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Comportamentos suicidas: estudo longitudinal a vinte e quatro meses, numa urgĂȘncia de psiquiatria
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Orientador(es)
Resumo(s)
RESUMO - Este estudo pretende identificar os fatores de risco para a ocorrĂȘncia de tentativas de suicĂdio (TS) e de
suicĂdios consumados ao longo de vinte e quatro meses, numa população adulta (18-65 anos) em risco
suicida, na urgĂȘncia de psiquiatria de um hospital geral. Definiram-se seis objetivos, trĂȘs baseados numa
componente transversal e trĂȘs numa componente longitudinal. A componente transversal incluiu: Objetivo
1- Caraterizar a amostra em termos sociodemogrĂĄficos, clĂnicos, de tratamento e das caracterĂsticas das
TS prĂ©vias; Objetivo 2- Caraterizar os subgrupos de ânĂŁo repetidoresâ de TS (0-1) e de ârepetidoresâ de TS
(â„ 2); Objetivo 3- Comparar o grau de risco suicida avaliado pela percepção clĂnica do psiquiatra (gold
standard), e por um instrumento quantitativo do risco de suicĂdio- escala SadPersons Modificada. A
componente longitudinal incluiu: Objetivo 4- Observar as ocorrĂȘncias de suicĂdios consumados, de TS, de
urgĂȘncias e de internamentos psiquiĂĄtricos, ao longo do perĂodo do estudo; Objetivo 5- Identificar os
fatores de risco individuais com capacidade preditiva dos indicadores de resultados (suicĂdios e TS nos
primeiros seis meses e no final dos 24 meses); Objetivo 6- Comparar a capacidade preditiva da avaliação
clĂnica do risco suicida com a sua complementação pela escala, face aos indicadores de resultados. ApĂłs
anĂĄlises descritivas, foram utilizados testes de independĂȘncia do qui-quadrado (p< 0,05), calculados os
coeficientes de concordĂąncia Kappa e aplicados modelos de regressĂŁo logĂstica binĂĄria (Odds bruta e
ajustada para faixa etåria e género, métodos enter e forward, p= 0,10-0,20, e determinadas as respetivas
curvas ROC). A amostra (n= 147) de idade média de 41,9 anos (±11,9) foi maioritariamente do sexo
feminino (61,9%), com patologia psiquiĂĄtrica na sua quase totalidade (94,6%), sobretudo do tipo afetivo
(61,2%) e perturbaçÔes da personalidade (59,2%). Teve como fatores de risco associados ao subgrupo de
ârepetidoresâ de TS (47,6% vs. ânĂŁo repetidoresâ: 52,4%): sexo feminino, antecedentes de comportamentos
autolesivos, existĂȘncia de maior nĂșmero de internamentos psiquiĂĄtricos prĂ©vios, e uma TS recente como
motivo da urgĂȘncia de recrutamento. A avaliação do risco suicida revelou uma concordĂąncia maioritĂĄria
entre os dois modos de avaliação, apenas com 27,2% (n= 40) de discrepùncia, com uma predominùncia de
grau "moderado" (54,4%) pelo psiquiatra, e âleveâ (55,1%) pela escala. Ao longo do estudo observaram-se
69 episĂłdios de TS (n= 24; 16,6%), ocorrendo maioritariamente nos primeiros seis meses, ao inverso dos
sete suicĂdios consumados (4,8% da amostra), que ocorreram predominantemente nos Ășltimos 18-24
meses do estudo. As caracterĂsticas individuais preditivas de futuras TS (regressĂŁo logĂstica binĂĄria, p=
0,10-0,20) foram a patologia somĂĄtica e o maior nĂșmero de internamentos psiquiĂĄtricos prĂ©vios. A
complementação da avaliação clĂnica do risco suicida pela escala, aumentou a capacidade preditiva de TS
quer aos seis quer aos 24 meses. Em conclusĂŁo, confirmou-se a existĂȘncia de um perfil de risco
sociodemogrĂĄfico, clĂnico, de antecedentes de tratamento e de TS prĂ©vias distinto para o subgrupo de
ârepetidoresâ de TS. Verificou-se um padrĂŁo de evolução temporal distinto para a ocorrĂȘncia de TS e de
suicĂdios consumados, bem como a existĂȘncia de fatores preditivos de TS (patologia somĂĄtica e maior
nĂșmero de internamentos psiquiĂĄtricos prĂ©vios) e de um acrĂ©scimo da capacidade preditiva de TS atravĂ©s
da complementação da observação psiquiĂĄtrica pela aplicação da escala. As limitaçÔes centram-se na subjetividade do investigador, na ausĂȘncia de uma validação da escala para a população portuguesa, nos
viĂ©ses de memĂłria dos utentes e nas lacunas de informação dos processos clĂnicos informatizados. Os
pontos fortes incluem a considerĂĄvel dimensĂŁo da amostra, a quase total ausĂȘncia de âdrop-outsâ e a
abrangĂȘncia integrada, clĂnica e epidemiolĂłgica, a nĂvel do prĂłprio local de prestação de cuidados clĂnicos
de urgĂȘncia. A originalidade do estudo, inĂ©dito a nĂvel nacional, consiste na sua metodologia longitudinal e
na aplicação de uma escala quantitativa do risco suicida, enquanto ferramenta de apoio à avaliação do
risco suicida. Como principal recomendação realça-se a necessidade de seguimento no perĂodo pĂłs-crĂtico
destes utentes que procuram os serviços de saĂșde, mas para os quais nĂŁo parece haver uma capacidade
de resposta adequada. Como perspetivas futuras consideram-se a ampliação da amostra num estudo
durante um mais alargado perĂodo temporal e incorporando outros nĂveis de cuidados de saĂșde. As
implicaçÔes pråticas deste estudo centram-se na melhoria do conhecimento epidemiológico acerca dos
fatores de risco associados aos comportamentos suicidas a nĂvel das urgĂȘncias de psiquiatria, e da
respetiva contribuição para a otimização do planeamento da saĂșde com vista Ă prevenção do suicĂdio.
ABSTRACT - This study aims to identify the risk factors for the occurrence of suicide attempts (SA) and completed suicides over 24 months, in an adult population (18-65 years) at suicidal risk, in the psychiatric emergency of a general hospital. This study defined six objectives, three based on cross-sectional, and three on longitudinal analyses: The cross-sectional component included: Objective 1- To characterize the sample in sociodemographic, clinical, treatment and characteristics of previous ST; Objective 2- To characterize the subgroups of "non-repeaters" of TS (0-1) and "repeaters" of ST (â„ 2); Objective 3- To compare the degree of suicidal risk assessed by the clinical perception of the psychiatrist (gold standard), and by a quantitative instrument of suicide risk- modified SadPersons scale. The longitudinal component included: Objective 4- To observe the occurrences of consummate suicides, ST, emergencies and psychiatric hospitalizations, throughout the study period; Objective 5- To identify individual risk factors with predictive capacity of outcome indicators (suicides and ST in the first six months and at the end of 24 months); Objective 6- To compare the predictive capacity of the clinical assessment of suicidal risk with its complementation by scale, in view of the result indicators. Statistical analysis` descriptive methods (chi-square independence test, p< 0.05, and Kappa coefficient of agreement) and binary logistic regression (crude and adjusted odds ratio for age and gender, enter and forward methods, p= 0.10-0.20 and ROC curves) were used. The sample (n= 147) showed a mean age of 41.9 years (±11.9), mostly of female gender (61.9%), with psychiatric pathology (94.6%), especially the affective type (61.2%) and personality disorders (59.2%). The risk factors associated with the SA` ârepeaters âsub-group (47.6%vs. "non-repeaters": 52.4%) were: female gender, history of non-suicidal self-harming behaviors, a greater number of previous psychiatric hospitalizations, and a recent SA as a reason for the emergency recruitment `episode. The suicidal risk assessment revealed a majority of agreement between the two modes of evaluation, with only 27.2% (n= 40) of discrepancy, with a predominance of a "moderate" degree (54.4%) by the psychiatristâ evaluation, and "mild" (55.1%) by the scale. Throughout the study, 69 episodes of SA (n= 24; 16.6%) were observed, occurring mostly during the first six months, in verse of the seven suicides (4.8% of the sample), which occurred predominantly in the last 18-24 months of the study. The future SA`predictive characteristics (binary logistic regression, p= 0.10-0.20) were somatic pathology and a higher number of previous psychiatric hospitalizations. The complementation of the clinical suicide risk evaluation by the scale increased the predictive capacity of SA at both six and 24 months. In conclusion, it was confirmed the existence of a distinct sociodemographic, clinical, previous treatment and SA antecedents for the SA "repeaters" subgroup. A distinct pattern of temporal evolution between the occurrence of SA and of completed suicides was observed, as well as the existence of SA`predictive factors (somatic pathology and a greater number of previous psychiatric hospitalizations).An increase in the SA` predictive capacity was obtained through the complementation of the clinical psychiatric evaluation by the scale. The limitations were the subjectivity of the researcher, the absence of the scale validation for the Portuguese population, the memory biases of users and the computerized clinical processes information gaps. The strong points included the considerable size of the sample, with an almost total absence of drop-outs and the integrated, clinical and epidemiological scope, at the level of the emergency clinical care setting. The originality of the study, unpublished at national level, consists of its longitudinal methodology and the application of a suicidal risk quantitative scale as a supporting tool to clinical intervention guiding. Recommendations highlight the need of a close follow-up of emergency department users at risk of suicide, during the post critical suicidal phase, for which it seems to be a lack of health services response. Future perspectives consider the expansion of the sample in a study over a longer period of time and incorporating other levels of health care. The practical implications of this innovative study, at a national level, focus on the improvement of epidemiological knowledge about the risk factors associated with suicidal behaviors at psychiatric emergencies, and their contribution to the optimization of health planning for suicide prevention.
ABSTRACT - This study aims to identify the risk factors for the occurrence of suicide attempts (SA) and completed suicides over 24 months, in an adult population (18-65 years) at suicidal risk, in the psychiatric emergency of a general hospital. This study defined six objectives, three based on cross-sectional, and three on longitudinal analyses: The cross-sectional component included: Objective 1- To characterize the sample in sociodemographic, clinical, treatment and characteristics of previous ST; Objective 2- To characterize the subgroups of "non-repeaters" of TS (0-1) and "repeaters" of ST (â„ 2); Objective 3- To compare the degree of suicidal risk assessed by the clinical perception of the psychiatrist (gold standard), and by a quantitative instrument of suicide risk- modified SadPersons scale. The longitudinal component included: Objective 4- To observe the occurrences of consummate suicides, ST, emergencies and psychiatric hospitalizations, throughout the study period; Objective 5- To identify individual risk factors with predictive capacity of outcome indicators (suicides and ST in the first six months and at the end of 24 months); Objective 6- To compare the predictive capacity of the clinical assessment of suicidal risk with its complementation by scale, in view of the result indicators. Statistical analysis` descriptive methods (chi-square independence test, p< 0.05, and Kappa coefficient of agreement) and binary logistic regression (crude and adjusted odds ratio for age and gender, enter and forward methods, p= 0.10-0.20 and ROC curves) were used. The sample (n= 147) showed a mean age of 41.9 years (±11.9), mostly of female gender (61.9%), with psychiatric pathology (94.6%), especially the affective type (61.2%) and personality disorders (59.2%). The risk factors associated with the SA` ârepeaters âsub-group (47.6%vs. "non-repeaters": 52.4%) were: female gender, history of non-suicidal self-harming behaviors, a greater number of previous psychiatric hospitalizations, and a recent SA as a reason for the emergency recruitment `episode. The suicidal risk assessment revealed a majority of agreement between the two modes of evaluation, with only 27.2% (n= 40) of discrepancy, with a predominance of a "moderate" degree (54.4%) by the psychiatristâ evaluation, and "mild" (55.1%) by the scale. Throughout the study, 69 episodes of SA (n= 24; 16.6%) were observed, occurring mostly during the first six months, in verse of the seven suicides (4.8% of the sample), which occurred predominantly in the last 18-24 months of the study. The future SA`predictive characteristics (binary logistic regression, p= 0.10-0.20) were somatic pathology and a higher number of previous psychiatric hospitalizations. The complementation of the clinical suicide risk evaluation by the scale increased the predictive capacity of SA at both six and 24 months. In conclusion, it was confirmed the existence of a distinct sociodemographic, clinical, previous treatment and SA antecedents for the SA "repeaters" subgroup. A distinct pattern of temporal evolution between the occurrence of SA and of completed suicides was observed, as well as the existence of SA`predictive factors (somatic pathology and a greater number of previous psychiatric hospitalizations).An increase in the SA` predictive capacity was obtained through the complementation of the clinical psychiatric evaluation by the scale. The limitations were the subjectivity of the researcher, the absence of the scale validation for the Portuguese population, the memory biases of users and the computerized clinical processes information gaps. The strong points included the considerable size of the sample, with an almost total absence of drop-outs and the integrated, clinical and epidemiological scope, at the level of the emergency clinical care setting. The originality of the study, unpublished at national level, consists of its longitudinal methodology and the application of a suicidal risk quantitative scale as a supporting tool to clinical intervention guiding. Recommendations highlight the need of a close follow-up of emergency department users at risk of suicide, during the post critical suicidal phase, for which it seems to be a lack of health services response. Future perspectives consider the expansion of the sample in a study over a longer period of time and incorporating other levels of health care. The practical implications of this innovative study, at a national level, focus on the improvement of epidemiological knowledge about the risk factors associated with suicidal behaviors at psychiatric emergencies, and their contribution to the optimization of health planning for suicide prevention.
Descrição
Palavras-chave
Ideação suicida suicĂdios consumados tentativas de suicĂdio Escala SadPersons Modificada urgĂȘncias de psiquiatria Suicidal ideation completed suicides suicide attempts Modified SadPersons scale psychiatric emergencies