Despite being preventable, approximately 800,000 people die by suicide each year worldwide. Evidence suggests that suicide rates decrease during crises, but once the immediate threat passes, suicide rates are expected to increase. The COVID-19 pandemic likely affects risk and protective factors for suicide. Studies show mixed results regarding whether suicide behaviours have increased among adults during the pandemic. The results are however different for young people. An increase in suicidal behaviours has been identified in some countries among young people after lockdown period and when returning to schools. Data also suggests that there may have been a rise in deaths by suicide among those younger than 18 years in China, and during the first phase of lockdown in the United Kingdom. Studies have found significant decreases in hospital admissions for suicidal behaviours and visits to emergency departments both for adults and adolescents. Suicide can be prevented if evidence-based methods that exist are implemented in a systematic way. Wasserman, D., Iosue, M., Wuestefeld, A., & Carli, V. (2020). Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World psychiatry: official journal of the World Psychiatric Association (WPA), 19(3), 294–306.

Globally, mental health legislation has been changing and evolving throughout time. Compulsory admission is when patients with mental disorders are admitted to a psychiatric unit against their own will to receive treatment. In Europe, as public attitudes and practices shifted, compulsory admission procedures were reformed to ensure patient rights and safety. Differences however exist for compulsory admission procedures between countries. In 2018, a survey was created and disseminated by the European Psychiatric Association Ethics Committee to National Psychiatric Associations within 40 European countries to learn more about the legislation, key actors involved, and reasons for admission. Results showed that approximately half of the responding countries required an independent medical expert, typically a psychiatrist, to be involved in the procedure. Most countries by law required the involvement of a court-appointed judge in making the decision about compulsory admission and to review the case after a certain period of time. All but one country have time limits on legal decisions for compulsory admission. Further, patients have the right to obtain legal counsel to assist them through the process of appeal or the decision in most countries. The primary reasons for admission were the patient being a danger to themselves or others. Despite continued efforts, stigma still surrounds mental health disorders. Public awareness and increased knowledge are needed to improve the perception of compulsory admissions. Moving forward, it is necessary to create educational courses, as well as written guidelines for key actors, to stimulate good practice and promote voluntary treatment (Wasserman et al. 2020; https://doi.org/10.1192/j.eurpsy.2020.79).

A literature search using PubMed and Google Scholar identified 64 articles assessing suicidal thoughts, suicide attempts and suicide during the COVID-19 pandemic in comparison with the pre-pandemic period in the six WHO regions of the world. Most studies come from high- and middle-income countries. There is a scarcity of data from South America, and no studies from the African and East-Mediterranean Regions. Compared to trends in previous years, suicide rates remained largely unchanged globally or declined in the early phase of the pandemic. However, increased suicide rates were reported among non-white residents and Afro - American groups in the US, as well as among adolescents in China. Japan and India showed a statistically significant increase in suicide rates after an initial decline. Similarly in Peru, after an initial decline, suicide rates increased among men during the course of the pandemic. This is in line with previous findings in the context of natural disasters and other epidemics where a similar increased suicide trend can be expected in the post-pandemic period in other countries. Among adolescents, there were no significant changes in suicide rates during the period of school closure, but an increase has been observed in the period after coming back to schools. The assessment of suicidal thoughts and attempts during the pandemic was mostly conducted through online cross-sectional surveys and showed significant increases, particularly in females and the young. Suicide can be prevented if evidence-based methods that exist are implemented in a systematic way (Wasserman et al. 2020; https://doi.org/10.1002/wps.20801).

As COVID-19 spread, many countries in the world responded swiftly in an attempt to reduce transmission. Sweden, however, took a different approach to many other nations and did not implement a nationwide lockdown, instead deciding on a more “holistic approach to public health”. The focus was on minimising transmission as much as possible, protecting those in risk groups, ensuring that the response strategies were sustainable long-term, mitigating other health concerns as a result of the response and that evidence-based methods were used as much as possible. At this stage, it is difficult to know how exactly the Swedish strategy has fared in comparison to other responses. In Sweden, there has been much debate about the strategy, particularly concerning the protection of the elderly due to unexpectedly high mortality rates in the older population as well as among residents in retirement homes. Many ethical questions remain in regard to which strategies would have been preferable.

As COVID-19 began to plague the world, the term ‘social distancing’ was frequently used, encouraging people to keep a safe physical distance from others to reduce the transmission of the virus. Despite being well-intended, the term has negative implications, further isolating vulnerable groups in society by evoking feelings of rejection and exclusion. For this reason, the members of the European Psychiatric Association Ethics Committee wrote an e-letter in response to an opinion piece published by Science (https://science.sciencemag.org/content/367/6484/1282/tab-e-letters), and also wrote to the European Psychiatry (https://doi.org/10.1192/j.eurpsy.2020.60) and the World Health Organisation explaining why the term ‘physical distancing’ should instead be used among policymakers, governments and the general public. Words are important and carry great meaning. Therefore, by using the term physical distancing and not social distancing the message becomes clear, individuals should remain physically distant but socially connected to protect the vulnerable communities in societies. The World Health Organisation, as well as the Lancet journals, adopting the term physical distancing in replacement of social distancing, was a rewarding and important step in the right direction.

Every year, around 800,000 people die by suicide globally. Whist suicide mortality rates are higher among men, women typically have higher rates of suicidal ideation and behaviours. Despite this fact, suicidality in women is still of grave concern as 71% of women’s violent deaths is accounted for by suicide – a greater percentage than men’s. Suicide patterns among women differ between countries and regions. For example, there is a greater difference in suicide rates between men and women in high-income countries in comparison to low- and middle-income countries. Furthermore, many theories exist to explain women’s suicidality. Yet many of the dominant theories have been challenged from studies in both low- to middle-income and high-income countries. Further research that focuses on the context and culture, rather than the individual, is warranted and will be important for preventative efforts of women’s suicidal behaviours.

Suicidal behavior (SB) is a major burden in most nations world-wide and a major public health concern. The causes of SB are complex, in which both genetic set-up and exposure to overwhelming psychological stress (environmental factor) contribute to a person's final predisposition for SB. One candidate system reflecting this causal route to SB is the stress-modulating hypothalamic-pituitary-adrenal (HPA) axis, and dysregulation of HPA is considered to play a major role in depression and SB. The corticotrophin-releasing hormone and its main receptor (CRHR1) have key regulatory functions in the HPA axis, and we hypothesized that genetic variation in CRHR1 may be associated and linked with SB and related endophenotypes. We analyzed single nucleotide polymorphisms (SNPs) in an extended sample of family trios (n = 672) with suicide attempter offspring, by using family-based association tests. Results showed that the minor T-allele of exonic SNP rs12936511 was significantly transmitted to suicidal males with increased Beck Depression Inventory (BDI) scores (P = 0.0028). Analysis of haplotypes showed that risk alleles of three different SNPs segregated onto separate haplotypes, whereas a fourth ‘nonrisk’ haplotype (‘CGC’) was preferentially transmitted to suicidal males with lowered BDI scores (P = 0.0007). Conversely, the BDI scores of those who carried a homozygous combination of any of the three risk haplotypes were significantly increased (P = 0.000089). We concluded that depression intensity in male suicidal offspring was related to genetic variability in the 5’-end of CRHR1, while the characteristics of the suicide female attempters remained unknown.

In EU, the latest available data estimates that some 63,000 individuals die annually due to suicide, which translates to 1 suicidal death every 40 seconds. Europe comprises seven countries that are among the top 15 countries with the highest suicide mortality rates. Statistics illustrate that the highest mortality rates for suicide (≥ 25/100,000) comprises mostly former Soviet Union Republics. Suicide rates among the age-group 15-24 years have been steadily increasing over the past few decades with statistics reporting rates up to approximately 22/100,000 among males and 4.8/100,000 among females in Europe.

Epidemiological research has demonstrated that suicide is significantly correlated with suicidal and risk behaviors. Studies have identified suicidal ideation and deliberate self-harm to be significantly correlated to both suicide and attempted suicide. Furthermore, the strongest predictor of suicide is in fact a previous suicide attempt. In Europe, there are 10-20 suicide attempts for every completed suicide. In the US, it is even higher, with estimations reporting 100-200 suicide attempts for every completed suicide. However, suicidal behavior is not an isolated act, rather is a result of a process that co-occurs with psychiatric illnesses, which can range from depressive episodes to schizophrenia. Moreover, epidemiological evidence stipulates that suicidal behavior coincides with a multitude of risk-taking behaviors that are frequently established in adolescent years. Studies have linked suicidal behavior to various types of risk-taking behaviors that include peer victimization, sexual risk behavior, delinquency, and substance abuse. Future epidemiological studies in suicide are fundamental in monitoring, identifying risks and formulating preventive interventions.

SAYLE is a health promoting programme, funded by the EU Commission for adolescents in European schools. Its main objectives are to lead adolescents to better health through decreased risk taking and suicidal behaviours, to evaluate outcomes of different preventive programmes and to recommend effective culturally adjusted models for promoting health of adolescents in different European countries. It is developed by a consortium of 12 countries: Austria; Estonia; France; Germany; Ireland; Hungary; Italy; Israel; Romania; Slovenia; Spain and Sweden (coordinating centre). In this health promotion programme, an intervention study will be implemented to assess the effects of three different health promoting/suicide preventing programmes in comparison with control groups in 11,000 students across 12 European countries. The three interventions are:

1. 1. A general health promotion programme targeting students awareness on healthy/unhealthy behaviors and students self-efficacy in diminishing unhealthy behaviors;

2. 2. TeenScreen - screening by professionals of at-risk students through a questionnaire. For adolescents identified as high risk, the program includes individual assessment and referral to mental health treatment and measures ensuring compliance;

3. 3. QPR (Question, Persuade & Refer) - a gatekeeper's program, training all adult staff at schools (teachers, counselors, nurses etc) and parents on how to recognize and refer a student with risk-taking behaviours or those suffering from mental illness to mental-health help resources.

The ultimate consequence of mental ill-health, suicidal behavior (SB), is a significant problem in most societies of the world. Suicide causes about one million deaths worldwide each year, and 10–20 times more people attempt suicide. The causes of why certain people engage in SB are complex, involving for e.g., both environmental and genetic factors, and interactions in-between. Well-established environmental risk factors are events causing significant psychological stress, which are particularly difficult to cope with, e.g. exposure to physical and sexual abuse. Excessive stress have the potential to induce unfavorable effects in a variety of higher brain-functions, incurred as side-effects to maladaptive responses in the genetically controlled stress-responsive neurosystems, e.g. the hypothalamic-pituitary-adrenal (HPA) axis; a major and systemic stress-modulator, which is mainly controlled by the regulatory corticotrophin releasing hormone receptor 1 (CRHR1) gene. Variation in-between individuals in such stress-regulatory genes such as CRHR1, may underlie the causes of the increased susceptibility of certain individuals towards SB. Here we review some of the current knowledge on what is known about the roles of the HPA axis in SB, with a focus on CRHR1.

Many European countries have a national suicide preventive programme. In June 2008, a new national programme for suicide prevention was approved by the Swedish Parliament in Sweden. One of the nine strategies in this programme is an assignment called ‘Lex Maria’ - to report all suicides that occur within or 28 days after contact with the healthcare system to The National Board of Health and Welfare (NBHW). Lex Maria guarantees that a systematic evaluation will always occur, providing opportunities to identify components which can be improved when treating suicidal patients. All Lex Maria reports are registered in a separate database at NBHW, allowing systematic analysis at a national level. The methodology used in this analysis will be presented, with examples of individual cases.

Analysis of all suicide cases, which occurred in Sweden in 2006 within the health care system, uncovered the following areas which should be improved when working with suicidal people:

• • Better routines for suicide risk assessment;

• • Better routines for documentation of suicide risk assessment and changes in patients mood;

• • Better routines for the transfer of information within the same unit;

• • Better communication between units to ensure correct transfer of information;

• • Better routines for collaboration between care givers to ensure a continuity of care.

According to WHO estimates, 1.5 million people worldwide will complete suicide in the year 2020 and approximately 10-20 times this number will attempt suicide. Given that suicide still remains the most serious outcome of mental disease, it is essential that psychiatrists are specifically trained regarding legal and ethical aspects related to the treatment of suicidal psychiatric patients.

Clinical decisions guided by evidence based knowledge and ethical judgments according to the principles of beneficence, non-maleficence and autonomy intimately interact when a psychiatrist performs suicide risk assessment, recommends treatment and follow- up rehabilitation measures. Ethical dilemmas of respecting acute suicidal or chronic suicidal patient's autonomy when she/he is unable to control self-destructive impulses, confidentiality, Do Not Resuscitate (DNR) orders and involuntary confinement for the institutional ward will be discussed.

Existing research indicates that suicide risk is higher in the immediate aftermath of discharge from the hospital and when patients are transferred to outpatient care without securing the follow- up visit. Psychiatrists are sometimes under considerable pressure, due to economical downsizing of the psychiatric care, to discharge suicidal patients from inpatient care, which can lead to serious legal and ethical repercussions. Following evidence-based procedures is crucial, as well as maintaining a high standard of documentation for all processes and decisions taken.

Continuous education of health care staff, scrutiny of existing routines and knowledge about own attitudes towards suicidal patients are needed in order to prevent suicide.

Suicide among young people age 15 – 24 constitutes a considerable burden on the global level. Data from 90 out of the 130 WHO members states show that suicide was the fourth leading cause among young males and the third for young females. Suicide rate is higher in young males (world average 10.5 per 100 000) than in young females (world average 4.1 per 100 000). A rising trend of suicide in young males is observed in many countries and particularly marked on other continents than Europe.

Since suicide risk is high among psychiatrically ill young people. Therefore, an adequate treatment of psychiatric disorders and improved detection of psychiatric illnesses in the general population is important. Preventive measures in the health care services after a suicide attempt and an early recognition of children and young people at risk in schools by screening, gate keepers training and other awareness programs are essential strategies.

The results of those studies as well as the worldwide initiative launched by the WHO in SUPRE for the prevention of suicide, will be presented.