1、Adult Suicide in Hong Kong SAR香港的成人自杀,Sandra ChanAssociate ProfessorDepartment of PsychiatryThe Chinese University of Hong Kong香港中文大学精神科学系陈秀雯副教授,Completed suicide自杀已遂,Sources of Mortality statistics in HK-A surveillance system enforced by Judicial System,As part of the Judicial System of HK, there e
2、xists a long-standing mandatory death enquiry system (Coroners Inquest) to investigate :“Dead-on-arrival” at the Emergency Room;“Deaths occurring within 24 hours of admission to hospital”;Suspected murder;Suspected suicide;Dead body found in public places or private premises;Deaths occurring in hosp
3、ital anytime after admission that cannot be satisfactorily explained by known medical conditions;The Coroners court works closely with the Police Department, Forensic Pathologist and Clinical Pathologist who gather information related to the circumstances surrounding death.,香港死亡率统计来源司法制度中执行的监察系统,作为香
4、港司法制度中的一部份，长期以来存在着强制死亡查询系统（呈报死亡个案）去调查：I)在急症室到达时已经死亡；II) 入院二十四小时内死亡； III) 怀疑谋杀； IV) 怀疑自杀；V) 在公众或私人地方发现尸体；VI) 住院期间任何死亡(不能用已知的医疗情况合理地解释 )死因裁判法庭与警方、法医及病理学家合作收集有关死亡情况的资料。,Closer look at trend in Suicide Rates (by Age Groups) from 1990-2005,Census and Statistics Dept of HKSAR,Latest official suicide stati
5、stics (up to 2005),Leading causes of death in HK香港主要死亡原因,Malignant neoplasm 恶性肿瘤 - 31.8% Cardiac Diseases 心脏病 - 15.7%Cerebrovascular Diseases 脑血管疾病 - 9.2%Pneumonia 肺炎 - 9.9%COPD慢性阻塞性肺病 - 5.7%Renal Diseases肾病 - 3.2%Suicide自杀 - 2.8%Others其它 - 7.5%,WHO Suicide Statistics世卫自杀统计,According to the latest s
6、tatistics from WHO, the average global suicide rate is 14/100,000.全球平均自杀率为14/100,000 HK ranks 24th while China (rates in selected areas) ranks 27th among 100 countries.在100个国家中，香港排行第二十四，而中国（选择地区）排行第二十七。 All top 8 ranking countries are from East Europee.g. Lithuania 38.6/100,000; Hungary 27.7/100,000
7、; Latvia 24.3/100,000). 首八位国家都在东欧（例如：立陶宛38.6/100,000；匈牙利27.7/100,000；拉脱维亚24.3/100,000）。 Japan ranks 8th (24/100,000), which is highest among Asian countries, followed by Sri Lanka (21.6/100,000) and Korea (17.9/100,000).日本排行第八，是亚洲区中最高，其后是斯里兰卡和韩国。 Finland ranks 12th, highest ranking among North Europ
8、ean countries (20.6/100,000).芬兰排行第十二，是北欧国家中最高。,Trend in Suicide methods in HK香港自杀方法趋势,Jumping from height (40-60%) across all age groups ever since late 1970s由高处堕下（40-60%）是自七十年代后所有年龄组别中最高。Hanging- second commonest method in over 55 yrs old (30%)在五十五岁以上组别（30%）上吊是第二个最普遍的方法Charcoal burning- second comm
9、onest method adopted by 15-55 yrs old (accounted for 1/3 suicide deaths since 2001)烧炭是15-55岁组别（由2001年占三分一自杀死亡）第二个最普遍的方法。,Risk factors for completed suicide in adult population in HK-evidence from a recent case-control psychological autopsy study,150 suicide deceased ( death occurring in 2002-04) age
10、d 15-59 were studied using psychological autopsy method (semi-structured diagnostic interview and psychosocial enquiry with proxy-informant); 150 living controls matched by age and gender were randomly selected from a representative pre-selected community sample involved in another epidemiologic sur
11、vey. Factors found to significantly and independently contribute to suicide were: Unemployment, indebtedness, being single, psychiatric illness and history of past attempts(Chen et al, 2006 in Psychological Medicine),香港成人自杀的风险因素从最近的心理剖析研究得出的证据,用心理剖析法来研究150位年龄由15至59岁的自杀死者（用半结构诊断访问及心理社会查询来访问死者近亲）而另外15
12、0位对照人士亦与死者年龄及性别配合，从社区中随机抽样选出来。独立地引致自杀的重要因素包括：失业、负债、单身、精神病及曾经尝试自杀的前科。 (Chen et al, 2006 in Psychological Medicine),Adjusted parameter estimates of risk factors in a logistic regression model (* p0.01; * p,0.001),Chen et al, 2006 in Psychological Medicine,Logistic regression showing the attributable r
13、isk for completed suicide by DSM IV Psychiatric Diagnoses,Chan et al, unpublished data,烧炭汉酿火警变焦尸 (明报) 2007年09月 21日 星期五 05:10AM 【明报专讯】一名染有不良嗜好的男子，怀疑在长沙湾家中烧炭自杀，其间疑炭块烧着床褥，男子被烧成焦尸，浓烟惊动街坊报警。由于消防犬在火场发现易燃物体，消防一度怀疑事件有可疑；警方深入了解后，相信该男子不堪追债临门而轻生。疑不堪上门追债轻生,Charcoal burning suicide in HK香港烧炭自杀,First index case i
14、n Nov 1998. Largely publicized by media;Review of Coroners record on charcoal burning deaths (Lee et al, 2000) showed that 60% were faced with financial debts and most victims had no prior history of psychiatric illness; this view is substantiated by an ethnographic study on a middle-aged suicide at
15、tempters who survived after charcoal burning (Chan et al 2005)首次发生在1998年11月，传媒广泛报导；回顾死因裁判法庭关于烧炭死亡的纪录(Lee et al, 2000)显示60%面对债务，很多受害者之前没有精神病历，这种看法后来在中年企图烧炭自杀人士获救后的研究得以被证实(Chan et al, 2005)。,Sociodemograhic profile of charcoal burning victims- results from the recent PA study,Chan et al, unpublished d
16、ata,Psychiatric profile of charcoal burning victims- results from the recent PA study,Chan et al, unpublished data,Health care utilization pattern in the psychological autopsy cohort,Among the 121 suicide victims with Axis I diagnoses, 60% had attended clinicians and 43% had received treatment from
17、psychiatrists in the six months before death. The overall service contact rate is similar to other case-control PA studies (25-60%). Among the 52 suicide decedents who had seen psychiatrists in their last 6 months, 33% had their last appointments within one week before death and 62% had their last a
18、ppointment within one month.,心理剖析群中使用医疗服务的状况,在121自杀死者有主轴I诊断中60%曾看医生及43%在死前六个月曾接受精神科医生诊治。整体使用率与其它心理剖析研究相近。 在52位过去六个月曾看精神科医生的自杀死者中，有33%曾在死前一个星期覆诊，而62%曾在一个月内覆诊。80%自杀死者有精神分裂征状，死前六个月看过精神科医生。,Eighty percent of suicide decedents with schizophrenic spectrum disorder had seen psychiatrists in their last 6 mo
19、nths of life. In cases with Mood (Major Depressive Disorder, current episode or lifetime diagnosis, Bipolar Affective Disorder) and Neurotic Spectrum Disorder, less than 50% had consulted with psychiatrists from the public and private sector in their last 6 months of life. Fewer suicide decedents Al
20、cohol Misuse Disorder (20%) and Substance Misuse Disorder (33%) had consulted psychiatrists in the 6 months before death.(Chan et al, unpublished data),有情绪病（抑郁症，包括现在或终身诊断，躁郁症）和神经过敏征状的死者，少过50%曾经在死前六个月看过公立和私家精神科医生。很少自杀死者是酗酒（20%）或滥用药物（33%）曾经在死前六个月看过精神科医生。(Chan et al, unpublished data),Attempted Suicide
21、企图自杀,Epidemiology of attempted suicide in HK香港企图自杀的流行情况,No accurate statistics on prevalence of attempted suicide;Estimates from HA figures - 10 times the number of completed suicide occurring in the territory没有准确统计香港企图自杀的流行状况；根据医院管理局的估计数字，数目大约是自杀已遂的10倍。,Access to professional help in HK香港寻求专业协助的方法,
22、Hospital-based mental/general medical health servicePrimary care in private sectorPsychiatric specialists care in private settingNGO hotlinesSocial welfare department- family services centre医院的精神科/普通科医疗服务私人基层医疗私人精神科医生非政府机构的热线社会福利署综合家庭服务中心,Clinical correlates of suicide attempters (observations from
23、a suicide attempters cohort presented to a regional service in 2004; N=71),Female= 63%; Male= 37%Mean age= 35 yrs +/- 12Method: DO (59%); Wrist laceration (20%); Jumping from height (20%); charcoal burning (11%)DSM-IV Psych Dx- Adjustment disorder (35.2%); MDD/Dysthymia (47.8%); Bipolar Affective Di
24、sorder (1.4%); SA/Alcohol Misuese disorder (11%); Schizophrenic spectrum disorder (15.5%); Anxiety disorder (2.8%)(Chan & Pang, 2006 in HK J of Psychiatry),企图自杀者的临床关系（研究来自2004年寻求地区服务的企图自杀者，N=71）,女=63%；男=37% 平均年龄=35岁+/-12方法：服食药物（59%）；割腕（20%）；高处堕下（20%）；烧炭（11%）精神科诊断：适应失调（35.2%）；抑郁症（47.8%）；躁郁症（1.4%）；滥用药
25、物/酗酒（11%）；精神分裂症（15.5%）焦虑症（2.8%）(Chan & Pang, 2006 in HK J of Psychiatry),*Global financial crisis and blow to the local stock/property market in 1998;*2003 SARS Epidemic (relatively well-defined natural disaster with territory-wide effect due to the community quarantine happening at that time, the p
26、ersistence of economic downturn as well as disruptions in other social infrastructure such as health care services)*from 1970s onwards, there have been rapid expansions of social welfare sector and govt-funded health care services ( including mental health service)Any speculations in such direction
27、is prone to ecological fallacy.,Macro-economic correlates of ups and downs in suicide rates,*1998年全球金融危机及本地股市/地产市场爆破；2003年沙士（自然灾害令到社区要隔离检疫，持续经济下滑令到其它社会基础，包括医疗服务受影响）*自1970年代以来，社会福利及政府医疗服务（包括精神科服务）快速增长。任何在这方面的猜测倾向生态学上的谬误。,自杀率起跌-宏观经济的相关,SARS,Econ downturn,Two Poisson Regression Models of non-elder suic
28、ide rates from 1986-2003 using 1986 and 2003 as years of reference respectively,Gross inspection shows that the suicide rate of the population under age 65 has remained between 8 and 10 per100,000 from 1986 to 1999. There was a steady rise in suicide rate from 2000 onwards, reaching 15.26 per 100,00
29、0 in 2003. Poisson regression of annual suicide rates in the population under 65 years of age using 1986 as the reference year shows that suicide rates in 1986-1997 do not differ significantly from the reference year, while rates in 1998-2003 are on the rise, with an IRR of 1.15-1.62 relative to the
30、 reference year, reaching statistically significant levels. Despite the rising trend in 1998-2003, the difference in suicide rate in the non-elder population in 2002 and 2003 does not reach statistical significance when Poisson Regression is run using 2003 as the reference. (Chan et al, 2006. In Int
31、ernational J of Geriatric Psychiatry),粗略检视看到在1980至1999年，65岁以下自杀率仍然介乎8至10每100,000人，2000年以后有稳定自杀率增加，达到2003年15.26每100,000人。以1986年作为参考年份，65岁以下全年整体自杀率的Poisson regression，1986-1999年自杀率并非有重大不同于参考年份，当自杀率在1998-2003上升，IRR1.15-1.62相对参考年份，达到统计学上有效程度。虽然上升趋势在1998-2003，当用2003年作Poisson Regression，2002年非长者人口的自杀率与200
32、3年相比不能得出统计有效。(Chan et al, 2006. In International J of Geriatric Psychiatry),Suicide自杀,Attempted suicide企图自杀,Method方法,Individual factorse.g. psychiatric disorders,drug abusepersonality, impulsivitycognitive style个人因素 例如：精神病、滥用药物、性格、冲动、认知方式,Local factorse.g. social support, family psychopathology,loca
33、l and family resources,local cultural norms本地因素 例如：社交支持、家族精神病、本地及家庭资源、本地文化规范,Macro-economic/political/societal forces宏观经济/政治/社会力量,Acknowledgements:Coroners Office, Government of HKSARForensic Pathology Service, Dept of HealthCentre for Suicide Research and Prevention, University of Hong KongProfessor Helen Chiu, Suicide Research Unit, The Chinese University of Hong Kong鸣谢：香港特别行政区死因裁判法庭卫生署法医科香港大学香港赛马会防止自杀研究中心香港中文大学自杀研究组赵凤琴教授,
