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研究生:吳承誌
研究生(外文):Cheng-ChihWu
論文名稱:台灣小兒門診抗憂鬱劑之處方型態分析
論文名稱(外文):Prescribing pattern of antidepressants for pediatric patients in ambulatory care in Taiwan
指導教授:高雅慧高雅慧引用關係
指導教授(外文):Yea-Huei Kao
學位類別:碩士
校院名稱:國立成功大學
系所名稱:臨床藥學與藥物科技研究所
學門:醫藥衛生學門
學類:藥學學類
論文種類:學術論文
論文出版年:2012
畢業學年度:100
語文別:中文
論文頁數:111
中文關鍵詞:抗憂鬱劑處方型態兒童青少年台灣全民健康保險資料庫
外文關鍵詞:antidepressantsprescribing patternchildren and adolescentsTaiwanNHIRD
相關次數:
  • 被引用被引用:3
  • 點閱點閱:556
  • 評分評分:
  • 下載下載:26
  • 收藏至我的研究室書目清單書目收藏:0
研究背景
抗憂鬱劑已被證實能有效改善憂鬱症或焦慮症等精神疾患症狀。受限於倫理因素,往往較難於兒童與青少年族群進行臨床試驗,而無法取得使用於該族群之核准適應症。各國於2003年起陸續發布的警訊指出抗憂鬱劑使用於小兒族群可能提高自殺風險。上述因素皆顯示出缺乏小兒族群使用抗憂鬱劑之療效與安全性資訊,更彰顯利用資料庫進行兒童與青少年族群的回溯研究重要性。
目前台灣使用抗憂鬱劑相關研究付之闕如,惟部分研究著眼於精神疾患盛行率或以成年人為研究對象,較難外推至兒童與青少年族群使用抗憂鬱劑之情況。因此,本研究旨在討論兒童與青少年族群之抗憂鬱劑使用之處方型態,探討其使用盛行率、各類抗憂鬱劑之比例及病患之臨床特性等議題。

研究方法
本研究利用全民健康保險資料庫進行分析,檔案擷取2006年至2007年,年齡小於18歲之兒童或青少年,以3:1的比例隨機抽樣,先行檢視2006年與2007年之盛行率。納入2006/07/01至2007/12/31於門診新使用抗憂鬱劑處方的病患,分析其第一筆處方。研究對象依其使用藥物種類分成selective serotonin reuptake inhibitors (SSRI)、serotonin norepinephrine reuptake inhibitors (SNRI)、tricyclic antidepressant (TCA)及其他 (others)等四組,分析其使用種類、臨床特性,包括人口學特徵、精神相關診斷(mental disorder)、共病症(co-morbidity)、合併使用精神藥物(psychotropic co-medication)情形、精神門診就醫次數(psychiatric visits)與住院次數(psychiatric hospitalization)、開立處方醫師專科別與醫療機構等級。
研究結果
兒童與青少年於2006年及2007年使用抗憂鬱劑之盛行率分別為0.39%及0.44%。在SSRI、SNRI、TCA、其他類等四組使用頻率最高之藥品分別為fluoxetine、venlafaxine、imipramine和trazodone。大部分抗憂鬱劑使用族群為女性及13-18歲,SSRI使用於憂鬱症、焦慮症、強迫症、飲食疾患與雙極性情感疾患,TCA多使用於偏頭痛、夜尿或頻尿等疾病,SNRI則常用於憂鬱症、焦慮症及睡眠障礙。最常與抗憂鬱劑合併使用之精神藥物依序為anxiolytics、hypnotics & sedatives和stimulant。

結論
TCA與其他抗憂鬱劑(SSRI、SNRI和others)的使用情形有較大差異,包括年齡、性別等。SSRI、SNRI及其他類藥物以治療精神相關疾病為主,TCA有較高比例用於偏頭痛及尿液相關疾病。

Background
Antidepressants are proved to be effective on alleviating the depressive or anxious symptoms. Lack of clinical trials including children and adolescents due to ethical considerations would limit efficacy and safety data of antidepressants use, and restrict authorized indications. Promulgated warnings in pediatric population indicate that antidepressants use may elevate suicidal risk. According to those mentioned above, it is worth conducting retrospective database research to obtain some information in this population.
There were some studies on antidepressants conducted in Taiwan. Weakness such as lack of drug use information and limited subjects impeded an overview of antidepressants use in these populations in real world, and could not be extrapolated from adult population. The study aimed to focus on the prescribing pattern of antidepressants use on children and adolescents, and investigate the prevalence of antidepressants use in 2006 and 2007, the proportion of different categories of antidepressants, and clinical characteristics of target population.

Methods
First of all, we surveyed the antidepressants prevalence in 2006 and 2007 utilizing the 3:1 sampled National Health Insurance claims database (NHIRD) composed of children and adolescents younger than 18 years old. Next, we identified the first outpatient antidepressant prescription between 1 July 2006 and 31 December 2007, and we focus on analyzing the first prescription. We divided those population into four groups based on antidepressants use: SSRI, SNRI, TCA, and others. Clinical characteristics, such as demographic traits, mental disorder, co-morbidity, psychotropic co-medication, psychiatric visits, psychiatric hospitalization, physician specialty, hospital ranking, would be further investigated.

Results
The study showed that prevalence of antidepressants use in children and adolescents was 0.39% and 0.44% in 2006 and 2007, respectively. Leading drugs of SSRI, SNRI, TCA, and others were fluoxetine, venlafaxine, imipramine and trazodone, respectively. Those who were female or age between 13-18 years old were the major antidepressant users. SSRI were applied to treat depressive disorder, anxiety disorder, obsessive compulsive disorder, eating disorder, and bipolar disorder. TCA were mostly used for migraine, enuresis and urinary frequency. Lastly, SNRI were found to be prescribed for depressive disorder, anxiety disorder, and sleep disorder. The most concurrent psychotropic agents were anxiolytics, hypnotics & sedatives, and stimulants.

Conclusions
Utilization of TCA group presented a different trait compared with other groups, including age and gender. SSRI, SNRI, and others were mainly used for psychiatric diseases, while TCA was observed that migraine and urinary diseases were the major application.

摘要 I
Abstract III
誌謝 V
目錄 VII
表目錄 X
圖目錄 XII
第一篇、台灣小兒門診抗憂鬱劑之處方型態分析 1
第一章、研究背景 1
第二章、文獻回顧 3
第一節、抗憂鬱劑之藥理機轉、特性與臨床作用 3
一、SSRI 3
二、SNRI 5
三、TCA 5
四、MAOI 6
五、Others 7
六、小結 7
第二節、抗憂鬱劑於小兒族群之臨床試驗、各國核准適應症與小兒精神疾患臨床治療指引 12
第三節、抗憂鬱劑處方型態相關研究 19
一、盛行率(prevalence)、性別與年齡分布 19
二、抗憂鬱劑種類與臨床診斷 20
第三章、研究目的與重要性 22
第四章、研究方法 23
第一節、研究設計 23
一、研究類型 23
二、研究材料與工具 23
三、研究對象與排除條件 25
四、基本資料 25
五、分組 26
六、研究流程 26
第二節、研究名詞、研究變項與操作定義 28
一、研究對象與研究藥品之定義 28
二、研究族群基本資料之定義 28
第三節、資料處理流程 34
第四節、統計資料分析 35
一、統計工具 35
二、統計模式設定 35
三、統計資料分析 35
第五章、研究結果 37
第一節、研究對象收入、排除與分組 37
第二節、兒童與青少年使用抗憂鬱劑之盛行率 37
第三節、各類抗憂鬱劑使用品項 37
第四節、病患基本特性 38
第五節、SSRI及TCA於憂鬱症治療之情形 46
第六章、研究討論 51
第一節、研究對象排除、收入與分組之分析 51
第二節、台灣小兒族群使用抗憂鬱劑盛行率分析 52
第三節、各類抗憂鬱劑使用品項之探討 55
一、SSRI 55
二、SNRI 56
第四節、病患基本特性之探討 57
一、抗憂鬱劑類別與性別年齡分布 57
二、Mental disorder & co-morbidity 58
三、精神門診就醫次數及精神疾患住院次數 62
第五節、SSRI及TCA於治療憂鬱症之探討 64
第六節、研究限制 66
第七章、結論與建議 67
第八章、未來研究方向 68
第二篇、過敏藥警訊系統建置與介面構想 69
第一章、服務背景 69
第二章、服務目的、工具與編纂流程 71
第一節、服務目的 71
第二節、服務工具與編纂流程 71
第三章、服務結果 73
第四章、服務結果探討與討論 78
第五章、如何改善過敏藥警訊系統? 85
第六章、實際應用 89
第七章、結論及未來方向 91
參考文獻 92
附錄:ATC code of categories 102

第一篇
Table 2.1-1 Pharmacological profile of SSRIs 4
Table 2.1-2 Overview of antidepressant use on psychiatric and non-psychiatric diagnoses & side effects 8
Table 2.2-1 Clinical studies of SSRI & SNRI 10
Table 2.2-2 FDA-, TFDA-, and UK-approved indication on antidepressants in pediatric population 10
Table 2.2-2 FDA-, TFDA-, and UK-approved indication on antidepressants in pediatric population (cont.) 11
Table 2.2-3 Clinical recommendation on psychiatric disorders in pediatric population 14
Table 2.3-1 Prevalence of antidepressants use in pediatric population 16
Table 2.3-2 Antidepressant subclasses and diagnoses in pediatric patients 17
Table 4.1-1各檔案間串檔變項說明 24
Table 4.2-1 Antidepressants and corresponding ATC codes 30
Table 4.2-2 Region of residence in Taiwan 31
Table 4.2-3共同使用精神相關藥品 31
Table 4.2-4 ICD-9-CM codes and corresponding diagnoses 33
Table 5.2-1 Prevalence of antidepressants use in Taiwan in 2006 and 2007 40
Table 5.4-1 Baseline characteristics of antidepressant users in pediatric population 42
Table 5.5-1 Baseline characteristics of SSRI &TCA users diagnosed with depressive disorder 48
Table 5.5-2 Average daily dosage in TCA users 50
Table 5.5-3 Dosage of TCA for depression treatment in pediatric population 50
Table 6.4-1 Comparison of antidepressants categories, gender & age distribution, and clinical diagnosis among different studies 59
第二篇
Table 2.2-1 Example of ciprofloxacin based on ATC system 72
Table 2.3-1初步排除範疇之範例列舉 74
Table 2.3-2正確性評估之項目範例列舉 74
Table 2.3-4純口服藥品〈只列出前十名〉 76
Table 2.3-5純針劑藥品〈只列出前十名〉 76
Table 2.3-6兼具針劑與口服劑型之藥品〈只列出前十名〉 77
Table 4.1-1藥品品項討論爭議與共識 81
Table 5.1-1 Common categories of drug allergy profiles 87
Table 6.1-1醫療品質暨病人安全委員會提案單 (節錄) 89
Table 6.1-2 Concise drug allergy categories 90
附錄:ATC code of categories 102

第一篇
Fig 4.1-1研究流程 27
Fig 5.1-1研究對象收入、排除與分組情況 39
Fig 5.3-1 Leading drugs of different pharmacological properties on antidepressants 41
Fig 6.2-1 Prevalence in different countries 54
第二篇
Fig 2.2-1 Algorithm of editing process 72
Fig 2.3-1 Algorithm of editing process & results 73
Fig 2.3-2正確性評估比例圖 77
Fig 5.1-1 Proposed design of drug allergy alerting system 86


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