疾病管理模式於重返社區之精神分裂症病患 的成效性研究

Abstract

本研究主要關切的研究主體為：精神分裂症病患，面對本國精神分裂症病患極為強烈、卻長期未被滿足的連續性照護需求，乃是觸動研究者專業良知與採取研究行動的主要動機。 本研究主要目的為發展與測試「疾病管理模式」於即將出院精神分裂症病患之臨床成效，採取隨機對照組實驗性研究設計，樣本為即將出院的精神分裂症病患，共97位，經以隨機方法將之分派至實驗組(由護理人員提供每週兩次、為期三週團體型式之「疾病管理模式」)或對照組(常規處置)，所測量的成效指標包括：疾病知識、服藥態度、遵囑服藥行為、病識感及精神症狀等五項，測量時間點為處置前、後、及處置後一個月。資料分析方面，本研究採取「意向分析(Intention to treat analysis)」，使用SPSS Window 13.0 版套裝軟體進行描述性統計分析，並在樣本數充分且符合常態分佈下，進行獨立樣本t 檢定、卡方檢定，以比較兩組於基本屬性變項及各成效指標之差異；對於處置前、後及之後一個月的縱貫性時間序列中各項成效指標的變化，則採用與時間有關之重複測量—以「線性混合模式(linear mixed model)」比較兩組隨時間而產生的成效變化。 本研究九十七位有效樣本中，共有八十七位完成三次的追蹤評量。在九十七位病患中，以男性、未婚、未就業者居多，各佔所有病患之七成，診斷為精神分裂症者佔96%(其餘為情感性精神分裂症)，教育程度為高中者佔近五成(國中及大學各佔兩成左右)，平均年齡為35.26歲(標準差為9.51)，患病年數為11. 52年(標準差為8.47)；兩組病患在基本屬性與疾病特性等變項皆未有顯著差異。在處置結束後的立即成效方面，實驗組較對照組病患更能顯著提高病患於服藥態度、病識感、及遵矚服藥行為的成效；延續性成效方面，對照組在第三次測量時(處置後一個月)其於疾病知識、服藥態度、與病識感的表現皆變差，但，實驗組於各項成效變項則仍持續進展且顯著優於對照組。在處置結束後的成效值變化，實驗組各項指標皆達中等成效值(除了遵囑服藥行為以外)，至處置後一個月，病識感已達高度成效值(0.95)，相對而言，處置後對照組在各項成效指標的表現皆低於或僅達最小成效值。以線性混合模式分析各項成效指標在縱貫性時間序列間的變化，發現實驗組病患在疾病知識、病識感、及服藥態度等三方面，隨著時間推移而產生的進展顯著優於對照組。 研究結果支持本研究所發展由精神科護理人員所實施的「疾病管理模式」是一套具有實證基礎與文化適應性的處置模式，其可改善即將出院精神分裂症病患之疾病管理能力，且該處置對於疾病知識、病識感、及服藥態度三方面的成效可延續至處置後一個月。未來研究可延長處置成效的追蹤時間、採用更為貼近之疾病管理行為的測量指標，並繼續驗證本模式於不同處置對象、使用不同處置實施者的處置成效。本研究的實證結果，可作為來日發展本國連續性精神衛生護理模式的參考依據。

This study aimed to develop and evaluate the effectiveness of the illness management model for patients with schizophrenia to reenter community by conducting a randomized controlled trial. Ninety-seven patients with schizophrenia were randomly assigned to the illness management model or the treatment as usual alone. Multiple outcomes were measured before the intervention, after completion of intervention, and at one-month after the intervention. Data analyses by using SPSS for Windows version 13.0 were conducted on an intention-to-treat basis. Differences of the pre- and posttest scores and demographic data between the two groups were assessed with independent t test or chi-square test, as appropriate. A linear mixed model of time-related repeated measurement was performed for the five dependent variables to determinate whether treatment was associated with the interactive effects postulated (group × time). The level of significance for the statistical tests was set at .05. Ninety percent of the patients completed the trial. More than sixty percent of the patients were men, and about two-thirds were unmarried, unemployed, and educated with 12 years. 95.9 percent of the patients were diagnosed as schizophrenia. The patients’ mean age was 35.26± 9.51 years and mean illness years were 11.52 ± 8.47 years. There was no difference on each demographic variable between two groups. Patients who received illness management model performed significantly greater and/or more enduring improvements after intervention completion and at one-month follow-up. The linear mixed model showed that the illness management model was associated with consistently greater improvements in illness knowledge, insight, and drug attitude over the follow-up period compared with the treatment as usual. The illness management model for patients with schizophrenia reenter to community provided by psychiatric nurses was effective to equip patients’ skills on illness management, and improve their illness knowledge, drug attitude, and insight lasted over the follow-up period. Future studies could further examine the effectiveness of different target populations, other interveners and the lasting effect of extended follow-up period, and adopt more sensitive measures.