Suicide and the COVID-19 pandemic: A qualitative study of discourse on an online pro-choice for suicide discussion forum

The mental health effects of those who have suffered the economic and social consequences of the COVID-19 pandemic have been profound. Studies have reported increased symptoms of anxiety disorder, depressive disorder, substance use, suicidal ideation, and emergency department admissions for individuals with risk of suicidal behavior (Ambrosetti et al., Citation2021; Czeisler et al., Citation2020; Niederkrotenthaler et al., Citation2020; Xiong et al., Citation2020), which are recognized risk factors for suicide death (Stuckler et al., Citation2009; Van Orden et al., Citation2010). The pandemic also contributed to an increase in insufficient and/or unsatisfactory sleep, use of at least one psychotropic drug, and unsatisfactory quality of life—including for children and adolescents (Amerio et al., Citation2021; Nobari et al., Citation2021). Furthermore, these adverse effects are likely to persist for an extended period of time (Gunnell et al., Citation2020). Other studies found conflicting evidence regarding increased suicidality – indicating that consequences of the pandemic are complex. For example, one study found that suicide-related internet Google searches worldwide (search terms “suicide,” “suicide methods,” and “how to kill yourself”) did not increase, while searches related to hope and resilience increased (Sinyor et al., Citation2020), and a systematic review found that some studies reported an increase in suicide death/attempt rates (n = 4), while others reported a decrease (n = 2) or no change (n = 1; Pathirathna et al., Citation2022). Nevertheless, the psychological experiences and emotional challenges for individuals at risk for suicide still require immediate attention so that the mental health community can respond appropriately.

The COVID-19 pandemic also impacted individuals’ social media behaviors. Social media serves various purposes, such as providing sources for health information, social connectivity, and an outlet for sharing personal experiences. Due to the potential anonymity offered by some online communities, social media platforms also provide individuals an opportunity to discuss taboo topics (e.g. suicide), self-disclose personal and mental health challenges in a disinhibited manner (De Choudhury & De, Citation2014), and seek social support (Ikunaga et al., Citation2013). Of interest are online forums dedicated to the discussion of suicide (also referred to as “pro-choice suicide” forums) that act as a main channel for sharing explicit suicide-related content, such as details about various methods of suicide that would not be permitted on other social media sites. Hence, these platforms can become a desirable resource for those who seek to connect with like-minded individuals, receive social support, and engage in conversations about their suicidality, particularly during periods of confinement. While it is unknown whether all users of these types of forums have a desire to die by suicide, many do – making these users more vulnerable due to the stressors brought on by the pandemic. Indeed, these forums have been documented to increase risk of suicidal behaviors for vulnerable groups (Luxton et al., Citation2012).

The textual data obtained from virtual communities are unique in its potential to provide unfiltered information about the nature and content of online discourse without interference from researchers (Bargh et al., Citation2002), unlike survey or interview responses in which the participant may alter their true feelings due to concern about how they are perceived by the researcher. Previous research shows that individuals who interact via virtual communities (vs. in person) are more likely to present their true selves online (Barg et al., Citation2002). Furthermore, Barak and Miron (Citation2005) claim that virtual communities offer a valid social environment for understanding users’ psychological states.

Given that the COVID-19 pandemic has affected a myriad of established suicide risk and protective factors and contributed to increased social media use, we hypothesized that some individuals who struggle with suicidality would utilize social media to engage in discussions about the impact of the pandemic on their life, well-being, and suicidality. Therefore, the aim of this exploratory study was to examine the textual record of public discourse related to the pandemic on a pro-choice suicide forum.

Method

Results

The search criteria and strategy identified 118 discussion threads. Ninety-nine different users posted content. Nine users posted two threads, three users posted three threads and one user posted five threads. All other threads were created by unique users (i.e., users who only posted one thread).

Six themes were identified from the data and were related to the pandemic’s impact on mental health and suicidality, exacerbated living conditions, and optimism. The themes and proportion of discussion threads reflecting each theme are presented in Table 1. Several themes unrelated to the impact of the pandemic on mental health and suicidality were identified but were excluded from reporting in this study due to the irrelevance to the aim of this study (e.g., users who shared information about conspiracy theories).

Discussion

The purpose of this study was to understand the impact and experiences of the COVID-19 pandemic among social media users on a pro-choice suicide forum. Results showed that users frequently discussed the effect of the pandemic on mental health and suicidality (i.e., suicide ideation, suicide plans and intentions), living conditions, and feelings of optimism. For example, some users expressed that their uncertainty about the future and conditions of confinement contributed to worsening mental health and suicidality; whereas for others, the inability to obtain lethal means and lack of opportunity to be alone prevented them from attempting suicide at that present time. Several major domains of users’ daily lives were affected, including economy, trade, employment, housing security, and self-care activities—consistent with previous research on the economic and social conditions of the pandemic (Haleem et al., Citation2020). Furthermore, some users expressed optimism or a positive outlook in light of the COVID-19 pandemic for various reasons, including being able to spend more time with their pets, confinement leading to reduced contact with individuals who were a source of distress, new job prospects due to the government-provided financial aid, and the perceived lowering of societal expectations to fit in.

The first major take-away from the present study is that there is no singular outcome of the pandemic on mental health and suicidality. Instead, the impact is complex and multifactorial – which is consistent with other studies showing varied outcomes (Pathirathna et al., Citation2022). Our findings indicated that the pandemic contributed to increasing suicide risk factors (e.g., financial and housing instability, interpersonal conflict) and worsening suicide ideation, as well as increasing optimism and delays to suicide plans (decreasing risk). Given this complexity, it is essential that media reports and publications on the impact of the pandemic on suicidality are accurate, do not sensationalize coverage, and consider the wider context of suicide to avoid misleading conclusions. Indeed, media coverage of the pandemic was cited as a reason for worsening mental health in this study, suggesting that how public health issues are reported can have a negative impact on vulnerable groups. As stated in Samaritans’ media advisory guidelines on suicide reporting (2020), suicide-related headlines that sensationalize and oversimplify the context by suggesting that the death was “triggered” by a single cause (e.g., the pandemic, job loss, or isolation) run the risk of increasing likelihood of suicidal behaviors for individuals who may be experiencing similar problems and over-identify with the deceased.

Another noteworthy take-away relates to suicide stigma and misconceptions of individuals who are suicidal. Public perceptions of suicide are largely negative, with a common belief that individuals who die by suicide are selfish and do not care about others (Kheibari et al., Citation2021). However, our findings show that many users felt concern for the well-being of others even as they considered dying by suicide and were mindful of the stigma associated with suicide. Whether users delayed suicide plans out of concern for the negative impact on others’ mental health or safety risks for others (i.e., spreading the virus) or the fact that some users contemplated suicide plans that involved masking the true cause of death, it is clear that these individuals are affected by suicide stigma and do consider the impact of their actions on others. Hence, breaking the stigma of suicide is a critical step toward helping those who are impacted as these misconceptions and harmful attitudes can contribute to decreased help-seeking for those at-risk (Niederkrotenthaler et al., Citation2014).

It is also important to acknowledge the broader implications of pro-choice suicide forums. The fact that individuals use these types of forums for various reasons brings to question the nature of these forums and highlights the controversy surrounding their existence. For example, our study found that users utilized the forum for purposes other than to express negative sentiment or to strictly seek information about suicide methods by posting messages of optimism and offering kind words to other users. However, while it appears that pro-choice suicide forums can serve multiple purposes, such as providing a non-judgmental space to openly discuss a taboo topic, they also pose the risk of increasing suicidal behaviors (Luxton et al., Citation2012). Previous research suggests that many of those who use these types of forums are adolescents or young adults, and that users often encourage other users to follow through with suicide plans, promote the idea that suicide is justifiable, and reject the mental health system (Westerlund, Citation2013). Mainstream suicide prevention and “pro-life” positions are viewed by forum users are oppressive and naïve (Marsh et al., Citation2022). There have also been instances where users live-stream their suicide on internet forums, with some users who responded encouragingly (Westerlund et al., Citation2015). Still, others have argued that these suicide-specific forums do not operate solely as a communication “tool" or a uniformly dangerous place, but as a discursive community where users create meaning, and share values and beliefs – in other words, a “safe space” for those who feel otherwise out of place in the external world and fear entrapment (i.e., involuntary, inpatient hospitalization) (Alvarez, Citation2022). Pro-choice suicide forum users present suicide differently than the clinical and theoretical presentation of suicide that frames the issue as pathological, marked by deficits in functioning, irrationality, and impulsivity—which may not only be a narrow but also a distorted view of suicide (Marsh et al., Citation2022). Therefore, it is important not to discredit the perspectives of individuals that use pro-choice suicide forums as their narratives about their suicidality can contribute to a broader interpretation of how suicide is constructed and planned. Furthermore, censorship or shutdown of these types of forums may pose legal, ethical, and logistical challenges. Giving voice to those who are suicidal is critical from an anti-oppressive perspective—although it comes with the challenge of inadvertently normalizing and/or validating suicide (Marsh et al., Citation2022). If there are true benefits to pro-choice suicide forums for individuals who seek social support to disclose their thoughts in a non-stigmatized space, then we need a better understanding of how these forums function and how to minimize risk. Future research should continue to explore characteristics of those who use pro-choice forums, their diverse motivations, and the various ways the forum functions (e.g., source of information on methods, a space to vent frustrations, social support).

This study has several the implications for suicide prevention. Forum users noted several protective factors, such as the benefits of pet ownership, improved opportunities for financial stability, and lowering societal pressures to fit in—which could serve to inform our approach to suicide prevention. However, it may be equally—if not more—valuable to draw our attention to the larger implications related to pro-choice suicide forums and the opportunity they provide us to learn about the diverse voices, perspectives, and attitudes of those who are suicidal. As argued by Marsh and colleagues (Citation2022, p. 23), suicide prevention is a “morally contested field” that marginalizes and silences the voices of those who are suicidal by assuming that their suicidality is irrational and pathological. Pro-choice suicide forums offer these marginalized voices a safe space to discuss their views. If the assumptions about suicide and prevention practices differ so greatly from the beliefs, attitudes, and behavior of the population we seek to help, then how can we expect to be successful in preventing suicide? Focusing solely on identifying risk and protective factors, improving suicide screenings, promoting mental health treatment and crisis intervention may not be adequate to provide the comprehensive preventative care needed for at-risk individuals. We need to address the gap between the assumptions of suicide prevention advocates and those who wish to die so to avoid perpetuating power imbalances and ineffective prevention practices. As it relates to pro-choice suicide forums and suicide prevention, Alvarez (Citation2022, p. 9) recommends that clinicians “resist the tendency to succumb to panic with regards to the online activities of their suicidal patients” and instead inform patients of the dangers posed by pro-choice suicide forums that contain triggering content. Additionally, individuals who struggle with suicide may benefit from having greater access to other virtual social support communities comprised of individuals who are non-judgmental and open-minded to reproduce a safe environment to discuss suicidal thoughts, and possibly without explicit content on lethal methods. Thus, suicide prevention efforts that emphasize informed consent, respect for persons, and empowerment may be more appropriate.

The present study has several noteworthy limitations. First, the time period captured in this data ranged from March 1, 2020 to August 19, 2020, which restricts further examination of users’ discussions as the pandemic progressed (e.g., pre- and post-vaccine availability, new COVID-19 variants). The nature of secondary data from virtual communities also limits the researchers’ ability to seek additional breadth, clarity, and context of users’ subjective experiences. The data were limited to original posts made by users and did not include replies from other users—thus, restricting our ability to examine how users interact and expand on the topics discussed. Furthermore, the results cannot be generalized to other types of internet forum where individuals discuss suicide and does not include the perspective of those who do not speak English as this forum was written in English only. Finally, while previous research supports the notion that online communication is likely to be authentic (Bargh et al., Citation2002), there is no way to be certain of the trustworthiness of online discussions.

In conclusion, more research is needed to understand the factors that influence the different responses to the pandemic. The findings described here not only highlight the impact of the COVID-19 pandemic on users’ mental health and suicidality, but they also highlight the nuanced topic of how pro-choice suicide forums function as an outlet for a variety of suicide- and non-suicide related discourse and the importance of including the diverse viewpoints from marginalized individuals who experience suicidal ideation.