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Pharmacologic Approaches to Suicide Prevention. 预防自杀的药物疗法。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.20220076
Sidney Zisook, Isabel Domingues, Jason Compton

Suicide is a leading cause of death that is often preventable. This article reviews the role of medications in treating suicidal behavior and in preventing suicide. For an acute suicidal crisis, ketamine, and perhaps esketamine, are emerging as important tools. For patients with chronic suicidality, clozapine remains the only U.S. Food and Drug Administration (FDA) approved antisuicidal medication, and its use is predominantly for patients with schizophrenia and schizoaffective disorder. An abundance of literature supports the use of lithium among patients with mood disorders, including those with major depressive disorder. Despite the black box warning regarding antidepressants and suicide risk among children, adolescents, and young adults, antidepressants are widely used and remain helpful in reducing suicidal thoughts and behaviors, primarily among patients with mood disorders. Treatment guidelines focus on the importance of optimizing treatment of the psychiatric conditions known to be associated with suicide risk. For patients with these conditions, the authors recommend focusing on suicide as an independent treatment target and using an enhanced medication management strategy that includes maintaining a supportive, nonjudgmental therapeutic relationship; flexibility; collaboration; measurement-based care; consideration of combining medications with nonpharmacologic, evidence-based strategies; and ongoing safety planning.

自杀是导致死亡的主要原因之一,而这通常是可以预防的。本文回顾了药物在治疗自杀行为和预防自杀方面的作用。对于急性自杀危机,氯胺酮,或许还有艾司氯胺酮,正在成为重要的工具。对于有慢性自杀倾向的患者,氯氮平仍然是美国食品和药物管理局(FDA)批准的唯一一种抗自杀药物,主要用于精神分裂症和分裂情感障碍患者。大量文献支持在情绪障碍患者(包括重度抑郁障碍患者)中使用锂盐。尽管关于抗抑郁药和儿童、青少年及年轻成年人自杀风险的黑框警告,抗抑郁药仍被广泛使用,并有助于减少自杀想法和行为,主要是在情绪障碍患者中。治疗指南着重强调了优化治疗已知与自杀风险相关的精神疾病的重要性。对于患有这些疾病的患者,作者建议将自杀作为一个独立的治疗目标,并采用强化的药物管理策略,其中包括保持支持性的、非评判性的治疗关系;灵活性;协作;基于测量的护理;考虑将药物与非药物的循证策略相结合;以及持续的安全规划。
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引用次数: 0
Clinical Considerations for Digital Resources in Care for Patients With Suicidal Ideation. 在护理有自杀倾向的患者时使用数字资源的临床考虑因素。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.20220073
Noy Alon, Sarah Perret, Rebecca Segal, John Torous

Smartphone apps offer accessible new tools that may help prevent suicide and that offer support for individuals with active suicidal ideation. Numerous smartphone apps for mental health conditions exist; however, their functionality is limited, and evidence is nascent. A new generation of apps using smartphone sensors and integrating real-time data on evolving risk offers the potential of more personalized support, but these apps present ethical risks and currently remain more in the research domain than in the clinical domain. Nevertheless, clinicians can use apps to benefit patients. This article outlines practical strategies to select safe and effective apps for the creation of a digital toolkit that can augment suicide prevention and safety plans. By creating a unique digital toolkit for each patient, clinicians can help ensure that the apps selected will be most relevant, engaging, and effective.

智能手机应用程序提供了便捷的新工具,可帮助预防自杀,并为有自杀倾向的人提供支持。目前已有许多针对精神健康状况的智能手机应用程序,但它们的功能有限,而且证据尚不充分。新一代的应用程序使用了智能手机传感器,并整合了有关不断变化的风险的实时数据,为提供更加个性化的支持提供了可能,但这些应用程序存在道德风险,目前仍更多地停留在研究领域而非临床领域。尽管如此,临床医生仍可使用应用程序造福患者。本文概述了选择安全有效的应用程序创建数字工具包的实用策略,该工具包可以增强自杀预防和安全计划。通过为每位患者创建一个独特的数字工具包,临床医生可以帮助确保所选应用程序最相关、最吸引人、最有效。
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引用次数: 0
Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review. 通过循证策略改进自杀预防:系统回顾。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.23021004
J John Mann, Christina A Michel, Randy P Auerbach

Objective: The authors sought to identify scalable evidence-based suicide prevention strategies.

Methods: A search of PubMed and Google Scholar identi- fied 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

Results: Training primary care physicians in depression rec- ognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active out- reach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are under-studied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

Conclusions: Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physi- cian settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.Reprinted from Am J Psychiatry 2021; 178:611-624, with permission from American Psychiatric Association Publishing. Copyright © 2021.

目的作者试图确定可扩展的循证自杀预防策略:在PubMed和Google Scholar上搜索发现了2005年9月至2019年12月期间发表的20234篇文章,其中97篇是以自杀行为或意念为主要结果的随机对照试验,或者是关于限制获得致命手段、使用教育方法以及抗抑郁治疗影响的流行病学研究:结果:对初级保健医生进行抑郁症诊断和治疗方面的培训可预防自杀。对青少年进行有关抑郁症和自杀行为的教育,以及在精神病患者出院后或出现自杀危机时积极向其伸出援手,可预防自杀行为。Meta 分析发现,抗抑郁药物可以预防自杀企图,但个别随机对照试验似乎效力不足。氯胺酮可在数小时内减少自杀意念,但在预防自杀行为方面尚未进行试验。认知行为疗法和辩证行为疗法可预防自杀行为。积极筛查自杀意念或行为的效果并没有被证明比只筛查抑郁症更好。对看门人进行有关青少年自杀行为的教育缺乏有效性。目前还没有关于对看门人进行培训以预防成人自杀行为的随机试验报告。以算法驱动的电子健康记录筛查、基于互联网的筛查和智能手机被动监测来识别高危患者的研究不足。包括枪支在内的手段限制可以预防自杀,但在美国却很少采用,尽管在美国所有自杀事件中有一半使用的是枪支:结论:对全科医生进行培训值得在其他非精神科医生的医疗机构中更广泛地实施和测试。对出院后或出现自杀相关危机的患者进行积极随访应成为常规做法,限制高危人群接触枪支也应得到更广泛的应用。在一些国家,医疗保健系统的综合方法在降低自杀率方面大有可为,但评估每个组成部分带来的益处至关重要。进一步降低自杀率需要评估更新的方法,如电子健康记录衍生算法、基于互联网的筛查方法、氯胺酮对预防自杀未遂的潜在益处以及对急性自杀风险变化的被动监测。版权所有 © 2021。
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引用次数: 0
Ethical Consideration in Dealing With Suicide in Different Populations. 处理不同人群自杀问题时的伦理考虑。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.20220082
Sutanaya Pal, Seetha Ramanathan
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引用次数: 0
Implementing Evidence-Based Suicide Prevention Strategies for Greatest Impact. 实施以证据为基础的自杀预防策略以产生最大影响。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.20220078
Nadine Melhem, Christine Yu Moutier, David A Brent

Suicide remains a leading cause of death in the United States and globally. In this review, epidemiological trends in mortality and suicide risk are presented, with consideration given to the impact of the COVID-19 pandemic. A public health model of suicide prevention with a community and clinical framework, along with advances in scientific discovery, offer new solutions that await widespread implementation. Actionable interventions with evidence for reducing risk for suicidal behavior are presented, including universal and targeted strategies at community, public policy, and clinical levels. Clinical interventions include screening and risk assessment; brief interventions (e.g., safety planning, education, and lethal means counseling) that can be done in primary care, emergency, and behavioral health settings; psychotherapies (cognitive-behavioral, dialectical behavior, mentalization therapy); pharmacotherapy; and systemwide procedures for health care organizations (training, policies, workflow, surveillance of suicide indicators, use of health records for screening, care steps). Suicide prevention strategies must be prioritized and implemented at scale for greatest impact.

自杀仍然是美国乃至全球的主要死亡原因。在本综述中,考虑到COVID-19大流行的影响,介绍了死亡率和自杀风险的流行病学趋势。具有社区和临床框架的自杀预防公共卫生模式,以及科学发现方面的进展,提供了等待广泛实施的新解决办法。提出了具有降低自杀行为风险证据的可操作干预措施,包括社区、公共政策和临床层面的普遍和有针对性的战略。临床干预措施包括筛查和风险评估;可在初级保健、急诊和行为卫生机构进行的简短干预(例如,安全规划、教育和致命手段咨询);心理治疗(认知行为、辩证行为、心理化治疗);药物治疗;以及卫生保健组织的全系统程序(培训、政策、工作流程、自杀指标监测、使用健康记录进行筛查、护理步骤)。必须优先考虑自杀预防战略,并大规模实施,以产生最大影响。
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引用次数: 0
Systems Approach to Suicide Prevention: Strengthening Culture, Practice, and Education. 预防自杀的系统方法:加强文化、实践和教育。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.20220081
Anthony R Pisani, Edwin D Boudreaux

Contemporary approaches to suicide prevention extend beyond an individual's interactions with care providers to seek opportunities for improvement in the wider care system. A systems-based analysis can yield opportunities to improve prevention and recovery across the care continuum. This article uses an example of an individual seeking care in an emergency department to show how a traditional clinical case formulation can be framed in terms of the outer and inner contexts of the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to illuminate the impact of systemic factors on outcomes and to identify opportunities for improvement. Three mutually reinforcing domains (a culture of safety and prevention; best practices, policies, and pathways; and workforce education and development) of a systems approach to suicide prevention are outlined, along with their defining characteristics. A culture of safety and prevention requires engaged, informed leaders who prioritize prevention; lived experience integrated into leadership teams; and adverse events review in a Restorative Just Culture focused on healing and improvement. Best practices, policies, and pathways that promote safety, recovery, and health require codesign of processes and services and evolve through continuous measurement and improvement. To support a culture of safety and prevention, and caring, competent application of policy, organizations benefit from a longitudinal approach to workforce education. This includes a common framework and language; models clinical and lived experience collaboration; and supports continuous learning, as well as onboarding of new staff, rather than following a "one-and-done" approach, so that suicide prevention training remains top of mind across the workforce.

当代预防自杀的方法已经超越了个人与护理提供者之间的互动,而是在更广泛的护理系统中寻求改进的机会。以系统为基础的分析可以为改善整个护理过程中的预防和康复提供机会。本文以一个在急诊科寻求治疗的人为例,说明如何根据 EPIS(探索、准备、实施、维持)框架的外部和内部环境来制定传统的临床病例,以阐明系统因素对治疗结果的影响,并找出改进的机会。本文概述了预防自杀系统方法的三个相辅相成的领域(安全和预防文化;最佳实践、政策和途径;以及劳动力教育和发展)及其定义特征。安全和预防文化要求领导者参与其中,了解情况,将预防工作放在首位;将生活经验融入领导团队;在注重治愈和改善的恢复性正义文化中对不良事件进行审查。促进安全、康复和健康的最佳实践、政策和途径需要对流程和服务进行编码设计,并通过持续的衡量和改进不断发展。为了支持安全和预防文化,以及关爱、称职地执行政策,各组织可从劳动力教育的纵向方法中获益。这包括一个共同的框架和语言;临床和生活经验合作模式;支持持续学习以及新员工入职,而不是遵循 "一劳永逸 "的方法,从而使自杀预防培训始终成为整个员工队伍的首要任务。
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引用次数: 0
Practitioner Review: Treatment for Suicidal and Self-Harming Adolescents-Advances in Suicide Prevention Care. 从业者评论:对有自杀倾向和自残行为的青少年的治疗--预防自杀护理的进展。
Pub Date : 2023-04-01 Epub Date: 2023-04-14 DOI: 10.1176/appi.focus.23021005
Joan Rosenbaum Asarnow, Lars Mehlum

Background: Suicide is a leading cause of death globally in youths, and suicidal behavior and self-harm are major clinical concerns. This article updates the previous practitioner review (2012) with the aims of integrating new research evidence, including that reported in this Special Issue.

Methods: The article reviews scientific evidence related to steps in the care pathway for identifying and treating youths with elevated suicide/self-harm risk, specifically: (a) screening and risk assessment; (b) treatment; and (c) community-level suicide prevention strategies.

Results: Review of current evidence indicates that major advances have been achieved in knowledge regarding clinical and preventive practices for reducing suicide and self-harm risk in adolescents. The evidence supports the value of brief screeners for identifying youths with elevated suicide/self-harm risk and the efficacy of some treatments for suicidal and self-harm behavior. Dialectical behavior therapy currently meets Level 1 criteria (2 independent trials supporting efficacy) as the first well-established treatment for self-harm, and other approaches have shown efficacy in single randomized controlled trials. The effectiveness of some community-based suicide prevention strategies for reducing suicide mortality and suicide attempt rates has been demonstrated.

Conclusions: Current evidence can guide practitioners in delivering effective care for youth suicide/self-harm risk. Treatments and preventive interventions that address the psychosocial environment and enhance the ability of trusted adults to protect and support youths, while also addressing the psychological needs of youths appear to yield the greatest benefits. Although additional research is needed, our current challenge is to do our best to effectively utilize new knowledge to improve care and outcomes in our communities.Reprinted from J Child Psychol Psychiatry 2019; 60:1046-1054, with permission from John Wiley and Sons. Copyright © 2019.

背景:自杀是全球青少年的主要死因,自杀行为和自残是临床关注的主要问题。本文更新了之前的从业人员综述(2012 年),旨在整合新的研究证据,包括本特刊中报道的证据:文章回顾了与识别和治疗自杀/自残风险较高的青少年的护理路径步骤相关的科学证据,具体包括:(a)筛查和风险评估;(b)治疗;以及(c)社区层面的自杀预防策略:对现有证据的审查表明,在降低青少年自杀和自残风险的临床和预防实践方面,我们已经取得了重大进展。有证据表明,简短筛查工具对于识别自杀/自残风险较高的青少年很有价值,而且一些针对自杀和自残行为的治疗方法也很有效。辩证行为疗法目前符合 1 级标准(2 项独立试验支持其疗效),是第一种行之有效的自残治疗方法,其他方法在单项随机对照试验中也显示出了疗效。一些基于社区的自杀预防策略在降低自杀死亡率和自杀未遂率方面的有效性也已得到证实:目前的证据可以指导从业人员为有自杀/自残风险的青少年提供有效的护理。针对社会心理环境、提高可信赖的成年人保护和支持青少年的能力以及满足青少年心理需求的治疗和预防干预措施似乎能产生最大的效益。虽然还需要进行更多的研究,但我们目前面临的挑战是尽最大努力有效利用新知识,改善社区的护理和治疗效果。本文转载自《儿童心理学精神病学杂志》(J Child Psychol Psychiatry 2019; 60:1046-1054),经 John Wiley and Sons 授权转载。版权所有 © 2019。
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引用次数: 0
Emergency Psychiatry: Core Concepts for All Psychiatric Physicians. 急诊精神病学》:所有精神科医生的核心概念》。
Pub Date : 2023-01-01 Epub Date: 2023-01-16 DOI: 10.1176/appi.focus.20220084
Tony Thrasher
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引用次数: 0
Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department. 探究约束使用中的偏差:在急诊科护理躁动病人时减少偏见的四种策略》(Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department)。
Pub Date : 2023-01-01 Epub Date: 2023-01-16 DOI: 10.1176/appi.focus.23022007
Rowen O Jin, Tiffany C Anaebere, Rohini J Haar

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.

躁动是急诊科(ED)的常见病,而且越来越常见。在对种族主义和警察使用武力进行全国性调查之后,本文旨在将这一反思延伸到急诊医学对急性躁动患者的管理中。本文概述了在使用束缚措施时的伦理法律考虑因素以及当前有关医学中隐性偏见的文献,讨论了偏见如何影响对躁动患者的护理。文章从个人、机构和医疗系统层面提出了具体策略,以帮助减轻偏见并改善护理。经 John Wiley & Sons 授权,转载自《Acad Emerg Med 2021; 28:1061-1066》。版权所有 © 2021。
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引用次数: 1
Community-Based Crisis Services, Specialized Crisis Facilities, and Partnerships With Law Enforcement. 以社区为基础的危机服务、专门的危机设施以及与执法部门的合作。
Pub Date : 2023-01-01 Epub Date: 2023-01-16 DOI: 10.1176/appi.focus.20220074
Margaret E Balfour, Scott L Zeller

How a community responds to behavioral health emergencies is both a public health issue and a social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments, boarding for hours or days while awaiting treatment. Such crises also account for a quarter of police shootings and 2 million jail bookings per year, and racism and implicit bias magnify these problems for people of color. Fortunately, the new 988 mental health emergency number compounded with police reform movements have created momentum for building behavioral health crisis response systems that deliver comparable quality and consistency of care as we expect for medical emergencies. This paper provides an overview of the rapidly evolving landscape of crisis services. The authors discuss the role of law enforcement and various approaches to lessening the impact on individuals experiencing behavioral health emergencies, especially for historically marginalized populations. The authors provide an overview of the crisis continuum, including crisis hotlines, mobile teams, observation units, crisis residential programs, and peer wraparound services that can help ensure that linkage to aftercare is successful. The authors also highlight opportunities for psychiatric leadership, advocacy, and strategies for creating a well-coordinated crisis system that meets the needs of the community.

社区如何应对行为健康紧急情况既是一个公共卫生问题,也是一个社会公正问题。遭遇行为健康危机的人往往在急诊室得不到适当的护理,在等待治疗期间要寄宿数小时或数天。这种危机也是每年四分之一的警察枪击案和 200 万次入狱的原因,而种族主义和隐性偏见则放大了有色人种的这些问题。幸运的是,新的 988 心理健康紧急求助号码与警察改革运动相结合,为建立行为健康危机应对系统创造了动力,该系统可提供与我们所期望的医疗急救质量和一致性相当的医疗服务。本文概述了快速发展的危机应对服务。作者讨论了执法部门的作用以及减轻对遭遇行为健康紧急情况的个人(尤其是历史上被边缘化的人群)的影响的各种方法。作者概述了危机处理的连续性,包括危机热线、流动小组、观察室、危机寄宿计划,以及有助于确保成功衔接后续护理的同伴陪伴服务。作者还强调了精神科领导、宣传的机会,以及创建协调良好的危机系统以满足社区需求的策略。
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引用次数: 0
期刊
Focus (American Psychiatric Publishing)
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