A Cross-Sectional Study on Factors Related to Suicidal Ideation in Individuals with Spiritist Involvement: Comparison before and during the Covid-19 Pandemic

Tiago Medeiros Sales^1, Rosa Maria Salani Mota^2, Raimunda Hermelinda Maia Macena³

1. Psychiatrist and Doctor of Public Health at the Faculty of Medicine of the Federal University of Ceará.
2. Statistician and Professor in the Department of Statistics and Applied Mathematics at the Federal University of Ceará.
3. Nurse and Professor in the Department of Physical Therapy and the Graduate Program in Public Health at the Faculty of Medicine of the Federal University of Ceará.

 

OPEN ACCESS

PUBLISHED: 30 November 2024

CITATION: Sales, TM., Mota, RMS., et al., 2024. A Cross-Sectional Study on Factors Related to Suicidal Ideation in Individuals with Spiritist Involvement: Comparison before and during the Covid-19 Pandemic. Medical Research Archives, [online] 12(11). https://doi.org/10.18103/mra.v12i11.6057

COPYRIGHT © 2024 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v12i11.6057

ISSN 2375-1924

Abstract

Purpose: Suicide increases in Brazil annually and the population search for spiritual care, as in Spiritism, a religion that attracts people in psychic pain. We sought to identify the factors associated with suicidal ideation among persons with some Level of Spiritism Engagement (LSE), before and during COVID-19.

Methods: This cross-sectional analytical research with 848 inhabitants from Ceará, Brazil, with some LSE, was conducted through digital data collection via snowball, with a bivariate (p < 0,30), multivariate (p < 0,30) and multinomial analysis (p < 0,05) of sociodemographic factors, psychic status, psychic care, spiritual belief and LSE related to suicidal ideation. Afterward, a multinomial regression analysis (p < 0.05) was conducted on all significant factors to identify those most strongly associated with suicidal ideation.

Results: Risk factors of mild/moderate suicidal ideation were to be single (OR=2,32; CI 1,19-4,52), previous psychotherapy before COVID-19 (OR=1,81; CI 1,10-2,98) and to be spiritist (OR=2,43; CI 1,34-4,38). Risk factors of severe suicidal ideation were: to be single (OR=4,05; CI 1,89-8,69), unemployed (OR=2,93; CI 1,45-5,92), have a regular/bad/worse self-perception of emotional health (OR=4,84; CI 2,55-9,17), previous psychotherapy before COVID-19 (OR=2,57; CI 1,40-4,71) and to be spiritist (OR=2,13; CI 1,00-4,52). Pre-pandemic regular/high/very high LSE was a protective factor for severe suicidal ideation during COVID-19 (OR=0,38; CI 0,16-0,90).

Conclusion: Negative self-perception of emotional health, psychotherapeutic follow-up, and identification as spiritist were associated with severe suicidal ideation, which appears to support the notion that spiritism attracts individuals experiencing psychic distress. Despite this disease profile, higher levels of spiritist engagement before the pandemic were protective against severe suicidal ideation during COVID-19, suggesting a potential positive effect of spiritism on mental health.

Keywords

Suicidal Ideation, Spiritism, COVID-19, Suicide, Spirituality.

List of Abbreviations

ICPs = Integrative and Complementary Practices
LSE = Level of Spiritist Engagement
MAST = Multi Attitude Suicide Tendency Scale
NCH = National Council of Health

Introduction

Suicide is a challenge for public health. Suicidal ideation stands out and it means the thought of actively provoking the self-death. Underdeveloped and developing countries are the most vulnerable with 800.000 deaths / year around the world. Brazil’s suicide incidence grows annually, at a 6,36 persons by 100.000 inhabitants rate, mainly among youngsters and adults aged under 30 yrs. Suicidal ideation and suicide are closely associated with Common Mental Disorders (CMDs), a term coined by David Goldberg and Peter Huxley, which corresponds to the set of mental disorders most commonly found in the general population, such as insomnia, fatigue, somatizations, stress, anxiety, depression, among others. Among CMDs, anxiety, depression, and stress stand out, recognized for their high prevalence and high rate of comorbidities.

The Brazilian National Health System hardly tackles suicide, due to an ineffective promotion of the main preventing factor – the treatment of psychiatric disorders such as anxiety, stress, depression, and suicidal ideation. Consequently, the Brazilian population with almost 90% of Christians seeks for mental health care of religious origin. The use of spirituality as a health resource is a common practice of most societies, that fortify themselves through faith, benefit from social and personal care and from community help.

Previous studies show that spirituality is linked to better mental health, as it plays a significant role in enhancing psychological well-being. Spiritual practices offer social and emotional support, reduce stress, anxiety, and depression levels. Additionally, spirituality fosters greater psychological resilience, helping individuals cope with trauma and find purpose and meaning in life. It serves as a psychological resource to face mental and emotional challenges, ultimately contributing to improved overall quality of life and mental health. Recently, the benefit of spirituality on mental health was seen during COVID-19.

Regarding spirituality in Brazil, Spiritism is widely spread and is considered a scientific-philosophical doctrine, in addition to being a religion. It offers a free assistance system aimed at improving mental health, regardless of the religion of the individuals involved. Thus, many people in need of healthcare engage with Spiritist therapy, making Spiritism a religion of psychological demand. The specific mechanisms of how Spiritist engagement influences mental health may vary based on individual beliefs and spiritual practices. Despite this, scarce studies have sought to understand this phenomenon.

During the pandemic, there was an increase in mental health issues, including a rise in suicidal ideation, which possibly led to a higher level of Spiritist engagement. However, this engagement was affected by limited access to Spiritist centers due to the lockdown. Thus, COVID-19 created a time divide, altering parameters related to suicidal ideation as well as Spiritist engagement, even among individuals who already had some level of engagement before the pandemic. This study, conducted during the pandemic, aimed to determine the factors associated with suicidal ideation among people with some Level of Spiritist Engagement (LSE), comparing before and during COVID-19 periods.

Materials and Methods

STUDY DESIGN, SETTING AND PARTICIPANTS

This cross-sectional analytical research was conducted with persons with some LSE in the state of Ceara, Brazil. This study was conducted throughout the year 2021, during the second wave of COVID-19. Inclusion criteria adopted were: being 18 years old or older and being an inhabitant of the state of Ceara. A total of 848 people participated in this study, more than double the minimum required.

SAMPLE SIZE

Although the number of Spiritists in the Brazilian population is known to be 2% of the total, the sample of people with Spiritist engagement is unknown, as well as the prevalence of Common Mental Disorders (CMDs) and suicidal ideation in this population. Therefore, since the prevalence of the outcome (suicidal ideation) is unknown, a prevalence of 50% was assumed, and the sample size was calculated for a 5% alpha with 95% power, resulting in a total of 350 individuals. Considering an assumed loss of 10%, the minimum desired sample size was 385 individuals, including both Spiritists and non-Spiritists.

The non-probabilistic snowball sampling method was used, which allows for the identification of rare characteristics in large populations, with recruitment done through the participants themselves. The digital approach for data collection was chosen due to the restrictions imposed by social distancing measures as a public health response to COVID-19, which temporarily closed community and social settings and hindered in-person approach to Spiritists and attendees of Spiritist centers. As an advantage, digital data collection enables finding samples within an extensive community network, and therefore, digital data collection has progressively become a dominant research instrument. However, as a disadvantage, it increases the possibility of sample bias.

INSTRUMENTS

The Informed Written Consent term was available with a questionnaire and the selected suicide scale. The questionnaire had sociodemographic data, variables connected to the psychic status and to psychic care and structured questions to measure spiritual belief and LSE before and during the pandemic. The suicide scale was the Multi Attitude Suicide Tendency Scale (MAST).

LEVEL OF SPIRITIST ENGAGEMENT (LSE)

To elaborate LSE, different scores (0 – 2) were attributed to related questions, with different answer scores (1 – 6), according to their higher or lower level of connection with spiritism. The final result was estimated by the addition and classification on 5 categories – very low (0-20%), low (21-40%), regular (41-60%), high (61-80%) and very high (81-100%). These categories were subdivided into 2 – very low/low and regular/high/very high. The instrument was elaborated in 3 blocks of questions to measure Sociodemographic Data, Psychic Status and Psychic Care, and Spiritual Beliefs and LSE.

MULTI ATTITUDE SUICIDE TENDENCY SCALE (MAST)

To assess suicidal ideation the MAST was used, and the index of suicide risk was obtained by subtracting the subindex “death” (attraction minus death aversion), by the subindex “life” (attraction minus life aversion), which generated a minimum and a maximum value. For bivariate analysis, 3 levels of suicidal ideation were used (mild, moderate and severe) and 2 levels for multivariate and multinomial analysis (mild/moderate and severe). Was developed by Orbach in 1991 and originally consisted of 30 items. The MAST is based on the assumption that suicidal behavior evolves around a conflict between four types of attitudes towards life and death: death repulsion, life repulsion, death attraction, and life attraction. The adapted Brazilian version of MAST allows for a principal component factor analysis, with items having a factor loading greater than |0.40|. As a result, a reduced version composed of 20 items was proposed. For this study, the adapted reduced version for the Brazilian context was used.

The MAST contains 20 items that address content related to life and death, and thus assumes that the risk of suicide increases as a conflict arises between the desire to live and the possibility of death.

DATA COLLECTION

Digital collection was used due to social distancing that closed communities, including spiritist houses. This was advantageous because it allowed to access a small and specific sample among a wide community. However, the sample bias mounted, which was hampered by the snowball technique and complemented by the use of several digital platforms.

Instagram, Facebook and WhatsApp were chosen due to the enormous popularity. Digital pages of research were made available for the general public in Instagram and Facebook with data about the study and with the link to access software SurveyMonkey®, used for data collection. WhatsApp worked to spread information through individuals and groups with some LSE, that posted the informative invitation video and the links for Instagram, Facebook and SurveyMonkey®.

DATA ANALYSIS

To analyse data, SurveyMonkey® database was downloaded to Excel® for Windows 2013. After digital analysis, data was exported to SPSS® software, version 23.0 (SPSS, Inc, USA). A bivariate analysis of questionnaire data (sociodemographic factors, psychic status, psychic care, spiritual belief and LSE) was conducted associated to the index of suicide risk with a significance level up to 30%. After, a multivariate analysis with the same significance level was done, which originated data that was submitted to multinomial regression with a 5% significance. Finally, a multinomial regression analysis (p < 0.05) was performed on all significant factors associated with suicidal ideation, identifying the factors most strongly associated with suicidal ideation.

ETHICAL CONSIDERATIONS

The research met the Law 466/2012 of the National Council of Health (NCH), related to Research Ethics involving Human Beings, with approval of the Ethics Committee of the Federal University of Ceará (n. 2.237.838).

Results

SOCIODEMOGRAPHIC FACTORS

Considering the bivariate analysis with a significance level of 30%, the highest prevalence of severe suicidal ideation was observed in females (21.5%), younger individuals (29.7%), white individuals (21.2%), homosexuals (24.3%), singles (30.0%), those with low education (complete secondary school/incomplete higher school/technical – 29.3%), those with a daily workload greater than 8 hours (20.4%), those who were not the main household income providers (15.9%), and those with a low household monthly income (up to R$ 2.600.00 – 30.3%).

The multivariate analysis showed that being single (OR = 4.45; CI 2.30 – 8.60, p < 0.001), having the lowest education level (OR = 2.35; CI 1.26 – 4.39, p = 0.006), and having a lower family income (R$ 0 to R$ 2.600 – OR = 2.54; CI 1.24 – 5.02, p = 0.037) were associated with a higher risk of severe suicidal ideation. Conversely, being the main income provider was found to be a protective factor against severe suicidal ideation (OR = 0.54; CI 0.32 – 0.90, p = 0.037).

Bivariate and multivariate analysis of sociodemographic factors associated to suicidal ideation levels of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Sociodemographic Factors	Levels of Suicidal Ideation	Related to Suicidal Ideation Level:	Mild / Moderate	Severe	p Value	OR¹	95% CI²	OR*	95% CI²
Gender			n	%
Female	494	82	16.6	306	61.9	106	21.5	0.926	0.586 1.463
Male	192	32	16.7	129	67.2	31	16.1	1.000	–
Age			n	%
Between 18 and 34 years	101	16	15.8	55	54.5	30	29.7	0.945	0.494 1.809
Between 35 and 54 years	340	54	15.9	220	64.7	66	19.4	1.120	0.716 1.752
55 years or over	245	44	18.0	160	65.3	41	16.7	1.000	–
Race			n	%
White	345	58	16.8	214	62.0	73	21.2	1.123	0.459 2.747
“Pardo” (Brown)	304	49	16.1	198	65.1	57	18.8	1.230	0.499 3.031
Others	37	7	18.9	23	62.2	7	18.9	1.000	–
Marital Status			n	%
Married or in a stable relationship	401	85	21.2	251	62.6	65	16.2	1.000	–
Single	170	15	8.8	104	61.2	51	30.0	2.348	1.296 4.255
Widower/Widow/ Divorced/ Separated	115	14	12.2	80	69.6	21	18.3	1.935	1.042 3.593
Education Level			n	%
Complete Secondary School /Incomplete Higher Education /Technical	140	18	12.9	81	57.9	41	29.3	1.238	0.708 2.164
Bachelor’s Degree/Graduation/Post-Graduation	538	96	17.8	349	64.9	93	17.3	1.000	–
Workload / Daily Workload			n	%
Up to 8 hours	308	48	15.6	200	64.9	60	19.5	1.000	–
8 hours or more	279	53	19.0	169	60.6	57	20.4	0.765	0.492 1.189
None	99	13	13.1	66	66.7	20	20.2	1.218	0.622 2.388
Main Household Income Provider	353	65	18.4	232	65.7	56	15.9	0.026	0.887 0.579
Household Monthly Income			n	%
R$ 0 up to R$ 2.600	119	15	12.6	68	57.1	36	30.3	1.189	0.630 2.246
R$ 2.601 up to R$ 7.800	262	46	17.6	165	63.0	51	19.5	0.941	0.603 1.469
R$ 7.801 or more	305	53	17.4	202	66.2	50	16.4	1.000	–

Sociodemographic factors that significantly influenced (p < 0.05) the shift in suicidal ideation were civil status and being the main household income provider. Single individuals had double the risk of severe suicidal ideation compared to widowers/widows/separated individuals. Being the main income provider was shown to be protective against the risk of severe suicidal ideation.

PSYCHIC STATUS

Bivariate analysis of psychic status with 30% significance showed that severe suicidal ideation was most prevalent in illicit drug users (87.5%) and in people’s self-harm (64.7%). Social distancing that affected very/totally emotional health prevailed in severe suicidal ideation (32.4%) than in those “noted “affected (10.6%), little (18.0%) or reasonably (21.3%). The self-perception of mental health as regular/bad/worse was more prevalent among individuals with severe suicidal ideation than in those who perceived themselves with good/excellent mental health (35.4% vs 9.0%).

Multivariate analysis, with a statistical significance < 30%, showed that severe suicidal ideation was the most found in unemployed (p < 0.001; OR = 3.88; CI 2.19 – 6.89) in relation to employed persons; individuals with physical disease (p = 0.002; OR = 2.81; CI 1.46 – 5.42) than those who were not affected; people in a marital crisis (p = 0.007; OR = 2.86; CI 1.28 – 6.37) than those not affected; alcohol /smoking users (p = 0.007; OR = 6.37; CI 1.41 – 28.66) than non-users; and victims of suffered violence (p = 0.015; OR = 3.07; CI 1.19 – 7.94) compared to those who did not suffer violence. During COVID-19, people that suffered reasonably with social distancing presented a higher risk of severe suicidal ideation (p = 0.002; OR = 2.82; CI 1.17 – 6.80) than those who were not affected; whereas those who were very/totally affected by social distancing had higher risk (p = 0.002; OR = 3.09; CI 1.24 – 7.67) when compared to those nothing affected. The self-perception of emotional health has shown that persons who perceived emotional health as regular/bad/worse had a higher risk (p < 0.001; OR = 6.07; CI 3.51 – 10.51) of severe suicidal ideation than those that perceived it as good/excellent.

Bivariate and multivariate analysis of factors related to psychic status connected to suicidal ideation levels of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Psychic status factors	Levels of Suicidal Ideation	Related to Suicidal Ideation Level	Mild / Moderate	Severe	p Value	OR¹	95% CI²	OR¹	95% CI²
Unemployment	201	22	10.9	113	56.2	66	32.8	0.000	1.468 0.879 2.449
Physical disease	134	15	11.2	78	58.2	41	30.6	0.002	1.442 0.795 2.616
Close person’s disease	247	36	14.6	154	62.3	57	23.1	0.245	1.187 0.764 1.846
Mourning	86	13	15.1	53	61.6	20	23.3	0.716	1.078 0.566 2.055
Marital Crisis	81	9	11.1	45	55.6	27	33.3	0.007	1.346 0.638 2.842
Alcohol or smoking	34	2	5.9	18	52.9	14	41.2	0.007	2.417 0.553 10.573
Illicit Drugs	8	0	0.0	1	12.5	7	87.5	–	–
Suffered Violence	57	6	10.5	31	54.4	20	35.1	0.015	1.381 0.562 3.396
Violence Committed	14	1	7.1	7	50.0	6	42.9	–	–
Self-harm	34	0	0.0	12	35.3	22	64.7	0.000	–
Social Distancing affecting Emotional Health	0.002	Nothing	104	21	20.2	72	69.2	11	10.6
A little	289	45	15.6	192	66.4	52	18.0	1.244	0.694 2.233
Reasonable	188	27	14.4	121	64.4	40	21.3	1.307	0.689 2.480
Very/ Totally	105	21	20.0	50	47.6	34	32.4	0.694	0.343 1.404
Self-perception of Emotional Health status	0.000	Good / Excellent	401	78	19.5	287	71.6	36	9.0
Regular / Bad / Worse	285	36	12.6	148	51.9	101	35.4	1.117	0.718 1.738

Psychic factors that significantly influenced suicidal ideation at a 5% significance level were: unemployment and self-perception of emotional health. Unemployed presented a higher risk (OR = 2.53; CI 1.38 – 4.62) of severe suicidal ideation than the employed individuals; regular/bad/worse self-perception of emotional health presented a higher risk (OR = 4.83; CI 2.74 – 8.51) of severe suicidal ideation when comparing to the individuals who perceived their own emotional health as good/excellent.

PSYCHIC CARE

When comparing severe suicidal ideation before and during the pandemic, bivariate analysis with approximately 30% significance related to psychic care showed that psychiatric follow-up decreased from 32.0% to 31.4%; the diagnosis of psychiatric disorders increased from 35.5% to 42.1%; the use of psychiatric drugs in general increased for psychiatric disorders, from 27.7% to 30.5%, and for non-psychiatric diseases, from 27.6% to 33.3%. Severe suicidal ideation was reported by 25.4% of individuals attending psychotherapy before the pandemic and 24.7% during the pandemic, while 21.8% were treated with Integrative and Complementary Practices (ICPs) before the pandemic and 19.5% during the pandemic.

Multivariate analysis with a statistical significance level of < 30% for psychiatric care before the pandemic indicated that severe suicidal ideation was higher among individuals with psychiatric follow-up (p < 0.001; OR = 3.05; CI 1.69 – 5.52), those diagnosed with psychiatric disorders (p < 0.001; OR = 3.67; CI 1.92 – 7.01), users of psychiatric drugs for psychiatric disorders (at least once) (p < 0.001; OR = 2.88; CI 1.67 – 4.97), and users of psychiatric drugs for non-psychiatric diseases (p = 0.026; OR = 1.82; CI 1.18 – 2.80). During the pandemic, severe suicidal ideation was higher among individuals with psychiatric follow-up (p = 0.002; OR = 2.98; CI 1.49 – 5.93), those diagnosed with psychiatric disorders (p < 0.001; OR = 7.42; CI 3.01 – 18.27), users of psychiatric drugs for psychiatric disorders (p = 0.002; OR = 2.31; CI 1.28 – 4.17), and users of psychiatric drugs for non-psychiatric diseases (p = 0.003; OR = 2.59; CI 1.26 – 5.30). Severe suicidal ideation before the pandemic was higher among individuals undergoing psychotherapy (p < 0.001; OR = 3.10; CI 1.82 – 5.26) and those receiving Integrative and Complementary Practices (ICPs) (p = 0.023; OR = 1.93; CI 1.13 – 3.31), while during the pandemic, it was higher among individuals with active psychotherapy follow-up (p = 0.036; OR = 2.21; CI 1.19 – 4.07) compared to those without follow-up.

Bivariate and multivariate analysis of factors associated with psychic care before and during COVID-19 connected to suicidal ideation levels of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Psychic Care factors before and during COVID-19	Levels of Suicidal Ideation	Related to Suicidal Ideation Level	Mild / Moderate	Severe	p Value	OR¹	95% CI²	OR¹	95% CI²
Psychiatric follow-up	172	20	11.8	95	56.2	54	32.0	0.000	1.313 0.770 2.239
Psychiatric Disorder	141	15	10.9	74	53.6	49	35.5	0.000	1.353 0.744 2.460
Psychiatric drugs for psychiatric disorder	0.000	Never	427	80	18.7	286	67.0	61	14.3
Yes, at least once	238	30	12.6	142	59.7	66	27.7	1.324	0.831 2.109
Psychiatric drugs for non-psychiatric disease	154	25	16.4	85	55.9	42	27.6	0.026	1.157 0.699 1.913
Psychiatric follow-up	121	13	10.7	70	57.9	38	31.4	0.002	1.490 0.792 2.802
Psychiatric disorder	95	6	6.3	49	51.6	40	42.1	0.000	2.285 0.953 5.477
Psychiatric drugs for psychiatric disorder	154	21	13.6	86	55.8	47	30.5	0.002	1.091 0.643 1.852
Psychiatric drugs for non-psychiatric disease	98	12	12.5	52	54.2	32	33.3	0.003	1.154 0.594 2.243
Psychotherapy	304	32	10.8	188	63.7	75	25.4	0.000	1.950 1.243 3.060
Integrative and Complementary Practices (ICPs)	264	30	11.7	171	66.5	56	21.8	0.023	1.814 1.146 2.870
Psychotherapy	174	19	11.2	109	64.1	42	24.7	0.036	1.672 0.976 2.864
Integrative and Complementary Practices (ICPs)	162	21	13.2	107	67.3	31	19.5	0.387	1.445 0.858 2.433

Factors of psychic care that greatly influenced (p < 0,05) suicidal ideation were: the use of psychiatric drugs for psychiatric disorders at least once before the pandemic, which presented a higher risk (OR = 2.25; CI 1.27 – 3.97) of severe suicidal ideation when compared to individuals who had never used this kind of medication; and psychotherapy follow-up before the pandemic, with a discreet higher risk (OR = 2.08; CI 1.28 – 3.36) on mild/moderate suicidal ideation and higher risk (OR=2.50; CI 1.41-4.42) on severe suicidal ideation if compared to people without follow-up.

SPIRITUAL BELIEF

Bivariate analysis with a significance level up to 30% has shown a higher prevalence of moderate suicidal ideation among individuals who classified themselves as spiritists (67.9%), those who reported a reasonable/high/very high preference for spiritism (66.8%), those with regular/high/very high levels of spiritual engagement (LSE) pre-pandemic (74.1%) and during the pandemic (73.4%), and those working in spiritist houses, including Public Lectures (62.3%), Spiritual Care (66.3%), and Charity/Volunteering (82.3%). On the other hand, the higher prevalence of severe suicidal ideation was observed among agnostics (46.2%), individuals with very low/low LSE pre-pandemic (21.2%) and during the pandemic (21.3%), and those who sought spiritism due to mental pain (26.1%).

Multivariate analysis with a significance level of up to 30% has shown that self-classification as Catholic is a protective factor against both mild/moderate suicidal ideation (p = 0.001; OR = 0.41; CI 0.26 – 0.65) and severe suicidal ideation (p = 0.001; OR = 0.48; CI 0.27 – 0.83). In contrast, individuals who self-classified as Spiritists presented a higher risk of mild/moderate suicidal ideation (p < 0.001; OR = 3.19; CI 2.00 – 5.08). A strong preference for Spiritism, rated as reasonable/very/totally, was associated with a higher risk of mild/moderate suicidal ideation (p < 0.001; OR = 3.23; CI 1.93 – 5.41). Regular/high/very high LSE before the pandemic was revealed as a protective factor, reducing the risk of severe ideation (p = 0.015; OR = 0.42; CI 0.19 – 0.96). Seeking Spiritism due to mental pain was associated with a higher risk of severe suicidal ideation (p = 0.034; OR = 2.11; CI 1.11 – 3.99). Engagement in Public Lectures reduced the risk of both mild/moderate suicidal ideation (p = 0.019; OR = 0.37; CI 0.18 – 0.75) and severe ideation (p = 0.019; OR = 0.33; CI 0.12 – 0.93). Similarly, working in Spiritual Care reduced the risk of both mild/moderate suicidal ideation (p = 0.039; OR = 0.44; CI 0.22 – 0.83) and severe ideation (p = 0.039; OR = 0.37; CI 0.15 – 0.93).

Bivariate and multivariate analysis of factors related to spiritual belief associated to suicidal ideation levels of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Spiritual Belief factors	Levels of Suicidal Ideation	Related to Suicidal Ideation Level	Mild / Moderate	Severe	p Value	OR¹	95% CI²	OR¹	95% CI²
Self-classified Religiousness	Without religion	26	5	19.2	9	34.6	12	46.2	0.002
Agnostic	10	2	20.0	2	20.0	6	60.0	–	–
Evangelist	29	7	24.1	13	44.8	9	31.0	0.079	–
Africa-Derived Religion	38	5	13.2	24	63.2	9	23.7	0.761	–
Catholic	157	42	26.8	85	54.1	30	19.1	0.001	0.416 0.266 0.652
Spiritist	545	73	13.4	370	67.9	102	18.7	0.000	3.197 2.009 5.087
Preference for Spiritism	None / A little	102	31	30.4	45	44.1	26	25.5	1.000
Reasonable / Very / Totally	584	83	14.2	390	66.8	111	19.0	3.237	1.934 5.418
Level of Spiritist Engagement before COVID-19	Very low / Low	523	78	14.9	334	63.9	111	21.2	1.000
Regular / High / Very high	112	18	16.1	83	74.1	11	9.8	1.077	0.611 1.897
Level of Spiritist Engagement during COVID-19	Very low / Low	607	101	16.6	377	62.1	129	21.3	1.000
Regular / High / Very high	79	13	16.5	58	73.4	8	10.1	1.195	0.630 2.267
Motivation to search for the spiritist doctrine	Origin / familial influence	102	16	15.7	63	61.8	23	22.5	0.570
Friends/socio-familial influence	141	20	14.2	91	64.5	30	21.3	0.770
Curiosity	203	34	16.7	131	64.5	38	18.7	0.747
Mental pain	153	18	11.8	95	62.1	40	26.1	0.034
Self-reported mediumship	126	15	11.9	84	66.7	27	21.4	0.489
Scientific/philosophical interest	228	31	13.6	163	71.5	34	14.9	0.056
Necessity/ familial pain	25	7	28.0	15	60.0	3	12.0	0.173
Worker/facilitator in the spiritist centre	288	42	14.6	205	71.2	41	14.2	0.046
Public Lecture	61	16	26.2	38	62.3	7	11.5	0.019
Spiritual Care	101	22	21.8	67	66.3	12	11.9	0.039
Systematic study of Spiritist doctrine	122	19	15.6	86	70.5	17	13.9	0.929
Mediumship studies	94	14	14.9	67	71.3	13	13.8	1.000
Fraternal service	62	10	16.1	42	67.7	10	16.1	0.767
Fluidotherapy (magnetised/fluidic water)	66	8	12.1	51	77.3	7	10.6	0.489
Mediumship meeting	142	21	14.8	103	72.5	18	12.7	1.000
Charity/ volunteering	62	6	9.7	51	82.3	5	8.1	0.096
Administrative role	78	12	15.4	57	73.1	9	11.5	0.761

Spiritual belief factors with 5% significance have demonstrated that the meaningfully influenced suicidal ideation were spiritist self-classification and pre-pandemic LSE. The former presented a higher risk of mild/moderate suicidal ideation (OR = 2.52; CI 1.42 – 4.47); whereas regular/high/very high LSE before the pandemic was a protective factor, with lower risk (OR = 0.37; CI 0.16 – 0.85) of severe suicide ideation.

MULTINOMIAL REGRESSION: ALL THE FACTORS

Multinomial regression analysis of all significantly factors associated to suicidal ideation indicated that to be single presented a higher risk of mild/moderate suicidal ideation (OR = 2.32; CI 1.19 – 4.52) and severe (OR = 4.05; CI 1.89 – 8.69). Unemployment has displayed a higher risk (OR = 2.93; CI 1.45 – 5.92) of severe suicidal ideation. Pre-COVID-19 follow-up was associated with mild/moderate suicidal ideation (OR = 1.81; CI 1.10 – 2.98) and showed a higher risk (OR = 2.57; CI 1.40 – 4.71) of severe ideation. The same happened to the spiritist self-classification that showed higher risk (OR = 2.43; CI 1.34 – 4.38) for mild/moderate suicidal ideation and higher risk (OR = 2.13; CI 1.00 – 4.52) for severe ideation. The only protection factor of high significance was pre-COVID-19 regular/high/very high LSE with lower risk (OR=0.38; CI 0.16-0.90) for severe ideation.

Multinomial regression of all significantly factors associated to suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Suicidal Ideation Factors	Related to Suicidal Ideation Level	Mild / Moderate	Severe	OR¹	95% CI²	OR¹	95% CI²
Civil Status	Married or in a stable relationship	1.000	–	1.000	–
Single	2.358	1.252 4.441	4.242	2.099 8.571
Widower/ Widow / Divorced/ Separated	2.036	1.081 3.835	2.253	1.036 4.900
Main Household Income Provider	0.814	0.525 1.262	0.501	0.293 0.857

Discussion

SOCIODEMOGRAPHIC FACTORS

Sociodemographic data indicated that the absence of a steady relationship was associated with suicidal ideation, which was higher among single individuals compared to those who had lost their partners. Single individuals had twice the chance of experiencing mild to moderate suicidal ideation, and this risk doubled for severe suicidal ideation. Individuals with low education had a higher probability of suicidal ideation. Being the main income provider had a protective effect against severe suicidal ideation, while individuals with lower household income were at a higher risk. However, the multinomial analysis of sociodemographic factors revealed that only the absence of a steady relationship was a risk factor, while being the main income provider was a protective factor.

Not being in a steady relationship and living alone have already been listed as relevant aspects for suicide, regardless of the culture. In Brazil, this trend is corroborated by regional data, as in Pernambuco, where more than 400 women legally separated committed suicide between 2013 and 2017; and in Ceará, divorce is linked to suicide, as over the double of national data. Low education has already been connected to suicide in Brazil, e.g., in Curitiba, where people with mental disorders and with education between 0 and 8 years (p = 0.016), or 9 and 12 (p = 0.013) were significantly associated to suicide. Similarly, persons holding 4 to 7 years of education presented the highest prevalence of suicide in Goiás, from 2009 to 2014, as well as in Ceará, from 2015 to 2017. In fact, more than half of Ceará’s inhabitants have not completed the elementary or secondary school.

Indeed, poverty raises the risk of mental disorders worldwide. In Brazil, the quintile of the population with the lowest income presented a 2 to 5 times higher risk of mental disorder, and who was born in a poor family or has impoverished after childhood have a higher risk to try suicide. In Ceará, low income was identified as one of the factors most connected to suicide, and more than half of this population has an income less than 1 minimum salary (up to R$ 1.046,00), which makes visible the state’s vulnerability. In parallel, to be the main household income provider, regardless of the value, has a lower risk for suicide due to parenthood and also family relationships are a protective factor for suicide, which is in line with the current study.

PSYCHIC STATUS

Bivariate analysis of psychic status with 30% significance showed that severe suicidal ideation was most prevalent in illicit drug users (87.5%) and in people’s self-harm (64.7%). Social distancing that affected very/totally emotional health prevailed in severe suicidal ideation (32.4%) than in those “noted” affected (10.6%), little (18.0%) or reasonably (21.3%). The self-perception of mental health as regular/bad/ worse was more prevalent among individuals with severe suicidal ideation than in those who perceived themselves with good/excellent mental health (35.4% vs 9.0%) (TABLE 3).

Multivariate analysis, with a statistical significance < 30%, showed that severe suicidal ideation was the most found in unemployed (p < 0.001; OR = 3.88; CI 2.19 – 6.89) in relation to employed persons; individuals with physical disease (p = 0.002; OR = 2.81; CI 1.46 – 5.42) than those who were not affected; people in a marital crisis (p = 0.007; OR = 2.86; CI 1.28 – 6.37) than those not affected; alcohol /smoking users (p = 0.007; OR = 6.37; CI 1.41 – 28.66) than non-users; and victims of suffered violence (p = 0.015; OR = 3.07; CI 1.19 – 7.94) compared to those who did not suffer violence. During COVID-19, people that suffered reasonably with social distancing presented a higher risk of severe suicidal ideation (p = 0.002; OR = 2.82; CI 1.17 – 6.80) than those who were not affected; whereas those who were very/totally affected by social distancing had higher risk (p = 0.002; OR = 3.09; CI 1.24 – 7.67) when compared to those nothing affected. The self-perception of emotional health has shown that persons who perceived emotional health as regular/bad/worse had a higher risk (p < 0.001; OR = 6.07; CI 3.51 – 10.51) of severe suicidal ideation than those that perceived it as good/excellent (TABLE 3).

Table 3 – Bivariate and multivariate analysis of factors related to psychic status connected to suicidal ideation levels of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Source: Author(s) (2022)
¹Odds Ratio, ²Confidence Interval, ³Lower Limit, ⁴Upper Limit

---

Factors that significantly influenced suicidal ideation at a 5% significance level were: unemployment and self-perception of emotional health. Unemployed presented a higher risk (OR = 2.53; CI 1.38 – 4.62) of severe suicidal ideation than the employed individuals; regular/bad/worse self-perception of emotional health presented a higher risk (OR = 4.83; CI 2.74 – 8.51) of severe suicidal ideation when comparing to those individuals who perceived their own emotional health as good/excellent (TABLE 4).

Table 4 – Multinomial regression of psychic status associated with levels of suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Source: Author(s) (2022)
¹Odds Ratio, ²Confidence Interval, ³Lower Limit, ⁴Upper Limit

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PSYCHIC CARE
When comparing severe suicidal ideation before and during the pandemic, bivariate analysis with approximately 30% significance related to psychic care showed that psychiatric follow-up decreased from 32.0% to 31.4%; the diagnosis of psychiatric disorders increased from 35.5% to 42.1%; the use of psychiatric drugs in general increased for psychiatric disorders, from 27.7% to 30.5%, and for non-psychiatric diseases, from 27.6% to 33.3%. Severe suicidal ideation was reported by 25.4% of individuals attending psychotherapy before the pandemic and 24.7% during the pandemic, while 21.8% were treated with Integrative and Complementary Practices (ICPs) before the pandemic and 19.5% during the pandemic (TABLE 5).

Multivariate analysis with a statistical significance level of < 30% for psychiatric care before the pandemic indicated that severe suicidal ideation was higher among individuals with psychiatric follow-up (p < 0.001; OR = 3.05; CI 1.69 – 5.52), those diagnosed with psychiatric disorders (p < 0.001; OR = 3.67; CI 1.92 – 7.01), users of psychiatric drugs for psychiatric disorders (at least once) (p < 0.001; OR = 2.88; CI 1.67 – 4.97), and users of psychiatric drugs for non-psychiatric ones (p = 0.026; OR = 1.82; CI 1.118 – 2.80). During the pandemic, severe suicidal ideation was higher among individuals with psychiatric follow-up (p = 0.002; OR = 2.98; CI 1.49 – 5.93), those diagnosed with psychiatric disorders (p < 0.001; OR = 7.42; CI 3.01 – 18.27), users of psychiatric drugs psychiatric drugs for psychiatric disorders (p = 0.002; OR = 2.31; CI 1.28 – 4.17), and users of psychiatric drugs for non-psychiatric diseases (p = 0.003; OR = 2.59; CI 1.26 – 5.30). Severe suicidal ideation before the pandemic was higher among individuals undergoing psychotherapy (p < 0.001; OR = 3.10; CI 1.82 – 5.26) and those receiving Integrative and Complementary Practices (ICPs) (p = 0.023; OR = 1.93; CI 1.13 – 3.31), while during the pandemic, it was higher among individuals with active psychotherapy follow-up (p = 0.036; OR = 2.21; CI 1.19 – 4.07) compared to those without follow-up (TABLE 5).

Table 5 – Bivariate and multivariate analysis of factors associated with psychic care before and during COVID-19 connected to suicidal ideation levels of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Source: Author(s) (2022)
¹Odds Ratio, ²Confidence Interval, ³Lower Limit, ⁴Upper Limit

---

Factors of psychic care that greatly influenced (p < 0.05) suicidal ideation were: the use of psychiatric drugs for psychiatric disorders at least once before the pandemic, which presented a higher risk (OR = 2.25; CI 1.27 – 3.97) of severe suicidal ideation when compared to individuals who had never used this kind of medication; and psychotherapy follow-up before the pandemic, with a discreet higher risk (OR = 2.08; CI 1.28 – 3.36) on mild/moderate suicidal ideation and higher risk (OR = 2.50; CI 1.41 – 4.42) on severe suicidal ideation if compared to people without follow-up (TABLE 6).

Table 6 – Multinomial regression of psychic care associated with levels of suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Source: Author(s) (2022)
¹Odds Ratio, ²Confidence Interval, ³Lower Limit, ⁴Upper Limit

---

SPIRITUAL BELIEF
Bivariate analysis with a significance level up to 30% has shown a higher prevalence of moderate suicidal ideation among individuals who classified themselves as spiritists (67.9%), those who reported a reasonable/high/very high preference for spiritism (66.8%), those with regular/high/very high levels of spiritual engagement (LSE) pre-pandemic (74.1%) and during the pandemic (73.4%), and those working in spiritist houses, including Public Lectures (62.3%), Spiritual Care (66.3%), and Charity/Volunteering (82.3%). On the other hand, the higher prevalence of severe suicidal ideation was observed among agnostics (46.2%), individuals with very low/low LSE pre-pandemic (21.2%) and during the pandemic (21.3%), and those who sought spiritism due to mental pain (26.1%) (TABLE 7).

Table 8 – Multinomial regression of spiritual belief associated with levels of suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Spiritual belief	Related to Suicidal Ideation Level
	Mild / Moderate
	OR¹
	LL³
Self-classified Religiousness — Spiritism	2.431
Level of Spiritist Engagement before COVID-19
Very low / Low	1.000
Regular / High / Very high	0.908

Source: Author(s) (2022)
¹Odds Ratio, ²Confidence Interval, ³Lower Limit, ⁴Upper Limit

---

MULTINOMIAL REGRESSION: ALL THE FACTORS

Multinomial regression analysis of all significantly factors associated to suicidal ideation indicated that to be single presented a higher risk of mild/moderate suicidal ideation (OR = 2.32; CI 1.19 – 4.52) and severe (OR = 4.05; CI 1.89 – 8.69). Unemployment has displayed a higher risk (OR = 2.93; CI 1.45 – 5.92) of severe suicidal ideation. Pre-COVID-19 follow-up was associated with mild/moderate suicidal ideation (OR = 1.81; CI 1.10 – 2.98) and showed a higher risk (OR = 2.57; CI 1.40 – 4.71) of severe ideation. The same happened to the spiritist self-classification that showed higher risk (OR = 2.43; CI 1.34 – 4.38) for mild/moderate suicidal ideation and higher risk (OR = 2.13; CI 1.00 – 4.52) for severe ideation. The only protection factor of high significance was pre-COVID-19 regular/high/very high LSE with lower risk (OR = 0.38; CI 0.16–0.90) for severe ideation (TABLE 9).

---

Table 9 – Multinomial regression of all significantly factors associated to suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Suicidal Ideation Factors	Related to Suicidal Ideation Level
	Mild / Moderate
	OR¹
	LL³
Civil Status
Married or in a stable relationship	1.000
Single	2.321
Widower/Widow/Divorced/Separated	1.923
Unemployment	1.750
Self-perception of Emotional Health status
Good / Excellent	1.000
Regular / Bad / Worse	1.031
Psychotherapy follow-up before COVID-19	1.812
Self-classified Religiousness — Spiritism	2.431
Level of Spiritist Engagement before COVID-19
Very low / Low	1.000
Regular / High / Very high	0.908

Source: Author(s) (2022)
¹Odds Ratio, ²Confidence Interval, ³Lower Limit, ⁴Upper Limit

---

Discussion

SOCIODEMOGRAPHIC FACTORS

Sociodemographic data indicated that the absence of a steady relationship was associated with suicidal ideation, which was higher among single individuals compared to those who had lost their partners. Single individuals had twice the chance of experiencing mild to moderate suicidal ideation, and this risk doubled for severe suicidal ideation. Individuals with low education had a higher probability of suicidal ideation. Being the main income provider had a protective effect against severe suicidal ideation, while individuals with lower household income were at a higher risk. However, the multinomial analysis of sociodemographic factors revealed that only the absence of a steady relationship was a risk factor, while being the main income provider was a protective factor.

Not being in a steady relationship and living alone also increased poverty rates, which in turn raised the risk of mental disorders and suicide attempts. In Ceará, low income was identified as one of the main factors connected to suicide, as more than half of this population earns less than one minimum salary (up to R$ 1,046.00), increasing the state’s vulnerability. In parallel, being the main household income provider, regardless of value, has a lower risk for suicide due to parenthood, and family relationships are a protective factor, in line with this study.

---

PSYCHIC STATUS

During the pandemic, emotional health was impacted by unemployment, physical disease, the use of alcohol and/or smoking, and social distancing that affected mental health. The self-perception of mental health as regular/bad/worse also triggered severe suicidal ideation. Only unemployment and poor self-perception of emotional health significantly contributed to the development of suicidal ideation.

Emotional pain and suicide were associated with physical disease, especially in the elderly. The use of illicit drugs and alcohol increased the risk of injury and suicide (including self-inflicted), and both were strongly linked to suicidal ideation, suicide attempt (OR = 3.13), and completed suicide (OR = 2.59). Social distancing, even alone, was associated with active and passive suicidal ideation, representing a “second pandemic” due to its mental health impact.

Unemployment caused emotional pain, one of the strongest predictors of suicide. In the U.S., job loss was the second main cause of mental disorder during the pandemic. In Ceará, unemployment doubled the risk of suicide compared to the rest of Brazil.

---

PSYCHIC CARE

Before the pandemic, psychiatric disorders, medication use, and psychotherapy follow-up were substantially associated with severe suicidal ideation. These remained relevant during COVID-19. Multinomial analysis showed that only the use of psychiatric drugs for psychiatric disorders and psychotherapy follow-up increased the risk of severe suicidal ideation.

The analysis confirmed that severe suicidal ideation was higher among individuals undergoing psychiatric follow-up before COVID-19. This group had a higher prevalence of psychiatric disorders and treatment compared to the general population, possibly due to better access to care through private means.

---

SPIRITUAL BELIEF

Self-declared spiritists and those who preferred Spiritism showed a higher risk of mild and moderate suicidal ideation, whereas self-classified Catholics showed protective effects. Those who sought Spiritism due to mental pain had higher suicidal risks, while those active in public lectures or spiritual care roles had lower risks.

Before COVID-19, high spiritual engagement (LSE) and Catholic self-identification were protective against suicidal ideation.

---

LIMITATIONS AND FUTURE RESEARCH

Despite significant findings, causal relationships could not be fully established because the study was cross-sectional. Future longitudinal research is needed to explore the impact of Spiritist engagement on mental health, its potential protective or aggravating effects, and subjective experiences related to spirituality and psychological resilience.

---

Conclusion

Individuals with Spiritist engagement at risk of having mild/moderate suicidal ideation were single, unemployed, receiving psychotherapy before COVID-19, and self-classified as Spiritists. Severe suicidal ideation was associated with unemployment and poor self-perception of emotional health.

A higher level of spiritual engagement before the pandemic proved to be a relevant protective factor against suicidal ideation during COVID-19.

Although Spiritism may attract individuals with psychological suffering, higher engagement may also mitigate suicidal tendencies, showing the complex dual role of spirituality in mental health.

Figure 1: Summary of the results of the multinomial regression of all significantly factors associated to severe suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.

Ethics approval and consent to participate

The research met the Law 466/2012 of the National Council of Health (NCH), related to Research Ethics involving Human Beings, with approval of the Ethics Committee of the Federal University of Ceará (n. 2.237.838).

Human and animal rights

No animals were used in this research. All human research procedures followed the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

Consent for publication

Informed consent was obtained from all participants.

Availability of data and materials

The authors confirm that the data supporting the findings of this study are available within the manuscript.

Funding

None.

Conflict of interest

The authors declare no conflict of interest, financial or otherwise.

Acknowledgements

Declare none.

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