COVID-19 and Suicide Mortality in a Population-Based Medico-Legal Registry: An Interrupted Time-Series and...

Background: Interrupted time-series studies have not shown a consistent increase in suicide mortality during COVID-19, but civil mortality registries cannot ascertain SARS-CoV-2 infection individually. We evaluated pandemic-related change in suicide mortality and the feasibility of integrating infection ascertainment into medico-legal surveillance. Methods: We analysed 395 suicide deaths in Galați and Brăila counties, Romania (January 2018-December 2024), where mandatory forensic autopsy ensures exhaustive ascertainment. The pre-specified primary analysis was seasonally adjusted segmented Poisson regression in January 2018-December 2022 with an onset in March 2020; the period 2023-2024 was excluded as incompletely ascertained. Changepoint detection and unadjusted period comparisons were descriptive. Infection was classified as laboratory-confirmed (documented ante-mortem RT-PCR) or possible/probable (compatible autopsy findings); no post-mortem testing was performed. Results: The level change at onset was not significant (IRR 1.29, 95% CI 0.80-2.08; p = 0.302), nor was the slope change (IRR 1.01, 95% CI 0.98-1.04; p = 0.639); power was 80% only against IRR ≥ 1.98. Posterior probabilities were 0.85 for any increase and 0.035 for a doubling. The unadjusted comparison (6.00 vs. 4.62 deaths/month; IRR 1.30, 95% CI 1.04-1.63) was descriptive; no changepoint coincided with onset. Among 140 deaths in 2020-2021, 34 (24.3%) met ascertainment criteria, 21 (15.0%) laboratory-confirmed. Conclusions: The data exclude a doubling of suicide mortality but not a modest increase: a regional surveillance signal, not a causal finding. Infection ascertainment proved feasible within routine medico-legal investigation, yielding a reproducible framework for other registries, an Eastern European series for future meta-analyses, and a proof-of-concept for a standing forensic surveillance capacity adaptable to future epidemics.