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Does the choice of religion have an influence on suicidal behaviour?

We read the differing findings of Burshtein et al. (1) and Cosco et al. (2) with great interest. The majority of Burshtein’s population was Jewish, whereas the population in the study Cosco and colleagues – although not specifically stated – was likely predominantly Christian. Given the broadly similar unfavourable views of the Abrahamic faiths on suicide, we examined suicidal ideation and attempts in a cohort of Muslim patients. As part of a larger long-term study on anxiety and depression in Saudi patients with neurological disorders (Y. Alamri, unpublished), we collected demographic and social information and administered a battery of neuropsychological assessments. When this study was started, there were no validated indices of religiosity in the Arabic language; however, it is generally accepted that Saudi Arabia is one of the most religious countries in the world (3). In our sample of 237 patients, only 10 (4.2%) reported current or previous suicidal ideation. None of the patients reported having attempted suicide and only one patient (0.4%) knew of a person who committed suicide. Consistent with trends elsewhere, females were significantly over-represented in the group of patients who had lifetime suicidal ideation (80% vs. 43%, P = 0.02). In addition, this group of patients was significantly more likely to be single (90% vs. 42%, P < 0.001). Employment, on the other hand, did not seem to differ between the groups (unemployment rate 50% vs. 38%, P = 0.5). Overall, the rates of suicidal behaviour in our study are even lower than the rates reported by both Burshtein et al. (1) and Cosco et al. (2). Due to the unavailability of appropriate tools at the time of our study’s conception, we are unable to put a numerical value on the association of religion and suicidal behaviour. Regardless, however, published literature is still equivocal on the effect of religion (and magnitude thereof) on suicidality (4, 5). As suggested by Cosco and colleagues (2), the relationship between suicide and religiosity is complicated and likely to be majorly influenced by three main factors: the choice of religion, geography and culture. Examining the literature reveals a plethora of evidence on the contribution of each of these factors on suicidal behaviour. For example, rates of suicide were found to vary with geographical distribution of deprivation (6), age structure (7) and land architecture (8). Likewise, the ethnic and cultural discrepancy in the rates of suicidal behaviour has been well described in the literature (9, 10). These studies, while focusing on one factor, did not attempt to specifically control for the potentially confounding effect of the other factors. It would be intriguing to ascertain the influence on suicidal behaviour when two factors are controlled while varying the third: choice of religion (e.g. Yemeni Muslims and Jews), geography (e.g. Christian Caucasians in the USA and New Zealand) and culture (e.g. Sunni and Shia Muslims in Iraq). Even then, however, it may prove impossible to dissect the exact association between religiosity and suicidal behaviour due to the axiomatic interdependence of these factors (11).