Suicide is a major public health problem; according to the latest WHO data, it is among the top twenty causes of death in the
world. After the sudden and unexpected spreading of a global pandemic in 2020, many mental health researchers have launched
alarms about a possible suicide rates\u27 rise, due to the inevitable consequences of the ongoing social and health emergency. However,
recent articles in scientific literature have disconfirmed this thesis. Trentino also seems not to deviate from this dynamic: preliminary
data, collected in an unconventional, and not yet official way, have been able to show that in 2020 the suicide rate remained stable.
The finding that excludes up to date such a rise in rates does not unfortunately provide any guarantee that the situation will remain
constant over time, and that there cannot be significant differences regarding gender, ethnicity, religious faith, sexual orientation or
social class in determining a different impact of the current crisis on the suicidal phenomenon. Further studies and insights into the
processing of the data in our possession are needed. Difficulties and uncertainties connected to the covid-19, with which it is now
clear that the community will have to "learn to live together", could also in the medium and long term constitute a prolonged stressgenerating
element with a greater negative impact on the mental health of the population. It is essential, in light of the particular
social and health situation we are experiencing, to carry out with even greater effectiveness, precision and continuity actions such as
those promoted within the Invito alla Vita Project for the prevention of suicide, in order to guarantee the most effective prevention of
this serious phenomenon. The psychological and social implications of the covid-19 pandemic will only be fully assessable in a few
years, when the crisis will be effectively over. Only then we will be able to understand if the efforts put in place at a global level, and
in particular in the province of Trento, have been effective in the managing of the suicidal phenomenon

di Napoli, Wilma Angela Renata

English

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164 Psychiatria Danubina, 2021; Vol. 33, Suppl. 9, pp 164-168 Conference paper  Medicinska naklada - Zagreb, CroatiaSUICIDAL PHENOMENON IN PANDEMIC TIMES.  Wilma Angela Renata di Napoli Mental Health Center of Trento, Trento, Italy SUMMARY Suicide is a major public health problem; according to the latest WHO data, it is among the top twenty causes of death in the world. After the sudden and unexpected spreading of a global pandemic in 2020, many mental health researchers have launched alarms about a possible suicide rates  rise, due to the inevitable consequences of the ongoing social and health emergency. However, recent articles in scientific literature have disconfirmed this thesis. Trentino also seems not to deviate from this dynamic: preliminary data, collected in an unconventional, and not yet official way, have been able to show that in 2020 the suicide rate remained stable. The finding that excludes up to date such a rise in rates does not unfortunately provide any guarantee that the situation will remain constant over time, and that there cannot be significant differences regarding gender, ethnicity, religious faith, sexual orientation or social class in determining a different impact of the current crisis on the suicidal phenomenon. Further studies and insights into the processing of the data in our possession are needed. Difficulties and uncertainties connected to the covid-19, with which it is now clear that the community will have to "learn to live together", could also in the medium and long term constitute a prolonged stress-generating element with a greater negative impact on the mental health of the population. It is essential, in light of the particular social and health situation we are experiencing, to carry out with even greater effectiveness, precision and continuity actions such as those promoted within the Invito alla Vita Project for the prevention of suicide, in order to guarantee the most effective prevention of this serious phenomenon. The psychological and social implications of the covid-19 pandemic will only be fully assessable in a few years, when the crisis will be effectively over. Only then we will be able to understand if the efforts put in place at a global level, and in particular in the province of Trento, have been effective in the managing of the suicidal phenomenon. Key words: suicide  prevention - mental health *  *  *  *  *  INTRODUCTIONSuicide is a major public health problem; according to the latest WHO data, it is among the top twenty causes of death in the world, with an estimated death toll of over 800,000 people worldwide each year. The "global" death rate from suicide in 2016 varied, between the different countries, between 5 and 30/100,000 inhabitants, higher among males than females (13.7/ 100,000 vs. 7.5/100,000), with an average total ratio of 1.8 to 1, with different weights in different countries; the male / female ratio is estimated at 3: 1 in the richest countries, while in the poorest ones it drops to 1.5 to 1 (Rizzello & Piffer 2021). Reducing the death rate from suicide is one of the targets of the United Nations 2030 agenda for sustainable development.After the sudden and unexpected spreading of a glo-bal pandemic in 2020 many mental health researchers have launched alarms about a possible suicide ratesrise, due to the inevitable consequences of the ongoing social and health emergency (Brown & Schuman 2021). The covid-19 linked crisis determined a global emer-gency as rarely has occurred in the past, characterized by the simultaneous presence of all possible suicidal risk factors: forced isolation, disruption of every daily habit, fear of an unknown and unpredictable disease, negative effects on the economic and employment level, uncertainties about the future.However, recent articles in scientific literature have disconfirmed this thesis: the analysis of data on suicides in the year 2020, which was possible in some countries, where the collection and processing of data is faster and more efficient, could in fact exclude the estimated increase in the suicidal phenomenon. In Australia, Canada, New Zealand, Norway, Peru, Sweden, US, the feared increase did not occur, only Japan for now shows a worrying upward trend in the suicidal phenomenon (Appleby 2021).PANDEMIC AND SUICIDE  IN TRENTINO Trentino also seems not to deviate from this trend: preliminary data, collected in an unconventional, and not yet official way, have been able to show that in 2020 the suicide rate remained stable (Figure 1, 2, 3).In the scientific literature, some reviews have actu-ally confirmed the absence of a close and certain rela-tionship between health emergencies and increasing rates of suicide and self-harm (Rogers et al. 2021).An hypothesis explaining this data concerns the resilience capacity of a community in facing cata-strophic events, which helps the development of grea-ter social inclusion and cohesion and facilitate forms of informal support, thus reducing the risk of suicidal behaviors.In the months that have just passed, more attention has also been paid to the problems mentioned above and further forms of emergency support have been activated.Wilma Angela Renata di Napoli: EALITY Psychiatria Danubina, 2021; Vol. 33, Suppl. 9, pp 164-168 165In Trentino, APSS, the Provincial Health Services Agency, and the Province Institution, decided the active-tion of psychological listening desks, free dedicated tele-phone lines, primary home care. And in this area, where the suicide prevention project Invito alla Vita has been ope-rating for years, an important increase of calls was recor-ded by the free "Invito alla Vita  help line, active from 7 in the morning to 1 in the night for 365 days a year.The highest number of calls was recorded in April 2020, with 667 calls received compared to an average in the other months of 2020 of 330 calls per month. March and April 2020, the months that coincided with the advent of an unknown and frightening calamity and the first lockdown in Italy, with the first restrictions on personal freedoms, also showed two peaks of new telephone line users (Figure 4, 5).Figure 1. Province of Trento; suicidal trend among residents; absolute number per year, period 1990-2019  Figure 2. Suicide percentage by gender among residens, 2019 Figure 3. Suicide percentage by gender among residens, 2019Figure 4. Total calls per month, 2020 Wilma Angela Renata di Napoli: EALITY Psychiatria Danubina, 2021; Vol. 33, Suppl. 9, pp 164-168 166 Figure 5. New users calling per month, 2020In its local reality, the telephone line Invito alla vita  was therefore able to record the social changes taking place and respond to the needs of listening, proximity and support of the community, at a time when the safety and psychological health of the population were strongly under strain. The help-line, an important tool of the project, is managed by about thirty listening volunteers who are constantly trained and supervised.The aim of the Invito alla Vita  telephone line is to relieve suffering in the actuality and possibly, if required, direct to the services available in the area. This goal is pursued through active and empathic listening, abstention from judgment and unconditional positive acceptance of the caller's emotions. The telephone line tries to be an invitation, for those who suffer, for those who are alone, for those who need help, to glimpse possible alternatives since every person in difficulty, experiencing a moment of attention and authentic sharing, can find new meanings, reasons for rethinking and opportunities for reflection on one's own situation.In the months of forced isolation due to the pan-demic, however, we feared that all this was not enough, and that the impossibility or greater difficulty of acces-sing forms of listening and face to face support, due to the greatly reduced health activity, dedicated only to emergencies, and to the self-help activity suspended and translated into online methods, were a significant risk for the growth of suicidal behaviors.The finding that excludes up to date such a rise in suicidal rates does not unfortunately provide any gua-rantee that the situation will remain the same over time, and that there cannot be significant differences regar-ding gender, ethnicity, religious faith, sexual orientation or social class in determining a different impact of the current crisis on the suicidal phenomenon. Further studies and insights into the processing of the data in our possession are needed, since there may be selected groups (women, minors, unemployed people, people suffering from mental illness) more at risk of suffering more frequent negative consequences such as difficult access to care, a higher rate of unemployment, violence, isolation, and consequently an increased risk of suicide or self-harm (Campos et al. 2021). Difficulties and uncertainties connected to the covid-19, with which it is now clear that the community will have to "learn to live together", could also in the medium and long term constitute a prolonged stress-generating element with a greater negative impact on the mental health of the population.In order to implement effective prevention policies, it is also necessary to have data on self-harm and suicide attempts as well as data on completed suicides. Having made a previous suicide attempt is in fact one of the most important predictors of death from suicide (Shelef et al. 2021). This motivated the decision to implement in Italy an Epidemiological Observatory on Suicides and Attempts at Suicide (OESTeS), to provide updated and comprehensive data on suicide attempts in our country on a routine basis, but this tool is not yet active to date (Istat 2021).Since 2008 Trentino health system has instead been using a form for detecting self-harm and suicidal at-tempts, created in collaboration with the Mario Negri Institute of Milan, which is filled in by the psychiatrist at each specialist visit carried out in the hospital, and constitutes a valuable tool for statistical survey, capable of providing data recorded by the provincial systems which, through the integration of other existing informa-tion flows, such as access to the emergency room, hos-pital discharge forms and mortality data, allow to obtain valuable information about the suicidal phenomenon and its characteristics in the Province, for example on the most frequent methods of self-harm, or on the categories of people most at risk, so as to allow the implementation of targeted and more effective prevention interventions in the area. The epidemiological analysis of the suicidal phenomenon in Trentino will in fact be a relevant element in the coming months and years to closely monitor the phenomenon and plan the prevention strategies of the Invito alla Vita  project.Wilma Angela Renata di Napoli: EALITY Psychiatria Danubina, 2021; Vol. 33, Suppl. 9, pp 164-168 167This also is relevant because of the current general worsening of the mental health of the population: the period marked by the Covid-19 pandemic has brought to an extensive sense of uncertainty and strong limi-tations especially in contacts between people, with a growing uneasiness, also in the Province of Trento, especially in the youth groups. The forced and pro-longed isolation at home imposed by the containment measures adopted, associated with the prolongation of the health threat, have undoubtedly favored the deve-lopment of reactive depressive-anxious forms even in previously healthy subjects, the aggravation of pre-existing forms of mental suffering in subjects more fragile and predisposed, and in the population with mental disorders. There has been a real explosion of adaptation disorders such as PTSD, sleep disorders, anxiety and mood disorders, and a general aggravation and diffusion of psychiatric problems (Campos et al. 2021, Rossi et al. 2021). The dedicated observatory in Italy also confirmed an increase in the problems re-lated to domestic violence and violence against minors, alcohol and substance abuse, eating disorders (Istat 2021).On the other hand, the objective difficulty of obtai-ning external assistance, from simple inter-human social contact to more or less specialized forms of support, has only aggravated this risk condition for the community mental health.SUICIDE PREVENTION STRATEGIES IN TRENTINO In this scenario in Trentino, alongside the mental health services, which have never ceased to guarantee the necessary assistance to the population, operates the suicide prevention project Invito alla Vita , which since 2008 has been involved in raising awareness and training to this issue, as well as supporting citizens in difficulty and people who have lost a loved one by suicide in the province of Trento. Assuming that suicide is an event that cannot remain confined exclusively to a private dimension but is a social fact, and that according to the WHO, suicide prevention programs must reflect the characteristics of the individual territories taking into account the different social realities, cultural and health, the prevention project Invito alla Vita  for Trentino proposes a diversified campaign and a work of cooperation with the different territorial realities, institutional and otherwise. The project operates with a strategy at various levels, with the aim of enhancing protective factors and intervening on risk factors, through collective action.The activities carried out within the project move at various levels of prevention, primary, secondary and tertiary:information addressed to the population, aimed at providing correct and in-depth knowledge of the phenomenon and at reducing the social stigma linked to suicidal behaviors, and to psychiatric illness in general; information campaigns that use different channels, from social media to the dissemination of paper material, to report support initiatives to people experiencing uneasy situations; health and not operator training, for whom most often come into contact with groups of subjects at risk (stakeholders); training of journalists and constant connection with the media so that they provide careful information to emphasize the seriousness of the phenomenon and the possible lines of behavior; support initiatives aimed at people at risk, who sufferm some form of suffering, especially people who are alone, with problems of depression, anxiety, panic attacks or with psychiatric pathologies; phone helpline available from 7 am to 1 am (at 800 061 650); self-help groups; constant networking, with social and health services; actions addressed to survivors, that is people who have experienced the death of a family member or friend by suicide and people who have attempted suicide; in both cases people suffering that require adequate attention and responses: support interviews for bereaved persons at AMA, with the aim of empathic reception, redefinition of traumatic bereavement, possible accompani-ment to the self-help group and/or individual support; self-family members of people who have committed suicide and people who have made suicide attempts. The group meets weekly and represents an important opportunity for discussion and emotional exchange, for people who are experiencing a particularly complex, painful and difficult grieving experience. Since 2013 A.M.A. coordinates the project, through a contract from the Health Authority, actively colla-borating with the APSS Mental Health Area. The AMA association is a volunteer organization present in the Trentino area since 1995, born with the aim of promoting self-help groups as an effective methodology for empowering people, and is currently engaged at the forefront of various initiatives with the aim of the well-being of individuals, families and groups in the Province of Trento. The coordination of the project requires a constant reformulation of the interventions in a network dimension that is carried out at different levels, both in an operational group that gathers the various health realities of the mental health service, and in a provincial table that meets in every six months, to which various local associations and institutions adhere.Wilma Angela Renata di Napoli: EALITY Psychiatria Danubina, 2021; Vol. 33, Suppl. 9, pp 164-168 168 CONCLUSIONSIt is essential, in light of the particular social and health situation we are experiencing, that actions such as those promoted within the Invito alla Vita Projectfor the prevention of suicide are carried out with even greater effectiveness, precision and continuity, in order to guarantee the most effective prevention of this serious phenomenon. The psychological and social implications of the covid-19 pandemic will only be fully assessable in a few years, when the crisis is effectively over. Only then we will be able to understand if the efforts put in place at a global level, and in particular in the province of Trento, have been effective in the managing of the suicidal phenomenon.Acknowledgements: I would like to express my special thanks of gratitude to Dr Roberto Rizzello, operating in the Clinical and Eva-luative Epidemiology Service of Trento, for his precious support in providing data regarding suicide phenome-non in Trentino, and I would like to extend my gratitude to Dr Camilla Bettella, psychologist, AMA operator, for her valuable contribution in analysis of help line activity. Conflict of interest: None to declare.References 1. Appleby L: What has been the effect of covid-19 on suicide rates? BMJ 2021; 372 2. Brown S, Schuman DL: Suicide in the time of COVID-19. A perfect storm. J Rural Health 2021; 37:211-214 3. Campos RC, Holden RR, Medina Pereira A: Psycho-logical impact of the COVID-19 pandemic and suicide ideation in community adults in Portugal: preliminary data. Minerva Psychiatry 2021; 62:74-8 4. Rizzello R, Piffer S: Rapporto annuale sugli eventi suicidari in provincia di Trento. 2021 Mar, Trento 5. Rogers JP, Chesney E, Oliver D, Begum N, Saini A, Wang S et al: Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis. Epidemiology Psychiatry Sci 2021; 30:e 32 6. Rossi R, Socci V, Talevi D, Mensi S, Niolu C, Paciti F et al.: COVID-19 pandemic and the lockdown measures impact on mental health among general population Italy. Front Psych, 2020 7. Sheklef L, Rabbany JM, Gutierrez PM, Kedem R, Ben Yehuda A, Mann JJ et al: The role of past suicidal behavior on current suicidality: a retrospective studiy in the Israeli military. Int J envorin Res Publice Health 2021; 18:649 Correspondence: Wilma Angela Renata di Napoli, MD Mental Health Center of Trento Via Borsieri 8, 38 100 Trento, Italy E-mail: wilmaangela.dinapoli@apss.tn.it 

SUICIDAL PHENOMENON IN PANDEMIC TIMES .THE TRENTINO\u27S REALITY

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