臺灣博碩士論文加值系統

研究背景及目的：
近來年雖然精神病住院患者整體死亡風險下降，但是仍較一般大眾為高，且其高死亡風險的原因也由早期的自然死因，轉變為非自然死因。本研究希望以出院的精神分裂症患者為研究對象，以明白精神分裂症患者出院後之死亡及其相關因素。本研究也運用「可預防的死亡」的概念，來評估精神分裂症患者的死亡風險及其所接受的醫療照護品質。

研究方法：
以某精神專科教學醫院，共五年之出院患者，且診斷符合精神分裂症(295)或妄想症(297)，年紀大於15歲以上個案為研究對象。針對研究對象，再繼續追蹤二年。以其身份證號，聯結衛生署共七年之死因登錄資料庫，以探查出院患者之存活狀況、死亡日期及死亡原因。以衛生署生命統計資料，與台閩人口統計資料，以計算出院患者之標準化死亡比 (SMR)。

研究結果：
符合本研究收案條件者共有1369人，平均追蹤人年數男性為4.05人年、女性為4.04人年。94人(6.9%)為死亡個案。所有死因標準化死亡比為2.4 (1.9- 2.9)。若以出院時年齡層的標準化死亡比來看，出院時年齡的增加，其標準化死亡比逐漸下降。所有個案的事故傷害死因標準化死亡比為5.4 (2.7-8.1)，所有個案的自殺及自傷死因標準化死亡比為17.8 (9.4-26.3)，女性個案的非自然死因標準化死亡比為14.6(6.7-22.5)，在統計上明顯高於全人口的死亡。以住院天數來看，以30天以下組別及31-180天組別，其標準化死亡比在統計上高於全人口的死亡。
符合「可預防的死因」的個案，共有20位。計算出「可預防的死因」的標準化死亡比為3.9 (2.2-5.6)，在統計上明顯高於全人口的死亡。有13位個案的死亡原因符合「健康照護品質指標」中的6項，「健康照護品質指標」的標準化死亡比為6.0 (2.7-9.3)，在統計上明顯高於全人口的死亡。「健康政策品質指標」共包含4項指標，其標準化死亡比為2.4 (0.6-4.1)，在統計上與全人口的死亡無差異。

結論：
本研究結果顯示精神分裂症患者死亡風險仍然相當高，年齡層愈低的精神分裂症患者，其標準化死亡比愈高。過高的非自然死因標準化死亡比，尤其是自殺死亡部份，與文獻的結果一致，其中以25-34歲的病患族群為最高。
自然死因的標準化死亡比雖然較低，但仍比一般人口來得高。且以「可預防死因」之標準化死亡比來看，其中「健康照護品質指標」的死亡風險過高，顯示精神分裂症患者的醫療照護品質，還有相當大的進步空間。而以「健康政策品質指標」的死亡風險來看，加上精神分裂症患者有高比率的不健康生活型態，更應將精神分裂症患者視為重要介入族群。

Background and purpose:
In general, the mortality of mental disorder inpatients has already declined in recent decades, however, the risk of mortality is still higher than the general population. The risk of mortality changed from natural causes to unnatural causes, which may related with the deinstitution-alization of mental disorder patients. This study aims to examine the mortality of discharged schizophrenic patients. We also introduce the concept of avoidable death to evaluate the quality of medical care and health policy in these schizophrenic patients.

Material and methods:
The subjects were included from one mental hospital in Taiwan, who was discharged with the DSM-IV diagnosis of schizophrenia or delusional disorder and aged over 15 year-old in 1999-2003. These subjects were followed through December 31, 2005. Record linkage performed by the unique identity number of each subject and computerized files of Death Certification System to identify the death of these patients.
Standardized mortality ratio (SMR) was measured, which was calculated as the observed number of deaths divided by the expected number of deaths. The expected number of deaths was calculated by multiplying the number of age - sex specific subjects by the death proportion of corresponding groups in general population. The indicators of avoidable mortality were chosen from the European Community working group list, which were divided into two types. One was medical care indicators, the other was the national health policy indicators .

Results:
1,369 schizophrenic patients were discharged in the study period. 94 patients (6.9%) died by the end of follow-up. The time of follow-up averaged in male patients were 4.05 person-years, in female were 4.04 person-years.
The SMR of discharged schizophrenic patients was 2.4(1.9 for men and 3.2 for women). The SMR was greatest for the younger age group, women, unnatural death, shorter length of hospital stay.
There were only 20 patients met the criteria of avoidable mortality. The SMR of avoidable mortality was 3.9, it is quite high compared with the general population. 13 patients met the health care indicators, the SMR was 6.0. The other 7 patients met the national health policy indicators, the SMR was 2.4.

Conclusions:
The mortality risk of discharged schizophrenic patients is still high, about 2.4-fold compared to the general population. The SMR of unnatural death, especially the suicide, was pronounced elevated. The SMR of avoidable mortality was also elevated, especially the health care indicators. Above all, there are urgent need to pay more attention to the psychiatric care and the physical care of schizophrenic patients.

中文摘要　　　 　I
英文摘要　　　 III
誌謝　　　　　 　V
目次 VI
第一章 研究背景及目的 1
第一節 研究背景 1
第二節 研究目的 3
第二章 文獻探討 4
第一節 精神病患死亡 4
一、精神病患之高死亡率及性別差異 4
二、不同診斷別之精神病患死亡 4
三、精神病患的非自然死因死亡 5
第二節 精神分裂症患者死亡 6
一、文獻回顧 6
二、非自然死因 7
三、第一次住院之精神分裂症患者 7
四、住院精神分裂症患者 8
第三節 可預防性死亡(Avoidable death) 8
一、可預防性死亡 8
二、精神分裂症患者的可預防性死亡 9
第三章 研究方法 11
第一節 研究方法 11
第二節 研究對象 11
第三節 死亡分析 13
第四章　研究結果 14
第一節 樣本及基本資料 14
一、研究樣本 14
二、研究樣本人年數 14
三、死亡樣本 14
第二節 所有死因 15
一、出院時年齡組�g 15
二、性別 15
三、標準化死亡比 15
四、住院次數 16
五、住院天數 17
第三節 自然死因 18
一、出院時年齡組�g及性別 18
二、標準化死亡比 18
三、自然死因診斷別 18
第四節 非自然死因 19
一、出院時年齡組�g及性別 19
二、標準化死亡比 19
三、非自然死因診斷別 20
四、事故傷害 20
五、自殺及自傷 20
第五節 可預防性死因 21
一、可預防性死因 21
二、標準化死亡比 21
三、性別 22
第五章 　討論　 23
第一節 所有死因 23
一、出院時年齡組別 23
二、性別與標準化死亡比 23
三、住院次數 24
四、住院天數 25
第二節 自然死因 26
一、出院時年齡組別 26
二、性別與標準化死亡比 26
三、自然死因診斷別 27
第三節 非自然死因 28
一、出院時年齡組別及性別 28
二、標準化死亡比 29
三、事故傷害 29
四、自殺及自傷 30
第四節 可預防性死因 31
一、標準化死亡比 31
二、可預防性死因的二大類指標 32
三、可預防性死因的診斷別及性別 33
四、可預防性死因的機轉 34
第五節 研究限制 36
第六節 臨床意涵 37
第六章 參考文獻 38
表目次 41
圖目次 61

Amaddeo, F., Barbui, C., Biggeri, A.,& Tansella, M. (2007). Avoidable mortality of psychiatric patients in an area with a community-based system of mental health care. Acta Psychiatrica Scandinavica, 115, 320-325.

Black, D.W., Warrack, G., &Winokur, G. (1985). Excess mortality among psychiatric patients. The Iowa record-linkage study. JAMA, 253(1), 58-61.

Brown, S. (1997). Excess mortality of schizophrenia. A meta-analysis. British Journal of Psychiatry, 171,502-508.

Brown, S., Birtwistle, J., Roe, L., & Thompson, C. (1999). The unhealthy lifestyle of people with schizophrenia. Psychological Medicine, 29, 697-701.

Brown, S., Inskip, H., & Barraclough, B. (2000). Causes of the excess mortality of schizophrenia. British Journal of Psychiatry, 177, 212-217.

Campbell M.J., Machin D. (1999) Medical Statistics. England: John Wiley & Sons Ltd.

Charlton, J.R.H., Silver, R., Hartley, R.M., & Holland, W.W. (1983). Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet, 1, 691-696.

Chen, W.J., Huang, Y.J., Yeh, L.L., Rin, H., & Hwu, H.G. (1996). Excess mortality of psychiatric inpatients in Taiwan. Psychiatric Research, 62, 239-250.

Goldacre, M., Seagroatt, V., & Hawton, K. (1993). Suicide after discharge from psychiatric inpatient care. Lancet, 342, 283-86.

Hansen, V., Jacobsen, B.K. &Arnesen, E. (2001). Cause-specific mortality in psychiatric patients after deinstitutionalization. British Journal of Psychiatry 179, 438-443

Haugland, M.A., Craig, T.J., Goodman, A.B., & Siegel, C. (1983).Mortality in the Era of Deinstitutionalization. American Journal of Psychiatry, 140, 848-852.

Hiroeh, U., Appleby, L., Mortensen, P.B., & Dunn, G. (2001).Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. Lancet, 358, 2110-12.

Holland, W.W. (1991). European Community Atlas of “Avoid-able Death”.2nd ed. Volume one. Commission of the European Communities Health Services Research Series No.6. Oxford：Oxford Medical Publication.

Joukamaa, M., Heliovaara, M., Knekt, P., Aromaa, A., Raitasalo, R., & Lehtinen, V. (2001). Mental disorders and cause-specific mortality. British Journal of Psychiatry, 179, 498-502.

Kuo, C.J., Tsai, S.Y., Lo, C.H., Wang, Y.P., & Chen, C.C. (2005). Risk factors for completed suicide in schizophrenia. Journal of Clinical Psychiatry, 66,579-585.

Licht, R.W., Mortensen, P.B., Gouliaev, G., & Lund, J.(1993) Mortality in Danish psychiatric long-stay patients, 1997-1982. Acta Psychiatrica Scandinavica, 87, 336-341.

Mortensen, P.B., Juel, K. (1990). Mortality and causes of death in schizophrenic patients in Denmark. Acta Psychiatrica Scandinavica, 81,372-377.

Mortensen, P.B., Juel, K. (1993). Mortality and Causes of Death in First Admitted Schizophrenic Patients. British Journal of Psychiatry, 163,183-189.

Osby, U., Correia, N., Brandt, L., Ekbom, A., & Sparen, P. (2000). Mortality and causes of death in schizophrenia in Stockholm County, Sweden. Schizophrenia Research, 45, 21-28.

Politi, P., Piccinelli, M., klersy, C., Madini, S., Lusignani, G.S., Fratti, C., & et al. (2002). Mortality in psychiatric patients 5 to 21 years after hospital admission in Italy. Psychological Medicine, 32, 227-237.

Rutstein, D.D., Berenberg, W., & Chalmers, .T.C. (1976). Measuring the quality of medical care. A clinical method. The New England Journal of Medicine, 294, 582-589.

Saha, S., Chant, D., & McGrath, J. (2007). A Systematic Review of Mortality in Schizophrenia. Archives of General Psychiatry, 64(10), 1123-1131.

Saugstad, L.F., Odegard, O. (1979). Mortality in psychiatric hospitals in Norway 1950-74. Acta Psychiatrica Scandinavica, 59, 431-447.

Sohlman, B., Lehtinen, V. (1999). Mortality among discharged psychiatric patients in Finland. Acta Psychiatrica Scandinavica, 99,102-109.

Stark, C., Macleod, M., Hall, D., O’Brien, F., Pelosi, A. (2003). Mortality after discharge from long-term psychiatric care in Scotland, 1977-94: a retrospective cohort study. BMC Public Health, 3, 30-34.