 pandemic. Some of this data is available at Mental health services in Australia.
These data show a rise in the use of crisis lines and mental health services since the onset of COVID-19 but it is not clear to what extent this rise in contacts is driven by rises in psychological distress rather than a higher proportion of people seeking assistance for other reasons such as loneliness and concern about contracting COVID-19. Given that a range of survey data indicate that there were rises in the level of psychological distress in 2020, increased contact with the crisis lines is almost certainly indicative of a rise in the need for assistance as a result of the pandemic.
Psychological distress is commonly measured using the Kessler Psychological Distress Scale—10 items (K10). The K10 questionnaire was developed to yield a global measure of psychosocial distress, based on questions about people’s level of nervousness, agitation, psychological fatigue and depression in the past 4 weeks. The Kessler 6 Scale is an abbreviated version of K10.
There is a correlation between high levels of psychological distress and common mental health disorders. As a result, instruments such as K10 and K6 can be used to track probable changes in the incidence of these disorders. This is important, as there is an association between mental health issues and deaths by suicide. Data from the Queensland Suicide Register for 2014–16 based on police and coroners reports, suggest that ‘mental health conditions were prominent in those who died by suicide, with 51.5% reportedly having a diagnosed mental health condition.’ (Leske et al. 2020). Around 64% of people who died by suicide in 2019 had mental and behavioural disorders recorded as an associated cause of death (ABS 2020).
There are several ways to gain insights into the level of psychological distress in the community, and monitor trends over particular time periods.
One way is to look at trends in the use of mental health services. The AIHW has been compiling data each week on the use of mental health services and crisis lines during the pandemic. While this approach is useful, it is not a direct measure of the level of psychological distress as it does not capture those who do not seek out or do not have access to mental health services and crisis lines.
Another way to analyse trends in the level of psychological distress since the onset of the pandemic is to use sample surveys. This approach has been challenging since the onset of COVID-19 due to the fact that face-to-face surveys are very difficult to undertake at this time and pose a potential health and safety risk to interviewers and interviewees. This has led to a number of online surveys being conducted but many of these surveys are not based on probability sampling. In some cases, samples are drawn by inviting all members of the public above a certain age to respond, with unknown response rates. Other samples are drawn from panels where individuals opt-in online. While this sort of approach can provide some useful information, especially regarding associations between factors that may affect outcomes for respondents, results may not be representative of the Australian population and therefore cannot be used, even with reweighting, to derive estimates for the Australian population. A major report on online panels for the American Association for Public Opinion Research (AAPOR 2010) noted that:
Researchers should avoid nonprobability online panels when one of the research objectives is to accurately estimate population values. There currently is no generally accepted theoretical basis from which to claim that survey results using samples from nonprobability online panels are projectable to the general population. Thus, claims of “representativeness” should be avoided when using these sample sources.
Given the need for representative data, the AIHW collaborated with the Centre for Social Research and Methods at the Australian National University to include questions on loneliness and the level of psychological distress using the Life in AustraliaTM Panel, managed by the Social Research Centre. Importantly, this panel exclusively uses random probability-based sampling methods and covers both online and offline populations (that is, people who do and do not have access to the internet). In addition, as a panel it is possible to obtain longitudinal data including from the same respondents prior to the spread of COVID-19 which provides richer information than a series of cross-sectional snapshots, especially with regards to changes through time. Data on psychological distress were collected in April, May, August, October and November 2020, January 2021, and further data collection is planned for April 2021.
To understand how COVID-19 may have affected Australians’ levels of psychological distress, it is important to look at data from before the pandemic. This is possible using results from the Australian Bureau of Statistics’ National Health Survey, which is conducted approximately every 3 years. It is particularly important to consider any existing trends prior to the pandemic—for example, if psychological distress was generally increasing among Australians in the years before COVID-19. Tables 1 to 3 show the proportion of males, females and people with high or very high levels of psychological distress as measured by the Kessler 10 Scale from 2004–05 to 2017–18. While the results vary by age, there is no consistent trend over this period. It is worth noting, however, that young women aged 18–24 consistently have higher levels of psychological distress than other groups. Having said that, there have been small increases in the proportion of both males and females with high or very high levels of psychological distress from 2011–12 to 2017–18, albeit with important fluctuations through time. The National Drug Strategy Household Survey (NDSHS) also shows rises from 2010 to 2019 (AIHW 2020).
The ANU poll results that are based on just over 3,000 respondents in 2020 and a little over 2,500 respondents in February 2017 suggest that the proportion of the population experiencing severe psychological distress as measured by the Kessler 6 Scale rose from 8.4% in February 2017 to 10.6% in April 2020 (Biddle et al. 2020b) with a subsequent fall to 9.7% in May 2020 (personal communication). Between April 2020 and January 2021 there were fluctuations in the percentages with values ranging from 10.9% in October 2020 to 9.4% in January—still significantly higher than in February 2017 (personal communication).
Another way of analysing trends in psychological distress is to look at how the average K6 score has changed over time. The data shows some notable changes in the level of psychological distress in 2020 with marked differences by age and some variation by jurisdiction.
The K6 measure of psychological distress used in the analysis prepared by the ANU has been constructed to have a minimum value of 6 and a maximum value of 30 (Biddle et al. 2020c). Higher scores indicate higher average levels of distress. People with a sum of 11–18 out of a possible maximum of 30 are categorised as experiencing moderate psychological distress. This group can be considered to be struggling with mental distress worthy of mental health support but are not at risk of clinical levels of mental health problems like those in the serious category (Prochaska et al. 2012). Those with a K6 sum of 19 or higher out of a possible maximum of 30 are categorised as experiencing severe psychological distress consistent with having a ‘probable serious mental illness’.
In February 2017, the average K6 value was 11.2. In April 2020, the score had increased to 11.9. Between April and May 2020 there was a significant reduction in psychological distress, although the K6 measure was still above the pre-COVID-19 values (mean of 11.5 in May 2020). The average score then rose from May 2020 to August 2020 (11.7) but showed very little change from August to October (11.8) (Biddle & Gray 2020). This was followed by a large and statistically significant fall in the average K6 score from October to November (11.4) (Biddle et al. 2020e). While the average score in November 2020 was quite a bit lower than it was in April it was higher than it was prior to the onset of COVID-19 in February 2017.
From November 2020 to January 2021 the average K6 score fell from 11.4 to 11.0 (Biddle & Gray 2021). The average score in January 2021 was similar to that in February 2017 (no statistically significant difference). In other words the average level of psychological distress was back to where it was prior to the pandemic. That said, there is a distinct pattern by age with younger people still having higher average levels of psychological distress than they had prior to the pandemic, see Psychological distress by age.
Changes in the level of psychological distress in 2020 are associated with the impact of COVID-19. The heightened level of distress in April coincided with the initial lockdown period while the improvement from April to May coincided with the loosening of restrictions. The worsening between May and August coincided with the second wave of COVID-19 in Victoria and the associated lockdown with much of the worsening in the average K6 score over this period reflecting changes in Victoria (Biddle & Gray 2020).
To test whether outcomes worsened in Victoria relative to the rest of the country due to the reintroduction of lockdowns, Biddle et al. conducted a Difference-in-difference analysis using linked data for May and August (that is, data across these months for the same people) (Biddle et al. 2020d). This showed a significant worsening in Victoria relative to the rest of the country on several outcomes including: psychological distress, loneliness, life satisfaction, satisfaction with direction of country, likely to be infected by COVID-19 and hours worked). On the other hand, the reduction in levels of psychological distress from October to November coincided with improvements in Victoria. According to Biddle et al. (2020e):
There has also been a continued convergence in psychological distress between Victoria and the rest of Australia. In October 2020, just as lockdown conditions had started to be eased, psychological distress in Victoria was more than 1-point higher in Victoria compared to the rest of Australia (12.67 compared to 11.52). By November 2020, however, this difference had declined to less than half of one point – 11.73 compared to 11.32.
Figure 1 shows average K6 scores by age. The chart shows a clear gradient with younger people experiencing higher average levels of psychological distress than people in older age groups (Biddle et al. 2020c,d; Biddle & Gray 2020 and Biddle & Gray 2021). The chart also shows a very distinct pattern over time. For younger people average K6 scores are higher in 2020 than they are in 2017 with the largest rises evident for those aged 18–24. In general, those aged 44 and under experienced higher levels of psychological distress in 2020 while those aged 45 and above either experienced either little change or improvements in their level of psychological distress. As an example, the average level of psychological distress among 18–24 year olds, 25–34 year olds and 35–44 year olds were significantly higher in April 2020 (in a statistical sense) than in February 2017 (Biddle et al. 2020c). On the other hand, it is worth noting improvements during the course of 2020—for example the level of psychological distress among 18–24 year olds showed a significant improvement from October to November (Biddle et al. 2020e).
Source: Life in Australia, February 2017, and ANUpoll April 2020, August, October and November 2020, and January 2021 and personal communication.
In January 2021, despite improvements during the year, the level of psychological distress was still higher than in February 2017 for people aged 18–24, 25–34, and 35–44. For those aged over 45, if anything the level of psychological distress was lower than it was in February 2017 (Biddle & Gray, 2021).
One of the advantages of the data collected through ANU poll is the fact that longitudinal data are available. This makes it possible to model the factors that appear to be contributing to rises in the level of psychological distress during the pandemic. In this modelling (Biddle et al. 2020c), the strongest predictor of psychological distress (K6) is where people say that their stress has worsened (this is not that surprising). Increased loneliness is also a strong predictor of K6 scores even when other factors like changes in employment status are controlled for. This suggests that increased loneliness during the pandemic is of concern and that this is not just being driven by job loss.
Job loss itself was a predictor of K6 scores in May (Biddle et al. 2020c). Controlling for other factors, people who were employed in February 2020 but not in May had higher levels of psychological distress. Interestingly, in all the models those who live outside capital cities had lower rates of psychological distress than those who lived in capital cities, controlling for other factors. This probably reflects the fact that the economic impact of shutdowns has been higher in the major cities than it has been in regional or remote areas and that infection rates have also been higher.
Once you control for things like relationships worsening and stress rising and employment loss then young people were no longer worse off than older people when it comes to K6 scores. This suggests that rises in the level of psychological distress among young people are being driven by things like increased stress and job loss.
One final point worth noting is that in the regression analysis of K6 scores, previous K6 scores in February 2017 had a significant predictive effect on K6 scores for May 2020 (Biddle et al. 2020c). This shows that people who are already experiencing high levels of psychological distress can be particularly vulnerable when the situation worsens.
The ANU also asked respondents whether ‘In the past week, how often have you felt lonely?’ Analysis summarised in Biddle et al. (2020c) shows that those who experienced loneliness had higher rates of psychological distress than those who did not.
Between April and May, there was a significant decline in experiences of loneliness, with 36.1% of the sample saying that they experienced loneliness at least some of the time, compared to 45.8% in April (Biddle et al. 2020c).
However, there was a distinct pattern by age with 18–24 year olds the only group to show no statistically significant reduction in the level of loneliness from April to May—despite the fact that this group had a higher proportion of respondents saying that they felt lonely at least some of the time in April (63.3%) than any other age group (Biddle et al. 2020c).
There was a rise in reported loneliness from 36.1% in May 2020 to 40.5% in August (Biddle et al. 2020d). However, this rise only occurred in Victoria where the proportion of the population who were lonely at least some of the time increased from 35.7% in May 2020 to 44.5% in August; in ‘the other seven States and Territories, there was no significant difference between loneliness in May 2020 (37.1%) and August 2020 (38.8%)’ (Biddle et al. 2020d). The increase in loneliness from May to August in Victoria coincides with the lockdown associated with the second wave.
Females experienced higher rates of loneliness than males (44.8% compared with 35.7% for males in August 2020). Those aged 18–24 years also experienced higher rates of loneliness than other ages groups (Biddle et al. 2020d).
The per cent of Australians who said that they had experienced loneliness at least some of the time declined between August and November from 40.5% to 35.2% (Biddle et al. 2020e). This is the lowest value observed over the COVID-19 period. In addition, according to Biddle et al (2020e):
There has been a very large decline in the proportion of Australians who said that they never meet socially with friends, relatives or work colleagues since the early days of the pandemic. In April 2020, 49.4 per cent of Australians said they never met socially. This declined to 26.5 per cent by May 2020, and even further to 6.8 per cent in November 2020. While this is a dramatic change over a reasonably short period of time, the level of social isolation in November 2020 is still above the pre-pandemic level of 2.0 per cent.
The proportion of Australians who said that they had experienced loneliness at least some of the time was similar in January 2021 (36.1%) to its level in November 2020 (35.2%) (Biddle & Gray 2021).
Loneliness has a clear impact on both levels of psychological distress and life satisfaction. In a regression analysis (that controlled for psychological distress in April) those who felt lonely either some, occasionally or most of the time all had significantly higher levels of psychological distress in November than others (Biddle et al. 2020e). This suggests that reductions in loneliness are contributing to reductions in levels of psychological distress. Equivalent results are evident for life satisfaction—that is, people who report feeling lonely have significantly lower levels of life satisfaction than others.
Another way of tracking wellbeing is to analyse changes in life satisfaction. In the ANU surveys life satisfaction is measured on a scale of 1 to 10 with higher scores indicating higher levels of satisfaction. Average life satisfaction fell substantially during the early stages of the pandemic from 6.9 in January 2020 to 6.52 in April, before rising from April to May (6.83) as the infection rates and lockdown conditions started to be eased (Biddle et al. 2020d). The average level of satisfaction then fell to 6.62 in August. However, between October and November, life satisfaction improved substantially from an average of 6.66 to 6.99 (Biddle et al. 2020e).
Importantly, life satisfaction in November 2020 was no longer significantly different to what it was in October 2019 (when life satisfaction averaged 7.05), and was higher than during the Black Summer Bushfire crisis (January 2020 – 6.90) (Biddle et al. 2020e). Life satisfaction showed little change from November 2020 (6.99) to January 2021 (6.95) (Biddle & Gray 2021).
While the overall level of life satisfaction is back to where it was in 2019 there was a substantial loss in life satisfaction during 2020. A regression analysis that takes advantage of the longitudinal nature of the data, suggests (controlling for the level of life satisfaction in January 2020) that, the loss in life satisfaction in 2020 has been greater for people living in Victoria, lower for those aged 65–74 and over 75 years, and lower for those who lived outside the capital cities (Biddle et al. 2020e). This is consistent with what you would expect given the greater impact of, among other things, lockdowns (through, for example, their impact on employment) for younger people, people in Victoria and people in the capital cities.
Source: ABS 4364.0.55.001 - National Health Survey
There was considerable commentary at the start of the pandemic on its potential to impact on the incidence of deaths by suicide. Much of this commentary was based on modelling based on previous experience including the relationship between unemployment and deaths by suicide. A ‘living systematic review’ (John et al. 2020) based on evidence until 7 June, concluded that:
There is thus far no clear evidence of an increase in suicide, self-harm, suicidal behaviour, or suicidal thoughts associated with the pandemic. However, suicide data are challenging to collect in real time and economic effects are evolving. Our LSR will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide.
It is true that some key risk factors associated with deaths by suicide have worsened since the onset of COVID-19. For example, there has been considerable job loss and rises in the level of psychological distress. On the other hand, it is possible that a general sense of ‘we are all in this together’ could have a protective impact. From February to April 2020 there were rises in the level of trust in others and in governments in Australia (Biddle et al. 2020a). In addition, some care is required as the vast majority of people who experience unemployment or high levels of psychological distress or mental health issues will never experience a suicide attempt. That said, it is very important to monitor trends in risk factors and trends in deaths by suicide in real time.
Another factor that should be considered is the impact of both JobKeeper and the JobSeeker supplement. This is important given the association between the risk of dying by suicide and socioeconomic outcomes. Modelling undertaken by the ANU suggests that not only are levels of poverty and housing stress lower than they otherwise would be a result of these payments they are also lower than they were prior to the spread of COVID-19 (Philips et al. 2020). Households who mainly relied on the JobSeeker payment prior to COVID-19 and the introduction of the JobSeeker supplement saw their poverty rate fall from 67% prior to COVID-19 to 6.8% (Phillips et al. 2020). On a similar note Biddle et al. (2020d) found that real incomes actually rose for those in the bottom decile of the income distribution from February to August 2020. Using data from the Taking the Pulse of the Nation Survey, Botha et al. (2020) have shown that the level of psychological distress among the unemployed has fallen since May. The ANU modelling suggests that the protective impact of JobKeeper and the JobSeeker supplement on housing stress and poverty have been reduced somewhat by the changes to these payments announced in July (Phillips et al. 2020).
In Australia, data on suspected deaths by suicide in 2020 have been released for Victoria, Queensland and New South Wales from their respective suicide registers. In all cases there is no evidence to date of any increase relative to previous years. For more information see Suspected deaths by suicide.
While data for Queensland does not show rises in suspected suicide rates compared with previous reports the following is worth noting (Leske et al. 2020):
The 2020 iQSR data show that up until 31 July 2020, police officers mentioned COVID-19 in 32 of 454 suspected suicides (7%). In four instances, it was unclear if COVID-19 contributed to the suspected suicide. COVID-19 did appear to contribute towards 28 suspected suicides. COVID-19 may have influenced suspected suicides through affecting mood, coping, stress and anxiety (14 people); employment (11 people); social isolation (8 people); changes in access to healthcare support and items (5 people); relationship breakdown (1 person) and finances (1 person). There was overlap (e.g. access to healthcare items and losing employment influenced mood).
A key part of the National Suicide and Self-harm Monitoring Project is the compilation and coding of data from ambulance attendances by Turning Point. This coding exercise is quite large as not only do Turning Point have to code data for 2020 they also have to code data for previous years to allow for analysis of trends.
The AIHW asked Turning Point if they could prioritise the coding of data for Victoria. Importantly, Turning Point are able to separate suicide attempts from self-injury and suicide ideation. Figure 2 shows monthly data on the number of ambulance attendances related to suicide attempts from January to June for 2020 and the equivalent periods in both 2019 and 2018. As the chart shows there is no clear difference from 2019 to 2020. The total number of ambulance attendances related to suicide attempts in Victoria from January to June 2020 was 2% lower than for the equivalent period in 2019. The number of ambulance attendances relating to suicidality (thinking about suicide) was also fairly similar across the 2 years (it was 4% higher in 2020).
Interestingly there was a pick up in the total number of mental health attendances (up 13% in the first half of 2020 compared with the same time in 2019). This is consistent with the overall greater use of mental health services in 2020 that is evident in other data. This highlights the fact that greater use of, and need for, mental health services does not necessarily equate to trends in the number of suicide attempts. The vast bulk of people who use mental health services will never have a suicide attempt but timely access to mental health services could reduce the number of deaths by suicide.
The number of self-injury ambulance attendances are up (17.6%) compared with 2019. This highlights the fact that self-injury and suicide attempts are not the same thing.
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