小美

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　April 15, 2010 — 根據線上發表於4月12日且即將於5月出版之小兒科(Pediatrics)期刊的一篇研究結果，一線照護時進行自殺風險的標準化篩檢，可以偵測出有自殺想法的青少年，而得以在發生致命或嚴重的自殺行為之前，轉介到行為健康照護中心。
　　
　　賓州費城Thomas Jefferson大學的Matthew B. Wintersteen博士寫道，許多協會和聯邦當局呼籲，在小兒一線照護進行憂鬱篩檢，而自殺風險篩檢只是其中一項。就我們所知，這是首次前瞻性檢視標準化自殺風險篩檢對於發現的影響、和小兒一線照護之轉診率的研究。
　　
　　研究目標是，評估在小兒一線照護使用簡短而標準的方式篩檢自殺風險，是否可以改善發現年輕人的自殺意念，維持偵測和轉診的改善率，且可推廣到其他實務。
　　
　　兩個一線照護診所(診所A和診所B)被選為介入組診所，另一個診所(診所C)要求參與研究且願意提供介入。在這三個診所中，醫師們接受偵測自殺風險的簡短訓練，將有關12.0-17.9歲青少年的兩個標準化問題加入現有的電子化病歷社會心理訪談中。在介入試驗中、以及之前一年的同一天，摘錄沒有識別符號的資料，從社工紀錄確認轉診率。
　　
　　這個介入和調查自殺風險的比率加倍有關，整體增加了219% (門診A組的勝算率[OR]為2.04；95% 信心區間為1.56 - 2.51；門診B組為 OR，3.20；95% CI，2.69 - 3.71；門診C組則是OR，1.85；95% CI，1.38 - 2.31。
　　
　　在門診A組中，案例偵測比率增加將近5倍(OR，4.99；95% CI， 4.20 - 5.79)，在運用介入方式之後維持6個月時數據為：OR，4.38；95% CI， 3.74 - 5.02，門診B組(OR，5.46；95% CI，3.36 - 7.56)和門診C組(OR，3.42；95% CI，2.33 - 4.52)也是。這三個門診組中，案例偵測比率增加達392%，有自殺想法之青少年轉診到門診行為健康照護中心的比率，和偵測比率一樣增加。
　　
　　Wintersteen博士寫道，一線照護的自殺風險標準篩檢，可以偵測出有自殺想法的青少年，促使在發生致命或嚴重的自殺行為之前，轉診到行為健康照護中心。
　　
　　研究限制包括，自殺行為想法是根據以前的紀錄，而不一定代表現在的想法；無法確認自殺風險簡短評估訓練的影響。
　　
　　Wintersteen博士結論表示，這篇研究發現及時呼應了美國預防工作小組最近提出的建議，對重度憂鬱異常青年進行例行性篩檢，此外，美國兒童與青少年精神病協會以及美國小兒科協會心智健康工作也聯合發表一篇文章指出，建議在一線照護進行例行性的行為健康篩檢。兩者都指出，若缺乏精神治療追蹤時，篩檢效用有限。
　　
　　美國自殺預防基金會支持這篇研究，Wintersteen博士宣告沒有相關財務關係。
　　
　　Pediatrics. 線上發表於2010年4月12日。


Standardized Screening May Help Identify Suicidal Adolescents

By Laurie Barclay, MD
Medscape Medical News

April 15, 2010 — Standardized screening for suicide risk in primary care can detect adolescents with suicidal ideation, allowing referral to a behavioral healthcare center before a fatal or serious suicide attempt is made, according to the results of a study reported online April 12 and published in the May print issue of Pediatrics.

"Several associations and federal agencies have called for depression screening in pediatric primary care," writes Matthew B. Wintersteen, PhD, from Thomas Jefferson University in Philadelphia, Pennsylvania. "Screening for suicide risk is a natural adjunct to this call....To our knowledge, this is the first study to prospectively examine the impact of standardized screening for suicide risk on detection and referral rates in pediatric primary care."

The goals of the study were to evaluate whether brief standardized screening for suicide risk in pediatric primary care practices could improve detection of youth with suicidal ideation, maintain improved rates of detection and referral, and be duplicated in other practices.

Two primary care clinics (clinic A and clinic B) were selected as intervention clinics, and a third clinic (clinic C) asked about participating in the study and was offered the intervention. At these 3 clinics, physicians underwent brief training in detecting suicide risk, and 2 standardized questions for adolescents aged 12.0 to 17.9 years were added to their existing electronic medical chart psychosocial interview. Data without identifiers were extracted during intervention trials and for the same dates of the preceding year, and referral rates were determined from social work records.

The intervention was associated with doubling of the rates of inquiry about suicide risk, which resulted in a 219% increase overall (clinic A odds ratio [OR], 2.04; 95% confidence interval [CI], 1.56 - 2.51; clinic B OR, 3.20; 95% CI, 2.69 - 3.71; and clinic C OR, 1.85; 95% CI, 1.38 - 2.31).

In clinic A, the rate of case detection increased nearly 5-fold (OR, 4.99; 95% CI, 4.20 - 5.79), was maintained for a 6-month period after the intervention was implemented (OR, 4.38; 95% CI, 3.74 - 5.02), and was replicated in both clinic B (OR, 5.46; 95% CI, 3.36 - 7.56) and clinic C (OR, 3.42; 95% CI, 2.33 - 4.52). Across all 3 clinics, case detection rate increased by 392%. The rate of increase of referral rates of suicidal youth to outpatient behavioral healthcare centers was commensurate to that of the detection rates.

"Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made," Dr. Wintersteen writes.

Limitations of this study include suicidal ideation based on history, not necessarily on present thoughts; and inability to determine the impact of the brief training in suicide risk.

"The findings from this study are particularly timely after the recent recommendation of the US Preventive Services Task Force to routinely screen youth for a major depressive disorder," Dr. Wintersteen concludes. "In addition, the American Academy of Child and Adolescent Psychiatry along with the American Academy of Pediatrics Task Force on Mental Health also released a joint article in which routine behavioral health screening in primary care was recommended....Both reports cautioned against screening when psychotherapy followup was not readily available."

The American Foundation for Suicide Prevention supported this study. Dr. Wintersteen has disclosed no relevant financial relationships.

Pediatrics. Published online April 12, 2010.