【作者】 谢伦芳；

【导师】 叶冬青；

【作者基本信息】 安徽医科大学 ， 流行病与卫生统计学， 2011， 博士

【摘要】 研究背景系统性红斑狼疮(systemic lupus erythematosus,SLE)是一种累及多系统、多器官并有多种自身抗体出现的自身免疫性疾病,在中国的患病率远远高于西方国家。SLE目前不能根治,患者病情呈反复发作与缓解交替过程,多数患者需要在相当长的时间内带病生存并存在不同程度的负性情绪反应,心理功能和社会功能也受到不同程度的影响,生活期望也随之下降。研究表明,SLE患者情绪障碍的发生比例较高,尤其是焦虑和抑郁。而抑郁情绪是自杀的独立危险因素。此外,SLE患者的社会支持水平较健康对照低,而社会支持也被认为是自杀意念形成的缓冲因素。早年就有研究者指出SLE患者的自杀行为与其他疾病相比显得更加频繁,SLE患者存在较大的自杀风险。自杀意念是自杀行为实施的最为强烈的预测因素。它是评估自杀危险性的一个重要指标。有研究指出,SLE患者的自杀意念与家庭成员之间的关系和每日大剂量服用类固醇类药呈显著关联,但未发现与患者的疾病活动有关联。另有研究也表明,SLE患者的自杀意念与病程有关,但与糖皮质激素用量无关。上述关于国外SLE患者自杀意念的研究十分有限,且国内外研究者对中国SLE患者自杀意念形成的影响因素的研究尚未见报道。Mann等提出的“应激-易感”模型认为:自杀是应激因素(包括急性精神病或躯体疾病、工作压力或家庭危机等)、保护性因素(包括家庭、社会、文化等)与个体易感性(生物和心理)三者之间相互影响的过程。此处的生物易感性主要是指脑脊液中五羟色胺(5-hydroxytryptamine, 5-HT)的水平,而血清胆固醇水平由于与五羟色胺的代谢产物五羟吲哚醋酸(5-hydroxyindoleacetic acid, 5-HTAA)受体之间的相关性,被多项研究作为自杀意念的生物学影响因素进行探讨,但存在争议。心理易感性则主要是指人格特征与认知,而应对是认知的直接表现形式。结合“应激-易感”模型和既往研究结果,我们假设SLE患者自杀意念的影响因素包括以下几个方面:①生物易感因素:血清总胆固醇水平;②心理易感因素:人格特征、应对方式;③危险(应激)因素:病程、复发次数、疾病活动度,激素用量、抑郁情绪、治病负担等;④保护因素:社会支持,家庭功能,对疾病的认识与治疗信心、宗教等。SLE患者自杀意念的形成是上述因素相互作用、相互影响的综合过程。目的(1)了解SLE患者自杀意念的发生率、严重程度及其持续性;(2)评估SLE患者产生自杀意念的生物易感因素和心理易感因素;(3)识别SLE患者自杀意念形成的影响因素。方法采用一般资料和自杀意念问卷、贝克抑郁自评量表、家庭关怀度指数问卷、社会支持评定量表、艾森克人格问卷和特质应对方式问卷对324名SLE患者开展一对一的调查。一般资料包括患者的社会人口学信息、对疾病的认知情况。同时,调查员采用疾病相关信息记录表从患者病历和主治医生处收集患者的病程、复发次数、疾病活动指数及激素用量。疾病活动指数评估参照系统性红斑狼疮疾病活动性指数(SLE disease activity index, SLEDAI)量表;糖皮质激素均以强的松为基准进行剂量转化。以患者接受调查前一个月内有无自杀意念分为两组,采用单因素和多因素Logistic回归方法,分析社会人口学特征、患者对疾病认知、疾病相关因素、心理健康水平、家庭功能、社会支持、人格特征、特质应对方式和血清总胆固醇水平对自杀意念的影响;并根据患者自杀意念的持续性建立因变量,分析上述因素对自杀意念持续性的影响。此外,通过路径分析初步探讨人格特征、应对方式、抑郁情绪对自杀意念的作用模式。采用SPSS 10.5进行统计分析。结果(1) 324名SLE患者中有33.3%的患者在接受调查前一个月内产生过自杀意念,而自杀意念严重程度分布为轻度占5.8%,中度占20.7%,重度占6.8%。此外,21.6%的患者在发病前有过自杀意念,38.0%的患者有过终生自杀意念;(2) SLE患者自杀意念形成的易感因素:神经质倾向(情绪不稳定)、较少的积极应对和较多的消极应对是患者形成自杀意念的心理易感因素,其中神经质倾向是独立影响因素(N量表标准分OR=1.099, P=0.000);血清总胆固醇水平作为生物易感因素指标,未发现其与自杀意念的关联性(OR=1.045, P=0.624);(3) SLE患者自杀意念形成的危险因素:无业或农民、不稳定的婚姻状态、宗教信仰、疾病对生活造成的负担、病程、发病前自杀意念、抑郁情绪;其中,宗教信仰(OR=2.654, P=0.024)、发病前自杀意念(OR=5.016, P=0.001)和抑郁情绪(OR=1.737, P=0.002)是自杀意念的独立影响因素和预测因素;(4) SLE患者自杀意念形成的保护因素:患者对治疗的信心、家庭功能(包括适应度、合作度、成熟度、情感度、亲密度)和社会支持(主观支持和客观支持),其中,亲密度(OR=0.392, P=0.027)和客观支持(OR=0.768, P=0.002)成为自杀意念的独立影响因素;而对于病程在一年以上的SLE患者,有儿女(OR=0.394, P=0.039)也成为了影响其自杀意念的独立保护因素;而亲密度(OR=0.544, P=0.047)和主观支持(OR=0.930, P=0.037)是患者在发病前后自杀意念发生从无到有变化的独立影响因素;(5)人格特征、应对方式和抑郁情绪对SLE患者自杀意念的作用模式:神经质倾向人格对自杀意念有直接的影响(β=0.208),也可通过抑郁情绪以间接方式进行(β=0.492);还可经由应对方式和抑郁情绪为中介间接影响自杀意念。应对方式通过抑郁情绪以间接方式影响自杀意念(β=0.164)。抑郁情绪是对自杀意念直接影响最大的因素(β=0.354)。结论本研究是首次在国内SLE患者中开展自杀意念及其影响因素的调查研究。我国SLE患者可能具有较高的自杀风险。神经质倾向是SLE患者形成自杀意念的心理易感因素,对自杀意念的影响较为显著,可作为患者自杀意念预防和干预的重点因素。发病前自杀意念和抑郁情绪是患者自杀意念形成的独立危险因素和预测因素,对这两个因素专业的评估和干预应受到临床医务工作者的高度重视。此外,预防和干预SLE患者的自杀意念也离不开患者家庭成员和社会力量所提供的重要的物质和精神支持。更多还原

【Abstract】 BackgroundSystemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by a diverse array of autoantibody production that affects multiple systems and organs. The prevalence of SLE in China far outclasses that of western countries. Until now, SLE cannot be cured. The course of SLE generally involves periods of intense flares and periods of remission. Most of patients have to live with the disease in a long time and have different level of negative emotion and low life expectation. Some studies indica- ted that SLE patients were prone to have mood disorder, especially anxiety and depression. Depression was proved to be an independent risk factor for suicide. Meanwhile, the level of social support in SLE was lower than that in the healthy people, which was considered as a buffering factor of suicide. Many years ago, some studies reported that the frequency of suicidal behavior in SLE patients was higher than that in other patients. SLE had a higher risk of suicide.Suicidal ideation is the most intensive predict factor of suicide and also an important index for assessment of suicide risk. One study suggested that suicidal ideation in SLE was significantly correlated with human relations among family members and high daily steroid dosage, but was not correlated with disease activity. Another study reported that suicidal ideation in SLE was correlated with disease duration, but not with steroid dosage. The studies on suicidal ideation in foreigner SLE patients were limited. There was not any existing research related to suicidal ideation in Chinese SLE patients.Mann and his colleagues (1998) have suggested a comprehensive stress- vulnerability model for suicide. According to proponents of this theory, suicide is a result of interaction of three aspects, namely, stress (such as acute psychiatric or somatic illness, pressing social problems or family crises, etc.), protective factors (such as family, social and culture, etc.) and susceptibility (biological and psychological domains). Biological susceptibility means the level of 5-hydroxytryptamine (5-HT) in cerebrospinal fluid, and its metabolic product called 5-hydroxyindoleacetic acid (5-HTAA). Considering the relationship between the serum cholesterol level and the receptor of 5-HTAA, serum cholesterol level has been considered as a biological susceptibility in many studies on suicidal ideation. Psychological susceptibility of suicide include personality and cognition, while coping is seen as a direct pattern of manifestation for cognition.Combining with the stress-vulnerability model and the results of previous researches, we raised the hypotheses as following: the influencing facors of suicidal ideation in SLE include biological susceptibility (serum cholesterol level), psychological susceptibility (personality and coping style), risk factors (disease duration, frequence of recurrence, disease activity, dosage of glucocorticoids, depression, load of treatment, etc.) and protective factors (social support, family function, perception of SLE, confidence in treatment, religious belief, etc. ). Suicidal ideation in SLE is due to the interactions of the factors mentioned above.Objective(1) To investigate the prevalence of suicidal ideation, the severity and persistence of suicidal ideation in SLE patients.(2) To assess the biological and psychological susceptibility of suicidal ideation in SLE patients.(3) To identify the influencing factors of suicidal ideation in SLE patients. Methods324 SLE patients were interviewed with questionnaires in respect of suicidal ideation, social-demographic characteristics, Beck Depression Inventory (BDI), Family APGAR, Social Support Rate Scale (SSRS), Eysenck Personality Questionnaire (EPQ), Trait Coping Style Questionnaire (TCSQ). The other medical information was collected from the patients’physicians and medical records. Disease activity was assessed with SLE Disease Activity Index. And the current dose of steroid medication was based on a conversion of the various medications into the same dosage for prednisolone.Based on the patients’current suicidal ideation, we investigated the correlation through univariate and multivariate logistic regression between suicidal ideation and social–demographic characteristics, the patients’perceptions of disease, the disease related factors, mental heatlh, family function, social support, personality, trait coping style and serum total cholesterol level. Then we set a dependent variable according to the persistence of suicidal ideation, and continued to investigate the correlation between the persistence of suicidal ideation and the above factors. In addition, we carried a path analysis to explore the role model of personality, trait coping style and depression to suicidal ideation in SLE patients. The data were analyzed by Statistical Package for Social Sciences version 10.5 software (SPSS, Chicago, IL, USA).Results(1) Current suicidal ideation was present in 33.3% of 324 SLE patients, and suicidal ideation was divided into three levels: mild(5.8%), moderate(20.7%), serious (6.8%). Premorbid suicidal ideation as an independent factor was present in 21.6% of SLE patients, whereas lifetime suicidal ideation was present in 38.0% of SLE patients.(2) The susceptibility of suicidal ideation in SLE patients: neurotic personality, low level of active coping and high level of negative coping were psychological suscepti- bility of suicidal ideation, and neurotic personality was an independent factor (the standard score of N scale: OR=1.099, P=0.000); but as a biological susceptibility, serum total cholesterol level was not significantly correlated with suicidal ideation(OR=1.045, P=0.624).(3) The risk factors of suicidal ideation in SLE patients: without job or be a famer, unstable marriage, religious belief, premorbid suicidal ideation, and depression were significantly related to the current suicidal ideation. Among these factors, religious belief(OR=2.654, P=0.024), premorbid suicidal ideation(OR=5.016, P=0.001), depr- session(OR=1.737, P=0.002) were independent influencing factors and predictive factors of suicidal ideation.(4) The protective factors of suicidal ideation in SLE patients: patients’confidence in treatment, family function (including adaptability, partnership, growth, affection and resolve), social support (including subjective support, objective support, availability of support) were significantly related to current suicidal ideation. Among them, resolve (OR=0.392, P=0.027), objective support(OR=0.768, P=0.002) were independent influencing factors. In the SLE patients with the disease durarion more than 1 year, having children(OR=0.394, P=0.039) became an independent protective factor of current suicidal ideation. In addition, resolve(OR=0.544, P=0.047)and subjective support(OR=0.930, P=0.037) could directly influence the change of suicidal ideation from“no”in the period before SLE to“yes”after SLE.(5) The role model of personality, trait coping style and depression to suicidal ideation in SLE: neurotic personality could influence the current suicidal ideation directly(β=0.208), and indirectly by depression(β=0.492),and indirectly by both coping style and depression. Coping style could only indirectly influence the current suicidal ideation by means of depression(β=0.164). Depression was the most direct influencing factor to the current suicidal ideation(β=0.354). ConclusionsIn conclusion, this is the first study to investigate suicidal ideation and its correlations in Chinese SLE patients. The study suggested that SLE patients in China might have a relatively higher risk of suicide. First, neurotic personality was the psychological susceptibility of suicidal ideation in SLE patients, so much attention should be given to the patients with this kind of personality to prevent and intervene in their suicidal ideation. Second, premorbid suicidal ideation and depression were independent risk and predict facors of suicidal ideation in SLE patients. Professional assessment and interventions for these two factors should be attached great importance to the clinical health personnel. Meanwhile, preventing and intervening in SLE patients’suicidal ideation, providing material and spiritual support from family and social forces should not be ignored as well.更多还原