愛滋感染者的憂鬱症與自殺行為之系列研究

Abstract

目前各國研究已發現愛滋感染者是發生憂鬱症與自殺行為的高危險群，其憂鬱症和自殺意念、企圖自殺的盛行率顯著高於健康族群。憂鬱已被發現是愛滋感染者的自殺行為之顯著預測因素，然而目前台灣缺乏長期研究調查愛滋感染者的憂鬱症盛行狀況與預測因素。此外，過去研究發現愛滋病毒感染確診後半年內是感染者發生自殺意念或企圖自殺的高風險時期，但是相關研究較少調查或追蹤確診半年後的愛滋感染者之自殺行為表現。基於憂鬱症和自殺行為兩項議題對於愛滋感染者的重要性及其密不可分的關係，本論文以此兩項議題為主題進行深入探討。 本論文主要由兩項主題研究所構成，第一個主題研究是以愛滋感染者的憂鬱症現況為主題，研究目的為希望了解台灣愛滋感染者的憂鬱症盛行率趨勢，並探討影響憂鬱症產生之預測因素，研究方法為運用國際疾病分類第九版臨床修正(ICD-9-CM)於台灣健保資料庫的2000到2011年之兩百萬人抽樣檔中篩選出769位愛滋感染者，檢視研究對象於愛滋感染後發生憂鬱症的狀況，運用卡方檢定(chi-squared test)先找出與憂鬱症相關的因素，再以羅吉斯迴歸分析(logistic regression analysis)確認出憂鬱症的主要預測因素。研究結果發現，研究對象於2000-2011年間在其確診感染愛滋後有20.03%曾被診斷有憂鬱症，而研究對象的憂鬱症盛行率從2000年的1.95%逐漸升高為2011年的6.93%，運用平均每年百分比變化(AAPCs)分析其成長趨勢達統計顯著(χ2 = 6.428, df = 11, p = .03)，而研究對象於2000-2011年間是否發生憂鬱症的羅吉斯複迴歸分析結果顯示，在診斷憂鬱症前有藥物濫用史是發生憂鬱症的主要預測因子。 論文的第二個主題研究是以愛滋感染者的自殺意念與企圖自殺為主題，研究目的為探討確診半年至一年間的愛滋感染者在六個月的追蹤期間，自殺意念與企圖自殺之表現與預測因子，並探討身體心像、生命意義感、社會支持因素於憂鬱症與自殺意念/企圖自殺之間關係是否為調節因子。此研究採縱貫性研究設計，於20152到2016年間於台北市某醫學中心感染科門診納入114位符合條件的愛滋感染者為研究對象，收集其人口學資料、愛滋疾病與醫療相關資料，並於參與研究、參與後三個月和六個月等三個時間點，測量其自殺意念與企圖自殺、憂鬱程度、身體心像、生命意義感、社會支持等項目。結果顯示，研究對象在三次追蹤測量中，最近一週內曾經出現自殺意念者分別佔27.2 %、21.6%、25.8%，最近一週內曾經企圖自殺者分別佔14.5%、8.6%、13.1%。六個月追蹤期間，較低的教育程度、較差的家庭社會支持、較高的憂鬱程度能顯著預測較高的自殺意念之發生，而有憂鬱症病史、較高的憂鬱程度、較多的朋友社會支持能顯著預測較高的企圖自殺之發生。調節因子的分析發現，知覺目前生命意義顯著減弱憂鬱程度和自殺意念之間的關係程度。 本論文研究結果可提供做為愛滋臨床照護之重要參考，由於研究結果發現台灣的愛滋感染者發生憂鬱症的比率於2000年至2011年期間顯著逐年增加，尤其以藥物濫用者為發生憂鬱症的高風險族群，因此愛滋照護應正視愛滋感染者的憂鬱症議題，常規進行憂鬱症之篩檢，並以較低教育程度的藥癮愛滋感染族群為最主要的憂鬱症防治對象，落實推動早期診斷憂鬱症並設計有效的防治措施。此外，研究結果發現也愛滋感染者在確診半年後仍有顯著的比例會產生自殺意念與企圖自殺行為，顯示愛滋照護亦應將自殺防治納為重點；由於教育程度、家庭社會支持、憂鬱程度顯著預測自殺意念，而憂鬱症病史、憂鬱程度、朋友的社會支持顯著預測企圖自殺，並且生命意義感能減弱憂鬱和自殺意念之間的關係強度，因此愛滋感染者的自殺防治措施可朝向常規監測感染者的憂鬱程度、高憂鬱程度感染者之心理輔導、建立感染者家庭輔導機制以強化其家庭社會支持、增進其生命意義感等方面進行規畫。

At present, numerous studies have found that HIV-positive patients are at high risk of depressive disorders and suicidal behaviors. The prevalence of depression, suicide ideation, and suicide attempt has been confirmed significantly higher than that of healthy populations. Depression has been revealed to be a significant predictor of suicide behaviors among HIV-positive patients, but there are few longitudinal studies investigating the prevalence of depression among HIV respondents in Taiwan. Suicide behaviors are found prevalent among HIV-positive patients newly diagnosed within 6 months, but there are few studies aiming at HIV-positive patients who were diagnosed as HIV-positive for 6-12 months. Moreover, the changes in suicide behaviors after diagnosis and the role of psychosocial factors in these behaviors are not well studied. Therefore, this thesis composing by two parts, including the research of depressive disorders and the research of suicide ideation and suicide attempt among HIV-positive patients, was conducted to enhance understanding of the profiles of depression, suicide ideation, and suicide attempt in Taiwan. The first part of this thesis inquired into the issue of depression among HIV-positive patients in Taiwan. The present research was aimed at examining the trend in the prevalence of depression and its main predictors among HIV-positive patients. The present study analyzed the 2-million-random-sample dataset of the Taiwanese longitudinal health research database between 2000 and 2011and applied The Ninth edition of the International Classification of Diseases (ICD-9-CM) diagnostic codes for the detection of HIV infection and depression. Chi-squared tests were conducted to explore associated factors of depression and logistic regression analyses were conducted to determine predictive factors of depression. A total of 769 PLWHA who met the criterion of HIV infection were extracted from the database. Of these respondents, 20.03% had a diagnosis of depression after their HIV-positive diagnosis. The annual prevalence of depression among the study respondents increased significantly from 1.95% in 2000 to 6.93% in 2011 according to time trend analysis (χ2 = 6.428, df =11, p = .03). Multivariate, logistic regression analysis indicated a history of drug abuse was the main predictor of a diagnosis of depression. The second part of this thesis inquired into the issue of suicide ideation and suicide attempt among HIV-positive patients in Taiwan. This study examined the changes and the predictors of suicide ideation/ suicide attempt, and the moderating effects of psychosocial factors including body image, meaning in life, and social support on the relationship between depression and suicide ideation/suicide attempts among HIV-positive patients at 6-12 months post-diagnosis. A longitudinal study was undertaken. A total of 114 participants diagnosed as HIV-positive for 6-12 months were recruited from the outpatient department of infectious diseases of a medical center in Taipei City. Data was collected from April 2015 to October 2016. They were asked to complete the demographic data, HIV medical related data, Beck’s Scale for Suicide Ideation, the Beck Depression Inventory-II, the Body Image Scale, the Meaning in Life Questionnaire, and the Multidimensional Scale of Perceived Social Support at baseline, the 3rd and the 6th month. The results showed the high occurrence rates for suicide ideation ranging from 21.6% to 27.2% and suicide attempt ranging from 8.6% to 14.5% in recent one week during the 6-month follow ups. The lower education level, lower social support from family, and higher depressive symptoms were the predictors of higher odds ratio of suicide ideation. With a history of depression disorders, higher depressive symptoms, and higher social support from friends were significant predictors of higher odds ratio of suicide attempt. Meaning in life-presence moderated the relationship between depressive symptoms and suicide ideation. The study results found the prevalence of depression among HIV-positive patients in Taiwan increased significantly over the period from 2000 to 2011, and drug abusers were at higher risk. HIV care plans should address the issue among HIV-positive patients, and drug abusers with lower education level should be the target population. Routine depression screening to enhance early diagnosis of depression and effective treatment are necessary for them. In addition, the findings of the study also showed that the prevalence of suicide ideation and suicide attempt among HIV-positive patients was still high post been diagnosed for 6 months. Suicide prevention should be taken into consideration as one part of HIV care. The study revealed that the degree of education, social support-family, and depression significantly predicted suicide ideation, and the history of depression, the degree of depression, and social support-friends significantly predicted suicide attempt, and meaning in life-presence weakened the relationship between depression and suicidal ideation. Future suicide prevention for HIV-positive patients may be aimed at routine monitoring of the levels of depression, providing counseling for high levels of depression, providing family counseling to enhance social support-family, and promoting sense of life meaning.