Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 16, 2020
RESEARCH ARTICLE

Suicidal Behavior in the Mediterranean Countries



Mehmet Eskin1, *
1 Department of Psychology, College of Social Sciences and Humanities, Koç University, Rumelifeneri Yolu, 34450 Sariyer, Istanbul, Turkey

Abstract

Introduction:

Suicidal behavior is a serious public health problem worldwide and shows large intersocietal variation. This study aimed at comparatively investigating the aspects of suicidal behavior in 22 countries surrounding the Mediterranean Sea.

Methods:

The study was conducted with official data retrieved from several sources. The suicidal mortality data were collected from World Health Organization’s data repository. Descriptive statistics, group comparison, correlational and regression statistical analyses were used to summarize the data.

Results:

The average age standardized suicide rates in the Mediterranean countries are lower than the world average. Except in Morocco, more men kill themselves than women. Suicide rates are lower in Mediterranean Muslim than in Mediterranean Christian countries. Slovenia, France and Croatia have the highest suicide mortality rates. Greatest percentages of suicidal ideation are seen in Croatia, Turkey and Slovenia and the greatest percentages of suicidal attempts are seen in Palestine, Cyprus, Greece and Slovenia. According to the results of the multiple regression analyses, the coefficient of human inequality index was associated with lower both-sex and male suicide rates. Greater percentages of people saying religion is unimportant in daily life in a country were found to be related to higher female suicide rates.

Conclusion:

The findings from the study have shown that the prevalence of suicidal deaths, thoughts and attempts vary between the Mediterranean countries. Lower suicide rates are observed in the Muslim Mediterranean nations than in the Judeo-Christian ones. However, the rates of suicide mortality in non-Arab Muslim nations being comparable to the rates in non-Muslim countries confirm the concerns over mis/underreporting of suicidal behavior in Arab Muslim countries due to religio-cultural stigma attached to suicide. The average suicidal mortality rates are lower in Mediterranean countries than the world average. Generally, more men than women kill themselves. Results from the multivariate analysis revealed that as the level of human inequality increases the rates for both-sex and male suicidal mortality decreases. Religion seem to be protective against female suicides. The study has also shown that more research is needed about suicidal behavior in the Mediterranean countries.

Keywords: Suicidal behavior, Mediterranean, Social indicators, Mental health, Suicidal mortality, Sucide rates.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 16
Issue: Suppl-1, M4
First Page: 93
Last Page: 100
Publisher Id: CPEMH-16-93
DOI: 10.2174/1745017902016010093

Article History:

Received Date: 18/02/2019
Revision Received Date: 25/03/2019
Acceptance Date: 25/03/2019
Electronic publication date: 30/07/2020
Collection year: 2020

© 2020 Mehmet Eskin.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Psychology, College of Social Sciences and Humanities, Koç University, Rumelifeneri Yolu, 34450 Sariyer, Istanbul, Turkey; E-mail: meskin@ku.edu.tr





1. INTRODUCTION

Suicidal thoughts, plans, attempts and deaths that are collectively termed as suicidal behavior constitute a significant public health concern for all societies. Suicide causes many premature deaths and is a tragedy not only for the deceased but also for families, friends, neighbors and society. Suicide is a preventable condition. According to World Health Organization (WHO), 804,000 people died by suicide annually worldwide in 2012 and it is the second leading cause of death in the ages of 15-29. The annual global age-standardized suicide rate is 11.4 per 100, 000 population (15.0 for males and 8.0 for females) [1World Health Organisation. Mental health preventing suicide: A global imperative 2014.]. Seventy eight percent of all global suicides occur in low-middle income countries and the data indicate that there are 20 attempts for every suicide mortality [1World Health Organisation. Mental health preventing suicide: A global imperative 2014.]. This means globally 16,000,000 individuals per annum attempt to kill themselves. Taking thoughts, plans and attempts into account, suicidal phenomena are without a doubt significantly contributing to the burden on national health care systems [2Goldman-Mellor SJ, Caspi A, Harrington H, et al. Suicide attempt in young people: A signal for long-term health care and social needs. JAMA Psychiatry 2014; 71(2): 119-27.
[http://dx.doi.org/10.1001/jamapsychiatry.2013.2803] [PMID: 2430 6041]
]. For instance, the annual cost of only suicide and suicide attempts are estimated to be 93.5 billion dollars in the United States [3Shepard DS, Gurewich D, Lwin AK, Reed GA Jr, Silverman MM. Suicide and suicidal attempts in the United States: Costs and policy implications. Suicide Life Threat Behav 2016; 46(3): 352-62.
[http://dx.doi.org/10.1111/sltb.12225] [PMID: 26511788]
].

Suicide is a preventable condition and the World Health Organization has adopted a mental health action plan which aims to reduce suicide rates by 10% by 2020 [1World Health Organisation. Mental health preventing suicide: A global imperative 2014.]. The success of this plan depends on the scientific knowledge base at hand and the willingness of member states to engage in the prevention policies and actions based on the scientific evidence. Therefore, there is an urgent need for scientific knowledge on the causal factors involved in and the etiology of societal variation of suicidal behaviors. The knowledge about causal mechanisms involved in the onset and the maintenance of suicidal process is a prerequisite for a possibility of prevention and treatment.

Prevention of suicidal behavior requires early identification of persons at risk for suicide. The scientific evidence indicates that the prediction of suicidal persons is not better than chance [4Franklin JC, Ribeiro JD, Fox KR, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull 2017; 143(2): 187-232.
[http://dx.doi.org/10.1037/bul0000084] [PMID: 27841450]
] and there is a large etiological heterogeneity [5Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016; 387(10024): 1227-39.
[http://dx.doi.org/10.1016/S0140-6736(15)00234-2] [PMID: 26385 066]
]. However, improved recognition of clinical, psychological, social and biological factors may help to identify those at risk for suicidal behavior for prevention and treatment [5Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016; 387(10024): 1227-39.
[http://dx.doi.org/10.1016/S0140-6736(15)00234-2] [PMID: 26385 066]
]. The research has identified some risk factors for and protective factors against suicidal behavior. Knowledge about these factors may create an opportunity for both the prevention and treatment efforts.

Research has identified several factors that may constitute a risk for suicidal behavior. Accordingly, factors associated with suicidal behaviors include mental health problems [6Chan MKY, Bhatti H, Meader N, et al. Predicting suicide following self-harm: Systematic review of risk factors and risk scales. Br J Psychiatry 2016; 209(4): 277-83.
[http://dx.doi.org/10.1192/bjp.bp.115.170050] [PMID: 27340111]
-10Bolton JM, Pagura J, Enns MW, Grant B, Sareen J. A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder. J Psychiatr Res 2010; 44(13): 817-26.
[http://dx.doi.org/10.1016/j.jpsychires.2010.01.003] [PMID: 20122 697]
], stressful life events [11Eskin M, Akoğlu A, Uygur B. [Traumatic life events and problem solving skills in psychiatric outpatients: Relationships with suicidal behavior]. Turk Psikiyatr Derg 2006; 17(4): 266-75.
[PMID: 17183443]
-14Belik SL, Cox BJ, Stein MB, Asmundson GJ, Sareen J. Traumatic events and suicidal behavior: Results from a national mental health survey. J Nerv Ment Dis 2007; 195(4): 342-9.
[http://dx.doi.org/10.1097/01.nmd.0b013e318060a869] [PMID: 174 35485]
], having a sexual minority status [15Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. J Abnorm Psychol 2017; 126(1): 125-36.
[http://dx.doi.org/10.1037/abn0000234] [PMID: 27831708]
-17Eskin M, Kaynak-Demir H, Demir S. Same-sex sexual orientation, childhood sexual abuse, and suicidal behavior in university students in Turkey. Arch Sex Behav 2005; 34(2): 185-95.
[http://dx.doi.org/10.1007/s10508-005-1796-8] [PMID: 15803252]
], previous suicidal behaviors [18Scoliers G, Portzky G, van Heeringen K, Audenaert K. Sociodemographic and psychopathological risk factors for repetition of attempted suicide: A 5-year follow-up study. Arch Suicide Res 2009; 13(3): 201-13.
[http://dx.doi.org/10.1080/13811110902835130] [PMID: 19590995]
-20Nock MK, Millner AJ, Joiner TE, et al. Risk factors for the transition from suicide ideation to suicide attempt: Results from the army study to assess risk and resilience in servicemembers (Army STARRS). J Abnorm Psychol 2018; 127(2): 139-49.
[http://dx.doi.org/10.1037/abn0000317] [PMID: 29528668]
], physical and sexual abuse [21Rosellini AJ, Street AE, Ursano RJ, et al. Sexual assault victimization and mental health treatment, suicide attempts, and career outcomes among women in the US army. Am J Public Health 2017; 107(5): 732-9.
[http://dx.doi.org/10.2105/AJPH.2017.303693] [PMID: 28323466]
, 22Holt MK, Vivolo-Kantor AM, Polanin JR, et al. Bullying and suicidal ideation and behaviors: A meta-analysis. Pediatrics 2015; 135(2): e496-509.
[http://dx.doi.org/10.1542/peds.2014-1864] [PMID: 25560447]
], substance and alcohol abuse [23Arenliu A, Kelmendi K, Haskuka M, Halimi T, Canhasi E. Drug use and reported suicide ideation and attempt among Kosovar adolescents. J Subst Use 2014; 19(5): 358-63.
[http://dx.doi.org/10.3109/14659891.2013.820803]
-26Värnik A, Kõlves K, Väli M, Tooding LM, Wasserman D. Do alcohol restrictions reduce suicide mortality? Addiction 2007; 102(2): 251-6.
[http://dx.doi.org/10.1111/j.1360-0443.2006.01687.x] [PMID: 1722 2279]
] and so on. Strongest protective factors against suicidal behaviors include social support and connectedness [26Värnik A, Kõlves K, Väli M, Tooding LM, Wasserman D. Do alcohol restrictions reduce suicide mortality? Addiction 2007; 102(2): 251-6.
[http://dx.doi.org/10.1111/j.1360-0443.2006.01687.x] [PMID: 1722 2279]
-28Mackin DM, Perlman G, Davila J, Kotov R, Klein DN. Social support buffers the effect of interpersonal life stress on suicidal ideation and self-injury during adolescence. Psychol Med 2017; 47(6): 1149-61.
[http://dx.doi.org/10.1017/S0033291716003275] [PMID: 27995812]
], problem-solving skills [11Eskin M, Akoğlu A, Uygur B. [Traumatic life events and problem solving skills in psychiatric outpatients: Relationships with suicidal behavior]. Turk Psikiyatr Derg 2006; 17(4): 266-75.
[PMID: 17183443]
, 29Eskin M, Ertekin K, Demir H. Efficacy of a problem-solving therapy for depression and suicide potential in adolescents and young adults. Cognit Ther Res 2008; 32: 227-45.
[http://dx.doi.org/10.1007/s10608-007-9172-8]
, 30Eskin M. Problem solving therapy in the clinical practice Newnes 2013.] and to some extent religiosity [31Norko MA, Freeman D, Phillips J, Hunter W, Lewis R, Viswanathan R. Can religion protect against suicide? J Nerv Ment Dis 2017; 205(1): 9-14.
[http://dx.doi.org/10.1097/NMD.0000000000000615] [PMID: 27805 983]
-33Gearing RE, Lizardi D. Religion and suicide. J Relig Health 2009; 48(3): 332-41.
[http://dx.doi.org/10.1007/s10943-008-9181-2] [PMID: 19639421]
].

Research in suicidology shows two invariant features of suicidal behavior. One is that suicidal behavior is a gender typed behavior. With some exceptions, scholarly work has often showed that women outnumber men in reports of suicidal ideation and attempts but more men than women kill themselves [34Möller-Leimkühler AM. The gender gap in suicide and premature death or: Why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci 2003; 253(1): 1-8.
[http://dx.doi.org/10.1007/s00406-003-0397-6] [PMID: 12664306]
]. This is known as “gender paradox” [35Schrijvers DL, Bollen J, Sabbe BGC. The gender paradox in suicidal behavior and its impact on the suicidal process. J Affect Disord 2012; 138(1-2): 19-26.
[http://dx.doi.org/10.1016/j.jad.2011.03.050] [PMID: 21529962]
, 36Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide Life Threat Behav 1998; 28(1): 1-23.
[PMID: 9560163]
] and relates to gender culture. The paradox has often been explained through a reference to the choice of method for and intent involved in suicidal behavior [37Denning DG, Conwell Y, King D, Cox C. Method choice, intent, and gender in completed suicide. Suicide Life Threat Behav 2000; 30(3): 282-8.
[PMID: 11079640]
-39Callanan VJ, Davis MS. Gender differences in suicide methods. Soc Psychiatry Psychiatr Epidemiol 2012; 47(6): 857-69.
[http://dx.doi.org/10.1007/s00127-011-0393-5] [PMID: 21604180]
]. The scientific investigations provide support for the view that men make use of more lethal methods for suicidal behavior than women that is in line with the cultural gender stereotypes [40Payne S, Swami V, Stanistreet DL. The social construction of gender and its influence on suicide: A review of the literature. J Men’s Health 2008; 5(1): 23-35.
[http://dx.doi.org/10.1016/j.jomh.2007.11.002]
]. The other invariant feature of suicidal behavior is that the prevalence rates present a large intersocietal variation [41Värnik P. Suicide in the world. Int J Environ Res Public Health 2012; 9(3): 760-71.
[http://dx.doi.org/10.3390/ijerph9030760] [PMID: 22690161]
]. The etiology of intersocietal variations in suicidal behavior are assumed to be the social and cultural factors [42Lester D. Suicide and culture. World Cult Psychiatry Res Rev 2008; 2008: 51-68.-43Stack S. Suicide: A 15-year review of the sociological literature. Part I: cultural and economic factors. Suicide Life Threat Behav 2000; 30(2): 145-62.
[PMID: 10888055]
].

The purpose of this paper is to undertake a comparative investigation of the aspects of suicidal behaviors in the Mediterranean countries. There are 22 states surrounding the Mediterranean Sea and they all have different social, cultural, levels of economic development, legal systems, religions, life styles and so on. The most distinctive features of the Mediterranean social fabric include its own diet, familial collectivism, a relaxed life style and emotional nature of its people. The Mediterranean basin is the cradle of civilization. The world’s most powerful empires flourished in the Mediterranean basin and is currently home for the three Abrahamic religions: Judaism, Christianity and Islam. The three Middle Eastern religions strongly disapprove suicide [33Gearing RE, Lizardi D. Religion and suicide. J Relig Health 2009; 48(3): 332-41.
[http://dx.doi.org/10.1007/s10943-008-9181-2] [PMID: 19639421]
, 44Lester D. Suicide and islam. Arch Suicide Res 2006; 10(1): 77-97.
[http://dx.doi.org/10.1080/13811110500318489] [PMID: 16287698]
].

2. MATERIALS AND METHODS

The data for the study were collected from several sources. The data reported in this study were as follows:

2.1. Suicidal Mortality Data

Age standardized suicide rates (per 100, 000 population) for the Mediterranean countries were collected from the World Health Organization’s suicide data repository [45World Health Organization. Age standardized suicide rates by country http://apps.who.int/gho/data/node.main.MHSUICIDEASDR?lang=en2016.].

2.2. Suicidal Ideation and Attempts

A literature search was done to locate empirical studies reporting the percentages of suicidal ideation and attempts through google scholar. To ensure comparability, studies exploring suicidal thoughts and attempts in student samples were included.

2.3. Mental Health and Alcohol Use

Estimates of percentages of country populations with depressive and anxiety disorders were taken from a WHO publication [46World Health Organization. Depression and other common mental disorders: Global health estimates World Health Organization 2017.]. Total alcohol consumption per capita was taken from World Bank data repository [47World Bank. 2016.https://data.worldbank.org/indicator/SH.ALC.PCAP.LI?view=chart]. It gives country specific liters of alcohol consumed per capita.

2.4. Social Indicators

Eight social indicators that may have a relevance for suicide were included in the study. Human development index for 2016; Coefficient of human inequality index for 2016 and Gender inequality index for 2016 were extracted from United Nations Development Program data repository [48United Nations Human Development Program. 2016.http://hdr.undp. org/en/data]. The country Gross Domestic Product per capita (PPP) for 2016 and Unemployment rates (% unemployed) for 2016 were extracted from World Bank resources [47World Bank. 2016.https://data.worldbank.org/indicator/SH.ALC.PCAP.LI?view=chart]. Percentages of people saying religion is unimportant in daily life based on Gallup Poll data was retrieved from RationalWiki [49RationalWiki. Importance of religion by country 2009.https://rational wiki.org/wiki/Importance_of_religion_by_country]. Finally, country democracy index for the year 2017 was collected from the Economist’s Intelligence Unit web site [50The Economist Intelligence Unit. The Economist’s Intelligence Unit Democracy Index. 2017.https://infographics.economist.com/2018/ DemocracyIndex/].

2.5. Statistical Analysis

Descriptive statistics were used to calculate the average age standardized suicide rates and Mann-Whitney U test was used for group comparisons. Pearson product moment correlation coefficients were calculated to examine the bivariate associations of mental health and social indicators to suicidal mortality rates. Stepwise multiple regression analyses were performed to examine the independent predictors of suicide rates.

3. RESULTS

3.1. Suicidal Mortality

Age standardized suicide rates (per 100, 000 population) are presented in Table 1. The table shows that Slovenia, France and Croatia have the highest, Montenegro, Turkey, Malta, Bosnia-Herzegovina, Spain, Albania, Italy, Libya and Israel have the medium high, and Cyprus, Egypt, Greece, Lebanon, Tunisia, Morocco and Syria have the lowest age standardized suicide rates.

The average age standardized suicide rates were 6.04 ( 3.09) for both genders and it was 9.29 (for males) and 2.95 (for females). Except for Morocco where more women killed themselves than men, more men killed themselves than women.

The average age standardized both-sex (Mean = 7.77±3.61 versus 4.62±1.68; Mann-Whitney Z = 1.98, p < 0.05) and male (Mean = 12.32±5.93 versus 6.81±3.07; Mann-Whitney Z = 2.13, p < 0.05) suicide rates were higher in Christian countries than in Muslim countries but the female suicide rates (Mean = 3.47±1.63 versus 2.52; Mann-Whitney Z = 1.37, p > 0.05) were similar in the two groups of countries.

3.2. Suicidal Ideation and Attempts

Table 2 presents the frequency of suicidal ideation and attempts in the Mediterranean countries. The table shows considerable variation in the rates of suicidal ideation and attempts. The highest percentages of suicidal ideation are observed in Croatia, Turkey and Slovenia, the lowest rates are seen in France, Spain and Lebanon. The highest suicide attempt rates are seen in Palestine, Cyprus, Greece and Slovenia but the lowest rates were in Spain, Italy, Lebanon and Morocco.

Table 1
Age standardized suicide rates per 100, 000 population in Mediterranean countries according to World Health Organization (2016).


Table 2
Suicidal ideation and attempts in community samples of youth in the Mediterranean countries.



Table 3
Bivariate correlation coefficients between social indicators and suicide mortality rates.



3.3. Social Indicators and Suicidal Mortality: Bivariate Analysis

The bivariate correlation coefficients between some social indicators and age standardized suicide rates are displayed in Table 3. Human development index, democracy index, percentage of population saying religion is unimportant, GDP per capita and alcohol consumption per capita are positively associated with suicide mortality rates. Coefficient of human inequality and gender inequality indices are inversely related to suicide rates.

3.4. Social Indicators and Suicidal Mortality: Multivariate Analysis

According to the results of the stepwise multiple regression analyses, the coefficient of human inequality index was the only significant predictor of both sex [B = - 0.341, β = - 0.689, t = - 4.037, p < 0.005, % 95CI for B = - 0.518 to - 0.163] and male [B = - 0.603, β = - 0.717, t = - 4.358, p < 0.001, % 95CI for B = - 0.893 to - 0.312] suicide rates. This index accounted for 48% of the variance in both sex [F = 16.301, df = 19, p < 0.005] and 51% of the variance in male [F = 18.992, df = 19, p < 0.001] suicide rates. Percentage of population saying religion is unimportant was the only independent predictor of female suicide rates [B = 0.040, β = 0.599, t = 3.175, p < 0.01, % 95CI for B = 0.014 - 0.067] and it accounted for 36% of the variance in female suicide rates [F = 10.078, df = 19, p < 0.01].

4. DISCUSSION

The Mediterranean region is known for its relaxed lifestyle and turquoise beaches not to mention its renowned diet based on vegetables, fruit and yoghurt. However, the region is remembered lately most by refugee crisis and human tragedies resulting from sinking boats filled with migrants from poor countries heading to the rich European countries. Considering the relaxed life style under sunny days, it is hard to associate self-killing within the context of this background. Do people really think about killing, attempting to kill and actually killing themselves despite a relaxed lifestyle while so many try hard to survive against all odds? Accordingly, this study investigated the prevalence of and associated social factors with suicidal behaviors in the Mediterranean countries.

Keeping the relaxed Mediterranean life style in mind one may anticipate lower suicide rates in the region. The findings obtained from this analysis confirmed this anticipation. The age standardized suicide rates in the Mediterranean countries were indeed lower than the world average. The average suicide rate in the world in 2012 was 11.4 (15.0 for males and 8.0 for females) per 100,000 population. The average suicide mortality rates observed in the Mediterranean region (6.04 for both-sexes; 9.29 for males and 2.95 for females) show clearly that the region has a distinct feature at the world scale. There are only three countries in the region that report above the world average suicide mortality rates: France, Slovenia and Croatia.

One feature of suicidal behavior is that it presents a large intersocietal variation [58Mortier P, Auerbach RP, Alonso J, et al. Suicidal thoughts and behaviors among first-year college students: Results from the WMH-ICS Project. J Am Acad Child Adolesc Psychiatry 2018; 57(4): 263-273.e1.
[http://dx.doi.org/10.1016/j.jaac.2018.01.018] [PMID: 29588052]
, 59Nock MK, Hwang I, Sampson N, et al. Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. PLoS Med 2009; 6(8)e1000123
[http://dx.doi.org/10.1371/journal.pmed.1000123] [PMID: 19668361]
]. The results from this analysis have also shown that the rates of suicide mortality vary considerably between the Mediterranean countries. The rates reported in Table 1 reveal some consistent yet contradictory patterns. The results from this study show that both-sex and male age standardized suicide mortality rates are lower in Muslim than in the Judeo-Christian countries but the rates for females are similar. The highest suicide rates are observed in the three largely Catholic nations: Slovenia, France and Croatia. Overall, the Arab Muslim nations report lowest suicide rates in the region. They also report lower suicide rates than the non-Arab Muslim nations: Turkey, Bosnia-Herzegovina and Albania. There is a strong suspicion that Arab nations mis/underreport suicides. For instance, Pritchard and Amanullah have shown that most suicides are misclassified as Other Violent Deaths in Middle Eastern Muslim Arab nations but not in non-Arab European Muslim nations such as Albania, Bosnia-Herzegovina or Turkey [60Pritchard C, Amanullah S. An analysis of suicide and undetermined deaths in 17 predominantly Islamic countries contrasted with the UK. Psychol Med 2007; 37(3): 421-30.
[http://dx.doi.org/10.1017/S0033291706009159] [PMID: 17176500]
]. There is a religio-cultural stigma attached to suicide in Muslims. The stigma may jeopardize help-seeking when it is indeed needed most.

As with suicide mortality, the rates of non-fatal suicidal behaviors vary considerably between the countries under scrutiny. According to the findings reported in Table 2, the highest percentages of suicidal ideation are seen in Turkey, Croatia and Slovenia. The lowest percentages are noted in France, Spain, Lebanon. The highest percentages of suicide attempts are seen in Palestine, Cyprus, Greece and Slovenia. The lowest rates were in Spain, Italy, Tunisia and Lebanon. The literature search about non-fatal suicidal behaviors in the Mediterranean countries revealed that the extant scholarly work on these behaviors is limited. There were no studies about suicidal thoughts and attempts in seven countries. Thus, there is an urgent need for more scientific work on suicide in this region.

Social and contextual factors play a role in the intersocietal variation of suicidal behavior. For the present investigation, the association of six social and contextual factors to suicide rates were examined at bivariate and multivariate levels. The bivariate analyses indicated that human development and democracy indices, percentage of population saying religion is unimportant in daily life and GDP per capita were positively but coefficient of human inequality and gender inequality indices were inversely related to suicide rates. It is interesting to note that percentages of depressed and anxious people in a society were unrelated to suicide rates despite an enormous body of research relating mental health problems to suicide. It is also interesting that as the human development and democracy indices increase so does suicide rates in a society. This condition is probably reflecting the association of sociocultural values and attitudes to suicidal phenomena [61Eskin M. The effects of individualistic-collectivistic value orientations on non-fatal suicidal behavior and attitudes in Turkish adolescents and young adults. Scand J Psychol 2013; 54(6): 493-501.
[http://dx.doi.org/10.1111/sjop.12072] [PMID: 24111627]
, 62Eskin M, Kujan O, Voracek M, et al. Cross-national comparisons of attitudes towards suicide and suicidal persons in university students from 12 countries. Scand J Psychol 2016; 57(6): 554-63.
[http://dx.doi.org/10.1111/sjop.12318] [PMID: 27538761]
].

A statistical problem with bivariate correlation analysis is that there may be multicollinearity between variables. Multivariate statistical methods are used to overcome this problem. The results from the multiple regression analyses have shown that coefficient of human inequality index was found to be the only independent predictor of both-sex and male suicide rates when the effects of other factors are controlled. As the human inequality in a society increases the suicide rates decreases. This may seem counterintuitive at first glance. It is possible that widened human inequality in a society diverts people’s attention to conditions conducive to inequality rather than to their own personal conditions. This may in turn influence attributional processes. That is, people may attribute their personal problems to external conditions (sources for inequality) under high inequality, but they may attribute their problems to their personal characteristics (personal inadequacies) when inequality is low. Indeed, the research indicates that attributional processes are amenable to external manipulation and play a role in people's mood [63Peters KD, Constans JI, Mathews A. Experimental modification of attribution processes. J Abnorm Psychol 2011; 120(1): 168-73.
[http://dx.doi.org/10.1037/a0021899] [PMID: 21319929]
].

The research indicates that religion is possibly protective against suicidal behavior [64Gearing RE, Alonzo D. Religion and Suicide: New Findings. J Relig Health 2018; 57(6): 2478-99.
[http://dx.doi.org/10.1007/s10943-018-0629-8] [PMID: 29736876]
]. For instance, religiosity is a protective factor against suicidal mortality [32Wu A, Wang JY, Jia CX. Religion and completed suicide: A meta-analysis. PLoS One 2015; 10(6)e0131715
[http://dx.doi.org/10.1371/journal.pone.0131715] [PMID: 26110867]
, 65Gearing RE, Lizardi D. Religion and suicide. J Relig Health 2009; 48(3): 332-41.
[http://dx.doi.org/10.1007/s10943-008-9181-2] [PMID: 19639421]
] and is associated with low suicide acceptability [66Stack S, Kposowa AJ. Religion and suicide acceptability: A cross-national analysis. J Sci Study Relig 2011; 50(2): 289-306.
[http://dx.doi.org/10.1111/j.1468-5906.2011.01568.x] [PMID: 21969 937]
]. Some research findings indicate that religious affiliation is not protective against suicidal ideation but protective against suicidal attempts [67Lawrence RE, Oquendo MA, Stanley B. Religion and suicide risk: A systematic review. Arch Suicide Res 2016; 20(1): 1-21.
[http://dx.doi.org/10.1080/13811118.2015.1004494] [PMID: 26192 968]
] and some research findings show that suicidal affiliation can indeed be a risk factor for suicide ideation in depressed patients [68Lawrence RE, Brent D, Mann JJ, et al. Religion as a risk factor for suicide attempt and suicide ideation among depressed patients. J Nerv Ment Dis 2016; 204(11): 845-50.
[http://dx.doi.org/10.1097/NMD.0000000000000484] [PMID: 26894 320]
]. Based on these observations it was anticipated in this study that percentage of people saying religion is unimportant in daily life in a society would be associated with heightened suicide rates. The data confirmed that this anticipation held true only for female suicide rates. As the percentage of people saying religion is unimportant in daily life increases so does the female suicide rates. It seems that level of religiosity is a protective factor against female suicides in the Mediterranean basin.

CONCLUSION

This study is the first to explore the aspects of suicidal phenomena in the Mediterranean countries from a comparative perspective. There are some limitations of the present study. Although the study shed some important light on the subject matter, the findings reported in this paper should be approached with caution for several reasons. First, the study has undertaken an analysis of data supplied to World Health Organization by the national governments. Suicide is a disapproved and hence a stigmatized event especially in the Muslim countries. Therefore, the official data are prone to under or misreporting. Second, the associations of social indicators to suicide mortality are correlational and hence causality cannot be inferred. Finally, the study has also showed that there is more need for scholarly work on suicidal behavior in countries surrounding the Mediterranean Sea.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Not applicable.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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