8 Suicide and Islam

This chapter will discuss the historical and philosophical aspects of suicide in Islam. Influences of Islamic culture on the phenomena of suicide and attempted suicide will be emphasized, focusing chiefly on attitudes in Egypt. All studies show that suicide is less prevalent in Islamic societies compared to countries associated with other religions. Here, the reasons for suicide in different Islamic and Arabic countries are evaluated in relation to the sociocultural context.

The cognitive schemata of Muslims follow the phrases of the Koran that humans were created for the main reason of worshipping God, and that life and death issues should be controlled by God and not by self-destruction. This faith can be a factor in preventing suicide attempts, especially in those practising their religious rituals. The phenomenology of psychiatric disorders in Islamic culture is characterized and dominated in its content, whether hallucinations or delusions by religious themes.

Nor take life which Allah has made sacred except for just cause. And if any one is slain wrongfully, we have given his heir authority to demand Qisas or to forgive, but let him not exceed bounds in the matter of taking life, for his helped (by God).

The Holy Koran (Surat Al Isra'a 33)

Take not life, which Allah has made sacred, except by way of justice and law. Thus does he command you that you may learn wisdom.

The Holy Koran (Surat Al Ana'am 151)

In ancient Egypt, suicide was a disaster for both the body and the soul. By destroying the body, instead of having it embalmed, the soul would lose its home, as the soul must return every night to the body to be reborn, and the following morning at sunrise in order to live eternally. Not only the soul, but the whole body is under the responsibility of the Gods. The subject of eternal reprobation and whether suicide was sinful is irrelevant: it makes no difference whether one reaches death by suicide or by waiting for it. Suicide was not an issue in ancient Egypt (Ebbel 1937), except in the case of Cleopatra, who was originally Greek.

Suicide is one of those issues that exist in a twilight zone between religion and psychiatry. Historically, there was always an overlap between those who provided the spiritual and the health needs of people, mostly represented by the clergy. This overlap, although separated throughout the ages, has in some cultures still left its imprint on the medical profession. In many Islamic cultures, a doctor is still referred to as ‘Hakim’, which means ‘the wise man’. When health concerns are psychological rather than physical ailments, the boundaries between medical and spiritual/religious healing may become even more blurred.

Few authors have investigated the influence of religion on suicide from a medical and suicidological perspective. Bertolote and Fleischmann (2002) discussed the importance of the religious context and the prevalence of a religion in a country as major cultural factors in the determination of suicide. There are some indications that the religiousness of a person might serve as a protective factor against suicide. The data collected in the WHO SUPRE-MISS community study investigated the religious denomination of the respondents and their religiousness (Bertolote et al. 2005). Whereas there was one predominant religion (i.e. religious denomination) in many of the sites, this was not always reflected in the perceived religiousness of the respondents, who were asked whether they considered themselves to be a religious person. In Campinas, Brazil and Chennai, India, the respondents were predominantly Christian and Hindu respectively; they also considered themselves to be religious persons. In Colombo, Sri Lanka, there was a mixture of several religions and the respondents considered themselves as religious persons. Durban, South Africa also had a variety of religious denominations; however, the perceived religiousness was lower. In Tallinn, Estonia, there was a mixture of Christian and no religion, and the religiousness was even lower. In Karaj, Iran, Islam was predominant at 100 per cent, however, not everyone thought of themselves as a religious person. In Hanoi, Vietnam, the large majority did not have a religious denomination; however, a number of people considered themselves as being religious (Table 8.1).

Methodological deliberations aside, the results are nevertheless confronted with cultural influences, and the subject of suicide as value laden. Some of the differences across sites were probably affected by differences in the willingness of respondents from different cultures to report suicidal thoughts, suicide plans, and attempts. Different levels of perceived stigmatization may also have affected responses to questions about physical illness, mental illness, and alcohol use in the SUPRE-MISS study (WHO 2002), and thus, explain some of the observed differences across the sites. The way mental illness is understood in different cultures, and the particular difficulty of grasping such perceptions despite culture-specific adaptations of the instrument of analysis should also be taken into account. The overall results of the SUPRE-MISS need to be further explored in a careful analysis of the complete questionnaire.

There might be differences, not only in openly discussing suicidal behaviours, but also in the general awareness of such questions. Religious families assess quality of life according to adherence to religious rituals, regardless of symptomatology. Negative symptoms (withdrawal, alogia and avolition) may be perceived by a group of Islamic followers as piousness, and hence deeper contemplation about God considered virtuous. Positive symptoms, like auditory and visual hallucinatory experiences and delusions related to religious matters, are sometimes perceived as gifts from God by extraordinary perception, and thus, considered singular. The comparison of Egyptian, Indian and British depressive patients revealed that Egyptians have a significant increase in suicidal tendencies, but not in actual suicide or attempted suicide (Okasha 2000).

Islam means submitting to God. This submission entails that at the end it is God who decides everything. It follows that everything that happens carries with it a certain wisdom or rationale. Even if the individual fails to grasp that wisdom, Islam demands that a Muslim believe in their presence and in God's final judgment. Suicide is prohibited by Islam. It is haram—forbidden. The logic behind the prohibition is that it is an act that manipulates something, in this case life itself, which is meant to be only God's concern. Furthermore, it indicates lack of trust in God who is capable of making things better. However, haram also means acting in a way that is unjust to self and to others.

The Arab social historian Ibn Khaldoun (1332–1406) was the first author to give a clear description of the relationship between mental health and culture. He described the effects of urbanization on Islamic tribe warriors when they moved from nomadic life to live in towns. The movement was associated with an increase in the prevalence of psychological ailments, namely jealousy, suspiciousness, self-indulgence, and fear of others. He viewed this behaviour as a reaction to the change of social structure. In his view, the tribal system failed to adjust to the process of urbanization. Such failure was, in Ibn Khaldoun's view, at the origin of decline of Islamic civilization. The prevailing concept of mental illness at a particular state in the Islamic world depends on the dominance of development or deterioration of genuine Islamic issues. For instance, during periods of deterioration, the negative concepts of the insane as being possessed by evil spirits dominates, whereas during periods of enlightenment and creative epochs, the disharmony concept dominates, and so forth (Okasha 1999).

In the West, an individual is brought up from an early age to appreciate separateness, freedom, and self-responsibility. Life, even within the family, is focused clearly on give and take, and dependence is not tolerated for long. The extended family has almost disappeared except among the very affluent, and the nuclear family is under serious challenge from a high rate of marriage breakdown. The individual is presumably left to fend for themself with a make it or break it philosophy. These general statements are often compounded in individuals who are less endowed or disabled in one or more ways. Society tends to impose a subtle form of isolation on those with physical illness, the elderly and the mentally ill, among others, creating a state of defeat and alienation that becomes self-perpetuating and malignant towards the end. Research shows that in many traditional societies the social structure is different. The family retains a presence in the individual's life, and anomie is probably less frequently encountered or recognized.

Islam bans self-destructive behaviour as an act of violation of the will of God in taking away life. Even the widely debated issue of suicide bombing, it is denounced by high-ranking religious authorities in the region, refusing to describe the actors as martyrs. Those who contemplate suicide know of never-ending graphic descriptions of torture in hell awaiting the person who takes their own life. A depressed believer would argue when questioned that they have been unhappy in this life and would not want to suffer eternally as well after death. Suffering in our common life is taken by believers as a test from God that should be endured, and promises even greater happiness in the after life. Suicidal behaviour drops markedly in frequency during the holy month of Ramadan (Bensmail et al. 1989; Al-Ansari et al. 1990). Ramadan is considered as a holy month because the Koran was revealed during this month: it is a time of fasting and it is dominated by religious rituals.

It is generally accepted in Western countries that suicide is under-reported, hence this is to be expected in Islamic societies to a larger extent, because suicide is considered a major sin and shameful event for the family. Under-reporting of both suicide and attempted suicide is prevalent, especially in the case of female suicides, which are usually taken to be associated with the breaking of moral codes. The Egyptian spheres of authority and power have traditionally been dominated by men, however, female resistance and influence has always been widespread, and more so recently. When a female attempts or commits suicide, the blame and guilt are laid on the family as having failed to provide security and faith.The male is supposed to be more autonomous in his decisions.

It is worthy of note that the Coptic Orthodox Church, also known as the Egyptian Orthodox Church of Alexandria, does not offer any prayers for those who have committed suicide. In Islam, the suicidal individual is considered to have violated God's decisions, but the death prayers are still performed in the Mosque for him. In both religions, the individual who committed suicide is buried according to the social customs in Egypt.

Symptoms of mental illness are perceived very differently across the Islamic world; ranging from scientific beliefs of alterations in brain functions to a state of possession by Jinni and evil spirits. However, in all situations they are considered as God's will and a lesson for the worshipper to repent. For religious Muslims, death is sometimes looked upon as a blessing and a way to be near God. It is accepted as a continuation of life dependent on the individual's deeds. In Islam, mental symptoms are not taboo, the stigma exists that these may be a curse or a test from God, and good Muslims should accept the will of God. Thus, there is a stigma, but its interpretation is different. Suicide is dishonoured because it connotes a lack of belief in God's creation and a lack of adherence to the codes of Islam. Lack of awareness of an underlying psychopathology is one major element that contributes to the moral judgement of suicide. The concept of depression and mania is overlooked. Depression is attributed to being lazy, to a weak personality, lack of faith and attributed to God's will for redemption. Mania is described as crazy, possessed by Jinni or evil spirits, and the individual is perceived as irresponsible.

The following hypothetical reactions of the different members of a Muslim family to the attempted suicide of a family member reflect various permissive and aggressive attitudes that are frequent. A senior female family member usually adopts the permissive attitude by alleviating the guilt feelings and shame in the family, regarding the failure of its members to provide enough faith to prevent self-destruction. A male family member, usually the family head, adopts the aggressive attitude by ostracizing the family member who shamed the family by their suicide attempt. Long prospective follow-up studies of parasuicide (attempted suicide) with blind assessments could highlight the prognostic correlates of the permissive, aggressive and combined family attitudes (Suleiman et al. 1989).

Table 8.2 shows that the WHO Eastern Regional Mediterranean office, which covers a region comprising 22 countries who are predominantly Islamic, has the lowest rate of suicide expressed in disability-adjusted life years (DALYs) percentages: it was 0.7% for the east Mediterranean region in 2002. It is only the African region which shows lower percentage measured in DALYs.

Table 8.3 shows the low reported suicide rates in some Islamic countries over different years. The lack of reporting of suicide suggests that these figures cannot be taken as representative of reality. However, in other Islamic countries, namely those which separated from the former Soviet Union. For example Turkmenistan, Uzbekstan and Bosnia, the percentage is rather high compared to the Middle East.

Personal and family problems can be said to constitute the main trigger for suicide and attempted suicide in traditional societies. In intergenerational conflict, the disagreement between members of the young generation and their elders was found to involve their attitudes towards family relationships, marriage and emancipation of women. Arab Gulf communities have undergone rapid social change in these spheres (El-Assra 1989). The rapid growth of mass media, tourism, secular education and new occupational opportunities associated with oil wealth have influenced social change. Members of the young generation prefer equal authority, and responsibility for all family members instead of family relationships that favour the older and male children; they prefer marriage based on love rather than arranged by the family and a multi-role as opposed to a mono-role for women. Such changes have influenced psychiatric disorders, with intergenerational strife stated as the reasons for parasuicide (attempted suicide) in 57 per cent of cases (El-Islam 1974, 1976, 1979).

In a cohort of 157 Egyptian depressive outpatients, El-Islam (1969) reported that 62.7 per cent presented guilt feelings. However, the definition of guilt was broad. It involved self-reproach, death wishes, and attempted suicide. The experience of self-reproach in the sample ranged over a wide spectrum of behaviour, e.g. being irritable, imagined inadequacy at work, neglect of family affairs, letting down friends, or minor transgressions in which the patient had caused harm. Guilt feelings were not found to correlate statistically with religion in this culture. There was no significant difference between Christians and Muslims. However, anecdotal reports seem to indicate that guilt feelings are more common in Christian depressed patients in Egypt. Guilt feelings were over-represented in the literate and psychotic groups of patients.

Feelings of hopelessness and the intention to kill oneself are rare among Muslim depressed patients, where losing hope in God's relief and self-inflicted death are considered blasphemous and punishable by eternal hell fire in the after life. However, the rates of suicidal attempts (parasuicide) as cries for help had no significant associations with religiosity among Muslims. Although, the wish to die is not uncommon among Muslim depressives, it usually remains at the level of wishing that God would terminate their life and does not progress to the wish to kill themselves (Okasha and Lotaif 1979).

An Egyptian investigation and a descriptive study of parasuicide in Cairo comprised 200 cases from a total of 1155 patients who attempted suicide in 1975 and were admitted to the casualty department of Ain Shams University Hospital in Cairo, with a catchment area comprising approximately 3 million people (Okasha et al. 1988). A crude rate of suicide attempts in Cairo was 38.5/100,000. There was a high percentage of attempted suicide among the 15–44 age group, with no major difference between the two sexes. Single patients represented 53 per cent of the total, with students showing the highest risk (40 per cent). Depressive illnesses, hysterical reactions, and the situational disorders, in that order of frequency, were the main causes of the attempt. Overdose by tablet ingestion was the most common method used (80 per cent). Official government reports are misleading and do not represent the true rate.

Another study of a sample of 91 persons who were admitted for attempted suicide to the casualty department of three hospitals in Cairo during the year 1981–1982, showed that a large majority of the attempters were young women (age range 15–34 years) belonging to large overcrowded families. They showed a higher tendency to be single, literate and unemployed than the corresponding age group in the general population. Drug overdose was the most common method used. The majority made their attempts at home when there was somebody nearby, and 31 per cent had previous non-serious attempts. Dysthymic disorders, adjustment, affective and personality disorders were the most common diagnoses encountered. Attempters scored higher in neuroticism, extraversion, and psychoticism and they tended to be more flexible. There was a high percentage among the 15–44 age group. Rates were higher among students, followed by the unemployed. Individuals whose education stopped after secondary education constituted one-third of the group, coinciding with the population category showing the highest rate of unemployment. Single men and married women attempted suicide more frequently than married men, for single and widowed women, however, there was no significant difference. Suicide attempts showed a peak in the months April–June, which not only coincides with the seasonal transition, but also with a time of examinations in Egyptian schools and universities, a period that has been described as one of national stress. Single patients represented 53 per cent of the total, with students showing the highest risk (40 per cent). Depressive illnesses, hysterical reactions, and situational disorders, in that order of frequency, were the main causes of the attempts. Analysis of the attempts revealed a low prevalence of suicidal feelings and intent for a period before the attempt, indicating the impulsivity thereof. The majority had threatened to attempt suicide and had history of previous attempts, all of which had taken place in the residence of the individual where they would most likely be saved by a family member: 97 per cent of the sample had expressed feelings of social isolation, and their attempts can be taken as a cry for help (Okasha 1984).

A recent study attempting to find out the current prevalence of attempted suicide by ingestion in a representative Egyptian sample showed interesting results. The prevalence of suicide attempts by ingesting drugs/toxins was 0.066/6 months in contrast to official records showing only 0.0002/6 months. In this sample, 85.3 per cent were serious suicidal attempts and 14.7 per cent were cries for help. 43.9 per cent of the attempters below the age of 20 years had socio-familial difficulties, while 49.2 per cent between the ages of 20 and 40 years had financial difficulties; 6.9 per cent were above 40 years old, and again gave reasons of socio-familial problems as the direct cause of their attempts. Regarding sex, 64.2 per cent of the sample were females with emotional problems, while males attempted suicide because of studies/work problems. As for the occupational status, 38.6 per cent of the attempters were students with emotional problems and 27 per cent were unemployed. The commonest drugs/toxins used were organophosphorous compounds (54.1 per cent) used by female students below age 20, followed by cardiopulmonary drugs (13 per cent) used mainly by unemployed females with ages ranging between 20 and 40 years. Underlying psychiatric disorders were distributed as follows: 30.5 per cent mood disorders, 17 per cent personality disorders, 9.8 per cent anxiety disorders, and 5.3 per cent other psychotic disorders. 37 per cent of the attempters had no psychiatric morbidity and attempted suicide for socio-familial difficulties (Okasha et al. 2006).

Studies of Muslim depressed patients suggest that symptom frequencies and expressions used in depressed Arab patients differ considerably from Western-derived definitions (El Islam et al. 1988; Hamdi et al. 1997). The Hamilton Depression Rating Scale was used in different Muslim communities (Pfieffer 1968; El Islam et al. 1988; Hamdi et al. 1997), and there was a higher incidence of retardation, somatic anxiety, and hypochondriasis, and a lower incidence of morning worsening of symptoms, suicide, guilt, and delayed insomnia. Our recent research suggests that Muslim countries are moving in the direction of the West; thus acquiring its ailments, including an increasing rate of suicide attempts (Okasha 2000).

Results of the WHO–EURO Multicentre Study on Suicidal Behavior in Turkey (Ozguven and Sayio 2003) investigated the rate and method of attempted suicides in all hospitals in the catchment area. The results were screened to identify suicide attempts for four years between 1 January 1998 and 31 December 2001. In the four-year period, 737 individuals attempted suicide (514 women and 223 men). The mean annual rate per 100,000 was 46.89 for men and 112.89 for women. The parasuicide rate increased by 93.59 per cent between 1998 and 2001. The most frequent method used by both men and women was self-poisoning. Compared with the results from other European research centres, attempted suicide rates in Turkey were relatively low. However, the increase in rates was striking. This upward trend may be related to the intense economic difficulties, increasing unemployment, and rapid social change experienced in Turkey in recent years. The risk groups appeared to be younger and female.

There is considerable confusion between the concepts of suicidal behaviour and deliberate self-harm. They overlap with evident suicidal intent at one end and acts of self-mutilation at the other. In Muslim countries, recent studies refer to the rise of parasuicide and probably failed suicide. In a study from Kuwait, attempted suicide constituted more than one quarter of 219 consecutive liaison referrals from all general hospitals (Al-Ansari et al. 1990). Another study from Kuwait on 208 inpatient referrals reported that attempted suicide constituted half the cases (Fido and Al-Munghaiseeb 1989). Daradkeh and Al-Zayer (1988) estimated the population attempting self-harm rate in the Eastern province of Saudi Arabia as 20/100,000, i.e. well below the 100–200/100,000 noticed in Western countries. In Egypt, Okasha (1984) estimated the rate of suicide attempts to be 38/100,000 of the population, well below European rates. The profiles of parasuicide are similar in that the majority is female; the ratio varies between 1.3–2 to 1 in Jordan (Daradkeh 1988) and 2.8:1 in UAE (Hamdi et al. 1989, 1991). In both studies, the act of deliberate self-harm followed acute stress reaction associated with interpersonal strains and frustration. The majority have low or medium intent as measured by the Beck Suicidal Intent Scale. Depressive disorders were diagnosed in one third of the patients. Low suicidal intent correlated with the ideo-affective states of frustration and anger. Serious suicidal intent correlated with antecedent feelings of hopelessness, helplessness, and being cut off and isolated. This is quite similar to very recent studies from the US (Soloff et al. 2000). In Kuwait, around 1.1 per cent of suicide attempters eventually killed themselves (Kuey and Gulec 1989). Around 20 per cent repeated suicide attempts in Dubai and Kuwait, a percentage not far removed from that reported in Western studies. The majority of suicide attempts, around 90 per cent, take the form of an overdose, usually of analgesics (Hamdi et al. 1991).

In a study of suicide from 1980 through 1985 in Jordan, there were 219 suicides with an annual suicide rate of 2.1 per 100,000. The peak suicide rate was found to be among the 15–34 age group. Nearly two-thirds of males that committed suicide were single, and unemployed. Females were married and suffering sociocultural problems. Nearly two-thirds of the total population that committed suicide had undergone previous psychiatric treatment. Violent methods of suicide were most frequent (Daradkeh 1989).

The suicide rate for the entire population in Saudi Arabia averaged 1.1/100,000 population per annum. The male to female ratio was 4.5:1. The highest suicide rate was among the 30–39 age group (44.3%). Immigrants formed 77% of the cases, and of these, Asians accounted for 70% of the overall cases, and Indians showed the highest suicidal rates (43%). The most common means of suicide chosen was hanging (63%), followed by jumping from heights (12%), and gunshot injuries (9%); death from poisoning accounted for only 6% of cases. Causes for suicide revolved around health and family related stressors (El-Fawal and Awad 1994).

Radovanovic (1994) studied the mortality patterns in Kuwait and concluded that there is a high likelihood of non-reporting of unnatural causes of death, including suicide, in death certificates. Still, this would not compensate for the repeated findings that completed suicide is much more frequent in non-Muslim countries. The difference is striking in that it probably is the most salient feature of cultural influence on mental illness and its complications. Two explanations have been invoked; namely the persisting influence of Islam compared to the declining presence of Christianity in the West, and a different social fabric allowing cohesiveness, and reinforcing belonging rather than individuality and social alienation in the West. A third explanation is closely related to religion, namely the marked prevalence of alcohol use in Western cultures compared to Islamic countries. In the UK, alcohol and drug use is involved in almost 15% of suicides in persons in contact with mental health services (Appleby et al. 1999).

Degrees of suicidal behaviour are described by Waziri in Afghani depressive patients (Waziri 1973). In this Islamic culture, 54% expressed death wishes or prayed for God to take their life away: 20% admitted to passing thoughts of suicide but had banished these by thinking of the great sin they would be committing; 14% admitted having had suicidal intentions, and only 2.7% had actually attempted suicide by cutting their throats. The spectrum of suicidal behaviour in this study involves a wide range of degrees of suicidality. Religion seems to suppress the suicidal actions but not the suicidal thoughts. This observation may be supported by the findings that suicidal thoughts were elicited in 58% of depressive patients in Kuwait and only 11% had attempted suicide (Leff 1986). Similarly, the comparison of Egyptian, Indian and British depressive patients revealed that Egyptians have a significant increase in suicidal tendencies, but not in actual suicide or attempted suicide (Arafa 1978).

In a cross-cultural study, El-Rashidi (1992) compared suicidal thoughts, tendencies, acts and histories in Egyptian and French psychiatric inpatients. In 45% of the cases, Egyptian patients reported suicidal thoughts, whereas their French counterparts declared having suicide thoughts in 15% of the cases. With regards to actual attempts, the picture is reversed, with French patients having 2.5 times more histories of suicide attempts, and a tendency to use violent methods.

Muslim patients frequently answer direct questions about suicidal actions negatively. With open-ended questions, the picture is different. In some cases, the disclosure of suicidal ideation may appear in an indirect way, e.g. a depressive patient who was an officer in the army parachute regiment denied feeling suicidal at the beginning, and then spontaneously revealed in a different context that he suggested to his supervisor he would like to jump from the airplane with the spare parachute. Keegstra (1986) reported that suicidal thoughts were never revealed spontaneously during the assessment of Ethiopian depressives. He commented that suicidal plans or ideas were common in 71% of depressed patients. In 19% of the patients, specified plans or previous attempts had been made.

Both ‘psychiatry’ and ‘religion’ are institutions developed over the course of cultural evolution to address and provide some relief for the inevitable problems that occur in the course of family and social interactions. Psychiatry and religion are parallel and complementary frames of reference for understanding and describing the human experience and human behaviour. All religions offer some type of explanation of how the universe was created, how life is maintained, and what happens when life ceases to exist. Religions attempt to give their followers explanations for life's meaning, including rationales for the reality of human suffering. They can, therefore, be an asset to enable religious individuals and groups to deal with painful conditions of existence.

It is deeply imbedded in the Islamic culture that life and death are God's will. The practice of religious duties, rituals, and the visits to the mosque reinforce the attribution of every deed to God. It is very interesting to note that believers in Islam, when they become depressed, lose interest in all aspects of life, but the last to disappear is their ablution rituals and their prayers to God. In Islamic code, humans were created primarily to worship God; this is followed by all other duties. Muslims' cognitive schema are geared day and night to remembering God's will. This has a strong protective value against suicide in that our lives do not belong to us, but to God.

The psychiatrist's knowledge about the religious background of the patient, and the careful evaluation and follow-up to observe symptom progression and effect on functioning and decision-making can be the keys to successful management. Religious belief systems may provide understandable explanations for traumatic life events or provide meaning for survival.