Response

We read with interest the research paper by Paterson et al (2023)^{Reference Paterson, Kent, O'Reilly, O'Hagan, O'Neill and Maguire1} who have wonderfully used the autoregressive integrated moving average to come up with this study measuring the impact of the COVID-19 pandemic on self-harm and self-harm/suicidal ideation. Their work is extensive and takes into account nine long years of data, which is commendable. The researchers have also managed to provide data of individuals across multiple demographics, which makes this study unique and impactful. However, upon reading, there were a few limitations to the study that come to one's mind. They are listed as follows.

The study notes how there is an overall decrease in the number of people who presented with self-harm or ideations during the pandemic; however, one is forced to think about if there was an actual drop in the numbers or were people not availing themselves of these services due to nation-wide lockdowns. This can also be noted from the fact that data was collected through the NIRSH (Northern Ireland Registry of Self-Harm), which contains information of people presenting ‘physically’ at hospital emergency departments. These numbers could have naturally been low given the norms around social distancing and stay-at-home guidelines.²

Along the same lines, the question of whether data was collected from other self-harm resources and helplines is raised; specifically helplines that are available online or on-call, which would've been more accessible given the situation of a nation-wide lockdown. Based on reports by the Samaritans, a registered charity providing emotional support during crisis, there was an increase of 23% in people reaching out to them for their services over email and an increase of 12% was observed on phone calls they received.³ Shout, a text-based mental health service, also noticed an increase in texts related to self-harm.⁴

A lesser number of people showing up to the emergency department could indicate an increase in deaths by suicide which have not been accounted for in the study. Consequently, it is also important to scrutinize the title of the study, which quotes ‘impact of the COVID-19 pandemic’ on self-harm, because we cannot say for sure that it was owing to the impact of the COVID-19 pandemic or the quarantine that the rates of self-harm or suicidal ideations were found to be lower than expected.

The fact that nation-wide lockdowns were in place meant that individuals were at home with other individuals. Due to restriction of movements, individuals with suicidal ideation might have been subjected to more supervision/scrutiny, which could have been a protective factor. Self-harm and suicide is a public health issue which means it can go way beyond just the basic demographics of an individual. Things that could have been considered other than existing demographics would be existing mental health issues, concerns and treatments.

The opportunity to seek out help when going through a dull phase is a privilege that a lot of people may not have had during the initial days of pandemic when focus was completely on staying safe and simply surviving.