LETTERS
Adolescent suicide in the Middle East: ostrich head in sand
Mustafa Afifi
Department of Non-Communicable Diseases, Directorate General of Health Affairs, Ministry of Health, PO Box 393, Muscat, P.C. 113, Oman (email: afifidr@yahoo.co.uk)
Editor - I have read with interest the editorial by Bertolote et al., recently published in the Bulletin.1 Suicide is one of the three leading causes of death worldwide among 15-34-year-olds and its prevalence is increasing significantly among adolescents. Recent data collected from Alexandria, Egypt,2 showed that 30% of the 1621 high-school adolescents sampled experienced a strong death wish in the year before the study. However, for many reasons, adolescents' suicide is still neglected in the Middle East.
First, there is a lack of research findings on adolescents' mental health and those studies that are available did not collect information using a uniform methodology, thus precluding sound comparison of the results. WHO has recently attempted to address this problem by setting up the Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS).3
Second, the absence of an integrated management approach to adolescent health problems can not be ignored. Woods et al. have shown that attempted suicides are associated with other risk behaviours in adolescents.4 Also, data from the Middle East showed that adolescent low self-esteem was a strong predictor of health-compromising behaviour.5 Conversely, the protective effect of positive health practices on adolescent depression has been proven.6 Therefore, in suicide prevention, promoting positive health practices and preventing risk behaviours are as important as the management of mental disorders.
Third, depression is a strong predictor of suicide. The clinical significance and the long-term implications of depressive symptoms do not depend on crossing the major depression diagnostic threshold.7 Therefore, adolescents' depression may best be conceptualized as a continuum, with the study of sub-threshold syndromes being important.
Finally, not all suicides are associated with depression. For example, in Alexandria, adolescents' aggression predicted suicide ideation and intent.2 There are, hypothetically at least, two types of suicidal behaviour most common during adolescence: a wish to die (depression) and a wish not to be here for a time (impulse control).8
To conclude, in the Middle East we need to know more about our adolescents, especially the impact on their mental health of socioeconomic problems, level of freedom, and democracy. We should spare no effort to investigate where they seek help and their strategies for coping. Now is the time to confront the problem of suicidal ideation, the more so because infant and maternal health, and communicable diseases pose a less immediate threat to morbidity and mortality in the Middle East. 
Competing interests: none declared.
References
1. Bertolote JM, Fleischmann A, Butchart A, Besbelli N. Suicide, suicide attempts and pesticides: a major hidden public health problem. Bull World Health Organ 2006;84:260.
2. Afifi M. Depression, aggression and suicide ideation among adolescents in Alexandria, Egypt. Neurosciences 2004;9:207-13. Available from: http://www.neurosciencesjournal.org/_cgi-bin/DetailArticle.asp?ArticleId=740
3. Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D, et al. Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey. Psychol Med 2005;35:1457-65.
4. Woods ER, Lin YG, Middleman A, Beckford P, Chase L, DuRant RH. The associations of suicide attempts in adolescents. Pediatrics 1997;99:791-6.
5. Jaffer YA, Afifi M, Al Agami F, Alouhaishi K. Knowledge, Attitudes, and Practices of Secondary- Schools Pupils in Oman: 1- Health-compromising behaviors. East Mediterr Health J 2006;12:133-47.
6. Afifi M, Al Riyami A, Morsi M, Al Kharusi H. Depressive symptoms among high school adolescents in Oman. East Mediterr Health J 2006;12:19-30.
7. Lewinsohn PM, Solomon A, Seeley JR, Zeiss A. Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. J Abnorm Psychol 2000;109:345-51.
8. Apter A, Gothelf D, Orbach I, Weizman R, Ratzoni G, Har-Even D, Tyano S. Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry 1995;34:912-8.