Discussion

We found no evidence of an increase of suicide in people who had contact with mental health and substance misuse services during the first 10 months of the COVID-19 pandemic in Norway. Rather, tendencies towards a reduction in the number of suicides in this group were observed in the context of no increase in suicide rates in the general population in Norway,^{Reference Stene-Larsen, Raknes, Engdahl, Qin, Mehlum and Strøm8} where reduced rate ratios were found for March–May and October–December, and an increased rate ratio for June–September, all of which were non-significant differences well within the 95% prediction intervals. Additionally, no change in the overall prevalence of contact with services was found.

Our findings are well aligned with results from studies in the general population consistently finding no evidence of increased suicide mortality in the first period of the pandemic,^{Reference Pirkis, John, Shin, DelPozo-Banos, Arya and Analuisa-Aguilar2} although the long-term effects remain to be established. Also, whether this finding will be replicated in other countries and health systems is important to examine.

The universal health insurance of Norway and the comparatively high access to mental healthcare may, in part, help explain the observed absence of increases in suicides, in addition to the substantial governmental efforts that were implemented to mitigate the effects of the pandemic on society. Initial reductions in access to mental health and substance misuse services were of brief duration; great efforts were made by both governmental and other organisations to keep these services open and accessible, although research on actual performance of and possible disruptions to services are lacking. Increased use of video consultations was one of the main recommended compensatory actions. Some evidence shows that most general practitioners were technically able to provide this from early in the pandemic, and there is more preliminary data pointing in the same direction from mental health and substance misuse services.^{Reference Wynn9}

We were not able to examine possible differential effects on suicidal mortality among subgroups of people in contact with services before suicide. One important area to study is whether there are differences in the effect on suicide risk connected with the pandemic between, for example, people with major psychiatric disorders and those with more stress-induced conditions.

There is growing evidence of the large and widespread impact of the COVID-19 pandemic on societies worldwide, including adverse economic effects, increased mental distress¹⁰ and an increase in suicidal thoughts.^{Reference John, Eyles, Webb, Okolie, Schmidt and Arensman11} The seeming lack of association with suicide rates at both the general population level and clinical level in a short time perspective merits considerable interest and might provide an opportunity for further study of risk and protective factors for suicide. Since long-term effects of the pandemic on suicide mortality remain to be established, it is necessary to stay vigilant both to possible effects on vulnerable groups, such as patients in contact with mental health and substance misuse services, as well as to possible changes in the prevalence of important risk factors in society in general.