8 自殺的危險因子 遠端因子﹝Distal﹞ 近端因子﹝Proximal﹞ 遺傳因素 (Genetic loading) 性格特質 (Personality characteristics: impulsivity, aggression)胎兒及周產期因素 (Restricted fetal growth and peri-natal circumstances)早年創傷經驗 (Early traumatic life events)神經生物學失調 (Serotonin and hypothalamic-pituitary dysfunction)近端因子﹝Proximal﹞精神科疾患 (Psychiatric disorder)身體疾患 (Physical disorder)心理社會危機 (Psychosocial crisis)致命工具的可得性 (Availability of means)模仿效應 (Exposure to models)Hawton K & von Heeringen K: Lancet 2009;373:1372–81.
9 Harris EC, Barraclough B, Br J Psychiatry 1997; 170: 205-28. Standardized Mortality Ratio (SMR) of Suicide by Different Behavioral and Emotional ProblemsSMRHarris EC, Barraclough B, Br J Psychiatry 1997; 170:
10 PAF: Population attributable fraction NNT: Number needed to treat Rate ratio, prevalence and population attributable fraction (PAF) for various approaches towards suicide preventionRate ratioProportion exposed per person-yearsPAFAssuming an intervention reduces suicide rate by 25%NNTHigh-risk strategyRecent discharge (1 month) from psychiatric hospital v. general population1309110.5%Recent discharge (1 month) from psychiatric hospital v. succeeding 11 months47.9%2.6%385Deliberate self-harm (DSH) referred to general hospital26.93007.2%1.9%185910022.9%5.8%500Doctors23630.4%<0.1%25 000Farmers1.50.2%33 000Population strategyUnemployed3600010.9%Analgesic overdosen/a[9.3%]Exhaust gases[20.1%]Antidepressants[4.5%]PAF: Population attributable fraction NNT: Number needed to treatNNT = 1/ARR (absolute risk reduction) ARR = |CER - EER|CER = control group event rate EER = experimental group event rateLewis G, Hawton K, Jones P., Br J Psychiatry. 1997;171:351-4.
19 Medical Condition and Increased Suicide Risk IllnessIncreased Risk (X)HIV and AIDS6.6Huntington’s disease2.9Malignant neoplasmAll sites1.8Head and neck11.4Multiple sclerosis2.4Peptic ulcer2.1Chronic renal failureDialysis14.5Transplantation3.8Spinal cord injurySystemic lupus erythromatosis4.3Douglas G. Jacobs ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. Jossey-Bass, 1999.
22 The Joint Commission's Office of Quality Monitoring Sentinel Event Statistics - Updated through September 30, 2009Type of Sentinel Event#%Wrong-site surgery86713.5%Suicide77012.0%Op/post-op complication71011.0%Delay in treatment5368.3%Medication error5268.2%Patient fall4066.3%Unintended retention of foreign body3094.8%Assault/rape/homicide2453.8%Perinatal death/loss of function2013.1%Patient death/injury in restraints198Date: 2010/03/04
23 Report from the Accreditation Committee of the Joint Commission's Board of Commissioners In General Hospitals Many of the Inpatient Suicides Occurred in Psychiatric UnitDate: 2010/03/04
30 Selective Serotonin Reuptake Inhibitors and Risk of Suicide: A Systematic Review of Observational StudiesReported completed or attempted suicideEight studies with more than 200,000 patientsModerate or severe depression exposed to SSRIsBarbui C et al., CMAJ 2009;180:291-7.
33 Safe SystemLow riskGrade 1security check every weekWard routine: check general condition of patient every 30 minutesSuicide Risk AssessmentHigh riskGrade 2, 3Security check Three times a dayUltra high riskGrade 4Security and general condition check every 15 min
42 Indications for Psycho-social Referral Physician is uncertain about psychiatric diagnosisPatient has a history of major psychiatric disorderPatient is suicidalPatient is requesting assisted suicide or euthanasiaPatient is psychotic or confusedPatient is unresponsive to therapy of first line antidepressantPatient’s family is dysfunctional
44 Knowledge Attitude Skill Belief Klinkman MS: Competing demands in psychosocial care. a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19:
46 The Rise and Fall of the Biopsychosocial Model The bio-psycho-social model is the conceptual status quo of contemporary psychiatry.It has played an important role in combating psychiatric dogmatismIt has devolved into mere eclecticism.Other non-reductionistic approaches to medicine and psychiatryWilliam Osler’s medical humanismKarl Jaspers’ method-based psychiatry should be reconsidered.The British Journal of Psychiatry 2009 v. 195, p. 3-4.
47 Wheat Field with Crows Vincent van Gogh (1853-1890) Source: