SUICIDE AND COVID-19: POSTVENTION IN PUBLIC HEALTH POLICES, A MUNICIPAL EXPERIENCE ¹

ABSTRACT:

This article reports on a professional experience in suicide postvention, carried out at the Municipal Health Department of Diadema, in the state of São Paulo, in 2020, following the death of a nurse from the impact of the COVID-19 pandemic. The procedures used are described based on the authors’ experience, who recount the initial psychological care and other structured actions taken over the course of six months. A Care Committee was structured using psychoanalytic listening, and conversation circles, religious rituals, and other support modalities were implemented to prevent subsequent suicide attempts or suicides among healthcare professionals and to promote an institutional mourning process in dialogue with the local health management. It is possible to assume that this forceful and impactful emergency action in the psychosocial field prevented the spread of feelings of panic and helplessness, as well as the Werther effect, given the contagion risk caused by disclosing the case and subsequent suicide attempts and/or suicides. This experience can contribute to similar situations in the future and can be incorporated into public health policies as well as other sectors. The scenario highlights the need for ongoing support for workers’ health, ensuring that demands related to work processes and environments are addressed, and promoting mental health prevention and development in workplaces and other settings.

Keywords:
suicide; COVID-19; postvention

RESUMO:

Este artigo relata uma experiência profissional de pós-venção em casos de suicídio, realizada na Secretaria Municipal de Saúde de Diadema, no estado de São Paulo, durante 2020, após a morte de uma enfermeira durante trabalho, sob o impacto da COVID-19. Os procedimentos utilizados são descritos a partir da vivência das autoras que relatam os primeiros cuidados psicológicos e demais ações estruturadas no transcurso de seis meses. Foi estruturado um Comitê de Cuidado em escuta psicanalítica, e implementadas rodas de conversa, rituais religiosos e ofertadas modalidades de acolhimento com o objetivo de prevenir subsequentes tentativas de suicídio ou suicídios de profissionais de saúde a fim de promover um processo de luto institucional em diálogo com a gestão de saúde local. É possível supor que ação contundente e de impacto emergencial no campo psicossocial evitou que se alastrassem sensações de pânico e desamparo ou de imitação do efeito Werther diante do risco de contágio provocado pela divulgação do caso com tentativas de suicídio e/ou suicídios adicionais. A experiência pode contribuir em situações similares futuras e pode ser incorporada em políticas públicas de saúde, assim como em outros setores. Todo esse cenário indica a necessidade de manter ações permanentes de saúde dos trabalhadores e das trabalhadoras, garantindo a escuta das demandas relacionadas aos processos de trabalho e à ambiência, favorecendo a prevenção e promoção da saúde mental no trabalho e em outros ambientes.

Palavras-chave:
Suicídio; COVID-19; pós-venção

RESUMEN:

Este artículo tiene como objetivo presentar y reflexionar críticamente sobre la experiencia innovadora de posvención de suicidio, realizada en la Secretaría Municipal de Diadema, en el estado de São Paulo, durante 2020, luego de la muerte de una profesional de la salud, una enfermera, durante el trabajo, bajo el impacto de COVID-19. Inmediatamente y en el transcurso de seis meses se implementaron: primeros auxilios físicos y psicológicos, estructuración de un Comité de Atención en escucha psicoanalítica, círculos de conversación, rituales religiosos, así como otras acciones encaminadas a prevenir posteriores intentos o suicidios por parte de los profesionales de la salud con el fin de promover un proceso de duelo institucional en diálogo con la dirección de salud local. La actuación contundente y el impacto de emergencia en el campo psicosocial impidieron la propagación de sentimientos de pánico e impotencia que, de no haber encontrado un terreno de anclaje psíquico, podrían haber generado otras manifestaciones desagregadoras, con rápida proliferación de angustias y mímicas, con intentos y/o suicidios adicionales. La experiencia puede contribuir en situaciones similares en el futuro e incorporarse en las políticas públicas de salud, así como en otros sectores. Todo este escenario indica la necesidad de mantener acciones permanentes de salud para los trabajadores, asegurando que las demandas relacionadas con los procesos de trabajo y el medio ambiente sean escuchadas, favoreciendo la prevención y promoción de la salud mental en el trabajo.

Palabras clave:
Suicidio; COVID-19; posvención

Introduction

This article describes a professional experience in suicide postvention, carried out at the Municipal Department of Diadema, in the state of São Paulo, in 2020, after the death of a nurse during her work shift amidst the COVID-19 pandemic. The process is described from the perspective of the authors, professionals from the municipal health network, and an institutional supervisor, and the actions implemented to support bereavement following suicide and prevent the occurrence of new cases are reported. The aim was to understand the phenomenon of suicide and implement timely interventions, which will be presented in this report.

The Landscape Of Actions For Bereaved Survivors Amidst A Pandemic

Since 2009, the municipality of Diadema has had policies in place to address situations of violence, including actions for surveillance, prevention, and control of accidents and violence, in sentinel services of the public and private health network. The sentinel units are referral services for the mandatory reporting of suspected or confirmed cases of violence. Attempted suicide requires immediate reporting to enable timely decision-making and prevention (Ordinance No. 104, 2011).

Starting in 2017, the municipality intensified improvements to mental healthcare related to suicide prevention by utilizing the mechanisms of the humanization policy and continuing education (Brasil, 2004). Matrixing processes were initiated to improve the documentation of self-inflicted violence and encourage collaboration among teams to develop interventions, reorganize work, and expand intersectoral practices. Additionally, a technical group (TG) on violence was formed, including representatives from all care and surveillance areas within the Health Department.

Between 2017 and 2021, Diadema recorded 100 suicide deaths, with 21 in 2017, 19 in 2018, six in 2019, 30¹⁰ in 2020, 22 in 2021, and 33 in 2022 (Brasil, 2025). Self-inflicted violence accounted for approximately 13% of reported incidents of violence between 2009 and 2018. Suicides represented 7% of mortality from external causes and mainly occurred in men aged 30 to 49 due to airway obstruction (suffocation), impact/contusions (falling from a height), poisoning, and firearm in 2018 (Secretaria Municipal da Saúde de Diadema, 2019).

The World Health Organization (WHO) declared the start of the 2020 pandemic on January 30 of that year. Due to excessive workload, isolation, and discrimination, healthcare professionals became vulnerable to experiencing physical exhaustion, fear, tension, anxiety, sleep problems, and emotional disturbances (Teixeira et al., 2020).

Studies on the mental health of healthcare workers during the pandemic identified concerns, fear, and insecurity about their own health and that of their families and the population. These studies also identified the presence of depressive disorders, anxiety, panic, somatic symptoms, self-censorship, guilt, post-traumatic stress disorder, delirium, psychosis, and suicide (Ramos-Toescher et al., 2020). Workers began to cope with new demands, as Almeida (2020) mentioned: difficulties that did not exist before, performing tasks that were previously done with assistance alone, using new or different equipment and resources, the scarcity of personal protective equipment, and weak descriptions of infection control protocols and workflows. In addition, there were long working hours and an insufficient number of professionals.

Amid the pandemic, numerous work demands, uncertainties, and suffering, the suicide of a nurse at her workplace mobilized colleagues and managers from the Municipal Health Secretariat, public service professionals in general, the workers’ union, and the community. This highlighted the importance of raising awareness about suicide and promoting timely intervention in response to such events.

Suicide And Postvention

Durkheim’s (2004) studies on suicide support the understanding of it as a complex social phenomenon. It is a multifactorial global public health problem involving biological, environmental, psychological, and social aspects (Botega, 2014), requiring different intervention modalities (World Health Organization [WHO], 2014).

Several people are negatively affected after a suicide. Shneidman (1999), a renowned suicidologist, demonstrated the complexity of suicide, death, and grief. Since the late 1960s, the author has been concerned about the family and friends of suicide victims. He designated the process of caring for the bereaved after the suicide of a loved one and discouraging suicidal thoughts as postvention.

Literature shows that preventing new cases stems from contagion, which Phillips (1974) described as the Werther effect. Cheng et al. (2011) described the occurrence of this phenomenon after suicide episodes in a company and recognized the likelihood of an increase in new cases within three days of the event. Haw et al. (2013) studied the psychological mechanisms of contagion, imitation, suggestion, and learning related to suicides within a given time and space.

Brazilian studies emphasize that bereaved survivors require care and support. Without adequate public policies or support services, postvention actions are necessary (Dantas et al., 2022; Ruckert et al., 2019). Grieving processes following a suicide or sudden, violent death are stigmatized and require intervention and care programs (Fukumitsu & Kovács, 2015).

The narrative constructed in this article, inspired by ethnography, describes the authors’ daily experience in an environment of sharing experiences and proximity with workers (Pinheiro, 2020). The article is based on conversations between the authors during meetings, as well as on each author’s records, and is motivated by the desire to discuss the implementation of postvention actions in contexts of pain and impact, in dialogue with the experiences of Scavacini et al. (2019) and Fukumitsu & Kovács (2015), and in response to the needs of the bereaved.

Suicide In The Workplace: How To Cope With Sudden And Violent Death?

In June 2020, a nurse committed suicide at a municipal specialized healthcare institution on a Friday morning. This event led to the need to promote actions directed at the affected community.

First aid was administered to the victim by colleagues called by those who found the body. Nurses and physicians attempted resuscitation while others called the emergency team from the municipal emergency room, which took over the procedures and other formalities, such as contacting family members.

The central coordination of the Health Department activated managers from various areas to form a support team for colleagues impacted by the situation. The team was deployed immediately to provide empathetic listening and possible clarifications. Support sessions were held in various locations by five mental health professionals who provided emergency support and follow-up care to approximately twenty individuals, both in groups and one-on-one. The aim was to address immediate anxieties and identify risks related to current suicidal ideation and a history of personal or family suicide attempts. This information would be used for monitoring and preventing new episodes, as well as the possible escalation of disruptive psychological acts, given the panic and helplessness described by Pereira (1999).

A Care Committee¹¹ was formed, bringing together local professionals who were already involved in educational initiatives for the prevention of self-harm. These professionals sought out other professionals, reference literature, regional support services, and inter-institutional contacts (partnerships). It was necessary to reorganize work routines and hold numerous in-person and WhatsApp conversations throughout the workday to assess emergencies, clarify and support colleagues’ pain and indignation, and listen to managers’ descriptions, among other listening tasks. Two physicians, an occupational therapist, and four psychologists were at the forefront of the support efforts. The situation required continuity of care to minimize the impact of the sudden death, cope with recollections of the events, and prevent other suicide attempts due to the risk of contagion from the news (Haw et al., 2013).

Postvention: A Painful But Necessary Intervention¹²

A postvention plan is structured to promote rituals for processing grief, guide professionals and family members through ethical and bureaucratic issues, and identify suicidal ideation and vulnerabilities due to social and behavioral issues that could lead to self-harm. In short, it provides interventions, support, and assistance for those affected by suicide, based on the experiences of suicide prevention and postvention described by Scavacini et al. (2019).

Postvention strategies considered the complexity of groups affected by suicide in different relationships and institutional spaces. The expanded clinical device anchored individual listening and shield of survivors, integrating care and management through collaborative efforts and the collective development of health spaces (Brasil, 2004).

Expanding Solidarity Networks And Providing Support For Bereaved Survivors

Depending on their contact and relationship with the deceased colleague, survivors of workplace suicide were exposed to the situation in different ways, leading to diverse intervention strategies following technical guidelines (Conselho Regional de Psicologia do Distrito Federal [CRP DR], 2020).

In this scenario, interventions were implemented to support those affected by suicide. These interventions aimed to strengthen a social network of institutional support for expressing and processing grief. They are described below.

Conversation Groups For Everyone Impacted By Suicide

Daily conversation sessions were offered in the mornings and afternoons and were open to all workers. These sessions were publicized through WhatsApp groups and posters. In addition, the meetings were open to participation according to subjective needs, i.e., expressions of suffering, recalling scenes, risky discourse, or other reasons. The sessions were facilitated by pairs of technicians, using a pre-established schedule developed with the participation of mental health professionals from different services, with an average duration of 1h30min. Seventeen meetings were held, and 95 people received support during the 15 days following the suicide. The following topics were discussed: the impacts of suicide, interpersonal relationships between colleagues and supervisors, service management methods, the need for care for workers, and various work-related difficulties, as illustrated below:

We need spaces like this, but not only in times of sadness... people think that [suicide] will never happen, but many people are suffering too much, crying [...] there could be a suggestion box [...] what needs to improve in your work environment, what are your dreams? [...] [there is a lack of] space for a chapel... a place with an open Bible for people to pray [...] nobody takes care of the gardens [...] we need psychological support, to help depressed employees... many people need help [...] (Reports from health professionals, 2020).

An ecumenical service was organized by the workers and held in the collective space of the gatherings on the seventh day after the nurse’s death. Representatives of Afro-Brazilian religions, Evangelicals, Catholics, and Spiritists attended the service, which honored the nurse’s life and included messages from her colleagues. A space for spiritual support was also created, where religious leaders provided comfort daily. This initiative revealed the dimensions of Brazilian religious syncretism, which is composed of elements from various religions and beliefs. This fusion operates in solidarity, constructing social support networks and symbolically ensuring comfort (Carvalho, 2005).

Support Groups For Bereaved Survivors: Building Connections

The group consisted of 12 nurses, eight of whom were permanent staff and four of whom were contracted through a partner company. They were responsible for 53 nursing technicians working in seven different sectors. Five nurses did not participate in the group, as three were on leave due to the pandemic, one had orthopedic problems, and one presented with post-traumatic stress disorder related to suicide. During the meetings, various resources were used to encourage interaction and expression of feelings about death and life. For instance, a dynamic activity was used for self-introduction and reflection on the use of time. At another meeting, the poem Morte e Vida Severina by João Cabral de Melo Neto was used to reflect on life and death.

Conversations addressed topics such as the lack of communication at work, different employment relationships, work overload, the impact of absenteeism on scheduling, and the tensions and fears generated by the pandemic. The growing engagement among participants resulted in continued meetings and dialogue on contentious issues.

It Is Necessary To Talk About Work: Sharing Care

Tensions in daily work life, difficulties with immediate supervisors, and individual processes of psychological suffering have triggered the need for specific listening in the laboratory sector. Three narratives of suicide attempts emerged in the group, involving intentional actions against oneself. It is important to emphasize that, although suicidal behaviors are intrinsically related, they must be analyzed in their specificities. Ideation, attempts, and the act itself have historicity, which changes the possibilities of intervention and can prevent stigmatization (CRP DF, 2020).

Another listening opportunity was proposed to the professionals in the work sector of the professional who committed suicide. However, there was no response from those interested, since activities were suspended due to the pandemic, and most of the team had been transferred to other sectors.

Psychological Duty Services and Therapeutic Projects

The collective development of therapeutic projects enabled the provision of individual psychological care in Basic Health Units (UBS) and online care in collaboration with partner services for 40 workers. Individual psychological support sessions were maintained to address needs and establish a new standard, as described by Souza et al. (2009). This service was also made available to family members who did not initially request it, as suggested by Sunde and Paqueleque (2021).

Inseparability Between Health Care And Management

The Care Committee team worked to coordinate psychosocial care for the workers and managers of the Health Department in the face of the professional’s death. Periodic listening sessions and meetings were held with the managers of the specialized municipal service where the suicide occurred. They also held discussions in collegiate management spaces (Brasil, 2004) and provided clarifications to the Municipal Health Council regarding the circumstances of the suicide and the postvention measures adopted.

Psychoanalytic Listening Space Of The Care Committee¹³

Additionally, a reception and anchoring process was structured for the Care Committee. During this process, the concrete possibility of using the arsenal of psychoanalysis was considered (Faria, 2020; Torres et al., 2021), introducing psychoanalytic contributions into the daily health practices. It considers the subjectivity of professionals and makes the psychic dimensions of public health processes explicit.

For six months, weekly listening sessions were held from a public health perspective and from the perspective of mental health in psychoanalysis. The aim was to clarify the place of the Care Committee in the institution, identify the scope of its support initiatives for health system professionals, strengthen and adapt strategies (such as forming a group of nurses), and promote individual and institutional grief by elaborating on the place left by M.

In this process, the Care Committee developed a working methodology that made it possible to understand the effects of the nurse’s death on the institutional process, as well as to understand the meaning of the death-metaphor experienced in this context and promoted coordination with managers to address the situation.

At the end of the process, the team presented a report to the Health Department managers, suggesting the reorganization of work processes and highlighting the need for worker participation and preventive actions against new self-harm events through institutional interventions, such as hiring a professional responsible for this task.

The fact that an employee chose the workplace as the outcome of a distressing situation suggests a possible relationship between the workplace and the act. Current studies in Brazil and worldwide (Barreto et al., 2011; Dejours & Bègue, 2010) are advancing on this topic. In this case, the Occupational Health Reference Center (CEREST) of Diadema acted to notify the occurrence of self-inflicted violence in the workplace and proceeded with an epidemiological occupational health investigation.

Final considerations

The described experience unfolded within the timeframe of the 2020 COVID-19 epidemic, during the first and second waves of the pandemic. The prevailing context was one of restricted public health services, followed by rescheduled appointments and a gradual resumption of activities based on criteria and guidelines for rigorously protecting healthcare professionals. However, an environment of fear and tension related to the possibility of contracting the virus — which has been described as highly stressful — was present and may have contributed to suicides within the institution. Birman (2020) places the traumatic experience at the center of reflections on the pandemic and the multi-causality of this social phenomenon. The author highlights feelings of vulnerability, loneliness, helplessness, and discouragement that emerge as a psychic collapse under the subjective experience.

As a contribution to defining a suicide postvention protocol in public institutions, this experience may contribute to similar future situations, considering the following aspects: (i) emergency action, immediately after the suicidal act, to listen to the emotions of people close to or institutionally linked to the person who committed suicide; (ii) formation of a care management group, with representatives from all sectors to plan interventions; (iii) offering conversation circles for additional emotional support and religious comfort; (iv) identification of individuals at risk of suicide due to a history of suicide attempts and risk groups, i.e., sectors closest to the person who committed suicide; (v) provision of specialized care to all individuals who request it; (vi) monitoring individuals identified as at risk of suicide; and (vii) a psychoanalytic listening group within the care management group to support, reflect on, and strengthen institutional actions.

There should be a special emphasis on immediate suicide postvention, which includes offering initial psychological care and mental support. Internal and external support networks must be activated quickly to work with the interdisciplinary team beyond inter-institutional processes. A process of this magnitude requires an ongoing and active suicide prevention policy within the institution.

In the reported case, applying different perspectives from the fields of public health, psychology, and psychoanalysis in distinct interventions facilitated the postvention process over approximately six months, which is considered a sufficient period of time. The forceful and impactful emergency action in the psychosocial field likely prevented the spread of feelings of panic and helplessness, as well as the Werther effect. Open public management to new processes, albeit difficult, and continuous monitoring and strengthening of the care team were necessary to promote effective interventions.

This process reveals the need for ongoing actions to promote the health of workers, ensuring that demands related to work processes and the work environment are addressed to prevent and promote mental health in the workplace. Thus, this article proposes reflections and indicates a possible technical appropriation for developing postvention public policies.

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• World Health Organization [WHO]. (2014). Preventing suicide: a global imperative

• 10
  Although the Mortality Information System (SIM/MS) recorded 30 cases in 2020, the Municipal Epidemiological Surveillance reported that, after investigation, one of them corresponds to a non-resident of the municipality.
• 11
  The Care Committee was composed of representatives from Surveillance of Workers’ Health/Occupational Health Reference Center (Cerest) (Andréia De Conto Garbin and Nancy Yasuda), Mental Health (Denise Miyamoto Oliveira), Primary Care (Ana Iria Negrão), and the Sexually Transmitted Infections/AIDS Reference Center (CR IST) (Mônica Guarnieri Machado) - authors of the report along with Margareth Arilha (NEPO/Unicamp)
• 12
  See text written by Karina Okajima Fukumitsu, available at: https://jornal.usp.br/artigos/posvencao-uma-intervencao-dolorida-porem-necessaria/#_ftnref1.
• 13
  The listening space of the Care Committee was coordinated by psychoanalyst Margareth Arilha, researcher at the Elza Berquó Population Studies Center (NEPO-Unicamp) and member of OUTRARTE: Psychoanalysis between Science and Art, Unicamp.

• 20
  Data Availability Statement: The dataset supporting the results of this study is available within the article.

Edited by

• 1
  Section editor: Alvaro Marcel Palomo Alves

Data availability

Data Availability Statement: The dataset supporting the results of this study is available within the article.

Publication Dates

• Publication in this collection
  23 Mar 2026
• Date of issue
  2025

History

• Received
  27 Nov 2021
• Accepted
  13 Dec 2023