Reanalyzing self-harm notifications trends in Brazil, 2011–2022- Author’s response to Volpe and Lacerda

We appreciate Volpe and Lacerda's valuable feedback on our published manuscript. Our study analysed annual rates of suicide and self-harm, considering the estimated Brazilian yearly population.1Oliveira Alves FJ Fialho E Paiva de Araújo JA et al.The rising trends of self-harm in Brazil: an ecological analysis of notifications, hospitalisations, and mortality between 2011 and 2022.Lancet Reg Health Am. 2024; 31: 100691https://doi.org/10.1016/j.lana.2024.100691Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Reanalyses could offer further insights into the topic. For instance, to assess short-term events, particularly the impact of the COVID-19 pandemic, we recognise the importance of absolute monthly numbers of occurrences, as Volpe and Lacerda did. However, our primary objective was to evaluate temporal trends for three different outcomes over time, extending beyond the scope of the COVID-19 pandemic. Previous research has demonstrated the increasing trend of suicide rates in Brazil, with specific moments, such as periods of austerity, impacting these rates.2Machado DB Pescarini JM Araújo LFSC Barreto ML Austerity policies in Brazil may affect violence related outcomes.Cien Saude Colet. 2019; 24: 4385-4394https://doi.org/10.1590/1413-812320182412.07422019Crossref PubMed Scopus (12) Google Scholar Our results indicated a pre-existing upward trend in suicide and self-harm rates in Brazil that persisted post-pandemic onset. Utilising the joint point methodology enabled us to identify overall inflection points, that characterise periods with different levels of trend increase, making it possible to hypothesize on potential drivers of these different trends. Volpe and Lacerda's visual analysis reinforced these findings, providing a closer look at a decline in self-harm notifications during the pandemic's onset, as already observed in our data. However, it is important to highlight that this reduction in notifications did not occur for death outcomes as shown in our paper, suggesting possible artefacts in the healthcare system. A decrease in notifications of infectious diseases,3Rocha CAO Santana GBA Leal TC et al.Impact of the COVID-19 pandemic on compulsory notification of meningitis during the first wave of the pandemic in Brazil: an ecological study using P-score.Sao Paulo Med J. 2022; 140: 305-309https://doi.org/10.1590/1516-3180.2021.0732.15092021Crossref PubMed Scopus (3) Google Scholar, 4Sallas J Elidio GA Costacurta GF et al.Decrease in compulsory notifications registered by the Brazilian National Hospital Epidemiological Surveillance Network during the COVID-19 pandemic: a descriptive study, 2017-2020.Epidemiol Serv Saude. 2022; 31 (English, Portuguese)e2021303https://doi.org/10.1590/S1679-49742022000100011Crossref Scopus (1) Google Scholar, 5Silveira JRS Lima SVMA Dos Santos AD et al.Impact of the COVID-19 Pandemic Surveillance of Visceral Leishmaniasis in Brazil: An Ecological Study.Infect Dis Rep. 2024; 16: 116-127https://doi.org/10.3390/idr16010009Crossref PubMed Scopus (0) Google Scholar as well as in hospital surveillance services,4Sallas J Elidio GA Costacurta GF et al.Decrease in compulsory notifications registered by the Brazilian National Hospital Epidemiological Surveillance Network during the COVID-19 pandemic: a descriptive study, 2017-2020.Epidemiol Serv Saude. 2022; 31 (English, Portuguese)e2021303https://doi.org/10.1590/S1679-49742022000100011Crossref Scopus (1) Google Scholar has also been demonstrated. This decrease suggests that the Brazilian healthcare system, especially high-complexity services, may have been overwhelmed by the demands of the pandemic, along with the population's fear of contracting SARS-CoV-2 and difficulty accessing healthcare services during the pandemic. Additionally, challenges in maintaining active epidemiological surveillance, leading to reduced surveillance and reporting of other health issues, contributed to the observed reduction in notifications of self-harm patients. These findings emphasize the importance of strengthening healthcare infrastructure and surveillance systems to ensure accurate reporting and effective response measures, particularly during emergency periods like pandemics. They also highlight the need to use multiple sources of morbidity and mortality to understand the trend of self-harm in a population, as done in our paper. FJOA, MB and DBM contributed to the conception and design. The first draft was written by FJOA and EF; MB and DMB commented on and edited the manuscript. All authors read and approved the final manuscript and were responsible for the decision to submit it. FJOA had the final responsibility to submit the manuscript. Authors report no conflicts of interest. None.