Socio-demographic and clinical correlates of lifetime suicide attempts and their impact on quality of life in Chinese schizophrenia patients 自杀未遂的精神分裂症患者社会人口学和 临床相关因素以及其对患者生活质量的影响 Xiang Yu-Tao, MD, PhD Dep. of Psychiatry, CUHK & Beijing Anding Hospital, China 项玉涛 首都医科大学北京安定医院 暨 香港中文大学医学院精神科学系

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 (Caldwell et al., 1990) 在西方国家自杀是精神分裂症患者非正常死亡的首要因素，约10%-15%的精神分裂症患者死于自杀 (Caldwell et al., 1990) Occurrence of lifetime suicide attempts in schizophrenia patients ranged from 18% to 55% (Roy, 1982) 根据既往研究，精神分裂症自杀未遂的发生率约为18% to 55% (Roy, 1982) Majority of schizophrenia patients who commit suicide have at least one previous attempt (Harkavy-Friedman et al, 1999) 大多数自杀成功的精神分裂症患者，既往至少有一次自杀未遂的经历 (Harkavy-Friedman et al, 1999) ---针对自杀未遂的研究，愈发引起人们的重视

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 positive family history of suicide (Addington et al., 1992) 西方国家研究显示，男性、年龄、未婚、抑郁状态、绝望、物质依赖史、无业和自杀阳性家族史等因素，与自杀未遂的发生有关 (Addington et al., 1992) No study focuses on socio-demographic and clinical correlates of lifetime suicide attempts in Chinese schizophrenia patients and the impact on their quality of life (QOL). 至今，没有针对中国城市精神分裂症患者自杀未遂相关因素的研究；亦没有自杀未遂对患者生活质量影响的研究

Aims 研究目的 Aim: To investigate the rate of lifetime suicide attempts in Chinese schizophrenia patients, and determine their correlates 目的: 调查香港、北京两地门诊精神分裂症患者自杀未遂的发生率，以及相关因素

Hypotheses 研究假设 Hypothesis 1: Rates of lifetime suicide attempts would significantly differ between Hong Kong and Beijing due to the differences between the two sites in socio-cultural and economic contexts and access to psychiatric care 假设-1: 香港、北京两地自杀未遂发生率有显著差异 – 由于两地社会文化经济背景不同，以及精神卫生服务体系不同 Hypothesis 2: Severity of depressive and psychotic symptoms and characteristic of psychotropic drug use would significantly correlate with suicide attempts 假设-2: 抑郁及精神病性症状，精神科药物的使用状况，与自杀未遂的发生显著相关 Hypothesis 3: Lifetime suicide attempts would negatively correlate with patients’ QOL 假设-3:自杀未遂与患者的生活质量呈显著负相关 Based on studies conducted in western countries,

Methods (1) 方法 (1) Study settings and subjects 研究地点和研究对象 Subjects in HK were randomly selected from schizophrenia patients attending the Psychiatric Outpatient Clinic at Prince of Wales Hospital 香港的患者由香港中文大学威尔士亲王医院李嘉诚精神科门诊随机抽取 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 Hospital 北京的患者，在首都医科大学附属北京安定医院门诊，按照配对（年龄，性别，发病年龄，病程）的原则，进行抽取

Methods (2) 方法 (2) Study criteria 研究标准 Diagnosis of schizophrenia according to DSM-IV 符合DMS-IV精神分裂症的诊断标准 Age between 18 to 60 years & length of illness >/=5 years 年龄介于18-60岁之间 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) 病情稳定3个月以上的门诊患者 (Lobana et al., 2001) Patients with history of or ongoing major medical conditions / past or current significant drug/alcohol abuse were excluded 无严重躯体疾病以及物质依赖者

Methods (3) 方法 (3) Data collection 数据收集 Socio-demographic and clinical data were extracted from medical notes and confirmed during the interview 患者的社会人口学及临床资料由病历中采集，随后在访谈中进行验证 Suicide attempt was defined as “a self-destructive act carried out with at least some intent to end one’s life” (Grunebaum et al., 2001). 自杀未遂的定义为“既往至少进行了一次尝试，来试图结束自己的生命”(Grunebaum et al., 2001) History of suicide attempts were confirmed by a review of medical records supplemented by a diagnostic interview 自杀未遂史通过查阅病历获得，并需要在随后的访谈中进行验证

Methods (4) 研究方法 (4) Outcome measures 评估工具 The Hong Kong and Chinese versions of the WHO Quality of Life scale-brief version 香港及大陆版WHO生活质量量表-简化版 Brief Psychiatric Rating Scale (BPRS) Simpson and Angus Scale of Extrapyramidal Symptoms (SAS) and Barnes Akathisia Rating Scale (BARS) The 17-item Hamilton Depression Rating Scale (HAM-D) 汉密尔顿抑郁量表

Methods (5) 研究方法 (5) Statistical analysis 统计分析 Comparisons between the HK and BJ groups, and between 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 独立样本t检验，Mann-Whitney U test, 卡方检验 Multiple logistic regression analysis was used to determine the predictors of lifetime suicide attempts 多元logistic回归

Results (1) 结果 (1) Of the 298 (HK) and 288 (BJ) patients who were eligible and approached, 43 and 38 patients, respectively, refused to participate in the study 共有298名 (香港) 和 288名 (北京) 患者分别在两地获得邀请，其中43名和38名分别拒绝参加 No significant difference was found between the study subjects and those who refused to participate with regard to age, sex, and length of illness 在参加者和拒绝参加者之间，主要社会人口学资料无显著性差异 Of the patients who were eligible and approached,

Results (2)

Results (3) Comparison of clinical characteristic between the two groups …….. (Clinically, it has relatively little significance despite the statistically significant differences) Clinically the differences are minimal despite the statistically significant differences

Results (4) In all domains of SQOL, HK subjects had significantly poorer scores in comparison with those of the HK general population;

Discussion (1) 讨论 (1) Difference in socio-demographic and clinical characteristics between the two sites 两地患者的社会人口学及临床因素的差异 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 and public health policies 患者月收入、工作状况及医疗保险方面的差异，与两地的社会文化，经济方面的差异有关 The difference between the two sites in type and doses of antipsychotics could be due to the different characteristics of prescription influenced by costs of treatment, mental health policies, health insurance, and different symptomatology (Sim et al., 2004) 在抗精神病药物的使用方便的差异，与两地的治疗成本、精神卫生政策、保险以及患者的疾病严重程度有关(Sim et al., 2004) In this study, the discrepancy …

Discussion (2) 讨论 (2) Hypothesis 1-supported 假设 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，北京两地患者自杀企图发生率之间的差异 (20% in HK vs 33.6% in BJ) 部分由于两地间精神卫生服务体系之间的差异 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 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 circumstances probably patients with suicide attempts could not be found in time by mental health professionals (Xiang et al., 2007) 例如, 在香港, 精神科随访门诊和社区精神卫生服务高度发达。一旦患者的精神症状波动，很快就可以被发现，并接受相应的治疗护理。可以有效降低自杀未遂的发生率；在北京，只有维持治疗门诊，此外社区精神卫生服务有待于进一步完善，患者病情波动后未必能被及时发现，可以导致自杀未遂发生率增高 Hypothesis 1: rates of lifetime suicide attempts will significantly differ between the two sites;

Discussion (2) 讨论 (2) Hypothesis 2-supported 假设 2– 支持 Severity of positive, and depressive symptoms, anxiety, and EPS was all positively correlated with presence of suicide attempts, which was consistent with previous findings (Walker et al., 1997;; Grunebaum et al, 2001) 阳性、抑郁、焦虑症状和锥体外系副作用与自杀未遂的发生显著正相关 – 与西方的结论一致(Walker et al., 1997;; Grunebaum et al, 2001) The higher doses of APs in suicide attempters could be explained by the fact that these drugs were used to control severe positive symptoms 具有自杀未遂史的患者服用抗精神病药物的剂量较高 – 与其阳性症状较重有关 More frequent hospitalizations in the ‘attempter’ group - The risk of suicide is one of most common reasons for the admission of schizophrenia patients (Addington & Addington 1992; Meltzer 2005) 具有自杀未遂史的患者住院次数较多 – 自杀未遂本身即为导致住院的重要原因之一 (Addington & Addington 1992; Meltzer 2005) More 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) 具有自杀未遂史的患者使用氯氮平的比例较大 – 据报道，氯氮平有助于降低自杀未遂的风险 (Keck et al., 2000; Meltzer et al, 2003)

Discussion (3) 讨论 (3) Hypothesis 2 (Cont’d) 假设 2 Depot APs were less frequently administered in the ‘attempter’ group. Inadequate or infrequent use of depot APs could lead to poor symptom control and more suicide attempts (Barnes & Curson 1994) 长效抗精神病药物在有自杀未遂史的患者中应用较少 – 长效药物使用不足可以减弱对于精神症状的控制，增加自杀的可能 (Barnes & Curson 1994) More ‘attempters’ than ‘non-attempters’ were taking BZDs - 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) 较多的有自杀未遂史的患者服用苯二氮䓬类药物 – 难以明确解释；可能与该类药物可以导致行为失控有关“behavioral disinhibition ”有关，进而导致自杀行为风险的增大 (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 (Ran 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 et al., 2002). This could lead to higher risk of suicide 自杀未遂和早期患病的正性相关 – 验证了既往研究 (Ran et al., 2003) ---早期患病的精神分裂症患者，在求职、婚姻方面的困难，可以增加自杀风险 (Phillips et al., 2002) Hypothesis 2: severity of depressive and psychotic symptoms will significantly correlate with presence of suicide attempts Severity of negative symptoms was inversely associated with presence of suicide attempts, which replicate and strengthen the notion that negative symptoms could be viewed as a relative protective factor of suicide (Black et al, 1992) since positive symptom severity might be more correlated with the severity of impulsive behavior while negative symptoms severity might be more closely related to failure to initiate purposeful acts, and subsequently decrease the likelihood of suicidality (De Hert et al., 2001). More frequently use of BZD and higher doses of APs in attempter group could be due to more severe anxiety and positive symptoms in that group

Discussion (4) 讨论 (4) Hypothesis 3-supported 假设 3—支持 Patients with a history of suicide attempts were less satisfied than non-attempters with each QOL domain 有自杀未遂史的患者各个领域的生活质量都差于没有自杀未遂史的患者 The differences between the two groups in physical and social QOL domains remained 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 (Heinze et al., 1997) 在控制了其它有混淆效果的变量的影响后，有自杀未遂史的患者在躯体和社会生活质量领域仍然很差–验证了早先的西方的研究结论 (Ponizovsky et al., 2003), 尽管生活质量和自杀均与文化因素相关 (Heinze et al., 1997) The third hypothesis that presence of lifetime suicide attempts will inversely influence schizophrenia patients’ QOL

Limitations of the study 不足 the study was cross-sectional therefore the causality of relationship between suicide attempts and socio-demographic and clinical variables could not be explored 断面研究，不能够探讨各个变量间的因果关系 The results are applicable only to clinically stable schizophrenia outpatients in the two of developed big cities in China 研究结论，不能推广到中国其它地区 First, the results are applicable only to clinically stable schizophrenia outpatients living in the two of developed big cities in China; Therefore the results may not be applicable to other parts of China, with different availability of psychiatric services, local cultural factors and attitudes towards suicide; second, the study was cross-sectional therefore the causality of relationships is rather tentative. The lack of normal population as reference group (control) instead of matched normal control groups The diagnosis was confirmed based on the review of case notes supplemented by a diagnostic interview in stead of using a standardized, structured diagnostic interview schedule.

Clinical implications 结论 The differences in social-cultural and economic contexts and in the access to psychiatric care between the two cities are likely to contribute to the discrepancy in the rate of suicide attempts 两个城市间的社会文化经济差异和精神卫生服务体系的不同，有可能导致了两地间患者自杀未遂发生率的差异 The judicious use of psychotropic drugs and psychosocial interventions are very important to achieve more effective control over psychotic and depressive symptoms and EPS to reduce suicide risk and to improve QOL in schizophrenia patients 采取有效的药物治疗和康复手段，改善患者的精神病性和抑郁症状，可以减少其自杀的可能，并有助于提高患者生活质量 follow-up psychiatric clinics and 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 精神科随访门诊和社区综合服务体系的建立，有可能会较低精神分裂症患者自杀风险 pharmacological agents and psychosocial interventions which could effectively control psychotic and depressive symptoms, and improve EPS, could also reduce the risk of suicide behaviors. Follow-up psychiatric clinic and comprehensive community mental health service should be promptly established in mainland China to lower the risk factors of suicide and improve QOL of schizophrenia patients.

本论文已被发表于 Journal of Psychiatric Research 可以从PubMed / Medline下载

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