Jeon HJ Bae J Woo JM 서 론 청소년자살은전세계적으로중요한사회문제가되고있다. 자살은죽음을스스로원해서치명적인행동을 통해사망에이른것으로정의할수있다 [1]. 자살은자살사 고 (suicidal idea) 와자살도구에접근, 자살기도 (suicidal attempt

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1 pissn: eissn: Focused Issue of This Month 한국청소년자살 전홍진 1,2 배주미 3 우종민 4-6* 1 성균관대학교의과대학삼성서울병원정신건강의학과우울증센터, 2 하버드대학교의과대학메사추세츠종합병원정신과 Depression Clinical and Research Program, 3 한국청소년상담복지개발원, 4 인제대학교의과대학서울백병원정신건강의학과, 5 인제대학교스트레스연구소, 6 한국보건의료연구원 Recent statistics and risk factors of suicide in children and adolescents Hong Jin Jeon, MD 1,2 Joomi Bae, PhD 3 Jong-Min Woo, MD 4-6* 1 Depression Center, Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 2 Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 3 Korea Youth Counselling and Welfare Institute, 4 Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, 5 Stress Research Institute, Inje University, 6 National Evidence-based Healthcare Collaborating Agency, Seoul, Korea *Corresponding author: Jong-Min Woo, jongmin.woo@gmail.com Received November 16, 2012 Accepted November 30, 2012 Youth suicide is like the tip of an iceberg; while many adolescents have died from suicide, many more adolescents have been harmed by suicide attempts and self-injury. Suicide influences not only the victims, but also their family members, friends, teachers, and neighbors. Witnesses can suffer from posttraumatic stress disorder. Suicide is the second leading cause of death among adolescents worldwide and the first cause of death among Korean adolescents. The number of suicides in Korea, especially among high school students and female students, is rapidly increasing when compared with Western countries. Suicide accounted for 28.2% of deaths among Korean adolescents in There were 4.44% and 18.97% of adolescents who had attempted suicide and had experienced suicidal ideation in their lifetime, which shows that many adolescents have a potential risk for suicide. Previous studies in Western countries have revealed that risk factors for adolescent suicide consist of three categories: sociodemographic factors (male and low socioeconomic and educational status), mental health factors (depression and drug abuse), and individual negative life events and family diversity (family history of suicidal behavior, parental death, and child abuse). In conclusion, suicide is common and rapidly increasing in Korean adolescents. However, the risk factors of suicide and suicide behaviors in Korean adolescents are yet to be determined. A well-designed nationwide survey is needed to investigate the prevalence and risk factors of suicide behaviors and mental disorders among Korean adolescents. Keywords: Adolescent; Suicide; Risk factors c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 대한의사협회지 93

2 Jeon HJ Bae J Woo JM 서 론 청소년자살은전세계적으로중요한사회문제가되고있다. 자살은죽음을스스로원해서치명적인행동을 통해사망에이른것으로정의할수있다 [1]. 자살은자살사 고 (suicidal idea) 와자살도구에접근, 자살기도 (suicidal attempt) 를거쳐완료 (completed suicide) 에이르는일련 의과정으로볼수있다 [2] (Figure 1). 따라서, 자살로사망한경우에그 20 배에달하는자살기 도자가있으며 [3], 훨씬더많은청소년이자해를시도한바 있음을주목해야한다 [4]. 또한한명의청소년이자살을했 을때가족, 친구, 학생을가르치는교사, 이웃등많은수가 큰충격을받게되고일부는충격으로외상후스트레스장애 (posttraumatic stress disorder) 를경험하게된다. 외상후 스트레스장애는우울증과자살시도의위험요인이된다 [5]. 이밖에도청소년자살에는성인과다른위험요인이많이있 는데, 우울증, 충동성, 낮은자존감등개인적인요인이외에 가정불화나부모와의갈등, 경제적어려움과같은가정요 인, 학교폭력, 교우관계, 학업스트레스와같은학교요인, 미디어영향, 주변인의자살과같은사회적요인등이위험 요인이된다 [6]. 이러한위험요인을파악함으로써청소년자 살의예방과조기개입에중요한근거를제시할수있다. 이논문에서는청소년자살의국내외현황을통계자료에 근거하여고찰하고, 청소년자살의예방에있어중요한위험 요인을검토하고자한다. 청소년자살률의국가간비교 자살은전세계적으로 세사망원인의 2 위를차지한 다 [4,7]. 하지만국가및민족에따라큰차이를보이고있다 (Figure 2) 년에 Organization for Economic Co- operation and Development (OECD) 국가에서 세 청소년자살사망은평균 6.5/100,000 로나타났으며, 우리 나라는다소높은 6.8/100,000 로나타났다. 최고치인러시 아 19.7/100,000 과그리스의 1.0/100,000 사이에는 20 배 정도의차이를보이고있다 [8]. 청소년자살률의변화 다른 OECD 국가들에서 세청소년사망률이전반 적으로감소추세를보이는것과는달리국내에서는지속적 인증가추세를보이고있다 (Figure 3). 미국에서는 1990 년 이후로청소년자살률이꾸준히감소하고있지만 OECD 평 균보다는높다. 미국에서 세사망원인의 3 위가자살이 다. 총기류를사용한자살이 45%, 질식이 40%, 음독이 8% 를차지하고있다 [9]. Suicide Suicidal attempt Approaching suicidal tools Suicidal idea Negative thoughts, depression Stress factors (social stress, life-events, poverty, etc.) Figure 1. The course of the suicidal process (From Bae SB, et al. J Korean Med Assoc 2011;54: , with permission from Korean Medical Association) [2]. 최근결과인 2010 년국내 세청소년자살률은 8.3/100,000 으로증가하였다. 특히, 여자에서증가율이남자 보다높은것이특징이다 (Figure 4). 국내 세청소년의 사망자절대숫자는지속적으로감소하고있으나, 사망원인 중자살이차지하는상대적비율은지속적으로증가하고있 다 (Figure 5) 년당시청소년사망원인 1 위는운수사 고 ( 교통사고 ) 였고자살은 2 위였으나, 지난 10 년간운수사고 로인한사망자는감소한반면, 자살로인한사망자는계속증 가하였다 [10] 년의경우, 세청소년의사망원인 1 순위는자살 ( 인구 10 만명당 15.3 명 ) 로교통사고 (8.4 명 ) 보 다두배가까이높았고, 세청소년사망원인중자살의 비중은 2000 년약 13.56% 에서 2010 년약 28.24% 로두배 94

3 Suicide in children and adolescents 특 집 Suicides per 100,000 persons (aged yr) Russia New Zealand Ireland 이상증가하였다 (Figure 5). Finland Chile Canada Estonia Poland Norway Sweden Belgium Switzerland Japan Slovenia Australia 최근 14 세이하연령의자살통계도파악되고있는데, 자 살이 1-14 세청소년의사망원인중 3 위에포함되고있으며, 세아동청소년사망원인중자살의비율이 2000 년 3.74% 에서 2010 년 14.63% 로 4 배이상증가하였다 (Figure 6). 6.8 United States Austria Korea Hungary OECD-33 Iceland Czech Republic Mexico Israel Germany 1-24 세인구의사망원인 1 위가자살로집계되고있어서정 책적관심및대처가필요하다. France Brazil Denmark Luxembourg Netherlands Slovakia United Kingdom Portugal Italy Spain South Africa Greece Figure 2. Adolescent suicide rates aged 15 to 19 years by the World Health Organization in 2008 [7,8]. OECD, Organization for Economic Cooperation and Development. Suicides per 100,000 persons (aged yr) Korea Finland United States Mexico Japan Ireland OECD-33 Figure 3. Changes of adolescent suicide rates aged 15 to 19 years by the World Health Organization and the Statistics Korea from 1990 to 2008 [7,8,10]. OECD, Organization for Economic Cooperation and Development 년한국보건의료연구원에서 년통계청 사망원인자료를이용하여 세청소년의십만명당자살 률을조사한결과, 자살로인한사망자는통계청주민등록연 간인구자료기준 742,816 명중 829 명으로서 5.7/100,000 이 었고, 이중남성은 5.8/100,000, 여성은 5.6/100,000 이었 다 [11]. 연령대가높은 세에서는 8.2/100,000 으로연 령대가낮은 세의 2.5/100,000 에비해 3 배이상차이가 나며, 이는 OECD 국가의 세평균자살률 6.8/100,000 보다높은수준이었다. 연령에따른차이가두드러지게나 타나므로, 학교를기반한자살예방사업에서는고등학생계 층의자살예방을위해더노력해야함을알수있다 년한국보건의료연구원에서 2009 년청소년건강행 태온라인조사자료를분석하여청소년의자살생각과자살 시도현황을살펴본결과, 조사대상자 57,009 명중자살생 각은 10,690 명, 자살시도경험은 2,376 명으로나타났다 [11]. 제 4 기 ( 년 ) 국민건강영양조사자료중청소년연령 대를분석한결과에서는자살생각은 317 명 /2,133 명, 자살시 도는 17 명 /2,132 명으로나타났다. 종합해보면, 세청 대한의사협회지 95

4 Jeon HJ Bae J Woo JM Suicides per 100,000 persons (aged yr) 소년의자살시도율은 4.44%, 평생자살생각률 18.97% 로 자살시도율은자살률에비해 772 배 ( 국외 : 배 ), 자살 생각률은 3,328 배높았다 [11]. 이는자살을고려하는잠재 적위험군이상당수존재함을시사한다 인임이밝혀졌다. Total Male Female Figure 4. Changes of Korean adolescent suicide rates aged 15 to 19 years by the Statistics Korea from 1983 to 2011 [10]. (15-19 yr) a) Annual no. of all cause of death b) Annual no. of suicide 1,800 1,600 1,400 1,200 1, ,777 1,495 1,226 1,240 1, ,058 1,004 1,073 1, b)/a)*100 (%) Figure 5. Changes of number of suicide and all cause of adolescent death aged 15 to 19 years by the Statistics Korea from 2000 to 2010 [10]. 청소년자살위험요인 이전의연구에의해알려 진청소년자살의위험요인 은 Table 1 과같다. 청소년자 살의위험요인은사회인구학 적요인, 정신건강요인, 개인 및가정적요인으로나누어 볼수있다. 정신건강문제인 우울증, 불안장애, 주의력결핍 과잉행동장애 (attention deficit hyperactivity disorder, ADHD), 알코올및약물오남 용의문제가자살과연관되어 있다 [4]. 자살방법에쉽게접 근할수있는것도중요한위 험요인이된다 [9]. Renaud 등 [12] 은캐나다 의퀘벡지방에서자살로사 망한청소년 55 명과다른이 유로사망한청소년 55 명에 대한사후부검연구를진행하 였다. 두군을비교하였을때 자살사망군에서우울증이 있는경우가 48.4 배높았고, 충동조절장애가 13.6 배높았 다. 이에비해서다른정신질 환은자살과의연관성이낮게 나타났다. 이를통해우울증 이성인기뿐아니라청소년에 서도자살사망의주요한원 Chronis-Tuscano 등 [13] 은 ADHD 를가진청소년 125 명 과대조군 123 명을장기추적관찰하였다. 우울증과자살시 도가초기 5 년간은두군에차이가없었으나 5 년부터 13 년 96

5 Suicide in children and adolescents 특 집 (%) Table 1. Risk factors for suicide in adolescents Sociodemographic factors Male (female for attempt and male for completed suicide) 1) Low socioeconomic status 1) 사이에 ADHD 가있는군에서유의한증가를나타내었다. 따라서청소년기 ADHD 가향후자살시도를예측하는위험 요인이된다고하였다 Low educational status 1) yr yr Figure 6. Changes of proportion of suicide among all cause of adolescent death aged 15 to 19 years by the Statistics Korea from 2000 to 2010 [10]. Mental health factors Depression, anxiety, and attention deficit hyperactivity disorder 3) Drug and alcohol abuse/ dependency 3) Hopelessness 1) Previous suicide attempt 2) Impulsive or aggressive tendencies 2) Parental mental disorder 1) Easy access to lethal methods 2) Exposure to the suicidal behavior of others 2) Aseltine 등 [14] 은미국메사추세츠주의웨슬리지방에서 32,217 명의청소년을대상으로자살예방을위한 Signs of Suicide (SOS) Program 을실시하였다. 심각한음주가청소 Individual negative life events and family diversity Parental separation or divorce 1) Parental death 3) Adverse childhood experiences, child abuse 3) Family history of suicidal behavior 3) Interpersonal difficulties 1) Incarceration 2) 1) From Hawton K, et al. Lancet 2012;379: [4]. 2) From Centers for Disease Control and Prevention. Suicide prevention: youth suicide. Atlanta: Centers for Disease Control and Prevention; 2012 [9]. 3) From both [4] and [9] 년자살의중요한위험요인이 되었고, 의사에의해서정기 적으로음주에대한평가를 하는것이자살위험을가진 청소년을발견하는데도움이 되었다고보고하였다. Russell 과 Joyner [15] 는 미국전역에서 11,840 명의 청소년을대상으로성정체 성과자살에대한연구를진 행하였다. 성적소수자의경 우자살에대한생각과시도 가남녀모두에서 2.5 배증가 하는것으로파악되었다. Glowinski 등 [16] 은미주 리지역에서쌍생아 3,416 명 에대해연구를진행하였다. 쌍생아중한명에서자살기도 를하였을때일란성은 5.6 배, 이란성은 4.0 배자살시도위 험이증가하였다. 이로서자 살시도가유전적인영향을 받는다는사실이밝혀졌다. 국내에서 2012 년한국보 건의료연구원이청소년자살 의위험요인에대해연구한 결과, 청소년우울증치료율 ( 우울증치료중인청소년 수 / 전체청소년인구수, %) 을 청소년자살률과비교해볼 때, 우울증치료율이자살률보다더낮은것으로나타났다. 청소년건강행태온라인조사및국민건강영양조사자료분석 에서도우울증이청소년자살의주요원인으로나타난점을 감안하면, 청소년자살생각및자살시도의가장큰위험요 인은우울증이라고볼수있다. 따라서청소년우울증에대 한체계적인관리가필요하다. 한편스트레스원인중교우 대한의사협회지 97

6 Jeon HJ Bae J Woo JM 관계와가정형편이주요한위험요인으로나타났으므로학교폭력과따돌림문제를해결하고사회경제적취약계층의청소년집단을적극적으로관리할필요가있다 [11]. 최근청소년자살관련예방요인에대한연구도활발히이루어지고있다. 스트레스대처능력과가정및사회적지지등이제시되고있으며 [17-20], 국내에서도연구가시작되는단계에있다 [21]. 몇몇국내연구에서는청소년들의자살생각감소에가족의지지 [22], 부모자녀간의애착관계 [23], 가정환경내부모및가족과의긍정적관계 [23,24], 친구와의애착관계 [24] 등이영향을끼치는요인임을밝히고있다. 이는스트레스대처능력과사회적지지의중요성을시사한다 [23,25]. 결론 청소년자살은서구선진국에서는감소하는추세인데반해서한국에서는증가하고있으며, 특히여아에서증가폭이크다. 청소년자살의위험요인은사회인구학적요인, 정신건강요인, 개인및가정적요인으로나누어볼수있다. 정신건강문제인우울증, 불안장애, ADHD, 알코올및약물오남용의문제를조기에발견해치료하고, 부모가제대로돌보고있는지학대를당하고있는지확인하고도움을제공하는것이청소년자살률을감소시키는데중요하다고할수있다. 현재국내여러기관에서청소년자살률, 자살시도율, 자살생각률에대한조사가이루어지고있으나, 자살예방사업의근거확보를위한지속적이고통합적인자료는확보되지못하고있으므로범국가적인종합대책의일환으로청소년자살에대한정기적실태조사가필요하다. 이를통해청소년자살관련위험요인과예방요인및상호관계에대한심층적인연구가필요하다. Acknowledgement This study was fully funded by the National Evidencebased Healthcare Collaborating Agency (NM11-003). 핵심용어 : 청소년 ; 자살 ; 위험요인 REFERENCES 1. Jeon HJ. Depression and suicide. J Korean Med Assoc 2011; 54: Bae SB, Woo JM. Suicide prevention strategies from medical perspective. J Korean Med Assoc 2011;54: World Health Organization. WHO suicide prevention. Geneva: World Health Organization; Hawton K, Saunders KE, O Connor RC. Self-harm and suicide in adolescents. Lancet 2012;379: Jeon HJ, Lee JY, Lee YM, Hong JP, Won SH, Cho SJ, Kim JY, Chang SM, Lee HW, Cho MJ. Unplanned versus planned suicide attempters, precipitants, methods, and an association with mental disorders in a Korea-based community sample. J Affect Disord 2010;127: American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 2001;40(7 Suppl):4S-23S. 7. World Health Organization. WHO mortality database. Geneva: World Health Organization; Organization for Economic Cooperation and Development. Teenage suicide (15-19 years old) [Internet]. Paris: Organization for Economic Cooperation and Development; 2011 [cited 2013 Jan 16]. Available from: familiesandchildren/ pdf. 9. Centers for Disease Control and Prevention. Suicide prevention: youth suicide. Atlanta: Centers for Disease Control and Prevention; Statistics Korea. Suicide rates: aged from 15 to 19 years in Korea. Daegeon: Statistics Korea; Ahn J, Hahn CS, Woo JM, Kim K. A study on Korean psychiatric disorder research: depression and suicide. Seoul: National Evidence-based Healthcare Collaborating Agency; Renaud J, Berlim MT, McGirr A, Tousignant M, Turecki G. Current psychiatric morbidity, aggression/impulsivity, and personality dimensions in child and adolescent suicide: a casecontrol study. J Affect Disord 2008;105: Chronis-Tuscano A, Molina BS, Pelham WE, Applegate B, Dahlke A, Overmyer M, Lahey BB. Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2010;67: Aseltine RH Jr, Schilling EA, James A, Glanovsky JL, Jacobs D. Age variability in the association between heavy episodic 98

7 Suicide in children and adolescents 특 집 drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program. J Am Acad Child Adolesc Psychiatry 2009;48: Russell ST, Joyner K. Adolescent sexual orientation and suicide risk: evidence from a national study. Am J Public Health 2001;91: Glowinski AL, Bucholz KK, Nelson EC, Fu Q, Madden PA, Reich W, Heath AC. Suicide attempts in an adolescent female twin sample. J Am Acad Child Adolesc Psychiatry 2001;40: Compton MT, Thompson NJ, Kaslow NJ. Social environment factors associated with suicide attempt among low-income African Americans: the protective role of family relationships and social support. Soc Psychiatry Psychiatr Epidemiol 2005;40: Walsh E, Eggert LL. Suicide risk and protective factors among youth experiencing school difficulties. Int J Ment Health Nurs 2007;16: Swahn MH, Ali B, Bossarte RM, Van Dulmen M, Crosby A, Jones AC, Schinka KC. Self-harm and suicide attempts among high-risk, urban youth in the U.S.: shared and unique risk and protective factors. Int J Environ Res Public Health 2012;9: Roberts RE, Roberts CR, Xing Y. One-year incidence of suicide attempts and associated risk and protective factors among adolescents. Arch Suicide Res 2010;14: Kim HS, Chae YS, Bae YJ. The protective factors of suicide probability in religious male high school students. J Korean Acad Nurs 2012;42: Lee JY, Hur JH. Family risk factors for child suicidal ideation. Korea J Youth Couns 2003;11: Kim IK, Cho NJ. The validation of structural models on adolescents suicidal ideation. Korea J Couns 2006;7: Moon KS. The effect of academic stress on suicidal impulse in adolescence: mediating roles of parent and peer attachment. Child Stud Divers Contexts 2006;27: Hong YS. The effect of life stress on adolescent suicidal behaviors and the buffering effect of problem-solving ability. J Korean Soc Child Welf 2005;20:7-33. Peer Reviewers Commentary 이논문에서는청소년자살의국내외현황을통계자료에근거하여고찰하였고, 청소년자살의위험요인을검토하였다. 청소년자살에는성인과다른위험요인이많이있는데, 이들위험요인을파악하여청소년자살의예방과조기개입을위한중요한정책적판단기준을마련할수있을것이다. 현재국내여러기관에서청소년자살에대한조사가이루어지고있으나, 자살예방사업의근거확보를위한지속적이고통합적인자료는확보되지못하고있는상황이기때문에이들연구를종합하고고찰하는것은중요한작업이다. 결론적으로소아와청소년의자살이주된사망원인으로증가됨에있어서우울증을포함한정신질환과스트레스의조기진단및조기개입의중요성이점점더커지고있음을보고하였다. 추후전국적인데이터베이스를마련하고, 정기적인추적관찰을통해청소년자살관련위험요인과예방요인및상호관계에대한심층적인연구가필요하겠다. [ 정리 : 편집위원회 ] 대한의사협회지 99

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Vol.266 C O N T E N T S M O N T H L Y P U B L I C F I N A N C E F O R U M 2018.08Vol.266 C O N T E N T S 02 06 30 48 54 66 80 120 M O N T H L Y P U B L I C F I N A N C E F O R U M 2 2018.8 3 4 2018.8 1) 6 2018.8 2) 7 8 2018.8 3) 9 4) 5) 6) 10 2018.8 7) 8) 9) 10) 11 12 2018.8