Suicidal behavior has been projected to increase globally (1) as a sequela of the anticipated mental health crisis stemming for the COVID-19 pandemic. The mental health needs of frontline healthcare workers (HCWs) have been highlighted as a global priority (2). Medical-related occupational groups have been established as an at-risk population for suicide. A pre-pandemic meta-analysis showed that physicians who are female, United States-based, and in disciplines such as anesthesia, psychiatry, general practice, and general surgery may have higher suicide risk compared to the general population (3).

The myriad stressors faced by HCWs worldwide in their personal and professional spheres are currently compounded by unprecedented challenges due to the COVID-19 pandemic. A meta-analysis showed that the mental health impact of the COVID-19 pandemic on healthcare workers was more severe compared to the general population (4). Significant levels of stress, depression, anxiety, psychological distress, post-traumatic stress symptoms, poor sleep quality, and insomnia have been demonstrated in this frontline population. Majority (92%) of the meta-analyzed studies were conducted in China, with the rest from Iran, Italy, Singapore, and Vietnam (4). Spanish and American healthcare workers' high levels of psychological distress were significantly correlated with fears of being infected or infecting others, especially family and friends, and clinical challenges i.e., perceived uncertainty/lack of control and inadequacy of PPE (5, 6).

Nepalese healthcare workers who felt stigmatized, had a history of receiving psychiatric medication, and reported insufficient preventive measures at work seemed to be at higher risk of experiencing mental health problems (7). Among a sample of Malaysian HCWs, depression, stress, and anxiety were shown to be significantly associated with being unmarried, experiencing fear and uncertainties surrounding COVID-19 infection risk via work-exposure to COVID-19 patients, and being in communities with high transmission rates (8). Potential psychological buffers for HCWs include perceived social recognition (5), perceived peer support and having more than three children (8).

Published systematic research in terms of the pandemic's effect specific to suicidal behavior (ideation, non-fatal and fatal attempt) in this high-risk population (HCWs) is limited. Anecdotal reports have linked the recent suicide deaths amongst frontline HCWs with the collective experience of fear, hopelessness, helplessness, and moral injury in the line of duty during the COVID-19 pandemic (3, 4). These authors speculated that multiple factors contributed to HCW suicide, such as social isolation from support networks and the experience of vicarious traumatization when caring for dying patients. In addition, the perceived risk of infection and transmission of the SARS-COV, compounded by uncertainties surrounding equitable allocation of personal protective equipment (PPE), were postulated to have increased HCW suicide risk. On the contrary, an online survey of 834 HCWs and 2,554 general population participants in Bangladesh did not show any significant association between patient care or PPE-related factors with suicidal behavior (ideation, intent, plan, and attempt) (9). Anxiety is a known risk factor for suicidal behavior (10). The potential impact of health anxiety on the behavioral response to COVID-19 has been highlighted by researchers (11). Therefore, the relationship between suicidal behavior and health anxiety pertaining to HCWs' fear of contracting SARS-CoV-2 is an important area for further research. In terms of gender, female HCWs seemed to be at higher risk of suicidal behavior compared to their male counterparts during this current pandemic (9).

With regards to the spectrum of suicidal behavior, it is important to identify risk factors of suicidal ideation which can be distinct from predictors of more severe spectrum of suicidal behaviors (planned, non-fatal, and fatal attempts) (12–15). Though suicide is a devastating fatal outcome, it is a rare occurrence relative to suicidal ideation or suicide attempts (3, 16). A meta-analysis showed that 17% of physicians experienced suicidal ideation while one percent had previously attempted suicide. Identification of HCWs with suicidal ideation is clinically relevant for implementation of early intervention and prevention of suicide (15). The evidence-base is currently mixed on whether there is a definite increase in suicidal behavior around the world as a sequela of the current pandemic (17). A significant knowledge gap exists in terms of the burden of suicidal ideation and its related factors amongst HCWs within the context of the COVID-19 pandemic, especially in low and middle income (LMIC) countries.

Therefore, the objectives of this study are to investigate the rate of suicidal ideation and the association between suicidal ideation with the following factors: socio-demographic profile, depression, health anxiety and lifetime anxiety disorder, and occupation and service-related factors, amongst a heterogenous and culturally diverse sample of Malaysian HCWs during the early phase of the COVID-19 pandemic.

Majority of the participants were within the 31–40 years age group, female (70.8%), Malay ethnicity (78.4%), married (62%), and with an educational level of a bachelor's degree or higher (70.2%). Most of the participants were physicians (56.2%), mainly working between 40 and 50 h per week (56.1%), and with a service duration of 7–10 years (36.8%). Eighty-three percent of study participants were healthcare workers in hospitals or healthcare facilities that were designated as COVID-19 treating or screening healthcare facilities. Cronbach alpha for HAI and PHQ were 0.879 and 0.873, respectively. Current clinical depression and lifetime anxiety disorder were present in 9.9% (17/171) and 11.1% (19/171) of participants, respectively. Nineteen out of 171 healthcare workers (11.1%) reported current suicidal ideation in the past 2 weeks. Fifty three percent (10/19) of those with suicidal ideation did not meet criteria for clinical depression (no or subthreshold depressive symptoms). Fifty three percent (9/17) of healthcare workers with clinical depression reported suicidal ideation. There was no multicollinearity between the independent variables. The correlation between the independent variables was 0.45 (<0.8).

From bivariate analysis (Table 1), factors significantly associated with current suicidal ideation were single status (p = 0.017), higher levels of health anxiety (p = 0.234), and higher severity of depression (p < 0.001). Participants with more than 10 years of service duration had a significantly lower rate of current suicidal ideation (p = 0.013). Multivariable logistic regression model (Table 2) showed that moderate to severe (clinical) depression was the strongest independent variable significantly associated with current suicidal ideation (p < 0.001, OR = 55.983, 95% CI = 9.015–347.671) followed by mild depression (p = 0.001, OR = 15.984, 95% CI = 2.977–85.804). Service duration of more than 10 years was associated with significantly less suicidal ideation (p = 0.049, OR = 0.072, 95% CI = 0.005–0.993).

The burden and risk factors of suicidal behavior among health care workers in low- and middle-income countries have not been well-established (33). Our present study showed that 11.1% of healthcare workers in Malaysia reported current suicidal ideation (past 2 weeks) during the early phase of the COVID-19 pandemic and lockdown. Based on Zunin and Meyers' model of phases of disaster, our study period coincides with phase 2, whereby the psychological impact of the initial rapid spread of COVID-19 and environment of unpreparedness can encompass a wide range from shock, overt panic, initial confusion, disbelief, focus on self-preservation and family protection (34). The prevalence rate for current suicidal ideation (past 1 month) was 1.7% in the general population from the 2011 Malaysian National Health Morbidity Survey (35). Malaysian HCWs appear to have a higher rate of suicidal ideation during the early phase of the COVID-19 pandemic compared to available pre-pandemic data among medical students (7%) and the general population in Malaysia (36). Our reported figure of 11.1% is lower than the prevalence of 17% for suicidal ideation among physicians in Dutheil et al. (3) meta-analysis of 61 predominantly Western studies (3). Nevertheless, direct comparison of trends in suicidal behavior (including ideation) among HCWs pre- and post-pandemic is challenging due to limitations of methodological heterogeneity from published data in Malaysia and globally.

Depression is a well-established risk factor for suicidal behavior (ideation, attempt and suicide) among medical physicians and nurses (37, 38). Our study showed that the severity of self-reported depressive symptoms was associated with suicidal ideation, with the clinical range of depression being the most significant factor. Nevertheless, a substantial proportion of HCWs who experienced suicidal ideation (50%) did not meet criteria for clinical depression, i.e., having no or subthreshold depressive symptoms. This finding underscores the importance of understanding other factors that contribute to suicidal ideation beyond depression.

Our study demonstrated that a longer duration of service (more than 10 years) appeared to be protective against suicidal ideation in Malaysian HCWs during the early phase of the COVID-19 pandemic. This finding remained significant after controlling for age, gender, marital status, ethnicity, educational level, type of health care occupation and medical specialty, working hours as well as self-reported clinical depression, health anxiety or other anxiety disorders. Previous research findings have been somewhat mixed in terms of the significance of seniority and suicidal behavior among physicians. The level of seniority was not significantly associated with suicide among physicians in England and Wales (39). Being in practice for more than 30 years seemed to be protective against suicidal ideation in a previous study of 7,905 American surgeons. However, service duration was no longer significant after controlling for burnout and depressive symptoms (40).

Findings from our study echo a signal of increased vulnerability to suicidal ideation in early career compared to senior HCWs. The exact mechanisms underlying the interaction between suicidal behavior and stressors (professional and personal) encountered by HCWs in tandem with their level of work experience; are beyond the scope of this study. Nevertheless, previous research highlighted that physician burn-out can contribute to the complex issue of suicidal behavior in the medical profession (41).

Burn-out has been conceptualized as an occupational phenomenon that is separate from a medical condition (42). This is an important distinction to address in terms of interventional implications and suicide prevention among HCWs. Physicians who were younger in age appear to be more susceptible to burn-out in Malaysian and Chinese populations (43, 44). Being at the frontline of the COVID-19 pandemic increased the risk of severe psychological distress such as insomnia, depressive, and anxiety symptoms among HCWs in China, especially among mid-career compared to senior clinicians (45). In Malaysia, findings from a small descriptive study seemed to suggest that residents experienced more stress, anxiety, and depressive symptoms compared to medical specialists (46). A qualitative study in Egypt identified the following COVID-related stressors faced by psychiatry residents: (i) inadequate precautions to guard against the outbreak, (ii) high exposure risk, (iii) the conflict between family and work, and (iv) the postponement of personal and career plans (47).

Often, clinicians in the early phases of their careers inadvertently end up at the frontline of critical health care provision as part of their training. A study from Singapore reported that COVID-19 frontline HCWs mainly comprised of residents (48). The hierarchical nature of medicine and health care service is also a likely exacerbating factor. Three quarters of the nurses working at the frontline of the COVID-19 pandemic epicenter in Wuhan, China were in the junior category of service (49). The perception of having to practice beyond one's level of competency without adequate supervision may contribute to burn-out in a sample of Australian junior physicians (50).

Data from the general population during the current pandemic have shown that British young adults (18–29 years) have a heightened risk for suicidal ideation compared to middle-aged and older adults (51). In the U.S., young adults (18–29 years) were also a high-risk population for serious psychological distress (52). In that study, stressors included fear of contracting COVID, issues with employment, financial, and educational interruptions. In Spain, financial and occupational stressors such as the perception of lack of supervision, communication, coordination and personnel were associated with suicidal ideation and behavior among health-care workers during the 1st wave of the COVID-19 pandemic. These environmental factors remained significant after accounting for pre-existing mood and anxiety disorders as well as level of exposure to COVID-19 (53). Early- to mid-career healthcare workers in Malaysia may have to contend with a heightened sense of unpreparedness during the initial critical phase of the COVID-19 pandemic and lockdown. This population may be in a more vulnerable position compared to senior, better-resourced colleagues in terms of financial stability, job insecurity and disruptions to career progression and advanced training (e.g., postgraduate, specialty/sub-specialty). Therefore, we postulate that such a scenario may contribute to an increased risk of suicidal ideation in less experienced, junior healthcare workers. Further evidence beyond our study is needed to substantiate these hypotheses.

Our study has highlighted that depression, both at the subthreshold level and particularly in the clinical range, may be associated with suicidal ideation, while a longer service duration is potentially protective against suicidal ideation amongst Malaysian HCWs. Identification and treatment of depression, as well as a focus on early-/mid-career HCWs as a target population for early intervention may be potential areas for suicide prevention amongst HCWs who have been exposed to the COVID-19 pandemic working environment.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

The studies involving human participants were reviewed and approved by Medical Research and Ethics Committee. The patients/participants provided their written informed consent to participate in this study.

NRNJ (P.I. and grant-holder of this study), HMSS, and LFC conceptualized this study. HMSS and FHAR was involved in the database collection and organization of this study. HMSS, TIMD, LFC, SAS, FHAR, and NRNJ were responsible for data analysis, interpretation of study results, and involved in the writing and review of the final draft of this manuscript. All authors contributed to the article and approved the submitted version.

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.