Comparison of Suicide Completion Rate in Korean Students Pre- and Post-COVID-19 Pandemics

Article information

Psychiatry Investig. 2025;22(2):204-211

Publication date (electronic) : 2025 February 17

doi : https://doi.org/10.30773/pi.2024.0242

Kyungjin Lee¹, Boram Nam², Kyoil Seo², Eunkyung Jo², Seohyun Kim², Deokyong Shin², Aeju Kim^2,3,4, Youngil Jeong^,2,3, Yeni Kim^,1,5

¹Department of Neuropsychiatry, Dongguk University School of Medicine, Goyang, Republic of Korea

²Creative Mindful Leadership, Dongguk University, Seoul, Republic of Korea

³Dharma College, Dongguk University, Seoul, Republic of Korea

⁴Department of English Language and Literature, Dongguk University, Seoul, Republic of Korea

⁵Institute of Clinical Psychopharmacology, Dongguk University International Hospital, Goyang, Republic of Korea

Correspondence: Yeni Kim, MD, PhD Department of Neuropsychiatry, Dongguk University School of Medicine, 27 Dongguk-ro, Ilsandong-gu, Goyang 10326, Republic of Korea Tel: +82-31-961-7235, Fax: +82-31-961-7236, E-mail: yenikim@dumc.or.kr

Correspondence: Youngil Jeong, PhD Creative Mindful Leadership, Dongguk University, 30 Phildong-ro 1-gil, Jung-gu, Seoul 04620, Republic of Korea Tel: +82-2-2260-1485, E-mail: eagleton@dongguk.edu

Received 2024 July 24; Revised 2024 October 27; Accepted 2024 December 23.

Abstract

INTRODUCTION

According to the World Health Organization, coronavirus disease-2019 (COVID-19) has had a severe impact on the mental health and well-being of people worldwide. Evidence suggests that the pandemic and its associated public health and social measure have led to a worldwide increase in mental health problems, including depression and anxiety [1].

In March 2020, “social distancing guidelines” mandated by the Korean Ministry of Health and Welfare was put in place to prevent the spread of COVID-19. Korean students also followed a stay-at-home order in response to the pandemic. Schools in Korea were completely closed on April 6, 2020, and classes were replaced with online classes [2-4].

Subsequently, as a measure against prolonged COVID-19 pandemic, the schools returned to normal classes by October 2021 in the following phases [2,3]:

1) Announcement of “step-by-step implementation plan for full-school-attendance in the second semester” in June 2020.

2) Announcement of “2nd semester academic management plan” in August 2020.

3) “A direction for normalizing educational activities” was presented by promoting a phased recovery of daily life at the national level in October 2020.

4) As of November 2020, 91.1% of all students participated in attendance classes.

Although, schools were reopened, entire grades were shut down if there was an outbreak. Moreover, various restrictions were applied regarding school attendance according to the COVID-19 infection status of the student or their immediate family members. Even when attending school, social distancing rules (masks, screens) were still in place restricting students from socializing physically during school hours.

Several studies have investigate the impact of COVID-19 and examined who and under what circumstances, mental health was compromised [5]. When looking at the suicide rate pre-COVID-19 (2015–2019) and post-COVID-19 (2020) outbreak in 14 states in the United States in 2020, there were areas where it decreased in adults but significantly increased in children and adolescents [6]. Similarly, in a Chinese study regarding suicidal behavior during 2020, the self-harm behavior, ideas with intent to die, ideas to plan suicide, suicide attempts, and suicide in children and adolescents in May 2020 (the second pandemic period) increased significantly compared to November 2019 [7]. In a study of student suicide rates in Japanese local governments, it was found that the suicide rate of children increased when they returned to school after the school closure by the pandemic [8].

The Mental Health Survey conducted by the Korean Ministry of Health and Welfare in June 2022, investigated the deterioration of mental health in adults due to COVID-19. The suicidal ideation rate was higher compared to the early period of the COVID-19 pandemic and was close to three times higher than pre-COVID-19 [4]. According to the Mortality Statistics in year 2020, the suicide death rate in Korea was 25.7 per 100,000 people, a decrease from the year 2019 (29.6 per 100,000). However, the student suicide rate increased from 5.9 per 100,000 people in 2019 to 6.5 per 100,000 people in 2020. It ranked as the leading cause of death in children and adolescents [9].

This study investigated the aggregated posthumous case reports of all known suicide victims who attend school in South Korea during the period of year 2017 to 2022. The case report was compiled by teachers of the suicide victims post under the directive of the Department of Education of South Korea [2,3]. We aimed to investigate the mental health consequences of COVID-19 by investigating the incidence of Korean student suicide cases before and after the pandemic. We compared the suicide rate and the relevant risk factors between the period of year 2017 to 2019 and the period of year 2020 to 2022, representing pre- and post-COVID-19 eras.

METHODS

Since 2015, Korean schools are mandated to submit “student suicide case reports” to the Ministry of Education. The teacher at the victim’s school was required to answer survey questions related to the circumstances surrounding the suicide posthumously. Additionally, the teacher of the victim was required to answer questions about changes in the various risk factors for suicide observed in the student over the past year and emotional behavioral problems prior to death.

The subjects of the study were children and adolescents aged 9–19 years (936 in total) who completed suicide during the period of year 2017 to 2022. This study compared student suicide number per 100,000 and examined the characteristics of suicide among elementary, middle, and high school students pre-COVID-19 (2017–2019) and post-COVID-19 (2020–2022) using the “suicide case report.” The study was conducted in accordance with the principles of the Declaration of Helsinki. Approval was granted by The Ethics Committee of Dongguk University, Seoul (IRB No. DUIRB-202208- 04, DUIRB-202308-01). The study was deemed to present no greater than minimal risk by the Institutional Review Board of Dongguk University; hence, a waiver of consent documentation was granted for all participants who completed assessments before the study began, and a waiver of authorization was granted for all participants recruited after the study began.

The analyzed data included the following factors for students who completed suicide: sociodemographic characteristics, family environment (e.g., family type, cohabitation status, economic level, and main income earner), school environment (e.g., attendance and peer relationships at school), and questions related to students’ problems before death (e.g., emotional and behavioral problems within the last two months).

Attendance was categorized based on the following multiple-choice options: good, illness (tardiness and early leave), illness (absence), no-permission (tardiness and early leave), truancy, and others. In the absence reason section, students with both truant and sick absences were categorized as truants, while those with only sick absences (and no history of truancy) were classified as illness absences.

Emotional and behavioral problems were assessed through responses to multiple-choice questions that included: depression, anxiety, impulsivity, social problems, aggression, others, none, and unknown. Peer relationships and behavioral issues at school were evaluated using the following options: victim of extortion and violence, perpetrator of extortion and violence, victim of bullying/cyberbullying, perpetrator of bullying/cyberbullying, joining a gang, relationship problems, conflicts in friendship, others, none, and unknown. Multiple responses were permitted for questions related to attendance, school relationships, and emotional or behavioral problems.

Frequency analysis, chi-square tests, and Fisher’s exact tests were used to determine differences between students across distinct periods (i.e., pre- and post-COVID-19). Statistical significance was set at p<0.05. All analyses were performed using SPSS 28.0 for Windows (IBM Corp., Armonk, NA, USA).

RESULTS

Sociodemographic characteristics

As shown in Table 1, 936 cases of completed suicide cases which were reported to the Department of Education of South Korea were investigated, of which 52.4% were male (490 boys). The study group consisted of 114 students who committed suicide in 2017 (mean age=16.0 years, 64 boys), 144 students in 2018 (mean age=16.0 years, 65 boys), 140 students in 2019 (mean age=16.0 years, 72 boys), 148 students in 2020 (mean age=15.9 years, 80 boys), 197 students in 2021 (mean age=15.9 years, 106 boys), and 193 students in 2022 (mean age=15.9 years, 103 boys).

Table 1.

Sociodemographic characteristics of the students who committed suicide by year (N=936)

Rate of school grade (p=0.873), gender (p=0.531), rate of marital status of parents (p=0.237), employment of parents (p=0.265), economic status (p=0.062), and living environment (p=0.719) did not differ significantly across the age groups.

Suicide incidence rate and odds ratio pre- and post-COVID-19

In January 2020, COVID-19 became a pandemic in Korea, causing school closures in March 2020. Table 2 shows student suicide rates pre-COVID-19 (2017–2019) and post-COVID-19 (2020–2022). Korean students displayed a suicide rate of 2.37 per 100,000 students pre-COVID-19 and 3.37 per 100,000 students post-COVID-19 (odds ratio [OR] 1.42, p<0.001) (Table 2).

Table 2.

Student suicide incidence rate pre- and post-COVID-19 state

Male student suicide rate increased post-COVID-19 (3.51 per 10⁵) compared to pre-COVID-19 (2.31 per 10⁵, p<0.001). Female students suicide rate also increased post-COVID-19 (3.22 per 10⁵) compared to pre-COVID-19 (2.44 per 10⁵, p=0.003). Middle school students suicide rate increased post-COVID-19 (4.61 per 10⁵) compared to pre-COVID-19 (3.19 per 10⁵, p=0.001). High school students suicide rate increased post-COVID-19 (8.39 per 10⁵) compared to pre-COVID-19 (5.50 per 10⁵, p<0.001) (Table 2).

Annual suicide rate trends pre- and post-COVID-19

The suicide rate in 2020 did not display a statistically significant difference from that of the pre-COVID-19 era (2017 to 2019). The suicide rate in 2021 (3.72 per 10⁵; 197 cases) increased significantly compared to 2017 (1.99 per 10⁵; 114 cases, p<0.001), 2018 (2.58 per 10⁵; 144 cases, p<0.001), 2019 (2.57 per 10⁵; 140 cases, p<0.001), and 2020 (2.77 per 10⁵; 148 cases, p=0.007). The suicide rate also increased significantly in 2022 (3.66 per 10⁵; 193 cases) compared to that in 2017 (p<0.001), 2018 (p=0.001), 2019 (p=0.001), and 2020 (p=0.010). There was no significant difference in the suicide rate between 2021 and 2022 (p=0.910).

The student suicide rate decreased in the first semester of 2020 compared to year 2019, when school closure was initiated. However, starting in the second half of 2020, it continued to increase compared to pre-COVID-19 eras. The suicide rate was the highest in the first half of 2021. In the second half of 2021, it returned to the level of the second half of 2020. In the first and second half of 2022, the suicide rates was higher compared to the second half of 2021, although lower than in the first half of 2021 (Figure 1).

Figure 1.

Suicide rates from year 2017 through 2022 for 9–19 years aged students in South Korea. Each number represents the student suicide rate per 100,000 people during the 6-month period. *p<0.05;**p<0.01;***p<0.001.

Pre- and post-COVID-19 school attendance in student who completed suicide

According to the attendance tallies, fair attendance showed a significant increase in year 2020 (74.83%, p=0.003), initial stage of school closure measures compared to 2019 (58.27%). However, fair attendance showed a significant decreasing trend in 2022 (57.07%) compared to 2020 (p<0.001) and compared to 2021 (68.88%, p=0.016) reaching similar attendance to year 2019 pre-COVID-19 (58.27%) (Figure 2A).

Figure 2.

(A) School attendance by the students before suicide completion. Fair_Attend, fair attendance without absence, tardiness or leave early. (B) Cause of missed attendance by the students before suicide completion. Illness_Absence, absence due to illness with certified documents from doctor (green pillar); Illness_TLE, tardiness and leaving early because of illness with certified documents from doctor (pale green pillar); NoPermi_TLE, tardiness and leaving early without sufficient reason or permission (red pillar); Truancy, absence without sufficient reason or permission (pink pillar). *p<0.05;**p<0.01;***p<0.001.

Compared to 2019, absence due to medical reasons and truancy significantly decreased in 2020, possibly due to school closure and online attendance. However, absences due to medical reason started to increase in 2021 (15.82%) and showed significant increase in 2022 (23.56%) compared to year 2019 (13.67%, p=0.025) and 2020 (9.52%, p=0.001). There has been a statistically significant increase in tardiness/early leaves due to illness in 2022 (26.18%) compared to 2021 (15.31%, p=0.008) and compared to 2020 (14.97%, p=0.013) (Figure 2B).

Emotional or behavioral abnormality observed by the teachers before student suicide completion

The number of students who was reported by teachers posthumously as showing at least one emotional or behavioral abnormality within the two months prior to suicide completion was 278 (32.7%) out of 849 responses.

Among the students who completed suicide pre-COVID-19, teachers reported depressive signs in 22.4% of the students (24 out of 107 responses) in 2017; 27.0% (34 out of 126 responses) in 2018; 35.6% (47 out of 132 responses) in 2019. Among the students who completed suicide post-COVID-19, teachers reported depressive mood in 31.5% of the students (41 out of 130 responses) in 2020; 35.0% (63 out of 180 responses) in 2021; 39.7% (69 out of 174 responses) in 2022. The rate of reported depressive signs in 2022 was increased significantly compared to that of 2017 (p=0.003) and 2018 (p=0.023). The rate of reported depressive signs in 2021 was increased significantly compared to that of 2017 (p=0.025) (Figure 3A).

Figure 3.

(A) Percentage of students who was reported by teachers posthumously as showing depressive signs within the 2 months prior to suicide completion. (B) Percentage of students who was reported by teachers posthumously as showing anxiety signs within the 2 months prior to suicide completion. *p<0.05;**p<0.01.

Among the students who committed suicide pre-COVID-19, teachers reported posthumously anxiety signs in 11.2% of the students (12 out of 107 responses) in 2017; 10.3% (13 out of 126 responses) in 2018; and 16.7% (22 of 132 responses) in 2019. Among the students who completed suicide post-COVID-19, teachers posthumously anxiety signs in 18.5% of the students (24 of 130 responses) in 2020, 23.9% (43 of 180 responses) in 2021, and 23.0% (40 of 174 responses) in 2022. The rate of reported anxiety signs in 2022 was increased significantly compared to that of 2017 (p=0.014) and 2018 (p=0.005). The rate of reported depressive signs in 2021 was increased significantly compared to that of 2017 (p=0.008) and2018 (p=0.003) (Figure 3B).

DISCUSSION

The present study revealed that the suicide rate among Korean students increased significantly from 2.37 per 100,000 students pre-COVID-19 to 3.37 per 100,000 students postCOVID-19, with an OR of 1.42. These results encompass all school-age groups, from elementary school to high school. When we analyzed middle school and high school students separately, the increase and ORs were even more pronounced. The suicide rate among middle school students rose from 3.19 per 100,000 pre-COVID-19 to 4.61 per 100,000 postCOVID-19, with an OR of 1.44. For high school students, the rate increased from 5.50 per 100,000 pre-COVID-19 to 8.39 per 100,000 post-COVID-19, resulting in an OR of 1.53. The adverse impact of COVID-19 on adolescent suicide rates is also reflected in Korea’s annual cause of death statistics by age [10]. Furthermore, the annual White paper on suicide prevention published by the Korean Ministry of Health and Welfare and the Korea Foundation for Suicide Prevention reports a steady rise in adolescent suicide rates over the three years since the pandemic, while other age groups exhibit a more fluctuating pattern [11]. Additionally, the percentage of suicides among all causes of death for teenagers significantly increased from 2020 to 2022, highlighting adolescence as the age groups most affected by the rise in suicide rates following the COVID-19 outbreak [10,11].

Although, the COVID-19 pandemic has significantly impacted suicide attempts across all age groups, our results indicate that the increase in suicide rates during this period was more pronounced among teenagers than among children. Middle school students showing an OR of 1.44 and high school students presenting an OR of 1.53. Even pre-COVID-19, it was reported that suicidal thoughts in children and adolescents, which are relatively low before age 10 years, increased linearly by age 15 years and continued to rise, albeit at a slower rate, by age 17 years [12]. We can speculate that the developmental characteristics specific to adolescence may have contributed to the increased vulnerability to suicide among adolescents during the COVID-19 pandemic. A systematic review suggested that the association between puberty and increased self-harm may be linked to neurodevelopmental vulnerabilities that emerge during this period, including a higher risk of emotional disorders and impulsive risk-taking behaviors. Meanwhile, the cortical developments necessary to mitigate these vulnerabilities to self-harm are not yet complete during adolescence [13].

Accordingly, we observed that among the students who completed suicide, teachers reported more signs of depressive and anxious behaviors compared to the pre-COVID-19 period. Research has shown that adolescents who commit suicide often experience emotional and behavioral dysregulation, irritability, and high levels of depression and anxiety, which play a significant role in suicidal behavior [14]. Studies on the COVID-19 pandemic indicate that it had a substantial negative impact on the emotional and behavioral experiences of children and adolescents, leading to increased rates of stress, helplessness, isolation, and changes in routine, as well as higher levels of depression and anxiety [14]. Magson et al. [15] found that depressive symptoms and anxiety rose 2 months after social isolation, highlighting the importance of feeling socially connected for Australian students. A systematic review of 77 studies examining the impact of COVID-19 on the mental health of young people (ages 10–24 years) in Europe identified five main causes of fluctuating mental health post-COVID-19: limitations in quality of life, education and learning, loneliness and social disconnection, changes in emotional lifestyle and behavior, and withdrawal of mental health support [16]. The authors emphasized that these short-term impacts can lead to a chain reaction of adverse psychiatric effects, underscoring the importance of continuous long-term support [16].

The quarantine measures following COVID-19 may have significantly reduced opportunities for adolescents with emotional dysregulation to seek psychiatric care or psychosocial counseling, resulting in higher suicide rates. During the implementation of social distancing measures in the first half of 2020, students were required to stay home instead of attending school, participating in classes via computer. The lack of social connection at school may have led to a decrease in help-seeking behavior among some groups and an exacerbation of overall mental health problems. Moreover, previous research has clearly shown that maintaining healthy social connections is essential for adolescent mental health [17,18]. Therefore, in future events that require extended quarantine or school closures, the need to maintain social contact for mental health monitoring should be a key consideration in the policymaking process for adolescents.

Furthermore, our study shows that attendance rates improved significantly while truancy decreased in 2020 during the initial stages of school closures. With online attendance, it became easier for students to demonstrate good attendance. However, this shift may have inhibited adolescents experiencing mental health crises from exhibiting early signs of distress, which would typically be recognized by adults through poor attendance. Consequently, attendance irregularities in schools may serve as a vital indicator for identifying students facing mental health challenges and prompting therapeutic interventions.

Another possible explanation for the higher suicide rates post-COVID-19 is the disruption of daily routines. Qi et al. [19] found that decreased sleep time, increased homework time, and reduced exercise among Chinese middle and high school students during the epidemic were significantly related to the presence and severity of anxiety. They also reported that students who received adequate sleep and engaged in regular exercise experienced a reduced risk of anxiety. Lee [20] highlighted that school routines serve as an important coping mechanism for students with mental health issues, particularly those with depression. The researcher suggested that school closures disrupt organized life schedules, which can exacerbate depressive symptoms. Additionally, Liu et al. [21] studied 1,594 students aged 9–16 years in China and found that the absence of daily routines strongly predicts psychological maladjustments, including depressive symptoms, parent-child conflict, and peer-related loneliness. In a previous paper, we reviewed research identifying both the direct and indirect effects of COVID-19 on children’s mental health internationally, emphasizing the importance of maintaining a healthy daily life and a sense of belonging within a school community [5].

Surprisingly, the results of our study indicated that the suicide rate decreased for 6 months immediately following the implementation of school closures. Penner et al. [22] investigated minority groups with elevated levels of mental health issues prior to the pandemic and reported a significant reduction in internalization, externalization, inattention, and subtle mental health problems one month after schools closed and video classes began. It can be inferred that students who struggled to cope with the stress of in-person schooling may have experienced fewer problems due to the absence of face-to-face classes, resulting in reduced demands on their energy for learning.

However, the suicide rate, which had initially decreased during school closures, began to rise again in the second half of 2020, reaching its highest point in the first half of 2021. By 2022, the suicide rate was higher compared to the second half of 2021, although it remained lower than in the first half of 2021. Therefore, it can be assumed that the decrease in suicide rates observed during the first 6 months of school closures was likely a short-term effect, providing only temporary relief or masking the underlying issues for students at risk of suicide.

In conclusions, the incidence of completed suicide among students was significantly higher in the post-COVID-19 years compared to pre-COVID-19. According to our study, students with emotional and behavioral dysregulation, which may manifest as disruptions in school attendance, are at a higher risk of suicide. Therefore, these students require close attention and support from school, similar to that provided to those with learning disabilities or trauma.

Finally, students are an age group for whom daily school routines and social relationships are vital. It is crucial to carefully consider the potential impact on their mental health if an epidemic situation necessitating quarantine policies arises again. In future events involving extended quarantines or school closures, a robust mental health monitoring system and targeted policies to maintain social contact and daily routines for young students are essential.

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