## 4 Discussion
### The Psychological Risk Factors and the Behavioral Changes  
Psychological factors and behavioral changes are less quantifiable. The psychological framework of these patients might have been addressed either using the verbal autopsy or the psychological autopsy reports. In poorer countries where autopsies are rare, and death certificates are inaccurate (Africa, Asia, Latin America), the verbal autopsy has been used as an epidemiological instrument. Verbal autopsy interviews the close relatives about the deceased symptoms, complaints, treatment type, compliance, and duration, and the disease course prior to his death with a random re-interviewing of 5% of the reports to assess the reliability [31,32]. However, caution should be taken regarding this method's reliability, and other autopsy methods should be further performed for its validation [31]. Psychological autopsy adds more data to the verbal autopsy reports integrating site investigation reports, death certificates, available medical documents, and medico-legal reports completed with histopathology and toxicology examinations. It brings essential data related to the patients' profile when there is no farewell letter linking the motives with the ongoing health emergency [3,31,33,34,35,36,37]. Based on the applied questionnaire, we could document that SARS-CoV-2 infection in association with other diseases had a psychological impact on these patients in a specific manner: the loneliness and the quarantine obligation, the loss of a family member due to SARS-CoV-2 infection, the fear of spreading SARS-CoV-2 infection to the loved ones. The behavioral changes presented in all the cases were sadness, anxiety, loneliness, insomnia, chronic fatigue. The depressive background was noticed only in two cases playing an important role in the suicidal act. In the other case, depression has been diagnosed for the first time during hospitalization. In a relatively recent study (2017) on a large cohort of New Zealanders aged >65 years, loneliness, poor self-reported health, depression were documented as independent, predictive variables of death. A death wish was found in 9.5% of this population sample, hence a special attention should be given on the aforementioned predictors along with the age factor, especially in COVID-19 patients [37]. Other behavioral changes such as aggression, nervousness, guilt, self-doubt, suicidal ideation, reluctance and difficult cooperation with the medical treatment, lack of communication with the family, and self-isolation were present in at least two out of three cases. Additionally, there were changes in behavior with an increase in impulsivity and aggression, which are involved in suicidal behavior, especially if associated with alcohol dependence. All the aforementioned behavioral changes and the risk factors suggest that they might have attempted suicide due to acute stress disorders. Our findings are in line with other research reports during the COVID-19 pandemic [5; 22; 38; 39; 40; 41; 42; 43]. Mounting evidence in the literature points out its role in this respect [33; 45; 46]. During the COVID-19 pandemic, suicide rates had a nonlinear trend. A decreasing trend was recorded in COVID-19 outbreak, then, over an extended period, the rates increased [47]. People with pre-existing mental illness were more vulnerable to stress caused by various risk factors related to COVID-19 and isolation [2; 3; 48]. All the pandemic problems, such as positive infection diagnosis, isolation, quarantine, social distancing, the economic consequences, can trigger behavioral changes such as sadness, anxiety, fear, anger, annoyance, frustration, guilt, helplessness, loneliness, and nervousness, increasing the risk of the suicidal behavior, and the committed suicide. A study conducted in China showed a moderate to severe psychological impact at more than half of the population studied with mild to severe symptoms of depression and anxiety [49].