| 摘要: | 研究目的：旨以系統性文獻與統合分析方式探討青少年失眠症狀與自殺行為相關性。
研究設計：系統性文獻回顧與統合分析。
研究方法：以系統性回顧的方式，蒐集至2017年4月30日止，國內、外探討青少年失眠症狀與自殺行為相關性之橫斷型研究及縱貫型研究結果。共五個電子資料庫包括:Embase、PubMed、PsychINFO、ProQuest及中國知識資源總庫，進行文獻檢索。納入之文獻品質以2016 JBI critical appraisal instruments評讀標準進行評讀。使用Egger's檢定及Begg相關性排序檢定判定是否出現出版偏差。
研究結果：共納入9篇研究進行統合分析，其中7篇為橫斷型研究，2篇為縱貫型研究，納入總人數為42,527人。針對7篇橫斷性研究結果發現，任一失眠症狀與自殺意念、計畫與企圖具有相關性(合併勝算比=1.68，95% CI = 1.50-1.88; 1.55，95% CI = 1.40-1.72; 1.95，95% CI = 1.53- 2.50 )。以失眠型態細分發現入睡困難型失眠與自殺意念、計畫與企圖具有相關性(合併勝算比=1.66，95% CI = 1.37- 2.02; 1.52，95% CI = 1.27-1.83; 2.01，95% CI = 1.36 -2.95)；睡眠維持困難型失眠僅與自殺意念及計畫具有相關性 (合併勝算比=1.72，95% CI = 1.34- 2.20; 1.93，95% CI= 1.40- 2.67)；早醒型失眠僅與自殺意念相關性合併勝算比為1.34 (95% CI = 1.03 -1.75)。針對2篇縱貫型研究結果顯示，在固定效應模式下，任一失眠症狀與自殺意念與企圖在統計上相關性(合併勝算比=1.21，95% CI = 1.10-1.33; 1.25，95% CI = 1.08-1.44)，但以隨機效應模式進行分析，則無相關性。次族群分析與後設迴歸分析發現，西方比東方國家有較高的失眠症狀與自殺意念相關性 (p = 0.02)。憂鬱症狀不影響失眠症狀與自殺意念、自殺計畫與自殺企圖之相關性 (p = 0.20、0.54與0.25)。年齡愈大的失眠症狀與自殺意念相關性會增強(B=0.24，p=0.05 )，女性百分比越高的失眠症狀與自殺企圖相關性會增強(B=0.04，p=0.003)。Egger’s test與Begg’s test顯示無出版偏差。
結論：有失眠症狀青少年較無失眠症狀的青少年更易產生自殺行為，其中，入睡困難型失眠症狀與自殺意念、計畫與企圖皆具相關性。憂鬱症狀非青少年失眠與自殺行為相關性之調節因子。未來應篩選出具有失眠症狀之青少年，設計有效護理措施，改善失眠症狀，進而與防青少年自殺。
Objective: This study aims to explore the correlations between insomnia symptoms and suicidal behaviors in adolescents.
Design: Systematic review and meta-analysis.
Method: We systematically searched electronic databases, including PubMed, EMBASE, PsycINFO, ProQuest, and CNKI, from their inception to April 30, 2017. Only observational studies that investigated the associations between insomnia symptoms and suicidal behaviors in adolescents were included. The 2016 JBI critical appraisal instruments for appraisal quality was used to assess the study quality. Publication bias was evaluated by the Egger's test and Begg's test.
Results: A total of nine studies (seven for cross-sectional design and two for prospectively longitudinal design) involving 42,527 participants were included. For seven cross-sectional studies, we found significant associations of any insomnia symptom with suicidal ideation, plan, and attempts (pooled odds ratios [ORs] =1.68，95% CI = 1.50-1.88; 1.55，95% CI = 1.40-1.72; 1.95，95% CI = 1.53- 2.50). After dividing insomnia difficulty in maintaining sleep [DMS], and early morning awakening [EMA]), we found that DIS significantly correlated to suicidal ideation, plan, and attempt, that DMS was significantly associated with suicidal ideation and plan, and that EMA significantly correlated to suicidal plan. For two longitudinal studies, there were significant associations of any insomnia symptoms with suicidal ideation and attempt using fixed-effects model (pooled ORs =1.21, 95% CI = 1.10-1.33; 1.25, 95% CI = 1.08- 1.44); however, the significant associations were not observed using random -effects model. For subgroup analyses and meta-regressions, the studies conducted in the Western countries reported a stronger association between insomnia symptoms and suicidal ideation compared to those conducted in the Eastern countries (p = 0.02). Studies that adjusted for depression had comparable association of any insomnia symptoms with suicidal ideation, plan, and attempts in comparison with those did not. (p = 0.20、0.54 and 0.25). The associated between insomnia symptoms and suicidal ideation elevated with increasing age (B = 0.24, p = 0.05). The association between insomnia symptoms and suicidal attempts increased with a higher percentage of women (B=0.04，p=0.003). Both the Egger's test and Begg's test proved no publication bias.
Conclusion: Our meta-analysis suggests substantial associations between insomnia symptoms and suicidal behaviors in adolescents, particularly DIS. Depression did not moderate the relationship. From the standpoint of preventing youth suicide, healthcare providers should screen out adolescents with insomnia symptoms, and scheme effective interventions to reduce youth suicidal rate. |
