Suicidality in the Arab World -...

The Arab Journal of Psychiatry (2008), Vol. 19, No .1, Page (1-24)

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Suicidality in the Arab World Part II: Community Studies

Elie G. Karam, Ranya V. Hajjar, Mariana M. Salamoun

Abstract

This paper reviews hospital and government based articles on suicidality in the

Arab world. A systematic search was conducted up to 2006 (Bahrain, Egypt,

Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Palestine, Saudi Arabia, Su-

dan and United Arab Emirates). Results varied across countries and methods.

The Arab hospital studies, estimated annual rates of attempted suicide ranging

from 1.9/100,000 to 127/100,000. The Arab police and government records

reported annual completed suicide rates of 1.1/100,000 to 6.2/100,000. Several

risk factors were identified. While in hospital based studies, attempt was relat-

ed to being single, aged 15-25 years, primary to secondary level education,

students, housewives, unemployed, belonging to over-crowded large families,

and having a low socio-economic status. In addition, many psychiatric disor-

ders were identified as risk factors, most commonly depressive disorders, ad-

justment, personality, and drug dependence/abuse disorders. Completed sui-

cide victims were more frequently males, 20 to 40 years old, single, manual

workers and unemployed. In conclusion, accurate recording methodology in

hospitals and governmental institutions are needed to assess the prevalence and

risk factors of suicidal behaviours in the Arab World.

Key Words: attempt, deliberate self-harm, suicidality, suicide

Word count: 157.

Introduction

Studies that assess suicidality are rare

in the Arab world. Given the fact

that suicide and attempted suicide are

considered disgraceful acts prohibit-

ed by religion, condemned by society

and hampered by legal consequences,

suicidality remains a taboo in this

region of the world. The present pa-

per builds on a sister publica-

tion in a previous issue of the Arab

Journal of Psychiatry and reviews

hospital and government based re-

ports. More specifically, it reviews

the prevalence of suicide ideation,

attempts, completed suicide, the so-

cio-demographic, mental health and

other risk factors associated with sui-

cidality in the Arab world.

Suicidality in the Arab World

2

Methodology

A search was conducted on PubMed,

PsycInfo and IDRAAC WEB/CD up

to 2006 using the following key

words: suicidality, suicidal behavior,

suicide ideation, suicide plan, suicid-

al gestures, attempted suicide, para-

suicide, deliberate self-harm, self-

harm, suicide and completed suicide.

This search included the Arab world

and Arab countries: Algeria, Bahrain,

Comoros, Egypt, Gaza, Iraq, Jordan,

Kuwait, Lebanon, Libya, Mauritania,

Morocco, Oman, Qatar; Somalia,

Sudan, Syria, Tunisia, United Arab

Emirates, West Bank, Yemen, and

Gulf, Middle East, and Arab. An ini-

tial list of 2750 abstracts were re-

viewed, and 32 articles were identi-

fied as relevant but only 22 articles

could be retrieved and reviewed after

several attempts to locate the original

authors. The articles tackled different

aspects of suicidality, such as suicide

attempt and completed suicide. Some

studies were hospital based (n= 17),

while others used police and gov-

ernmental records (n=5). Community

based studies are reviewed in a pre-

vious article.

Terminology

In the following review, non-fatal

self-injurious behavior is referred to

as attempted suicide, parasuicide and

deliberate self-harm. These terms are

used interchangeably and encompass

specific types of self-injurious behav-

iors such as deliberate self-poisoning.

In some studies, intent to die is as-

sessed not for the purpose to distin-

guish suicide attempt from suicide

gesture, but rather as a characteristic

of the suicide attempt itself. In addi-

tion, several studies included in this

review differentiated deliberate self

poisoning (by using household chem-

icals or poisons) from deliberated

drug overdose (by using prescribed

or non-prescribed medication), on the

basis of the type of substances in-

gested in order to attempt or commit

suicide. Other studies defined delib-

erate self poisoning as the ingestion

of household chemicals and drugs,

prescribed and non-prescribed, in

order to attempt or commit suicide.

Results

Bahrain In a study by Al Ansari et al.1 a case-

control study was intended to com-

pare socio-demographic, mental

health and psychosocial characteris-

tics of drug overdose in two different

age groups: adolescents (15-18 years)

and young adults (19-24 years) that

were consecutively admitted to Sal-

maniya Medical Centre, Bahrain De-

fense Force Hospital and Psychiatric

Hospital (June 1993-December

1994). One-hundred-and-nine cases

were admitted but only 100 cases

were included due to the expiration

of their residency. Both age groups

were assessed according to several

instruments: a semi-structured inter-

view, a special questionnaire (to

gather information about socio-

demographic characteristics and cir-

Elie G. Karam, et al

3

cumstances that surrounded the act),

DSM III-R (to assess the presence of

psychiatric illness), the Beck Suicide

Intent Scale (in order to assess intent

to die) and Hollingshead and Rahae

scale in order to assess socio-

economic status. The most frequently

observed socio-demographic charac-

teristics were similar in both adoles-

cents (n= 57) and young adults (n =

43), with the most common charac-

teristics being female (77.2% and

72.1%, respectively), never being

married (91.2% and 65.1%, respec-

tively), having more than 7 years of

education (91.2% and 100%, respec-

tively), and belonging to lower socio-

economic class (70.2% and 74.4%,

respectively). Adolescents and young

adults differed in terms of employ-

ment status, adolescents were more

commonly students (82.5%) and

young adults were more commonly

unemployed (46.5%).Young adults

were significantly more likely to be

married (P<0.001) and unemployed

(P< 0.0001) in comparison to the ad-

olescent group. The most frequently

reported precipitating factors by both

groups were marital problems be-

tween their parents (70%), conflict

with parents (45%), work and school

problems (38%) and problems with

their significant other (28%). Adoles-

cents were significantly more likely

to have had problems with peers

(P<0.01) and social isolation as pre-

ceding the act (p<0.01), and to take

two or more drugs as compared to

young adults (p < 0.05). Young

adults were significantly more likely

to score higher on the Beck Suicide

Scale (P< 0.01). DSM III-R diagno-

ses were made in 48% of the total

sample, adolescents and young adults

being diagnosed with adjustment dis-

order (31.6% and 39.5%, respective-

ly), depression (1.8% and 7%, re-

spectively), and adolescents with

conduct disorder (3.6%). Out of the

total sample, 27% had a previous his-

tory of parasuicide (85% overdosed

and 15% injured themselves). Ado-

lescents who have had a previous

history of drug over-dose were more

likely (19%) to do so in the past year

in comparison to adolescents

(8.1%).The drug most commonly

used in more than half of the total

sample was the non-opiate analgesic

paracetamol (58%). Seventy-nine

percent attempted by using drugs that

were either present at home or that

had been prescribed to them or indi-

viduals in their family. There was no

significant difference between the

two groups in terms of where and

how the drug became available and

the type of drug used. Adolescents

were more likely than young adults

to request the aid of general practi-

tioners (29.8% vs.9.4%, respectively)

and social workers (12.4% vs. 2.3%,

respectively).

Egypt Mabrouk and colleagues2 assessed

suicidal burns in the population of

patients who attended the burn unit


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of Ain Shams University (serves 4

million) from May 1995- December

1996. Seven-hundred-and-fifty-nine

cases were admitted to the Burn Unit,

23 were self-immolators (age range:

14-55) with a mean age of 23 years.

Self-immolators were mostly females

(91.4%), less than 20 years old (61

%), single (52%), illiterate or with

primary school level education

(56.5%), from low socio-economic

class (82.6%), housewives (52.2%)

and unskilled workers (31.4%). All

cases of self-immolation were exam-

ined by a psychiatrist and assessed

according to ICD-10 criteria; the re-

ported diagnoses were depressive

disorder (74%), borderline personali-

ty (13%), psychotic disorders (9%)

and unknown (4%). Twenty-two per-

cent had made a previous suicide at-

tempt and none had received prior

psychiatric treatment. Family con-

flicts were the “main” precipitating

factor among all self-immolators.

Even after extensive treatment, 74%

of self-immolator died. Kerosene was

used in all cases of self-immolation.

In a study by Okasha et al.,3 clinical

and social factors which predispose

individuals to attempt suicide in Cai-

ro were assessed in subjects who

were admitted for attempted suicide

to the casualty department of 3 dif-

ferent hospitals (catchment area: 4

million) during the first week of each

month, during a one year period

(1981-1982). Several instruments

were used to assess the different

characteristics of suicide attempters:

a semi-structured interview (to as-

sesses the characteristics of the at-

tempt, psychiatric symptoms and so-

cio-demographic characteristics);

suicidal feelings questionnaire (to

assess the presence of suicidal idea-

tion in attempters); Suicide Risk

Scale (to assess the risk of future sui-

cide); two psychometric tests ( the

Arabic version of Eysenck Personali-

ty Questionnaire and the Extreme

Response test); and the Hamilton

scale for depression and anxiety. The

attempter’s spouses were also given

personality tests to take. Ninety-one

attempters were recorded. A “higher”

prevalence of attempted suicide was

observed during May, June and July.

Suicide attempters were more signif-

icantly observed to be: female (69%),

single (71%), literate (71%), students

(37%) and unemployed (14 %),

which are all reported by the author

to be overrepresented in the sample

in comparison to the general popula-

tion. The most frequently observed

characteristics among attempters

were: being an adolescent or young

adult (60%); having children with a

mean number of 3.27 +/- 1.72 (93%);

belonging to overcrowded large

families (mean number 7.8 +/- 2.2);

living in a small mean number of

rooms (2.2 +/- 6.6); and belonging to

low socio-economic class (59%).

Eighty-three percent of all cases were

diagnosed with psychiatric disorders.

Of those diagnosed, the most com-


5

mon were (27%) adjustment disorder

(32% of males and 25% of females),

(20%) personality disorder (18 % of

males and 2% of females), and (12%)

dysthymic disorder (16% of males

and 9% of females). Reported precip-

itating factors differed according to

gender, with females more likely to

report bereavement, romantic rela-

tionship problems and marital prob-

lems, and males were more likely to

report financial difficulties and con-

flicts related to work and school (no

numbers in article). Drug overdose

was the most commonly used method

(60%), while aspirin was the most

commonly used licit drug; violent

methods (cutting, piercing, burning

and jumping) were less commonly

used, but when used, they were more

often used by males. When suicide

attempters were compared with the

general population, attempters scored

higher on measures of psychoticism,

neuroticism and criminality. Male

attempters were more likely to be

classified as introverts in comparison

to female attempters. On the Extreme

Response test, suicide attempters

were reported to be more flexible and

less rigid in comparison to the aver-

age population. Male (6.3 +/-2.79)

and female (5.2+/-2.17) spouses of

suicide attempters had higher scores

for psychoticism than the average

population. Male spouses were re-

ported to be more extroverted (13.2

+/- 3.5) than the average population

and female spouses were more likely

to be introverted (11.9 +/- 4.3).

Okasha and Lotaif 4 investigated the

prevalence of attempted suicide and

the socio-demographic and mental

health characteristics of suicide at-

tempters in Cairo that were admitted

to the casualty department of Ain

Shams University Hospital during a

one year period (1975). One-

thousand-one-hundred-and-fifty-five

suicide attempters were recorded

which resulted in a reported approx-

imate annual rate of 38.5/100,000.

The sample was selected by choosing

the first 16 or 17 attempters admitted

during each month, resulting in a

sample of 200 cases. Interviews were

conducted with the use of the Ain

Shams case-taking sheet and ques-

tionnaire created for this study.

There was an observed increase of

attempted suicide during the months

of May, June and July. The highest

incidence of attempted suicide oc-

curred mostly in 15- 24 year olds

(60%), males (61.5%), single persons

(53%), those who practiced their re-

ligious beliefs (72%), students

(40%), the unemployed (23%), those

that completed secondary school

(35%) and individuals from middle

to low socio-economic class(no

numbers in article). One-hundred

percent of the total sample was diag-

nosed with a psychiatric disorder; the

diagnoses were (diagnostic method

not mentioned in article): 63% de-

pressive disorder (66% males), 13%


6

hysterical reactions (77% females),

8.5% situational disorder (53%

males), 8% schizophrenia (94%

males), 5% personality disorders

(50% males) and 2.5% substance

abuse/ dependence (100% males).

Seventy-five percent of those diag-

nosed with depression attempted sui-

cide 4 months after the onset of their

depressive episode and the rest were

depressed for less than 8 months be-

fore making their suicide attempt.

Five percent sought psychiatric assis-

tance before attempting suicide. Thir-

teen percent made previous suicide

attempt, 5% made 1 previous at-

tempt, and 7% made 2 previous at-

tempts, and 1% made 3 previous at-

tempts. Seventeen percent of at-

tempters reported a family history of

suicide attempts. The most common

stressors and conflicts reported were

marital problems, unemployment,

work related problems, and financial

problems (numbers missing in arti-

cle). The methods used to attempt

suicide were: 80% overdose (61%

males), 10% used poisoning material

(85% females), 7% bodily harm

(100% males) and 3% intoxication

(100% males).

Iraq In order to identify the socio-

demographic and clinical characteris-

tics of self-poisoning, Al-Samarrai

and Hussein5 prospectively studied

all self-poisoning patients that were

brought to the emergency department

of University Hospital of Saddam

College of Medicine in Baghdad dur-

ing a 4 month period (January 1,

1998- April 30, 1998). With the use

of a semi-structured interview, 58

patients were diagnosed with parasu-

icide and self poisoning (age range:

15-59), which stand for almost

8.8/1000 total emergency cases. The

total sample mortality rate was

3.50%. Females (69%) constituted

the majority of cases, with a male to

female ratio of 1: 2.2. The average

age for the total sample was 28 years

(31 y for males and 25 y for fe-

males); females were significantly

younger than males (p< 0.05). The

most commonly observed socio-

demographic characteristics among

attempters were: 70.7% between the

ages 15-29 years (76% females),

48% single (61%females), 36% em-

ployed (52% males), 33% house-

wives, 72% lived in urban areas

(64% females) and 48% had univer-

sity or postgraduate level education

(75% females). Patients were almost

equally distributed among socio-

economic classes (upper, middle and

low). Only 8.6% were in the age

group 40- 59 years. No incidences

were recorded for older age groups.

A psychiatrist used a semi-structured

interview to assess parasuicide pa-

tients. Ten percent of the whole sam-

ple had a history of mental illness

and psychiatric treatment (diagnostic

method not mentioned in article).

Ten percent made previous suicide

attempts, 5% made one previous at-


7

tempt and 5% made 2 or more sui-

cide attempts. The three most com-

monly reported motives for attempt-

ing suicide were to relieve stress

(27.5%), confused emotions (21%)

and desire to die (14%). The most

commonly reported precipitating fac-

tors were 27.6% family conflicts,

26% marital problems and 17.2% the

loss of someone important in their

lives as a result of death or separa-

tion. Self-poisoning was consistently

reported by attempters as an impul-

sive reaction during an argument or

fight in 78% of the total sample. The

most common drugs used in self-

poisoning were psychotropic medica-

tion (39% males and 52.5% females).

Only 26% were referred to a psychia-

trist and 39.6% were discharged

without follow up.

Jordan Abu-Hijleh 6 examined the effect of

life events in predisposing adoles-

cents to suicidal behavior in Jordan.

The study administered the Adoles-

cent Life Change Events Question-

naire (ALCEQ) and compared the

scores of adolescents (N=36; age

range = 14-19) who were admitted to

Jordan University Hospital (1995-

1997) for attempted suicide, with

those who were admitted for “neurot-

ic and anxious symptoms,” with a

control group selected from nearby

schools. There was no significant

difference in the total Life Change

Events score between neurotic and

suicidal adolescents; nonetheless,

there were significant differences on

particular life events: problems with

family (p < 0.001) and beginning to

have opposite sex friends (p < 0.05).

Losing a close friend was significant-

ly reported in both suicidal and neu-

rotic groups (p < 0.01).

In a retrospective study, Saadeh et

al.,7 examined all those who were

admitted for carbamate and organo-

phosphate poisoning to the Medical

Center of Princess Basma Hospital

during a 5 year period (January 1990

to January 1995) in order to assess

the incidence, socio-demographic

and clinical aspects of carbamate and

organophosphate poisoning in North

Jordan. Seventy adults were admitted

for carbamate and organophosphate

poisoning, 64% (56% females) were

assessed to be suicide attempts with a

total sample mean age of 23.25 +/-

8.2 years (the mean age of attempters

was not reported). The most common

characteristics observed in the total

sample were being young: 15-19

years old (43%), being single (67%),

being unemployed (43%) and living

in a rural area (57%).

In another retrospective study by

Saadeh et al.,8 the clinical and socio-

demographic characteristics of delib-

erate self- poisoning by drugs and

household products in Jordan were

assessed by reviewing the medical

records of all patients over the age of

15 years who were admitted for self-

poisoning at the medical department

of Princess Basma Teaching Hospital


8

(January 1990-1994). Using ICD-9

criteria, 709 cases were diagnosed as

being cases of deliberate self harm,

making a reported average annual

rate of approximately 127/100,000

with a mortality rate of 0.60%. Due

to missing data, only 647 cases were

included in the study. Cases of delib-

erate self-poisoning were frequently

observed to be female (58%), be-

tween the ages 15-24 (76%), single

(62%), students (41%), unemployed

(22%) and housewives (21%). The

estimated annual rate of self-

poisoning in 15-19 year olds was

416/100,000. The incidence of self-

poisoning decreased with increasing

age, resulting in the least amount of

incidences in the age group 35 and

over (5%). Medical doctors and a

psychiatrist diagnosed (method not

clear) 17% of the total sample with

mental disorders; the disorders were

depression (7%), drug abuse (4%),

schizophrenia (4%) and personality

disorders (2%). Previous suicide at-

tempts were reported by 10% of the

sample. Paracetamol (15%) and pre-

scribed drugs (15%) were two of the

most frequently used drugs in the

total sample. In 38% of cases, the

medicine used for self-poisoning had

been prescribed to the patient or to a

family member. Twenty percent were

immediately placed in intensive care

upon admission, while the rest stayed

in the hospital for a mean number of

2.7 days.

In a study by Daradkeh,9 characteris-

tics of individuals who committed

suicide in Jordan were assessed by

reviewing all suicide deaths recorded

at the Department of Public Security

during the years 1980-1985. Two-

hundred-and-nineteen completed sui-

cides were recorded, the author re-

porting an estimated average annual

rate of 2.1/100,000 attempts. Males

had a mean age of 31 years and fe-

males had a mean age of 28 years.

Fifty-nine percent were males

(2.55/100,000), who were between

the ages of 15 to 24 (3.35/100,000)

and 25-34 (3.73/100,000). Female

suicide victims were also observed to

reach a peak of incidence between

the ages 15-24 (3.38/100,000) and

25-34 (2.53/100,000). The frequency

of suicide was observed to be less

common in the age range 65 years

and older for both males

(2.58/100,000) and females

(2.06/100,000). Police investigators

labeled 63% of the total sample as

mentally ill (diagnostic method not

mentioned in article). Males were

more likely to be single (70%), man-

ual workers (35%), unemployed

(22%), used insecticides (26%), or

self-shooting (26%) to commit sui-

cide. Females were more likely to be

married (51%), housewives (41%),

students (29%), and unemployed

(27%), and used the methods self-

immolation (41%) and insecticides

(37%) to commit suicide.


9

Kuwait A retrospective hospital based study;

bang et al.10 assessed the various

characteristics of those who died due

to burns during a period of 16 years

(1982-1997) at 3 different hospitals

in Kuwait. During the study period,

234 patients died as a result of their

burn injuries (mean age = 30y),

11.5% were the result of self-

immolation. Kuwaiti nationals con-

stituted 37.2% of the total sample.

Out of those deemed to be suicidal

deaths, the highest incidences were

among Kuwaiti citizens and non-

Kuwaiti Arabs (numbers not in arti-

cle), females (9.4%) and married

(9.8%). Psychological disorders were

found to be present in 56% of those

that died as a result of suicidal burns

(diagnostic method not mentioned in

article). Benzene was the most com-

monly used accelerant in cases of

self-immolation.

In another retrospective study, Emara

and colleagues11 investigated all re-

ported cases of attempted suicide by

drug overdose admitted to the medi-

cal wards of the Mubarak Teaching

Hospital during a 3 year period from

1983-1985 (serves 240,000).Two-

hundred-and-twenty-seven cases of

attempted suicide were recorded (age

range: 14-48), and two died (mortali-

ty rate of 0.88%). Kuwaiti nationals

constituted 36% of the total sample.

Out of the total sample, the most

common socio-demographic factors

were being female (77%) and under

the age of 25 years (68%). In the

total sample, females were signifi-

cantly younger (22.5 +/- 6.1 years)

than males (26.05 +/- 7.2 years) (p <

0.005). Forty-nine percent of cases

were assessed using ICD-9 criteria,

34.8% were diagnosed with a mental

illness. Those with a diagnosis:

21.4% had depression (14.8% of

males and 23.5% of females), 10.7%

drug dependence (33.3% of males

and 3.5% of females), 0.89% schizo-

phrenia (4% males) and 2% mental

retardation (4% of males and 1% of

females). Previous suicide attempts

were recorded in 13.2% of the total

sample, 7% had one, 5% had two and

1.5% had three previous attempts.

Attempters with a history of drug

dependence were significantly more

likely to have made multiple previ-

ous suicide attempt (p =0.0013), in-

gested fewer tablets (p = 0.9934), and

utilized an unidentified variety of

drugs (p = 0.0389). The most com-

monly used drugs were paracetamol

(36.5%), aspirin (19%), tranquilizers

and antidepressants (14.5%). The

majority of cases used only one type

of drug (64%) and took a dose of up

to 20-40 tablets (45.3%). Expatriates

were significantly more likely to take

larger doses than Kuwaiti nationals

(p=0.0107).

Suleiman et al.12 investigated the psy-

chosocial profile of 92 parasuicide

patients (age range: 14-44) brought to

the Mubarak Al-Kabir Teaching

Hospital in Kuwait (serves 449,000)


10

during a 1 year period (December

1984- November 1985). Kuwaiti citi-

zens comprised 41.7% of the total

sample. Females were younger than

males with a mean age of 22.2 +/-

5.03 vs. 27.2+/- 7.3, respectively.

Females outnumbered males with a

ratio of 6:1 and they were significant-

ly more likely to feel regret over their

suicide attempt (P< 0.003). Attempt-

ers that were 30 years and younger

were significantly more likely to use

self-poisoning and jump from high,

while those 30 years and older were

more likely to use sharp tools to at-

tempt suicide (P < 0.005). Males

were significantly more likely to use

sharp tools, while females were more

likely to use self-poisoning (P >

0.002). Non-Kuwaiti Arabs were sig-

nificantly more likely to use self-

poisoning, while non-Kuwaiti non-

Arabs were more likely to use sharp

tools and jump from high (P<0.001).

Those with more than eight years of

education were significantly more

likely to use self-poisoning, whereas

patients with 8 years or less of formal

education were more likely to use

sharp tools to attempt suicide (P <

0.0001). Using ICD-9 criteria to as-

sess the presence of psychiatric dis-

orders, the most frequently made di-

agnoses were 25% depression, “acute

situational distress” and “personality

disorders” (numbers not available in

article). Kuwaitis were more likely

to report family conflict (P < 0.05)

and educational problems ( P <

0.007) as precipitating factors, while

non-Kuwaiti non-Arabs reported that

work conflicts ( P < 0.001) and al-

tered work conditions ( P < 0.0001)

most often preceded suicide attempt.

Drugs used for self-poisoning were

more often taken from free clinics or

belonged to a relative or family

member (P < 0.001). Kuwaitis were

more likely to take a combination of

drugs and the most frequently used

drugs were non-opiate analgesics (P

<0.0001). The attitudes of the at-

tempter’s families were assessed too

regarding the patients suicide at-

tempt: Kuwaiti patients were signifi-

cantly more likely to report that they

were met by “aggressive attitudes”

from family members (P <0.0001).

Lebanon In 1994, Alyahfoufi13 retrospectively

assessed the prevalence of attempted

suicide in Lebanon by using the files

of 6 different hospitals in different

areas of Beirut with a reported

catchment area of 800,000. One-

hundred-and-forty-seven attempters

were documented, making an annual

rate of approximately 21.4/100,000

attempts. Attempters were more fre-

quently single (76.92%), females

(65.31%) and between the ages of

16-25 (57.14%). Psychological prob-

lems were assessed by medical doc-

tors (diagnostic method not men-

tioned in article), depression reported

to be present in 23.9% of all attempt-

ers. The most common precipitating

factors or reasons given for attempt-


11

ing suicide were family problems

(63.8%), and the two most common-

ly used methods for attempting sui-

cide were drug overdose (59.8%) and

self-poisoning (27.2%).

Abou- Daoud14 investigated the prev-

alence of completed suicide in the

Beirut area over a 5 year period

(1968-1972) by using the register of

deaths in the Municipal Health De-

partment of the city of Beirut with a

reported catchment area of

1,000,000. One-hundred-and-twenty

completed suicides were recorded, a

reported estimate of about

2.4/100,000 completed suicides an-

nually. Lebanese citizens constituted

the majority of the sample (61%).

Out of the total sample, suicide vic-

tims were frequently male (58%), in

the age group 10-29 years (52%), of

the Muslim religion (64%), and sin-

gle (54%). Parathion poisoning was

the most frequently used method in

the total sample (20%) and among

females (28%), while fire-arms were

the most commonly used method for

males (20%). Cases of completed

suicide appeared to successively de-

crease from 31 cases (1968) to 19

cases (1972).

Oman In a retrospective study by Zaidan

and colleagues,15 information about

the demographic characteristics, pre-

cipitating factors, and substances

used for deliberate self-poisoning

(DSP) were taken from the files of

deliberate self poisoning cases who

were brought to the Accident &

Emergency clinics of 4 different hos-

pitals in Urban Muscat during the

years 1993-1998 (serves 557,500).

Suspected cases deliberate self poi-

soning was assessed according to

ICD-10 criteria. One-hundred-and-

twenty-three cases of deliberate self

poisoning cases were recorded (age

range: 12-56) with a mean age of

23.5 years (SD = 6.86), of which

77.2% were Omani citizens. Out of

the total sample, deliberate self poi-

soning was more common in persons

20-30 years old (54.1%) and persons

less than 20 years old (30.3%). Oma-

ni patients were mostly females

(83%), single (63%), students (36%),

unemployed (26%), and received up

to secondary school education (72%).

Among the total sample, 20% were

diagnosed with psychiatric disorders,

(11.4%) depression, personality dis-

orders (4.1%), substance abuse

(2.2%), a history of seizures (1.6%)

and a history of criminal activity

(1.6%). Twelve percent of the total

sample reported previous instances of

deliberate self-harm, with an average

of 3.28 months in between attempts.

Family conflicts (30.9%) and social

problems (15.4%) were the most fre-

quently reported precipitating factors

among the total sample. The most

commonly used substance for self-

poisoning among the total sample

were non-steroidal analgesics

(40.7%). The majority of cases

(75.6%) were admitted to the general


12

medical ward, 8.3% were treated in

the psychiatric ward, and a minority

(7.3%) experienced complication and

had to be admitted to the ICU. A rise

in reported instances of deliberate

self-poisoning in Omani citizens was

observed from 1995 (1.9/100,000) to

1998 (12.8/100,000).

Saudi Arabia In a retrospective study by Al-Jahdali

et al.,16 cases of intentional drug

overdose admitted to the King Fahd

National Guard Hospital (catchment

area: 250,000) from 1997 to1999

were assessed by reviewing patient’s

charts in order to ascertain socio-

demographic and mental health char-

acteristics of intentional drug over-

dose in Saudi Arabia. Seventy-nine

cases were studied (age range: 15-40

years old) with a mean age of 22

years (SD 4.6 yrs). Saudi nationals

constituted 96% of attempters. Inci-

dences of suicide attempts were ob-

served to increase in September

(20%). Out of the total sample, inten-

tional drug overdose patients were

frequently female (80%) with a fe-

male to male ratio of 4:1, single

(75% of males and 44% of females),

unemployed (60%), with a high

school education (41%), and from a

family of 5 or more members (59%).

Upon admission and prior to dis-

charge, a psychiatrist interviewed

each case, 25% were assessed to have

had an unspecified psychiatric disor-

der and 5% had a history of drug

abuse. The most frequently reported

precipitating factors were family con-

flicts (60%), while school perfor-

mance was an important precipitating

factor in school aged patients. The

most commonly used drug was acet-

aminophen (30%); one type of drug

was used in the majority of cases

(80%); and patients were most likely

to have been prescribed the drugs

that they used to overdose on (53%).

Twenty-three percent made previous

attempts, of which 39% made one

previous attempt, 22% made 2 at-

tempts, and 39% made 3 previous

attempts. Out of the total sample,

63% had either normal or negative

drug levels, 15% were admitted to

the intensive care

unit, staying for a mean number of

1.5 days (SD 0.5), while the rest of

the patients were admitted to the reg-

ular ward for a mean number of 5

days (SD 3) .

AbuMadini and Adel Rahim,17 pro-

spectively assessed characteristics of

deliberate self-harm subjects by us-

ing two structured questionnaires to

collect information about socio-

demographic characteristics and de-

liberate self-harm characteristics for

each deliberate self-harm patients

attending the Accident & Emergency

at the King Fahd University Hospital

from 1994 to 2000. Three-hundred-

and-ninety-eight cases were recorded

(age range 13-74), only 362 cases

were included in the study (drop out

rate of 9%) with a mean age of 26.3

(SD 9.5). Saudi nationals comprised


13

the majority of the sample (76.2%).

Deliberate self-harm patients were

frequently females (64.4%), single

(48.9%), between the ages of 20-29

years (53.3%), and unemployed

(37.6%). In comparison to males,

females were significantly more like-

ly to be less than 20 years old (p <

0.0001), unemployed (p <0.0001)

and students (p < 0.01). The majority

of deliberate self-harm patients re-

ceived a psychiatric admission

(53.6%) and had a family history of

psychiatric disorders (51%). ICD-10

diagnoses were made for 87% of the

total sample; the most common diag-

noses were personality disorder

(32%), adjustment disorder (30.1%)

and depressive disorder (8.6%). The

most frequently reported precipitat-

ing factor among deliberate self-harm

patients was family problems

(50.3%). Females were significantly

more likely to have a personality dis-

order (p<0.01), an adjustment disor-

der ( p < 0.01), to have had acute on-

set of mental illness (p< 0.0001), to

report stressful life events ( p <

0.0001) and family conflicts (p <

0.00001) as preceding their attempt,

and to describe their attempt as a way

to get back at others ( p < 0.001).On

the other hand, males were more sig-

nificantly diagnosed with substance-

related disorders (p < 0.0001), schiz-

ophrenia (p < 0.01), depressive dis-

order (p<0.01), delusional disorders

(p < 0.01), having psychotic symp-

toms (p < 0.001), difficulty with law

enforcement individuals(p < 0.0001),

to report internal conflicts (p <

0.00001) as a precipitating factor and

to report serious intent to die (p <

0.0001) as their main motive. The

methods most used in all cases of

deliberate self-harm were drug over-

dose (78.7%) and self cutting (26%),

and the most used drug was parace-

tamol (80%). Drug overdose was

significantly observed in females (p

< 0.0001), while self-cutting was

more frequent in males (p < 0.001).

One previous attempt was reported

by 21.5%, two previous attempts

were reported by 19.9%. Females

were significantly more likely to

have made the attempt in the pres-

ence of others (p < 0.0001), to have

made more than one previous attempt

(p< 0.5) and to have been admitted to

the ICU (p < 0.01). Males were more

likely to be admitted to the surgical

ward (p< 0.0001).

By examining all cases of recorded

suicide in the Medical Legal center in

Dammam, Saudi Arabia from 1986-

1995, Elfawal18 was able to ascertain

the different methods used to commit

suicide and the frequency with which

such methods were employed in the

different age, gender and racial

groups in Saudi Arabia. Two-

hundred-and-twenty-one cases were

recorded, producing an annual esti-

mated population rate of 1.1/100,000.

Saudi nationals constituted 23%

(84% males and 17% females) of the

total sample. Suicide victims were


14

more likely to be: males (82%), be-

tween the ages of 30-39 years old

(44%), single for males (59%) and

married for females (65%). Low in-

cidences (3.2%) of suicide were ob-

served in the age group 60 years and

older. The most commonly used

methods among Saudi nationals were

hanging (39%) and gunshot injuries

(37%). The two most frequently used

methods by females were hanging

(55%) and drug overdose (23%)

There was no significant difference

in the number of suicides among in-

dividual months of the year.

In a study by Osman and Ibrahim,19

cases of deliberate self-harm attend-

ing the Accident and Emergency De-

partment at the King Fahd University

Hospital were assessed by psychia-

trists during a period of 9 months

(April 1994- December 1994). Fifty-

five deliberate self-harm cases were

recorded (18.2% males and 81.8%

females), 65.5% were Saudi nation-

als. Saudi female attempters were

younger (mean age: 20.8 y) than

Saudi male attempters (mean age:

29.7 y). Saudi attempters were more

frequently females (89 %), single (78

%) with secondary education or less

(89 %). Expatriates were significant-

ly more likely to be older (p < 0.05),

married, to have previously seriously

considered attempting suicide and

were less likely to have made previ-

ous attempts (p < 0.005). Psychiatric

disorders and previous deliberate

self-harm each occurred in 29 % of

the total sample. The majority of de-

liberate self-harm patients denied

suicidal intent (88 %) and reported

family conflict as the main precipitat-

ing factor that preceded the act

(50.9%). Out of the total sample, the

most frequently used methods were

self-poisoning (80%) and jumping

from high (22%). Serious cases were

more likely to be expatriates, males,

older age groups and those with pre-

vious suicide attempts.

In a retrospective study, Malik et al.,

20 reviewed the files of all drug over-

dose patients that attended Asir Cen-

tral Hospital during a 5 year period

(1985-1993). Fifty-seven cases of

drug overdose were recorded, 81%

were suicide attempts and the rest

were accidental in nature. Results

indicated that the frequency of drug

overdose had increased over the 5

year study period, from 2 cases in

1989 to 22 cases in 1993. The ma-

jority of attempters were Saudi citi-

zens (89%). The most common char-

acteristics among all cases of drug

overdose were: less than 40 years

(95.6%) with a mean age of 23.6 +/-

9.1 years, single (57.8%), and have

between 6-12 years of education

(82%). ICD-9 psychiatric disorders

were diagnosed in 74% of intentional

drug overdose patients, the most

common diagnosis were depressive

disorder (39.5%) followed by per-

sonality disorder (34.9%). In 60% of

the total sample, family and interper-

sonal problems were reported as cen-


15

tral precipitating factors. The most

frequently used drugs were analge-

sics and non-steriod anti-

inflammatory drugs (25.9%). Illicit

drugs were not detected in any cases

and only one patient was found to

have consumed alcohol. Illiterate pa-

tients and male patients were signifi-

cantly less likely to be referred for a

psychiatric evaluation (P < 0.05). No

mortalities were recorded.

In another study, Daradkeh and Al-

Zayer21 investigated the social and

clinical characteristics of parasuicide,

retrospectively and prospectively,

among the Arabian-American Oil

Company (ARAMCO) employees

(n=31,814) and their dependents (n=

127,614) who were qualified for

treatment in ARAMCO’s medical

services, specifically Dahran Health

Center (1985-1986). In the retrospec-

tive part of the study (1985), 30 Sau-

di citizens were admitted for parasui-

cide, with a mean age of 23.4 years.

In the prospective part of the study

(1986), 36 incidences of attempted

suicide were presented, 92% were

Saudi nationals with a mean age of

24 years (24.9 years for males and

23.2 years for females). In the pro-

spective sample, the rate of attempted

suicide among Saudi employees and

their dependents was estimated to be

20.7/ 100,000. Out of all cases of

Saudi nationals in both groups, the

most frequently observed socio-

demographic characteristics among

the retrospective and prospective

sample were: female (87% and 73%,

respectively), married (63% and

55%, respectively), housewives (50%

and 36%, respectively) and students

(33% and 33%, respectively). The

most frequently reported motives by

Saudi nationals in both samples (ret-

rospective and prospective) were a

desire to die (47% and 30%, respec-

tively) and attention seeking (33%

and 36%, respectively). Among Sau-

di nationals, ICD-9 diagnoses were

made for the retrospective (77%) and

prospective (85%) samples, the most

frequently made diagnoses were

acute reaction to stress (40% and

55%, respectively) and depressive

disorder (20% and 18%, respective-

ly). The most commonly used meth-

od in the retrospective and prospec-

tive samples was drug overdose

(67% and 70%, retrospectively) and

the drugs most commonly used drugs

were non-opiate analgesics (43% and

52%, respectively). In the prospec-

tive sample, the most frequently re-

ported precipitating factors were

marital problems (30%) and disa-

greements with parents (36%), and

the majority attempted without a plan

(88 %). Twenty- one percent of the

prospective sample reported a previ-

ous suicide attempt.

United Arab Emirates In a study by Koronfel,22 all deaths

confirmed as suicides for the years

1992-2000 by the Forensic Medicine

Department in Dubai were examined

in order to ascertain specific charac-


16

teristics related to suicide deaths in

Dubai (population covered: 650,000).

Three-hundred-and-sixty two cases

were recorded, with a reported annu-

al rate of about 6.2/100,000. Dubai

citizens constituted the minority of

cases (6%). A non-significant in-

crease of suicide was recorded during

November, along with a decrease

during July. Fridays were observed to

have a non-significant low incidence

of reported suicide, along with a non-

significant difference between Mus-

lims and non-Muslims. Out of the

total sample, the majority of suicide

victims were males (85%), expatri-

ates (94%), in the age group 21-40

(81.5%) and chose to commit suicide

in their homes (63%). A peak of in-

cidence was observed during the ages

26-30 (29%) with a decline in vic-

tims 50 years old and older (2.7%). A

significant increase was observed in

the prevalence of teenage girls (P =

0.024), especially among teenage

female citizens (P = 5.8E-06), and in

non-Indian expatriate females (P=

0.007). Hanging was the most com-

monly used method to commit sui-

cide among the total sample (75 %),

in the age group 21-40 year old

(62%), in males (79%), and in Dubai

citizens (71%). Females and non-

Indian expatriates showed a signifi-

cant inclination for jumping from

high and self-poisoning (P =0.008).

The most commonly used substances

for self-poisoning were corrosives

(23%). Information about the vic-

tim’s mental health history (diagnos-

tic method not mentioned in article)

and life stressors was only available

in 9.7% of the total sample. Of the

latter, 34 % were being treated for

depression, 9% suffered from drug

addiction, 23% had work or financial

problems, 11% were having family

problems, and 1.65% had made pre-

vious suicide attempts.

Discussion

The lack of national epidemiological

studies in the Arab world and the dif-

ferences in methodologies used, ren-

der it difficult to compare results and

make generalizations. In addition,

properly defined catchment areas for

the distribution of health care ser-

vices are practically non-existent in

Arab countries; thus, making it unre-

liable to make regional estimates of

attempted suicide by using hospital

based studies. Therefore, results

should be interpreted with caution. It

has been observed that official rec-

ords of suicide and attempted suicide

are filled with inconsistencies and

missing information which create an

incomplete picture of suicidal behav-

ior in several Arab countries.

In the reviewed hospital based sui-

cide studies, authors reported esti-

mated annual rates of attempted sui-

cide that widely ranged from

1.9/100,000 to 127/100,000. Obvi-

ously these estimates we presume are

not very reliable for several reasons

(accuracy of catchment areas, report-

ing etc.). Suicide attempters were


17

most frequently: females, between

the ages of 15-25 y , single, with

primary to secondary level education

, students, housewives , unemployed

, belonged to over-crowded large

families , lived in crowded living

conditions , and were from low so-

cio-economic status. Male attempters

were frequently older than female

attempters and were more commonly

unemployed or unskilled workers.

The psychiatric diagnoses ranged

from 10% -87%. The most frequently

diagnosed psychiatric disorders were

depressive disorder, dysthymic dis-

order, adjustment disorder, personali-

ty disorder, “acute reaction to stress,”

and drug dependence/abuse disor-

ders. The most commonly reported

precipitating factors among suicide

attempters were: family conflicts,

work/school problems and financial

problems. Suicide attempters fre-

quently reported low intent to die.

Previous suicide attempts were not

consistently reported in all Arab hos-

pital based studies, but when they

were, they ranged from 5% to 31%.

The two most common methods used

to attempt suicide were drug over-

dose and self-poisoning.

The Arab suicide studies that used

police and government records re-

ported annual completed suicide rates

of 1.1/100,000 to 6.2/100,000, again

keeping in mind the caveats of re-

porting. The most frequently ob-

served characteristics among suicide

victims were: male gender; between

the ages 20 to 40 years old, single,

manual workers and unemployed.

Female suicide victims were fre-

quently younger than male attempters

and were either students or house-

wives. Information about mental dis-

orders, previous suicide attempts and

precipitating factors were typically

not recorded on death registrations.

With this in mind, depression was the

most recorded psychiatric disorder,

and family problems were the most

recorded precipitating factor. The

most commonly used methods to

commit suicide, across all Arab sui-

cide studies, were hanging and self-

poisoning, males being more likely to

self-shoot and females to self-poison

and self-immolate.

Despite the difficulty in making

comparisons to western countries, yet

we can say, with great caution, that

data from North America23 point to

higher annual rates of attempted sui-

cide (500/100,000) and completed

suicide (14/100,000) than the rates

depicted in the Arab hospital based

studies on attempted suicide that we

reviewed.

On the other hand, the reviewed Arab

government based studies on com-

pleted suicide agree with other west-

ern reports24 on the higher prevalence

among males, but still point to lower

rates in the Arab world as compared

to western countries (Canada, Den-

mark, France, Germany, United

Kingdom, etc.)


18

Many have hypothesized that the rel-

atively low prevalence of suicidal

behavior in the Arab world, as com-

pared to western industrialized coun-

tries, is related to underreporting by

all socioeconomic classes, to improp-

er record keeping by official institu-

tions involved in this essential pro-

cess, and in part to legal and confi-

dentiality issues. Others have ex-

plained that the low prevalence of

suicide, especially among the elderly

population, is related to the social

environment of this part of the world,

where irrespective of region, the still

strong family cohesiveness shields

against suicidal impulses.

Still some Arab studies found a re-

cent increase in the rate of suicidal

behavior15,18, 20 and this is thought to be

due to economic and social changes

which are the result of rapid modern-

ization and urbanization in the re-

gion, such rapid changes creating a

growing rift between younger and

older generations, with the resulting

dissonance and intensifying conflicts

between Arab youth, the conservative

society and homes they live in. It is

possible though that there no real in-

crease in the rates of suicidal behav-

ior, but an increase in the effort to

record it.

An interesting issue has come to light

with our review and due to the popu-

lation distributions in a number of

Arab countries such as Saudi Arabia

and Dubai, where citizens represent

only a segment (at times a minority)

of the entire population: the preva-

lence and correlates of suicide and

attempted suicide were difficult to

distinguish from the expatriates re-

siding in those countries. In this re-

view, we attempted to report mainly

on the citizens of Arab countries.

However, it is difficult to overlook

the much higher prevalence of sui-

cide in expatriates living in Arab

countries in comparison to those re-

ported for the local citizens

A limitation to this review is that not

all Arab countries are represented

here (although we did not exclude

any from our search) and it is possi-

ble we might have missed important

studies in spite of our best attempt to

locate the authors and retrieve the

articles.

In conclusion, national epidemiologic

studies and proper book keeping

methodology in hospitals and gov-

ernmental institutions are needed to

assess suicidal behaviors in the Arab

World. This could help in developing

prevention programs and awareness

activities locally against suicidality.

The Arab Journal of Psychiatry (2008), Vol. 19, No .1, Page (1-24)

19

ل يض ا ح دزاسبدان رساجع ر انقبنخ كم أجس ذ له لا بد انز زح بز ي انل بنى انلسث

ذنك لج س جج ساب ثح ن يج حز ل بو . انشسطخ اندائس انحكياخ أ يسجالد ي انسزشفبد،

انجحس، يص س، انل سا ، ادز،، انك ذ، نج ب، ان سة، س هاخ ل ب، يهس ا، انهك خ ) 2002

بد أظ سد اندزاس . رلد،د انزبئج يقب نهجهدا اناس انزاجل خ . (،ا ا يبزادانلسثاخ انسل،اخ، انس

1.1/100,000زح بز ي ب ث انل دااد انس اخ نحبن خ ا أانز أجس ذ ي انسزش فبد

خرشس انسجالد ند انشسطخ اندائس انحكياخ ي انجهدا انلسثاخ جن يلدااد سا. 121/100,000

انلد د ي انلاي م انز رل سا نق د ر ىا رحد د . 2.2/100,000جن 1.1/100,000زح بز ي نإل

. زح بز نإل زح بز ن ب لالب خ ثلاي م ل داح انسزش فبد رج ا أ يح باد ا اندزاس بد انز أجس ذ ي

ز دائ جن ثجس خ، انس ز اندزاس ي 25جن 15ك انفس، غس يسرجط، انل س ز سام ي : يب

جزبب جن لبئالد كجسح، يس ز رح، زثخ يزل، لبطم ل انلم، ا ثب، رالي بزص ب، ج-جز بل

خ انز رلزج س كلاي م ر ، جن ض اساثبد انفس اض بيخ جن ذن ك، ب انكل س ي ا ثب . ي ضف

أياب ثبنس جخ جن . ضدزادكزئبة، انزكاف، انشضصاخ، ا ،يب له انضاساثبد ا جزحبز خصصب ا

س خ، غ س ي سرجا، 00 20يى له ادغهت ذكز، لسى ي ب ث ألشضبص انر ازحسا يلالن

ا بل دا أل بطه ل انل م ا س رس جم ،بق خ ي انسزش فبد ن، ب حبج خ ضبر خي ان. ل

.ي انلبنى انلسث ،اخ جننلايم انزحبز ااخ ي أجم رقى سجخ انسه ا اندائس انحكي

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community: The Arababian-

American Oil Company, Saudi

Arabia. Acta Psychiatr Scand

1988; 77: 707-11.

22. Koronfel AA. Suicide in Dubai,

United Arab Emirates. Journal of

Clinical Forensic Medicine 2002;

9: 5-11.

23. Kessler RC, Berglund P, Borges

G, Nock M, Wang PS. Trends in

Suicide Ideation, Plans, Gestures,

and attempts in the United States.

JAMA 2005; 293 (20): 2487-95.

24. Schmidtkhe A, Weinacker B,

Apter A, Batt A, Berman A, et al.

Suicide rates in the world: Up-

date. Arch of Suicide Res 1999;

5:81-9.

Acknowledgement

This project was partially funded by the Institute for Development, Re-

search, Advocacy and Applied Care (IDRAAC), the Lebanese Ministry of

Public Health and the World Health Organization (WHO, Lebanon). The

authors wish to thank Ms. Lynn Farah for editing the manuscript and Ms

Dania Younes for helping in the literature review.

Table 2: Hospital based studies on attempted suicide in the Arab world

Country /

Author /Year

N Age (years)

and Gender

Characteristics of the

sample

Mental disorders Meth-

ods of

attempt

Bahrain

Al Ansari et al.

(1997)

2 groups:

Adoles

cents n=

57 Young

adults n=

43

Adolescents:

15-18

Young adults:

19-24

F>M

Never married (Adoles-

cents: 91.2%, Young adults:

65.1%)

Students: Adolescents:

82.5% , Unemployed:

Young adults 46.5%

Low SES (Adolescents:

70.2%, Young adults:

74.4%)

adjustment (31.6%

adolescents, 39.5%

young adults)

depression (1.8%

adolescents; 7%

young adults);

conduct (3.6% adoles-

cents)

Drug

overdose

(only)

Egypt

Mabrouk et al.

(1999)

759

(23

suicidal

burns)

Mean 23

F>M

52% single

56.5% illiterate and prima-

ry school

52.5% housewives

30.4% unskilled workers

82.6% low SES

Depressive (74%) Self-

immola-

tion

(only)

Egypt

Okasha et al.

(1986)

91 Adolescents

to early 20s

(60%)

F>M

71% single

Majority belong to large

families (mean 7.8 mem-

bers +/- 2.2)

71% literate

37% students & 31% em-

ployed

59% low SES

83% were diagnosed:

adjustment: 27%

personality: 20%

dysthymia: 12%

60%

drug

overdose

Egypt 1,155 15-24 (60%) 53% single depressive: 63% 80%


22

Okasha & Lo-

taif

(1979)

(200

studied)

M > F 35% secondary school

40% students & 23% un-

employed

Mainly from middle to low

SES

“hysterical reactions”:

13%

drug

overdose

Iraq

Al-Samarrai &

Hussein

(2000)

58 Mean 28

Males: mean

31

Females:

mean 25

15-29 : 71%

F > M

48% single

48% University & post-

graduate

36% employed & 33%

housewives

Equal distribution of SES

classes

10.3% history of

psychiatric

consultation, admis-

sion or used psycho-

tropic drugs

Self-

poi-

soning

(only)

Jordan

Saadeh et al.

(1996)

70

(45

attempters)

Mean 23.25

+/- 8.2 1

15-19 : 43%1

F > M

67% single 1

57% lived in rural areas 1

43% unemployed 1

no data Self-

poison-

ing (on-

ly)

Jordan

Saadeh et al.

(1995)

709

(647

included)

15-24 : 76%

F > M

62% single

41% students, 22%

unemployed &

21%houswives

17% were diagnosed:

depression: 7%

drug addiction : 4%

schizophrenia : 4%

Self-

poi-

soning

(only)

Kuwait

Emara et al.

(1988)

227 2 Female: mean

22.5 +/- 6.

Male: mean

26.05 +/- 7.2 3

<25: 68

F > M

no data 35.0% were

diagnosed: 3

depression: 21%

drug dependence: 11%

Drug

overdose

(only)

Kuwait

Suleiman et al.

(1986)

92 4 Males: mean

27.2 +/- 7.3 3

Females:

mean 22.2 +/-

5.03 3

F > M

no data

"acute situational

distress" and depres-

sion (25%) 3

86%

drug

over-

dose3

Lebanon

Alyahfoufi

(1998)

147 16-25:

57.14%

F > M

77% single 24% psychological

problems

60%

drug

over-

dose27%

self-

poi-

soning

Oman

Zaidan et al.

(2002)

123 5 Mean: 23.5

+/- 6.86 3

20-30: 54%3

F > M

63% single

72% secondary school

36% students & 26%

unemployed

19% were diagnosed: 3

depression 11.4%

personality 4.1%

Self-

poi-

soning

(only)

Saudi Arabia

Al-Jahdali et al.

(2004)

79 6 Mean: 22 +/-

4.6 3

F > M

51% single 3

59% from large families 3

41% high school education 3

60% unemployed 3

psychiatric disorders

25%3

history of drug abuse

5%3

Drug

overdose

(only)


23

Saudi Arabia

AbuMadini &

Abdel Rahim

(2001)

398

(362

included)7

Mean 26.3 +/-

9.5 3

20-29: 53

F > M

49% single3

22% student3 & 38%

unemployed 3

69% had no income 3

87% of attempters

were diagnosed: 3

personality 32 %

adjustment 30%

79%

over-

dose3

26 %

self-

cutting 3

Saudi Arabia

Osman & Ibra-

him

(1997)

55 8 Female: mean

20.

Males: mean

29.7

F > M

78% single

89% secondary school or

less

29% with psychiatric

disorders 3

80%

self-

poison-

ing 3

Saudi Arabia

Malik et al.

(1996)

57

(46

attemp

ters) 9

Mean 23.6

+/- 9.11,3

< 40: 96% 1,3

F > M1,3

57.8% single 1,3

82% had 6-12 years of

school 1,3

74% of attempters

were diagnosed:1

depressive 40%

personality 35%

Drug

overdose

(only)

Saudi Arabia

Daradkeh &

Al-Zayer

(1988)

36 10,11

Female: mean

23.

Males: mean

24.9

F > M

55% married

36% housewives and 33%

students

55% "acute reaction

to stress"

70%

drug

overdose

1 Out of the total sample: not only among attempted suicide patients.

2 36% Kuwaiti nationals.

3 Out of the total sample: not only among Arab citizens.

4 41.7% Kuwaiti nationals.

5 77.2% Omani nationals.

6 96% Saudi nationals.

7 76.2% Saudi nationals.

8 65.5% Saudi nationals.



11 prospective.

Note: A study by Abu-Hijleh (1998) was not included in this table because it did not

Share common outcomes listed under the table

Table 3. Government record based studies on completed suicide in the Arab world. Country

/Author /

Year

N Annual

rate

/100,000

Age

(years)

Gender Marital

Status/

Family size

Education /

Employment

/ Socio-

economic

status

Mental

Disorders

Methods

Jordan

Daradkeh

(1989)

219 2.1 Males:

mean 31

Females:

mean 28

M > F

Males:

70% singl

Females:

51% mar-

ried

Males: 35%

manual work-

ers; 22% un-

employed

Females: 41%

housewives;

29% students

and 27%

unemployed

63%

"mentally ill"

Males: 26%

insecticides

and 26% self-

shooting

Females: 41%

self-immolation

and 37% insecti-

cides

Lebanon

(Beirut)

Abou-

Daoud

(1974)

12

01

2.42

10-29

(52%) 2

M > F 54% single 2

no data no data Males: 20%

fire-arms 2

Females: 28%

parathion

poisoning 2

Saudi

Arabia

Elfawal

(1999)

22

13

1.12

30-39

(44%) 2

M > F2 Males:

59% single2

Females:

65% married2

no data no data 39% hanging

and 37% gun-

shot injuries


24

United

Arab

Emirates

(Dubai)

Koronfel

(2002)

36

24

6.22

21-40

(81.5%) 2

M > F no data no data 9.7% were

previously di-

agnosed:2, 5

34% depress

sion and 9%

drug addic tion

71 % hanging

1 61% Lebanese nationals.,

2 Out of the total sample: not only among Arab citizens.m


4 6% Dubai nationals. ,

5 Dependent on availability of such information in records.

Note: A study by Bang et. al (2000) was not included in this table because it did not share common

outcomes listed under the table.

__________________________________________________________________

Correspondence:

Elie G Karam, MD

Department of Psychiatry and Clinical Psychology,

Faculty of Medicine, Balamand University, Beirut Lebanon.

Institute for Development Research Advocacy and Applied Care (IDRAAC)

POBox: 166227, Ashrafieh,

Beirut, Lebanon 1100 2110

Tel/Fax: 961 1583583

Email: [email protected]

Ranya P. Hajjar, BA

Department of Psychiatry and Clinical Psychology,

St Georges Hospital University Medical Center,

Beirut, Lebanon.

Mariana M. Salamoun, BS, BA

Institute for Development Research Advocacy and Applied Care (IDRAAC),

Beirut, Lebanon.

mailto:[email protected]

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