The present study aimed at determining the prevalence and the risk factors of suicidal behaviors mainly suicide ideation, suicide planning, and suicide attempts among Moroccan school students. Regarding suicide ideation, the prevalence was 15 % in subjects aged 13 to 15 years, which was almost identical to the national prevalence (15.7 %) reported by the 2010 Morocco GSHS [9]. The reported prevalence in Morocco was indeed similar to the GSHS results in other Arab countries, (15 %) in Lebanon in 2011, and (15.5 %) in United Arab Emirates in 2010; while, it was lower than the GSHS findings in Tunisia in 2008 (19.8 %) and in Mauritania in 2010 (31.1 %) [18]. Contrariwise, the overall prevalence of suicide ideation among Moroccan school students was among the lowest in comparison with other African countries (Benin, Ghana, Kenya, Zambia), some countries in the Americas (Chile, Guyana, and Santa Lucia), some European and Asiatic countries (Austria, Turkey, China), in which suicidal ideation was found to be very common among youth (up to 44 % among high school students) [18–20].

Concerning suicide attempts, it was demonstrated that the lifetime prevalence of these attempts among Moroccan school students (10.5 %) was seemingly equivalent to the average global rate (9.7 %) as reported in a systematic review from the international literature on the prevalence of suicidal phenomena among 513,188 adolescents in 2005 [21]. Nevertheless, the self-reported lifetime prevalence of suicide attempts in the present study (10.5 %) proved high in comparison with American and European countries. According to a recent survey conducted among 6483 American adolescents in 2013, the estimated lifetime prevalence of suicide attempts was 4.1 % [22]. Indeed, the Saving and Empowering Young Lives in Europe (SEYLE) project (2014), conducted across 11 European countries, revealed that 4.2 % adolescents attempted suicide during their lifetime [23].

The previous findings are surprising, in the sense that the prevalence of suicide ideation was low; while, the prevalence of suicide attempts proved high compared with western countries.

In essence, any comparison with western countries should be interpreted with caution due to the methodological differences present across suicide studies; therefore, it is difficult to make generalizations about the prevalence of suicidal behaviors.

To explain the previous contrast in the light of Moroccan culture specificities, suicide ideation low prevalence can be relegated to the religious and cultural prohibition of suicide, or even suicide thoughts. To illustrate, Baasher argued that Islam was behind the low rates of suicidal behaviors recorded in Muslim communities [24]. In general terms, an expanding body of literature has thoroughly examined religiosity as a potential protective factor against the development and the persistence of mental disorders and risk behaviors among youth [25, 26].

Despite the fact that all participants in this study adhere to Islam, the lifetime prevalence of suicide attempts hints on youth non-conformist or deviant religious attitudes. Among the limitations of this study is unfortunately the absence of any question about religiosity degrees since there is no validated scale in Morocco developed to assess such a variable.

The high prevalence of suicide attempts can also be interpreted in relation to the ongoing economic and social changes occurring in the Moroccan society, which have created a growing rift between younger and older generations, and led to intensifying conflicts between Moroccan youth and the conservative society. Likewise, adults still perceive youth problems as superficial. Thus, suicide attempts could be a call for communication in a society that pays no heed to youth dilemmas. For this reason, medically non-serious suicide attempts are more common than medically serious ones. The present study, be it a community-based survey, tends to represent all suicidal attempts regardless of their severity degree. Generally speaking, medically non-serious suicide attempts are more reported than medically serious ones. For example, although 8.0 % of United States students (grades 9 to 12) reported suicide attempts in the past year, the proportion reporting medically serious attempts- treated by a doctor or a nurse- was only 2.7 % [27].

The most important characteristic of attempted and completed suicide is the extent to which the act was planned. In this study, 6.3 % of students reported having made a suicide plan in the past month. For unplanned suicide attempts, the prevalence among Moroccan school students was unknown. Internationally, several studies revealed that the prevalence of unplanned or impulsive acts of suicide estimates has exceeded 50 % among adolescents [28].

On the account of these alarming results, attention shifted towards the study of suicide risk factors. The obtained results showed that all suicidal behaviors were more common among girls than boys. Such findings were consistent with those reported internationally. Lewinsohn et al. found that the prevalence rates of suicide attempts are two to three times higher in females than in males [29]. Rezaeian using data from the World Health Organization Global Burden of Disease Project, reported that in the Eastern Mediterranean Region, the rates of suicide were higher in females than males in age groups 5–14 and 15–29 years [30]. Even for females aged 18–65, Weissman et al. noted that compared with males, females had higher rates of suicidal ideation and suicide attempts in nine countries (The United States, Canada, Puerto Rico, France, West Germany, Lebanon, Taiwan, Korea and New Zealand) [31]. Focusing on suicide attempts, the expression is mostly associated with gender-specific norms. Males for instance are more inclined towards risk-taking behaviors, and PASs use. Eventually, their suicide attempts are more likely to result in fatalities as they employ violent means and irreversible methods. Concerning females, gender specific norms, in conjunction with low social status and the lack of economic and personal power can result in more suicide ideation, rumination, depression, and nonfatal suicide attempts [32, 33]. Suicide rates as matter of fact are typically higher in males than females, and the opposite for suicide attempts. This gender paradox was clarified in regards to genetic vulnerabilities and gender differences in early adverse environments, neurodevelopment, mental Disorder, social expectations and their complex interconnections [34].

In this study, an association was detected between tobacco consumption, PASs use, and suicidal behaviors. Current smoking was more associated with suicidal ideation and PASs consumption with suicide attempts. Such findings were consistent with other surveys depicting the consumption of tobacco and PASs as strong risk factors of suicidal behaviors [12, 35, 36]. Evren et al. and Juan et al. indicated a direct association between suicidal ideation and current smoking of cigarettes [37, 38]. Likewise, drinking alcohol was directly associated with suicidal attempts. Certain characteristics of alcohol use appeared to be predictive of attempted suicide, such as high alcohol consumption, and the uptake of strong alcoholic drinks [39, 40]. Moreover, alcohol use could facilitate suicide attempts; it was observed that many subjects use some substance mostly alcohol before committing suicide [41]. Equally important, most longitudinal studies proved that early adolescent cannabis use increased the risk of later depression and suicidal behaviors [42–44]. In fact, the relationship between suicidal behaviors, tobacco and PASs is complicated. The association has been well established, yet causal links remain unclear because suicidal behaviors, tobacco and PASs use are multiply determined. To illustrate, the use of certain PASs alongside with suicidal behaviors are related with strong feelings of escapism [45, 46].

Similarly to our findings, previous studies on the potential risk factors of suicidal behaviors revealed that socioeconomic deprivation, poverty and stress or worry about the economic situation of the family were relevant correlates to suicidal behaviors among adolescents [47, 48]. The association between parents’ cohabitation status and suicidal behaviors has already been investigated in many studies, and showed an indirect association between these two factors [39]. Family harmony on the other hand was found to have a stronger effect on reducing suicidal behaviors risk.

At last, the results of the present study should be considered in the light of several limitations. The study was based on a cross sectional sample, which indicated that the causal relations could not be determined. Indeed, despite of employing validated instruments to measure suicidality, the survey used self-reported data, which may reduce objectivity and introduce the possibility of misreporting. Furthermore, the sample consisting of school students cannot be considered as a representative sample of all Moroccan youth, because the study did not include unschooled teens. Finally, the study lacked data on characteristics such as mental disorders, parents’ psychopathology, sexual abuse, and adverse childhood experiences; hence, the impact of these characteristics on suicidal behaviors could not be studied. Further research needs to be conducted in this regard.

Concerning the strengths of the present study, it included a large representative sample. It was the first study in kind to be performed among middle and high school students in the North Centre region of Morocco with the aim of investigating the prevalence and exploring the risk factors of suicidal behaviors.