The impact of the COVID-19 pandemic on health service utilisation following self-harm: a systematic review

Background Evidence on the impacts of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020. Aims To systematically review evidence on health services utilisation for self-harm during the COVID-19 pandemic. Methods A comprehensive search of multiple databases (WHO COVID-19 database, Medline, medRxiv, Scopus, PsyRxiv, SocArXiv, bioRxiv, COVID-19 Open Research Dataset, PubMed) was conducted. Studies reporting presentation frequencies for self-harm published from 1st Jan. 2020 to 7th Sept. 2021 were included. Study quality was assessed using a critical appraisal tool. Results Fifty-one studies were included. 59% (30/51) were rated as low quality, 29% (15/51) as moderate and 12% (6/51) as high-moderate. Most evidence (84%, 43/51 studies) was from high-income countries. 47% (24/51) of studies reported reductions in presentation frequency, including all 6 rated as high-moderate quality, which reported reductions of 17-56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the 3 higher quality studies including study observation months from 2021 reported reductions in service utilisation. Evidence from 2021 suggested increased use of health services following self-harm among adolescents, particularly girls. Conclusions Sustained reductions in service utilisation were seen into the first half of 2021. However, evidence from low- and middle-income countries is lacking. The increased use of health services among adolescents, particularly girls, into 2021 is of concern. Our findings may reflect changes in thresholds for help seeking, use of alternative sources of support and variable effects of the pandemic across different groups.


Introduction
The COVID-19 pandemic has led to deterioration in population mental health and has placed considerable additional strains on health systems. 1 2 The pandemic has also heightened many of the risk factors for suicidal behaviour, such as job insecurity and unemployment, access to food, education and healthcare and the availability of family and community support. 3 Understanding and quantifying trends in help seeking for self-harm is a vital part of the public mental health response to COVID-19. It could help expound the apparent paradox observed during the early stages of the pandemic; while population mental health deteriorated, 4 fewer people sought help for their mental health from primary and secondary care services. 5 Examining self-harm presentations across health settings could help understand longer-term population impacts and inform planning of services and interventions in the future phases of the pandemic.
Numerous studies from high-income countries reported marked reductions in health service utilisation during the second quarter of 2020 following the start of the COVID-19 pandemic.
For example, considerable reductions in diagnoses for acute physical and mental illnesses were found in the UK following introduction of the national lockdown in March 2020, with only partial recovery by July 2020. 6 In another UK study, reductions of around a third in health service contacts specifically for self-harm were found. 7 Focussing specifically on hospital admission for self-harm, overall reductions of just over 8% were reported in France, though increases in more serious potentially lethal acts of self-harm were observed. 8 Evidence relating to the indirect health impacts resulting from the pandemic in low-and middle-income countries also suggests care for non-communicable diseases and mental disorders has been severely disrupted. 9 A systematic review on the impact of the pandemic on suicide and self-harm in low-and middle-income countries found mixed evidence, with either a decrease or no discernible impact in reported self-harm episodes along with increases in certain age groups. 10 In 2020, a living systematic review was established to provide an up-to-date resource and data synthesis of evidence on the impact of the COVID-19 pandemic on self-harm and suicidal behaviour. 11 The most recent update of the review included studies up to 19 th October 2020 and included 20 health service utilisation studies, including 11 focussing specifically on health service contact following self-harm/suicide attempts. 12 The review reported that most studies reported a decrease in presentations to health services for selfharm during the early months of the COVID-19 pandemic.
However, all 20 studies were of high-income countries and the latest month of observation was August 2020. [13][14][15] In the subsequent months many health services adapted and 'stay at home' orders eased, although these restrictions later returned in many countries and regions. While studies suggest service utilisation had returned to expected volumes in some countries by the third quarter of 2020, 12 it is not known how subsequent restrictions and ongoing pressures on health systems in response to further waves of COVID-19 affected help-seeking and access to healthcare for self-harm. In this article we report on evidence concerning the frequency (reported incident or prevalent episode counts or rates) of health service utilisation for self-harm after the onset of the pandemic compared to before the pandemic. There has been no synthesis of studies published since October 2020, some of which would be expected to include the later observation periods covering the latter months of 2020 and first half of 2021, as the pandemic continued to affect populations globally. Our aim was to systematically identify, review and synthesise evidence relating to utilisation of health services for self-harm since the COVID-19 pandemic began in the first quarter of 2020.

Methods
The protocol for the methodology applied in conducting the systematic review is registered within a living systematic review of the impact of the COVID-19 pandemic on self-harm and suicidal behaviour (PROSPERO ID CRD42020183326; registered on 1st May 2020). 11 5 12 Additional inclusion and exclusion criteria specific to our research question were applied and further screening, data extraction and study quality assessments were conducted. To address our research question, 'did the frequency of health service presentation for selfharm during the pandemic change compared to antecedent periods?', we applied the following inclusion and exclusion criteria:
• Written in any language.
• Investigation of health service utilisation among the general population o Including presentations to general hospital emergency departments (EDs), primary healthcare services, specialist mental healthcare services (accessible to general population), other secondary healthcare services that treat people who have self-harmed / attempted suicide (e.g. surgery) and admission to hospitals.
• Outcomes were presentations for self-harm, including: o broad definition of self-harm (defined as non-fatal intentional self-injury, intentional self-poisoning involving drugs or non-ingestible substances, including non-suicidal acts) or attempted suicide, including hospital attendance and/or admission for these reasons 11 o narrower definition, for example studies focussed only on suicide attempts or specific methods of self-harm.
• Comparisons: o health service presentation frequencies (including incident or prevalent episode counts or rates) for self-harm before and after the beginning of the COVID-19 pandemic, considering specific time periods separately; for example, both initial and subsequent lockdown periods.

Exclusion criteria
• Studies without pre-pandemic observation periods or measurements, including those reporting use of service initiatives implemented in response to the pandemic, with no pre-pandemic comparison period.
• Reports where only an abstract was available.
• Studies focussing on specific groups such as those with a specific physical of psychiatric diagnosis (including  or where the baseline population was existing patients within a specialist service, such as psychiatric inpatients.
• Studies reporting self-harm and suicidal thoughts as a combined measure.
• Studies reporting proportions of self-harm presentations, without reporting absolute figures • Studies of suicides.

Data analysis
The list of studies used for screening was obtained from the main living systematic review database. 12 This database is updated automatically using daily electronic searches of multiple databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) (see Supplement 2 for search strategy for each database). Screening was conducted in two stages: the citations returned by the automated searches were assessed by four screeners (CO, EE, DD, CM-H) to identify potentially relevant studies, then AJ, DG, DK or RW assessed the full text of the 8 studies to identify studies to be included in the main living systematic review. In addition, expert reviewers (AJ, DG, DK and RW) completed daily assessments of the automated results, which included basic data extraction and assigning studies manually to a study design category, along with a description of the study design.
Identification and screening of studies for the current review was conducted using a methodology developed as part of an existing living systematic review (Fig. 1). 12 Studies included publications identified in the living systematic review from 1 st Jan. 2020 up to 7 th Sept. 2021. Screening was conducted according to the inclusion and exclusion criteria for the current review. The list of studies was extracted from the main living systematic review database on 14 th Sept. 2021. Categories assessed for inclusion in the current review were 'service utilisation', 'before/after studies', 'time trends analysis' and 'examination of electronic health records' (Fig. 1). 16 As part of the identification and screening procedure, further screening and data extraction was completed for the current systematic review using a proforma designed to collect standardised information from each study (Table S1). Study quality and risks of bias were assessed using an adapted version of an existing National Institute for Health (NIH) quality assessment tool, designed specifically for studies using before and after designs. 17 The NIH tool was adapted by authors DK, JH and DG to include consideration of the pandemic and associated lockdown periods and other societal restrictions as the intervention of interest and to account for the use of health service data sources in the study designs. The overall assessment tool was used to judge the quality of studies, with predefined criteria established for studies to be rated as high or moderate quality. Screening, data extraction and quality assessments were conducted by SS. A second rater (DD) assessed eligibility for 20% of the studies sought for retrieval and conducted independent data extraction and analysis on 10% of the included studies. There was agreement on all eligibility assessments and study quality ratings. If a source was not available in English, data extraction was conducted by expert reviewers fluent in the language that the article was written in. Where included studies were preprints, searches for peer-reviewed version were conducted and the updated peerreviewed version was used for data extraction where available. Data synthesis was conducted by extracting, assessing and tabulating key aspects of the studies, including setting, study design, data sources, outcome measures, follow-up and comparison periods, main findings and study quality. The main effect measure of interest was percentage difference in presentation frequency during a defined COVID-19 period compared to a pre-COVID-19 comparison period. If this data were missing, the overall direction of change (e.g. increase/no change/decrease) was recorded. Higher quality studies were prioritised and reported separately during data synthesis and presentation of results.

Findings of included studies
Almost half (47%, 24/51) of the studies reported reductions in presentation frequency (Figure 2) for the duration of the period studied, the majority of which included months no later than August 2020. All 6 studies rated as high-moderate quality found decreases in service utilisation during the early months of the pandemic, with reductions of between 17 and 56% reported. 6 7 18-21 These studies were of primary and secondary care settings combined (4 studies), ED presentations among ages 18 to 25 years (1 study) and selfpoisoning presentations to hospital (1 study). Four studies used healthcare records in the UK to compare expected vs. observed primary and secondary-care recorded episodes of self-harm, and found reductions of between 26 and 44%. 6 7 19 21 Another study based in Sri Lanka found a 32% reduction in hospital presentations for self-poisoning compared to prepandemic numbers. However, these estimates included months no later than August 2020.
Five studies used national or nationally representative data. Four of these were assessed as high-moderate quality and reported decreases in service utilisation of between 26 and 56%.
One moderate quality study reported a 6% increase in ED presentations. 22 This US-based 1 0 study only included self-harm episodes classified as suicide attempts, therefore may not reflect service use for self-harm more broadly.
Increases were reported in 15/51 (29%) studies, none of which were assessed as being of high-moderate quality and 4 were rated as moderate quality. An examination of the number of people admitted to a surgical department following self-harm by ingestion of corrosive substances was found to increase by 55% in one Bangkok hospital, though numbers in the study were relatively low. 23 Other moderate quality studies reporting increased patient numbers included ED and surgery services, settings likely to be encountering patients with more medically severe episodes of self-harm.
Twelve out of 51 (24%) studies reported no change in service utilisation, including no highmoderate quality studies and 2 assessed as moderate quality. These were both conducted in ED settings, with one New Zealand ED reporting no change in self-harm presentations 24 and a UK-based study reporting no change in hospital admission following ED presentations for self-harm 25 A further 6 studies were conducted in trauma settings, though all were rated as low quality.
Most studies (46/51) included up to a maximum of 8 months of follow-up from the first wave of the pandemic (March to October 2020). Among the 4 studies including months from 2021 in their observation period (up to May 2021), 3 were rated as high-moderate quality. Among these, 2 studies of primary and secondary care-recorded self-harm reported longer-term reductions of between 8 and 30% respectively 19 21 and another study of ED presentations by young people aged 12 to 25 years found no overall change. 18 Studies including follow-up months beyond 2020 were limited to those originating from high-income countries.

Findings by study settings and subgroups
7/51 (14%) studies were conducted in upper-middle-income (3 studies), middle-income (1) and lower-middle income (3) countries, one of which was rated as high-moderate quality.
Four studies found a decrease in service use and three reported an increase. The study rated as high-moderate quality reported on self-poisoning episodes in a lower-middleincome setting; using health record data from a toxicology unit in a Sri Lankan hospital, a 32% reduction in hospital presentations for self-poisoning was found compared to prepandemic numbers. 20 A study of moderate quality conducted in one Nepalese ED found an increase of 44% in presentations for self-harm during the lockdown period compared to the same period the previous year, with indications that severity of self-harm was higher, though These findings are in contrast to those reported in other moderate quality studies using earlier COVID-19 observation periods (up to June 2020) where younger people were found to have significantly fewer self-harm presentations than in the equivalent period in 2019. 27 28

Main findings
All of the studies assessed as high-moderate quality reported decreases in service utilisation following self-harm and were conducted in settings reflecting a broad spectrum of self-harm with higher frequency of presentations such as primary care. We found that settings treating episodes of self-harm with lower frequency and higher lethality, such as trauma admissions and ambulance calls, were overrepresented among studies that reported increased or no change in demand. Among higher quality studies that included months from 2021 in their observation period, numbers of people seeking help from health services were found to be either closer to pre-pandemic levels, though still lower than expected, or in line with expected numbers. Evidence from 2021 also suggested there was increased utilisation of health services following self-harm among adolescents, girls particularly so. However, studies including follow-up months from 2021 were limited to those originating from highincome countries.

Strengths and limitations
. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 28, 2022. ;https://doi.org/10.1101https://doi.org/10. /2022 This systematic review is the first to examine up-to-date evidence regarding associations between the COVID-19 pandemic and frequency of health service utilisation for self-harm.
An established, peer-reviewed living systematic review methodology, 11 with ongoing data extraction by a panel of suicide prevention experts, was used as the basis for this review.
This approach, along with a specific focus on studies comparing frequency in utilisation of health services following self-harm in different settings during the COVID-19 pandemic versus antecedent pre-pandemic periods, enables timely synthesis of the evolving evidence base.
The findings of our study should be interpreted with some important caveats in mind. We excluded 6 studies that reported self-harm and suicidal thoughts as a combined measure as it was not possible to make a like-for-like comparison with findings pertaining specifically to acts of self-harm. However, we included studies using a broad range of definitions of selfharm, including those that measured and reported on suicide attempts or self-poisoning methods only. We also did not include temporal trends in the proportion of all presentations that were for self-harm as a primary outcome, due to the limitation that this outcome would be affected by changes in the overall number of presentations for reasons other than selfharm.
We conducted a comprehensive narrative synthesis of the data rather than a meta-analysis due to heterogeneity in the pandemic and antecedent comparison periods, definitions of selfharm applied, and healthcare settings that studies were conducted in. Performing a metaanalysis will be considered for future updates of the living systematic review. The studies included in our review are of mixed quality and are greatly under-representative of middleand low-income countries. While we have reported findings according to these characteristics, overall findings should be interpreted in light of these considerations.

Implications and comparison with existing evidence
Most studies came from high-income countries. Findings from higher quality studies suggested either there were continued reductions in health service utilisation into 2021, though to a lesser extent than earlier months of the pandemic, or that service use had broadly returned to pre-pandemic levels. However, these findings cannot necessarily be generalised to low-and middle-income countries. For example, allocation of COVID-19 vaccinations has been disproportionately skewed towards high-income countries. 29 Consequently, many low-and middle-income countries have experienced major subsequent waves of COVID-19 well into 2021. 30 The effects of these further waves of infection on Another study conducted in a paediatric ED in New York City, USA found that while overall there were significant decreases in emergency attendances, visits for suicidal ideation and self-harm among young people increased. 40 Increases in numbers of adolescents referred to mental health services in Ireland were found from September 2020, following initial decline in April 2020. 41 Our findings of increased utilisation of health services for self-harm 1 4 into the early months of 2021 among adolescents, particularly girls, within this context, are concerning and warrant urgent attention.

Conclusions
All high-quality studies reported a fall in attendance frequency for self-harm during the early months of the pandemic. New evidence relating to the first and second quarters of 2021 indicated that longer-term impacts on health services were less marked than during the first wave of the pandemic, though reductions in frequency of presentation versus expected levels persisted. These patterns likely reflect changes in thresholds for help seeking, increases in frequency of higher acuity episodes of self-harm and increased use of nonstatutory health services. The increased utilisation of health services among adolescents, particularly girls, into the early months of 2021 warrants particular attention. However, evidence from low-and middle-income countries is still limited. High-quality, multi-centre studies examining the longer-term impacts on health service utilisation for self-harm, particularly in low-and middle-income countries, including observation periods into 2021 and among children and young people, are urgently needed. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

Declaration of Interest
The copyright holder for this preprint this version posted January 28, 2022. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. ; is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.
1 8 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.  . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.26.22269901 doi: medRxiv preprint e  t  a  l  .  P  e  n  e  t  r  a  t  i  n  g  t  r  a  u  m  a  d  u  r  i  n  g  a  g  l  o  b  a  l  p  a  n  d  e  m  i  c  :  C  h  a  n  g  i  n  g  p  a  t  t  e  r  n  s  i  n  i  n  t  e  r  p  e  r  s  o  n  a  l  v  i  o  l  e  n  c  e  ,  s  e  l  f  -h  a  r  m  a  n  d  d  o  m  e  s  t  i  c  v  i  o  l  e  n  c  e  i  n  t  h  e  C  o  v  i  d  -1  9  o  u  t  b  r  e  a  k  .  S  u  r  g  e  o  n  -J  o  u  r  n  a  l  o  f  t  h  e  R  o  y  a  l  C  o  l  l  e  g  e  s  o  f  S  u  r  g  e  o  n  s  o  f  E  d  i  n  b  u  r  g  h  a  n  d  I  r  e  l  a  n  d  2  0  2  1  ;  1  9  (  1  ) : . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.  r  e  t  r  o  s  p  e  c  t  i  v  e  i  n  t  e  r  n  a  t  i  o  n  a  l  c  o  h  o  r  t  s  t  u  d  y  .  E  u  r  o  p  e  a  n  C  h  i  l  d  &  A  d  o  l  e  s  c  e  n  t  P  s  y  c  h  i  a  t  r  y  2  0  2  1  d  o  i  :  1  0  .  1  0  0  7  /  s  0  0  7  8  7  -0  2  1  -0  1  7  4  1  -6  2  8  .  M  o  u  r  o  u  v  a  y  e  M  ,  B  o  t  t  e  m  a  n  n  e  H  ,  B  o  n  n  y  G  ,  e  t  a  l  .  A  s  s  o  c  i  a  t  i  o  n  b  e  t  w  e  e  n  s  u  i  c  i  d  e  b  e  h  a  v  i  o  u  r  s  i  n  c  h  i  l  d  r  e  n  a  n  d  a  d  o  l  e  s  c  e  n  t  s  a  n  d  t  h  e  C  O  V  I  D  -1  9  l  o  c  k  d  o  w  n  i  n  P  a  r  i  s  ,  F  r  a  n  c  e  :  a  r  e  t  r  o  s  p  e  c  t  i  v  e  o  b  s  e  r  v  a  t  i  o  n  a  l  s  t  u  d  y  .  A  r  c  h  i  v  e  s  o  f  d  i  s  e  a  s  e  i  n  c  h  i  l  d  h  o  o  d  2  0  2  0  d  o  i  :  1 0  . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. ; e  t  a  l  .  P  s  y  c  h  i  a  t  r  i  c  e  m  e  r  g  e  n  c  y  c  a  r  e  d  u  r  i  n  g  C  o  r  o  n  a  v  i  r  u  s  2  0  1  9  (  C  O  V  I  D  1  9  )  p  a  n  d  e  m  i  c  l  o  c  k  d  o  w  n  :  r  e  s  u  l  t  s  f  r  o  m  a  D  e  p  a  r  t  m  e  n  t  o  f  M  e  n  t  a  l  H  e  a  l  t  h  a  n  d  A  d  d  i  c  t  i  o  n  o  f  n  o  r  t  h  e  r  n  I  t  a  l  y  .  P  s  y  c  h  i  a  t  r  y  R  e  s  e  a  r  c  h  2  0  2  0  ;  2  9  3  d  o  i  :  1  0  .  1  0  1  6  /  j  .  p  s  y  c  h  r  e  s  .  2  0  2  0  .  1  1  3  4  6  3  4  3  .  C  h  e  n  S  ,  J  o  n  e  s  P  B  ,  U  n  d  e  r  w  o  o  d  B  R  ,  e  t  a  l  .  T  h  e  e  a  r  l  y  i  m  p  a  c  t  o  f  C  O  V  I  D  -1  9  o  n  m  e  n  t  a  l  h  e  a  l  t  h  . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.  5  5  .  C  a  n  z  i  G  ,  D  e  P  o  n  t  i  E  ,  C  o  r  r  a  d  i  F  ,  e  t  a  l  .  E  p  i  d  e  m  i  o  l  o  g  y  o  f  M  a  x  i  l  l  o  -F  a  c  i  a  l  T  r  a  u  m  a  D  u  r  i  n  g  C  O  V  I  D  -1  9  L  o  c  k  d  o  w  n  :  R  e  p  o  r  t  s  F  r  o  m  t  h  e  H  u  b  T  r  a  u  m  a  C  e  n  t  e  r  i  n  M  i  l  a  n  .  C  r  a  n  i  o  m  a  x  i  l  l  o  f  a  c  i  a  l  T  r  a  u  m  a  &  R  e  c  o  n  s  t  r  u  c  t  i  o  n  2  0  2  0  d  o  i  :  1  0  .  1  1  7  7  /  1  9  4  3  3  8  7  5  2  0  9  8  3  1  1  9  5  6  .  G  r  a  c  i  a  R  ,  P  a  m  i  a  s  M  ,  M  o  r  t  i  e  r  P  ,  e  t  a  l  .  I  s  t  h  e  C  O  V  I  D  -1  9  p  a  n  d  e  m  i  c  a  r  i  s  k  f  a  c  t  o  r  f  o  r  s  u  i  c  i  d  e  a  t  t  e  m  p  t  s  i  n  a  d  o  l  e  s  c  e  n  t  g  i  r  l  s  ?  J  o  u  r  n  a  l  o  f  A  f  f  e  c  t  i  v  e  D  i  s  o  r  d  e  r  s  2  0  2  1  ;  2  9  2  :  1  3  9  -4  . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.  O  j  e  d  a  J  L  ,  G  o  r  d  i  l  l  o  -U  r  b  a  n  o  R  M  ,  C  a  r  r  i  l  l  o  -P  e  r  e  z  T  ,  e  t  a  l  .  S  u  i  c  i  d  e  P  r  e  s  e  n  t  a  t  i  o  n  s  t  o  a  n  E  m  e  r  g  e  n  c  y  D  e  p  a  r  t  m  e  n  t  P  r  e  a  n  d  D  u  r  i  n  g  t  h  e  C  O  V  I  D  L  o  c  k  d  o  w  n  ,  M  a  r  c  h  -M  a  y  2  0  2  0  ,  i  n  S  p  a  i  n  .  A  r  c  h  i  v  e  s  o  f  S  u  i  c  i  d  e  R  e  s  e  a  r  c  h  2  0  2  1  d  o  i  :  1  0  .  1  0  8  0  /  1  3  8  1  1  1  1  8  .  2  0  2  1  .  1  8  8  7  0  2  3  7  0  .  R  a  j  p  u  t  K  ,  S  u  d  A  ,  R  e  e  s  M  ,  e  t  a  l  .  E  p  i  d  e  m  i  o  l  o  g  y  o  f  t  r  a  u  m  a  p  r  e  s  e  n  t  a  t  i  o  n  s  t  o  a  m  a  j  o  r  t  r  a  u  m  a  c  e  n  t  r  e  i  n  t  h  e  N  o  r  t  h  W  e  s  t  o  f  E  n  g  l  a  n  d  d  u  r  i  n  g  t  h  e  C  O  V  I  D  -1  9  l  e  v  e  l  4  l  o  . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. ;

8
Supplement 1: is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.

9
Authors Report type In April 2020, incidence and event rates for self-harm were substantially lower than expected for women and people aged below 45 years. Self-harm incidence increased from August 2020, in the 10-17-year age group.
It is not known how many of the primary care recorded selfharm episodes had resulted in hospital presentations. Seasonal trends were accounted for in the analysis.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. The specific suicidal behaviours included in the outcome measure were not specified, though ICD-10 codes were used.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. This was a letter so was relatively brief with very little information on methods of data extraction, inclusion criteria, coding and pooing of data from the three centres.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.

9
Authors Report type Only EDs that consistently reported data to the surveillance programme were included to improve data quality.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. In 2020, 31 episodes of self-harm meeting the study inclusion criteria were recorded, an increase compared The outcome was limited to self-harm resulting in major trauma.

0
The process for data Low .

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. More cases, and a larger proportion of the total, required hospital admission in the 2020 period.
The main focus of the study was on proportions of total presentations that involved self-harm.
Only data from 2019 were included in the pre-COVID-19 comparison period. Electronic health records from more than 3,500 EDs contributing data to the US National Syndromic

ED visits for suicide attempts
Median ED presentation counts were significantly higher in weeks 12 to Did not include selfharm not classified as a suicide attempt.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. There was a significant increase in the frequency of hospital admissions due to attempted suicide, though numbers were very small (5 in the comparison period vs. 10 in the lockdown period). The number of selfharm episodes increased from n=1 in 2018 to 5 in 2019 and 8 in 2020.
Number of self-harm cases was too small to draw any strong conclusions.

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. The study only included 'violent' methods of self-harm and was limited to persons who presented to hospital and were treated by the trauma centre.
The study was underpowered, with Low .

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. During March and April 2020, no difference in admissions following self-harm was seen (7 in 2020 vs. an average of 3 to 6 in 2016 to 2019).
The methods of data collection were not described.
The study was under-powered for examination of mean monthly self-harm Low .

CC-BY-ND 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.
The numbers of presentations in were relatively small (55 in the lockdown period and 38 in the 2019 comparison period) and the comparison periods were also brief. 1 high/moderate quality if risk of bias is considered low (i.e. Q3, Q6, Q7 & Q8 on adapted JBI for before/after studies all scored "yes".) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted January 28, 2022.   . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 28, 2022. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 28, 2022.