臺灣博碩士論文加值系統

研究目的:長久以來，精神病人的健康情形被認為比一般民眾差，世界衛生組織(WHO)在2013年就提到患有嚴重精神障礙者比一般民眾減少10-25年的壽命。而台灣根據衛生福利部統計顯示，因慢性精神病領有身心障礙手冊者，至2015年底計有124,240人，佔身心障礙者總數的10.75%(第3位)。精神疾病患者的照護是全球性的問題，因此，本研究主要探討影響慢性精神疾病死亡之風險及相關因素。
研究方法:本研究屬回溯性世代研究，研究資料來自內政部之全國身心障礙登錄檔，串聯全民健保資料庫及死因檔。以2002年至2008年領有身心障礙手冊之慢性精神病患者82,114人為研究對象，觀察至死亡或2012年底止，共計11年的研究期間，針對其人口特質、經濟狀況、都市化程度、精神疾病嚴重度、患者健康狀況、主要照護機構特性等構面，先以univariate Poisson regression analysis了解各變項與死亡率之間的關係、以對數等級檢定(log-rank test)比較不同變項與慢性精神病患者是否死亡之相關性、以Cox proportional hazard model analysis探討影響慢性精神病患者死亡之相關因素。再將慢性精神病患者與一般民眾以propensity score matching進行1:1配對，比較兩組樣本死亡風險及影響因素之差異。
研究結果: 慢性精神病患者死亡率為每千人年19.55，平均死亡年齡為53.45歲。精神障礙程度愈高則死亡率隨之增高，輕度障礙者死亡率每千人年13.29，極重度則升至38.68。若含有其他障礙類別，則死亡率為35.43，較未含其他障礙者高出近2倍。男性死亡率每千人年22，顯著高於女性之16.74。影響死亡之因素最大的為年齡，≧65歲者為＜35歲者之6.39倍(95% CI：5.91~6.91)，其次為共病嚴重度，CCI 3分以上者為無共病者的4.21倍。教育程度較高者則死亡風險偏低(HR=0.78~0.9)，已婚或離婚者較未婚者低(HR=0.44~0.89)，原住民為非原住民的1.24倍，高每月薪資者(≧22,801)較低每月薪資者(≦17,280)死亡風險低(HR=0.93, 95% CI：0.88~0.98, P＜0.05)、居住地區都市化程度較愈高則死亡風險愈低。主要就醫機構為區域級以下醫療院所者死亡風險較醫學中心就醫者高(HR=1.04~1.08)；而主要就醫機構分屬公、私立醫院則無顯著差異。慢性精神病患者與一般民眾相比，死亡風險達3.12倍。在控制其他變項下，與一般民眾相比，不同程度精神障礙者之死亡風險分別為輕度2.47倍、中度2.93倍、重度3.73倍、重度4.08倍。
結論:本研究發現慢性精神病患者死亡風險比一般民眾高出許多，其中以年齡、障礙程度及共病嚴重度為主要的影響因素，研究結果期能作為患者預防保健和政府衛生單位擬定相關政策之參考，藉以降低死亡率。

Objectives: The health condition of patients with chronic psychiatric disorder is generally worse than that of the general public. In 2013, WHO reported that patients with severe psychiatric disorder have a lifespan 10–25 years shorter than that of the general public. This study correlated the risk of death in patients with chronic psychiatric disorder and related factors contributing to their deaths.
Methods: This research is a retrospective and longitudinal cohort study of 82,114 people with chronic psychiatric disorder who were enrolled during 2002-2008 and were registered in National Disability Registration Database. The relevant medical data and cause of death data were taken from the National Health Insurance Research Database. Their incidence of death from that time was noted up until 2012 - a total of 11 years of the study period. First, univariate Poisson regression analysis was undertaken to understand the relationships between variables and mortality, and the log rank test was used to examine the difference among variables in patients with chronic psychiatric disorders leading to death. A Cox proportional hazard model was adopted to analyze the relative risks and related factors for the mortality of patients. These patients were matched 1: 1 with the general public by propensity score matching, and Cox proportional hazard model was used to compare the difference of mortality risk and related factors.
Results：The mortality rate of patients with chronic psychiatric disorders was 19.55 per 1000 person-years and increases with the severity level of the disorder. In addition, their average age at death was 53.45. The mortality rate of patients with mild psychiatric disorders was 13.29 per 1000 person-years, and that of patients with severe mental disorder increased to 38.68. The mortality rate of male patients with psychiatric disorders was 22 per 1000 person-years, which was significantly higher than that of female patients (16.74). The most crucial factor influencing patient death was age (i.e., those aged 65 years or older were 6.39 times more likely to die than those aged 35 years or older), followed by the Charlson Comorbidity Index (CCI; i.e., those who scored greater than 3 in CCI were 4.21 times more likely to die than those who scored 0). Other less crucial factors also affected the patient mortality rate: Specifically, patients who had a higher education or higher income, live in highly urbanized areas, are married or divorced, are nonindigenous origin, or visit medical centers as their primary medical institutions exhibited a higher mortality rate. When all other variables were controlled, the risk of death in patients with chronic psychiatric disorder was 3.12 times higher than that of the general public; and the risk of death in patients with mild, moderate, severe, and very severe psychiatric disorder was 2.47, 2.93, 3.73, and 4.08 than that of the general public, respectively.
Conclusions：This study found that patients with chronic psychiatric disorders have the higher risk of death than those of general public. The most associated factors were age, severity level of the disorder, and comorbidity. The study results can be applied to government agencies while practicing preventive health care or formulating relevant policy. By adapting the appropriate policy, the risk of mortality could be lower and the society could be benefited as well.

第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻探討 4
第一節 慢性精神疾病的定義 4
第二節 慢性精神病患者身心障礙程度之分級 6
第三節 慢性精神疾病死亡率、人口學特質及影響因素 7
第四節 文獻小結 13
第三章 研究設計與方法 14
第一節 研究架構 14
第二節 研究假設 16
第三節 研究對象及資料來源 17
第四節 研究變項說明與操作型定義 20
第五節 資料分析方法 23
第四章 研究結果 24
第一節 慢性精神病患者人口學特質之描述性分析 24
第二節 慢性精神病患者死亡之相關因素分析 25
第三節 慢性精神病患者與一般民眾死亡風險之差異 26
第五章 討論 28
第六章 結論與建議 32
第一節 結論 32
第二節 建議 33
第三節 研究限制 34
參考文獻 45
一、共病嚴重度Charlson Cormorbidity Index(Charlson,1987) 52
二、台灣地區359 鄉鎮市區分層研究結果表(劉介宇,2006) 53

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