Suicidal ideation and suicide attempts in healthcare professionals during the COVID-19 pandemic A systematic review

TYPE Systematic Review PUBLISHED 06 December 2022 DOI 10.3389/fpubh.2022.1043216 OPEN ACCESS EDITED BY Wai-kit Ming, City University of Hong Kong, Hong Kong SAR, China REVIEWED BY Guanhua Fan, Shantou University, China Manuel Vaquero-Abellan, University of Cordoba, Spain *CORRESPONDENCE Juan Gómez-Salgado [email protected] Luciano Rodríguez-Díaz [email protected] SPECIALTY SECTION This article was submitted to Public Mental Health, a section of the journal Frontiers in Public Health RECEIVED 13 September 2022 ACCEPTED 18 November 2022 PUBLISHED 06 December 2022 CITATION García-Iglesias JJ, Gómez-Salgado J, Fernández-Carrasco FJ, Rodríguez-Díaz L, Vázquez-Lara JM, Prieto-Callejero B and Allande-Cussó R (2022) Suicidal ideation and suicide attempts in healthcare professionals during the COVID-19 pandemic: A systematic review. Front. Public Health 10:1043216. doi: 10.3389/fpubh.2022.1043216 COPYRIGHT ©2022 García-Iglesias, Gómez-Salgado, Fernández-Carrasco, Rodríguez-Díaz, Vázquez-Lara, Prieto-Callejero and Allande-Cussó. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Suicidal ideation and suicide attempts in healthcare professionals during the COVID-19 pandemic: A systematic review Juan Jesús García-Iglesias1, Juan Gómez-Salgado1,2*, Francisco Javier Fernández-Carrasco3,4, Luciano Rodríguez-Díaz5*, Juana María Vázquez-Lara5, Blanca Prieto-Callejero6and Regina Allande-Cussó7 1Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, Huelva, Spain, 2Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil, Ecuador, 3Department of Obstetrics, Punta de Europa Hospital, Algeciras, Spain, 4Nursing and Physiotherapy Department, Faculty of Nursing, University of Cádiz, Algeciras, Spain, 5Faculty of Health Sciences, University of Granada, Ceuta, Spain, 6Department of Nursing, University of Huelva, Huelva, Spain, 7Department of Nursing, Faculty of Nursing, Podiatry and Physiotherapy, University of Seville, Seville, Spain Background: COVID-19 has caused a series of economic, social, personal, and occupational consequences that may affect the mental health of healthcare workers (HCWs), with the consequent risk of developing suicidal ideation and behaviors. Objectives: The aim of this study was to identify the main risk factors that may predispose HCWs to suicidal ideation and suicide attempts during the COVID-19 pandemic. Methods: A systematic review of studies published between January 2020 and August 2022 was conducted following the PRISMA guidelines in the following electronic databases: Pubmed, Scopus, Web of Science, CINAHL, and PsycINFO. Methodological quality was assessed using the critical appraisal tools for non-randomized studies of the Joanna Briggs Institute (JBI). The followed protocol is listed in the International Prospective Register of Systematic Reviews (PROSPERO) with code CRD42022340732. Results: A total of 34 studies were included in this review. There are a number of underlying factors such as higher rates of depression, anxiety, pre-pandemic lifetime mental disorders or previous lifetime suicide attempt, living alone, having problems with alcohol and/or other drugs, etc. that favor the emergence of suicidal tendencies and ideation in times of COVID-19. Similarly, the pandemic may have precipitated a series of factors such as economic concerns, assessing one’s working conditions as poor, having family members or friends infected, changes in services or functions, and feeling discriminated against or stigmatized by society. Other factors such as age, sex, or type of healthcare worker show differences between studies. Frontiers in Public Health 01 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 Conclusion: Organizations should ensure the adoption of strategies and programmes for early detection of suicides as well as increased attention to the mental health of professions with a high workload. Systematic review registration: PROSPERO, identifier CRD42022340732. KEYWORDS COVID-19, health personnel, suicide, mental health, risk factors, public health Introduction The WHO (1) estimates that there are more than 700,000 suicide deaths per year. This phenomenon is considered a complex public health problem due to its multivariate casuistry, where psychological, sociocultural, biological, economic, and personal factors may converge. According to the Columbia Classification Algorithm of Suicide Assessment (C-CASA) (2), there are eight categories related to suicidal behavior. Among these eight categories, we find completed suicide (self-injurious behavior that triggers the death of an individual); suicide attempt (potentially selfinjurious behavior in which the individual had the intention to commit suicide); preparatory acts toward imminent suicidal behavior (where the individual takes steps to self-harm but the self or third parties prevent the act of self-harm itself); suicidal ideation (passive thoughts about wanting to be dead or active thoughts about killing oneself but not accompanied by preparatory behavior); and self-injurious behavior (selfinjurious behavior where the associated intention to die is unknown and cannot be inferred). In an attempt to explain what drives a person to commit suicide, to plan and think about it, a number of theories have been established. According to the Interpersonal Theory of Suicide (3), a person will not attempt suicide unless they have both the desire to die by suicide and the ability to do so, so there must be thwarted belongingness and perceived burdensomeness. According to the Integrated Motivational-Volitional Model of Suicidal Behavior, individuals go through three phases in which feelings of defeat and entrapment are key elements, and in which the biopsychosocial context in which suicidal behavior arises, the factors involved in suicidal ideation, and those factors linked to the transition between suicidal ideation and suicidal action are precipitating factors (4). In addition, there are other theories (5) such as the Eco-developmental Model of Suicide Attempts (6), in which individual, relational, community, and social factors converge; the Cultural Theory and Model of Suicide, where there is a cultural component of suicide that goes beyond the individual and can affect relationships, the community, and society; or the Three-Step Theory (7), in which factors such as grief and hopelessness, lack of connection or attachment to other people, the absence of a meaningful job or life project coexist with the capacity for suicide itself, among others. All these theories refer to risk or predisposing factors for suicidal behavior. The risk factor construct is understood in terms of probability and refers to a variable or factor that predisposes an individual to develop a certain disease or pathology (8). For the general population (3,9), there are a number of risk factors that predispose to suicidal behavior such as childhood abuse, mental disorders and previous suicide attempts, situations of social isolation, despair, lack of resources, family conflict, incarceration or unemployment, problems with authorities, alcohol and other drug abuse, family history of suicide, diagnosis of physical illness, serotonergic dysfunction, seasonal variation, and personal traits such as impulsivity, predisposition to struggle, and low self-esteem or feelings of shame or guilt. Likewise, females have a higher risk of attempted suicide than males, although males have higher rates of completed suicide (10,11), a phenomenon known as the gender paradox (12). With all these factors, we have now added a variable such as the pandemic caused by COVID-19 [Coronavirus disease 2019, an infectious disease caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV2)]. The COVID-19 pandemic has led to confinement, limited mobility, changes in people’s social lives, and economic problems that have negatively affected both the mental health and wellbeing of individuals (13). Compared to previous epidemics (14), suicide rates may have increased during and after health crises, as corroborated by a systematic review on suicidal ideation and behaviors during the COVID-19 pandemic (15). It is true that in recent years it has become apparent that some occupations are more prone to suicide risk, such as healthcare workers (HCWs), who are 3–5 times more likely to be at risk of suicide (16) and who, as expected, have been closely affected by the different epidemic waves of the COVID-19 pandemic (17). This suggests that suicide rates may be increased by pre-existing or emerging mental health conditions. In fact, it is estimated that the suicide rate among male clinicians is almost 1.5 times higher than that of female clinicians and 2.3 times higher than in the general population (11,18). Among female nurses, there are also higher suicide rates than in the general population (19). Healthcare professionals appear to have occupation-specific risks for suicide as a result of their highly stressful work Frontiers in Public Health 02 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 environment or the impact of the situations they experience, such as being involved in a physician error, among others (11). The consequences of suicidal ideation can lead to suicide attempts and completed suicide with the resulting personal loss. More specifically, in clinical practice, such thoughts can affect adequate professional performance due to a lack of empathy, kindness, compassion, and active listening skills, in detriment to the quality of care provided (17). Especially at the beginning of the pandemic, HCWs may have felt worried about infecting their loved ones, may have been afraid of the disease, felt stigmatized and isolated by society, suffered traumatic experiences and ethical dilemmas, and may have been subjected to high levels of stress, anxiety, and depression (20,21). In addition, in the work environment, many HCWs have lacked personal protective equipment, have had increased patient load, have had to make difficult decisions, have witnessed a high number of deaths of patients under their care, have been forced to double shifts, and have been relocated from their services (22). All this factors have had the potential to undermine the mental health of HCWs, with the consequent risk of developing suicidal ideation and behavior (23). While it is true that the pandemic has fluctuated, a study in Bangladesh (15) found that, from April 2020 to July 2020, the prevalence of suicidal ideation had increased from 5 to 19%, similar figures to those reported by Mortier et al. (24), which range from 4.4 to 13%. In another study, suicidal thoughts had a prevalence of 11% among HCWs, compared to 6% in the general population (25). It should not be disregarded that suicidal ideation is a predictor of future suicide attempts and suicide deaths (26), hence the importance of addressing it at early stages. In this regard, Sahimi et al. (27) and Rodney et al. (21) found that 17% of physicians reported suicidal ideation, of whom 1% had attempted suicide. Furthermore, HCWs are more likely than non-HCWs to succeed in suicide attempts as they have greater access to more lethal drugs and have knowledge about the sufficient dosage to end their lives (28). In the systematic review by Dutheil et al. (20) carried out in 2019, ∼1.0% of physicians attempted suicide and 17% of physicians had suicidal ideation. These figures decreased as the pandemic progressed, especially in European countries. The monitoring of cases throughout the pandemic could require a specific approach to this issue, and also more longitudinal studies should be carried out to assess events in this field. As can be seen, there is wide variability and contradictions between different research results affecting suicide. For this reason, the aim of this review was to identify the main risk factors that may predispose a healthcare professional to suicidal ideation and suicide attempts during the COVID-19 pandemic. Materials and methods Study design A systematic review was conducted following the PRISMA guidelines (Preferred Reporting Items for Systematic reviews TABLE 1 PECOT format: keywords. Population Healthcare professionals Event Suicidal tendencies: suicide attempts and suicidal ideation Comparison Risk/protective factors Outcomes Number of cases, risk vs. protective factors, occupational vs. non-occupational factors, quantification of suicidal tendencies, comparison of levels before vs. during the COVID-19 pandemic, comparison according to type of profession/service Time During the COVID-19 pandemic Research question What factors may influence a healthcare professional to present suicide attempts and suicidal ideation during the COVID-19 pandemic? TABLE 2 Search terms. MeSH†terms Terms Health personnel Healthcare professionals OR Healthcare workers OR Healthcare providers OR Physician* OR Nurse* OR Doctor* COVID-19 COVID-19 OR Coronavirus OR 2019-ncov OR SARS-CoV-2 OR Cov-19 OR pandemic Suicide Suicide OR Suicide Attempt* OR Suicide Completed OR suicidal ideation OR suicidal behavior OR self-harm* OR self-injury †MeSH, Medical Subject Headings. and Meta-Analyses) (29). The protocol followed is listed in the International Prospective Register of Systematic Reviews (PROSPERO) with code CRD42022340732. Ethical aspects. Databases and search strategy The databases used were Pubmed, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature Complete (CINAHL), and PsycINFO. The search strategy used to collect the studies in the aforementioned databases was based on the key words obtained from the PECOT strategy, which yielded the research question: What factors may influence a healthcare professional to present suicide attempts and suicidal ideation during the COVID-19 pandemic? (Table 1). Following these keywords, the Medical Subject Headings (MeSH) thesaurus was consulted, yielding the descriptors health personnel, COVID-19, and suicide. In order to expand the search for published studies in line with the subject of the study, the use of free terms together with the MeSH descriptors was put in practice through the use of the Boolean operators AND and OR (Table 2). Frontiers in Public Health 03 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 TABLE 3 Search strategy for each database. Database Search strategy Results Pubmed ((((((((Suicide[Title/Abstract]) OR (Suicide Attempt*[Title/Abstract])) OR (Suicide Completed[Title/Abstract])) OR (suicidal ideation[Title/Abstract])) OR (suicidal behavior[Title/Abstract])) OR (self-harm*[Title/Abstract])) OR (self-injury[Title/Abstract])) AND ((((((Healthcare professionals[Title/Abstract]) OR (Healthcare workers[Title/Abstract])) OR (Healthcare providers[Title/Abstract])) OR (Physician*[Title/Abstract])) OR (Nurse*[Title/Abstract])) OR (Doctor*[Title/Abstract]))) AND ((((((COVID-19[Title/Abstract]) OR (Coronavirus[Title/Abstract])) OR (2019-ncov[Title/Abstract])) OR (SARS-CoV-2[Title/Abstract])) OR (Cov-19[Title/Abstract])) OR (pandemic[Title/Abstract])) Filters: from 2020 - 2022 133 Scopus (TITLE-ABS-KEY (suicide) OR TITLE-ABS-KEY (“suicide attempt*”) OR TITLE-ABS-KEY (“suicide completed”) OR TITLE-ABS-KEY (“suicidal ideation”) OR TITLE-ABS-KEY (“suicidal behavior”) OR TITLE-ABS-KEY (self-harm*) OR TITLE-ABS-KEY (self-injury) AND TITLE-ABS-KEY (“Healthcare professionals”) OR TITLE-ABS-KEY (“Healthcare workers”) OR TITLE-ABS-KEY (“Healthcare providers”) OR TITLE-ABS-KEY (physicians) OR TITLE-ABS-KEY (nurses) OR TITLE-ABS-KEY (doctors) AND TITLE-ABS-KEY (covid-19) OR TITLE-ABS-KEY (coronavirus) OR TITLE-ABS-KEY (2019-ncov) OR TITLE-ABS-KEY (SARS-CoV-2) OR TITLE-ABS-KEY (cov-19) OR TITLE-ABS-KEY (pandemic) AND (LIMIT-TO (PUBYEAR, 2022) OR LIMIT-TO (PUBYEAR, 2021) OR LIMIT-TO (PUBYEAR, 2020) 279 Web of science TOPIC: (Suicide OR Suicide Attempt* OR Suicide Completed OR suicidal ideation OR suicidal behavior OR self-harm* OR self-injury) AND TOPIC: (Healthcare professionals OR Healthcare workers OR Healthcare providers OR Physician* OR Nurse* OR Doctor*) AND TOPIC: (COVID-19 OR Coronavirus OR 2019-ncov OR SARS-CoV-2 OR Cov-19 OR pandemic) Refined By: Publication Years: 2022 or 2021 or 2020 240 CINAHL AB (Suicide OR Suicide Attempt* OR Suicide Completed OR suicidal ideation OR suicidal behavior OR self-harm* OR self-injury) AND AB (Healthcare professionals OR Healthcare workers OR Healthcare providers OR Physician* OR Nurse* OR Doctor*) AND AB (COVID-19 OR Coronavirus OR 2019-ncov OR SARS-CoV-2 OR Cov-19 OR pandemic) Refined By: Publication Years: 2022 or 2021 or 2020 89 PsycInfo tiab(Suicide OR Suicide Attempt* OR Suicide Completed OR suicidal ideation OR suicidal behavior OR self-harm* OR self-injury) AND tiab(Healthcare professionals OR Healthcare workers OR Healthcare providers OR Physician* OR Nurse* OR Doctor*) AND tiab(COVID-19 OR Coronavirus OR 2019-ncov OR SARS-CoV-2 OR Cov-19 OR pandemic) Filters: from 2020 to 2022 48 Date of search 08/08/2022 Total 789 Table 3 shows the search strategy used, carried out on 08 August 2022 for each of the above-mentioned databases during the search process. Selection criteria The following inclusion criteria were used for the selection of articles: (1) design criterion: cross-sectional, longitudinal, and interventional studies; (2) language criterion: articles published in English, Spanish, French, and Portuguese; (3) data collection period: articles where data were collected during the COVID19 pandemic and; (4) outcome measure criterion: articles measuring any of the following values/indicators: number of cases or proportion of suicidal tendencies, risk factors vs. protective factors, occupational vs. non-occupational factors, comparison of levels before vs. during the COVID-19 pandemic, comparison according to type of profession/service/level of exposure to COVID-19. On the other hand, the exclusion criteria were (1) language reasons (language other than English, Spanish, French, and Portuguese); (2) low scientific-technical quality after applying the quality assessment tool; (3) by type of article (published conference proceedings, conference abstracts, and theses or studies including animals); (4) population: students who do not perform healthcare practices; and (5) studies in which the collection date, study population, or measurement instrument could not be determined. Data collection and extraction For data collection and extraction, two researchers independently searched the databases according to agreed keywords. They eliminated duplicate studies and selected articles that could be included according to the previously established criteria after reading the title and abstract. Then, these two authors reviewed the full text of the studies that could potentially be included in the review and the decision Frontiers in Public Health 04 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 to include or exclude them in the review was made at this stage by consensus, with a third author having the discretion to include or not a study in case of discrepancy between the two authors. For the selection report, the two authors collected information from the studies regarding authorship, year of publication, country and date of data collection, overall objective, study design, population, measurement instrument, and main results; in addition, the results of the Joanna Briggs Institute (JBI) critical appraisal tool were added. Methodological quality assessment Two reviewers independently determined the methodological quality of the selected studies using the critical appraisal tools for non-randomized studies of the JBI of the University of Adelaide (30). These tools allow assessing the methodological quality of a study and determining the extent to which a study had minimized the possibility of bias in its design, development, and/or analysis. The versions for cross-sectional quantitative studies (eight items) and for case control studies (10 items) were used, setting the cut-off point at 6/8 for the former and 8/10 for the latter to accept their inclusion in this review (Supplementary material). Results Literature search The primary search in the databases yielded 789 citations. After eliminating duplicates (n=288), titles and abstracts of 501 articles were screened. Of these, 414 citations were discarded upon reviewing title and abstract. After having read the full text of the 87 remaining citations, 53 were discarded, either because they contained repeated data (n=2), the population was not HCWs (n=8), the data were collected before the pandemic by COVID-19 or the date of collection was not stated (n=8), the tool was not detailed (n=3), because of the type of study (n= 12), because the study was not related to the objective (n=17), and for low quality (n=3). The flow diagram is presented in Figure 1. Study characteristics Table 4 presents the study characteristics of the 34 selected articles. Of the total number of studies, five were conducted in China, five in Spain, four in the United States, four in the United Kingdom, two in Australia, and one in other countries (Bangladesh, Belgium, Brazil, Chile, Colombia, Egypt, Germany, India, Iran, Malaysia, Pakistan, Republic of Ireland, Russia, and Turkey). Regarding the data collection period, in 32 of the 34 studies it was carried out during the year 2020, preferably in the first and second quarter of the year, coinciding with the first wave of the pandemic. Regarding the sample, 5 of the 34 studies only included nurses and 3 of the 34, only physicians; the rest included two or more healthcare professions. Finally, regarding the measurement instrument, 12 of the 34 studies used item 9 of the PHQ-9, 8 of the 34 used the C-SSRS, 5 used a dichotomous question on whether they had suicidal thoughts, and the rest used other instruments (SSEV, question 17 of the SRQ-20, BSSI, CES-D-SI, SIS, CIS-R, Self-Injurious Thoughts and Behavior Interview, and SSI). The included studies were assessed with the JBI critical appraisal tool, where high mean scores were obtained in all the finally included studies. Main findings Suicidal thoughts were reported by 21.7 to 2.4% of HCWs. 0.5 to 12.6% reported at least one lifetime suicide attempt, 0.5 to 3.5% reported a recent suicide attempt, and 3.0 to 0.5% had self-harmed (33,48,54). Major factors associated with increased suicidality include higher rates of depression (27,32,33,36,37,39,40,55); anxiety (19,27,32,36–39,52,55); post-traumatic stress disorder (32,42); pre-pandemic lifetime mental disorders (24) or previous lifetime suicide attempt; insomnia severity; nightmare frequency; poorer subjective health (32,33,36,47,60); and burnout (32). In addition, other personal factors predisposing to suicidal thoughts include being female (58); having friends or family members infected with COVID-19 (24,32,56); living alone; having poor physical health (32); being single (27,39), divorced, legally separated, or widowed (24); higher alcohol consumption (32,34); psychotropic drug use (34,42); and change in vitamin D levels (45). Younger age is considered a risk factor for some participants (32,35), a protective factor for others (39), and shows no clear age pattern for the rest (35). Regarding work-related factors during the pandemic, suicidal ideation was associated with financial concerns (24,32,34), assessing one’s working conditions as poor (34) or perceived lack of preparedness of the health care facility (24); having had job functions changed (51); having been isolated or quarantined for COVID-19 (24,56); having been moved to a specific workplace related to COVID-19; being an auxiliary nurse (24) or a nurse (44,46); reporting high workload (34) or stress (56); feeling perceived discrimination (43,50) and not feeling support from family (47) or superiors (52); and reporting an increased post-pandemic burden (34). As for HCWs coping with COVID-19, no differences in suicidal ideation were found between nurses with and without direct contact with persons with COVID-19 (33,49,57), although another study presents Frontiers in Public Health 05 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 FIGURE 1 Identification of studies via databases (PRISMA flow diagram). discrepancies indicating that frontline HCWs reported a clearly higher presence of thoughts of death (35,37,38). Finally, factors such as having dependent children (32), having a per capita income of more than three minimum monthly wages (34) or higher than 2200 euros (24), resilience and self-perceived social support (35), not having an infected family member, and lower work stress had protective effects on suicidal ideation (47). In addition, HCWs with more than 10 years of service had a significantly lower rate of current suicidal ideation (27). Discussion This study sought to review the factors that may protect or predispose HCWs to suicide attempts and suicidal ideation during the COVID-19 pandemic. The results suggest that there are a number of personal, social, and occupational factors that may predispose HCWs to develop and tend to suicidal ideation, as well as others that may reduce the number of suicidal thoughts and tendencies, such as support systems and certain personal factors. Frontiers in Public Health 06 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 TABLE 4 Characteristics of the studies included in the systematic review. Studies Context Main aim Type of study Population Instrument Main outcomes JBI Brady et al. (31) Republic of Ireland (November 2020 to January 2021) To quantify the mental health of nursing home staff during the COVID-19 pandemic in the Republic of Ireland Cross-sectional study 390 nurses C-SSRS Suicidal ideation and suicide planning were reported, respectively, by 13.8% (95% CI, 10.4−17.3%) and 9.2% (95% CI, 6.4−12.1%) of participants with no between group differences. 7/8 Bismark et al. (32) Australia (August–October, 2020) To identify the prevalence and predictors of (a) thoughts of suicide or self-harm among HCWs during the COVID-19 pandemic and (b) help-seeking among those HCWs with thoughts of suicide or self-harm. Cross-sectional study 7,795 HCWs PHQ-9 (question 9) 10.5% of HCWs reported thoughts of suicide or self-harm. HCWs with these thoughts experienced higher rates of depression, anxiety, post-traumatic stress disorder and burnout than their peers. The odds of suicide or self-harm thoughts were higher among HCWs who had friends or family infected with COVID-19 (OR=1.24, 95% CI =[1.06, 1.47]), were living alone (OR=1.32, 95% CI =[1.06, 1.64]), younger (?30 years cf. >50 years; OR=1.70, 95% CI = 1.36-2.13), male (OR=1.81, 95% CI =[1.49, 2.20]), had increased alcohol use (OR=1.58, 95% CI =[1.35, 1.86]), poor physical health (OR=1.62, 95% CI = [1.36, 1.92]), increased income worries (OR=1.81, 95% CI =[1.54, 2.12]) or prior mental illness (OR= 3.27, 95% CI =[2.80, 3.82]). Having dependent children was protective (OR=0.75, 95% CI =[0.61, 0.92]). Fewer than half (388/819) of the HCWs who reported thoughts of suicide or self-harm sought professional support. 7/8 Höller et al. (33) Germany (February–April, 2021) To examine (1) the psychological burden and (2) suicidal ideation and its associated risk factors one year after the COVID19 pandemic begun Cross-sectional study 1,311 nurses SSEV 21.7% of HCWs reported recent (in the last 4 weeks) suicidal ideation and 0.5% reported a recent suicide attempt. 44.5% of HCWs reported lifetime suicidal ideation and 12.6% reported at least one life-time suicide attempt. Only depression, perceived burdensomeness, agitation and previous lifetime suicide attempt were associated with suicidal ideation. No differences in suicidal ideation were found between nurses with versus without direct contact with people with COVID-19. 7/8 (Continued) Frontiers in Public Health 07 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 TABLE 4 (Continued) Studies Context Main aim Type of study Population Instrument Main outcomes JBI Oliveira et al. (34) Brazil (June–July, 2020) To identify the prevalence of and factors associated with suicidal ideation among nursing professionals from a municipality in southern Brazil. Cross-sectional study 890 nurses SRQ-20 (question 17) The observed prevalence of suicidal ideation was 7.4%. Suicidal ideation was inversely related to per capita income >3 minimum monthly wages (PR: 0.28; 95% CI: 0.11–0.68), and positively related to the use of psychotropic drugs (PR: 3.14; 95% CI: 1.87–5.26). In addition, suicidal ideation was also associated with assessing one’s working conditions as poor (PR: 2.16; 96% CI: 1.13–4.13), reporting a heavy burden at work (PR: 1.93; 95% CI: 1.08–3.43), reporting increased burden post-pandemic (PR: 2.03; 95% CI: 1.13–3.64), and problems with alcohol (PR: 2.56; 95% CI: 1.31–4.96). 8/8 Mortier et al. (24) Spain (May–September, 2020 and October–December, 2020) To estimate four-month STB incidence among Spanish HCW active during the first wave of the Spain COVID-19 pandemic; and to investigate individual-and population-level associations of a wide range of potential risk factors with STB incidence. Cross-sectional study 4,809 HCWS C-SSRS (modified) Suicidal thoughts and behaviors incidence was estimated at 4.2%. Risk factors significantly associated with suicidal thoughts and behaviors incidence were pre-pandemic lifetime mental disorders (OR range 1.59–2.53), being an auxiliary nurse (OR=2.07), being single, divorced, legally separated, or widowed (OR= 1.72). Having a pre-pandemic monthly income level higher than 2200ewas a protective factor (OR range 0.49–0.53). Interpersonal stress (OR range =1.23–1.57) was strongly associated with STB, followed by personal health-related stress and stress related to the health of loved ones (OR range 1.30–1.32), and by the perceived lack of preparedness of the healthcare center (OR= 1.34). Other significantly associated risk factors were financial factors (OR range 1.26–1.81), having been isolated or quarantined for COVID-19 (OR=1.53), and having changed to a specific COVID-19 related work location (OR=1.72). 7/8 (Continued) Frontiers in Public Health 08 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 TABLE 4 (Continued) Studies Context Main aim Type of study Population Instrument Main outcomes JBI Ortiz-Calvo et al. (35) Spain (April–June, 2020) To study the potential effect of self-perceived social support and resilience on the mental health outcomes of a large sample of HCWs from Spain during the initial COVID-19 pandemic outbreak Cross-sectional study 2,372 HCWS C-SSRS (modified) The rate of death thoughts was 7%, and higher among HCWs who reported a history of prior mental health problems (21%). Resilience and self-perceived social support were inversely associated with death thoughts. Death thoughts did not show a clear age pattern. Women reported death thoughts more frequently than men. Frontline HCWs reported distinctly higher presence of death thoughts. 7/8 Que et al. (36) China (May–July, 2020) To examine the relationship between COVID-19-related traumatic event exposure and suicidal ideation among hospital HCWs, and identify mediating roles of sleep disturbances in this relationship Cross-sectional study 16,220 hospital HCWs PHQ-9 (question 9) 13.3% of HCWs reported suicidal ideation n the past month. Insomnia severity (β=0.309, p<0.001), nightmare frequency (β=0.455, p<0.001), depressive symptoms (β=0.358, p<0.001), and anxiety symptoms (β=0.371, p<0.001) were positively associated with the risk of suicidal ideation. 7/8 Salman et al. (37) Pakistan (first wave) To assess suicidal ideation and its predictors among Pakistani HCWs during the early phase of the COVID-19 pandemic Cross-sectional study 398 HCWs PHQ-9 (question 9) 14.3% prevalence of suicidal ideation among Pakistani HCWs. Participants’ occupation, their duty during the pandemic, working experience, anxiety and depression were found be associated with suicidal ideation (p< 0.05). HCWs directly engaged in managing COVID-19 patients were 2.25 times more likely to have suicidal ideation than the second-line health professionals. 7/8 Abdelghani et al. (38) Egypt (March–May, 2020) To explore the newly termed phenomenon, coronaphobia, and identify its associated correlates among physicians during their battle against the COVID-19 pandemic in Egypt. Cross-sectional study 426 physicians A question was asked (Yes/No) 10.1% of HCWs reported self-harm thoughts during pandemic. Frontline workers had more self-harm thoughts, compared to second-line workers (13.6% vs. 9.4%, respectively). Excessive anxiety and fears of COVID-19 virus infection were found to be associated with suicidal thoughts and intense feelings of hopelessness 6/8 (Continued) Frontiers in Public Health 09 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 TABLE 4 (Continued) Studies Context Main aim Type of study Population Instrument Main outcomes JBI Mamun et al. (58) Bangladesh (April, 2020) To investigate the suicidality and its associated risk factors of HCWs by comparing with that of general population as it is anticipated that the HCWs may have higher suicidality as of being exposed to critical situation and higher mental health sufferings Cross-sectional study 834 HCWs A question was asked (Yes/No) About 6.0% of HCWs had suicidal behavior, with no detectable differences within the groups (i.e., general population and HCWs). Regression analysis showed that being female, being divorced, and having no child were emerged as independent predictors for suicidality. There was no significant association between the personal protective equipment related or patient-care related variables and suicidal behavior of the HCWs. Majority of the participants sometimes had fear of death although no significant relation of the factor was found with suicidality. 6/8 Rathod et al. (59) UK (May–July, 2020 and Oct-Dec, 2020) To investigate the psychological impact of COVID-19, resultant restrictions, impact on behaviors and mental wellbeing globally Cross-sectional study 3,933 HCWs A question was asked (Yes/No) Most of the key HCWs have higher likelihood of suicidal thoughts and worries about coronavirus compared to others. Suicidal thoughts increase amongst almost all individuals with pre-existing health conditions. Individuals with pre-COVID-19 suicidal thoughts show lower likelihood of following government advice, communications with friends and family, coping activities, confidence on coping, but higher likelihood of doing risky activities, with higher scores on PHQ-9, GAD-7, and IES-R. 7/8 Xiaoming et al. (60) China (February, 2020) To investigate the psychological status of hospital HCWs and provide references for psychological crisis intervention in the future Cross-sectional study 8,817 hospital HCWs SSI The prevalence of SSI was 6.5%. Various epidemic-related attitudes and behaviors were independent factors for SSI, such as the need for psychological assistance before or during the epidemic (OR=1.826, 95% CI =1.310–2.545; OR=2.277, 95% CI =1.636–3.171), unconfident about defeating COVID-19 (OR=2.435, 95% CI =1.184–5.005), ignorance about the epidemic (OR=2.559, 95% CI = 1.451–4.531), willingness of attending parties (OR= 2.235, 95% CI =1.339–3.731), and poor self-rated health condition (OR=5.228, 95% CI =3.650–7.489) among hospital HCWs (P <0.05). 8/8 JBI, Joanna Briggs Institute; HCWs, Healthcare Workers; OR, Odds Ratio; CI, Confidence Interval; UK, United Kingdom; GAD, Generalized Anxiety Disorder; PTSD, Posttraumatic Stress Disorder; PHQ-9, Patient Health Questionnaire (9 items); BSSI, Beck Scale for Suicidal Ideation; C-SSRS, Columbia Suicide Severity Rating Scale; CES-D-SI, Suicidal Ideation Scale of the Center for the Epidemiological Study of Depression; SIS, Suicidal Ideation Scale; SSEV, Suicide Ideation and Behavior Scale; SSI, Self-Harm Ideation; CIS-R, Clinical Interview Schedule; SRQ-20, Self-Reporting Questionnaire. Frontiers in Public Health 16 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 In previous studies, suicidal behaviors were found to have increased during the pandemic in the general population and in samples of HCWs (61). This already corroborates findings from pre-pandemic studies where suicide rates among HCWs were already higher than those reported in the general population, with differences between men and women, especially among female physicians. There is a wide variability in the prevalence of suicidal ideation and suicide attempts in the different samples consulted within a COVID-19 (38) pandemic setting. This phenomenon could be explained by the variability of the samples, by the impact of disease control measures in each country, as well as by the difference in the levels of stress, anxiety, fear, and depression experienced by HCWs during the pandemic (62). Indeed, in the meta-analytic study by Dragioti et al. (63) of one hundred and seventy-three studies conducted between February and July 2020, the COVID-19 pandemic was found to have a greater impact on mental health in people living in lowincome countries, in those who had adopted more restrictive measures, and in more vulnerable populations. Rudenstine et al. (64) consider that the risk factors influencing the general population are those that affect material and economic variables, the social level, and those related to accessing vital resources. In the case of HCWs, these factors may have a different relevance during the pandemic and others may become more relevant, so synergistic relationships may be established between them (55). In this line, there are a number of factors associated with higher suicidality such as higher rates of depression (27,32, 33,36,37,39,40,55); anxiety (19,27,32,36–39,52,55); post-traumatic stress disorder (32,42); pre-pandemic lifetime mental disorders (24) or previous lifetime suicide attempt; insomnia severity; nightmare frequency; a poorer self-perceived health (32,33,36,47,60); and burnout (32). In most cases, all these risk factors have increased in impact during the COVID-19 pandemic and, as Mamun and Ullah (65) estimate, approximately 90% of suicides are due to psychological distress in the face of continued exposure to highly stressful situations. Although most suicidal ideation is due to problems related to psychological distress, the explanation may be varied and multicausal (60,66). HCWs have been repeatedly exposed to death and pain during the COVID-19 pandemic (67), and as postulated by Smith and Cukrowicz (68), constant exposure to pain and death may favor suicidal behavior and ideation. This may suggest that work environments where there is a higher risk of infection may favor a worsening of the mental health of particularly exposed HCWs (69). In this case, there is certain controversy as to the higher or lower prevalence of suicide rates among frontline HCWs compared to other types of workers. Some studies (33,49,57) have found no statistically significant differences in terms of suicidal ideation rates between HCWs working on the front line and those without direct contact. Others, on the other hand, have indeed found differences in this regard (24,35,37,38). In the latter case, this could be justified by a change in the work environment, the functions to be carried out, and a greater perception of risk in relation to the disease. Studies such as the one by Salman et al. (37) estimated that HCWs working on the front line are up to 2.25 times more likely to have suicidal ideation. Changing functions or work location has also been considered by Mediavilla et al. (51) as another risk factor, since it can worsen the mental health of HCWs. In fact, even before the pandemic, there were services in which suicide rates were higher than in others, such as the case of HCWs working in the operating room (70). Other authors found that Internal medicine and other non-surgical specialties had the highest rates of suicidal ideation (39). Other factors such as having been hospitalized due to COVID-19 infection, having had family members infected with COVID19, and self-perceived probability of contracting COVID-19 may be predisposing factors to the uncertainty caused by the disease (71). In this regard, in a case study of press reports, being infected with COVID-19 was the most common reported reason for suicide, followed by work-related stress, fear of COVID-19 infection, fear of transmitting the virus to others, anxiety about witnessing overwhelming death, and mental distress (14). On the other hand, a series of factors do not show a clear trend between studies. This is the case of age, sex, or the type of HCW studied. As indicated by Mamun et al. (58), Alvarado et al. (40), Jahan et al. (14), and Mosolova et al. (53), being female may be a risk factor that increases the rates of suicidal ideation compared to males, but other studies such as the one by Bismark et al. (32) and another one by Dobson et al. (44) differ from these conclusions and postulate that males offer higher ideation rates than females. To overcome this dichotomy, homogeneous samples should be compared to avoid possible biases. Being younger is considered a risk factor for some studies (32), a protective factor for others (39), and shows no clear age pattern for the rest (35). In relation to the type of role of the HCW, the prevalence of suicidality may vary. In the study by Mortier et al. (52) in Spain, an auxiliary nurse was 2 times more likely to develop suicidal thoughts and behaviors. In the case of the study by Greenberg et al. (46), 1 in 5 nurses reported suicidal thoughts compared to 1 in 10 physicians. Likewise, in the study by Mosolova et al. (53), the group with the highest risk was that of physicians, compared to the rest of HCWs. In contrast, in the study by Xu et al. (56), physicians, nurses, technicians, and administrators showed a similar prevalence. In this vein, the study by Dobson et al. (44) carried out in Australia (April– May, 2020) on a sample of 320 HCWs, suicidal ideation was more present among nurses. The differences between groups may respond to the fact that nurses may have a more intense nurse-patient relationship than other professionals because of the long hours they spend with patients. Just as some factors have proven to be predisposing to suicidal tendencies and behaviors, there are others that can be considered protective. In many cases, these factors are related to the support system that the HCW has at the individual, family, and work level. Factors such as having dependent children Frontiers in Public Health 17 frontiersin.org García-Iglesias et al. 10.3389/fpubh.2022.1043216 (32), per capita income >3 minimum monthly wages (34) or higher than 2200 euros (24), resilience and self-perceived social support (35), no family member infected, and lower job-related stress had protective effects on suicidal ideation (47). In addition, HCWs with more than 10 years of service duration had a significantly lower rate of current suicidal ideation (27). All in all, the findings of this review show that the context surrounding the COVID-19 pandemic at the social, occupational, family, personal, and public health levels may have had an impact on suicidal ideation and suicide attempts in the general population and, in particular, in healthcare workers as a result of the factors they are exposed to in their professional performance and the social and healthcare context that surrounds them. It is true, though, as previously mentioned, that suicidal ideation and suicide attempts will not only depend on the extrinsic factors that affect the healthcare worker in a pandemic context, but internal factors related to previous health problems, adequate support networks, financial solvency, among others, are also particularly relevant. Limitations This systematic review is not without limitations. Firstly, most of the included studies were cross-sectional and used hetero-administered instruments via online surveys. In this sense, population characteristics, methodological differences, heterogeneous samples, etc. meant that the resulting findings were very heterogeneous. Thirdly, the timing of data collection and measures of confinement/isolation was different in each study, hence the data were considered inadequate for metaanalysis. Finally, the health system, the allocation of resources for mental health promotion, as well as the adoption of preventive measures adopted by different countries may differ, and these deviations may influence the comparability of indicators. Conclusion There are a number of underlying factors such as higher rates of depression, anxiety, pre-pandemic lifetime mental disorders or previous lifetime suicide attempt, living alone, having problems with alcohol and/or other drugs, etc. that favor the emergence of suicidal tendencies and ideation in times of COVID-19. Similarly, there are a series of factors that the pandemic may have precipitated, such as economic concerns, assessing one’s working conditions as poor, having infected family members or friends, changes in services or functions, feeling discriminated against or stigmatized by society. Other factors such as age, sex, or type of HCW differ between studies. Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Author contributions FF-C, RA-C, JG-S, and JV-L: conceptualization and writing– review and editing. BP-C, JV-L, and JG-I: data curation. BP-C, FF-C, RA-C, JV-L, and JG-I: formal analysis. BP-C and FF-C: investigation. RA-C, JG-S, JV-L, and JG-I: methodology. RA-C, JG-S, and JG-I: project administration. BP-C, FF-C, RA-C, JG-S, JV-L, and JG-I: resources. BP-C and RA-C: software. RA-C, JGS, and JV-L: supervision. FF-C, RA-C, JG-S, and JG-I: validation. BP-C, JG-S, JV-L, and JG-I: visualization. BP-C, FF-C, and JG-I: writing–original draft. All authors contributed to the article and approved the submitted version. Funding Funding for open access charge: Universidad de Huelva/CBUA. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher’s note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. 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