Introduction

While the coronavirus disease 2019 (COVID-19) continues to spread across the globe, Korea Centers for Disease Control and Prevention implemented a strict social distancing policy from February 29^th, 2020 as a primary protective measure. Schools were closed and the public was advised to stay at home and avoid social gatherings as part of a social distancing policy to slow down transmission of disease.

There is increasing concern about the impact on people of official stay-at-home directives, quarantines, and social isolation [1]. In recent pandemics, isolation and quarantine have precipitated depression and anxiety [2,3], while social distancing measures have caused stress, depression, irritability, insomnia, fear, confusion, anger, frustration, and boredom in confined people with altered daily routines, and livelihoods [1].

Social distancing measures may also exacerbate domestic violence. In Hubei province, China, domestic violence more than tripled during the lockdown in February from 47 in 2019, to 162 in 2020 [4]. However, few studies have examined the effect of social distancing measures on intentional injury. The purpose of this study was to evaluate the effect of social distancing on the prevalence of domestic incidents and intentional injury, including self-harm or injury by violence.

Materials and Methods

The data of trauma patients who visited the Level 1 trauma center of Dankook University hospital from January 2015 to December 2019, and March 2020, were analyzed to evaluate changes in the prevalence of domestic incidents and intentional injury after social distancing measures were adopted in March 2020. The variables reviewed included basic demographics, the place of the incident, injury mechanism, injury severity score (ISS), familial discord, previous history of mental illness, and intention of the injury. Domestic incident was defined as an incident that took place at home or in its immediate surroundings. Intentional injury was categorized into self-harm and injury by violence. Suicidal behavior was included in the self-harm category, and injury by violence was defined as behavior with intention. Each domestic incident was reviewed by a psychiatrist and a psychologist to establish whether there was an intention to do harm. The prevalence of trauma injury in March 2020 was compared with the 5-year average and the averages for March from 2015 to 2019. Seasons were defined as spring (March–May), summer (June–August), autumn (September–November), and winter (December–February) to check for seasonal variations in self-harm. For the comparison, Chi-square tests or Fisher’s exact test were used. p < 0.05 were considered statistically significant. All statistical analyses were performed using PASW Statistics 19 (IBM Corp., Armonk, NY, USA). This study was approved by the Institutional Review Board of Dankook University Hospital (approval no.: DKUH 202005003). Informed consent was waived.

Results

1. Demographics

Data of 12,638 patients who visited a Level 1 trauma center in Chungnam province from 2015 to 2019, and March 2020 were analyzed. The mean age was 50.4 years, and most were male (69.0%). The percentage of patients with an ISS > 15 was 19.5%. There were 90.1% of patients injured by blunt trauma. Patients visiting the trauma center in March every year as a ratio of the whole year ranged between 6.5% and 8.3% (Table 1).

2. Domestic incidents

The prevalence of domestic incidents increased significantly in March 2020 compared with the 5-year average (31.0% vs. 16.1%, p < 0.001), and the average for every month of March between 2015–2019 (18.0%, p < 0.001). The prevalence of major trauma including moderate (ISS 9–15) and serious trauma (ISS 16–24) increased significantly compared to the 5-year average, and average for every March between 2015–2019 (Table 2).

3. Familial discord and intentional injury

Familial discord was higher during the period of social distancing in March 2020 (2.2%) than the 5-year average (0.4%, p = 0.002), and average for every March between 2015–2019 (0.5%, p = 0.007). Due to the uncertainty over the intention to do harm and limited information, in 3 cases, these were omitted from the analysis. The prevalence of intentional injury in March 2020 was significantly higher than the 5-year average (4.4% vs. 2.2%, p = 0.031), but when compared to the average for every March between 2015–2019, there was no statistical difference although the ratio was 4.4% to 2.7% (p = 0.197; Table 3). The prevalence of self-harm did not differ by season (p = 0.085) or month (p = 0.590; Table 4). Spring and summer (May–August, 79/4,386, 1.8%) showed no difference in the prevalence of self-harm compared to other seasons (115/8046, 1.4%, p = 0.110).

4. Adolescents

Among adolescents in March 2020, 3 patients had intentional domestic injury: a 19-year-old female was beaten by her boyfriend (ISS = 16), a 15-year-old male attempted suicide by jumping from a balcony (ISS = 12), and a 15-year-old male sustained injuries after being pushed off from a balcony during a fight with his brother (ISS = 9). The prevalence of intentional injury among adolescents in March 2020 (30.0%) was significantly higher than the 5-year average (4.5%, p = 0.031), and the average for every March between 2015–2019 (5.2%, p = 0.037). Injury due to acts of violence was also higher among adolescents during the period of social distancing in March 2020 (20.0% vs. 2.0%, p = 0.019; Table 3).

Discussion

Public health emergencies requiring confinement, the restriction of normal routines, and reduced social and physical contact with others can cause a range of emotional responses and unhealthy behaviors [1,5,6] There is mounting concern about the psychological distress caused by the COVID-19 pandemic related to isolation and social distancing [7,8].

There have been several reports regarding the effects of isolation and quarantine. During the outbreak of Severe Acute Respiratory Syndrome in Toronto in 2004, it was noted that 129 quarantined people responding to a web-based survey, exhibited a high prevalence of psychological distress such as post-traumatic stress disorder (28.9%) and depression (31.2%) [2]. During the Boston marathon bombings in 2013 resulting in the city-wide lockdown, there was a 3.4-fold increase in the symptoms of pediatric functional neurological symptom disorder [9]. During the outbreak of the Middle East Respiratory Syndrome coronavirus in Korea during 2015, indicators of psychophysical stress in plasma such as the levels of circulating cell-free genomic DNA and circulating cell-free mitochondria DNA were measured during hemodialysis in isolated patients and followed for 3 months, and showed a significant delay in normalization was observed, which implied that isolation caused high levels of stress [10]. A recent systematic review showed consistent evidence linking social isolation and loneliness to deteriorating cardiovascular and mental health outcomes [11].

The findings from this study showed that the prevalence of domestic incidents and intentional injury was significantly higher in March 2020 than in the past 5 years. During the 1918–19 influenza pandemic in the United States, and the 2003 Severe Acute Respiratory Syndrome outbreak in Hong Kong, deaths by suicide increased [12–14]. Although the etiology for the increase in suicides during an epidemic is unknown, the psychological distress induced by an economic downturn, social discrimination, and barriers to mental health treatment are suggested as possible predictors [15,16].

Previous studies have reported higher suicide rates in late spring and summer in the Northern hemisphere [15,17]. In this current study, no seasonal variation or monthly variation was observed however, the prevalence of intentional injury and self-harm in March 2020 was not higher than the average for March over the past 5 years. However, the cohort was too small to power this study. Since there have been several reports that the seasonality of suicide in late spring and summer tends to diminish [17,18], the coincidence of COVID-19 and the seasonal effects needs further investigation.

The increase in violence, especially domestic violence, is an important concern associated with the effects of social distancing [19–22]. The psychological stress associated with the lockdown due to factors such as closure of schools, more interaction within the family, and isolation from social support may leave families vulnerable to intra-familial conflict and domestic violence [19,21,22]. Globally there has been a substantial increase in domestic violence in the wake of the COVID-19 pandemic and enforced confinement. Domestic violence increased in Brazil by 40–50%, 1 region of Spain recorded 20%, and Cyprus reported a 30% increase [21]. An Australian article also reported that domestic violence increased by 5% during the lockdown and a 40% drop in overall crime rate [21]. Reports of domestic violence in France have increased 30% since they initiated lockdown. Helpline calls increased 33% in Singapore and 25% in Argentina [23]. Alarming trends in US domestic violence have also been reported [23].

In this study, a marked increase in the prevalence of intentional injury and injury by domestic violence in adolescents was observed after social distancing measures were implemented in March 2020. Although scientific debate on the effectiveness of school closures on virus transmission is ongoing [24], school closure for a long period of time could have detrimental consequences [25]. For adolescents with mental health issues school routines are important coping mechanisms [4], and school closures mean a lack of access to the resources that schools usually provide [26]. Evidence shows that violence and vulnerability increase in adolescents during long periods of school closures [22] including summer holidays [27]. An increased rate of child abuse, neglect, and exploitation have been reported during previous public health emergencies, such as the Ebola outbreak in West Africa in 2014 to 2016 [4]. During the COIVD-19 pandemic, stressors such as fear of infection, frustration, boredom, lack of in-person contact with classmates, friends, and teachers, lack of personal space at home, and financial issues in the family become problematic [6] as observed in this current study with increases in intentional injuries.

Social distancing requires physical space between people but ideally it should include social solidarity. To mitigate the consequences of home confinement, the potential unintended adverse outcomes on mental health-related issues should be addressed and the government, community, teachers, parents, and healthcare professionals need to be aware of this [4,5]. Adolescents who are more vulnerable may benefit from technology-enabled modalities such as open-access online resources [22] or online services to cope with mental health issues caused by domestic conflicts or tension with parents [4].

There are several limitations in this study. Firstly, the number of subjects was too small to statistically compare the average incidents of trauma for March over the past 5 years. Secondly, the patients who visited the Level 1 trauma center were not representative of the whole province or countrywide figures and therefore generalizations cannot be made. Since patients are referred after an initial examination and according to the severity of their trauma, those with minor injuries may not visit a Level 1 trauma center. In 2019, only 26% of severely injured patients were transferred to the Level 1 trauma center in Chungnam province. Thirdly, psychological abuse without physical assault was not included in this cohort. In addition, patients who provide incorrect histories regarding injury mechanisms may have also been excluded.

Conclusion

In conclusion, the prevalence of domestic incidents and intentional injury increased significantly during March 2020 in the implemented period of social distancing in South Korea. Our findings warrant further study regarding the psychological impact of the COVID-19 pandemic and social distancing measures. The development of social consensus, policies, and psychological support services needs to be considered, especially if there is a second or third wave of infections.

Article information

Conflicts of Interest

The authors have no conflicts of interest to declare.

References

• 1. Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. N Engl J Med 2020;383(6). 510−2.ArticlePubMed
• 2. Hawryluck L, Gold WL, Robinson S, et al. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis 2004;10(7). 1206−12.ArticlePubMedPMC
• 3. Jeong H, Yim HW, Song YJ, et al. Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiol Health 2016;38:e2016048. ArticlePubMedPMC
• 4. Wang G, Zhang Y, Zhao J, et al. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet 2020;395(10228). 945−7.Article
• 5. Venkatesh A, Edirappuli S. Social distancing in covid-19: what are the mental health implications? BMJ 2020;369:m1379. ArticlePubMed
• 6. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395(10227). 912−20.ArticlePubMedPMC
• 7. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA 2020;323(21). 2133−4.ArticlePubMed
• 8. Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr 2020;52:102066. ArticlePubMedPMC
• 9. Guerriero RM, Pier DB, de Gusmao CM, et al. Increased pediatric functional neurological symptom disorders after the Boston marathon bombings: a case series. Pediatr Neurol 2014;51(5). 619−23.ArticlePubMed
• 10. Kim YG, Moon H, Kim SY, et al. Inevitable isolation and the change of stress markers in hemodialysis patients during the 2015 MERS-CoV outbreak in Korea. Sci Rep 2019;9(1). 5676. ArticlePubMedPMC
• 11. Leigh-Hunt N, Bagguley D, Bash K, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health 2017;152:157−71.ArticlePubMed
• 12. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910–1920. Suicide Life Threat Behav 1992;22(2). 240−54.ArticlePubMed
• 13. Cheung YT, Chau PH, Yip PS. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry 2008;23(12). 1231−8.ArticlePubMed
• 14. Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020;7(6). 468−71.ArticlePubMedPMC
• 15. Reger MA, Stanley IH, Joiner TE. Suicide Mortality and Coronavirus Disease 2019-A Perfect Storm? JAMA Psychiatry 2020;77(11). 1093−4.ArticlePubMed
• 16. Thakur V, Jain A. COVID 2019-suicides: A global psychological pandemic. Brain Behav Immun 2020;88:952−3.ArticlePubMedPMC
• 17. Ajdacic-Gross V, Bopp M, Sansossio R, et al. Diversity and change in suicide seasonality over 125 years. J Epidemiol Community Health 2005;59(11). 967−72.ArticlePubMedPMC
• 18. Ajdacic-Gross V, Bopp M, Ring M, et al. Seasonality in suicide--a review and search of new concepts for explaining the heterogeneous phenomena. Soc Sci Med 2010;71(4). 657−66.ArticlePubMed
• 19. Usher K, Bhullar N, Durkin J, et al. Family violence and COVID-19: Increased vulnerability and reduced options for support. Int J Ment Health Nurs 2020;29(4). 549−52.ArticlePubMedPMC
• 20. Campbell AM. An increasing risk of family violence during the Covid-19 pandemic: Strengthening community collaborations to save lives. Forensic Science International: Reports 2020;2:100089. ArticlePMC
• 21. Bradbury-Jones C, Isham L. The pandemic paradox: The consequences of COVID-19 on domestic violence. J Clin Nurs 2020;29(13–14). 2047−9.ArticlePubMedPMCPDF
• 22. Cluver L, Lachman JM, Sherr L, et al. Parenting in a time of COVID-19. Lancet 2020;395(10231). e64. ArticlePubMedPMC
• 23. Boserup B, McKenney M, Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic. Am J Emerg Med 2020;[Epub ahead of print]. Epub 2020 Apr 28..Article
• 24. Cohen J, Kupferschmidt K. Countries test tactics in ‘war’ against COVID-19. Science 2020;367(6484). 1287−8.ArticlePubMed
• 25. Van Lancker W, Parolin Z. COVID-19, school closures, and child poverty: a social crisis in the making. Lancet Public Health 2020;5(5). e243−4.ArticlePubMedPMC
• 26. Lee J. Mental health effects of school closures during COVID-19. Lancet Child Adolesc Health 2020;4(6). 421. ArticlePubMedPMC
• 27. Morgan K, Melendez-Torres GJ, Bond A, et al. Socio-Economic Inequalities in Adolescent Summer Holiday Experiences, and Mental Wellbeing on Return to School: Analysis of the School Health Research Network/Health Behaviour in School-Aged Children Survey in Wales. Int J Environ Res Public Health 2019;16(7). 1107. ArticlePubMedPMC

Figure & Data

References

Citations

Citations to this article as recorded by  

• Impact of the COVID-19 Pandemic on Adolescent Self-Harm: Based on a National Emergency Department Information System
  Ju-Hyeon Park, Young-Woo Seo, Seungbum Chae
  International Journal of Environmental Research an.2023; 20(5): 4666.     CrossRef
• Changes in Injury Pattern and Outcomes of Trauma Patients after COVID-19 Pandemic: A Retrospective Cohort Study
  Myungjin Jang, Mina Lee, Giljae Lee, Jungnam Lee, Kangkook Choi, Byungchul Yu
  Healthcare.2023; 11(8): 1074.     CrossRef
• Intimate Partner Violence in the Orthopaedic Patient Population
  Jennifer A. Kunes, Marisa N. Ulrich, Charlotte E. Orr, Lisa K. Cannada, Christen M. Russo
  JBJS Reviews.2023;[Epub]     CrossRef
• Characteristics of Attempted and Completed Suicides During the COVID-19 Pandemic
  Nathan Flesher, Marisa-Nicole Zayat, Elizabeth Ablah, Hayrettin Okut, Kelly Lightwine, James M. Haan
  The American Surgeon™.2023; : 000313482311739.     CrossRef
• Comparison of Clinical Characteristics of Traumatic Brain Injury Patients According to the Mechanism Before and After COVID-19
  Jonghyun Sung, Jongwook Choi, Kum Whang, Sung Min Cho, Jongyeon Kim, Seung Jin Lee, Yeon gyu Jang
  Korean Journal of Neurotrauma.2023; 19(3): 307.     CrossRef
• Effect of the COVID‐19 pandemic at a major Danish trauma center in 2020 compared with 2018–2019: A retrospective cohort study
  Frederik Trier, Jesper Fjølner, Nikolaj Raaber, Anders H. Sørensen, Hans Kirkegaard
  Acta Anaesthesiologica Scandinavica.2022; 66(2): 265.     CrossRef
• Impact of the COVID-19 lockdown on trauma team activations in a single major Lithuanian trauma center: A retrospective single-center study
  Vytautas Aukstakalnis, Kristina Blaziene, Juozas Cepla, Greta Vileitaite, Kestutis Stasaitis, Dinas Vaitkaitis
  International Journal of Critical Illness and Inju.2022; 12(1): 17.     CrossRef
• Transmission parameters of coronavirus disease 2019 in South Asian countries
  Mridul Sannyal, Abul Mukid Md. Mukaddes
  Osong Public Health and Research Perspectives.2022; 13(3): 191.     CrossRef
• The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review
  Sarah Steeg, Ann John, David J. Gunnell, Nav Kapur, Dana Dekel, Lena Schmidt, Duleeka Knipe, Ella Arensman, Keith Hawton, Julian P. T. Higgins, Emily Eyles, Catherine Macleod-Hall, Luke A. McGuiness, Roger T. Webb
  The British Journal of Psychiatry.2022; 221(4): 603.     CrossRef