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研究生:陳韻玲
研究生(外文):Yun-Ling Chen
論文名稱:憂鬱症個案生活調適技巧訓練方案之成效研究
論文名稱(外文):Efficacy of Life Adaptation Skills Training for persons with depression
指導教授:潘璦琬潘璦琬引用關係
指導教授(外文):Ay-Woan Pan
口試委員:熊秉荃鍾麗英高淑芬賴金雪
口試委員(外文):Ping-Chuan HsiungLyinn ChungSusan Shur-Fen GauJin-Shei Lai
口試日期:2015-07-16
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:職能治療研究所
學門:醫藥衛生學門
學類:復健醫學學類
論文種類:學術論文
論文出版年:2015
畢業學年度:103
語文別:英文
論文頁數:120
中文關鍵詞:憂鬱症生活品質職能治療方案可行性成效
外文關鍵詞:depressive disorderquality of lifeoccupational therapy programfeasibilityefficacy
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背景
憂鬱症已成為全球關注的健康照護議題,世界衛生組織指出,憂鬱症在目前全球疾病負擔的排名上位居第四名,但至2030年將躍升為首位。在心理疾患的健康照護和研究方面,生活品質是重要的個案自評成效指標,它是一個多層面的概念,反映了個人對其一般生活滿意度、生理健康、心理健康、社會關係/功能,以及環境的主觀感受。過去的研究顯示職能勝任感、自我掌控信念、環境資源充足度、社會支持滿意度、憂鬱程度、焦慮程度、服用抗憂鬱劑、年齡、性別、教育程度,是憂鬱症生活品質的重要預測因子。
憂鬱症是一種慢性疾病,常會嚴重地影響個人的安適感、工作能力以及心理社會功能,造成社會的重大負擔。職能治療的角色是透過職能活動的參與,幫助人們促進健康和生活參與。研究顯示,適當的職能參與與心理疾患的憂鬱症狀降低有顯著關聯。然而,目前在台灣仍較少研究針對憂鬱症個案探討以職能為基礎的生活品質促進方案之成效。因此,研究者根據過去研究的生活品質預測模式、臨床經驗、已發展的心理社會治療方案以及網路相關資源,針對台灣居住於社區中的憂鬱症個案,發展出一套標準化的生活調適技巧訓練之介入方案。
在進行本研究前先進行兩個初探研究,結果顯示,生活調適技巧訓練方案適用於居住於社區的心理疾患個案,且能夠有效改善其憂鬱程度。本研究目的是透過單盲隨機控制試驗,驗證生活調適技巧訓練方案在憂鬱症個案的生活品質、症狀、職能和環境改善之介入成效。

方法
自台北市的精神科門診招募憂鬱症個案,將68位同意參與研究者隨機分派至介入組(33位)與控制組(35位)。介入組個案接受24次生活調適技巧訓練團體及電話關懷,控制組僅接受24次電話關懷。本研究主要的成效評量為台灣簡明版世界衛生組織生活品質問卷,次要的成效評量包括職能自我評估、自我掌控信念量表、社會支持問卷、貝氏焦慮量表、貝氏憂鬱量表、貝氏自殺意念量表。運用混和效應模式分析生活調適技巧訓練的療效,並採用部分埃塔平方(ηp2)來計算組間與組內的效果值。

結果
研究結果顯示,生活調適技巧訓練能有效降低憂鬱症個案的焦慮程度和自殺意念程度,具有中度至大的組間和組內效果值,並至少能再有三個月的持續療效。在六個月的研究期間,治療組個案能夠顯著改善其整體生活品質、整體健康、生理健康生活品質、心理健康生活品質、焦慮嚴重度、憂鬱嚴重度,且相較於控制組,具有更大的組內效果值,但未具有顯著的治療成效。
團體參與者享受於介入的課程,個案覺得受用的部分特別是能學習重塑生活安排及學習新的因應技巧來處理壓力情境。此方案能夠提供參與者的療效因子,特別在普同感、灌注希望、存在性因子、情緒宣洩及社交技巧發展。

結論
針對居住於社區的憂鬱症個案,透過24次以職能為基礎,聚焦於重塑生活型態及提升因應技巧的生活調適技巧訓練方案,能夠顯著地改善其焦慮程度及自殺意念程度,具有中度至大的組間和組內效果值,並至少能再有三個月的持續療效。再者,生活調適技巧訓練方案適用於居住於社區的心理疾患。建議未來可針對以下做進一步研究,包括簡短版的生活調適技巧訓練方案的成本效益、生活調適技巧訓練方案在其他族群的成效,以及電話關懷的成效。


Background
Depression has become a significant health care problem around the world. The World Health Organization ranked depression as the fourth leading cause of disability and predicted it to be the first leading causes of burden of disease in high-income countries by 2030. Quality of life (QOL) has gained prominence as a patient-reported outcome (PRO) in healthcare services and research for people with mental illness. Quality of Life (QOL) is a generic, multidimensional construct that describes an individual’s subjective perception of his or her overall life satisfaction, physical health, psychological health, social relationships/functioning, and environment. The results of previous studies showed that sense of competence, sense of mastery, environmental resources, satisfaction with social support, level of depression, level of anxiety, use of anti-depressant medication, age, gender, and education level all played important roles in determining QOL for persons with depression.
Depression is often chronic and can result in difficulties with work and psychosocial functioning, as well as creating a social burden on the community in which the individual resides. The role of occupational therapy is to promote health and participation through engagement in occupation, which has been associated with a reduction in depressive symptoms and significantly correlated with QOL for persons with mental illness. However, there is limited evidence of the effectiveness of occupation-based QOL intervention programs for persons with depression in Taiwan. Based on previous predictive QOL models, experiences, psychotherapeutic workbooks and manuals and relevant online resources, the researcher has developed a novel and manualized treatment program called “Life Adaptation Skills Training (LAST)” for persons with depression in Taiwan.
Prior to research, two pilot studies were conducted which found that the LAST program was a feasible option for people with mental illness who lived in the community and that the program decreased their levels of depression. The purpose of the study was to examine the efficacy of LAST for QOL, symptom reduction, and occupational and environmental improvement for persons with depression, as compared with a control group in a single blind, randomized controlled trial.

Methods
Sixty-eight subjects with depressive disorder were recruited from psychiatric outpatients clinics in Taipei City and were randomly assigned to either the intervention group (N=33) or control group (N=35). The intervention group participated in 24 group sessions of LAST and was contacted 24 times by phone. The control group received only the 24 phone calls. The primary outcome measure was the World Health Organization Quality of Life-BREF-Taiwan version. The secondary outcome measures included occupational self assessment, mastery scale, social support questionnaire, Beck anxiety inventory, Beck depression inventory-II, and Beck scale for suicide ideation. The mixed-effects linear model was applied to analyze the efficacy of LAST and the partial eta squared (ηp2) was used to examine the within- and between-group effect size.

Results
The results showed that LAST was effective in reducing the level of anxiety and suicidal ideation with a moderate to large between- and within-group effect size for persons with depression; it also had a maintenance effect of at least three months. The experiment group subjects significantly improved their overall QOL, overall health, physical QOL, and psychological QOL, as well as reduction their levels of anxiety and levels of depression, with larger within-group effect size than those in the control group during the 6-month study period. However, these outcomes did not show significant intervention effect.
The LAST group participants enjoyed the intervention sessions and felt that the sessions helped them to manage their daily life routines and learn new ways to cope with stressful problems. The intervention provided them with some therapeutic factors, including universality, instillation of hope, existential factors, catharsis, and development of socializing techniques.

Conclusion
For persons with depression living in the community, the 24-session occupation-based LAST program, which focuses on lifestyle rearrangement and coping skills enhancement, significantly reduced levels of anxiety and suicidal ideation, with moderate to large between- and within-group effect size and a maintenance effect of at least three months. Moreover, the LAST program was feasible to use with persons suffering from mental illness who lived in the community. In the future, the cost-effectiveness of the short-term LAST program, the efficacy of LAST on other populations, and the positive effects of phone contact could be further examined.


口試委員會審定書 i
致謝 ii
摘要 iv
ABSTRACT vi
CHAPTER 1 Significance, background, and literature review 1
1.1 Depression 1
1.2 Recovery from depression 2
1.3 Course of illness and medical treatment for depression 3
1.4 Quality of Life (QOL) 5
1.4.1 The concept of QOL 5
1.4.2 The role of occupational therapy in QOL for depression 6
1.4.3 The predictors of QOL 7
1.5 The QOL intervention for persons with depression 10
1.5.1 Pharmacotherapy 12
1.5.2 Psychotherapy 15
1.5.2.1 Cognitive behavioral therapy 17
1.5.2.2 Interpersonal psychotherapy 23
1.5.2.3 Problem solving therapy 26
1.5.2.4 Psychodynamic approach 28
1.5.3 Occupation-based intervention 29
1.5.3.1 Occupational therapy intervention 29
1.5.3.2 Lifestyle intervention 33
1.5.3.3 Life skills training 35
1.5.4 Other interventions 38
1.5.5 Summary of the systematic review of quality of life intervention for depression 40
1.5.6 The delivery of psychosocial intervention 42
1.6 Limitations in previous studies 43
1.7 Purposes of research 44
1.8 Hypotheses of research 44
1.9 The quality of life outcome measure in the study 46
CHAPTER 2 Model of study 48
2.1 Theoretical base 48
2.2 Program content 50
CHAPTER 3 Pilot study 54
3.1 Introduction 54
3.2 The first pilot study 54
3.2.1 Methods 54
3.2.2 Results 56
3.2.3 Discussion 57
3.3 The second pilot study 59
3.3.1 Methods 59
3.3.2 Results 65
3.3.3 Discussion 67
CHAPTER 4 Methodology 70
4.1 Subjects 70
4.2 Research design 70
4.3 Intervention 71
4.4 Measures 72
4.4.1 The Mini-Mental State Examination (MMSE) 73
4.4.2 The World Health Organization Quality of Life-BREF-Taiwan version (WHOQOL-BREF-TW) 73
4.4.3 The Occupational Self Assessment (OSA) 74
4.4.4 Mastery scale 74
4.4.5 Social Support Questionnaire-Short Form (SSQ-SF) 75
4.4.6 Beck Depression Inventory-II (BDI-II) 75
4.4.7 Beck Anxiety Inventory (BAI) 76
4.4.8 Beck Scale for Suicide Ideation (BSS) 77
4.4.9 Activity Participation Questionnaire 78
4.5 Statistical analysis 79
CHAPTER 5 Results 83
CHAPTER 6 Discussion and future study 89
CHAPTER 7 Conclusion 95
REFERENCES 96

LIST OF FIGURES
Figure 1. The framework of Life Adaptation Skills Training (LAST) for depression 1
Figure 2. The framework of the study 2
Figure 3. The consort diagram of the 1st pilot study 3
Figure 4. The consort diagram of the 2nd pilot study 4
Figure 5. The consort diagram of the study 5
Figure 6. The average score of overall QOL for the intervention group and control group over time 6
Figure 7. The average score of overall health for the intervention group and control group over time 7
Figure 8. The average score of physical QOL for the intervention group and control group over time in the formal study 8
Figure 9. The average score of psychological QOL for the intervention group and control group over time 9
Figure 10. The average score of social QOL for the intervention group and control group over time 10
Figure 11. The average score of environmental QOL for the intervention group and control group over time 11
Figure 12. The average score of sense of competence (OSA-Self) for the intervention group and control group over time 12
Figure 13. The average score of environmental resources (OSA-environment) for the intervention group and control group over time 13
Figure 14. The average score of sense of mastery (Mastery scale) for the intervention group and control group over time 14
Figure 15. The average score of satisfaction with social support (SSQ) for the intervention group and control group over time 15
Figure 16. The average score of level of anxiety (BAI) for the intervention group and control group over time 16
Figure 17. The average score of level of depression (BDI-II) for the intervention group and control group over time 17
Figure 18. The average score of level of suicidal ideation (BSS) for the intervention group and control group over time 18

LIST OF TABLES
Table 1. The group sessions of LAST in the 1st pilot study 1
Table 2. Basic information of the 1st pilot study subjects (Time 1) 2
Table 3. The raw score of each outcome measure in the 1st pilot study: Mean (SD) 3
Table 4. The group sessions of LAST in the 2nd pilot study 4
Table 5. Basic information of the 2nd pilot study subjects (Time 1) 5
Table 6. The raw score of each outcome measure in the 2nd pilot study: Mean (SD) 7
Table 7. Basic information of the study subjects (Time 1) 8
Table 8. The raw score of outcome measures in the study: Mean (SD) 10
Table 9. Results of independent sample t-test and repeated measure ANOVA on the outcome measures in the study: Mean (SD) 11
Table 10. Results of the linear mixed-effects model on the outcome measures in the study (ITT analysis) 13
Table 11. Results of the linear mixed-effects model on the outcome measures after controlling for the effects of working status and age at onset of the subjects in the study (ITT analysis) 14
Table 12. Results of the linear mixed-effects model on the outcome measures in the study (per protocol analysis) 16
Table 13. Results of the linear mixed-effects model on the outcome measures after controlling for the effects of working status and age at onset of the subjects in the study (per protocol analysis) 17

LIST OF APPENDICES
Appendix A. The Life Adaptation Skills Training (LAST) program 1
Appendix B. The approval document provided by the ethical committee of National Taiwan University Hospital 5
Appendix C. The accepted paper of the 2nd pilot study 13
Appendix D. The basic information form 22
Appendix E. Mini-Mental State Examination-Chinese version (MMSE-C) 25
Appendix F. The World Health Organization Quality of Life-BREF- Taiwan version (WHOQOL-BREF-TW) 26
Appendix G. The Occupational Self Assessment-Chinese version (OSA-C) 30
Appendix H. Mastery Scale-Chinese version (Mastery-C) 31
Appendix I. Social Support Questionnaire-Short Form-Chinese version (SSQSF-C) 32
Appendix J. Beck Depression Inventory-II-Chinese version (BDI-II-C) 34
Appendix K. Beck Anxiety Inventory-Chinese version (BAI-C) 36
Appendix L. Beck Scale For Suicide Ideation-Chinese version (BSS-C) 37
Appendix M. Activity Participation Questionnaire (sample) 39
Appendix N. The SAS syntax of the mixed effect models in the study 41
Appendix O. The published paper of a part of the study 49

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