臺灣博碩士論文加值系統

【前言】
糖尿病在許多國家盛行率都相當高，醫療成本支出也越來越多。精神科病人合併糖尿病的比例比一般族群高，治療難度也大幅提升。

【研究動機與目的】
目前大部分關於糖尿病治療的文獻，皆以非精神科病人的整合醫療照護研究為主。本研究將分析比較，全職內分泌新陳代謝科醫師加入精神科機構之長期照護團隊，直接參與整合照護後，第二型糖尿病之慢性精神科病人的血糖變化。

【研究方法】
本研究以回溯性研究方式回顧，研究對象為慢性病房住院中的56位精神病人。107年1月新陳代謝科醫師介入照護團隊，本研究先以成對樣本t檢定分析比較新陳代謝科醫師介入之前，105年度與106年度之糖化血色素、空腹血糖變化；再比較新陳代謝科醫師介入之後，106年度與107年度之糖化血色素、空腹血糖變化。

【結果】
研究結果顯示，此照護模式對病人的飲食習慣、活動習慣皆有正面的影響。以卡方檢定分析，飲食習慣改善與HbA1c的進步之間，有顯著相關(X2=4.487, p=0.034)，活動參與度改善與HbA1c的進步之間，亦有顯著相關(X2=11.864, p=0.001)。全體病人之平均糖化血色素、空腹血糖皆有顯著改善(p<0.05)。針對女性患者而言，平均糖化血色素、空腹血糖雖有改善，但未達顯著意義(p>0.05)。至於男性患者，平均糖化血色素有顯著改善(P<0.05)，而空腹血糖雖有改善，但未達顯著意義(p>0.05)。

【結論】
本研究是第一個以全職內分泌新陳代謝科醫師直接參與精神科長照機構之長期照護團隊所進行的糖尿病照護研究，研究結果顯示，此照護模式對病人的飲食習慣、活動習慣皆有正面的影響。經由此照護模式介入後，病人的平均糖化血色素與空腹血糖皆有顯著改善。此研究不僅替長期照護醫療系統提供了正向且可行的做法，更是值得重視且應積極進行並推廣的健康促進措施。

Introduction:
Diabetes is prevalent in many countries and its costs of medical care are increasing. The proportion of diabetes is higher in psychiatric patients than that of general population, and the difficulties of treatment also raises significantly.

Purpose:
Most studies about integrated diabetes care were focused on non-psychiatric patients. Our study will analyze the glycemic change in chronic psychiatric patients with type 2 diabetes in a psychiatric center, after a full-time specialist of endocrinology and metabolism participated in the long-term-care team and directly involved in the integrated care.

Methods:
Our retrospective study included 56 resident patients in the chronic psychiatric wards. The specialist of endocrinology and metabolism was engaged in the integrated care team since January 2018. We first used paired-t test to analyze the glycemic change between 2016 and 2017 before our interventional care, and then analyze the glycemic change between 2017 and 2018 after our interventional care.

Results:
The results showed that this care model has positive impacts on the patient's eating habits and activity habits. Chi-square test analysis showed significant relationship between the improvement of eating habits and average glycated hemoglobin (HbA1c) level (X2=4.487, p=0.034), and also between the improvement of activity habits and average HbA1c level (X2=11.864, p=0.001). The average HbA1c and fasting blood glucose (AC) of all patients were both significantly improved (p<0.05). For female patients, the average HbA1c and AC were both improved, but there was no significant change noted (p>0.05). For male patients, the average HbA1c was significantly improved, but there was no significant change found in average AC (P>0.05).

Conclusion:
To our best knowledge, this is the first study of diabetes care based on a full-time specialist of endocrinology and metabolism, who was directly involved in the long-term care team in a psychiatric center. The results showed that this care model has positive impacts on the patient's eating habits and activity habits. The average HbA1c and AC were both significantly improved after our intervention. This study not only provides a positive and feasible approach to medical systems of long-term care, but also setup a health promotion measure that deserves attention and should be actively implemented and promoted.

第一章：緒論
第一節：研究動機
第二節：研究目的

第二章：文獻探討
第一節：慢性精神科病人常見的新陳代謝疾患
第二節：慢性精神科病人之營養
第三節：慢性精神科病人之運動治療
第四節：慢性精神科病人整合醫療照護

第三章：研究方法
第一節：名詞定義
第二節：研究架構
第三節：研究設計

第四章：結果
第一節：收案機構之慢性精神科住院患者基本資料分析
第二節：105年與106年血糖變化分析
第三節：介入前後個案飲食習慣分析
第四節：介入前後個案活動參與度分析
第五節：106年與107年血糖變化分析
第六節：106年與107年TG分析
第七節：106年與107年LDL分析
第八節：106年與107年BMI分析
第九節 ：總結與分析資料彙整

第五章：討論
第一節：慢性精神科糖尿病病人血糖改善分析
第二節：慢性精神科糖尿病病人血脂控制分析
第三節：慢性精神科糖尿病病人的營養照護
第四節：慢性精神科糖尿病病人的運動照護
第五節：研究限制

第六章：結論

第七章：未來展望

參考文獻
圖表目錄

1、Annamalai, A., Staeheli, M., Cole, R. A., & Steiner, J. L. (2018). Establishing an Integrated Health Care Clinic in a Community Mental Health Center: Lessons Learned. Psychiatr Q, 89(1), 169-181. doi:10.1007/s11126-017-9523-x
2、Aucoin, M., LaChance, L., Cooley, K., & Kidd, S. (2018). Diet and Psychosis: A Scoping Review. Neuropsychobiology, 1-23. doi:10.1159/000493399
3、Baker, A., Sirois-Leclerc, H., & Tulloch, H. (2016). The Impact of Long-Term Physical Activity Interventions for Overweight/Obese Postmenopausal Women on Adiposity Indicators, Physical Capacity, and Mental Health Outcomes: A Systematic Review. J Obes, 2016, 6169890. doi:10.1155/2016/6169890
4、Balhara, Y. P. (2011). Diabetes and psychiatric disorders. Indian J Endocrinol Metab, 15(4), 274-283. doi:10.4103/2230-8210.85579
5、Berk, M., Williams, L. J., Jacka, F. N., O'Neil, A., Pasco, J. A., Moylan, S., . . . Maes, M. (2013). So depression is an inflammatory disease, but where does the inflammation come from? BMC Med, 11, 200. doi:10.1186/1741-7015-11-200
6、Biddle, S. (2016). Physical activity and mental health: evidence is growing. World Psychiatry, 15(2), 176-177. doi:10.1002/wps.20331
7、Black, R. L., & Duval, C. (2019). Diabetes Discharge Planning and Transitions of Care: A Focused Review. Curr Diabetes Rev, 15(2), 111-117. doi:10.2174/1573399814666180711120830
8、Castelnuovo, G., Pietrabissa, G., Manzoni, G. M., Cattivelli, R., Rossi, A., Novelli, M., . . . Molinari, E. (2017). Cognitive behavioral therapy to aid weight loss in obese patients: current perspectives. Psychol Res Behav Manag, 10, 165-173. doi:10.2147/prbm.S113278
9、Chen, D. C., Zhou, M. A., Zhou, D. H., Xiu, M. H., Wu, G. Y., Kosten, T. R., & Zhang, X. Y. (2011). Gender differences in the prevalence of diabetes mellitus in chronic hospitalized patients with schizophrenia on long-term antipsychotics. Psychiatry Res, 186(2-3), 451-453. doi:10.1016/j.psychres.2010.07.054
10、Chien, I. C., Hsu, J. H., Lin, C. H., Bih, S. H., Chou, Y. J., & Chou, P. (2009). Prevalence of diabetes in patients with schizophrenia in Taiwan: a population-based National Health Insurance study. Schizophr Res, 111(1-3), 17-22. doi:10.1016/j.schres.2009.04.003
11、Correll, C. U., Solmi, M., Veronese, N., Bortolato, B., Rosson, S., Santonastaso, P., . . . Stubbs, B. (2017). Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry, 16(2), 163-180. doi:10.1002/wps.20420
12、Deng, C. (2013). Effects of antipsychotic medications on appetite, weight, and insulin resistance. Endocrinol Metab Clin North Am, 42(3), 545-563. doi:10.1016/j.ecl.2013.05.006
13、Druss, B. G., Rohrbaugh, R. M., Levinson, C. M., & Rosenheck, R. A. (2001). Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry, 58(9), 861-868.
14、Druss, B. G., Zhao, L., Von Esenwein, S., Morrato, E. H., & Marcus, S. C. (2011). Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care, 49(6), 599-604. doi:10.1097/MLR.0b013e31820bf86e
15、Ho, M., Marger, M., Beart, J., Yip, I., & Shekelle, P. (1997). Is the quality of diabetes care better in a diabetes clinic or in a general medicine clinic? Diabetes Care, 20(4), 472-475. doi:10.2337/diacare.20.4.472
16、Holt, R. I., & Mitchell, A. J. (2015). Diabetes mellitus and severe mental illness: mechanisms and clinical implications. Nat Rev Endocrinol, 11(2), 79-89. doi:10.1038/nrendo.2014.203
17、Horn, M., Procyshyn, R. M., Warburton, W. P., Tregillus, V., Cavers, B., Davidson, J., & Panagiotopoulos, C. (2012). Prescribing second-generation antipsychotic medications: Practice guidelines for general practitioners. British Columbia Medical Journal., 54(2), 75-82.
18、IDF. (2017). Diabetes Atlas. Retrieved from http://www.diabetesatlas.org/across-the-globe.html
19、Jesus, M., Silva, T., Cagigal, C., Martins, V., & Silva, C. (2018). Dietary Patterns: A new therapeutic approach for depression? Curr Pharm Biotechnol. doi:10.2174/1389201019666180925122116
20、Kruse, J., Schmitz, N., & Thefeld, W. (2003). On the association between diabetes and mental disorders in a community sample: results from the German National Health Interview and Examination Survey. Diabetes Care, 26(6), 1841-1846.
21、Leinung, M. C., Gianoukakis, A. G., Lee, D. W., Jeronis, S. L., & Desemone, J. (2000). Comparison of diabetes care provided by an endocrinology clinic and a primary-care clinic. Endocr Pract, 6(5), 361-366. doi:10.4158/ep.6.5.361
22、Li, C., Xu, D., Hu, M., Tan, Y., Zhang, P., Li, G., & Chen, L. (2017). A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for patients with diabetes and depression. J Psychosom Res, 95, 44-54. doi:10.1016/j.jpsychores.2017.02.006
23、Logan, A. C., & Jacka, F. N. (2014). Nutritional psychiatry research: an emerging discipline and its intersection with global urbanization, environmental challenges and the evolutionary mismatch. J Physiol Anthropol, 33, 22. doi:10.1186/1880-6805-33-22
24、Lopuszanska, U. J., Skorzynska-Dziduszko, K., Lupa-Zatwarnicka, K., & Makara-Studzinska, M. (2014). Mental illness and metabolic syndrome--a literature review. Ann Agric Environ Med, 21(4), 815-821. doi:10.5604/12321966.1129939
25、Matthew, C. R. (2018). Standards of Medical Care in Diabetesd-2018: American Diabetes Association.
26、Matthew, C. R. (2019). Standards of Medical Care in Diabetesd-2019: American Diabetes Association.
27、Meyer, J. M., Davis, V. G., Goff, D. C., McEvoy, J. P., Nasrallah, H. A., Davis, S. M., . . . Lieberman, J. A. (2008). Change in metabolic syndrome parameters with antipsychotic treatment in the CATIE Schizophrenia Trial: prospective data from phase 1. Schizophr Res, 101(1-3), 273-286. doi:10.1016/j.schres.2007.12.487
28、Morkl, S., Wagner-Skacel, J., Lahousen, T., Lackner, S., Holasek, S. J., Bengesser, S. A., . . . Reininghaus, E. (2018). The Role of Nutrition and the Gut-Brain Axis in Psychiatry: A Review of the Literature. Neuropsychobiology, 1-9. doi:10.1159/000492834
29、Pearsall, R., Smith, D. J., Pelosi, A., & Geddes, J. (2014). Exercise therapy in adults with serious mental illness: a systematic review and meta-analysis. BMC Psychiatry, 14, 117. doi:10.1186/1471-244x-14-117
30、Rao, T. S., Asha, M. R., Ramesh, B. N., & Rao, K. S. (2008). Understanding nutrition, depression and mental illnesses. Indian J Psychiatry, 50(2), 77-82. doi:10.4103/0019-5545.42391
31、Ripoli, C., Pinna, A. P., Podda, F., Zanni, R., Tronci, M. G., & Nurchi, A. M. (2017). Second-generation antipsychotic and diabetes mellitus in children and adolescents. Pediatr Med Chir, 39(4), 149. doi:10.4081/pmc.2017.149
32、Roberts, S. H., & Bailey, J. E. (2011). Incentives and barriers to lifestyle interventions for people with severe mental illness: a narrative synthesis of quantitative, qualitative and mixed methods studies. J Adv Nurs, 67(4), 690-708. doi:10.1111/j.1365-2648.2010.05546.x
33、Rummel-Kluge, C., Komossa, K., Schwarz, S., Hunger, H., Schmid, F., Lobos, C. A., . . . Leucht, S. (2010). Head-to-head comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis. Schizophr Res, 123(2-3), 225-233. doi:10.1016/j.schres.2010.07.012
34、Scharf, D. M., Eberhart, N. K., Hackbarth, N. S., Horvitz-Lennon, M., Beckman, R., Han, B., . . . Burnam, M. A. (2014). Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report. Rand Health Q, 4(3), 6.
35、Stubbs, B., Firth, J., Berry, A., Schuch, F. B., Rosenbaum, S., Gaughran, F., . . . Vancampfort, D. (2016). How much physical activity do people with schizophrenia engage in? A systematic review, comparative meta-analysis and meta-regression. Schizophr Res, 176(2-3), 431-440. doi:10.1016/j.schres.2016.05.017
36、Sun, X., Tang, W., Ye, T., Zhang, Y., Wen, B., & Zhang, L. (2014). Integrated care: a comprehensive bibliometric analysis and literature review. Int J Integr Care, 14, e017.
37、Suzuki, V. F., Carmona, E. V., & Lima, M. H. (2011). [Planning the hospital discharge of patients with diabetes: the construction of a proposal]. Rev Esc Enferm USP, 45(2), 527-532.
38、Teasdale, S. B., Ward, P. B., Samaras, K., Firth, J., Stubbs, B., Tripodi, E., & Burrows, T. L. (2019). Dietary intake of people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry, 1-9. doi:10.1192/bjp.2019.20
39、Thornton-Jones, Z., Neill, J. C., & Reynolds, G. P. (2002). The atypical antipsychotic olanzapine enhances ingestive behaviour in the rat: a preliminary study. J Psychopharmacol, 16(1), 35-37. doi:10.1177/026988110201600111
40、Ulcickas Yood, M., Delorenze, G. N., Quesenberry, C. P., Jr., Oliveria, S. A., Tsai, A. L., Kim, E., . . . L'Italien G, J. (2011). Association between second-generation antipsychotics and newly diagnosed treated diabetes mellitus: does the effect differ by dose? BMC Psychiatry, 11, 197. doi:10.1186/1471-244x-11-197
41、Vancampfort, D., Firth, J., Schuch, F. B., Rosenbaum, S., Mugisha, J., Hallgren, M., . . . Stubbs, B. (2017). Sedentary behavior and physical activity levels in people with schizophrenia, bipolar disorder and major depressive disorder: a global systematic review and meta-analysis. World Psychiatry, 16(3), 308-315. doi:10.1002/wps.20458
42、Vancampfort, D., Guelinckx, H., Probst, M., Stubbs, B., Rosenbaum, S., Ward, P. B., & De Hert, M. (2015). Health-related quality of life and aerobic fitness in people with schizophrenia. Int J Ment Health Nurs, 24(5), 394-402. doi:10.1111/inm.12145
43、Vardanjani, A. E., Reisi, M., Javadzade, H., Pour, Z. G., & Tavassoli, E. (2015). The Effect of nutrition education on knowledge, attitude, and performance about junk food consumption among students of female primary schools. J Educ Health Promot, 4, 53. doi:10.4103/2277-9531.162349
44、Weinmann, S., Read, J., & Aderhold, V. (2009). Influence of antipsychotics on mortality in schizophrenia: systematic review. Schizophr Res, 113(1), 1-11. doi:10.1016/j.schres.2009.05.018
45、Weltin, A. M., & Lavin, R. P. (2012). The effect of a community garden on HgA1c in diabetics of Marshallese descent. J Community Health Nurs, 29(1), 12-24. doi:10.1080/07370016.2012.645724
46、Weston-Green, K., Huang, X. F., & Deng, C. (2013). Second generation antipsychotic-induced type 2 diabetes: a role for the muscarinic M3 receptor. CNS Drugs, 27(12), 1069-1080. doi:10.1007/s40263-013-0115-5
47、WHO. (2016). Global report on diabetes. Retrieved from http://www.who.int/diabetes/global-report/en/
48、Wildgust, H. J., Hodgson, R., & Beary, M. (2010). The paradox of premature mortality in schizophrenia: new research questions. J Psychopharmacol, 24(4 Suppl), 9-15. doi:10.1177/1359786810382149
49、社團法人中華民國糖尿病衛教學會. (2018). 2018糖尿病衛教核心教材. 台北市: 社團法人中華民國糖尿病衛教學會.
50、社團法人中華民國糖尿病學會. (2018). 2018糖尿病臨床照護指引. 台北市: 社團法人中華民國糖尿病學會.
51、衛生福利部國民健康署. (104). 104年健康促進統計年報. Retrieved from https://www.hpa.gov.tw/Pages/Detail.aspx?nodeid=268&pid=7530
52、衛生福利部國民健康署. (2018). 食物代換表.