phdthesis-thehongkongmedicalassociation香港醫(yī)學(xué)會(huì)

1、,Socio-demographic and clinical correlates of lifetime suicide attempts and their impact on quality of life in Chinese schizophrenia patients自殺未遂的精神分裂癥患者社會(huì)人口學(xué)和臨床相關(guān)因素以及其對(duì)患者生活質(zhì)量的影響,Xiang Yu-Tao, MD, PhDDep. of Psychiatr

2、y, CUHK & Beijing Anding Hospital, China項(xiàng)玉濤首都醫(yī)科大學(xué)北京安定醫(yī)院 暨 香港中文大學(xué)醫(yī)學(xué)院精神科學(xué)系,2,,,3,,4,Background (1)研究背景 (1),Suicide is the chief cause of premature death in schizophrenia patients and 10%-15% of them die by suicide

3、(Caldwell et al., 1990) 在西方國家自殺是精神分裂癥患者非正常死亡的首要因素，約10%-15%的精神分裂癥患者死于自殺 (Caldwell et al., 1990)Occurrence of lifetime suicide attempts in schizophrenia patients ranged from 18% to 55% (Roy, 1982) 根據(jù)既往研究，精神分裂癥自殺未遂的發(fā)生率約

4、為18% to 55% (Roy, 1982)Majority of schizophrenia patients who commit suicide have at least one previous attempt (Harkavy-Friedman et al, 1999) 大多數(shù)自殺成功的精神分裂癥患者，既往至少有一次自殺未遂的經(jīng)歷 (Harkavy-Friedman et al, 1999) ---針對(duì)自殺未

5、遂的研究，愈發(fā)引起人們的重視,5,Background (2)研究背景 (2),Risk factors of suicide attempts included male gender, younger age, unmarried status, presence of depression and hopelessness, history of substance abuse, unemployment, and positi

6、ve family history of suicide (Addington et al., 1992)西方國家研究顯示，男性、年齡、未婚、抑郁狀態(tài)、絕望、物質(zhì)依賴史、無業(yè)和自殺陽性家族史等因素，與自殺未遂的發(fā)生有關(guān) (Addington et al., 1992)No study focuses on socio-demographic and clinical correlates of lifetime suicide a

7、ttempts in Chinese schizophrenia patients and the impact on their quality of life (QOL).至今，沒有針對(duì)中國城市精神分裂癥患者自殺未遂相關(guān)因素的研究；亦沒有自殺未遂對(duì)患者生活質(zhì)量影響的研究,6,Aims研究目的,Aim: To investigate the rate of lifetime suicide attempts in Chinese

8、schizophrenia patients, and determine their correlates目的: 調(diào)查香港、北京兩地門診精神分裂癥患者自殺未遂的發(fā)生率，以及相關(guān)因素,7,Hypotheses研究假設(shè),Hypothesis 1: Rates of lifetime suicide attempts would significantly differ between Hong Kong and Beijing due

9、 to the differences between the two sites in socio-cultural and economic contexts and access to psychiatric care假設(shè)-1: 香港、北京兩地自殺未遂發(fā)生率有顯著差異 – 由于兩地社會(huì)文化經(jīng)濟(jì)背景不同，以及精神衛(wèi)生服務(wù)體系不同Hypothesis 2: Severity of depressive and psychotic

10、 symptoms and characteristic of psychotropic drug use would significantly correlate with suicide attempts假設(shè)-2: 抑郁及精神病性癥狀，精神科藥物的使用狀況，與自殺未遂的發(fā)生顯著相關(guān)Hypothesis 3: Lifetime suicide attempts would negatively correlate with p

11、atients’ QOL假設(shè)-3:自殺未遂與患者的生活質(zhì)量呈顯著負(fù)相關(guān),8,Methods (1) 方法 (1),Study settings and subjects研究地點(diǎn)和研究對(duì)象Subjects in HK were randomly selected from schizophrenia patients attending the Psychiatric Outpatient Clinic at Prince of

12、 Wales Hospital香港的患者由香港中文大學(xué)威爾士親王醫(yī)院李嘉誠精神科門診隨機(jī)抽取Their counterparts in Beijing, matched according to age, sex, age at onset, and length of illness, were recruited from the Psychiatric Outpatient Clinic at Beijing Anding

13、Hospital北京的患者，在首都醫(yī)科大學(xué)附屬北京安定醫(yī)院門診，按照配對(duì)（年齡，性別，發(fā)病年齡，病程）的原則，進(jìn)行抽取,9,Methods (2) 方法 (2),Study criteria 研究標(biāo)準(zhǔn)Diagnosis of schizophrenia according to DSM-IV符合DMS-IV精神分裂癥的診斷標(biāo)準(zhǔn)Age between 18 to 60 years & length of illness

14、 >/=5 years年齡介于18-60歲之間 以及 病程在5年以上者Outpatients who have been clinically stable for at least 3 months before recruitment according to Lobana ‘s criteria (2001) 病情穩(wěn)定3個(gè)月以上的門診患者 (Lobana et al., 2001)Patients with hi

15、story of or ongoing major medical conditions / past or current significant drug/alcohol abuse were excluded 無嚴(yán)重軀體疾病以及物質(zhì)依賴者,10,Methods (3) 方法 (3),Data collection 數(shù)據(jù)收集Socio-demographic and clinical data were extracted

16、 from medical notes and confirmed during the interview患者的社會(huì)人口學(xué)及臨床資料由病歷中采集，隨后在訪談中進(jìn)行驗(yàn)證Suicide attempt was defined as “a self-destructive act carried out with at least some intent to end one’s life” (Grunebaum et al., 20

17、01). 自殺未遂的定義為“既往至少進(jìn)行了一次嘗試，來試圖結(jié)束自己的生命”(Grunebaum et al., 2001)History of suicide attempts were confirmed by a review of medical records supplemented by a diagnostic interview 自殺未遂史通過查閱病歷獲得，并需要在隨后的訪談中進(jìn)行驗(yàn)證,11,Methods (4

18、) 研究方法 (4),Outcome measures 評(píng)估工具The Hong Kong and Chinese versions of the WHO Quality of Life scale-brief version香港及大陸版WHO生活質(zhì)量量表-簡化版Brief Psychiatric Rating Scale (BPRS)Simpson and Angus Scale of Extrapyramidal S

19、ymptoms (SAS) and Barnes Akathisia Rating Scale (BARS)The 17-item Hamilton Depression Rating Scale (HAM-D)漢密爾頓抑郁量表,12,Methods (5)研究方法 (5),Statistical analysis 統(tǒng)計(jì)分析Comparisons between the HK and BJ groups, and betwe

20、en the attempter and non-attempter groups with regard to socio-demographic and clinical characteristics were performed by independent sample t-test, Mann-Whitney U test and chi-square test as appropriate獨(dú)立樣本t檢驗(yàn)，Mann-Whi

21、tney U test, 卡方檢驗(yàn)Multiple logistic regression analysis was used to determine the predictors of lifetime suicide attempts多元logistic回歸,13,Results (1)結(jié)果 (1),Of the 298 (HK) and 288 (BJ) patients who were eligible and ap

22、proached, 43 and 38 patients, respectively, refused to participate in the study共有298名 (香港) 和 288名 (北京) 患者分別在兩地獲得邀請(qǐng)，其中43名和38名分別拒絕參加No significant difference was found between the study subjects and those who refused to

23、 participate with regard to age, sex, and length of illness在參加者和拒絕參加者之間，主要社會(huì)人口學(xué)資料無顯著性差異,14,Results (2),15,Results (3),16,Results (4),17,Discussion (1)討論 (1),Difference in socio-demographic and clinical characteristics

24、between the two sites兩地患者的社會(huì)人口學(xué)及臨床因素的差異Discrepancy in monthly income, employment status and health insurance coverage between the two sites is the consequence of the different social-cultural and economical contexts an

25、d public health policies患者月收入、工作狀況及醫(yī)療保險(xiǎn)方面的差異，與兩地的社會(huì)文化，經(jīng)濟(jì)方面的差異有關(guān)The difference between the two sites in type and doses of antipsychotics could be due to the different characteristics of prescription influenced by costs

26、 of treatment, mental health policies, health insurance, and different symptomatology (Sim et al., 2004)在抗精神病藥物的使用方便的差異，與兩地的治療成本、精神衛(wèi)生政策、保險(xiǎn)以及患者的疾病嚴(yán)重程度有關(guān)(Sim et al., 2004),18,Discussion (2) 討論 (2),Hypothesis 1-supported

27、假設(shè) 1– 支持Discrepancy in rate of lifetime suicide attempts between HK and BJ (20% in HK vs 33.6% in BJ) could be partly due to the differences in mental health care system香港，北京兩地患者自殺企圖發(fā)生率之間的差異 (20% in HK vs 33.6% in BJ)

28、部分由于兩地間精神衛(wèi)生服務(wù)體系之間的差異E.g, In HK, follow-up clinics and community mental health services are both well developed. Patients could be soon identified once their mental health status become unstable, which could effectively

29、 lower the risk of suicide attempts. In BJ, there are only maintenance psychiatric clinics (patients need to see psychiatrists voluntarily); and no community mental health services are available. Thus, under such circums

30、tances probably patients with suicide attempts could not be found in time by mental health professionals (Xiang et al., 2007)例如, 在香港, 精神科隨訪門診和社區(qū)精神衛(wèi)生服務(wù)高度發(fā)達(dá)。一旦患者的精神癥狀波動(dòng)，很快就可以被發(fā)現(xiàn)，并接受相應(yīng)的治療護(hù)理?？梢杂行Ы档妥詺⑽此斓陌l(fā)生率；在北京，只有維持治療門診，此外社區(qū)

31、精神衛(wèi)生服務(wù)有待于進(jìn)一步完善，患者病情波動(dòng)后未必能被及時(shí)發(fā)現(xiàn)，可以導(dǎo)致自殺未遂發(fā)生率增高,19,Discussion (2) 討論 (2),Hypothesis 2-supported假設(shè) 2– 支持Severity of positive, and depressive symptoms, anxiety, and EPS was all positively correlated with presence of suicid

32、e attempts, which was consistent with previous findings (Walker et al., 1997;; Grunebaum et al, 2001)陽性、抑郁、焦慮癥狀和錐體外系副作用與自殺未遂的發(fā)生顯著正相關(guān) – 與西方的結(jié)論一致(Walker et al., 1997;; Grunebaum et al, 2001)The higher doses of APs in su

33、icide attempters could be explained by the fact that these drugs were used to control severe positive symptoms具有自殺未遂史的患者服用抗精神病藥物的劑量較高 – 與其陽性癥狀較重有關(guān)More frequent hospitalizations in the ‘a(chǎn)ttempter’ group - The risk of s

34、uicide is one of most common reasons for the admission of schizophrenia patients (Addington & Addington 1992; Meltzer 2005)具有自殺未遂史的患者住院次數(shù)較多 – 自殺未遂本身即為導(dǎo)致住院的重要原因之一 (Addington & Addington 1992; Meltzer 2005)More

35、attempters than non-attempters were taking clozapine ---Clozapine could reduce rate of suicide attempts in schizophrenia patients (Keck et al., 2000; Meltzer et al, 2003) 具有自殺未遂史的患者使用氯氮平的比例較大 – 據(jù)報(bào)道，氯氮平有助于降低自殺未遂的風(fēng)

36、險(xiǎn) (Keck et al., 2000; Meltzer et al, 2003),20,Discussion (3) 討論 (3),Hypothesis 2 (Cont’d)假設(shè) 2Depot APs were less frequently administered in the ‘a(chǎn)ttempter’ group. Inadequate or infrequent use of depot APs could lead t

37、o poor symptom control and more suicide attempts (Barnes & Curson 1994) 長效抗精神病藥物在有自殺未遂史的患者中應(yīng)用較少 – 長效藥物使用不足可以減弱對(duì)于精神癥狀的控制，增加自殺的可能 (Barnes & Curson 1994)More ‘a(chǎn)ttempters’ than ‘non-attempters’ were taking BZDs -

38、no clear explanation for this finding; Speculation: BZDs could lead to behavioral dis-inhibition which might contribute to the increased number of suicide attempts (Michel & Lang 2003)較多的有自殺未遂史的患者服用苯二氮?類藥物 – 難以明確解釋；

39、可能與該類藥物可以導(dǎo)致行為失控有關(guān)“behavioral disinhibition ”有關(guān)，進(jìn)而導(dǎo)致自殺行為風(fēng)險(xiǎn)的增大 (Michel & Lang 2003) Patients with suicide attempts had an earlier age at onset in this sample, confirming the finding of a previous study from China (Ra

40、n et al., 2003) ---schizophrenia patients in urban regions who fall ill at an early age are less likely to find satisfactory jobs or a spouse due to the stigma and discrimination related to schizophrenia (Phillips e

41、t al., 2002). This could lead to higher risk of suicide 自殺未遂和早期患病的正性相關(guān) – 驗(yàn)證了既往研究 (Ran et al., 2003) ---早期患病的精神分裂癥患者，在求職、婚姻方面的困難，可以增加自殺風(fēng)險(xiǎn) (Phillips et al., 2002),21,Discussion (4) 討論 (4),Hypothesis 3-supported假設(shè) 3

42、—支持Patients with a history of suicide attempts were less satisfied than non-attempters with each QOL domain 有自殺未遂史的患者各個(gè)領(lǐng)域的生活質(zhì)量都差于沒有自殺未遂史的患者The differences between the two groups in physical and social QOL domains r

43、emained significant after adjusting for clinical variables -- supports the conclusion of a study of Caucasian schizophrenia inpatients (Ponizovsky et al., 2003), even though suicide and QOL are both culture sensitive (He

44、inze et al., 1997) 在控制了其它有混淆效果的變量的影響后，有自殺未遂史的患者在軀體和社會(huì)生活質(zhì)量領(lǐng)域仍然很差–驗(yàn)證了早先的西方的研究結(jié)論 (Ponizovsky et al., 2003), 盡管生活質(zhì)量和自殺均與文化因素相關(guān) (Heinze et al., 1997),22,Limitations of the study不足,the study was cross-sectional therefore the

45、 causality of relationship between suicide attempts and socio-demographic and clinical variables could not be explored斷面研究，不能夠探討各個(gè)變量間的因果關(guān)系The results are applicable only to clinically stable schizophrenia outpatients

46、in the two of developed big cities in China研究結(jié)論，不能推廣到中國其它地區(qū),23,Clinical implications結(jié)論,The differences in social-cultural and economic contexts and in the access to psychiatric care between the two cities are likely to

47、 contribute to the discrepancy in the rate of suicide attempts兩個(gè)城市間的社會(huì)文化經(jīng)濟(jì)差異和精神衛(wèi)生服務(wù)體系的不同，有可能導(dǎo)致了兩地間患者自殺未遂發(fā)生率的差異The judicious use of psychotropic drugs and psychosocial interventions are very important to achieve more e

48、ffective control over psychotic and depressive symptoms and EPS to reduce suicide risk and to improve QOL in schizophrenia patients采取有效的藥物治療和康復(fù)手段，改善患者的精神病性和抑郁癥狀，可以減少其自殺的可能，并有助于提高患者生活質(zhì)量follow-up psychiatric clinics and

49、 comprehensive community mental health services should be established in mainland China, which would be also expected to reduce the risk of suicide of schizophrenia patients精神科隨訪門診和社區(qū)綜合服務(wù)體系的建立，有可能會(huì)較低精神分裂癥患者自殺風(fēng)險(xiǎn),24,本論文已被