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The coronavirus disease 2019 (COVID-19) pandemic has shaken the health systems worldwide, with more than 214 million reported cases and over 4.470.000 deaths until August 2021 [1]. This negative impact has also extended to psychiatry [2]. In this context, severe depression and anxiety symptoms are expected to be the most prevalent psychopathological presentations of accumulated stress connected with global health crisis like the COVID 19 pandemic [3]. Untreated depression and severe anxiety are noticed to be the most prevalent accompanying medical conditions in social, public health crisis which result in a suicide attempt very often [4]. This paper presents a case report where the “trigger” for a suicide attempt was the current situation during the Covid-19 Pandemic. The suicide attempt was a poisoning with Anti-HIV drugs. To our knowledge, this is the first reported case of poisoning with Anti-HIV agents worldwide in the time of Covid 19 pandemics.

Case report

Patient P.D., male, 28 years old, student, worker, homosexually oriented, HIV positive, single, with previously diagnosed general anxiety disorder, with no treatment adherence or follow-up . He was living in a flat alone and his family lived in the countryside. Shortly before the pandemic began, in April 2020, he broke off a long relationship, because his partner found out he was HIV positive. During the first weeks of the pandemic he felt lonely, frightened, anxious, watching television all the time and seeking information about Covid-19, slept short and shallow, lost appetite. In the period of the lockdown, he lost his job at the hairdresser՚s. The last three weeks before the suicide attempt, although curfew was lifted, he was frightened to go out, feeling that something terrible would happen and experienced 3-4 panic attacks every day. Several times the patient tried to seek help at the local health centre, but was unable to make an appointment with his family doctor because, as he was told, his problems were not a priority in the context of the Covid-19 pandemic. Patient felt exhausted, could not sleep or eat any more. Then he decided to attempt suicide as he did not see another way out from this situation and could not take it anymore. He took 30 tablets of his Anti-HIV drug (Aluvia® 100 mg + 25 mg tablets), which he was regularly taking for his HIV infection with a half bottle of water, than he changed his mind and called ambulance for help. Firstly, he was taken care of in the emergency centre for 12 hours. At the admission, the patient was awake, communicative, and crying. Gastro lavage was done. Blood and urine were sampled for laboratory and toxicological analyses. Laboratory findings showed that the patient was dehydrated, with minimal liver lesion (ALT 86 U/L, AST 74 U/L, GGT 43 U/L). Other laboratory findings were in the reference range. Numerous tablet particles were obtained in the gastric contents. Toxicology analyses were negative for PAS, alcohol and medicaments. After detoxification and initial management in the emergency centre, the patient was admitted to a psychiatric clinic. Physically, he was in satisfactory condition but depressive, anxious, crying and calling for help. In the next period, support and cognitive behavioral therapy was administered in combination with antidepressants. After four weeks the patient was dismissed, he went home to live with his family during summer holidays. He had no longer anxiety or panic attacks, became euthymic and distanced himself from suicidal thoughts. In the next six months patient regularly came to psychiatric control examinations, remission persisted and he took psychopharmacs and came to visit psychologist too.

Discussion

The Covid-19 pandemic has a big impact on our lives in every its segment - sociological, psychological, economical, professional, private etc. with various results like anxiety, fear, chronic stress, economic difficulties, unemployment. It is not surprising that this crisis can lead to exacerbation of anxiety, depression, substance use and other psychological or psychiatric disorders. Many cross-culturally studies all over the world have shown an increased prevalence of psychological symptoms and distress, during the Covid-19 situation [5,6]. In Europe, predominantly increased were levels of low mood, anxiety, depressions and fear of economic disruption [7]. A study from Austria, in which, during the period from March to April 2020, in Austria there were nearly 27% study participants registered who reported severe or moderate depression, and around 20% anxiety [8]. On the other hand, a study from the UK reported that during the lockdown a number of psychiatric presentations was lower compared to the number before the pandemic, but patients were more likely with the severe symptoms [9]. A study from Spain in adult general population during the first wave of the pandemic, March-July 2020, has shown prevalence of suicidal ideation of 4.5%, and 9.5% among 34.3% of patients with pre-pandemic diagnosed mental disorder, and nearly 2% among 65.7% patients without pre-pandemic diagnosed disorder. Also, these authors have linked higher risk of suicidal attempt to current mental disorder and lifetime mental disorder. Most frequently registered were severe depression (39.2%) and anxiety (36.3%), but also PTSD, panic attacks and alcohol or substance abuse [10]. Depending on gender, men reported a little bit lower rate of anxiety than women, but they had higher prevalence of depression and suicidal ideation, with symptoms of depression like aggression or abuse of drugs or alcohol [11]. Also, some results have shown that men, as well aswomen, can frequently feel the loneliness or the lack of social support, which are risk factors for depression, anxiety, substance use and suicide [11].
In relation to suicide attempts some authors also associate work or financial status. For example, a study from the UK in the period from May to September 2020 reported that the financial distress in same cases was related to depression and suicidal ideation [12]. On the other side, students showed a higher rate of depression, anxiety and suicide thoughts during the pandemic than non-students. [13]. A imilar study was done in Wuhan, China, 6 months after the pandemic began, and it involved university students who experienced isolation. The highest rate was for the symptoms of depression (41.5%), then for anxiety (32.6%), PTSD (8%) and suicidal ideation (2%). The level of stress, distant relationship with parents and other changes in lifestyle were in a correlation with a (higher) risk for these disorders [14]. This study has shown a higher rate of depression symptoms than another online study, performed one month after the Covid-19 beginning [15]. Suicidal ideation in student population was also related to social isolation or fear of infection [16,17]. Mental disorders diagnosed before pandemic can be associated with new-onset mental disorder during a stress situation or with the suicidal ideation during the pandemic [18,19].
To conclude, one of the leading reasons for the increased number of attempted and committed suicides is the unrecognition and lack of treatment of mental disorders symptoms. In currentpandemic and in the following period, it is necessary for medical staff to look for various, but mainly symptoms of depression and anxiety in patients, that frequently result in a suicide attempt, if unrecognized and untreated. That is the best way to prevent suicide and to improve mental health.
A written consent from the patient was obtained for this information to be published.

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