Document Type : Original Article


1 Department of Emergency Medicine, Sree Gokulam Medical College & Research Foundation, Trivandrum, Kerala, India

2 Department of Internal Medicine, Sree Gokulam Medical College & Research Foundation, Trivandrum, Kerala, India

3 Assistant Professor, Institute of Community Medicine, Madurai Medical College, Tamil Nadu.

4 Assistant Professor, Department of Emergency Medicine Government Medical College, Trivandrum

5 Department of Emergency Medicine, Sree Gokulam Medical College & Research Foundation, Trivandrum, Kerala.India


Background: Emergency physicians must be updated about the variations in poisoning pattern during Covid19 pandemic. Limited data exist on the incidence and characteristics of patients presenting with poisoning in Indian Emergency Departments (ED) during the COVID 19 pandemic. Hence, we aimed to explore the impact of Covid19 pandemic on poisoning cases presenting to the ED.
Methods: This cross-sectional retrospective study was conducted on poisoning patients presenting to ED during the pandemic period (April 1-October 30, 2020 (period 2)), and a matching period before the pandemic (September 1,2019 to March 31, 2020 (period 1)). The rate of prevalence and clinical profile were compared between period 1 and 2 using appropriate statistical test.
Results: A total of 111 (periods 1 = 57, and periods 2 = 54) cases were analysed. Poisoning prevalence rates had slightly increased by 2.7% before the pandemic (51.33%) in comparison to during the pandemic (48.6%) period (p=0.3). Females were predominant in both periods, and the mean age of 32.5 years. The predominant (57%) patient age group was 15-34 years. 36.9% (n=41) patients consumed multiple poisons, 19.8% (n=22) consumed paracetamol, and 14.4% (n=16) patients consumed psychiatric medications. Before lockdown, 27.02% (n=30) patients presented within 3 hours ingestion, and 21.6% (n=24) presented after 3 hours ingestion (p=0.12). A significant delay in arrival of poisoning cases during lockdown (p= 0.12) with increased hospital admission (p=0.03) was observed.  A psychiatric disorder was observed in 36.03% cases. Majority of the cases were admitted in the ICU, and 0.9%(n=1) death was recorded.
Conclusions: This is the first Indian study that describes the incidence of poisoning cases and their pattern during the COVID 19pandemic period, study revealed that increased mental health crisis in low resource settings in rural Kerala affects predominantly young population. Study implies the importance of priming the mental health care professionals to initiate their mental health screening programmes.



Today, toxicology has grown widely to include Occupational Toxicology, Adverse Effects of Drug Overdose, Environmental Toxicology, Medical and Analytical Toxicology, Forensic Toxicology, and Toxicological Research in its domains. In 1992, the American Board of Medical Studies (ABMS) identified the Medical Toxicology as a separate entity.1 Suicide and the self-harm were preventable with timely and low-cost interventions.2,3 Poisoning is one of the common cause to visit the ED.4-8 Wide availability, easy access, and extensive use in medical, industrial, household, and agricultural applications increase the risk, exposure, and incidence of poisoning. Mortality and morbidity due to pesticide poisoning in farmers continue to be a significant problem in India. In India, after hanging (45.6%), poisoning (27.9%) is the second most common means of suicide, which increased by 2% from 2014 (26%). The number of fatalities due to poisoning increased by 18.5% in 2015 (28,445 deaths) in comparison to 2014 (23,162 deaths). In India, the fourth fundamental reason for death is poisoning.10,11,12 

Although the burden of poisoning is acknowledged internationally, little recent data exist on the incidence and characteristics of patients presenting with poisoning in Indian Emergency Departments. A few studies focus on the epidemiological aspects of poisoning. Still, none of them included the patients' clinical profile, which is crucial for designing critical care units dedicated to the care of such patients.

The nationwide lock-down announced on March 24, 2020, by the Indian government in response to pandemic of COVID-19 has had tremendous impact on the health and well-being of the public, apart from the morbidity and mortality of COVID 19 infection. Recent literature during this pandemic revealed high levels of stress, anxiety, and depression in population.12,13 Few reports on COVID-19 related to suicide have been published.14-20 As poisoning is directly related to the public's mental health21-23 and well-being, we anticipated a change in the incidence pattern of poisoning patients presenting to ED  due to COVID 19 induced nationwide lock-down. It would also be interesting to ascertain whether there were any changes in the toxic agents consumed and the severity of clinical symptomatology of such patients who presented in the two time frames of our study. Hence we planned to conduct a retrospective study on poisoning patients coming to the Emergency Department of our institute to analyse the incidence pattern and clinical profile of patients presenting in the ED before and during the pandemic and to identify any significant change in the patterns of the same due to the nationwide lock-down.


Study design and setting

This retrospective, comparative cross-sectional study performed on acutely intoxicated patients presenting to the ED during pandemic period (April 1-October 30, 2020 (period 2)), matching period in the previous year (September 1 2019, March 31 2020 (period 1)). This was conducted at Sree Gokulam Medical College and Research Foundation, Kerala, India.

Inclusion/exclusion criteria

All patients, irrespective of age and sex, registered in the ED with complaints of consumption of poison like medicines, alcohol, and chemical used in households, agriculture, and industries were included in the study. Patient charts with incomplete data, patients diagnosed with food poisoning, pregnant women, patients with snake bites, scorpion stings, or other insect bites were excluded from the study.

Data Collection

Data collection initiated after getting approval from Ethical Committee (IEC) of SGMC & RF number (SGMC IEC/44/570/04/2021/F) dated 19/04/2021. The design and protocol of this observational retrospective study was approved. A semi-structured questionnaire was formatted, including demographics, comorbid illnesses; symptomatology; Type of poisons consumed, and clinical presentation of the patients. The semi-structured questionnaire was pre-tested with details of poisoning patients treated at the hospital. The nature of the toxic substance was identified by the patient's diagnosis report or patient’s relatives.

Statistical Analysis

Variables studied were collected from EMR, such as time to presentation ED, previous co-morbidities, history of psychiatric illness, symptoms, vital signs, clinical investigations, treatment management, etc. These data was expressed as mean, standard deviation, and percentage.  Statistics was done using Statistical Package for the Social Sciences Software Package version 17 (SPSS; IBM Corp., New York, USA). Chi-square test, post hoc test, and the Spearman correlation coefficient were analysed to identify the significance between two periods. P-value less than 0.05 considered as statistical significant.


Over fourteen months, we evaluated 111 poisoning patients who attended the emergency department. Out of these, 49 (44%) were male, and 62 (56%) were females. The majority belong to 15-24 years age (n=37, 33.3%), followed by 25-30 years in 20 cases, 35-44 years in 16 patients, 45 years in 21 patients, respectively. The mean age was 32.5 ± 26.5 years (CI: 95%, 3.5-48.5). The majority of the patients (86.4%) were from Trivandrum. We defined two time frames to record events related to poison ingestion and arrival to the ED. The first one was from (8:00 to 20: 00) while the second was from 20: 01 to 7: 59. Most of them (n= 84, 75.6%) had ingested the poison during the first time frame, while only 68 (61.2%) had presented to the ED in the first time frame (8 AM–8 PM). Remaining 43 (38.73%) had presented to the ED between 8:01PM–7:59AM.

In total, 68 patients presented between 8 am and 8 pm. About 57% patients presented within three hours of consumption of poison (Table 1). 51.5% of patients presented before lock-down at the ED. A substantial proportion of the patients (n=64, 57.6%) presented to ED within 3 hours of poison ingestion. Twenty-four patients (21.62%) had reached between 3-6 hours, and another 23 patients (20.72%) arrived after 6 hours of toxin ingestion. Fifty-seven patients who comprised 0.22% of the total ED census presented in the time frame before lock-down, while 54 patients who comprised 0.44 % of the total ED census presented during the lock-down. Forty-four patients had consumed multiple drugs, while paracetamol (n= 22, 19.8%) was the most common single poisoning  agent in our study (Figure 1). With respect to co-morbidities, 40 (36%) patients had psychiatric disorders, and 17(15.31%) patients were hypertensives. 8.18%(n=9) cases were Diabetes Mellitus, and coronary artery disease in 1.8%(n=2) cases. Notably, 10.8% of the patients had coexistent thyroid dysfunction. The detailed profile of toxicological agent consumed.

Clinical profile

Forty-one patients presented with tachycardia, which was the most common vital sign abnormality observed in the study population.  While 4.5%(n=5) patients presented with bradycardia, 9.9%(n=11) patients had elevated Systolic BP, and 4.5%(n=5) patients had presented in shock, which shows the mean arterial pressure below of 65 mm of Hg. 14.4%(n=16) patients had respiratory distress, while 5.4%(n=6) of them had presented with oxygen saturation below 94% on presentation. The drugs which cause Tachycardia and Bradycardia were described in Figure 2. The predominant symptom of ED presentation was nausea and vomiting 29.7% (n= 33), followed by generalised tiredness 27.9% (n= 31). 5.4 % (n=6) patients had presented with Low GCS requiring endotracheal intubation, while 2.7% (n=3) patients presented with seizures (Table 2).

Outcome data -Disposition

ED disposition categorized into admission, left against medical advice (LAMA), discharge, and mortality. 65.7 %(n=73) were admitted to ICU, 33.33%(n=37) were discharged against medical advice (DAMA). Death occurred to 0.9% (n=1) of the patients. It was a patient with rat poison ingestion who presented after 12 hours of ingestion in severe metabolic acidosis, was intubated, and planned for admission while he suffered sudden cardiac arrest.

The majority of the patients, 53% (n=59), were disposed from the ED within 2 hours, while only 3.6% of patients had to wait for more than 4 hours for disposition from ED.

Among all the patients with poisoning, 41 patients consumed multiple poisons. Twenty-two patients consumed paracetamol, while 16 patients consumed psychiatric medications (Table 3) (Figure 1).

Before lock-down, 25 belonged to the less than 24 years age group, while during lock-down, 29 belonged to the same age group(p =0.3). Before lock-down, 33 were females, while during lock-down, 29 were females (p =0.67). Before lock-down, 30 patients presented within 3 hours, while during lock-down, 34 presented within 3 hours (p =0.12). Among all patients, 40 patients had psychiatric disorders, and 12 patients had thyroid disorders.

Lockdown impact

We observed that among the patients aged below 24 years, there was an increase in incidence of poisoning during lock-down. The male: female ratio increased from 0.76 to 0.86 during lock-down. The predominant patient age group of 15-34 years were observed as 57%. There was no significant difference seen between the both periods regarding age (p=0.3)(Table 3).

Poisoning rate had slightly increased by 2.7% before pandemic (51.33%) in comparison to during pandemic (48.6%) period without significant difference (p=0.3).

Females were predominant in all two periods. Predominantly 26.12% (n=29) females admitted during pandemic than males 22.5% (n=25). But there was no significant difference observed between gender between the two periods (p=0.6626).

During the pandemic, 27.02% (n=30) of patients presented within 3 hours of ingestion, and 21.6 %(n=24) presented after the 3 hours of ingestion. There was significant delay recorded in the arrival of patients to ED during lock-down period (p=0.12) with increased hospital admission(p = 0.03). In total, before the pandemic, 59.6% of the patients could reach ED within 3 hours of ingestion, but during the pandemic, 55.5% of the patients could reach ED within 3 hours of ingestion.

Predominantly 36.9% (n=41) patients consumed multiple poisons, followed by 19.8% (n=22) consumed paracetamol, and 14.4%(n=16) patients consumed psychiatric medications.


This study aimed to explore the COVID-19 pandemic on the pattern of hospital admissions due to poisoning. Majority of the cases arrived from rural areas. A total of 111 patients were registered in the ED with a history of poisoning in this study, which accounted for 0.44% and 0.27% of the annual ED visits during the pandemic and before the pandemic, respectively. This poisoning rate is similar to Western countries' data ranging from 0.26% to 0.7%.24,25 This high incidence of poisoning can be credited to the easy availability of poisons in India. The prevailing dogma is that mortality due to poisoning is associated with significantly less suffering than other means of self-harm.

In our study, the poisoning prevalence rate had slightly reduced by 2.7% during the pandemic (48.6%) period when compared to before pandemic (51.33%) (p=0.3). The reduction of rural admissions during the pandemic is best explained by the quarantine measures those restricted the transport facility from remote residents.26 Neumann et al. showed decreased admissions of poisoned cases during lock-down, but they predicted that pandemic progression results in higher suicidal rates due to depression.27

In our study, high female preponderance was observed; similar observations were found in other studies. This pattern can be attributed to increasing challenges, family burden, stress, and females are higher prone to risk than males.28

The majority (54%) of the poisoning cases were less than 25 years, which is comparable to other studies.4,29The high number of poisoning patients below 25 years of age can be attributed to increased peer pressure, stress, competitiveness, and heavy expectations from family or loved ones. The significant number of accidental poisoning among children (below 5years) can be attributed to chemicals/poisons stored in easily accessible places and lack of awareness among parents, resulting in an increase in accidental poisoning.30 In our study, the decrease in paediatric cases during the lock-down was recorded than compared to before the pandemic, which is similar to Italy and Egypt studies.31,32  The current study report regarding gender proportion was verified by study in Egypt.32

The popular time for ingestion of poison was the daytime (8 am to 8 pm) in 68 cases (61.26%), comparable to other studies.33-35 This can be attributable to stress at working hours, school, agriculture, and home, making the victim more helpless to consume poison out of impulsivity.  The prevalence rate of toxicity during the pandemic was 48.6% compared to before the pandemic period (p=0.3).

Among the poisons consumed, multiple drugs were consumed by a maximum number of patients, 36.93%(n=41), followed by paracetamol in 22 cases, psychiatric drugs in 16 cases, Benzodiazepine tablet overdose in 15 cases, etc. The prevalence of psychiatric disorders in this study population was 36.03%, comparable to findings in other studies.9,36 The current study showed that multiple drugs were the commonly reported toxicant during and before the pandemic.  Studies conducted in Egypt shows that phosphide was the common encountered toxic agent in cases admitted to ED.32  Acetaminophen exposure was the common toxic agent seen in Malaysia study (35.0%), and pesticides constituted 6.6%.37 This pattern noted in study of United Kingdom38 and Saudi Arabia.39 Studies in the US Turkey and Oman reported that analgesics are the most cause of poisioning.40 

In our study, 16 cases were intoxicated with antipsychotic drugs; the prevalence of antipsychotic toxicants during the pandemic was comparable  with other studies.32,41,42 Studies from countries such as Pakistan43, China44, India17, and Bangladesh45, have raised the concerns regarding the increased suicide rate due to COVID-19.

The majority of the patients in this study were hospitalized for further treatment. A higher number of patients (65.7%) were admitted to the ICU, while 33.33% were discharged against medical advice from the ED, and just 0.9%(n=1) patients died, which is comparable to other studies. Moreover, a bulk of the patients in this study completely recovered and were discharged after complete treatment. One patient who died in this study was admitted to the ICU with the consumption of rat poison.

Our study reported more delays in admission to the hospital during the pandemic, similar to Egypt and Nepal studies.32,46 The late admission during the pandemic could be due to difficult access to transport facilities. Our study suggested that delayed presentations of patients more than three hours after ingestion to the ED during the pandemic may have delayed initiating resuscitative measures, which could be the possible factor that increased hospitalization during the pandemic.

There are some limitations in this study such as it is a single-center study, these results cannot be generalized, and they do not reflect the whole country's situation. The socioeconomic status of the patients was not recorded. As many patients consumed multiple agents, the clinical profile of the patients could not be attributed to the respective poisons.


A change in the incidence pattern was observed due to the COVID Pandemic, but the change was not statistically significant. COVID-19 pandemic reformed the usual intoxication pattern of the cases presenting to ED with higher multiple drugs and antipsychotic toxicity. Before lock-down, 30 patients presented within 3 hours, while during lock-down, 34 presented within 3 hours (p =0.12). The lock-down status was delaying hospital arrival time, which was reflected in a more extended hospital stay. Our study recommends restricting drug availability, educating regarding the pesticides, and starting psychiatric consultations, which help to reduce the suicide attempts. We also recommend that concerned authorities make online stress relaxation programs freely accessible to the public so that the mental health crisis triggered by the lock-down measures can be eased.


Authors acknowledge to ED and supporting staff.

Conflict of interest: None to be declared

Funding and support: None

  1. Liebelt EL. The specialty of medical toxicology: beyond poisonous arrows and activated charcoal. Clin. Pharmacol. Ther. 2010;88(3):298-301.
  2. Watson WA, Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Youniss J, Reid N, Rouse WG, Rembert RS, Borys D. 2003 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2004 Sep;22(5):335-404.
  3. Akkose S, Fedakar R, Bulut M, Armagan E, Cebicci H. Acute poisoning in adults in the years 1996–2001 treated in the Uludag University Hospital, Marmara Region, Turkey. Clin Toxicol 2005;43(2):105-109.
  4. Hanssens Y, Deleu D, Taqi A. Etiologic and demographic characteristics of poisoning: a prospective hospital-based study in Oman. J Toxicol Clin Toxicol. 2001;39(4):371-80.
  5. Goksu S, Yildirim C, Kocoglu H, Tutak A, Oner U. Characteristics of acute adult poisoning in Gaziantep, Turkey. J Toxicol Clin Toxicol. 2002;40(7):833-7. 
  6. Lamireau T, Llanas B, Kennedy A, Fayon M, Penouil F, Favarell-Garrigues JC, Demarquez et al JL. Epidemiology of poisoning in children: a 7-year survey in a paediatric emergency care unit. Eur J Emerg Med. 2002;9(1):9-14. 
  7. Tüfekçi IB, Curgunlu A, Sirin F. Characteristics of acute adult poisoning cases admitted to a university hospital in Istanbul. Hum Exp Toxicol. 2004;23(7):347-51.
  8. Fernando R. The National Poisons Information Centre in Sri Lanka: the first ten years. J Toxicol Clin Toxicol. 2002;40(5):551-5. 
  9. Quah LJ, Tan BK, Fua TP, Wee CP, Lim CS, Nadarajan G, et al. Reorganising the emergency department to manage the COVID-19 outbreak. Int J Emerg Med 13, 32 (2020).
  10. Kondle Raghu PS, Kumar SS, Gopal S, Shaik MV, Ahammed B. Incidence and Outcome of Poisoning Patients in a Tertiary Care Teaching Hospital. Asian J pharmacol Toxicol 2015;3(7):23.
  11. National Crime Records Bureau. Accidental death and suicides in India 2015. National Crime Records Bureau 2016:192-206.
  12. Unnikrishnan B, Singh B, Rajeev A. Trends of acute poisoning in South Karnataka. Kathmandu Univ Med J (KUMJ). 2005;3(2):149-54. 
  13. Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health. 2020; 16(1):57
  14. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health. 2020; 17(5):1729
  15. Lim LJH, Fong LM, Hariram J, Lee YW, Tor P-C. COVID-19, a pandemic that affects more than just physical health: Two case reports. Asian J Psychiatr. 2020; 53:102200
  16. Bhuiyan AKMI, Sakib N, Pakpour AH, Griffiths MD, Mamun MA. COVID-19-Related Suicides in Bangladesh Due to Lockdown and Economic Factors: Case Study Evidence from Media Reports. Int J Ment Health Addict. 2020:1–6.
  17. Sahoo S, Rani S, Parveen S, Pal Singh A, Mehra A, Chakrabarti S, et al. Self-harm and COVID-19 Pandemic: An emerging concern—A report of 2 cases from India. Asian J Psychiatr. 2020; 51:102104
  18. Simpson SA, Loh RM, Cabrera M, Cahn M, Gross A, Hadley A, et al. The Impact of the COVID-19 Pandemic on Psychiatric Emergency Service Volume and Hospital Admissions. Journal of the Academy of Consultation-liaison Psychiatry. 2021 May 28.
  19. Butler M, Delvi A, Mujic F, Broad S, Pauli L, Pollak TA, et al. Reduced Activity in an Inpatient Liaison Psychiatry Service During the First Wave of the COVID-19 Pandemic: Comparison With 2019 Data and Characterization of the SARS-CoV-2 Positive Cohort. Front Psychiatry. 2021;12:54.
  20. Andrew E, Nehme Z, Stephenson M, Walker T, Smith K. The impact of the COVID-19 pandemic on demand for emergency ambulances in Victoria, Australia. Prehosp Emerg Care. 2021:1-8.
  21. McDowell MJ, Fry CE, Nisavic M, Grossman M, Masaki C, Sorg E, et al. Evaluating the association between COVID-19 and psychiatric presentations, suicidal ideation in an emergency department. Plos one. 2021;16(6):e0253805.
  22. Striley CW, Hoeflich CC. Converging public health crises: substance use during the coronavirus disease 2019 pandemic. Curr Opin Psychiatry. 2021;34(4):325.
  23. Sampson EL, Wright J, Dove J, Mukadam N. Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study. Eur Psychiatr. 2021 Jun 4.
  24. McCaig LF, Burt CW. Poisoning-related visits to emergency departments in the United States, 1993-1996. J Toxicol Clin Toxicol. 1999;37(7):817-26. 
  25. Bajracharya MR, Deo KMK, Pahari SK. Age and gender distribution in deliberate self-poisoning cases. Post-Graduate Medical Journal of NAMS 2008 June 1;8(01
  26. Saddique A. Poisoning in Saudi Arabia: ten-year experience in King Khaled University Hospital. Ann Saudi Med. 2001;21(1-2):88–91
  27. Neumann NR, Chai PR, Wood DM, Greller HA, Mycyk MB. Medical toxicology and COVID-19: our role in a pandemic. J Med Toxicol. 2020:16 (3):245–247
  28. Paudyal BP. Poisoning : Pattern and profile of admitted cases in a hospital in Central Nepal. JNMA J Nepal Med Assoc. 2005;44(159):92-6. 
  29. Gloglu C, Kara IH. Acute poisoning cases admitted to a university hospital emergency department in Diyarbakir, Turkey. Hum Exp Toxicol 2005;24(2):49-54.
  30. Kanchan T, Menezes RG. Mortalities among children and adolescents in Manipal, Southern India. J Trauma. 2008;64(6):1600-7.
  31. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health. 2020;4 (5): e10–e11.
  32. Fayed MM, Sharif AF. Impact of lock-down due to COVID-19 on the modalities of intoxicated patients presenting to the emergency room. Prehosp Disaster Med. 2021;36(2):145-62.
  33. Kanchan T, Menezes RG, Kumar TM, Bakkannavar SM, Bukelo MJ, Sharma PS, et al. Toxicoepidemiology of fatal poisonings in Southern India. J Forensic Leg Med  2010;17(6):344-347.
  34. Sinha US, Kapoor AK, Agnihotri AK, Srivastava PC. A profile of poisoning cases admitted in SRN Hospital, Allahabad with special reference to aluminium phosphide poisoning. J Forensic Med Toxicol. 1999;16(1):43-42.
  35. Senanayake N, Peiris H. Mortality due to poisoning in a developing agricultural country: trends over 20 years. Hum Exp Toxicol. 1995;14(10):808-11
  36. Ramesha KN, Rao KB, Kumar GS. Pattern and outcome of acute poisoning cases in a tertiary care hospital in Karnataka, India. Indian J Crit Care Med. 2009;13(3):152-5.
  37.  Fathelrahman AI, Zain ZM. Self-poisoning by drugs and chemicals: variations in demographics, associated factors and final outcomes. Gen Hosp Psychiatry. 2008;30 (5):467–470.
  38. Prescott K, Stratton R, Freyer A, Hall I, Le Jeune I. Detailed analyses of self-poisoning episodes presenting to a large regional teaching hospital in the UK. Br J Clin Pharmacol. 2009;68 (2):260–268
  39. Al-Barraq A, Farahat F. Pattern and determinants of poisoning in a teaching hospital in Riyadh, Saudi Arabia. Saudi Pharm J. 2011;19 (1):57–63
  40. Taft C, Paul H, Consunji R, Miller T. Childhood Unintentional Injury Worldwide: Meeting the Challenge. Washington, DC USA: SAFE KIDS Worldwide; 2002.
  41. Caballero-Domínguez CC, Jiménez-Villamizar MP, Campo-Arias A. Suicide risk during the lockdown due to coronavirus disease (COVID-19) in Colombia. Death studies. 2020 Jun 25:1-6.
  42. Thakur V, Jain A. A global psychological pandemic. Brain Behav Immun. 2020; 88:952–953
  43. Mamun MA, Ullah I. COVID-19 suicides in Pakistan, dying off not COVID-19 fear but poverty?-The forthcoming economic challenges for a developing country. Brain Behav Immun. 2020; 87:163–166.
  44. Lim LJH, Fong LM, Hariram J, Lee YW, Tor P-C. COVID-19, a pandemic that affects more than just physical health: Two case reports. Asian J Psychiatr. 2020; 53:102200
  45. Bhuiyan AKMI, Sakib N, Pakpour AH, Griffiths MD, Mamun MA. COVID-19-Related Suicides in Bangladesh Due to Lockdown and Economic Factors: Case Study Evidence from Media Reports. Int J Ment Health Addict. 2020 15:1–6
  46. Shrestha R, Siwakoti S, Singh S, Shrestha AP. Impact of the COVID-19 pandemic on suicide and self-harm among patients presenting to the emergency department of a teaching hospital in Nepal. PLoS one. 2021;16(4):e0250706.