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研究生:鍾其祥
研究生(外文):Chung, Chi-Hsiang
論文名稱:2000-2008年臺灣重複自殺住院傷患長期追蹤研究
論文名稱(外文):A Nationwide, Population-based, Long-term Follow-up Study of Repeating Suicide Inpatients in Taiwan From 2000 to 2008
指導教授:簡戊鑑簡戊鑑引用關係
指導教授(外文):Chien, Wu-Chien
口試委員:高森永簡戊鑑楊聰財白璐李美璇
口試委員(外文):Kao, SenyongChien, Wu-ChienYang, Tsung-TsairPai, LuLee, Meei-Shyuan
口試日期:2012-10-20
學位類別:博士
校院名稱:國防醫學院
系所名稱:生命科學研究所
學門:生命科學學門
學類:生物學類
論文種類:學術論文
論文出版年:2012
畢業學年度:101
語文別:中文
論文頁數:181
中文關鍵詞:自殺重複自殺追蹤全民健保學術研究資料庫
外文關鍵詞:suiciderepeated suicidefollow-upNational Health Insurance Research Database (NHIRD)
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背景:
過去關於重複自殺追蹤研究指出,一年內重複自殺累積風險約為5.7%-15%、重複自殺死亡比例約為0.5%-2%,女性是重複自殺的高風險族群。然而,先前研究有樣本數太少(少於200人)、追蹤時間不夠長(少於2年)、未控制身體與心理疾患、未探討性別與自殺方法是否有交互作用等缺點,此外針對亞洲地區的研究也很少。

目的:
計算自殺後不同追蹤時間點(三個月、六個月、一年、二年、三年、四年、五年、六年、七年與八年)的重複自殺累積風險與重複自殺死亡比例,找出重複自殺影響因子與重複自殺住院死亡風險因子,並探討性別與自殺方法間是否有交互作用。

方法:
本研究使用全民健保學術研究資料庫,選取2000-2007年間自殺住院者的資料,追蹤其三個月、六個月、一年、二年、三年、四年、五年、六年、七年與八年內重複自殺住院累積風險與重複自殺死亡比例,追蹤時間至2008年12月31日。本研究使用negative binomial regression來找出重複自殺住院影響因子,使用Cox proportional hazard regression來分析重複自殺住院死亡風險因子。

結果:
研究期間自殺個案有39,875人,其中重複自殺者有3,388人(佔8.5%)。自殺住院者在三個月內重複自殺累積風險為7.19%、一年為8.00 %、八年則為8.70%,女性重複自殺風險較男性高,重複自殺者大多選擇固液體方式或切割方式,有精神疾患者重複自殺風險較高,重複自殺住院者就醫科別大多為精神科,重複自殺住院者大多未接受手術處置,重複自殺住院者住院天數較長;此外,性別與重複自殺方法間有交互作用,女性常用的自殺方法為固液體物質與切穿工具,但男性則為固液體物質與氣體蒸氣。重複自殺住院者有144人死亡(佔4.3%),重複自殺住院者在三個月內重複自殺累積死亡比例為1.42%、一年為2.89%、八年則為4.25%,重複自殺住院死亡風險包括了使用激烈方法(上吊、溺斃、槍械、跳樓)、低收入、有重大傷病者、在醫學中心就醫、有接受手術處置者、住院天數越短者;此外,低收入與重大傷病是重複自殺住院死亡的協同作用因子。

結論:
自殺防制的介入關鍵時間點為重複自殺三個月內,此外,應針對不同性別制訂合適的防治策略。低收入者及重大傷病患者是重複自殺的高危險族群,除了醫療單位救治之外,更需要社福單位(如:社工人員)積極協助,減緩他(她)們的經濟壓力。
Background:
Previous follow-up studies of repeated suicide showed that the cumulative risk of repeating suicide within one year were about 5.7%-15%, the prevalence of death by repeating suicide within one year were about 0.5%-2%, and with females were at greatest risk; however, they had limitations such as small sample sizes (less than 200 people), short tracking time (less than 2 years), no controls for physical and mental disorders, and no investigation of interactions between gender and self-harm method. In addition, relatively few studies had focused on the Asia.

Objectives:
To calculate the cumulative risk of repeating suicide and the prevalence of death by repeating suicide over different lengths of follow-up time (3 months, 6months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years after the first suicide hospitalization), to determine predictors of repeating suicide and death by repeating suicide, and to investigate whether there was an interaction between gender and the suicide method.

Methods:
We selected suicide inpatient data from National Health Insurance Research Database (NHIRD) in Taiwan from 2000 to 2007. Hospitalization and death by repeating suicide among the members of this cohort was tracked after 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years. The tracking continued until December 31, 2008. We found risk factors of repeating suicide using negative binomial regression, and we analyzed predictors of death by repeating suicide using Cox proportional hazard regression.

Results:
Of the 39,875 individual study samples, 3,388 individuals (8.5%) were repeating suicide during study period. The cumulative risk of repeating suicide within three months was 7.19%, and within one year was 8.00%. Within 8 years it was 8.70%. Females were more likely to repeatedly suicide than males. The main method of suicide was solid or liquid substances, or cutting or piercing, and inpatients with psychiatric disorders were more likely to suicide. Most of repeating suicide inpatients were visited in the department of psychiatric, without employing surgical procedures, and had longer length of days; moreover, there was an interaction between gender and the suicide method. Females generally used solid or liquid substances, and cutting or piercing, while males used solid or liquid substances, and gases or vapors. Of the 3,388 individuals with a history of suicide included in the study, a total 144 (4.3%) died by repeating suicide. The prevalence of death by repeating suicide within three months was 1.42%, and within one year was 2.89%. Within 8 years it was 4.25%. The predictors of death by suicide were violent methods (such as hanging, drowning, firearms, and jumping), low income, and severe illness, visited in medical center, employed surgical procedures, and lower length of days; moreover, an synergism modification was noted between low income and severe illness on the outcome (death by suicide).

Conclusions:
The key time for intervention for repeated suicide was within three months. Appropriate prevention programs should be developed based on gender differences. People with low incomes and severe illnesses had an elevated risk of death by repeating suicide, and it seems that effective healthcare for individuals who engage in self-harming behaviour would benefit from supplementing medical care with social assistance, such as the support of a social worker.
目 錄
目 錄 Ⅰ
表 目 錄 Ⅲ
圖 目 錄 Ⅳ
附錄目錄 Ⅴ
中文摘要 Ⅵ
Abstract Ⅷ

第一章 緒言 1
第一節 問題背景 1
第二節 研究動機與研究目的 5
第二章 文獻探討 9
第一節 自殺理論 9
第二節 重複自殺影響因子 15
第三節 重複自殺與重複自殺死亡方式比較 27
第四節 臺灣的重複自殺研究 33
第三章 材料與方法 36
第一節 研究問題與研究架構 36
第二節 名詞解釋 39
第三節 資料來源 41
第四節 變項操作型定義 44
第五節 統計分析方法 50
第四章 研究結果 54
第一節 重複自殺住院流行病學 54
第二節 重複自殺住院累積風險 66
第三節 重複自殺住院影響因子 69
第四節 重複自殺住院預後流行病學 77
第五節 重複自殺住院死亡比例 91
第六節 重複自殺住院死亡風險因子 93
第五章 研究討論 98
第一節 重複自殺住院累積風險與死亡比例 98
第二節 重複自殺住院影響因子 101
第三節 重複自殺住院死亡風險因子 106
第四節 研究優點與研究限制 111
第六章 結論與建議 114
第一節 結論 114
第二節 建議 116
參考文獻 122
英文文獻 122
中文文獻 143

表目錄
表1 :自殺住院流行病學特性 56
表2 :自殺住院者重大傷病原因 59
表3 :重複自殺住院者自殺方式類型 61
表4 :女性重複自殺住院者自殺方式類型 63
表5 :男性重複自殺住院者自殺方式類型 65
表6 :不同追蹤時間點重複自殺住院風險 67
表7 :重複自殺住院影響因子 71
表8 :女性重複自殺住院影響因子 73
表9 :男性重複自殺住院影響因子 75
表10:不同性別重複自殺住院方法 76
表11:重複自殺住院流行病學特性 79
表12:重複自殺住院者重大傷病原因 81
表13:重複自殺住院存活者自殺方式類型 83
表14:女性重複自殺住院存活者自殺方式類型 85
表15:男性重複自殺住院存活者自殺方式類型 87
表16:重複自殺住院死亡者自殺方式類型 88
表17:女性重複自殺住院死亡者自殺方式類型 89
表18:男性重複自殺住院死亡者自殺方式類型 90
表19:不同追蹤時間點重複自殺住院死亡比例 92
表20:重複自殺住院死亡風險因子 95
表21:自殺住院傷患於不同醫院層級與科別之精神科會診情況 120
表22:重複自殺住院傷患於不同醫院層級與科別之精神科會診情況 121

圖目錄
圖1:臺灣1987-2010年自殺死亡率趨勢圖 2
圖2:研究架構圖 36
圖3:重複自殺住院影響因子研究分析架構圖 37
圖4:重複自殺住院死亡風險因子研究分析架構圖 38
圖5:研究設計圖 42
圖6:研究樣本選擇流程圖 43
圖7:利用Kaplan-Meier曲線比較不同性別重複自殺住院累積風險 68
圖8:不同收入與是否為重大傷病患者的重複自殺住院死亡風險 97
圖9:利用Kaplan-Meier曲線比較不同地區重複自殺住院累積風險 99

附錄目錄
附錄一:全球各國自殺死亡數據 149
附錄二:自殺ICD-9-CM E-Code一覽表 165
附錄三:重大傷病一覽表 166
附錄四:精神疾患ICD-9-CM一覽表 171
附錄五:查爾森合併症指數與ICD-9-CM對照表 172
附錄六:跨理論模式(行為發展改變模式) 173
附錄七:臺灣自殺防制策略 178
附錄八:博士候選人資格考證明 179
附錄九:期刊文章發表 180
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196.張朝琴。貧窮與健康-社經地位與原住民族健康問題探析。嘉義大學通識學報2008;6:461-86。
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1. 206. 劉介宇、洪永泰、莊義利、陳怡如、翁文舜、劉季鑫等。臺灣地區鄉鎮市區發展類型應用於大型健康調查抽樣設計之研究。健康管理學刊2006;4(1):1-22。
2. 204. 齊美婷、蔣秀容;宋素真。運用認知治療於一位自殺企圖患者之護理經驗。高雄護理雜誌2004;21(1):17-30
3. 196. 張朝琴。貧窮與健康-社經地位與原住民族健康問題探析。嘉義大學通識學報2008;6:461-86。
4. 190. 陳錦宏、陳億倖、陳俊鶯、薛素霞、邵文娟、王姿乃等。青少年自殺意念與自殺未遂之相關因子研究。臺灣精神醫學2008;22(1):57-66。
5. 189. 郭嘉琪、林秋菊、馬淑清。運用壓力評價因應理論於一位自殺企圖病患的護理經驗。長庚護理2008;19(1):110-8。
6. 185. 洪雅鳳、羅皓誠。自殺未遂學生的危機介入處遇策略。輔導季刊2006;42(2):13-24。
7. 183. 胡正申。社會工作處遇自殺未遂個案的理論探討與評估。復興崗學報2001;72:191-212。
8. 181. 林俊宏、邱震寰、陳喬琪、黃蒂、林純綺。自殺企圖後之電話諮商。北市醫學雜誌2006;3(10):1030-4。
9. 180. 林俊宏、邱震寰、陳映燁、郭千哲、陳喬琪、黃蒂等。臺北市自殺企圖者之特徵。北市醫學雜誌2006;3(10):1008-16。
10. 177. 林妙容、黃雅羚。青少年自傷經驗發展歷程之分析研究-以五個個案為例。高雄師範大學輔導與諮商研究所諮商輔導學報2005;12:101-26。
11. 168. 李佳諭、林梅鳳、曾弘富、王文玲。南臺灣高中職生自殺危險行為盛行率及相關因素之探討。實證護理2008;4(1):71-81。
12. 172. 吳珮瑀。自殺未遂者之心理介入措施。諮商與輔導2007;260:27-30。
13. 174. 邱震寰、郭千哲、陳映燁、陳喬琪、李明濱、林俊宏等。初次自殺企圖者與重複自殺企圖者流行病學特徵之比較。北市醫學雜誌2006;3(10):1000-7。