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希死念慮

著者: 宮本浩司1) 帝京大学溝口病院 精神科、高津心音メンタルクリニック

著者: 張賢徳2) 帝京大学溝口病院 精神科、医療法人社団清愛会 七生病院

監修: 上島国利 昭和大学

著者校正/監修レビュー済:2021/06/16

概要・推奨   

  1. 精神疾患の罹患は希死念慮のリスクを高める(O)。
  1. 自殺者の9割の精神疾患の診断がつき、うつ病、双極性障害、アルコール・薬物の乱用・依存、統合失調症、パーソナリティ障害で多いと報告されている(O)。
  1. 自殺者の77%が自殺に至る前1年以内にプライマリケア医を受診していたことが示されている(O)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
宮本浩司 : 未申告[2021年]
張賢徳 : 未申告[2021年]
監修:上島国利 : 原稿料(大日本住友製薬)[2021年]

改訂のポイント:
  1. 定期レビューを行い、希死念慮のリスク因子とエビデンスについて加筆修正を行った。

病態・疫学・診察

まとめ  
  1. 希死念慮とは、自らの死を願う気持ちであり、その程度の強弱は幅広い。「ずっと眠りたい」、「消えたい」など消極的に死を意識する心理状態も含まれる。逆に、程度が強く、自殺を明確に意識する場合は自殺念慮と呼ばれる。
  1. 希死念慮が自殺に直結するわけではないが、自殺予防のためには、希死念慮を自殺行動に至るプロセスの「初期症状」と考え、対処すべき対象とする。
  1. 希死念慮に傾聴することは、どの職種でもできる。「希死念慮⇒ただちに精神科へ」という対応ではなく、まず共感的な傾聴を行い、患者の気持ちを和らげる(カタルシス効果)。
  1. 希死念慮の背景にはさまざまな苦境がある。その苦境への着眼が対処の糸口になる。環境調整にはケースワーク、心理的苦悩にはカウンセリングや精神科診察につなげる。
  1. うつ病に限らず精神疾患に罹患している、あるいは疑われる場合には、精神科受診につなげる。
  1. 自殺企図歴のある患者では再企図の可能性が高いので、現在の精神疾患が明らかでなくとも精神科受診につなげる。
精神疾患が明らかな場合  
  1. 精神疾患の罹患は希死念慮のリスクを高める[1]。自殺者の9割に精神疾患の診断がつき、うつ病、双極性障害、アルコール・薬物の乱用・依存、統合失調症、パーソナリティ障害で多いと報告されている[2]。うつ病以外の診断が主診断であっても、自殺時にはうつ状態が併存していることが多い。
  1. うつ病・うつ状態の患者に対しては、自ら希死念慮を訴えなくても、希死念慮について確認する必要がある。

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文献 

著者: Matthew K Nock, Irving Hwang, Nancy Sampson, Ronald C Kessler, Matthias Angermeyer, Annette Beautrais, Guilherme Borges, Evelyn Bromet, Ronny Bruffaerts, Giovanni de Girolamo, Ron de Graaf, Silvia Florescu, Oye Gureje, Josep Maria Haro, Chiyi Hu, Yueqin Huang, Elie G Karam, Norito Kawakami, Viviane Kovess, Daphna Levinson, Jose Posada-Villa, Rajesh Sagar, Toma Tomov, Maria Carmen Viana, David R Williams
雑誌名: PLoS Med. 2009 Aug;6(8):e1000123. doi: 10.1371/journal.pmed.1000123. Epub 2009 Aug 11.
Abstract/Text BACKGROUND: Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
METHODS AND FINDINGS: Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9-8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5-5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
CONCLUSIONS: This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.

PMID 19668361  PLoS Med. 2009 Aug;6(8):e1000123. doi: 10.1371/journal.・・・
著者: José Manoel Bertolote, Alexandra Fleischmann
雑誌名: World Psychiatry. 2002 Oct;1(3):181-5.
Abstract/Text
PMID 16946849  World Psychiatry. 2002 Oct;1(3):181-5.
著者: Jason B Luoma, Catherine E Martin, Jane L Pearson
雑誌名: Am J Psychiatry. 2002 Jun;159(6):909-16. doi: 10.1176/appi.ajp.159.6.909.
Abstract/Text OBJECTIVE: This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide.
METHOD: The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects.
RESULTS: Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults.
CONCLUSIONS: While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.

PMID 12042175  Am J Psychiatry. 2002 Jun;159(6):909-16. doi: 10.1176/a・・・
著者: Wilfred R Pigeon, Todd M Bishop, Kelsey M Krueger
雑誌名: Curr Psychiatry Rep. 2017 Aug;19(8):44. doi: 10.1007/s11920-017-0802-x.
Abstract/Text PURPOSE: We aimed to systematically review recent publications (01/2014-03/2017) with longitudinal designs allowing for the assessment of the prospective risk of insomnia on new onset mental illness in key conditions: anxiety, depression, bipolar disorder, posttraumatic stress disorder, substance use disorders, and suicide.
RECENT FINDINGS: A literature yielded 1859 unique articles meeting search criteria were identified; 16 articles met all selection criteria and reviewed with some studies reporting on more than one mental health outcome. Overall, the review supports the hypothesis that insomnia is a predictor of subsequent mental illness. The evidence is strongest for an insomnia-depression relationship. The new studies identified and reviewed add to a modest number of publications supporting a prospective role of insomnia in new onset mental illness in three areas: anxiety disorders, bipolar disorder, and suicide. The few selected new studies focused on SUD were mixed, and no studies focused on PTSD were identified that met the selection criteria. Treatment of insomnia may also be a preventive mental health strategy.

PMID 28616860  Curr Psychiatry Rep. 2017 Aug;19(8):44. doi: 10.1007/s1・・・
著者: Jessica D Ribeiro, Xieyining Huang, Kathryn R Fox, Joseph C Franklin
雑誌名: Br J Psychiatry. 2018 May;212(5):279-286. doi: 10.1192/bjp.2018.27. Epub 2018 Mar 28.
Abstract/Text BACKGROUND: Many studies have documented robust relationships between depression and hopelessness and subsequent suicidal thoughts and behaviours; however, much weaker and non-significant effects have also been reported. These inconsistencies raise questions about whether and to what degree these factors confer risk for suicidal thoughts and behaviours.AimsThis study aimed to evaluate the magnitude and clinical utility of depression and hopelessness as risk factors for suicide ideation, attempts and death.
METHOD: We conducted a meta-analysis of published studies from 1971 to 31 December 2014 that included at least one longitudinal analysis predicting suicide ideation, attempt or death using any depression or hopelessness variable.
RESULTS: Overall prediction was weaker than anticipated, with weighted mean odds ratios of 1.96 (1.81-2.13) for ideation, 1.63 (1.55-1.72) for attempt and 1.33 (1.18-1.49) for death. Adjusting for publication bias further reduced estimates. Effects generally persisted regardless of sample severity, sample age or follow-up length.
CONCLUSIONS: Several methodological constraints were prominent across studies; addressing these issues would likely be fruitful moving forward.Declaration of interestNone.

PMID 29587888  Br J Psychiatry. 2018 May;212(5):279-286. doi: 10.1192/・・・
著者: A Dumais, A D Lesage, M Alda, G Rouleau, M Dumont, N Chawky, M Roy, J J Mann, C Benkelfat, Gustavo Turecki
雑誌名: Am J Psychiatry. 2005 Nov;162(11):2116-24. doi: 10.1176/appi.ajp.162.11.2116.
Abstract/Text OBJECTIVE: Major depression is a major risk factor for suicide. However, not all individuals with major depression commit suicide. Impulsive and aggressive behaviors have been proposed as risk factors for suicide, but it remains unclear whether their effect on the risk of suicide is at least partly explained by axis I disorders commonly associated with suicide, such as major depression. With a case-control design, a comparison of the level of impulsive and aggressive behaviors and the prevalence of associated psychopathology was carried out with control for the presence of primary psychopathology.
METHOD: One hundred and four male suicide completers who died during an episode of major depression and 74 living depressed male comparison subjects were investigated with proxy-based interviews by using structured diagnostic instruments and personality trait assessments.
RESULTS: The authors found that current (6-month prevalence) alcohol abuse/dependence, current drug abuse/dependence, and cluster B personality disorders increased the risk of suicide in individuals with major depression. Also, higher levels of impulsivity and aggression were associated with suicide. An analysis by age showed that these risk factors were more specific to younger suicide victims (ages 18-40). A multivariate analysis indicated that current alcohol abuse/dependence and cluster B personality disorder were two independent predictors of suicide.
CONCLUSIONS: Impulsive-aggressive personality disorders and alcohol abuse/dependence were two independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie these risk factors. A developmental hypothesis of suicidal behavior, with impulsive and aggressive behaviors as the starting point, is discussed.

PMID 16263852  Am J Psychiatry. 2005 Nov;162(11):2116-24. doi: 10.1176・・・
著者: Ricardo Gusmão, Sónia Quintão, David McDaid, Ella Arensman, Chantal Van Audenhove, Claire Coffey, Airi Värnik, Peeter Värnik, James Coyne, Ulrich Hegerl
雑誌名: PLoS One. 2013;8(6):e66455. doi: 10.1371/journal.pone.0066455. Epub 2013 Jun 19.
Abstract/Text BACKGROUND: Research concerning the association between use of antidepressants and incidence of suicide has yielded inconsistent results and is the subject of considerable controversy. The first aim is to describe trends in the use of antidepressants and rates of suicide in Europe, adjusted for gross domestic product, alcohol consumption, unemployment, and divorce. The second aim is to explore if any observed reduction in the rate of suicide in different European countries preceded the trend for increased use of antidepressants.
METHODS: Data were obtained for 29 European countries between 1980 and 2009. Pearson correlations were used to explore the direction and magnitude of associations. Generalized linear mixed models and Poisson regression distribution were used to clarify the effects of antidepressants on suicide rates, while an autoregressive adjusted model was used to test the interaction between antidepressant utilization and suicide over two time periods: 1980-1994 and 1995-2009.
FINDINGS: An inverse correlation was observed in all countries between recorded Standardised Death Rate (SDR) for suicide and antidepressant Defined Daily Dosage (DDD), with the exception of Portugal. Variability was marked in the association between suicide and alcohol, unemployment and divorce, with countries depicting either a positive or a negative correlation with the SDR for suicide. Every unit increase in DDD of an antidepressant per 1000 people per day, adjusted for these confounding factors, reduces the SDR by 0.088. The correlation between DDD and suicide related SDR was negative in both time periods considered, albeit more pronounced between 1980 and 1994.
CONCLUSIONS: Suicide rates have tended to decrease more in European countries where there has been a greater increase in the use of antidepressants. These findings underline the importance of the appropriate use of antidepressants as part of routine care for people diagnosed with depression, therefore reducing the risk of suicide.

PMID 23840475  PLoS One. 2013;8(6):e66455. doi: 10.1371/journal.pone.0・・・
著者: Atsuo Nakagawa, Michael F Grunebaum, Steven P Ellis, Maria A Oquendo, Haruo Kashima, Robert D Gibbons, J John Mann
雑誌名: J Clin Psychiatry. 2007 Jun;68(6):908-16.
Abstract/Text OBJECTIVE: We examined the relationship of increasing prescription volume of newer antidepressants, introduced in Japan in 1999, to national rates of suicide.
METHOD: The relationship between annual changes in rates of suicide (obtained from the Japanese Ministry of Health, Labor, and Welfare Vital Statistics Database) and prescription volume of the newer antidepressants paroxetine, fluvoxamine, and milnacipran (obtained from the database of IMS Japan K.K.), stratified by gender and age groups, was modeled statistically for the years 1999 through 2003. Effects of unemployment and alcohol consumption and the interaction of gender and age with antidepressant prescribing were assessed.
RESULTS: From 1999 through 2003 in Japan, total antidepressant prescriptions increased 57% among males and 50% among females. Approximately 80% of this increase involved the selective serotonin reuptake inhibitors (SSRIs). To reduce a limitation of ecological analysis, we compared annual change in prescription and suicide rates, which eliminates the effect of long-term (secular) linear trends. We found an inverse association between year-to-year changes in the suicide rate and prescription volume of newer antidepressants (fluvoxamine, paroxetine, and milnacipran) (beta = -1.34, p = .008) and SSRIs specifically (fluvoxamine, paroxetine) (beta = -1.41, p = .019). An increase of 1 defined daily dose of SSRI use/1000 population/day was associated with a 6% decrease in suicide rate. Exploratory analysis suggested a stronger association in males, who experienced a greater increase in antidepressant use. Changes in unemployment and alcohol consumption rates did not explain the association.
CONCLUSION: In Japan during 1999 through 2003, absent long-term linear trend effects, annual increases in prescribing of newer antidepressant medications, mainly SSRIs, were associated with annual decreases in suicide rates, particularly among males.

PMID 17592916  J Clin Psychiatry. 2007 Jun;68(6):908-16.
著者: Carol Coupland, Trevor Hill, Richard Morriss, Antony Arthur, Michael Moore, Julia Hippisley-Cox
雑誌名: BMJ. 2015 Feb 18;350:h517. Epub 2015 Feb 18.
Abstract/Text OBJECTIVE: To assess the associations between different antidepressant treatments and the rates of suicide and attempted suicide or self harm in people with depression.
DESIGN: Cohort study.
SETTING: Patients registered with UK general practices contributing data to the QResearch database.
PARTICIPANTS: 238,963 patients aged 20 to 64 years with a first diagnosis of depression between 1 January 2000 and 31 July 2011, followed up until 1 August 2012.
EXPOSURES: Antidepressant class (tricyclic and related antidepressants, selective serotonin reuptake inhibitors, other antidepressants), dose, and duration of use, and commonly prescribed individual antidepressant drugs. Cox proportional hazards models were used to calculate hazard ratios adjusting for potential confounding variables.
MAIN OUTCOME MEASURES: Suicide and attempted suicide or self harm during follow-up.
RESULTS: During follow-up, 87.7% (n = 209,476) of the cohort received one or more prescriptions for antidepressants. The median duration of treatment was 221 days (interquartile range 79-590 days). During the first five years of follow-up 198 cases of suicide and 5243 cases of attempted suicide or self harm occurred. The difference in suicide rates during periods of treatment with tricyclic and related antidepressants compared with selective serotonin reuptake inhibitors was not significant (adjusted hazard ratio 0.84, 95% confidence interval 0.47 to 1.50), but the suicide rate was significantly increased during periods of treatment with other antidepressants (2.64, 1.74 to 3.99). The hazard ratio for suicide was significantly increased for mirtazapine compared with citalopram (3.70, 2.00 to 6.84). Absolute risks of suicide over one year ranged from 0.02% for amitriptyline to 0.19% for mirtazapine. There was no significant difference in the rate of attempted suicide or self harm with tricyclic antidepressants (0.96, 0.87 to 1.08) compared with selective serotonin reuptake inhibitors, but the rate of attempted suicide or self harm was significantly higher for other antidepressants (1.80, 1.61 to 2.00). The adjusted hazard ratios for attempted suicide or self harm were significantly increased for three of the most commonly prescribed drugs compared with citalopram: venlafaxine (1.85, 1.61 to 2.13), trazodone (1.73, 1.26 to 2.37), and mirtazapine (1.70, 1.44 to 2.02), and significantly reduced for amitriptyline (0.71, 0.59 to 0.85). The absolute risks of attempted suicide or self harm over one year ranged from 1.02% for amitriptyline to 2.96% for venlafaxine. Rates were highest in the first 28 days after starting treatment and remained increased in the first 28 days after stopping treatment.
CONCLUSION: Rates of suicide and attempted suicide or self harm were similar during periods of treatment with selective serotonin reuptake inhibitors and tricyclic and related antidepressants. Mirtazapine, venlafaxine, and trazodone were associated with the highest rates of suicide and attempted suicide or self harm, but the number of suicide events was small leading to imprecise estimates. As this is an observational study the findings may reflect indication biases and residual confounding from severity of depression and differing characteristics of patients prescribed these drugs. The increased rates in the first 28 days of starting and stopping antidepressants emphasise the need for careful monitoring of patients during these periods.

© Coupland et al 2015.
PMID 25693810  BMJ. 2015 Feb 18;350:h517. Epub 2015 Feb 18.
著者: Mark Zimmerman, Janine N Galione, Naureen Attiullah, Michael Friedman, Cristina Toba, Daniela A Boerescu, Moataz Ragheb
雑誌名: J Clin Psychiatry. 2010 Apr;71(4):484-90. doi: 10.4088/JCP.08m04978blu.
Abstract/Text OBJECTIVE: The presence of medication side effects is one of the most frequent reasons depressed patients discontinue medication, and premature discontinuation of medication is associated with poorer outcome in the treatment of depression. Despite the clinical importance of detecting side effects, few studies have examined the adequacy of their detection and documentation by clinicians. We are not aware of any studies comparing psychiatrists' clinical assessments to a standardized side effects checklist in depressed patients receiving ongoing treatment in clinical practice. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to test the hypothesis that fewer side effects would be recorded by psychiatrists in their patients' charts compared to the number reported by patients on a side effects checklist.
METHOD: Three hundred depressed outpatients (diagnosed according to DSM-IV criteria) in ongoing treatment completed a self-administered version of the Toronto Side Effects Scale (TSES). The patients rated the frequency of each of the 31 side effects and the degree of trouble caused by them. A research assistant reviewed patients' charts to extract side effects information recorded by the treating psychiatrist. The study was conducted from June 2008 to July 2008.
RESULTS: The mean number of side effects reported by the patients on the TSES was 20 times higher than the number recorded by the psychiatrists (P < .01). When the self-reported side effects were limited to frequently occurring or very bothersome side effects, the rate was still 2 to 3 times higher (P < .01).
CONCLUSIONS: Psychiatrists may not be aware of most side effects experienced by psychiatric outpatients receiving ongoing pharmacologic treatment for depression.

Copyright 2010 Physicians Postgraduate Press, Inc.
PMID 20409445  J Clin Psychiatry. 2010 Apr;71(4):484-90. doi: 10.4088/・・・
著者: D Wasserman, Z Rihmer, D Rujescu, M Sarchiapone, M Sokolowski, D Titelman, G Zalsman, Z Zemishlany, V Carli, European Psychiatric Association
雑誌名: Eur Psychiatry. 2012 Feb;27(2):129-41. doi: 10.1016/j.eurpsy.2011.06.003. Epub 2011 Dec 1.
Abstract/Text UNLABELLED: Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. SUICIDAL CRISIS: Acute intervention should start immediately in order to keep the patient alive.
DIAGNOSIS: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.
TREATMENT: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT TEAM: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FAMILY: The suicidal person independently of age should always be motivated to involve family in the treatment. SOCIAL SUPPORT: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.
SAFETY: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. TRAINING OF PERSONNEL: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Copyright © 2011 Elsevier Masson SAS. All rights reserved.
PMID 22137775  Eur Psychiatry. 2012 Feb;27(2):129-41. doi: 10.1016/j.e・・・
著者: Andrea Cipriani, Keith Hawton, Sarah Stockton, John R Geddes
雑誌名: BMJ. 2013 Jun 27;346:f3646. Epub 2013 Jun 27.
Abstract/Text OBJECTIVE: To assess whether lithium has a specific preventive effect for suicide and self harm in people with unipolar and bipolar mood disorders.
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Medline, Embase, CINAHL, PsycINFO, CENTRAL, web based clinical trial registries, major textbooks, authors of important papers and other experts in the discipline, and websites of pharmaceutical companies that manufacture lithium or the comparator drugs (up to January 2013).
INCLUSION CRITERIA: Randomised controlled trials comparing lithium with placebo or active drugs in long term treatment for mood disorders.
REVIEW METHODS: Two reviewers assessed studies for inclusion and risk of bias and extracted data. The main outcomes were the number of people who completed suicide, engaged in deliberate self harm, and died from any cause.
RESULTS: 48 randomised controlled trials (6674 participants, 15 comparisons) were included. Lithium was more effective than placebo in reducing the number of suicides (odds ratio 0.13, 95% confidence interval 0.03 to 0.66) and deaths from any cause (0.38, 0.15 to 0.95). No clear benefits were observed for lithium compared with placebo in preventing deliberate self harm (0.60, 0.27 to 1.32). In unipolar depression, lithium was associated with a reduced risk of suicide (0.36, 0.13 to 0.98) and also the number of total deaths (0.13, 0.02 to 0.76) compared with placebo. When lithium was compared with each active individual treatment a statistically significant difference was found only with carbamazepine for deliberate self harm. Lithium tended to be generally better than the other active comparators, with small statistical variation between the results.
CONCLUSIONS: Lithium is an effective treatment for reducing the risk of suicide in people with mood disorders. Lithium may exert its antisuicidal effects by reducing relapse of mood disorder, but additional mechanisms should also be considered because there is some evidence that lithium decreases aggression and possibly impulsivity, which might be another mechanism mediating the antisuicidal effect.

PMID 23814104  BMJ. 2013 Jun 27;346:f3646. Epub 2013 Jun 27.
著者: Marc Stone, Thomas Laughren, M Lisa Jones, Mark Levenson, P Chris Holland, Alice Hughes, Tarek A Hammad, Robert Temple, George Rochester
雑誌名: BMJ. 2009 Aug 11;339:b2880. Epub 2009 Aug 11.
Abstract/Text OBJECTIVE: To examine the risk of suicidal behaviour within clinical trials of antidepressants in adults.
DESIGN: Meta-analysis of 372 double blind randomised placebo controlled trials.
SETTING: Drug development programmes for any indication in adults.
PARTICIPANTS: 99 231 adults assigned to antidepressants or placebo. Median age was 42 and 63.1% were women. Indications for treatment were major depression (45.6%), other depression (4.6%), other psychiatric disorders (27.6%), and non-psychiatric disorders (22.2%).
MAIN OUTCOME MEASURES: Suicidal behaviour (completed suicide, attempted suicide, or preparatory acts) and ideation.
RESULTS: For participants with non-psychiatric indications, suicidal behaviour and ideation were extremely rare. For those with psychiatric indications, risk was associated with age. For suicidal behaviour or ideation and for suicidal behaviour only, the respective odds ratios were 1.62 (95% confidence interval 0.97 to 2.71) and 2.30 (1.04 to 5.09) for participants aged <25, 0.79 (0.64 to 0.98) and 0.87 (0.58 to 1.29) for those aged 25-64, and 0.37 (0.18 to 0.76) and 0.06 (0.01 to 0.58) for those aged >or=65. When age was modelled as a continuous variable, the odds ratio for suicidal behaviour or ideation declined at a rate of 2.6% per year of age (-3.9% to -1.3%, P=0.0001) and the odds ratio for suicidal behaviour declined at a rate of 4.6% per year of age (-7.4% to -1.8%, P=0.001).
CONCLUSIONS: Risk of suicidality associated with use of antidepressants is strongly age dependent. Compared with placebo, the increased risk for suicidality and suicidal behaviour among adults under 25 approaches that seen in children and adolescents. The net effect seems to be neutral on suicidal behaviour but possibly protective for suicidal ideation in adults aged 25-64 and to reduce the risk of both suicidality and suicidal behaviour in those aged >or=65.

PMID 19671933  BMJ. 2009 Aug 11;339:b2880. Epub 2009 Aug 11.
著者: Christine Y Lu, Fang Zhang, Matthew D Lakoma, Jeanne M Madden, Donna Rusinak, Robert B Penfold, Gregory Simon, Brian K Ahmedani, Gregory Clarke, Enid M Hunkeler, Beth Waitzfelder, Ashli Owen-Smith, Marsha A Raebel, Rebecca Rossom, Karen J Coleman, Laurel A Copeland, Stephen B Soumerai
雑誌名: BMJ. 2014 Jun 18;348:g3596. Epub 2014 Jun 18.
Abstract/Text OBJECTIVE: To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people.
DESIGN: Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends.
SETTING: Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network.
PARTICIPANTS: Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million).
MAIN OUTCOME MEASURES: Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides.
RESULTS: Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were -31.0% (95% confidence interval -33.0% to -29.0%) among adolescents, -24.3% (-25.4% to -23.2%) among young adults, and -14.5% (-16.0% to -12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100,000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, -6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100,000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group.
CONCLUSIONS: Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.

© Lu et al 2014.
PMID 24942789  BMJ. 2014 Jun 18;348:g3596. Epub 2014 Jun 18.
著者: Maciej Zygo, Beata Pawłowska, Emilia Potembska, Piotr Dreher, Lucyna Kapka-Skrzypczak
雑誌名: Ann Agric Environ Med. 2019 Jun 17;26(2):329-336. doi: 10.26444/aaem/93817. Epub 2018 Aug 24.
Abstract/Text OBJECTIVE: The aim of this study was to assess the prevalence of suicidal thoughts, tendencies and suicide attempts in young people. An attempt was also made to identify factors which, according to those young people, contributed to their suicide attempts.
MATERIAL AND METHODS: The study involved 5,685 individuals aged 13-19 years. The participants were surveyed using an inquiry form designed by the study authors.
RESULTS: Suicidal behaviour in adolescents correlates with the female gender, intake of psychoactive substances, running away from home, being raised in a single-parent family, addiction of family members to alcohol, and experiences of violence.
CONCLUSIONS: 1) Suicidal ideation was reported by 24.66%, suicidal plans - by 15.55%, and suicide attempts - by 4.37% of the adolescents studied. 2) Girls were significantly more likely to attempt suicide out of a sense of helplessness, loneliness, rejection and guilt, as well as conflicts with parents and peers. Boys were significantly more likely than girls to attempt suicide as a result of pressure from peers or cyber acquaintances. 3) Suicide attempts were significantly more common among girls than boys between the ages of 13-19, and significantly more common among young people living in urban areas than those living in the countryside. 4) Significantly more young people who reported suicidal thoughts and plans and suicide attempts than those not reporting such experiences were raised in single-parent families. 5) Compared with non-suicidal controls, young people who admitted to having suicidal thoughts and plans and to having attempted suicide, were significantly more likely to report alcohol abuse by parents and experiences of psychological and physical violence from family members.

PMID 31232067  Ann Agric Environ Med. 2019 Jun 17;26(2):329-336. doi: ・・・
著者: D M Fergusson, A L Beautrais, L J Horwood
雑誌名: Psychol Med. 2003 Jan;33(1):61-73.
Abstract/Text BACKGROUND: We aimed to examine factors that influence vulnerability/resiliency of depressed young people to suicidal ideation and suicide attempt.
METHOD: Data were gathered during a 21-year longitudinal study of a birth cohort of 1,265 New Zealand young people. Measures included: suicide attempt; suicidal ideation; major depression; childhood, family, individual and peer factors.
RESULTS: Young people who developed major depression had increased rates of suicidal ideation (OR = 54: 95% CI 4.5-6.6) and suicide attempt (OR = 12.1; 95% CI 7.9-18.5). However, the majority of depressed young people did not develop suicidal ideation or make suicide attempts, suggesting that additional factors influence vulnerability or resiliency to suicidal responses. Factors influencing resiliency/vulnerability to suicidal responses included: family history of suicide; childhood sexual abuse; neuroticism; novelty seeking; self-esteem; peer affiliations; and school achievement. These factors operated in the same way to influence vulnerability/resiliency among those depressed and those not depressed.
CONCLUSIONS: Vulnerability/resiliency to suicidal responses among those depressed (and those not depressed) is influenced by an accumulation of factors including: family history of suicide, childhood sexual abuse, personality factors, peer affiliations and school success. Positive configurations of these factors confer increased resiliency, whereas negative configurations increase vulnerability.

PMID 12537037  Psychol Med. 2003 Jan;33(1):61-73.
著者: David N Juurlink, Muhammad M Mamdani, Alexander Kopp, Donald A Redelmeier
雑誌名: Am J Psychiatry. 2006 May;163(5):813-21. doi: 10.1176/appi.ajp.163.5.813.
Abstract/Text OBJECTIVE: The authors explored the relationship between the initiation of therapy with selective serotonin reuptake inhibitor (SSRI) antidepressants and completed suicide in older patients.
METHOD: The authors linked population-based coroner's records with patient-level prescription data, physician billing claims, and hospitalization data for more than 1.2 million Ontario residents 66 years of age and older from 1992 to 2000. For each suicide case, four closely matched comparison subjects were selected using propensity score methods. The authors determined the odds ratio for suicide with SSRIs versus other antidepressant treatment, calculated at discrete monthly intervals from the start of treatment.
RESULTS: Of 1,329 suicide cases, 1,138 (86%) were each fully matched to four comparison subjects using propensity scores. During the first month of therapy, SSRI antidepressants were associated with a nearly fivefold higher risk of completed suicide than other antidepressants (adjusted odds ratio: 4.8, 95% confidence interval=1.9-12.2). The risk was independent of a recent diagnosis of depression or the receipt of psychiatric care, and suicides of a violent nature were distinctly more common during SSRI therapy. Numerous sensitivity analyses revealed consistent results. No disproportionate suicide risk was seen during the second and subsequent months of treatment with SSRI antidepressants, and the absolute risk of suicide with all antidepressants was low.
CONCLUSIONS: Initiation of SSRI therapy is associated with an increased risk of suicide during the first month of therapy compared with other antidepressants. The absolute risk is low, suggesting that an idiosyncratic response to these agents may provoke suicide in a vulnerable subgroup of patients.

PMID 16648321  Am J Psychiatry. 2006 May;163(5):813-21. doi: 10.1176/a・・・
著者: J John Mann, Alan Apter, Jose Bertolote, Annette Beautrais, Dianne Currier, Ann Haas, Ulrich Hegerl, Jouko Lonnqvist, Kevin Malone, Andrej Marusic, Lars Mehlum, George Patton, Michael Phillips, Wolfgang Rutz, Zoltan Rihmer, Armin Schmidtke, David Shaffer, Morton Silverman, Yoshitomo Takahashi, Airi Varnik, Danuta Wasserman, Paul Yip, Herbert Hendin
雑誌名: JAMA. 2005 Oct 26;294(16):2064-74. doi: 10.1001/jama.294.16.2064.
Abstract/Text CONTEXT: In 2002, an estimated 877,000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.
OBJECTIVES: To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.
DATA SOURCES AND STUDY SELECTION: Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.
DATA EXTRACTION: Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.
DATA SYNTHESIS: Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.
CONCLUSIONS: Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.

PMID 16249421  JAMA. 2005 Oct 26;294(16):2064-74. doi: 10.1001/jama.29・・・

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