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研究生:林冠含
研究生(外文):Kuan-Han Lin
論文名稱:勞工職業傷害發生後之精神疾病調查
論文名稱(外文):Psychological Outcome of Workers after Occupational Injury
指導教授:郭育良郭育良引用關係
口試委員:郭乃文蕭淑銖廖士程
口試日期:2013-04-09
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:職業醫學與工業衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:英文
論文頁數:104
中文關鍵詞:共病症職業傷害創傷後壓力症候群創傷後壓力症候群亞症候群重鬱症復工
外文關鍵詞:comorbiditymajor depressionoccupational injurypost-traumatic stress disorder (PTSD)partial post-traumatic stress disorder (PPTSD)return to work (RTW)
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前言: 職傷後所引起之精神方面損傷是造成勞工無法回復正常工作一個很重要的因素,在回到工作後因心理精神損傷而再度離職的比例也不容忽視。到目前為止,在台灣並沒有針對職場傷害後產生之創傷後壓力症候群(Post-traumatic stress disorder, PTSD)的盛行率與其危險因子進行調查。由於職傷引起之創傷後壓力症候群已列於職業病補償項目當中,因此藉由建立當前台灣勞工職傷後產生之創傷後壓力症候群盛行率及調查其影響回復正常工作情況,作為介入預防之憑據。因此,本研究之目標為:1) 調查職傷後3個月勞工發生創傷後壓力症候群及其他精神疾病的盛行率與可能之危險因子;2)追蹤職傷後12個月勞工發生慢性創傷後壓力症候群及其他精神疾病的盛行率與可能之危險因子;3) 評估職傷後勞工之精神症狀對於復工的影響。

方法: 本研究使用之評量工具為簡式精神症狀自陳量表 (Brief symptom rating scale, BSRS-50)、創傷後症候群檢查表 (Post-traumatic symptom checklist, PTSC)與中文版迷你國際神經精神會談工具 (the Chinese version of the mini-international neuropsychiatric interview, MINI)。研究分為兩階段式評估調查,第一階段將在勞工受傷發生之後的3個月與12個月以郵寄問卷方式寄給4403位勞工填答,作為問卷評估,問卷內容包含BSRS-50、PTSC、復工。第二階段則是針對問卷初篩發現可能有心理問題,尤其PTSD者,由精神科專科醫師使用MINI作電話訪談,進行診斷之篩檢。本研究經台大醫院研究倫理委員會審查通過。

結果: 總共有2001位職傷勞工受傷後3個月第一階段BSRS及PTSC評估,回收率為45.5% (2001/4403)。結果17.8% (357/2001)顯示精神症狀得分較高。有高精神症狀得分者,41.5% (148/357)完成MINI電話訪視。結果發現勞工職業傷害後3個月發生PTSD的個案佔2.7%、創傷後壓力症候群亞症候群(Partial PTSD, PPTSD)4.1%、重鬱症3.0%、而PTSD/PPTSD與重鬱症共病者有2.3%,因此有PTSD/PPTSD或重鬱症者為7.5%。在危險因子方面,研究發現性別(女性)、婚姻狀態(離婚/分居/鰥寡)、職傷後曾昏迷、受傷影響外觀、傷後住院天數、自評受傷嚴重程度、受傷前經歷生活重大事件與受傷後經歷生活重大事件、受傷前收入提供家用都是勞工職傷後容易有慢性精神症狀與創傷後壓力症候群症狀的危險因子。在復工方面,1149位勞工在受傷後3個月復工,而852位尚未復工的勞工在受傷後12個月有225位復工。在未復工危險因子方面,研究發現女性、低教育程度、受傷後住院天數、傷造成身體外觀上的缺陷、受傷類型、受傷後3個月BSRS-50與BSRS-5量表得分高為勞工職業外傷後12個月未能復工之危險因子。而BSRS-50中所評估的十種常見精神症狀中,發現畏懼是未復工的危險因子之一。

結論: 本研究顯示一部分的勞工發生職業傷害後會罹患精神疾病,甚至發展成慢性精神疾病,需要心理輔導及精神醫療。此外,職傷後的精神症狀可預測勞工的復工情形,而畏懼是最能預測未復工的精神症狀。所以,本研究結果顯示職業外傷對於勞工不僅僅造成身體外傷的影響,心理的創傷也需要及時介入,做為預防慢性精神疾病的依據。


Background and objective: The labor who has exposed to a traumatic event may display significant psychiatric disorders that make them unable to return to the work place. The proportion of those returned to the work place, but immediately retarded has been increased. So far, in Taiwan there has no research focused on the prevalence and risk factors of post-traumatic stress disorder (PTSD) in the workplace. However, PTSD has been included in the list of occupational diseases; therefore, the purposes of this study are to examine the prevalence rates of post-traumatic stress disorder in the workplace after occupational injuries, risk factors of post-traumatic stress disorder after occupational injuries, and the effects on return to work (RTW) among the injured workers, in order to reduce the employer’s doubt and to ensure the quality of life of the labors. Therefore, the aims of this study are: 1) To determine the prevalence and risk factors of post-traumatic stress disorder (PTSD) and other psychiatric disorders at 3 months after occupational injuries; 2) To determine the prevalence and risk factors of chronic post-traumatic stress disorder (PTSD) and other psychiatric disorders at 12 months after occupational injuries; 3) To investigate the impact of psychological symptoms on return to work (RTW) in workers after occupational injuries.

Methods: Our study candidates were injured workers in Taiwan who were hospitalized for 3 days or longer and received hospitalization benefits from the Labor Insurance program. A two-staged survey study was conducted. A self-reported questionnaire including the Brief Symptom Rating Scale (BSRS-50) and Post-traumatic Symptom Checklist (PTSC) was sent to workers at 3 months and 12 months after injury. Those who met the criteria were recruited for the second stage phone interview with a psychiatrist using the Mini-international Neuropsychiatric Interview (MINI).

Results: A total of 2001 workers completed the questionnaire (response rate 45.5%) at 3 months after occupational injury. Among them, 357 (17.8%) fulfilled the criteria for the MINI interview and were invited. A total of 148 (41.5%) completed the phone interview. The estimated rates of PTSD, partial PTSD (PPTSD), major depression, comorbid PTSD/PPTSD and major depression, and either PTSD/PPTSD or major depression were 2.7%, 4.1%, 3.0%, 2.3%, and 7.5%, respectively. The risk factors for developing psychological symptoms at 3 months after occupational injury were gender, loss of consciousness after occupational injury, injury affecting physical appearance, occupational injury experience before this event, life experience before and after this injury, length of hospital stay, self-rated injury severity, and percentage of income to the family. On the other hand, a total of 1233 workers completed the questionnaire (response rate 28.0%) at 12 months after occupational injury. Among them, 167 (13.5%) fulfilled the criteria for the MINI interview and were invited. A total of 106 (63.5%) completed the phone interview. The estimated rate of either PTSD/PPTSD or major depression was 5.2%. The risk factors for developing long-term psychological symptoms were gender, education level, loss of consciousness after occupational injury, injury affecting physical appearance, occupational injury experience before this event, life experience before and after this injury, length of hospital stay, self-rated injury severity, and percentage of income to the family. Among 2001 workers who completed RTW questionnaire at 3 months after injury, 1149 had returned to work. Among the 852 who were unable to return to work at 3 months after injury, 225 reportedly returned to work by one year. A proportional hazards regression indicated that after adjusting for all possible risk factors, higher scores in BSRS-50 and BSRS-5 at 3 months after injury were significant risk factors for not return to work (NRTW) at one year after injury. Other risk factors were gender, education level, length of hospitalization, affected physical appearance, and injury type. Among 10 psycho-physiological symptoms of BSRS-50, a proportional hazards regression indicated that high score in phobic-anxiety scale was a risk factor for NRTW.

Conclusion: These results showed that after occupational injuries, a significant proportion of workers suffered from psychiatric disorders, and occupational injury can cause long-term psychological impact in the workers. After considering all other factors, psychological symptoms further predicted poorer probability of returning to work after occupational injury, and phobic-anxiety was the most significant symptom predicting poor RTW. Development of preventive measures among injured workers according to the risk factors identified in this study is warranted.

口試委員會審定書 II
誌謝摘要 III
摘要 IV
Abstract VII
Table of contents X
List of Tables XII
List of Figures XIV
Glossary XV
Chapter 1 Introduction 1
Chapter 2 Literature Review 4
A. Psychological Outcome following Traumatic Event 4
B. Psychological Outcome following Traumatic Event in the Workplace 4
C. Psychological Outcome after Occupational Injury 6
D. Psychological Outcome following Traumatic Event in Taiwan 6
E. Return to Work after Injury 7
F. Psychological Symptoms and Return to Work 8
Chapter 3 Material and Method 10
A. Part I 10
B. Part II 13
C. Part III 17
Chapter 4 Results 21
A. Part I 21
B. Part II 23
C. Part III 26
Chapter 5 Discussion 29
A. Prevalence of PTSD and other psychiatric disorders after occupational injury 29
B. PTSD and PPTSD 32
C. Comorbidity of PTSD/PPTSD and major depression 32
D. Prevalence of psychiatric disorders varied among different types of injuries 33
E. The association between risk factors and the occurrence of psychological symptoms 34
F. RTW after occupational injury 36
G. Predictors of RTW 36
H. Limitation 38
I. Suggestion 40
Chapter 6 Conclusion 42
Reference 43
Publication List 54
A. Referred papers 54
B. Conference papers 54
Appendix 101
A. Brief Symptom Rating Scale-50 (BSRS-50) 101
B. Post-traumatic Symptom Checklist (PTSC) 103
C. Brief Symptom Rating Scale-5 (BSRS-5) 104


List of Tables
Table 1. DSM-IV Criteria for Post-traumatic Stress Disorder 56
Table 2. Injury mechanisms and injury types in participants and non-participants. 59
Table 3. Characteristics of injured workers who completed the questionnaire (Total=2001) 60
Table 4. Number and percent of participants who scored at severe levels by BSRS-50 General severity index (GSI), the ten psycho-physiological symptoms of BSRS-50, and PTSC. 63
Table 5. Prevalence rates of psychiatric disorders among Mini-international Neuropsychiatric Interview (MINI) interviewees and estimated prevalence rates of psychiatric disorders 3 months after occupational injuries. 64
Table 6. Prevalence of PTSD symptoms from Mini International Neuropsychiatric Interview (MINI). 65
Table 7. Estimated prevalence rates of psychiatric disorders 3 months after different occupational injuries. 66
Table 8. Risk factors of psycho-physiological symptoms and post-traumatic stress disorder symptoms by BSRS and PTSC in linear regression model at 3 months after injury. 67
Table 9. Risk factors of psycho-physiological symptoms and post-traumatic stress disorder symptoms by BSRS and PTSC in multiple logistic regression model at 3 months after injury. 68
Table 10. Characteristics of injured workers who completed the questionnaire at 12 months after occupational injury. (Total=1233) 71
Table 11. Number and percent of participants who scored at severe levels by BSRS-50 General severity index (GSI) and the ten psycho-physiological symptoms of BSRS-50. 74
Table 12. Prevalence rates of psychiatric disorders among Mini-international Neuropsychiatric Interview (MINI) interviewees and estimated prevalence rates of psychiatric disorders 12 months after occupational injuries. 75
Table 13. Prevalence of PTSD symptoms from Mini International Neuropsychiatric Interview (MINI). 76
Table 14. Estimated prevalence rates of psychiatric disorders 12 months after different occupational injuries. 77
Table 15. Risk factors of psycho-physiological symptoms and post-traumatic stress disorder symptoms by BSRS and PTSC in linear regression model at 12 months after injury. 79
Table 16. Risk factors of psycho-physiological symptoms and post-traumatic stress disorder symptoms by BSRS and PTSC in multiple logistic regression model at 12 months after injury. 80
Table 17. Comparison of characteristics between workers who completed the questionnaire at 3 months and 12 months after occupational injury. 83
Table 18. Comparison of the severity of BSRS score at 3 months and 12 months. (N=853). 85
Table 19. Comparison of the severity of PTSC score at 3 months and 12 months. (N=853). 86
Table 20. Demographics, condition associated with the injury, and return to work of injured workers who participated this study. (Total=2001) 87
Table 21. Number and percent of participants who scored at severe levels by BSRS-50 General severity index (GSI), the ten psycho-physiological symptoms of BSRS-50, or BSRS-5. 90
Table 22. Adjusted Ratio of return to work 1 year after Occupational Injury by a proportional hazards analysis. 91
Table 23. Adjusted Ratio of return to work one year after injury by psycho-physiological symptoms of BSRS-50 and BSRS-5. 93

List of Figures
Figure 1. PTSD among survivors of 1999 Taiwan Earthquake. 95
Figure 2. Enrollment of subjects in the study. 96
Figure 3. Distribution of mechanisms of occupational injury in injured workers (N=2001). 97
Figure 4. Distribution of mechanisms of occupational injury in injured workers (N=1233). 98
Figure 5. The percentage of participants not yet return to work one year after occupational injury, as GSI score of BSRS-50. 99
Figure 6. Receiver-operating characteristic curves for the prediction of not return to work by model 1 and model 2. Factors of model 1 include gender, age, education, length of hospital stay, injury affected physical appearance, injury type, and loss of consciousness. Model 2 includes model 1 variables, BSRS-5, and phobic-anxiety score of BSRS-50. The diagonal line indicates a reference area under curve (AUC) = 0.5 (no better than chance alone). *p-value for AUC of models compared with AUC = 0.5. 100

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