The study found that 1 in 6 and 1 in 7 school attending adolescents in Morocco reported suicide ideation and planning respectively. That, suicidality is positively associated with age, being a female, lack of parental support, increased hunger frequency, risky behaviors and worse mental health wellbeing. Studying psychosocial factors associated with completed suicide poses a significant challenge, alternatively, factors affecting ideation and planning can be assessed. It is challenging to compare the data to the global international trends due to sociocultural differences impacting the perception of suicide and thus affecting the willingness to self-report ideation and planning (1). However, the results and trends are comparable to those of other countries in the region with similar sociocultural influences (3, 21, 22).

The results indicate that the prevalence of suicidal ideation and planning among school-attending adolescents in Morocco is comparable to that of countries in the Eastern Mediterranean Region, which ranges from 16–21% and 9–17% respectively. In comparison to the other regions, GSHS data indicated that the prevalence of suicidal ideation and planning in Morocco is lower than that of countries in Africa and the Americans but higher than countries in South-East Asia and Western Pacific (Table 1). The results indicate that studying factors associated with suicide need to be socioculturally relevant to the said region as different factors may impact suicidality differently based on external factors.

Mental health and wellbeing in the Eastern Mediterranean Region are influenced by many parameters that are unique to the region. Belief and religiosity are found to be a source of wellbeing and a protective factor against suicide (23). The region contains an amalgam of religions: Islam, Christianity, and Judaism. Islam accounts for the belief of 90% of the citizens in the region (24). Religion plays a significant role in the lives of individuals in the region. Considering Islam, Christianity, and Judaism prohibit suicide, it may in turn affect the prevalence of suicide. The scarcity of data and research assessing suicide in Muslim-majority countries further challenges understanding suicide and associated factors in the region (4). Additionally, studies have shown the potential presence of a relationship between climate change and mental health (25). As such, the similarities in the climate in the region may play a role in the trends of mental illnesses particularly anxiety and depression (24).

The Eastern Mediterranean Region is rich in culture and historic backgrounds. Culturally, families in the region are more closely knit than other regions (24). Being in a supportive, healthy family-oriented environment is found to be protective of mental illness (26). Both cultural background and a family environment supports mental wellbeing (24).

The common misconceptions and negative attitudes toward mental illness generate stigma that impacts access to mental healthcare and mental wellbeing. Due to the influence of culture and religion in the Arab world, mental illness is often viewed as the result of a higher power. For instance, Muslims often view mental illness as the “evil eye” or “jinn possession,” Christians often view it as the “devil possession” and in certain countries due to cultural influences it is viewed as a “case of contamination” that can be accidentally contracted by “stepping on sorcery or drinking it” as seen in Morocco (27).

The results indicate that the prevalence of suicidal ideation and planning are similar in the region, which could be due to the sociocultural differences as highlighted above. Additionally, the results support the global sex differences in suicidal ideation, which indicates that females are more likely to express suicidal ideation (28).

Additionally, the demographic data associated with suicidal ideation was similar to that of other countries in the region. For instance, an increasing hunger frequency was associated with an increase in suicidal ideation (22). Multiple studies exploring variables that increase the likelihood of suicidal ideation also revealed an increased likelihood associated with increased bullying, cigarette smoking, feeling lonely, feeling worried, drug use, and marijuana use (15, 22, 28). Interestingly however, our study revealed an association between suicidal ideation and increasing age, which was similar to a study conducted in Lebanon using data from 2005 but opposing another study conducted in Lebanon in 2020 (15, 22).

Suicidal planning trends and associations were similar to that of other countries in the region. A study assessing factors associated with suicidal ideation and planning amongst Palestinian adolescents also revealed that feeling lonely, feeling worried, experiencing bullying, smoking cigarettes, using marijuana, and using amphetamines increased the likelihood of suicidal planning. Similarly, our study revealed similar findings using both bivariate and multivariate analysis. Additionally, our results revealed that drug use before the age of 14 increased the likelihood of suicidal planning. In terms of participants characteristics, our data indicates an association between increasing hunger frequency, living in a rural area and suicidal planning. Both parameters may be associated with socioeconomic status affecting food scarcity. Additionally, it was found that decreasing educational levels was associated with increasing rates of suicidal planning.

The study adds to the limited data available in the region. Based on the results and regional trends, national systemic interventions need to be studied to decrease the prevalence of the growing public health threat. Interventions need to be aimed at tackling hunger frequency, creating supportive school environments, introducing school counselors in order to recognize early signs and intervene early, and educate students about mental health and the consequences of cigarette smoking, marijuana use, and drug use. Additionally, significant efforts are needed to address the stigma associated with mental illness, which impacts individuals' willingness to seek help.

It is challenging to study the factors associated with completed suicide, as such suicidal ideation and planning are used instead to draw inferences. Additionally, it is also challenging to conduct a prospective study to explore factors associated with completed suicide. Alternatively, a cross-sectional design was used. The main limitation of such study design is reverse causality, and thus only allows us to determine associations rather than causation. Additional limitations include under-reporting, sample size not including adolescents not enrolled in schools, and the lack of pertinent demographics such as socioeconomic status, religion, and family dynamics. On the other hand, the study's large sample size ensures the diversity and representativeness of the data, and since the data was a part of the WHO's Global Schools Health Survey it allows for better comparison between regions and countries. Further research needs to be conducted to consider specific sociocultural differences in order to better understand their impact on suicidality.

Based on the study results, monitoring of adolescent mental health wellbeing in schools should be a priority, awareness campaigns with parents should be initiated and culturally acceptable interventions should be developed and tested to address suicidality. The effort should come from all involved parties (Government, School, Parents and Adolescents) focusing on psychoeducation, taking into account sociocultural factors and also tackling the associated stigma to build community-based interventions.