Assessment of suicidality in a Moroccan metropolitan area

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Brief report

Assessment of suicidality in a Moroccan metropolitan area

Mohamed Agoub *, Driss Moussaoui, Nadia Kadri

Ibn Rushd University Psychiatric Centre, Department of Psychiatry, Rue Tarik Ibn Ziad, Casablanca 20000, Morocco Received 13 July 2005; received in revised form 8 September 2005; accepted 29 September 2005

Available online 13 December 2005

Abstract

Background: The aim of the study was to evaluate the prevalence of suicidal ideations and suicide attempts in a representative sample of the general population of the urban area of Casablanca, Morocco.

Methods: The survey was conducted based on face-to-face household interviews. The Mini International Neuropsychiatric Interview (M.I.N.I.) was used to assess axis I diagnoses according to DSM-IV criteria and the M.I.N.I. suicidality module to rate the severity of active suicidality.

Results: The 1-month prevalence of suicidal ideation was 6.3%. Seventeen subjects (2.1%) reported at least one suicide attempt during their lifetime. Some variables were positively associated to suicidal ideation: the non-married status, subjects with a history of psychiatric disorders, and subjects without children. At least one mental disorder was present among 88.2% of subjects with suicidal ideation. Major depressive disorder was the most prevalent one (23.5%).

Limitations: The sample was small and the prevalence was not determined longitudinally.

Conclusion: Suicidal ideation being relatively frequent in the general population, there is a need to develop programs of prevention of suicide.

Keywords:Suicidality; Epidemiology; Comorbidity

1. Introduction

Suicidality spans a spectrum that ranges from suicidal thoughts (thoughts about wanting to be dead) to suicidal acts (self-destructive behaviours with at least some intent to end one’s life) (Ahrens et al., 2000).

Approximately 10–18% of population across diverse countries report suicidal ideation and 3–5% have made a suicide attempt at some point in their life (Weissman et al., 1999). In the Arab culture, suicidal behaviour is stigmatised and an expressed hostility to the suicidal patient is the usual reaction (Suleiman et al., 1986). The

prevalence of suicidal ideation in Arab general popula- tions has been rarely explored (Weissman et al., 1999).

Some studies have attempted to evaluate the extent of the phenomenon in non-representative population sam- ples by recruiting in the health care services (Suleiman et al., 1986; Hamdi et al., 1991) or in specific popula- tions (Daradkeh and Al-Zayer, 1988).

Suicide is usually most accurately viewed as a multi- determined act. Risk factors include psychiatric disorders, social, psychological, biological and physical factors (Hawton and Van Heeringen, 2000; Van Heer- ingen, 2001). Regarding mental disorders, it has been shown that depressive disorders and alcohol and/or substance dependence or abuse are the most prevalent ones accompanying suicidal ideation and behaviour.

However, a number of factors unrelated to psychopa-

doi:10.1016/j.jad.2005.09.014

* Corresponding author. Tel.: +212 63 67 99 36; fax: +212 22 20 68 67.

E-mail address:magoub@fmpc.ac.ma (M. Agoub).

Journal of Affective Disorders 90 (2006) 223 – 226

www.elsevier.com/locate/jad

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thology, such as socio-demographic factors (Lewis and Sloggett, 1998), serious medical illness (Druss and Pincus, 2000) or traumatic events (Goldney et al., 2000), have been shown to be independently associated with suicidal ideation and/or suicide attempt.

The main aim of the current study is to assess the prevalence of suicidal ideations and suicide attempts in a representative sample of a general population in the metropolitan area of Casablanca, Morocco. The secondary aim is to identify risk factors associated with suicidality, especially the comorbidity with psychiatric disorders.

2. Methods

2.1. Subjects and diagnostic procedures

The survey was conducted based on face-to-face interviews by trained interviewers who were medical doctors and clinical psychologists. A stratified random general population sample was drawn from the adult population of Casablanca, Morocco, aged 15 years and above. Only 2.6% were 60 years old or more. Informed consent was obtained from all respondents.

The Mini International Neuropsychiatric Interview (M.I.N.I.) (Sheehan et al., 1998) in its Moroccan Col- loquial Arabic version (Kadri et al., 2005) was used to assess axis I diagnoses according to the DSM-IV criteria (APA, 1994).

2.2. Suicidality assessment

THE M.I.N.I. suicidality module was used to rate the severity of active suicidality. It included the following items:

bIn the past month did you:

1. think you would be better off dead or wish you were dead? (1 point),

2. want to harm your self? (2 points), 3. think about suicide? (6 points), 4. have a suicide plan? (10 points), 5. attempt suicide? (10 points).

In your life:

6. did you ever make a suicide attempt? (4 points).Q A current suicide risk is present if at least one item is coded yes. The total number of points is used to classify the current suicide risk on three levels as follows: low if the total score ranges from 1 to 5 points, moderate if it ranges from 6 to 9 points and high if it is above 10 points.

2.3. Statistical analysis

The data were analysed using the 6th version of the Epi Info software. The significance of the differences between suicidal and non-suicidal groups was assessed with the aid of 95% confidence intervals (CI). Level of significance was set at 0.05 for all analyses.

3. Results

Out of 850 interviewed subjects, 800 completed the whole evaluation: 400 men and 400 women. Single people represented 58% of the population; 35.3% of them were married.

The level of unemployment was 24.1%; 41.5% had a professional activity. The remaining subjects were stu- dents (18.8%) or housewives (15.5%).

Concerning the level of education, 15.2% had no education, 16.3% had a primary school level (1–5 years), 53.1% had 6–13 years of education and 15.3%

had a university level.

During the previous 1-month period, 6.3% of subjects (n= 51, 95% CI, 3.7–8.9%) presented a suicidal

Table 1

Prevalence of suicidal ideation and suicide attempts

Total Men (N= 400) Women (N= 400)

N % N % N %

In the past month

Think you would be better off dead? 62 7.8 22 5.5 44 11.1

Want to harm your self? 17 2.1 9 2.2 8 2

Think about suicide? 15 1.9 8 2 7 1.8

Have a suicide plan? 8 1.0 3 0.7 5 1.3

Attempt suicide? 6 0.8 3 0.7 3 0.7

In your life

Did you ever make a suicide attempt? 17 2.1 6 1.5 11 2.7

M. Agoub et al. / Journal of Affective Disorders 90 (2006) 223–226 224

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ideation. The prevalence was 10.5% in women (n= 42, 95% CI, 8.0–12.9%) and 2.25% in men (n= 9, 95% CI, 0.5–3.9%) (OR = 5.1, 95% CI, 2.33–11.5).

A total of 17 subjects (2.1%) reported at least one suicide attempt during their lifetime, 11 women (2.75%) and 6 men (1.5%). The difference was not significant (OR = 1.8, 95% CI, 0.6–5.7). Table 1 shows the detailed answers to the 6-item questions targeting suicidal ideation and behaviour by gender.

The following variables were positively associated with suicidal ideation:

– non-married status (single, widowed divorced) (OR = 5.4, 95% CI, 2.0–15.7),

– subjects with a history of psychiatric disorders (OR = 5.3, 95% CI, 2.3–11.8),

– subjects without children (OR = 2.5, 95% CI, 1.1–5).

The comorbidity with mental disorders was high in people with suicidal ideation (88.2%). In this respect only 6 subjects had no current psychiatric disorder.

Depressive disorders were the most prevalent ones followed by anxiety disorders and substance and/or alcohol related disorders (Table 2).

Twenty-one subjects had two comorbid psychiatric disorders, essentially depressive and anxiety disorders.

4. Discussion

The discrimination between suicidal thoughts and acts is present in surveys conducted across the world.

The month prevalence of suicidal ideation in a representative sample of the general population in Casa- blanca, Morocco was 6.4%, according to the M.I.N.I.

suicidality module. The risk was higher among women (10.5%) than men (2.2%). Weissman et al.

(1999) conducted an epidemiological survey using similar diagnostic assessment and criteria independently in nine countries including an Arab country:

Lebanon. The lowest lifetime prevalence rate for suicide ideation was reported in Beirut, Lebanon (2.09%), and the highest rate was found in Christch- urch, New Zealand (18.51%). On the other hand, the current prevalence of suicidal ideation on the present sample was higher than in other studies conducted in Western countries. Hintikka et al. (2001) found a 12- month prevalence of suicidal ideation in the Finnish general population of 2.4% in women and 2.3% in men. There are several methodological differences between the Finnish study and ours: the period explored was 12 months versus 1 month in our studies and most interviews were conducted by phone versus face-to-face interviews in Casablanca. Waern et al.

(2002) explored suicidal ideation in women; the weighted 1-year prevalence of suicidal thoughts was 6.6%.

In the current study, we explored also the occur- rence of suicidal acts. The lifetime rate of suicide attempts was 2.1%. In the study of Weissman et al.

(1999), the lifetime prevalence rate for suicide attempts ranged from 0.72% to 5.93% with the lowest rate in Beirut, Lebanon (0.72%). The WHO/EURO Multicentre Study on Parasuicide retrieved an average male age-standardized rate of suicide attempts ranging from 45/100,000 (Guipuzcoa, Spain) to 314/100,000 (Helsinki), and an average female age-standardized rate ranging from 69/100,000 (Guipuzcoa) to 462/

100,000 (Cergy-Pontoise, France) (Schmidtke et al., 1996).

Concerning the gender factor, females as compared to males had higher rates for suicide attempts, reaching a two- to three-fold increase in most countries (Weiss- man et al., 1999). We retrieved the same ratio (the lifetime prevalence of suicide attempts was 2.7% in women and 1.5% in men).

Since the suicidal ideation is relatively frequently reported by subjects in this representative sample of the general population, there is a need to develop programs of prevention of suicide. The exploration of suicidal ideation has to be systematically assessed in mental patients. Finally, training of general practitioners on this issue in all countries, especially developing ones is crucial.

Table 2

Comorbidity with current psychiatric disorders according to DSM IV (N= 51)

N %

No current psychiatric disorder 6 11.7

Depressive disorders

Major depressive disorder 12 23.5

Dysthymia 11 21.5

Anxiety disorders

Panic disorder 4 7.8

Agoraphobia 12 23.5

Social phobia 8 15.7

PTSD 5 9.8

OCD 10 19.6

GAD 8 19.6

Substance and/or alcohol abuse/dependence 8 15.7 PTSD: post-traumatic stress disorder, OCD: obsessive-compulsive disorder, GAD: generalised anxiety disorder.

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