至急診之自傷青少年的特色及個案管理計畫之療效評估

Emergency Management of Adolescent Self-harm: Patients’ Characteristics and Effect of Case Management

背景：臺灣對於因自傷行為至急診求助的青少年的相關資料較缺乏，本研究評估這類青少年的特色、自傷促發因子、處置對門診回診的影響。方法：回顧2004年6月至2007年7月間，因自傷行為至某綜合醫院急診就診的未滿二十歲青少年的病歷。2005年11月起此醫院開始進行自傷個案管理計畫，採準實驗設計，以描述及分析性統計比較計畫進行前的40位就診青少年及計畫開始後的47位的門診回診率。結果：共回顧了87位青少年的病歷，平均17.7歲，66位是女性。最常見的自傷方式為藥物過量；最常見的促發因子是人際關係問題。54人(62%)目前罹患精神疾患，重複自傷個案罹患精神疾患則高達86%。個案管理計畫開始前，僅5位(12.5%)在急診出院後三個月內有回診；開始後則增為7位(36.2%)(p=0.016)。邏輯斯迴歸顯示回診率與急診出院時有預約精神科回診及提供個案管理計畫有關。結論：自傷青少年有高比率罹患精神疾患；尤以重複自傷者為甚。回精神科門診的比率頗低，但若在急診出院時予以預約掛號或提供個案管理計畫則能改善。

Objective: Data on adolescents visiting emergency departments (ED) in Asia after acts of self-harm are lacking. This study was to assess characteristics, initial management, and patient compliance with outpatient follow-up in a series of those adolescents with episode of self-harm. Methods: We reviewed the records for the information of demographic and clinical characteristics of adolescents who had visited the ED of a general hospital for self-injurious behavior from June 2004 to June 2007. Types of self-harm and precipitating factors were assessed. We started to implement case management program for suicidal patients in November 2005. We used a quasi-experimental design, to compare the rate of show-up for outpatient clinic between those seen before (n = 40) and after (n = 47) the implementing of this program. Results: Of 87 patients (66 females, mean age: 17.7 years), we found that the most common form of self-harm was drug overdose, and that the most common precipitating factor was having interpersonal stressor. Their current mental disorders were diagnosed in 54 (62%) patients. Those with multiple suicide attempts were found to be more likely to have psychiatric morbidity than those with only one attempt. The outpatient attendance rate was poor. Before the implementation of the case management, only 5 (13%) of those adolescent patients returned for outpatient psychiatric follow-ups in the subsequent three months compared with 17 (36%) after case management was implemented (p = 0.016). Logistic regressions showed that compliance with follow-up was associated with scheduling a follow-up appointment before ED discharge and with being contacted by case managers. Conclusion: Adolescents who harmed themselves had a high rate of psychiatric morbidity, especially those with multiple attempts. Compliance with follow-up was improved after implementing a case management program.