Danilo Bastos Bispo Ferreira1*
Renata Maria Silva Santos2
Maria Carolina Lobato Machado2
Victhor Hugo Martins Rezende2Patrícia Gazire de Marco1
Marco Aurélio Romano-Silva2
Débora Marques de Miranda1- 1Department of Pediatrics, Federal University of Minas Gerais, Belo Horizonte, Brazil
- 2Department of Psychiatry, Federal University of Minas Gerais, Belo Horizonte, Brazil
Introduction: Adolescent mental health, self-harm, and suicidality are critical concerns during this developmental stage, marked by intense physical, emotional, and social changes. The COVID - 19 pandemic has further intensified these vulnerabilities by disrupting daily routines, increasing social isolation, limiting access to mental health services, and exacerbating academic and emotional stressors.
Methods: This systematic review followed the PRISMA 2020 guidelines and employed the PECO strategy to identify relevant studies. A total of 55 quantitative studies published between 2010 and 2024 were included. These studies examined the prevalence and risk factors of self-harm and suicidal behaviors among adolescents aged 10 to 19 years, comparing findings from the pre-pandemic and pandemic periods. Psychosocial, economic, and cultural determinants were also evaluated.
Results: The analysis revealed a consistent increase in self-harm and suicidality during the pandemic, with adolescent girls being disproportionately affected. Gender disparities were observed across diverse cultural contexts. Contributing factors included social isolation, excessive screen time, reduced access to education and healthcare, and increased family or financial stress. Cultural variability shaped both prevalence and clinical expression.
Discussion: These findings underscore the amplifying effect of the COVID - 19 pandemic on adolescent mental health vulnerabilities and highlight the need for culturally sensitive, gender-informed preventive strategies. Public policies should prioritize mental health support for youth and address systemic inequities to mitigate the psychological consequences of global crises. This review offers important insights into adolescent mental health in times of collective adversity.
Clinical trial registration: PROSPERO https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024538641, identifier CRD42024538641.
1 Introduction
Adolescence is a crucial transition period between childhood and adulthood, characterized by significant changes in physical, emotional, and social development. The World Health Organization (WHO) defines adolescence as the stage of life that spans from ages 10 to 19, a critical period during which profound biological and psychological transformations occur, alongside the emergence of new vulnerabilities, particularly related to mental health (1). Adolescents have an increased risk of self-harm and suicidal behaviors, especially in contexts of social and economic crises, such as the COVID - 19 pandemic (2).
The COVID - 19 pandemic brought a series of negative impacts on adolescent mental health, exacerbating pre-existing conditions and generating new psychological challenges (3). The prolonged closure of schools, social isolation, disruption of daily activities, and increased use of electronic devices contributed to the worsening of conditions such as depression, anxiety, self-harm, and suicidality (4, 5). Previous studies had already identified a growing trend of self-harm and suicidal behavior especially among girls before the pandemic; however, the pandemic period intensified these patterns (6, 7). Factors such as loneliness, bullying, family conflicts, and economic difficulties emerged as significant risk factors during the pandemic related to the increase in adolescents’ vulnerability to mental health crises. Gender disparities and cultural variations modulates the expression of suicide-related behaviors, suggesting that effective interventions must be sensitive to the specific needs of different population groups (8, 9).
In Latin America, estimates from the Global Burden of Disease 2019 show that while the absolute number of suicide deaths rose in most countries between 1990 and 2019, age-standardized rates varied substantially across settings; suicide burden is consistently higher among males, peaks in youth/early adulthood, and often tracks with sociodemographic development, underscoring heterogeneous risk profiles across the region (10).
This systematic review aims to explore the prevalence and the risk features of self-harm and suicidal behaviors among adolescents in the period before and during the COVID - 19 pandemic, as a particular stressful and uncertain timing with disorganized coping strategies, comparing the changes in these two contexts. Contributing to the understanding of the complex interactions between psychosocial, economic, and cultural factors that influence adolescent mental health, this article looks to provide insights into the formulation of public policies and interventions that can mitigate the effects of this global crisis on youth.
2 Method
A systematic review was conducted to address the following research question: {it}”Was there a change in the prevalence and risk factors of suicidality and self-harm among adolescents before and after the onset of the COVID - 19 pandemic up to the present day?”{/it} The review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol (11) and was registered in PROSPERO under the ID CRD42024538641. To define the search strategy, preliminary searches were independently conducted by two reviewers in the databases, following the PECO strategy, as detailed in Table 1.
Table 1. Description of PECO strategy elements.
Considering the WHO concept of adolescence, individuals aged between 10-19 years were considered as adolescents for inclusion. The official search was conducted on 07/05/2024, combining the descriptors “adolescents”, “suicidality”, “self-harm”, and “prevalence”. For the post-pandemic search, the descriptor “COVID-19” was added. The descriptors were combined using the AND operator in the following databases: PubMed, PsycNet, Embase, and Scopus. To ensure a sensitive search, the following eligibility criteria were employed: quantitative studies in community samples with populations aged 10 to 19 years (adolescents), published in English between 2010 and 2024. The time frame was established to encompass the period of technological expansion with increased adolescent engagement with the internet, allowing comparison with the COVID - 19 pandemic period, aiming to assess the magnitude of these two events concerning the study outcomes. The search syntaxes for each database are available in the Supplementary Material of this article.
Only peer-reviewed articles were included, and grey literature was excluded. Qualitative studies, reviews of any type, case reports, case series, and studies conducted in clinical samples were also excluded. To ensure greater specificity, the researchers excluded studies that did not address the associations between prevalence and risk factors for suicidality and self-harm. Titles and abstracts were first screened independently and in a blinded manner; potentially eligible records then underwent independent full-text assessment, with disagreements resolved by consensus or a third reviewer. For the factor’s synthesis, a deductive–inductive codebook guided categorization; a study contributed to a category only when the factor was analytically examined and reported as associated with suicidality/self-harm; descriptive mentions were not counted. The selection procedures were performed by at least two researchers, independently and in a blinded manner, using the AI platform Rayyan (12). The consensus was reached by a discussion between the three authors D, MC and RM on which articles would remain in the review.
2.1 Data extraction
A standardized data extraction table was created to extract the information: reference and study type, country of publication, sample characteristics, study objectives, prevalence of self-harm and suicidality, main associations with risk factors, and the Evidence Quality Score of each article included in the review. The studies were listed in the table in alphabetical order. To define the magnitude of the associations found, Cohen’s d test was extracted from the articles, which reflects the statistical power analysis for behavioral sciences (13). If this test was not used, others such as Odds Ratio (OR) and regression tests, which could correspondingly provide the magnitude of the association, would be extracted from the studies, and effect sizes were defined according to the values presented. An OR of 1.44 corresponds to a small effect size, 2.47 to a medium effect size, and a large effect size begins at 4.25. For regression tests, 0.10 corresponds to a small effect size, 0.30 to a medium effect size, and a large effect size starts at 0.50 (14).
Although effect size measures (e.g., Cohen’s d, odds ratios, and regression coefficients) were extracted when available to enhance interpretative value, a meta-analysis was not feasible due to substantial heterogeneity among the included studies. Variability in study design (e.g., cross-sectional versus longitudinal), outcome definitions (such as suicidal ideation, non-suicidal self-injury, or suicide attempts), population characteristics, and measurement tools hindered statistical comparability. Therefore, a rigorous narrative synthesis was conducted, in line with PRISMA 2020 recommendations for systematic reviews without meta-analyses.
2.2 Quality assessment
The quality of the studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tool. This checklist-based instrument was chosen due to its rigorous evaluation criteria for the included studies and its recommendation in the literature for use in analytical cross-sectional and cohort observational studies that seek to collect data on risk or causality (15, 16). The tool evaluates the detailed description of the sample to ensure compatibility with the population of interest. The study should clearly describe the exposure measurement method and clarify any potential confounding factors that may influence the interpretation of the results. Additionally, measurements should be conducted using validated instruments, and the statistical method used should be the most appropriate (16).
The available guidelines for applying the JBI tool do not specify a cutoff point for determining whether a study is of “High”, “Moderate”, or “Low” quality. Given the nature of the review and the inclusion of studies, mostly with a cross-sectional design, the team placed greater emphasis on criteria assessing risks of selection bias, measurement bias, and confounding bias, specifically questions 1, 3, 4, 5, 6, and 7. For cohort studies, greater weight was given to questions 1, 3, 4, 5, 6, 7, 8, and 9. Using this strategy, the overall methodological quality of each study was classified as “High”, “Moderate”, or “Low” based on the percentage of “Yes” responses considering these “key” items.
Studies classified as “High” quality must have 100% positive responses (“Yes”) to these key items. If they received one or two uncertain or negative responses (“Uncertain” or “No”, respectively), the methodological quality of the study was rated as “Moderate”. If there were more than two uncertain or negative responses (“Uncertain” or “No”, respectively), the study’s methodological quality was rated as “Low” (17). The evaluation was conducted in pairs, and discrepancies were resolved through consensus with a third reviewer.
3 Results
The search yielded a total of 8,433 articles, of which 2,319 were duplicates, leaving 6,114 articles for title and abstract screening. At this stage, 5,935 articles were excluded for not meeting the pre-established inclusion criteria. Therefore, 179 articles were read in full, and 55 were included in this study, considering the inclusion of full-text articles retrieved. Figure 1 - PRISMA flow study diagram (18), illustrates the selection process.
Figure 1. PRISMA flowchart.
3.1 Study characteristics
A total of 55 articles on suicidal behavior published between 2010 and 2024 were included in this study. Of these, 45 were cross-sectional (27 from the pre-pandemic period and 18 from the post-pandemic period), and 10 were longitudinal (3 from the pre-pandemic period and 7 from the post-pandemic period). Among the 30 articles analyzing self-harm and suicidal ideation during the pre-pandemic period, only 1 addressed both topics comprehensively. The remaining studies focused on a single dimension: 4 exclusively on non-suicidal self-injury (NSSI) and 25 solely on suicidality. In contrast, of the 25 articles exploring the post-pandemic period, 3 examined both topics, while 7 focused on NSSI and 15 on suicidality.
The 55 studies included a total of 2,109,801 participants. Among the 30 studies covering the pre-pandemic period, 12 did not report mean ages (40% of the sample). In the 25 studies from the after-pandemic group, 7 did not provide this information (28% of the sample). The mean age was 15.08 years with a standard deviation of 1.23 for the articles allocated to the pre-pandemic group, and a mean age of 15.08 years with a standard deviation of 1.47 for the post-pandemic group, resulting in an overall mean age of 15.08 years with a standard deviation of 1.34. The age range was 5-22 years. The predominant gender was female. The geographical distribution of the studies is illustrated in Figure 2, and the characteristics of the pre- and post-pandemic studies are detailed in Tables 2, 3.
Figure 2. Map showing suicidality and self-harm study distribution by country, highlighting research focus on suicidality.
Table 2. Descriptive characteristics of included studies (Pre-Pandemic).
Table 3. Descriptive characteristics of included studies (Post-Pandemic).
3.2 Prevalence profile of suicidality and non-suicidal self-injury over the past 14 years
Despite the shorter and more variable durations of post-pandemic study periods, a significant shift in self-harm prevalence was observed, particularly in NSSI. During the pre-pandemic period, spanning nine years (2010-2019 based on study time frames), data revealed that 45,233 adolescents attempted suicide, 5,025/yearly, representing 5.14% of the investigated population, while 4,411 adolescents engaged in NSSI, 490/yearly, accounting for 0.5%.
In contrast, the post-pandemic period (2020-2024 spanning 4 years), characterized by shorter and more heterogeneous study intervals, included datasets with varying temporal coverage. Aggregated data for the post-pandemic period revealed a significant reduction in suicide attempts, with 9,436 adolescents attempting suicide (0.76% of the population), 2,359/yearly. Conversely, NSSI prevalence surged, involving 29,970 adolescents, 7,492/yearly or 2.43% of the population.
To account for differences in study durations, the average annual prevalences were calculated. For suicide attempts, the pre-pandemic average was 0.57%, decreasing to 0.19% post-pandemic, representing a 66.67% reduction. Conversely, NSSI showed a significant increase, with the pre-pandemic average of 0.056% rising to 0.61% post-pandemic, corresponding to a 992.86% increase. These findings highlight a pronounced escalation in NSSI behaviors among adolescents during the post-pandemic period, despite the marked reduction in suicide attempts. Although the focus on suicidality has dominated the scientific agenda, recent findings underscore a significant and genuine rise in self-injury rates post-pandemic, reflecting the amplification of risk factors exacerbated by the pandemic context.
3.2.1 Risk and protective factors across contexts
The main factors associated with self-harm and suicidality were identified through thematic frequency across the 55 included studies. Lack of family and social support was reported in 30 studies, physical and psychological health problems in 21, bullying involvement in 9, psychoactive substance use in 8, self-image/self-esteem issues in 5, and academic performance difficulties in 4. These counts indicate how frequently each factor was examined and reported across studies; no pooling of participant-level prevalence or effect estimates was performed due to heterogeneity of designs and measures.
3.3 Across time: changes in prevalences between the pre- and post-pandemic periods
During the period from 2010 to 2019, most studies (n=24, corresponding to 82% of the articles) reported a high prevalence of suicidality and non-suicidal self-injury (NSSI) among adolescents. Physical, psychological, contextual, and environmental factors were consistently associated with these behaviors. Notably, the lack of family support, bullying, mental health problems, and academic difficulties were key factors.
Gender also played a significant role, with a higher prevalence of suicidality among female adolescents, often linked to low self-esteem and family conflicts.
Regarding the 2020-2024 period, most reviewed studies (n=18, corresponding to 69.23% of the articles evaluated in this review) identified an increase in the prevalence of suicidality and self-harm among adolescents. Contributing factors included a lack of family support, psychological and physical problems, socioeconomic and environmental issues, as well as excessive use of psychoactive substances.
The COVID - 19 pandemic transformed the landscape of risk factors associated with suicidality and NSSI among adolescents, revealing new dimensions of mental vulnerability. Social isolation and increased loneliness, driven by prolonged school closures and social distancing measures, emerged as critical risk factors. Increased loneliness correlated strongly with self-harm risk, emphasizing the urgency of preventive interventions. Furthermore, intensified use of technology and social media, while serving as an outlet for many, exacerbated deteriorations in sleep quality, a factor directly linked to heightened suicidal ideation and self-harm behaviors.
This scenario was aggravated by financial instability and complex family dynamics. Families facing economic hardship and pandemic-related losses presented adolescents with an elevated risk of suicide and self-harm. Adolescents experiencing heightened levels of depression and anxiety during the pandemic showed intensified vulnerabilities, amplified by low self-esteem and lack of family support.
Gender remained a critical determinant, with a higher prevalence of suicidality and self-harm among female adolescents. Sexual orientation and gender identity also significantly influenced these behaviors, with higher rates of suicidal ideation among homosexual and transgender adolescents compared to their heterosexual and cisgender peers.
Finally, adolescents who face academic difficulties, bullying, or low self-esteem exhibited a substantial increase in suicidal ideation and self-harm behaviors.
4 Discussion
Risk factors for suicidality and non-suicidal self-injury (NSSI) among adolescents underwent significant changes during the COVID - 19 pandemic. Pandemic stressors, such as loneliness during social isolation and economic hardship, were strongly heightened the risk non-suicidal self-injury (NSSI) globally, as observed in countries like China, the United Kingdom, Uganda, and South Korea (6, 49, 50, 54). Contrary to widespread concerns about a potential surge in suicide-related behaviors during the COVID - 19 pandemic, evidence from numerous studies suggests a more stable pattern in adolescent suicidality. For instance, research conducted in Maryland revealed that adolescent suicide rates remained relatively consistent throughout the pandemic, with only minor fluctuations during specific periods (4). Similarly, a study in Mexico found no significant differences in the prevalence of suicide attempts between pre-pandemic and pandemic periods, further emphasizing the stability of these behaviors (61). In Korea, longitudinal analysis showed improvements in suicidal ideation and attempts during both short- and long-term pandemic phases, highlighting potential resilience among adolescents (54). However, the broader picture demands caution before assuming a homogeneous trend.
While this systematic review identified a significant rise in non-suicidal self-injury, particularly among female adolescents, it is essential to acknowledge that this trend was not universally accompanied by a parallel increase in suicide attempts or ideation. Several studies, including those conducted in the United States (4), Mexico (61), and South Korea (54), reported stability or even reductions in certain suicide-related outcomes. Such variability suggests that the impact of the pandemic on adolescent suicidality may have been modulated by a combination of regional policy responses, cultural attitudes toward mental health, differences in access to healthcare services, stigma surrounding self-reporting, and the specific temporal phase in which data were collected.
Well-known pre-existing stressors exacerbate the impact of new stressors, such as remote schooling, social isolation, and economic instability. These factors heightened loneliness, disrupted sleep patterns, and intensified anxiety and depression, particularly in adolescents already at risk (40, 50). The interplay between contextual and individual risk factors created heightened challenges, emphasizing the need for targeted interventions (51).
4.1 Environmental or contextual risk factors
4.1.1 Family and socioeconomic challenges
Factors such as lack of family support, financial instability, and family disconnection, previously were linked to increased suicidality, became even more pronounced as economic hardships deepened and social isolation restricted access to coping resources (6, 40, 49, 50). These challenges created new layers of vulnerability, highlighting the effects of pre-existing stressors (51). Supportive family environments have been shown to reduce self-injury rates by fostering psychological resilience and mitigating depressive symptoms (68). Conversely, dysfunctions within the family, such as conflict, poor communication, and lack of parental supervision, exacerbate maladaptive behaviors and significantly contribute to psychological distress and suicidal behaviors among adolescents (67, 69).
The loss of primary caregivers due to COVID - 19-related deaths placed many adolescents in precarious living arrangements, often with unfamiliar or distant relatives. These new environments sometimes led to exploitation or continued cycles of abuse, exacerbating adolescents’ sense of grief and emotional instability (70–73). Parental stress fosters environments conducive to abuse. Economic hardships, job losses, and fears of COVID - 19 infection contributed to elevated levels of parental anxiety, which often manifested as aggressive or neglectful behaviors toward adolescents (71, 72). Parents struggling with substance abuse during lockdowns further diminished their caregiving capacities, creating an environment where physical and emotional maltreatment became more frequent and severe (74). This is consistent with earlier findings that households with pre-existing dysfunctions, including parental alcoholism, saw a marked increase in violence and neglect during prolonged periods of stress (75, 76).
Economic instability, including parental job loss and food insecurity, significantly heightens these risks, as adolescents facing household financial difficulties display higher rates of depressive symptoms, suicidal ideation, and suicide attempts (77–80). The experience of reduced access to healthcare compounds their mental health challenges (81, 82).
Cultural and ethnic dynamics introduced additional layers of complexity. Adolescents from ethnic minority groups and immigrant families faced increased vulnerability to suicidality (26, 35, 44, 81). Unemployment and financial uncertainty have been shown to increase the prevalence of suicidal behaviors, particularly among adolescents from low-income households (77, 83).
The interplay between chronic stressors and acute stressors such as pandemic-related disruptions add on the effects on depression and suicide-related behaviors (67, 84).
4.1.2 Bullying
The COVID - 19 pandemic significantly altered the prevalence and dynamics of bullying behaviors. Traditional bullying generally decreased during lockdowns due to reduced peer interaction in physical school settings, a trend attributed to school closures and enhanced parental supervision at home (85, 86). However, this decrease was counterbalanced by a substantial increase in digital bullying, as adolescents turned to online platforms for social interaction during periods of isolation (85, 87). Cyberbullying often intensified in severity, with prolonged digital exposure augmenting risks of mental health deterioration, particularly in individuals with pre-existing conditions, such as anxiety and depression (8, 88). Digital bullying impact is profound and multifaceted, coursing with heightened anxiety, depression, and social withdrawal, conditions exacerbated by the anonymity and permanence of online harassment (87, 88). Victims of any bullying exhibited markedly higher rates of suicidal ideation and attempts, often accompanied by depressive symptoms and diminished self-esteem (21, 24, 56, 88). During and after the pandemic, both traditional and cyberbullying emerged as significant predictors of suicidal behaviors (8, 60). Again, specific groups, including low-income households, LGBTQ+ and racialized youth, faced disproportionate rates of cyberbullying, reflecting enduring patterns of identity-based victimization that were intensified during the pandemic (82, 87, 89).
Socioeconomic and cultural contexts played a crucial role in shaping bullying dynamics. In countries with stricter public health measures, traditional bullying rates declined due to increased teacher supervision and minimized unstructured peer interactions (85, 86). Cyberbullying trends varied significantly, with sharp increases reported in regions with extended lockdowns and less stringent anti-cyberbullying policies (87, 89).
4.2 Individual factors
4.2.1 Psychiatric and psychological problems
Pre-existing mental health conditions such as anxiety and depression experienced significant worsening of symptoms due to the stress of the pandemic (90). Poor sleep quality and excessive screen time disrupted emotional regulation (50). Adolescents with difficulties regulating emotions often turned to maladaptive coping mechanisms like NSSI to manage overwhelming feelings of loneliness and helplessness during prolonged lockdowns (65). This pattern underscores the pivotal role of emotional regulation skills in mitigating the adverse effects of pandemic-related stress on mental health (73, 76).
Prolonged confinement in households where abuse was already present increased exposure to physical, emotional, and even sexual violence, as adolescents were isolated from potential protective buffers (71, 72). Adverse childhood experiences (ACEs) heightened emotional distress and reduced the ability of adolescents to adapt to changing circumstances (49, 55, 91). Accumulative exposure to ACE played a significant role in increasing susceptibility to self-harm and suicidal ideation. Low resilience emerged as a critical factor, who lacked robust coping mechanisms facing greater challenges in managing stress effectively (92). The ones with limited coping skills and emotional resources were less equipped to handle pandemic-related stressors, leaving them particularly vulnerable to suicidality and NSSI (92, 93). Difficulties in access to mental health resources, disproportionately affected underserved communities, intensifying their struggles with mental health (75, 76). Increases in self-injury behaviors were driven by a lack of effective coping strategies and emotional resilience (70).
4.2.2 Substance use and media exposure
The use of psychoactive substances, including alcohol and tobacco, was frequently associated with suicidal behaviors, particularly in socially vulnerable adolescents (35, 51). Dependency on digital platforms also emerged as a significant factor, with adolescents experiencing higher rates of anxiety and depression due to constant comparison and exposure to harmful content online (50). Substance use and digital dependency appear to act as mechanisms for coping with stress and emotional distress, though they simultaneously exacerbate mental health vulnerabilities (94, 95).
When it comes to digital dependency, a phenomenon must be cited: Snapchat dysmorphia. It represents a growing phenomenon intricately linked to the interaction between social media usage, body self-image, and self-esteem, particularly among adolescents. Platforms like Snapchat, with their AI-driven filters, create unrealistic standards of beauty, often leading to distorted self-perceptions and behaviors aimed at achieving unattainable physical ideals (96, 97). Adolescents became particularly susceptible to body dissatisfaction and disordered eating behaviors, such as meal skipping and compulsive exercise, as they attempted to conform to the idealized images portrayed on these platforms (97). The appearance-based activities, including editing selfies and comparing oneself to filtered images, strongly correlate with depressive symptoms and body dissatisfaction, particularly in female adolescents (96). These activities perpetuate a cycle of negative self-evaluation, reinforcing the need for external validation and increasing vulnerabilities to mental health challenges (96). In the long-term, it seems to compromise identity formation, as constant exposure to idealized imagery contributes to maladaptive self-modeling and body image distortions (98). In extreme cases, adolescents use Snapchat as a platform to exchange extreme dieting goals and set unrealistic body standards. When these goals are not met, some engage in self-punishing behaviors, including self-harm, reflecting the pressures of peer influence and digital beauty culture (97, 98).
In a Saskatchewan study, the risk associated with co-occurring substance use was identified, particularly the simultaneous use of cannabis and alcohol. Adolescents with problematic use of both substances demonstrated a significant increase in suicidal ideation compared to those using only one substance (99). Recent changes in substance use patterns, such as increased frequency or quantity, were linked to heightened vulnerability, particularly among younger ones (99). Online gaming environments have been increasingly linked to heightened risks of problematic behaviors, including the consumption of alcohol. Adolescents, isolated due to pandemic restrictions, often turned to online gaming and alcohol consumption as maladaptive coping mechanisms to alleviate stress and loneliness (94, 95, 100). The reward systems in online gaming, coupled with peer interactions and challenges normalize or even incentivize risky behaviors like alcohol consumption (94, 95).
The interplay between gaming and substance use has been explained through the shared mechanism of escapism and coping strategies. Gamers, particularly those engaged in multiplayer games, are exposed to social interactions where alcohol consumption may be encouraged or rewarded, implicitly or explicitly (94, 95, 100). Anonymity and detachment provided by digital platforms, reduces the perceived consequences of risky behaviors (94, 95). The competitive and immersive nature of online gaming often leads to long sessions, in which players may resort to substances like alcohol to sustain engagement or bond socially, amplifying the risks of dependency and health issues (100).
These patterns are especially concerning for adolescents who are simultaneously navigating identity development and social relationships. Vulnerable groups, such as those already facing bullying or other social pressures, may find online gaming a double-edged sword, a refuge that inadvertently exposes them to additional risks, such as substance abuse (100).
4.2.3 Self-image and self-esteem
Negative self-image and low self-esteem were closely linked to suicidality, particularly in adolescents facing body image challenges or social conflicts (19, 42). Personality traits such as neuroticism and impulsivity, which were amplified during the pandemic, further heightened vulnerability to self-injurious behaviors (5, 51).
Another interesting behavioral phenomenon is Fear of Missing Out (FoMO), which also plays a crucial role in the interaction between social media use, self-image, and self-esteem, particularly among adolescents. FoMO increases vulnerability to the negative influences of social media on self-image and self-esteem. The pervasive use of platforms amplifies feelings of inadequacy and exclusion, particularly when individuals perceive themselves as missing out on rewarding experiences shared by their peers (101). This phenomenon often drives excessive engagement with social media, contributing to a cycle of comparison and dissatisfaction with personal achievements or appearance (102). The adolescents from families with poor cohesion or rigid structures are more likely to seek validation and social gratification online, intensifying the risks associated with low self-esteem and distorted self-perception (101).
The impact of FoMO on adolescents’ mental health is worsened by societal pressures to conform to idealized standards of beauty and success frequently portrayed on social media. This exposure often exacerbates existing insecurities, particularly when with limited emotional regulation skills (103). As adolescents, they struggle to reconcile their perceived inadequacies with the curated realities of their peers (101).
4.2.4 School-related stressors and risk of self-harm
The COVID - 19 pandemic significantly altered the educational landscape for adolescents, introducing new challenges to academic performance, particularly through the increased use of social media and rising levels of procrastination. Academic difficulties were amplified by the COVID - 19 pandemic, following the abrupt closure of schools and the shift to remote learning (104). The pandemic disrupted routines, increased stress levels, and created barriers to effective learning, particularly for students without access to adequate resources or those who struggled to adapt to online platforms (105). The lack of a structured learning environment at home contributed to a loss of academic performance that had lasting effects on adolescents’ mental health (104).
Low academic performance or repeated failures were strongly linked to an increased likelihood of suicidal ideation and attempts (31). Adequate school support and a positive school environment served as protective factors, reducing the risk of suicidal thoughts and self-harm (31, 36, 39, 106).
Adolescents facing academic challenges experienced intensified feelings of isolation and stress due to the lack of interaction and support (107). Improved access to digital resources, mental health interventions, and strategies to mitigate the psychological impact of academic stress could have been beneficial (104, 106).
Social media became a primary tool for adolescents to maintain connections during periods of isolation, but this also led to increased screen time, distracting students from academic tasks and promoting procrastination (108, 109). Long online engagement disrupted study routines and sleep schedules, which are critical for cognitive functioning and academic success (108, 110).
The shift to online learning intensified the temptation to engage with non-educational digital content, detracting from academic focus. Adolescents who struggled to regulate their social media use reported higher levels of academic stress and lower performance outcomes (108–110). The lack of in-person interactions with teachers and peers deprived students of essential support structures, undermining their ability to stay motivated and engaged with schoolwork (109). The interaction between procrastination and social media use during the pandemic reveals a cyclical relationship: adolescents turned to social media to avoid academic responsibilities, but this avoidance magnified feelings of guilt and anxiety about incomplete tasks, perpetuating a cycle of procrastination (108, 110).
Social isolation deprived adolescents of essential protective factors, such as meaningful peer interactions and structured environments, which typically buffer against psychological distress. For instance, the absence of in-person schooling not only limited access to mental health resources but also removed a critical outlet for problem-solving and stress management (110). This loss, compounded by family conflicts and economic instability, left adolescents with diminished opportunities to engage in constructive coping, forcing many to turn to harmful alternatives, including social media overuse and substance abuse to manage their distress (100, 109). Adolescents who previously relied on external support systems, including peers, teachers, and extracurricular activities, found these resources unavailable, leading to increased reliance on maladaptive behaviors such as avoidance, rumination, and self-harm (70, 71). Addressing these vulnerabilities requires a concerted effort to rebuild supportive school environments and strengthen interventions aimed at reducing academic stress, particularly in underserved populations (105, 106).
Lack of access to therapy, school counseling, and community programs significantly hindered adolescents’ ability to navigate heightened stressors. These barriers contributed to an increased prevalence of maladaptive behaviors, such as NSSI and suicidality, as adolescents struggled to process grief, fear, and uncertainty (96, 103). Additionally, the normalization of harmful behaviors through online platforms, such as exchanging dieting tips or self-harm methods, amplified these challenges (97, 101).
4.2.5 Sociocultural and structural determinants as individual vulnerability factors
To enrich the cultural and geographic scope of the findings, data were incorporated from additional studies conducted in diverse global contexts, which provide further nuance to the understanding of adolescent suicidality and self-harm.
Community-based prevalence studies remain essential to understanding the hidden burden of adolescent self-harm. In a self-report survey conducted among adolescents aged 13 to 18 years in England, a lifetime prevalence of 12% for self-harm was observed, with higher rates among females and those aged 15-16. Importantly, over half of the adolescents who reported self-harming did not seek help, suggesting that official records may significantly underestimate the true scope of the problem. These findings underscore the need for proactive screening strategies within schools and community services to identify adolescents who do not access traditional clinical pathways (30).
Cultural factors and public stigma also influence the expression and reporting of self-injurious behaviors. In a South Korean study, differences were observed not only in prevalence by sex but also in the underlying motivations for self-harm. Girls were more likely to use self-injury as a coping mechanism for internalized emotional distress, whereas boys demonstrated more impulsive patterns. These distinctions highlight the importance of gender-sensitive prevention and treatment approaches, especially in non-Western contexts where cultural norms shape emotional expression and help-seeking behaviors (32).
The role of social connectedness and school environment was further emphasized in a multi-country study across ten Southeast Asian nations, which found that adolescents who reported loneliness, poor parental bonding, and low peer support were significantly more likely to engage in NSSI and experience suicidal ideation. In the context of heightened social isolation during the COVID - 19 pandemic, these findings draw attention to the urgent need for interventions that strengthen protective relationships at home and in school settings (33).
Emerging data from post-pandemic contexts suggest that adolescents experienced not only an increase in suicidal ideation but also a shift in the underlying factors contributing to such outcomes. In a recent analysis of adolescent suicide deaths in Maryland, it was observed that the most significant increases occurred among youth aged 10 to 14 years, particularly among males and black adolescents. The authors highlighted the importance of recognizing early developmental vulnerability and structural inequalities, which may have been exacerbated by the pandemic (34). Longitudinal evidence from van Vuuren et al. (45) further demonstrated temporal trends in suicidal ideation and attempts, with differences across sociodemographic groups. These findings support the notion that intersectional factors such as race, age, and socioeconomic context must be considered when analyzing temporal trends in youth suicidality.
Notably, studies conducted in Tanzania reinforced the association between teacher support, school engagement, and reduced suicidal ideation among adolescents, as well as the cumulative impact of psychosocial stressors such as bullying and family dysfunction (37, 38), mirroring patterns observed in diverse global contexts.
Taken together, these findings reinforce the urgent need for culturally sensitive, developmentally appropriate, and equity-driven strategies to address adolescent suicidality and self-harm across global settings. Integrating this broader lens into research, policy, and clinical practice is essential to build more inclusive and responsive mental health systems. As this systematic review highlights, understanding the changing dynamics of youth self-injury in the pandemic era demands not only epidemiological vigilance but also the centering of adolescent voices and local realities as a foundation for global action. Nonetheless, it is important to interpret these findings in light of several methodological and contextual limitations that may influence the generalizability and applicability of the conclusions.
4.3 Methodological considerations
The evidence base is constrained by the predominance of cross-sectional designs; non-probabilistic or school-based samples collected during periods of remote schooling and service disruption; heterogeneous outcome definitions and instruments; reliance on self-report; limited adjustment for confounders; and asynchronous data collection across different pandemic phases. These features introduce selection and measurement biases, restrict comparability, and limit temporal inference. Moreover, most included studies were conducted in North America, Europe, and East Asia, with comparatively fewer from Latin America and sub-Saharan Africa, reducing external validity to under-represented regions. Finally, potential publication bias and language bias due to English-only inclusion further limit generalizability. Accordingly, findings should be interpreted as a structured synthesis of patterns rather than precise pooled effect-size estimates, and causal inferences should be made with caution.
5 Limitations
This study faced several limitations that should be acknowledged. The diversity in methodologies, study designs, and population characteristics hindered the ability to integrate data effectively and draw consistent conclusions. The predominance of cross-sectional studies restricted the analysis to associations, without allowing for the establishment of causal links between risk factors and outcomes such as suicidality and NSSI. Additionally, the reliance on self-reported data introduced inherent biases, such as recall and social desirability biases, which may have compromised the accuracy of the reported behaviors and perceptions.
Moreover, this review retrieved no eligible studies from certain regions (e.g., Latin America, Francophone Africa), which may reflect publication bias, limited indexing in global databases, or lower research output from these regions. Such geographic gaps may limit the generalizability of findings and underscore the need for more inclusive, globally representative research efforts.
The adoption of digital tools for education and communication reshaped adolescent experiences, creating variability in risk factors and outcomes over time. Lastly, the reliance on digital platforms for data collection during the pandemic likely excluded adolescents from lower-income households with limited access to technology. This may result in an underestimate of the prevalence of mental health challenges among these groups, particularly in regions where digital differences were significant.
Despite these limitations, this study provides valuable insights into the complex interplay of risk factors influencing adolescent mental health during and beyond the pandemic. Future research should aim to address these gaps by adopting standardized methodologies, incorporating longitudinal designs, and ensuring inclusive sampling that captures the diverse and evolving experiences of adolescents worldwide.
6 Conclusion
The pre- and post-pandemic data analysis provides a nuanced answer to the question: {it}”Was there a change in the prevalence and risk factors of suicidality and self-harm among adolescents before and after the onset of the COVID - 19 pandemic up to the present day?”{/it} The answer is yes, with important distinctions. There is a significant rise in non-suicidal self-injury (NSSI) during the pandemic, while the prevalence of suicide attempts seems to decrease in pooled data. While the prevalence of suicide attempts decreased significantly during the pandemic (approximately 66.67%), NSSI exhibited a dramatic increase of about 992.86%.
Risk factors evolved and intensified throughout the pandemic change, with common challenges including lack of family support, academic difficulties, bullying, and mental health issues such as depression and anxiety, which persist to this day. In contrast, NSSI was strongly associated with poor emotional regulation, heightened loneliness, and the normalization of self-injury through online platforms. These findings highlight the distinct emotional and contextual pathways leading to these outcomes.
A complex interplay between pre-existing vulnerabilities and novel stressors, such as social isolation, economic hardship, and disruptions to routine particularly minority groups and poor faced disproportional severe impacts, emphasizing the interplay between socioeconomic and cultural dynamics in shaping mental health outcomes. Despite a decrease in suicide attempts, the persistence and escalation of NSSI behaviors highlight the enduring emotional toll of the pandemic, further exacerbated by restricted access to mental health services during critical periods. This represents a convergence of new and pre-existing challenges, carrying significant long-term repercussions.
Therefore, global mental health policy must now rise to this challenge with coordinated, equity-driven, and adolescent-informed responses that leave no voice unheard.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material Further inquiries can be directed to the corresponding author.
Author contributions
DF: Data curation, Conceptualization, Writing – original draft, Writing – review & editing, Methodology, Investigation. RS: Writing – review & editing, Supervision, Writing – original draft, Methodology, Formal analysis, Data curation. MM: Writing – review & editing, Methodology, Formal analysis, Writing – original draft, Conceptualization, Data curation, Supervision, Investigation. VR: Writing – original draft, Formal analysis, Data curation. PM: Formal analysis, Data curation, Writing – original draft. MR-S: Methodology, Formal analysis, Data curation, Investigation, Writing – review & editing, Writing – original draft, Conceptualization. DM: Data curation, Project administration, Conceptualization, Formal analysis, Methodology, Writing – review & editing, Supervision, Investigation, Writing – original draft.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. INCT Neurotech R (CNPq, Capes, Fapemig) provided support with publication fees.
Acknowledgments
The author expresses sincere gratitude to the co-authors for their valuable contributions throughout the development of this work. Special thanks are extended to the co-supervisors and the main supervisor for their dedicated guidance, both in this study and throughout the journey of the Master’s program.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2025.1643145/full#supplementary-material
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Keywords: adolescents, suicidal behavior, suicidality, suicide attempt, self-harm, COVID-19 pandemic, mental health, risk factors
Citation: Ferreira DBB, Santos RMS, Machado MCL, Rezende VHM, de Marco PG, Romano-Silva MA and de Miranda DM (2025) Suicidality and self-harm in adolescents before and after the COVID-19 pandemic: a systematic review. Front. Psychiatry 16:1643145. doi: 10.3389/fpsyt.2025.1643145
Received: 08 June 2025; Accepted: 21 August 2025;
Published: 19 September 2025.
Edited by:
Bogdana Adriana Nasui, University of Medicine and Pharmacy Iuliu Hatieganu, RomaniaReviewed by:
Gilberto Uriel Rosas Sánchez, Universidad Veracruzana, MexicoElif Benderlioğlu, Ankara Sehir Hastanesi Cocuk Hastanesi, Türkiye
Copyright © 2025 Ferreira, Santos, Machado, Rezende, de Marco, Romano-Silva and de Miranda. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Danilo Bastos Bispo Ferreira, ZGFuaWxvYmJmQHVmbWcuYnI=; ZGFuaWxvLmJpc3BvQGFyYXBpcmFjYS51ZmFsLmJy; ZGFuaWxvLmZlcnJlaXJhLjI2QGdtYWlsLmNvbQ==