Approaching Suicide as a Public Health Issue
Approaching Suicide as a Public Health Issue
复制标题
将自杀视为一个公共卫生问题
DOI：
10.7326/m14-0914
复制
发表时间：
2014
影响因子：
39.2
通讯作者：
K. Knox
中科院分区：
文献类型：
--
作者：
K. Knox
临床医生普遍认识到自杀是一个主要且日益常见的死亡原因，尤其是中年男性 (1)。然而，许多临床医生不太熟悉自杀作为公共卫生问题的概念 (2)。许多团体已认识到自杀负担是一个重要的公共卫生问题，例如，美国卫生局局长和国家自杀预防行动联盟 2012 年发布的国家自杀预防战略就表明了这一点 (3)。如果我们要减少这一悲剧性且可预防的问题，将临床知识与公共卫生方法相结合至关重要。公共卫生方法认识到，最大的疾病负担可能存在于看似风险最低的人身上。英国流行病学家杰弗里·罗斯 (Geoffrey Rose) 的工作阐释了这一概念，他设想基于人群的预防方法比专注于治疗症状严重的人的简化方法具有更大的影响 (4)。此外，预防自杀的公共卫生方法有助于整合遗传、神经、心理和社会文化因素，以及更广为人知的精神病诊断危险因素和自杀企图史。要了解如何预防自杀，我们必须首先更好地了解使人们面临故意自残风险的因素。为了获得最大的实用性，自杀风险的研究应该来自于对没有确定的精神疾病的人群进行的大规模、纵向的流行病学研究。与此形成鲜明对比的是，我们目前关于预测和保护因素的大部分知识都来自于已知精神病学诊断的人的小型临床样本。此外，我们对自杀风险的了解大部分来自研究，这些研究规模太小，无法检测自杀造成的死亡率差异，而是很大程度上依赖于替代结果，例如自杀意念。现有证据的局限性妨碍了将数据转化为可能对人口水平产生重大影响的循证实践（5）。最近在《年鉴》(Annals) 上发表的一项临床指南 (6) 和本期报道的一项研究 (7) 很重要，因为它们从批判性和互补性的角度解决了自杀预防问题。美国预防服务工作组的临床建议重点关注对未发现精神疾病的青少年、成人和老年人进行初级保健筛查的有效性。 Tsai 及其同事报告了一项针对男性的大型纵向队列研究的一个特殊例子，该研究在 24 年的随访中检验了社会融合与自杀死亡率之间的关系。总之，这些论文为尽管没有精神病学诊断但可能有自杀风险的人的识别和早期干预提供了宝贵的见解。迄今为止，研究还不足以解释为什么男性，尤其是中年男性，特别容易自杀。先前研究的缺点包括缺乏纵向随访、未能衡量社会融合和压力维度指标等因素、过度依赖精神病理学的分类测量以及关注代理结果而不是自杀死亡。蔡英文及其同事为克服这些缺陷做出了值得称赞的尝试。他们的前瞻性研究将自杀作为主要结局，对 34901 名年龄在 40 至 75 岁的男性样本进行了 24 年的随访。医学研究所的两份报告 (8, 9) 强调了解决心理复原力和心理健康对降低自杀风险的重要性。蔡及其同事的研究强烈支持社会融合作为中年及以后男性的重要安全网。该研究的优点之一是用于衡量主要兴趣暴露的方法：社会融合。研究人员使用了7项指数，包括婚姻状况、社交网络规模、接触频率、宗教参与度以及其他社会群体的参与度。广泛的敏感性分析证实，在该样本的 24 年随访中，社会融合与自杀死亡风险降低 2 倍以上相关。从另一个角度来看，美国预防服务工作组审查了现有证据，证明初级保健筛查对普通无症状人群自杀风险的有效性。结论是，这种筛查将识别出高危患者的证据不足，而这些患者原本不会因现有的精神疾病或以前的自杀企图而被识别为高危患者。然而，工作组认识到现有筛查工具的不足，这些工具预测个人在特定时间自杀的能力有限 (6)。报告指出，现有筛查工具目前未涵盖的许多因素都是自杀的潜在风险因素，包括社会孤立、社会经济地位和被欺负的历史。对于这些以及无数其他社会文化因素，我们的基于人口的数据有限。最近的这两篇文章强调，迫切需要更多地了解除精神病学诊断之外的与自杀相关的因素。有了这些知识，就有可能制定有效的临床干预措施、基于社区的计划和自杀筛查计划。对于临床医生、流行病学家和公共卫生科学家来说，合作收集此类知识并制定减轻自杀负担的干预措施仍然是一个充满挑战的机会。
Clinicians generally recognize that suicide is a major and increasingly common cause of death, especially in middle-aged men (1). Less familiar to many clinicians, however, is the concept of suicide as a public health issue (2). Many groups have recognized the burden of suicide as a critical public health concern, as shown by, for example, the 2012 release of the National Strategy for Suicide Prevention by the U.S. Surgeon General and the National Action Alliance for Suicide Prevention (3). Integrating clinical knowledge with a public health approach is essential if we are to reduce this tragic and preventable problem. A public health approach recognizes that the greatest burden of disease may lie in persons who seem to be at lowest risk. This concept is illustrated by the work of the British epidemiologist Geoffrey Rose, who envisioned the greater impact of population-based approaches to prevention than of a reductionist approach focused on treating highly symptomatic persons (4). In addition, a public health approach to suicide prevention facilitates integration of genetic, neurologic, psychological, and sociocultural factors along with the more well-recognized risk factors of psychiatric diagnoses and a history of suicide attempt. To understand how to prevent suicide, we must first better understand factors that put people at risk for intentional self-harm. To be of greatest utility, studies of suicide risk should be derived from large, longitudinal epidemiologic studies in populations of individuals that do not have an identified psychiatric disorder. In stark contrast, much of our current knowledge about predictive and protective factors comes from small clinical samples of persons with a known psychiatric diagnosis. Furthermore, much of what we know about suicide risk comes from studies that were too small to detect differences in mortality due to suicide and instead largely relied on proxy outcomes, such as suicidal ideation. The limitations of available evidence impair translation of data into evidence-based practices that are likely to have substantial impact at the population level (5). A clinical guideline recently published in Annals (6) and a study reported in this issue (7) are important in that they address suicide prevention from critical and complementary perspectives. Clinical recommendations from the U.S. Preventive Services Task Force focus on the effectiveness of primary carebased screening of adolescents, adults, and older adults without an identified psychiatric disorder. Tsai and colleagues report an exceptional example of a large, longitudinal cohort study of men that examined the relationship of social integration and suicide mortality over 24 years of follow-up. Together, these papers provide valuable insight into the identification of and early intervention for persons who may be at risk for suicide despite the absence of a psychiatric diagnosis. To date, research has been insufficient to explain why men, especially during middle age, are particularly vulnerable to taking their own lives. The shortcomings of prior studies include lack of longitudinal follow-up, failure to measure such factors as social integration and dimensional indicators of stress, overreliance on categorical measures of psychopathology, and a focus on proxy outcomes instead of death by suicide. Tsai and colleagues have made a commendable attempt to overcome these deficits. Their prospective study evaluated suicide as the primary outcome in a sample of 34901 men aged 40 to 75 years over 24 years of follow-up. Two reports by the Institute of Medicine (8, 9) underscore the importance of addressing resilience and psychological well-being in reducing risk for suicide. Tsai and colleagues study strongly supports social integration as a critical safety net for men during middle age and beyond. Among the study's strengths was the method used to measure the primary exposure of interest: social integration. The researchers used a 7-item index that included marital status, social network size, frequency of contact, religious participation, and participation in other social groups. Extensive sensitivity analyses confirmed that social integration was associated with a more than 2-fold reduction in risk for death by suicide over 24 years of follow-up in this sample. From an alternative perspective, the U.S. Preventive Services Task Force reviewed the current evidence for the effectiveness of primary carebased screening for suicide risk in a general, asymptomatic population. It concluded that the evidence that such screening will identify at-risk patients who would not have otherwise been identified as high-risk due to an existing psychiatric disorder or previous suicide attempt is insufficient. However, the Task Force recognized the inadequacy of available screening tools, which have limited ability to predict suicide in an individual at a particular time (6). It noted that many factors not currently covered in available screening instruments are potential risk factors for suicide, including social isolation, socioeconomic status, and a history of being bullied. We have limited population-based data for these and myriad other sociocultural factors. These 2 recent articles highlight the dire need to know more about the factors associated with suicide other than psychiatric diagnoses. With such knowledge, it might be possible to develop effective clinical interventions, community-based programs, and screening programs for suicidality. It remains a challenging opportunity for clinicians, epidemiologists, and public health scientists to collaboratively work to gather such knowledge and develop interventions that reduce the burden of suicide.
男性的社会融合和自杀死亡率：针对美国卫生专业人员的 24 年队列研究。
影响因子：
39.2
作者：
Tsai,AlexanderC;Lucas,Michel;Sania,Ayesha;Kim,Daniel;Kawachi,Ichiro
通讯作者：
Kawachi,Ichiro