Psychiatry (Abingdon, England)最新文献

Suicide is a major cause of death across the world. Self-harm refers to a deliberate non-fatal act, whether physical, drug overdose, or poisoning, carried out in the knowledge that it is potentially harmful. Self-harm is strongly associated with the risk of suicide but is an important public health problem in its own right. The epidemiology of suicide and self-harm is changing. Suicide in England and Wales is becoming less common, but rates for young men have doubled in the last 20 years. With respect to self-harm, paracetamol overdoses have decreased but alcohol misuse has increased. In most centres, almost as many men as women now present with self-harm. Risk factors for suicide and self-harm overlap to an extent, but the clinical prediction of these behaviours is difficult because they are comparatively rare outcomes. Two sets of guidelines on the management of self-harm have been published recently. They provide a consensus view of best practice, but the evidence base for them is weak. The National Suicide Prevention Strategy for England suggests both high-risk and population-based measures to reduce the rate of suicide. Recent work suggests the most effective strategies might involve restricting access to lethal methods of suicide and educating physicians to recognize and treat depression.

Effective intervention following self-harm is vital because of the strong link between self-harm and suicide. Unfortunately, services for people who self-harm have been poor in the UK and elsewhere. In 2004, the National Institute for Health and Clinical Excellence issued a guideline setting out clear standards for care following self-harm, many of which are included in this article. Whether this guideline has led to much needed improvements in care is not clear; there are few published experiences concerning implementation of the guidance but some studies suggest that care continues to be unsatisfactory. The barriers to implementation of self-harm guidelines are not clear, but the lack of definitive research evidence for effective treatments is a potential candidate. Several systematic reviews have failed to demonstrate a statistically significant reduction in fatal or non-fatal repetition following intervention after self-harm. Recent studies have, however, shown clear benefits for some psychological therapies – in particular for cognitive behavioural therapy with a problem-solving element. Promising results have also been demonstrated for some brief interventions designed to encourage uptake of aftercare following self-harm. This article sets out a little of the evidence for these potentially beneficial interventions, including recent developments in research evidence and implications for future research.

Around 100 studies have been conducted to examine the ‘Werther effect’ – the phenomenon whereby there is an increased rate of completed or attempted suicide following the depiction of an individual’s suicide in the media. These ‘media influence studies’ provide strong evidence for the existence of the Werther effect in the news media, and equivocal evidence for its existence in the entertainment media. Having established this, there is now a need to complement these media influence studies with inter-related studies that draw on approaches from a range of disciplines, particularly that of communication. The studies can be thought of as investigating the full spectrum of news and entertainment media processes and content, from how suicide stories are produced (news/entertainment production studies), to what information they contain and how this is framed (content analysis studies), to how this information is received and perceived (audience reception studies). This will assist in explicating the mechanisms by which the Werther effect might operate, and in designing and evaluating interventions to improve the practices of news and entertainment media professionals.

Adolescent suicidal behaviour is a significant public health problem presenting complex challenges to Health and Welfare professionals, which, in some cases, may continue from adolescence into adulthood. Severe and continuing depression, in particular, may serve as one of a number of markers for subsequent, adverse adult outcomes. A comprehensive psycho-social assessment is crucial to identifying and modifying the individual, familial, peer group and wider social contexts in which the behaviour occurs, and helps in formulating strategies for successful therapeutic intervention. As many suicidal adolescents live with their families, and are physically and economically dependent upon their parents, therapeutic techniques that use the family context as a platform from which to explore the stresses and strains within roles and relationships, as well as the family’s positive accomplishments, seem to offer the best chances of success. The principles of managing suicidal behaviour in adolescents, the main clinical procedures, and the evidence base for their efficacy are described here.

Physician-assisted suicide (PAS) is the death of an individual that occurs as a result of deliberate, purposive actions taken by that individual, with the assistance of a physician. In the UK, assisting with the death of another individual is illegal, but other parts of the world, such as the state of Oregon in the USA, have laws that permit PAS in certain circumstances. In the Netherlands, PAS may be provided for either physical or psychiatric illness, although requests for PAS emanating from psychiatric practice rarely tend to be granted. PAS, especially in the context of psychiatric illness, raises a range of clinical, ethical, and legal issues for patients, families, healthcare providers. and society at large. Even in jurisdictions where PAS is not provided on the grounds of psychiatric illness alone, there is a range of other ways in which the issues surrounding PAS may come to the attention of psychiatrists and mental health teams. These include: requests to provide mental health care to individuals with terminal physical illness, who may or may not request PAS; requests to assess the capacity or capability of individuals with terminal physical illness who request PAS; and requests to assess, support, or treat families or staff members who have had involvement with PAS. There are important issues that merit close attention and point to a strong need for enhanced psychiatric liaison with terminal care providers.

Suicide is one of the leading causes of death globally. Suicide prevention has become a policy priority in many countries. Some countries have implemented national suicide prevention strategies, in line with guidance from the United Nations and the World Health Organization. However, there are still several issues that require further attention in relation to suicide prevention strategies. First, although a growing number of countries have adopted national suicide prevention strategies, suicide prevention is still not a health priority globally. Second, there is an ongoing debate regarding the efficacy and effectiveness of individual interventions. Although evidence on interventions from ‘gold standard’ studies (e.g. randomized controlled trials) is desirable, this is often not achievable. Using the best available evidence is a pragmatic approach to the development of suicide prevention strategies. Third, best practice is informed by evaluating what does and does not work. This requires an evaluation of both the efficacy of specific interventions and the effectiveness of suicide prevention strategies as health policy initiatives. A focus on international evaluation data would help to develop global understanding of best practice in relation to suicide prevention.

Since earliest recorded times people have attempted and completed suicide. The reasons and methods of suicide show variations across cultures. UK censuses carried out in 2001 revealed that the proportion of the UK population belonging to a non-white minority ethnic group increased, from 3 million to 4.6 million (or 7.9% of the total UK population). This population is diverse in terms of age, education and occupation. Based on available research over the years, an increase in number of suicides, particularly among Asians, has been reported. Social and cultural factors, mainly social integration and religion, play an important part in determining varying rates of suicide. Cross-sectional surveys suggest that factors to do with people's attempts to commit suicide relate to both their home culture and the culture of the host country – ‘acculturation stress’. This may increase the likelihood of attempted suicide. Committing suicide by burning, poisoning and using pesticides are common in female migrants. Despite a comparatively high prevalence of depression, self-harm and suicide, there is a lack of treatment evidence for these ethnic minority groups, which results in a delay in help-seeking and in accessibility and awareness of pathways of care. Issues that are related to the person's sociocultural background should be examined in particular while assessing for suicide risk. Additionally, there is a need to look at risk and protective factors in these ethnic groups, which can guide us in developing culturally sensitive interventions.

Patients with mental illness are at a greatly increased risk of suicide. Approximately 90% of those who die by suicide are suffering from a psychiatric disorder at the time of death. The relationship between mental illness and psychiatric disorder can be investigated by the retrospective collection of detailed information from interviews with informants (psychological autopsy study) or by following up those with mental illness and recording the incidence of suicide (cohort study). Affective disorder is probably associated with the greatest increase in suicide risk. Risk factors for suicide may vary from diagnosis to diagnosis, between age groups, by treatment setting, and by country. Much of what we know about suicide in the mentally ill in the UK is based on data collected for an ongoing national clinical survey (the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness). Patients who die by suicide while in-patients or shortly after discharge from hospital may be a particularly important group because the circumstances of their death could highlight deficiencies in service provision. Rates of suicide among psychiatric in-patients in the UK are falling. The rigorous clinical assessment and treatment of mental disorder is a useful starting point for reducing suicide in the mentally ill, but the evidence base for this is not strong. This is partly because suicide is a rare event. General strategies for suicide prevention and specific strategies to reduce suicide in those in mental health contact are both likely to be important.

Suicide in prison is a major concern. Previous research showed that the factors associated with prison suicide were being white, male, and on remand. The most common method was asphyxiation, and around half of the suicides occurred in the first month of imprisonment. Most individuals had a history of drug and/or alcohol misuse, had received a psychiatric diagnosis at reception into prison, and several prisoners had secondary diagnoses, suggesting complex mental health needs. The current prison suicide prevention policy aims to monitor risk and plan the care of at-risk individuals using the Assessment, Care in Custody, Teamwork (ACCT) plan, which was fully implemented across the whole prison estate in 2007. The ACCT plan ensures a fast first response and the provision of flexible individual care. It is supported by improved staff training in assessing and understanding at-risk prisoners. The recent changes to policies regarding deaths in custody may influence a reduction in rates of suicide. As these changes have been fully implemented only relatively recently, it may be some time before their impact is reflected in the rates.

The ability of health professionals and other professionals in contact with people at risk of suicide to assess and respond appropriately to suicide risk is central to any public health programme to reduce suicide in the local population. The sharing of similar concepts concerning suicide risk is essential if services staffed by different professionals from different agencies are to communicate effectively and respond appropriately to an individual risk of suicide. This contribution outlines the clinical assessment and management of suicide risk in an individual (whatever their sociodemographic background or diagnosis), outlining factors that make the risk of suicide (as opposed to self-harm or mental illness) more or less likely. The assessment of a person who has recently self-harmed is also covered. Immediate management of suicide is outlined, ranging from how to conduct the interview, releasing emotion, specific approaches to bolster self-esteem and hopefulness, ensuring safety, and providing support through family and professionals. A categorization of risk, used successfully in studies of the mass training of health professionals to assess and manage patients at risk of suicide (Skills Training on Risk Management (STORM) studies), is offered, ranging from low to very high risk. The level of risk assessed is allied to a clear action plan for each category of risk. In this way staff will know what the management implications are in terms of managing suicide risk (but not other clinical needs) based on the assessment of category of risk. Finally, the issue of acquiring these clinical skills is discussed briefly.