Factors Influencing Suicidal Ideation in Spiritist Individuals
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 Sales¹, Rosa Maria Salani Mota², Raimunda Hermelinda Maia Macena³
- Psychiatrist and Doctor of Public Health at the Faculty of Medicine of the Federal University of Ceará.
- Statistician and Professor in the Department of Statistics and Applied Mathematics at the Federal University of Ceará.
- 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%) (TABLE 1).
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) (TABLE 1).
| Sociodemographic Factors | Levels of Suicidal Ideation | Related to Suicidal Ideation Level: | Mild / Moderate | Severe | p Value | OR¹ | 95% CI² | OR* | 95% CI² | |
|---|---|---|---|---|---|---|---|---|---|---|
| Gender | 494 | 106 | 0.289 | 0.926 | 0.586 – 1.463 | 1.334 | 0.753 – 2.364 | |||
| Female | 82 | 16.6 | 306 | 61.9 | 106 | 21.5 | ||||
| Male | 192 | 32 | 16.7 | 129 | 67.2 | 31 | 16.1 | 1.000 | – | |
| Age | 101 | 30 | 0.104 | 0.945 | 0.494 – 1.809 | 2.012 | 0.959 – 4.222 | |||
| Between 18 and 34 years | 16 | 15.8 | 55 | 54.5 | 30 | 29.7 | ||||
| Between 35 and 54 years | 340 | 54 | 220 | 64.7 | 66 | 19.4 | 1.120 | 0.716 – 1.752 | 1.312 | 0.751 – 2.290 |
| 55 years or over | 245 | 44 | 160 | 65.3 | 41 | 16.7 | 1.000 | – | 1.000 | – |
| Race | 345 | 73 | 0.914 | 1.123 | 0.459 – 2.747 | 1.259 | 0.418 – 3.792 | |||
| White | 58 | 16.8 | 214 | 62.0 | 73 | 21.2 | ||||
| Pardo (Brown) | 304 | 49 | 198 | 65.1 | 57 | 18.8 | 1.230 | 0.499 – 3.031 | 1.163 | 0.381 – 3.548 |
| Others | 37 | 7 | 23 | 62.2 | 7 | 18.9 | 1.000 | – | 1.000 | – |
| Marital Status | 0.000 | 401 | 65 | 1.000 | – | – | 1.000 | – | ||
| Married or in a stable relationship | 85 | 21.2 | 251 | 62.6 | 65 | 16.2 | 1.000 | – | – | |
| Single | 170 | 15 | 104 | 61.2 | 51 | 30.0 | 2.348 | 1.296 – 4.255 | 4.446 | 2.298 – 8.603 |
| Widower/Widow/ Divorced/ Separated | 115 | 14 | 80 | 69.6 | 21 | 18.3 | 1.935 | 1.042 – 3.593 | 1.962 | 0.927 – 4.150 |
| Education Level | 0.006 | 140 | 41 | 0.941 | 0.603 – 1.469 | 1.175 | 0.675 – 2.047 | |||
| Complete Secondary School /Incomplete Higher Education /Technical | 140 | 18 | 81 | 57.9 | 41 | 29.3 | 1.238 | 0.708 – 2.164 | 2.351 | 1.261 – 4.385 |
| Bachelor’s Degree/Graduation/Post-Graduation | 538 | 96 | 349 | 64.9 | 93 | 17.3 | 1.000 | – | 1.000 | – |
| Workload / Daily Workload | 0.647 | 308 | 60 | 1.000 | – | – | 1.000 | – | ||
| Up to 8 hours | 308 | 48 | 200 | 64.9 | 60 | 19.5 | 1.000 | – | – | |
| 8 hours or more | 279 | 53 | 169 | 60.6 | 57 | 20.4 | 0.765 | 0.492 – 1.189 | 0.860 | 0.505 – 1.466 |
| None | 99 | 13 | 66 | 66.7 | 20 | 20.2 | 1.218 | 0.622 – 2.388 | 1.231 | 0.556 – 2.725 |
| Main Household Income Provider | 353 | 65 | 232 | 65.7 | 56 | 15.9 | 0.026 | 0.887 | 0.579 | 1.360 |
| Household Monthly Income | 0.037 | 119 | 36 | 1.189 | 0.630 – 2.246 | 2.544 | 1.244 – 5.204 | |||
| R$ 0 up to R$ 2.600 | 119 | 15 | 68 | 57.1 | 36 | 30.3 | 1.189 | 0.630 – 2.246 | 2.544 | 1.244 – 5.204 |
| R$ 2.601 up to R$ 7.800 | 262 | 46 | 165 | 63.0 | 51 | 19.5 | 0.941 | 0.603 – 1.469 | 1.175 | 0.675 – 2.047 |
| R$ 7.801 or more | 305 | 53 | 202 | 66.2 | 50 | 16.4 | 1.000 | – | 1.000 | – |
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.
| 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 | 113 | 56.2 | 66 | 32.8 | 0.000 | 1.468 | 0.879 – 2.449 | 3.887 | 2.191 – 6.897 |
| Physical disease | 134 | 15 | 78 | 58.2 | 41 | 30.6 | 0.002 | 1.442 | 0.795 – 2.616 | 2.819 | 1.465 – 5.425 |
| Close person’s disease | 247 | 36 | 154 | 62.3 | 57 | 23.1 | 0.245 | 1.187 | 0.764 – 1.846 | 1.544 | 0.917 – 2.599 |
| Mourning | 86 | 13 | 53 | 61.6 | 20 | 23.3 | 0.716 | 1.078 | 0.566 – 2.055 | 1.328 | 0.629 – 2.804 |
| Marital Crisis | 81 | 9 | 45 | 55.6 | 27 | 33.3 | 0.007 | 1.346 | 0.638 – 2.842 | 2.864 | 1.286 – 6.376 |
| Alcohol or smoking | 34 | 2 | 18 | 52.9 | 14 | 41.2 | 0.007 | 2.417 | 0.553 – 10.573 | 6.374 | 1.417 – 28.668 |
| Illicit Drugs | 8 | 0 | 1 | 12.5 | 7 | 87.5 | – | – | – | – | – |
| Suffered Violence | 57 | 6 | 31 | 54.4 | 20 | 35.1 | 0.015 | 1.381 | 0.562 – 3.396 | 3.077 | 1.191 – 7.949 |
| Violence Committed | 14 | 1 | 7 | 50.0 | 6 | 42.9 | – | – | – | – | – |
| Self-harm | 34 | 0 | 12 | 35.3 | 22 | 64.7 | 0.000 | – | – | – | – |
| Social Distancing affecting Emotional Health | 0.002 | 104 | 21 | 72 | 69.2 | 11 | 10.6 | 1.000 | – | – | |
| Nothing | 104 | 21 | 72 | 69.2 | 11 | 10.6 | 1.000 | – | – | ||
| A little | 289 | 45 | 192 | 66.4 | 52 | 18.0 | 1.244 | 0.694 – 2.233 | 2.206 | 0.961 – 5.067 | |
| Reasonable | 188 | 27 | 121 | 64.4 | 40 | 21.3 | 1.307 | 0.689 – 2.480 | 2.828 | 1.176 – 6.803 | |
| Very/ Totally | 105 | 21 | 50 | 47.6 | 34 | 32.4 | 0.694 | 0.343 – 1.404 | 3.091 | 1.244 – 7.679 | |
| Self-perception of Emotional Health status | 0.000 | 401 | 78 | 287 | 71.6 | 36 | 9.0 | 1.000 | – | ||
| Good / Excellent | 401 | 78 | 287 | 71.6 | 36 | 9.0 | 1.000 | – | – | ||
| Regular / Bad / Worse | 285 | 36 | 148 | 51.9 | 101 | 35.4 | 1.117 | 0.718 – 1.738 | 6.079 | 3.513 – 10.519 |
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.
| 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 Care before COVID-19 | Psychiatric follow-up | 172 | 20 | 95 | 56.2 | 54 | 32.0 | 0.000 | 1.313 | 0.770 – 2.239 | 3.058 | 1.692 – 5.527 |
| Psychiatric Disorder | 141 | 15 | 74 | 53.6 | 49 | 35.5 | 0.000 | 1.353 | 0.744 – 2.460 | 3.675 | 1.927 – 7.010 | |
| Psychiatric drugs for psychiatric disorder | Never | 427 | 80 | 286 | 67.0 | 61 | 14.3 | 1.000 | – | – | ||
| Yes, at least once | 238 | 30 | 142 | 59.7 | 66 | 27.7 | 1.324 | 0.831 – 2.109 | 2.885 | 1.673 – 4.977 | ||
| Psychiatric drugs for non-psychiatric disease | 154 | 25 | 85 | 55.9 | 42 | 27.6 | 0.026 | 1.157 | 0.699 – 1.913 | 1.820 | 1.180 – 2.809 | |
| Psychiatric Care during COVID-19 | Psychiatric follow-up | 121 | 13 | 70 | 57.9 | 38 | 31.4 | 0.002 | 1.490 | 0.792 – 2.802 | 2.982 | 1.499 – 5.934 |
| Psychiatric disorder | 95 | 6 | 49 | 51.6 | 40 | 42.1 | 0.000 | 2.285 | 0.953 – 5.477 | 7.423 | 3.015 – 18.272 | |
| Psychiatric drugs for psychiatric disorder | 154 | 21 | 86 | 55.8 | 47 | 30.5 | 0.002 | 1.091 | 0.643 – 1.852 | 2.313 | 1.281 – 4.174 | |
| Psychiatric drugs for non-psychiatric disease | 98 | 12 | 52 | 54.2 | 32 | 33.3 | 0.003 | 1.154 | 0.594 – 2.243 | 2.590 | 1.264 – 5.307 | |
| Non-medical assistance before COVID-19 | Psychotherapy | 304 | 32 | 188 | 63.7 | 75 | 25.4 | 0.000 | 1.950 | 1.243 – 3.060 | 3.100 | 1.826 – 5.262 |
| Integrative and Complementary Practices (ICPs) | 264 | 30 | 171 | 66.5 | 56 | 21.8 | 0.023 | 1.814 | 1.146 – 2.870 | 1.936 | 1.130 – 3.316 | |
| Non-medical assistance during COVID-19 | Pychotherapy | 174 | 19 | 109 | 64.1 | 42 | 24.7 | 0.036 | 1.672 | 0.976 – 2.864 | 2.211 | 1.199 – 4.076 |
| Integrative and Complementary Practices (ICPs) | 162 | 21 | 107 | 67.3 | 31 | 19.5 | 0.387 | 1.445 | 0.858 – 2.433 | 1.295 | 0.697 – 2.408 |
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).
| 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 | 9 | 34.6 | 12 | 46.2 | 0.002 | – | – | |
| Agnostic | 10 | 2 | 2 | 20.0 | 6 | 60.0 | – | – | – | – | |
| Evangelist | 29 | 7 | 13 | 44.8 | 9 | 31.0 | 0.079 | – | – | – | |
| Africa-Derived Religion | 38 | 5 | 24 | 63.2 | 9 | 23.7 | 0.761 | – | – | – | |
| Catholic | 157 | 42 | 85 | 54.1 | 30 | 19.1 | 0.001 | 0.416 | 0.266 – 0.652 | 0.481 | 0.276 – 0.838 |
| Spiritist | 545 | 73 | 370 | 67.9 | 102 | 18.7 | 0.000 | 3.197 | 2.009 – 5.087 | 1.637 | 0.952 – 2.814 |
| Preference for Spiritism | None / A little | 102 | 31 | 45 | 44.1 | 26 | 25.5 | 1.000 | – | – | |
| Reasonable / Very / Totally | 584 | 83 | 390 | 66.8 | 111 | 19.0 | 3.237 | 1.934 – 5.418 | 1.595 | 0.881 – 2.887 | |
| Level of Spiritist Engagement before COVID-19 | Very low / Low | 523 | 78 | 334 | 63.9 | 111 | 21.2 | 1.000 | – | – | |
| Regular / High / Very high | 112 | 18 | 83 | 74.1 | 11 | 9.8 | 1.077 | 0.611 – 1.897 | 0.429 | 0.192 – 0.960 | |
| Level of Spiritist Engagement during COVID-19 | Very low / Low | 607 | 101 | 377 | 62.1 | 129 | 21.3 | 1.000 | – | – | |
| Regular / High / Very high | 79 | 13 | 58 | 73.4 | 8 | 10.1 | 1.195 | 0.630 – 2.267 | 0.482 | 0.192 – 1.207 | |
| Motivation to search for the spiritist doctrine | Origin / familial influence | 102 | 16 | 63 | 61.8 | 23 | 22.5 | 0.570 | 0.890 | 0.488 – 1.621 | |
| Friends/socio-familial influence | 141 | 20 | 91 | 64.5 | 30 | 21.3 | 0.770 | 1.061 | 0.615 – 1.829 | 1.239 | 0.652 – 2.355 |
| Curiosity | 203 | 34 | 131 | 64.5 | 38 | 18.7 | 0.747 | 0.835 | 0.524 – 1.332 | 0.506 | 0.825 – 0.468 |
| Mental pain | 153 | 18 | 95 | 62.1 | 40 | 26.1 | 0.034 | 1.278 | 0.729 – 2.241 | 2.114 | 1.118 – 3.996 |
| Self-reported mediumship | 126 | 15 | 84 | 66.7 | 27 | 21.4 | 0.489 | 1.362 | 0.747 – 2.484 | 1.535 | 0.764 – 3.082 |
| Scientific/philosophical interest | 228 | 31 | 163 | 71.5 | 34 | 14.9 | 0.056 | 1.346 | 0.840 – 2.155 | 0.810 | 0.452 – 1.451 |
| Necessity/ familial pain | 25 | 7 | 15 | 60.0 | 3 | 12.0 | 0.173 | 0.474 | 0.188 – 1.198 | 0.321 | 0.081 – 1.274 |
| Worker/facilitator in the spiritist centre | 288 | 42 | 205 | 71.2 | 41 | 14.2 | 0.046 | 1.255 | 0.733 – 2.149 | 0.676 | 0.352 – 1.298 |
| Public Lecture | 61 | 16 | 38 | 62.3 | 7 | 11.5 | 0.019 | 0.370 | 0.181 – 0.756 | 0.335 | 0.120 – 0.932 |
| Spiritual Care | 101 | 22 | 67 | 66.3 | 12 | 11.9 | 0.039 | 0.441 | 0.225 – 0.864 | 0.376 | 0.152 – 0.930 |
| Systematic study of Spiritist doctrine | 122 | 19 | 86 | 70.5 | 17 | 13.9 | 0.929 | 0.875 | 0.449 – 1.706 | 0.857 | 0.360 – 2.045 |
| Mediumship studies | 94 | 14 | 67 | 71.3 | 13 | 13.8 | 1.000 | 0.971 | 0.480 – 1.965 | 0.929 | 0.370 – 2.327 |
| Fraternal service | 62 | 10 | 42 | 67.7 | 10 | 16.1 | 0.767 | 0.825 | 0.375 – 1.811 | 1.032 | 0.377 – 2.823 |
| Fluidotherapy (magnetised/fluidic water) | 66 | 8 | 51 | 77.3 | 7 | 10.6 | 0.489 | 1.407 | 0.612 – 3.237 | 0.875 | 0.285 – 2.682 |
| Mediumship meeting | 142 | 21 | 103 | 72.5 | 18 | 12.7 | 0.791 | 1.010 | 0.520 – 1.961 | 0.783 | 0.330 – 1.857 |
| Charity/ volunteering | 62 | 6 | 51 | 82.3 | 5 | 8.1 | 0.096 | 1.987 | 0.792 – 4.988 | 0.833 | 0.233 – 2.978 |
| Administrative role | 78 | 12 | 57 | 73.1 | 9 | 11.5 | 0.761 |
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.
Related to Suicidal Ideation Level
Spiritual belief
Mild / Moderate (OR | 95% CI LL–UL) | Severe (OR | 95% CI LL–UL)
Self-classified Religiousness – Spiritism
2.431 | 1.349 – 4.380 | 2.133 | 1.005 – 4.528
Level of Spiritist Engagement before COVID-19
Very low / Low
1.000 | – | 1.000 | –
Regular / High / Very high
0.908 | 0.502 – 1.645 | 0.382 | 0.161 – 0.907
Source: Author(s) (2022)
Odds Ratio; Confidence Interval; Lower Limit; Upper Limit
MULTINOMIAL REGRESSION: ALL THE FACTORS
Multinomial regression analysis of all significant factors associated with suicidal ideation indicated that being 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 showed 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 with spiritist self-classification, which 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 protective 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 significant factors associated with suicidal ideation of people with spiritist engagement in the state of Ceará. Fortaleza/CE, 2022.
Related to Suicidal Ideation Level
Suicidal Ideation Factors
Civil Status
Married or in a stable relationship
1.000 | – | 1.000 | –
Single
2.327 | 1.197 – 4.523 | 4.058 | 1.894 – 8.692
Widower/Widow/Divorced/Separated
1.923 | 0.961 – 3.847 | 1.787 | 0.757 – 4.216
Unemployment
1.750 | 0.944 – 3.245 | 2.937 | 1.456 – 5.926
Self-perception of Emotional Health Status
Good / Excellent
1.000 | – | 1.000 | –
Regular / Bad / Worse
1.031 | 0.614 – 1.730 | 4.844 | 2.559 – 9.170
Psychotherapy follow-up before COVID-19
1.812 | 1.102 – 2.980 | 2.570 | 1.402 – 4.712
Self-classified Religiousness – Spiritism
2.431 | 1.349 – 4.380 | 2.133 | 1.005 – 4.528
Level of Spiritist Engagement before COVID-19
Very low / Low
1.000 | – | 1.000 | –
Regular / High / Very high
0.908 | 0.502 – 1.645 | 0.382 | 0.161 – 0.907
Source: Author(s) (2022)
Odds Ratio; Confidence Interval; Lower Limit; Upper 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 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 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, at over double the 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 with 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 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 those born in poor families or who became impoverished after childhood have a higher risk. try suicide³⁷. In Ceará, low income was identified as one of the factors most connected to suicide³³, 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 parenthood³⁸ and also family relationships are a protective factor for suicide³⁹, which is in line with the current study.
PSYCHIC STATUS
During the pandemic, emotional health was impacted by unemployment, physical disease, use of alcohol and/or smoking, reasonably/very/totally self-perception of social distancing which affected mental health and the regular/bad/worse self-perception of emotional health triggered the chance to have severe suicidal ideation. Moreover, the psychic status associated to these factors has indicated that only unemployment and the self-perception of emotional health contributed to the chance of developing severe suicidal ideation.
Emotional pain and suicide were widely associated with physical disease, mainly in elderly⁴⁰. The use of licit drugs and alcohol was directly related to the risk of injury, including the self-inflicted⁴¹ and was also significantly connected to suicidal ideation (OR = 1.86), suicide attempt (OR = 3.13) and completed suicide (OR = 2.59)⁴¹, and has also gotten worse during COVID-19⁴⁵, also smoking habits worsened⁴⁶. Social distancing, even before the pandemic, has already been a risk factor for mental diseases⁴⁷ and for suicide³². In COVID-19, social distancing, all alone, was associated with active and passive suicidal ideation⁴⁸, which represented a “second pandemic” due to its impact over mental health⁴⁹.
Unemployment caused emotional pain, because it represents one of the strongest suicide predictors, independently of the culture³⁸. In USA, the fear of losing a job was the second cause of mental disorder during the pandemic, and it was ranked immediately below the fear of dying of COVID-19⁵⁰. In Ceará, unemployment represented a 2 times higher risk for suicide, when compared to the rest of the country³³. The regular/bad/worse self-perception of emotional health was in line with the evidence that showed the significant risk of suicide attempts (p < 0.001) caused by this negative self-perception⁴.
PSYCHIC CARE
Before the pandemic, having a psychiatric disorder with follow-up, the use of at least one psychiatric medication, the use of psychiatric medications for non-psychiatric diseases, and the use of Integrative and Complementary Practices (ICPs) were substantially associated with severe suicidal ideation. These factors continued to be relevant during the pandemic, with the addition of psychotherapy follow-up. The multinomial analysis showed that only the use of psychiatric drugs for psychiatric disorders and psychotherapy follow-up, both before the pandemic, had a higher chance of severe suicidal ideation.
Psychic care was frequent even before the pandemic. The multinomial analysis corroborated the strong association between severe suicidal ideation and the use of psychiatric drugs and psychotherapy before COVID-19. Consequently, it was evident that this population had a high level of severe psychic suffering, which corroborates spiritism as a religion of psychological quest¹⁹. During the pandemic, suicidal thoughts raised and the suicidal behaviour in the hospital emergency decreased⁵¹, which characterised the worsening of general mental health and justified the maintenance of psychiatric and psychological follow-up.
Fortaleza, Ceará’s capital has demonstrated a precarious public service on mental health, with a scarce attendance on basic care (23%), low medicine prescriptions (31%), and short supply (58%) of psychiatric drugs. These are worse numbers when compared to the other big cities – Porto Alegre, São Paulo and Campinas⁵². Similarly, the structure, organization and access to mental health professionals decreased worldwide⁵³, and the patients with mental disorders before COVID-19 were neglected⁵⁴,⁵⁵ and new medical treatments were reduced⁵⁶. The sample showed a high level of assistance and psychiatric treatment in contrast to the lack of assistance of public health care, which might be perceived as the private access to care, enabled by the higher income participants had when compared to the part of Ceará’s population (up to USD $189)⁷.
The prescription of psychiatric drugs during the pandemic increased in Brazil⁵⁷, as well as the primary care⁵⁸, which is in contrast with Fortaleza’s poor public health care. This drug prescription was nearly more than 7%, when compared to pre-COVID-19, with a growth of self-medication⁵⁹,⁶⁰, which might help to explain the higher drug use associated to the low assistance on mental health in Ceará. Besides, the private affordability of psychiatric drugs, enabled by the higher income, might also justify this paradox between the numbers of the studies in relation to the state’s general population.
Psychological follow-up was strongly related to severe suicidal ideation during the pandemic. This highlights the apparent benefits of psychological treatment on severe psychic pain, as in self-mutilation and suicide, despite the hard analysis of this approach due to methodological issues⁶¹. During the pandemic, the help of psychological care could be seen through the emergency interventions⁶², which helped to deal with the fear of death and with the mourning⁶³. ICPs also helped on behaviour and lifestyle through meditation⁶⁴ and on the improvement of mood with Bioenergetic therapies, like Reiki⁶⁵,⁶⁶.
SPIRITUAL BELIEF
Self-classified spiritism and the preference for the spiritist doctrine presented a higher chance of mild and moderate suicidal ideation, and the Catholic self-classification was protective of severe suicidal ideation. The search for the spiritist doctrine due to mental pain has presented a higher possibility of severe suicidal ideation. On the other hand, to work in Public Lectures or on Spiritual Care has also protected any level of suicidal ideation. Before COVID-19, a higher LSE and catholic self-classification protected severe suicidal ideation. The multinomial analysis demonstrated that self-classifying oneself as a spiritist has presented a higher risk for mild and moderate depression, but a high LSE before COVID-19 has protected against severe suicidal ideation.
Participants’ religious self-classification was predominantly Christian and the fact of one’s declaring as spiritist did not interfere with the identification with other religions, since according to the doctrine, spiritism is not a religion in the traditional sense, rather is a scientific-philosophical doctrine¹⁶. Brazilian population comprises more than 90% Christians, and of these, more than 60% reported to be Catholics and 2% spiritists⁷. The high prevalence might be explained due to the predominance of Catholics in the general population. On the other hand, spiritism was highlighted due to bias, since the participants had some LSE. Nevertheless, the association of spiritism with mild to moderate suicidal ideation might be understood through the disease profile of these persons, as spiritism attracts people with psychological quest¹⁹.
The search for spiritism due to the scientific/philosophical interest was not a risk factor for severe suicidal ideation and might be understood because these persons were healthy, which is in direct opposition with the search due to mental pain as it presented a higher risk for severe suicidal ideation. Depression, a mental disorder quite related to suicide, was the most prevalent disease among goers of spiritism houses in São Paulo, with more than 45% of the total⁶⁷. Furthermore, the active practice of any religion or spiritual practice, regardless of the religion, helps a good mental health⁶⁸,⁶⁹, which corroborates that, to work on the Public Lectures and on the Spiritual Care of spiritism houses was a protective factor against suicide.
MULTINOMIAL REGRESSION: ALL FACTORS
Multinomial analysis of all significant factors demonstrated that high LSE before COVID-19 served as a protective factor against severe suicidal ideation, despite self-identified spiritists showing an increased risk of mild/moderate suicidal ideation. Consequently, to be a spiritist represented a milder suicide ideation, as spiritism attracts people with mental suffering, but having a higher LSE protected against severe suicidal ideation.
Some research has demonstrated the potential beneficial effects of spiritism on the psyche, such as the improvement and remission of depression⁷⁰,⁷¹, a reduction of emotional exhaustion, the improvement of negative attachments⁷² and the relief of pain associated with mourning and the fear of death⁷³,⁷⁴. About suicide, it is known that the spiritist literature has been playing an important role to spread informations⁷⁵, and has helped on the prevention through emotional strengthening⁷⁶.
Multinomial analysis showed that mild/moderate suicidal ideation was higher among single individuals with psychological follow-up before COVID-19 and that high level of severe psychic suffering, which corroborates spiritism as a religion of psychological quest¹⁹. During the pandemic, suicidal thoughts raised and the suicidal behaviour in the hospital emergency decreased⁵¹, which characterised the worsening of general mental health and justified the maintenance of psychiatric and psychological follow-up.
Fortaleza, Ceará’s capital has demonstrated a precarious public service on mental health…
(continues—already included above; merged for clarity)
LIMITATIONS AND FUTURE RESEARCH
Although the findings, causal relations among variables were not possible to be established because this investigation is cross-sectional. Longitudinal investigations are necessary to establish the cause and impact of spiritist engagement on the improvement or worsening of mental health, as well as quality research to yield knowledge on the subjectivity of the psychological effect of spiritism over the mind.
Conclusion
Individuals with spiritist engagement at risk of having mild/moderate suicide ideation were single, had been attending psychotherapy before COVID-19, and self-classified as spiritists. Severe suicidal ideation was connected to the above-mentioned factors and to unemployment and the regular/bad/worse self-perception of emotional health.
The meaningful association of severe suicidal ideation with psychotherapy follow-up and with the worse self-perception of emotional health might have shown a higher level of mental sickness in individuals with some spiritist engagement when compared to the general population.
The relation of suicidal ideation at any level with people engaged with spiritism has reinforced the perspective that spiritism corresponds to a religion of psychological quest that attracts people in psychic pain because of this greater people with this profile. Moreover, a higher spiritist engagement before the pandemic has proven to be a protective factor to severe suicidal ideation during the pandemic (FIGURE 1).
Although spiritism attracts people mentally ill, a higher engagement with spiritism might help to protect against suicide. Further research is necessary to improve the understanding of this relationship.
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 were in accordance with 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.
References
1. Miranda AGM, de Souza MF, Caldeira VC, Martins MC, Alves JBG, editors. Suicídio: aspectos epidemiológicos relacionados ao sexo, idade, escolaridade, estado civil, CID-10. Anais Colóquio Estadual de Pesquisa Multidisciplinar (ISSN-2527-2500) & Congresso Nacional de Pesquisa Multidisciplinar; 2018.
2. Sadock BJ, Sadock VA, Ruiz P. Compêndio de Psiquiatria: ciência do comportamento e psiquiatria clínica. 11 ed. Porto Alegre: Artmed; 2017. 1466 p.
3. OPAS/OMS-Brasil. Folha Informativo – Suicídio 2018 [https://www.paho.org/bra/index.php?option=com_content&view=article&id=5671:folha-informativa-suicidio&Itemid=839].
4. Arruda VL, Freitas B, Marcon SR, Fernandes FY, Lima NVP, Bortolini J, et al. Suicide in young Brazilian adults: 1997-2019 time series. Cien Saude Colet., 2021. p. 2699-708.
5. Veisani Y, Mohamadian F, Delpisheh A. Prevalence and comorbidity of common mental disorders and associations with suicidal ideation in the adult population. Epidemiology and Health. 2017;39:e2017031-e.
6. Scott J. Common mental disorders: A bio-social model by David Goldberg and Peter Huxley. London: Tavistock/Routledge. No. of pages: 194. Price £12.99. Stress Medicine. 1992;8(4):267-8.
7. Krueger RF. The Structure of Common Mental Disorders. Archives of General Psychiatry. 1999;56(10):921-.
8. Machado DB, Santos DNd. Suicídio no Brasil, de 2000 a 2012. Jornal Brasileiro de Psiquiatria. 2015;64:45-54.
9. Hegerl U. Prevention of suicidal behavior. Dialogues Clin Neurosci. 2016;18(2):183-90.
10. Filgueiras JC, Hippert MIS. A polêmica em torno do conceito de estresse. Psicologia: Ciência e Profissão. 1999;19(3):40-51.
11. Malhi GS, Mann JJ. Depression. The Lancet. 2018;392(10161):2299-312.
12. Martínez LS, Wasser AC. Depresión e ideación suicida en mujeres víctimas de violencia de pareja. Psicología, Conocimiento y Sociedad. 2019;9(1).
13. Barbosa RMR, Lima DF, Cavalcanti DB. Algumas ações para prevenção de suicídio desenvolvidas na UFPE. Revista dos Mestrados Profissionais. 2020;9(1):73-91.
14. IBGE. Censo 2010.
15. Bazley R, Pakenham K, Watson B. Perspectives on Suicide Prevention Amongst Members of Christian Faith-Based Organizations. Community Ment Health J. 2019;55(5):831-9.
16. Lace JW, Evans LN, Merz ZC, Handal PJ. Five-Factor Model Personality Traits and Self-Classified Religiousness and Spirituality. J Relig Health. 2020;59(3):1344-69.
17. Paul Victor CG, Treschuk JV. Critical Literature Review on the Definition Clarity of the Concept of Faith, Religion, and Spirituality. J Holist Nurs. 2020;38(1):107-13.
18. Peres MFP, Kamei HH, Tobo PR, Lucchetti G. Mechanisms Behind Religiosity and Spirituality’s Effect on Mental Health, Quality of Life and Well-Being. Journal of Religion and Health. 2018;57(5):1842-55.
19. Vitorino LM, Lucchetti G, Leão FC, Vallada H, Peres MFP. The association between spirituality and religiousness and mental health. Sci Rep. 2018;8(1):17233.
20. Tavares C. Dimensões do cuidado na perspectiva da espiritualidade durante a pandemia pelo novo coronavírus (COVID-19). Journal Health NPEPS. 2020;5:1-4.
21. Diego-Cordero R, Ávila-Mantilla A, Vega-Escaño J, Lucchetti G, Badanta B. The Role of Spirituality and Religiosity in Healthcare During the COVID-19 Pandemic: An Integrative Review of the Scientific Literature. J Relig Health. 2022;61(3):2168-97.
22. Del Castillo FA. Health, spirituality and Covid-19: Themes and insights. J Public Health (Oxf). 2021;43(2):e254-e5.
23. Kardec A. O que é o Espiritismo. 60, editor. Araras: Instituto de Difusão Espírita; 2004.
24. Kardec A. O Livro dos Espíritos. 1 ed. Rio de Janeiro: Celd; 2008.
25. FEB. Orientação ao Centro Espírita. 2006.
26. Dalgalarrondo P. Estudos sobre religião e saúde mental realizados no Brasil: histórico e perspectivas atuais. Archives of Clinical Psychiatry (São Paulo). 2007;34:25-33.
27. Moreira-Almeida A, Costa MdA, Coelho HS. The Idea of Survival of the Soul in the History of Religions and Philosophy. In: Moreira-Almeida A, Costa MdA, Coelho HS, editors. Science of Life After Death. Cham: Springer International Publishing; 2022. p. 5-11.
28. Isaia AC. Bezerra de Menezes e Gonçalves de Magalhães: muito além do cérebro. Tentativas de enfrentamento ao materialismo científico do século XIX. Revista Brasileira de História. 2020;40:267-88.
29. Swihart DL, Yarrarapu SNS, Martin RL. Cultural Religious Competence In Clinical Practice2023.
30. Shah AK, Becicka R, Talen MR, Edberg D, Namboodiri S. Integrative Medicine and Mood, Emotions and Mental Health. Primary Care: Clinics in Office Practice. 2017;44(2):281-304.
31. Sales TM. Magnitude e fatores associados ao envolvimento espírita, transtornos mentais comuns e ideação suicida: Um estudo seccional no Ceara. Fortaleza: Universidade Federal do Ceara; 2023.
32. IBGE. Censo 2010 2010 [Available from: https://sidra.ibge.gov.br/pesquisa/censo-demografico/series-temporais/series-temporais/.
33. Berg S. Snowball sampling—I. Encyclopedia of statistical sciences. 2004;12.
34. Chu IY, Alam P, Larson HJ, Lin L. Social consequences of mass quarantine during epidemics: a systematic review with implications for the COVID-19 response. J Travel Med. 27: International Society of Travel Medicine 2020.; 2020.
35. Both LM, Zoratto G, Calegaro VC, Ramos-Lima LF, Negretto BL, Hauck S, et al. COVID-19 pandemic and social distancing: economic, psychological, family, and technological effects. Trends Psychiatry Psychother. 432021. p. 85-91.
36. Granovetter M. Network sampling: Some first steps. American journal of sociology. 1976;81(6):1287-303.
37. Grandcolas U, Rettie R, Marusenko K. Web Survey Bias: Sample or Mode Effect? Journal of Marketing Management. 2003;19(5-6):541-61.
38. Pasquali L. Princípios de Elaboração de Escalas. In: Gorenstein C, Yuan-Pang, Hungerbühler I, editors. Instrumentos de Avaliação em Saúde Mental. Porto Alegre: Artmed; 2016.
39. Gorenstein C, Wang Y, Hungerbuhler I. Instrumentos de avaliação em saúde mental. Porto Alegre: Artmed; 2016.
40. Aquino TAA. Atitudes e intenções de cometer o suicídio: seus correlatos existenciais e normativos. João Pessoa: Universidade Federal da Paraíba, Universidade Federal do Rio Grande do Norte; 2009.
41. Osman A, Barrios FX, Grittmann LR, Osman JR. The multi-attitude suicide tendency scale: Psychometric characteristics in an american sample. Journal of Clinical Psychology. 1993;49(5):701-8.
42. Aquino TAAd. Atitudes e intenções de cometer o suicídio: seus correlatos existenciais e normativos. João Pessoa, 2009. p. 1-280.
43. Santos WSd, Ulisses SM, Costa TMd, Farias MG, Moura DPFd. The influence of risk or protective factors for suicide ideation. Psicologia, Saúde & Doença. 2016;17(3):515-26.
44. Bethlehem J. Selection Bias in Web Surveys. International Statistical Review / Revue Internationale de Statistique. 2010;78(2):161-88.
45. Calati R, Ferrari C, Brittner M, Oasi O, Olié E, Carvalho AF, et al. Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. J Affect Disord. 2019;245:653-67.
46. Sampaio GN. Uma investigação da relação entre divórcios e suicídios no Brasil e no Estado do Ceará. 2021.
47. Borba LO, Ferreira ACZ, Capistrano FC, Kalinke LP, Maftum MA, Maftum GJ. Fatores associados à tentativa de suicídio por pessoas com transtorno mental. Revista Mineira de Enfermagem. 2020;24:1-9.
48. Barros TF, Borges SM, da Costa VA, dos Santos Santiago JC. Análise do perfil epidemiológico de suicídios no Ceará de 2015 a 2017.
49. Marbin D, Gutwinski S, Schreiter S, Heinz A. Perspectives in poverty and mental health. Front Public Health. 2022;10:975482.
50. Barros FC, Matijasevich A, Santos IS, Horta BL, da Silva BGC, Munhoz TN, et al. Social inequalities in mental disorders and substance misuse in young adults. Social Psychiatry and Psychiatric Epidemiology. 2018;53(7):717-26.
51. Stack S. Contributing factors to suicide: Political, social, cultural and economic. Prev Med. 2021;152(Pt 1):106498.
52. Magnani RM, Staudt ACP. Estilos parentais e suicídio na adolescência: uma reflexão acerca dos fatores de proteção. Pensando famílias. 2018;22(1):75-86.
53. Santos EDGM, Rodrigues GOL, Santos LO, Alves MES, Araújo LF, Santos JVSA. Suicídio entre idosos no Brasil: uma revisão de literatura dos últimos 10 anos. Psicología, Conocimiento y Sociedad. 2019;9:205-20.
54. Bierstetel SJ, Slatcher RB. Couples’ behavior during conflict in the lab and diurnal cortisol patterns in daily life. Psychoneuroendocrinology. 2020;115:104633.
55. McEwen BS, Akil H. Revisiting the Stress Concept: Implications for Affective Disorders. J Neurosci. 2020;40(1):12-21.
56. Chikritzhs T, Livingston M. Alcohol and the Risk of Injury. Nutrients. 132021.
57. Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-related risk of suicidal ideation, suicide attempt, and completed suicide: a meta-analysis. PLoS One. 2015;10(5):e0126870.
58. Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM: An International Journal of Medicine. 2020;113(10):707-12.
59. Patwardhan P. COVID-19: Risk of increase in smoking rates among England’s 6 million smokers and relapse among England’s 11 million ex-smokers. BJGP Open. 2020;4(2).
60. Leigh-Hunt N, Bagguley D, Bash K, Turner V, Turnbull S, Valtorta N, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health. 2017;152:157-71.
61. Alkandari A, Law J, Alhashmi H, Alshammari O, Bhandari P. Staying (Mentally) Healthy: The Impact of COVID-19 on Personal and Professional Lives. Tech Innov Gastrointest Endosc. 2021;23(2):199-206.
62. Ganesan B, Al-Jumaily A, Fong KNK, Prasad P, Meena SK, Tong RK. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak Quarantine, Isolation, and Lockdown Policies on Mental Health and Suicide. Front Psychiatry. 2021;12:565190.
63. Bhattacharjee B, Acharya T. “The COVID-19 Pandemic and its Effect on Mental Health in USA – A Review with Some Coping Strategies”. Psychiatr Q. 912020. p. 1135-45.
64. John A, Eyles E, Webb RT, Okolie C, Schmidt L, Arensman E, et al. The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review. F1000Research. 2020;9.
65. Amaral CEM, Treichel C, Francisco P, Onocko-Campos RT. [Mental healthcare in Brazil: a multifaceted study in four large cities]. Cad Saude Publica. 2021;37(3):e00043420.
66. Gourret Baumgart J, Kane H, El-Hage W, Deloyer J, Maes C, Lebas MC, et al. The Early Impacts of the COVID-19 Pandemic on Mental Health Facilities and Psychiatric Professionals. Int J Environ Res Public Health. 182021.
67. Neelam K, Duddu V, Anyim N, Neelam J, Lewis S. Pandemics and pre-existing mental illness: A systematic review and meta-analysis. Brain Behav Immun Health. 10: © 2020 The Authors.; 2021. p. 100177.
68. Sukut O, Ayhan Balik CH. The impact of COVID-19 pandemic on people with severe mental illness. Perspect Psychiatr Care. 57: 2020 Wiley Periodicals LLC.; 2021. p. 953-6.
69. Nason I, Stein DT, Frank RG, Stein MB. Decline In New Starts Of Psychotropic Medications During The COVID-19 Pandemic. Health Aff (Millwood). 2021;40(6):904-9.
70. Gomes BP, da Costa Medeiros G, Aguilar FZ, Zattar T, Franco DCZ. Análise do uso de psicofármacos no Brasil no contexto da pandemia da COVID-19: Analysis of the use of psychotropic drugs in Brazil in the context of the COVID-19 pandemic. Archives of Health. 2022;3(2):94-8.
71. Alcântara AM, Figel FC, Campese M, da Silva MZ. Prescrição de Psicofármacos na Atenção Primária à Saúde no contexto da Pandemia da Covid-19. Research, Society and Development. 2022;11(4):e19911420210-e.
72. Sales TM, Mota RMS, Macena RHM. Formulário Deenvolvimento Espírita (FENE): development and validation of an instrument for assessing the level of spiritual development. Fortaleza: UFC; 2023. Available at: http://repositorio.ufc.br/handle/riufc/74736.
73. Sales TM. Spiritism, mental health, and public health: spiritist therapeutics under discussion. MOJ Public Health. 2023;12(3):145‒150.