Article

Long COVID as a Possible Contributor to Rising Suicide

Mortality in Bharat (India): An Analysis of Suicide Trends Since
the Emergence of COVID-19
Karan Varshney 1,2, * and Mansoor Ahmed Panhwar 1

1 School of Medicine, Deakin University, Waurn Ponds, VIC 3216, Australia; [email protected]
2 School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
* Correspondence: [email protected]

Abstract: Mortality due to suicide is amongst the largest public health concerns across the world
today in Bharat (India). There have been concerns that the COVID-19 pandemic has contributed to
worsening mental health outcomes across the world, including in Bharat. Furthermore, long COVID
has been proposed to be a major consequence of COVID-19, which can also worsen mental health
outcomes. Therefore, our objective in this study was to analyse trends in suicide mortality across
Bharat and to compare these trends to changes prior to the COVID-19 pandemic; in addition, we
aimed to analyse if long COVID had any role in these changes. It was found that, at a national level,
the average annual increase in the suicide rate between 2019 and 2022 was 0.7 per 100,000 people
(a 6.41% increase). There was also an average annual rise in suicide rates across 27 states/union
territories (out of the 33 that were analysed). States/UTs with the highest annual increases since
the start of the COVID-19, despite a decrease from 2018 to 2019, were Tamil Nadu (increased by
2.7; a 15.17% increase) and Telangana (increased by 1.9; a 9.22% increase). Multi-linear regres-
sion showed that the annual suicide rate changes were not associated with COVID-19 deaths per
10,000 people (standardized beta coefficient = 0.077; p = 0.605) but were associated with COVID-19
Citation: Varshney, K.; Panhwar, M.A.
cases per 100 people (standardized beta coefficient = 0.578; p < 0.001). It has been shown that suicide
Long COVID as a Possible
mortality has worsened, and long COVID may have a potential role in this in Bharat.
Contributor to Rising Suicide
Mortality in Bharat (India): An
Analysis of Suicide Trends Since the
Keywords: Bharat; COVID-19; long COVID; suicide; mortality
Emergence of COVID-19. COVID
2024, 4, 1684–1693. https://doi.org/
10.3390/covid4100117
1. Introduction
Academic Editors: Chiara Lorini,
Mirko Duradoni, Andrea Guazzini,
Suicide, which involves the intentional act of taking one’s own life, is a major public
Guglielmo Bonaccorsi and concern across the world. Each year, over 700,000 people die by suicide globally, with
Letizia Materassi more than 77% of these deaths occurring in low- and middle-income countries [1]. Suicidal
mortality is often attributed to many causes and may occur at a result of an exacerbation of
Received: 10 September 2024
major mental health problems; prior to death by suicide, one may have issues of suicidal
Revised: 14 October 2024
behaviour, which encompass suicidal ideation, threats or plans of suicide, suicide attempts,
Accepted: 15 October 2024
and completed suicides [2,3]. There is a wide array of potential risk factors for suicide, and
Published: 16 October 2024
these include affective disorders, addiction, antisocial behaviours, physical illness, being
elderly, and a history of suicide attempts [4–6].
Bharat (India) is a nation in which suicidality is a major concern. Bharat has the highest
Copyright: © 2024 by the authors. number of deaths by suicide compared to any other nation, and suicide has been shown to
Licensee MDPI, Basel, Switzerland. be the leading cause of death in those who are aged 15–39 [7]. It has been demonstrated
This article is an open access article previously that factors associated with suicide mortality differ greatly from European and
distributed under the terms and American nations, with marriage having previously been shown not to be a protective factor
conditions of the Creative Commons in Bharat, and the female-to-male ratio being higher in this country [8]. Other risk factor
Attribution (CC BY) license (https:// previously noted in the country include traumatic/difficult family problems, academic
creativecommons.org/licenses/by/ stress, exposure to violence, and economic distress [9].
4.0/).

COVID 2024, 4, 1684–1693. https://doi.org/10.3390/covid4100117 https://www.mdpi.com/journal/covid

COVID 2024, 4 1685

In 2020, the coronavirus disease of 2019 (COVID-19) pandemic had begun. The
pandemic has resulted in significant morbidity and mortality across the globe. It has been
estimated that there have been more than seven million deaths attributed to COVID-19
worldwide [10]. Along with the direct impacts of the virus, the pandemic has led to
a challenging life circumstance for many, with the psychological impact of COVID-19
being adverse. Quarantine restrictions and lockdowns increased the risk of suicide by
causing fear and panic, frustration, scarcity of basic supplies, a lack of reliable information,
perceived stigma, financial distress, and a lack of physical exercise [11]. Strict spatial
distancing measures and social isolation tend to elevate anxiety levels, profoundly affecting
vulnerable groups such as the elderly, individuals with preexisting medical conditions like
respiratory issues, and those with preexisting mental health conditions such as depression
and anxiety. These factors can significantly increase the risk of suicidality. Additionally,
loneliness associated with lockdowns can lead to depression, which, if untreated, can
drive individuals toward suicidal behaviour [12,13]. As a result of all of this, in terms of
mental health impacts, there have been significant rises in depression, with approximately
53 million more cases of depression and 76 million more cases of anxiety disorders [14].
In Bharat, similar patterns have been seen, with 23% out of 2640 adult respondents in a
survey reporting major anxiety, and 26% reporting major depression [15].
Although the COVID-19 pandemic has been declared over, concerns have been
expressed regarding the persisting impacts of long COVID in Bharat, and across the
world [16,17]. The WHO defines long COVID (also referred to as post-COVID-19 con-
dition) as an illness in individuals with a history of probable or confirmed SARS-CoV-2
infection, usually three months after the onset of COVID-19, with symptoms lasting at least
two months and these symptoms being unable to be attributed to another diagnosis [17].
Some research has shown that psychiatric consequences of COVID-19 are widespread and
can persist beyond six months [18]. Studies in Hong Kong and Colombia found that long
COVID can worsen mental health, increasing depression and other psychiatric disorders [19].
In Haryana, India, long COVID significantly impacted mental health, with participants
reporting persistent anxiety, depression, and stress [20]. A study in Eastern India found that
4% of long COVID patients post-Omicron wave self-reported depression [21].
Despite the rising evidence of the potential impacts of long COVID, much is not known
about this syndrome and its resultant impacts. In particular, the evidence regarding its
impacts on suicidal behaviour and suicide mortality among survivors of COVID-19 globally
and in Bharat remains limited. Therefore, our objectives for this study were twofold: to
assess the longer-term impacts of the COVID-19 on suicide mortality in Bharat at the state
and national level and to determine if long COVID may be a contributor to changes in
suicide mortality rates across the nation.

2. Methods
For this work, we intended to analyse and compare trends in suicide across Bharat
both before and after the start of the COVID-19 pandemic. We carried this out by first
evaluating the total numbers of suicide and suicide rates (per 100,000 individuals) annually
with national level data. More precisely, this entailed analysing trends in each of these
parameters between the years of 2012 to 2022. These trends were visually depicted in
figures. To analyse trends in further detail, we also evaluated annual increases/decreases
between the years 2018 to 2019 with the average annual change from the years 2019
to 2022. Absolute increases/decreases and percent changes across these time periods
were evaluated.
After providing a comparison of national level trends, trends at the state and union
territory (UT) levels were next analysed. With the exception of Jammu and Kashmir,
Ladakh, Dadra and Nagar Haveli, Daman and Diu, all states and UTs were included in
our analyses. These states and UTs were excluded from this study due to issues with
inconsistencies in the reporting of data across years for these regions. Once again, data on
total number of suicides and suicide rates (per 100,000 individuals) from 2018 to 2022 are
COVID 2024, 4 1686

provided and shown in tabular format. Annual absolute increases/decreases and percent
changes were calculated for state/UT, and comparisons were made for 2018 to 2019 and
the average annual change from 2019 to 2022. The most notable increases and decreases are
thereafter described.
Data for suicide mortality across Bharat were retrieved from the annual reports known
as the Accidental Deaths and Suicides in India (ADSI) by the National Crime Records
Bureau of the Ministry of Home from each of the years between (and including) 2018 and
2022 [22–26]. These reports contain publicly available data that are published annually by
the Government of Bharat and contain detailed data on factors relating to suicide mortality,
but also on mortality relating to accidental causes [22–26].
Next, to assess for the role of the COVID-19 pandemic, and the potential role of long
COVID, we aimed to analyse the relationship between COVID-19 incidence and mortality
to suicide mortality. To carry this out, we conducted bivariable linear regression analysis
between COVID-19 cases per 100 individuals and annual change in suicide rate from 2019
to 2022 at the state/UT level, and again between COVID-19 deaths per 10,000 individuals
and annual change in suicide rates from 2019 to 2022 at the state/UT level. Thereafter,
multivariable linear regression was conducted with annual change in suicide rates from
2019 to 2022 to the two aforementioned COVID-19 variables. COVID-19 data were acquired
from publicly available datasets by the Government of Bharat [27]. Statistical analysis was
completed using SPSS Version 28 [28].
As this study did not involve human participants and instead involved analysing data
from publicly available sources, ethics board approval was not required.

3. Results
3.1. National Suicide Trends
Long-term trends demonstrate that there was a net decrease in total suicides between
2012 and 2017, from 135,445 annual deaths to 129,887. From 2017 onwards, the total number
of suicides has increased at the national level, with the highest number of deaths occurring
in 2022 at 170,924. However, the annual total number of suicide deaths has risen since the
start of the COVID-19 pandemic in 2020. Between 2018 and 2019, there was an annual
increase of 4607 deaths (percent increase of 3.42%). In comparison, the average annual
COVID 2024, 4, FOR PEER REVIEW 4
increase in deaths since 2020 was 10,600.33 (percent increase of 7.62%). A depiction of
long-term annual suicide deaths is shown in Figure 1.

Figure 1. Long-term
Figure 1. Long-termtrends
trends in
in number ofsuicides
number of suicides per
per year
year in Bharat.
in Bharat.
COVID 2024, 4 1687

Similar trends have been shown for suicide rates at a national level. There were contin-
ual declines in suicide rate across Bharat from 2012 to 2017, decreasing from
11.2 suicides per 100,000 people to 9.9. However, after 2017, there were annual rises
in the suicide rate across the country. Furthermore, the rise in suicide rates has accelerated
since the start of the COVID-19 pandemic. Between 2018 and 2019, the suicide rates rose
by 0.2 per 100,000 people (percent increase of 1.96%), whereas the average annual increase
between 2019 and 2022 was 0.7 per 100,000 people (percent increase of 6.41%). Long-term
Figuretrends
annual 1. Long-term trendsrates
in suicide in number of suicides
at the national per year are
level in Bharat.
shown in Figure 2.

Figure
Figure 2. 2. Long-termtrends
Long-term trends in suicides
suicidesper
per100,000
100,000byby
year in Bharat.
year in Bharat.

3.2.3.2.
State
StateLevel
LevelTrends—Total
Trends—Total Suicides
Suicides
Trends
Trends acrossstates
across statesand
and UTs
UTs in Bharat
Bharatofoftotal
totalnumber
numberof of
suicides are are
suicides shown in Table
shown in Table 1.
1. Across the 33 states and UTs that were analysed, the majority had an overall
Across the 33 states and UTs that were analysed, the majority had an overall increase increase in
total suicides prior to the COVID-19 pandemic. Between 2018 to 2019, 20 states
in total suicides prior to the COVID-19 pandemic. Between 2018 to 2019, 20 states and and UTs
UTshad an an
had increase in suicide
increase rates, compared
in suicide to 13 thattohad
rates, compared 13 an overall
that had decrease.
an overall The largest The
decrease.
decreases in this period were in West Bengal (decreased by 590; 4.45% decrease), Tamil
largest decreases in this period were in West Bengal (decreased by 590; 4.45% decrease),
Tamil Nadu (decreased by 403; 2.90% decrease), Karnataka (decreased by 273; 2.36%),
Telangana (decease by 170; 2.17% decrease), and Himachal Pradesh (decreased by 156;
21.08% decrease). In contrast, the largest increases occurred in Andhra Pradesh (increased
by 1146; 21.55% increase), Maharashtra (increased by 944; 5.25% increase), Madhya Pradesh
(increased by 682; 5.79% increase), Punjab (increased by 643; 37.51% increase), and Uttar
Pradesh (increased by 615; 12.68% increase).

Table 1. Total number of suicides and changes in total suicides across Bharat.

Absolute
Number of Suicides Percent Increase/Decrease
Increase/Decrease

State/Union Territory 2019–2022 2019–2022

(Average (Average
2018 2019 2020 2021 2022 2018–2019 2018–2019
Annual Annual
Change) Change)
Andhra Pradesh 5319 6465 7043 8067 8908 1146 814.33 21.55 12.60
Arunachal Pradesh 132 112 160 160 149 −20 12.33 −15.15 11.01
COVID 2024, 4 1688

Table 1. Cont.

Absolute
Number of Suicides Percent Increase/Decrease
Increase/Decrease

State/Union Territory 2019–2022 2019–2022

(Average (Average
2018 2019 2020 2021 2022 2018–2019 2018–2019
Annual Annual
Change) Change)
Assam 2379 2370 3243 3262 3320 −9 316.67 −0.38 13.36
Bihar 443 641 809 827 702 198 20.33 44.70 3.17
Chhattisgarh 7046 7629 7710 7828 8446 583 272.33 8.27 3.57
Goa 256 259 308 321 302 3 14.33 1.17 5.53
Gujarat 7793 7655 8050 8789 9002 −138 449.00 −1.77 5.87
Haryana 3547 4191 4001 3692 3783 644 −136.00 18.16 −3.25
Himachal Pradesh 740 584 857 889 644 −156 20.00 −21.08 3.42
Jharkhand 1317 1646 2145 1825 2181 329 178.33 24.98 10.83
Karnataka 11,561 11,288 12,259 13,056 13,606 −273 772.67 −2.36 6.85
Kerala 8237 8556 8500 9549 10,162 319 535.33 3.87 6.26
Madhya Pradesh 11,775 12,457 14,578 14,965 15,386 682 976.33 5.79 7.84
Maharashtra 17,972 18,916 19,909 22,207 22,746 944 1276.67 5.25 6.75
Manipur 52 58 44 49 26 6 −10.67 11.54 −18.39
Meghalaya 189 198 224 226 213 9 5.00 4.76 2.53
Mizoram 79 70 108 99 153 −9 27.67 −11.39 39.52
Nagaland 36 41 48 43 49 5 2.67 13.89 6.50
Odisha 4592 4582 5546 5651 6140 −10 519.33 −0.22 11.33
Punjab 1714 2357 2616 2600 2441 643 28.00 37.51 1.19
Rajasthan 4333 4531 5658 5593 5343 198 270.67 4.57 5.97
Sikkim 199 220 285 266 293 21 24.33 10.55 11.06
Tamil Nadu 13,896 13,493 16,883 18,925 19,834 −403 2113.67 −2.90 15.66
Telangana 7845 7675 8058 10,711 9980 −170 768.33 −2.17 10.01
Tripura 720 728 845 771 713 8 −5.00 1.11 −0.69
Uttar Pradesh 4849 5464 4804 5932 8176 615 904.00 12.68 16.54
Uttarakhand 421 516 943 717 814 95 99.33 22.57 19.25
West Bengal 13,255 12,665 13,103 13,500 12,669 −590 1.33 −4.45 0.01
A&N Islands 164 181 180 159 171 17 −3.33 10.37 −1.84
Chandigarh 160 131 128 120 131 −29 0.00 −18.13 0.00
Delhi (UT) 2526 2526 3142 2840 3417 0 297.00 0.00 11.76
Lakshadweep 3 0 2 1 2 −3 0.67 −100.00 N/A
Puducherry 500 493 408 504 481 −7 −4.00 −1.40 −0.81
Bharat (total) 134,516 139,123 153,052 164,033 170,924 4607 10,600.33 3.42 7.62

Overall, the highest number of suicides in 2022 occurred in Maharashtra

(22,746 deaths), followed by Tamil Nadu (19,834), and Madhya Pradesh (15,386). Af-
ter the start of the pandemic, there was an increase in total suicides across 28 states and
UTs, with a decrease in five (Haryana, Manipur, Tripura, Andaman and Nicobar Islands
and Puducherry). Haryana had the largest decrease, with an annual decline of suicide
deaths of 136 per year (3.25% annual decrease). Overall, there was also a higher increase
in total suicides annually from 2019 to 2022 compared to 2018 to 2019. States with the
highest annual increases, despite an annual decrease from 2018 to 2019, were Tamil Nadu
(2113.67 annual increase; 15.66% increase), Karnataka (772.67 annual increase; 6.85% in-
crease), Telangana (768.33 annual increase; 10.01% increase), and Odisha (519.33 annual
COVID 2024, 4 1689

increase; 11.33% increase). Other states with the highest increase in total annual suicides
after the start of the COVID-19 pandemic were Maharashtra (1276.67 annual increase;
6.75% increase), Madhya Pradesh (976.33 annual increase; 7.84% increase), Andhra Pradesh
(814.33 annual increase; 12.60%), and Kerala (535.33 annual increase; 6.26% increase).

3.3. State Level Trends—Suicide Rates

Trends in suicide rates (per 100,000 people) across the states and UTs are shown in
Table 2. Across the 33 states and UTs, suicide rates increased in 20 states and decreased in
13 from 2018 to 2019. The largest decreases in suicide rates occurred in Meghalaya (de-
creased by 9.9; a 61.88% decrease) and Lakshadweep (decreased by 4.3; a 100% decrease),
followed by Chandigarh (decreased by 2.6; a 18.98% decrease) and Himachal Pradesh
(decreased by 2.2; a 21.57% decrease). In contrast, the largest increases in suicide rates
occurred in Andaman and Nicobar Islands (increased by 4.5; a 10.98% increase), Mizoram
(increased by 3.4; a 136.00% increase), Sikkim (increased by 2.9; a 9.60% increase), and
Andhra Pradesh (increased by 2.2; a 21.57% increase). The change in the suicide rate across
states and UTs from 2018 to 2019 was a decrease of 0.05.

Table 2. Rates of suicide (per 100,000) and changes in suicide rates across Bharat.

Absolute
Rate of Suicide (Per 100,000) Percent Increase/Decrease
Increase/Decrease

State/Union Territory 2019–2022 2019–2022

(Average (Average
2018 2019 2020 2021 2022 2018–2019 2018–2019
Annual Annual
Change) Change)
Andhra Pradesh 10.2 12.4 13.4 15.3 16.8 2.2 1.5 21.57 11.83
Arunachal Pradesh 8.9 7.4 10.5 10.4 9.6 −1.5 0.7 −16.85 9.91
Assam 7 6.9 9.3 9.3 9.4 −0.1 0.8 −1.43 12.08
Bihar 0.4 0.5 0.7 0.7 0.6 0.1 0.0 25.00 6.67
Chhattisgarh 24.7 26.4 26.4 26.4 28.2 1.7 0.6 6.88 2.27
Goa 16.7 16.8 19.9 20.6 19.2 0.1 0.8 0.60 4.76
Gujarat 11.6 11.2 11.6 12.5 12.7 −0.4 0.5 −3.45 4.46
Haryana 12.5 14.5 13.7 12.5 12.6 2 −0.6 16.00 −4.37
Himachal Pradesh 10.2 8 11.6 12 8.7 −2.2 0.2 −21.57 2.92
Jharkhand 3.6 4.4 5.6 4.7 5.6 0.8 0.4 22.22 9.09
Karnataka 17.7 17.1 18.4 19.5 20.2 −0.6 1.0 −3.39 6.04
Kerala 23.5 24.3 24 26.9 28.5 0.8 1.4 3.40 5.76
Madhya Pradesh 14.5 15.1 17.4 17.6 17.9 0.6 0.9 4.14 6.18
Maharashtra 14.8 15.4 16.1 17.8 18.1 0.6 0.9 4.05 5.84
Manipur 1.7 1.9 1.4 1.5 0.8 0.2 −0.4 11.76 −19.30
Meghalaya 16 6.1 6.9 6.9 6.4 −9.9 0.1 −61.88 1.64
Mizoram 2.5 5.9 8.9 8.1 12.4 3.4 2.2 136.00 36.72
Nagaland 1.7 1.9 2.2 2 2.2 0.2 0.1 11.76 5.26
Odisha 10.5 10.5 12.2 12.3 13.3 0 0.9 0.00 8.89
Punjab 5.8 7.9 8.7 8.6 8 2.1 0.0 36.21 0.42
Rajasthan 5.7 5.8 7.2 7 6.6 0.1 0.3 1.75 4.60
Sikkim 30.2 33.1 42.5 39.2 43.1 2.9 3.3 9.60 10.07
Tamil Nadu 18.4 17.8 22.2 24.7 25.9 −0.6 2.7 −3.26 15.17
Telangana 21.2 20.6 21.5 26.9 26.3 −0.6 1.9 −2.83 9.22
COVID 2024, 4 1690

Table 2. Cont.

Absolute
Rate of Suicide (Per 100,000) Percent Increase/Decrease
Increase/Decrease

State/Union Territory 2019–2022 2019–2022

(Average (Average
2018 2019 2020 2021 2022 2018–2019 2018–2019
Annual Annual
Change) Change)
Tripura 18.2 18.2 20.9 18.9 17.3 0 −0.3 0.00 −1.65
Uttar Pradesh 2.2 2.4 2.1 2.6 3.5 0.2 0.4 9.09 15.28
Uttarakhand 3.8 4.6 8.3 6.3 7 0.8 0.8 21.05 17.39
West Bengal 13.7 13 13.4 13.7 12.8 −0.7 −0.1 −5.11 −0.51
A&N Islands 41 45.5 45 39.7 42.8 4.5 −0.9 10.98 −1.98
Chandigarh 13.7 11.1 10.7 9.9 10.7 −2.6 −0.1 −18.98 −1.20
Delhi (UT) 12.9 12.7 15.5 13.7 16.2 −0.2 1.2 −1.55 9.19
Lakshadweep 4.3 0 2.9 1.5 2.9 −4.3 1.0 −100.00 N/A
Puducherry 33.8 32.5 26.3 31.8 29.7 −1.3 −0.9 −3.85 −2.87
Bharat (total) 10.2 10.4 26.3 12 12.4 0.2 0.7 1.96 6.41

After the occurrence of the COVID-19, in 2022 the highest suicide rates per
100,000 people were in Sikkim (43.1), Andaman and Nicobar Islands (42.8), Puducherry
(29.7), Kerala (28.5) and Chhattisgarh (28.2). After the start of the pandemic, there was an
average annual rise in suicide rates across 27 states/UTs and a decrease in seven states/UTs
(Haryana, Manipur, Tripura, West Bengal, Andaman and Nicobar Islands, Chandigarh, and
Puducherry). The largest decreases were in the Andaman and Nicobar Islands (decreased
by 0.9; a 1.98% decrease) and Haryana (decreased by 0.6; a 4.37% decrease). While there
was a decrease in the suicide rate from 2018 to 2019, the average annual change in suicide
rates across states and UTs from 2019 to 2022 was an increase of 0.65. The states/UTs with
the highest annual increases since the start of the COVID-19, despite a decrease from 2018
to 2019, were Tamil Nadu (increased by 2.7; a 15.17% increase), Telangana (increased by
1.9; a 9.22% increase), Delhi (increased by 1.2; a 9.19% increase), Karnataka (increased by
1.0; a 6.04% increase) and Assam (increased by 0.8; a 12.08% increase). The other states
with the highest annual increase in suicide rates were Sikkim (increased by 3.3; a 10.07%
increase), Mizoram (increased by 2.2; a 36.72% increase), Andhra Pradesh (increased by 1.5;
a 11.83% increase), Kerala (increased by 1.4; 5.76% increase) and Odisha (increased by 0.9;
a 8.89% increase).

3.4. Associations with COVID-19 Caseload and Deaths

For bivariable regression conducted between COVID-19 cases per 100 people and
average annual change in suicide rates by state/UT from 2019 to 2022, there was a statis-
tical correlation (Pearson correlation coefficient = 0.581; p < 0.001; 95% CI: 0.297, 0.771).
For bivariable regression, there was no statistical correlation between COVID-19 deaths
per 10,000 people and the average annual change in suicide rates (Pearson correlation
coefficient = 0.101; p = 0.577; 95% CI: −0.251, 0.429). Multi-linear regression was next
conducted, and it was shown that the annual changes in suicide rate were not associated
with COVID-19 deaths per 10,000 people (standardized beta coefficient = 0.077; t = 0.523;
p = 0.605) but were associated with COVID-19 cases per 100 people (standardized beta
coefficient = 0.578; t = 3.904; p < 0.001).

4. Discussion
In this study, it has been demonstrated that there has been a major rise in suicide
mortality across Bharat since the emergence of COVID-19. While the rise in total suicide
deaths and suicide rates was occurring prior to the start of the pandemic, our analysis has
demonstrated that these rises have accelerated since the start of the COVID-19 pandemic.
COVID 2024, 4 1691

These trends regarding disease control differ from those for major conditions in Bharat,
such as HIV and tuberculosis [29,30]. Overall, these findings demonstrate that there is
a clear need for more research to be conducted in order to understand the many factors
that have contributed to these rises in suicide mortality. Of note, in a number of states,
the rate of suicide has instead decreased since the start of the COVID-19 pandemic. For
example, in both Andaman and Nicobar Islands and Haryana, there was a notable decrease
in suicide rates between the years 2019 and 2022. More research should be conducted in
these contexts to aim to understand the factors that led to these decreases. Such findings
may offer utility in efforts to reduce suicide rates throughout Bharat.
The trends of rising suicide in Bharat also demonstrate a larger need to focus on up-
stream factors that contribute to poor mental health outcomes and mental health conditions
such as depression and anxiety in Bharat. During the pandemic, aside from those pertaining
to suicide, it has been shown that mental health outcomes have worsened across Bharat [15].
There is hence a need for more research to determine how mental health morbidities can
be improved across the country. Connected to this point, these findings indicate a clear
need for more allocation of funding towards mental health care as part of government
initiatives. Access to more psychiatrists in the nation is clearly needed, as the country
currently only has approximately 0.30 psychiatrists per 100,000 population [31]. Increased
funding for mental health supports should also involve a focus on improving access to
counselling while also working to improve traditional approaches and fostering protective
factors. For example, it has been shown that traditional healers have a valuable role in
providing mental health support in certain regions, and there may be notable benefits in
improving integration of such healers into health and medical systems [32].
An additional crucial finding from our analyses has been that pertaining to the link
between the COVID-19 caseload in certain geographic regions with changes in suicide rates
after the emergence of COVID-19. Importantly, it was found that COVID-19 deaths in the
population were not associated with these rises in suicide rates—this may indicate that it is
specifically those who survive from COVID-19 who are at a higher risk of suicide. These
findings may demonstrate a possible role of long COVID leading to higher suicide rates in
the country. While there are potentially confounding factors to this, these findings regarding
long COVID may have important implications in explaining the extent of the long-term
impacts of the COVID-19 pandemic. There is a need for further research on the biological
basis for long COVID causing all forms of mental health impacts, but especially suicide.
Further research should also work towards focusing on providing tools for diagnosing long
COVID, providing a prognosis, and determining factors that increase risk of occurrence of
this condition. Furthermore, there is a clear need to better understand the condition so that
treatment regimens can be developed.
There are a number of limitations to this study that need to be considered. First of all,
this was a study at the level of the nation and the state; while these findings may provide
important insights regarding trends on a large scale, they do not provide thorough insights
regarding the realities in local settings. Furthermore, they do not provide explanation
regarding the geographic and health factors across these regions that may provide explana-
tions regarding the differences in rates. An additional limitation is that, while this study
does provide important insights regarding the potential role of long COVID in exacerbating
suicide risk, the study does not provide answers as to the ways in which or reasons why
they occur; of note, there also may be an array of other confounding factors, such as impacts
of quarantining measures and the loss of social connection during the pandemic, which
may have had a role on suicide rates but were not able to be considered in our analysis.
Regardless of these limitations, our study has provided important insights regarding the
mental health impacts of the COVID-19 pandemic, and in potentially demonstrating the
role that long COVID may have had in the rising rates of suicide across Bharat.
COVID 2024, 4 1692

5. Conclusions
In our study, we have demonstrated that, with the COVID-19 pandemic, there have
been major rises in suicide deaths and suicide at both a state and national level in Bharat. A
particularly worrying aspect of these trends has been that this rise in suicide mortality has
occurred at a rate that is faster than that prior to the COVID-19 pandemic. Our study has
also demonstrated that, as the COVID-19 caseload has been associated with these changes
in suicide mortality rates, there is potential for long COVID to have had an important
role in contributing to overall suicidality across Bharat. These findings indicate an urgent
need for improved mental health care and access across the country, whether this be with
psychiatrists, counsellors, or traditional healers. Additionally, there is a clear need for more
research on the causes, risks, outcomes, and treatments of long COVID.

Author Contributions: Conceptualization, K.V., M.A.P.; methodology, K.V.; analysis, K.V., data
curation, K.V., writing—original draft preparation, K.V., M.A.P., writing—review and editing, K.V.,
M.A.P. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The original contributions presented in the study are included in the
article, further inquiries can be directed to the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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