suicide in schizophrenia

Stephen Rush，医学博士，临床精神病学副教授

According to the National Institutes of Mental Health (NIMH) in 2017, 10.6 million adults in the United States had serious thoughts of committing suicide, 2.8 million made suicide plans, 1.3 million attempted suicide, and 47,173 died by suicide.  The World Health Organization estimates that 1 million people across the word die by suicide each year at a rate of 3 people every 2 minutes.

Death by suicide in those with schizophrenia occurs at a rate much higher than that of the general population, sometimes reported as high as 13,000 per 100,000 people with this disorder compared to 13 per 100,000 in the general population.  It is the largest cause of premature death in this population.  The risk of death by suicide is highest in the first 2 years after the onset of schizophrenia and occurs more often in males, those with co-occurring depression and substance use disorders and those with a history of suicide attempts.  Often, the focus of treatment in schizophrenia is reduction in hallucinations and delusions, but clearly, an important part of any treatment plan involves suicide prevention strategies.

Prevention of suicide in schizophrenia requires breaking down barriers around the stigma of mental illness and bringing discussions of this topic into the light, whether with clinicians, family members, or support groups.  This is a challenging task given the stigma that already exists, even amongst those affected by this brain disorder.  It has been reported that most people who commit suicide give definite warnings about their intentions and often do so in ample time before an attempt.  Additionally, a majority of people who are suicidal are ambivalent about death.  This contradicts stigma that suicide occurs in people who never discuss it, without warning and who are intent on ending their lives.  The high risk of suicide in persons with schizophrenia mandates that we must discuss this topic openly, without bias and without fear of negative consequences.  Increased awareness of suicidal thinking is, in fact, associated with decreasing the risk of completed suicide.

普遍的预防策略必须包括通过媒体渠道传播准确的信息，消除不准确和有偏见的信息，这些信息会使有自杀倾向的个人边缘化。限制使用高度致命的自杀手段（如枪支）已被证明可以减少自杀的发生率，并且要求我们作为一个社会，提倡保护我们弱势公民的法律法规，即使面对来自的尖锐批评反对。

Selective strategies must target those at risk for suicide and require broad screening of these populations and having frank and open discussions about suicide.  We must educate and train all members of society to manage issues of suicide in the same vein as interventions such as cardiopulmonary resuscitation (CPR), a widely known treatment for cardiac arrest with education provided in many sectors of society not limited to health care professionals.  Imagine if raising suicide awareness is established as a requirement in the same way various occupations and activities require CPR training and what this could do to reduce completed suicide.

涉及精神分裂症患者的个体策略必须包括家庭、社区和医生的参与。必须让精神科医生了解氯氮平在降低精神分裂症患者自杀风险方面的明显益处（Meltzer 等人，2003 年），因为研究表明这种治疗方法未被广泛利用。社区合作，其中多学科团队可以为精神分裂症患者提供一系列支持，例如积极的社区治疗 (ACT) 应该成为护理标准，并且更容易为社会各界所接受。家庭教育、社交技能培训和认知行为治疗，如果所有患者都能轻松获得，无论保险和支付能力如何，同样会对预防自杀产生重大影响。

总之，作为一个社会，我们必须认识到我们社区中患有精神分裂症的人自杀的高风险是预防的第一步。我们必须减少围绕这种脑部疾病和自杀的耻辱感，并注意风险因素。我们必须提倡立法和医疗改革。或许最重要的是，我们必须作为一个社区行动起来，为我们这部分人口提供支持，并增加获得有效护理的机会。

参考

精神病院住院后青少年及时门诊心理健康服务与自杀死亡风险的关联。 丰塔内拉等； JAMA 网络公开赛。 2020；3(8)：e2012887。

氯氮平治疗精神分裂症的自杀倾向：国际自杀预防试验 (InterSePT)。 梅尔策等；国际自杀预防试验研究小组。 Arch Gen 精神病学。 2003. 一月;60(1):82-91

精神分裂症谱系障碍诊断时的自杀预测因素：一项在加拿大安大略省进行的为期 20 年的总人口研究. Zaheer 等人（出版中）； Schizophr 水库 https://doi.org/10.1016/j.schres.2020.04.025

预防自杀.谢尔，L. QJM。 2004 年 10 月；97(10)：677-680。

精神分裂症治疗中对疾病和自杀风险的认识：国际自杀预防试验的结果。 资产阶级 M 等人。是。 J精神病学。 2004. 161:1494-1496

管理精神分裂症患者的自杀风险。  Kasckow J、Felmet K 和 Zisook S. CNS 药物。 2011;25(2): 129-143

自杀。 （2020 年 9 月）。取自 https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154969