台灣50歲以上失能者精神疾病之門診醫療利用分析

Abstract

本研究之目的係呈現台灣50歲以上失能者之精神疾病門診利用情形，並探討精神疾病就診強度與科別選擇之相關影響因素。研究資料來自2002 年行政院衛生署委託台灣大學公共衛生學院執行之「全國長期照護需要評估計畫」，該計畫調查對象為台灣50歲以上失能樣本共14,049人，由調查檔中得到樣本之性別、年齡、教育程度、籍貫、憂鬱傾向、認知功能狀況、身體功能狀況、照顧模式等資訊，並且連結健保檔門診處方及治療明細檔，取得樣本於調查日後一年內精神疾病西醫門診就醫資訊。 台灣50歲以上失能者精神疾病門診利用率為14.4%（2.035人），最常見的三種診斷是「老年期及初老年期器質性精神病態」（848人，6.0%）、「焦慮狀態」（358人，2.5%）、「精神官能性憂鬱症或其他方法未能分類之憂鬱症」（174人，1.2%）。半數以上的精神疾病就醫者（56.1％）都僅在非精神科的科別就診，約四成（44.4%）就醫人次在精神科，五成以上(55.6％)就醫人次在非精神科，最常見前三名非精神科就診科別為：家醫科(含不分科)（18.3%）、神經科（17.9%）、內科（8.4%）。輕型精神疾病就醫患者曾於精神科就診的比率不到兩成（19.3%），八成以上（80.4%）僅在非精神科就診，有45.6%曾就診於家醫科（含不分科）最多。 精神疾病就醫患者就診強度的影響因素方面，有較高的就診次數者為：重型精神疾病患者(β=0.320，95%CI=0.197~0.443)、免部分負擔者(β=0.260，95%CI=0.128~0.392)受過教育者(β=0.278，95%CI=0.138~0.417)；有較低就診次數者為：居家無看護照顧者（β=－0.430，95%CI=－0.639~－0.220）、身體功能重度失能者（β=－0.222，95%CI=－0.386~－0.057）。 精神疾病就醫患者比較容易選擇精神科者為：重型精神疾病患者（OR=8.277，95%CI=6.065~11.296）、免部分負擔者(OR=1.729，95%CI=1.271~2.352)、居住於都市或次都市地區（OR=1.616，95%CI=1.090~2.396，OR=1.400，95%CI=1.023~1.917）；比較不會在精神科就診者為：年齡層越高者、身體功能重度失能者。 規劃精神疾病照護政策時，建議加強不同科別醫師對於精神疾病辨識、早期的發現、病情的控制與轉介專科治療的教育，尤其強調家醫科、神經科、內科等醫師在輕型精神疾病診治轉介的繼續教育。此外，精神健康照護政策規劃者應重視失能者的前傾與使能因素對精神醫療利用的影響，並且一併納入規劃考量。

The objectives of this study were to determine the patterns and correlates of utilization of mental health outpatient services of the disabled over age 50 in Taiwan. A total sample of 140,049 disabled people over age 50 was drawn from the Evaluation of Taiwan National Requirements for Long-Term Care and linked to their mental health outpatient care records 12 months onward. Among disabled people over age 50, the one-year rate of mental health outpatient services was 14.4%. The leading categories of mental illness were ‘senile and presenile organic psychotic conditions’ (6.0%), ‘anxiety states’ (2.5%), and ‘neurotic depression or depressive disorder, not elsewhere classified’ (1.2%). Over half of mental patients sought non-psychiatric services only (56.1%). For mental illness, the leading non-psychiatry departments used were family medicine (18.3%), neurology (17.9%), and internal medicine (8.4%). Of those diagnosed as minor mental cases, less than 20% had consulted a psychiatrist (19.3%), more than 80% visited non-psychiatry departments only (80.4%), and 45.6% had seen a doctor in the department of family medicine. Higher intensity of utilization is found to significantly correlate with having a diagnosed major mental illness (β：0.320, 95% CI：0.197~0.443), being co-payment waived (β：0.260, 95% CI：0.128~0.392) , and being educated (β：0.278, 95% CI：0.138~0.417). Those who were dwelling in community without a fulltime caregiver(β：- 0.430, 95% CI：- 0.639~ - 0.220) or with more ADL limitations (β：- 0.222, 95% CI：- 0.386~ - 0.057) had lower intensity of mental health outpatient services utilization. The tendency to seek psychiatric consultations was associated with a diagnosis of major mental illness (OR：8.277, 95% CI：6.065~11.296) , being co-payment waived (OR：1.729, 95% CI：1.271~2.352) and living in urban or suburban areas （OR=1.616，95%CI=1.090~2.396，OR=1.400，95%CI=1.023~1.917）. Older age and more ADL limitations were negatively associated with using psychiatric services. Medical providers in non-psychiatry departments such as family medicine, neurology and internal medicine do play a role in and share responsibility for mental heath care. Therefore, it is important to strengthen the ability of those health providers with mental health related disciplines in the continuous medical education program. In addition, policy makers of mental health care programs should consider the development of target approaches to meet the needs of the older, uneducated, rural, and co-payment paying individuals.