詢問自殺想法不會有傷害


  【24drs.com】一線照護醫師不太願意詢問憂鬱病患是否有自殺念頭,因為他們害怕會引起自殺意念或促成自殺,其實不需要擔心這點;英國精神病學期刊上的一篇研究顯示,篩檢自殺意念不會導致不值得活下去的想法。
  
  英國倫敦皇家學院的Mike J. Crawford醫師表示,相較於只問一般健康與生活型態問題者,初次就診時詢問有關自殺的想法,並不會造成在後來幾週更可能想到這個議題。
  
  Crawford醫師等人在之前的研究中針對100名家庭醫師進行調查,結果發現,醫師們承認不喜歡詢問自殺想法方面的問題,因為他們擔心會讓病患感覺更糟糕。
  
  此外,Crawford醫師指出,我們從以前的研究也暸解到,在媒體討論自殺會增加自我傷害和自殺的風險。
  
  在這個多中心單盲隨機試驗中,共有443名病患因憂鬱症而求診於家庭醫師,其中半數詢問健康狀態與生活型態等問題,另外半數詢問自殺想法;這些病患住在倫敦北部和西部,平均年紀是48.5歲(範圍16 – 92歲),其中137人(30.9%)是男性。
  
  兩週之後,研究人員再度訪談所有病患,詢問他們在過去14天內的心智健康情況、是否覺得生活不值得活下去;此時,若病患承認自己認為生活不值得活下去,就鼓勵他們與健康照護者討論他們的感覺,並利用生命線或服務熱線等其他資源。
  
  研究顯示,詢問自殺意念並不會增加研究對象開始擔心生活不值得活下去的可能性,在詢問自殺意念者和詢問健康及生活型態者之間,認為生活不值得活下去的感覺差距為0.88 (95%信心區間為0.66 – 1.18)。
  
  研究人員也發現,37名病患(22.3%)在開始時表示想過要結束生命,但是,兩週之後,只有24人(14.6%)表示有過這個想法。
  
  Crawford醫師表示,這篇研究有其限制,但是也有其強度。在研究限制方面,樣本不夠大,無法研究這些問題的次組分析影響,例如年輕族群。此外,這篇研究在失業率較高的人口稠密區進行,我們不知道在其他不同區域是否會有類似的結果。
  
  至於研究強度,Crawford醫師表示,這是篇隨機控制試驗,研究人員並不知道蒐集的追蹤資料是哪種分配狀態,所以不知道研究對象在初次訪談時被問哪些問題。
  
  雖然有研究限制,但Crawford醫師相信,醫師不需要害怕詢問自殺意念的問題。他表示,醫師應更有信心詢問憂鬱病患是否感覺生命不值得活下去、或者曾想過或嘗試過了結生命,只要在詢問這些問題時保持敏感即可。
  
  紐約羅徹斯特大學牙醫與醫學院的Yeates Conwell醫師評論指出,這是重要消息!
  
  未參與研究的Conwell醫師表示,有關自殺的迷思很多,其中之一就是:詢問某人的自殺想法會使其成真。
  
  重點在於家庭醫師必須知道這些最佳證據、隨機試驗的結果顯示,詢問這些問題不會造成問題。此外,可藉此指出我們有哪些介入方式、幫助我們減少自殺相關發生率和死亡率,這也是這篇研究的重要之處。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=6521&x_classno=0

No Harm in Asking About Suicidal Thoughts

By Fran Lowry
Medscape Medical News

May 16, 2011 — Primary care physicians who may be reluctant to ask depressed patients if they think about suicide for fear it will trigger suicidal ideation or prompt a suicide attempt have no need to worry.

A new study published in the May issue of the British Journal of Psychiatry shows that screening for suicidal ideation does not lead to increased feelings that life is not worth living.

"People who were asked about suicidal thoughts at the first interview were no more likely to think about this topic during the following week than those who were asked general questions about health and lifestyle," lead study author Mike J. Crawford, MD, from Imperial College, London, United Kingdom, told Medscape Medical News.

In earlier work, Dr. Crawford and his team conducted a survey among 100 family practitioners and found that the physicians confessed that they did not like asking people about suicidal thoughts because they were worried that it might make them feel worse.

"We also know from previous studies that discussion of suicide in the media can increase levels of self-harm and suicide," Dr. Crawford noted.

Reduction in Suicidal Thoughts

In this multicenter, single-blind, randomized trial, half of 443 patients who presented to their family practitioner with signs of depression were asked about their health and lifestyle, and half were asked about suicidal thoughts.

The patients lived in north and west London; their mean age was 48.5 years (range, 16 – 92 years), and 137 (30.9%) were male.

Two weeks later, the investigators interviewed all patients again and asked them about their mental health and whether they had felt that life was not worth living during the previous 14 days.

At this point, patients who admitted that they had thoughts that life was not worth living were encouraged to discuss their feelings with healthcare staff and to make use of other resources, such as helplines.

The study showed that asking about suicidal ideation did not increase the likelihood that participants in the study would start to worry that their life was not worth living. The odds of feeling that life was not worth living among patients screened for suicidal ideation compared with those asked about their health and lifestyle was 0.88 (95% confidence interval, 0.66 – 1.18).

The investigators also found that 37 patients (22.3%) reported thinking about taking their life at baseline, but 2 weeks later, just 24 (14.6%) reported that they had this thought.

Unfounded Fear

Dr. Crawford admitted the study has limitations but it also has strengths.

"Among its limitations, it was not large enough to study the impact of these questions in subgroups of people such as young people. Also it was conducted in a relatively deprived inner-city area with high levels of unemployment. We do not know if we would have found similar results in a different type of area," he said.

As for its strengths, "it was a randomized controlled trial and researchers collecting follow-up data were blind to allocation status and so did not know what type of questions people had been asked during the first interview," said Dr. Crawford.

Notwithstanding the limitations, Dr. Crawford believes that fears about asking about suicidal ideation that general physicians might have are not warranted.

"Clinicians should feel more confident about asking people who are depressed if they feel their life is not worth living or have thought about or tried to end their life, as long as these questions are asked in a sensitive manner," he said.

Myth-Busting Research

"This is important news," commented Yeates Conwell, MD, from the University of Rochester School of Dentistry and Medicine in New York.

"There is a lot of mythology out there about suicide. The notion that asking somebody about their suicidal ideas might precipitate something is one of the most prevalent," Dr. Conwell, who was not involved in the research, told Medscape Medical News.

"It is important for family doctors to know that the best evidence, in this case a randomized trial, shows that asking these questions does not cause problems. Rather, doing so brings to light issues for which we have available interventions and helps us reduce suicide-related morbidity and mortality. That is why this study is important."

This study was funded by an educational grant from Imperial College London and supported by St. Mary's Paddington Charitable Trust. Dr. Crawford and Dr. Conwell have disclosed no relevant financial relationships.

Br J Psychiatry. 2011;198:379-384.

    
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