急診兒科精神病患就診之趨勢與臨床特徵: 台灣某區域醫院七年之回溯性分析

Abstract

研究背景: 近年國際研究均發現兒童罹患精神疾病比例有增加之勢，台灣於2017年首次針對兒童精神疾病的研究調查顯示，近三分之一兒童終其一生有心理健康疾患，近六個月自殺意念盛行率達3.1%；因精神疾患至急診就醫之兒科病患數目亦逐年上升。精神疾患對於生理尚在發育，心理人格正處形塑階段之兒少產生重大且長期的影響，對社會之衝擊亦不容小覷。家庭能否給予支持、學校有無適切的輔導、在醫療體系中是否持續且妥善被治療，都是病患康復程度、保有正常社交工作與生活能力的關鍵。除了急性處置，兒科精神病患在急診是否得到適切的專科照會、轉介、後續追蹤等，目前仍缺乏研究。 研究目的: 本研究針對兒科病人因精神疾患至急診就診之流行病學，其在急診室接受之處置、等待時間、離院動向、再返診頻率做分析探討，以了解近年兒科急診精神病患就診趨勢、疾病診斷與臨床因子分布，及其與急診兒科其他病患的差異，並檢視相關醫療資源和人力之運用。研究成果可提供醫療機構、政策制定單位作為客觀參考依據。 研究方法: 本研究分析自2015年1月1日至2021年12月31日七年間，於臺大醫院新竹分院兒科急診就診之零至十八歲，且符合精神疾患診斷之個案，其臨床表徵(年齡、性別、疾病診斷)、是否有自傷傷人行為(性別差異、所用的自傷方式是否不同)、是否接受精神科醫師及社工會診、在急診停留的時間、離院動向、一年內返診頻率，並與主訴非精神疾患之兒科急診病患做比較。 研究結果: 2015至2021年間，至台大醫院新竹分院兒科急診就診之案例共105976人次，其中925人次(0.87%)有精神疾患診斷。歷年兒科急診就診人次有下降趨勢，但因精神疾患就診人數佔比卻增加十倍之多，尤其新冠疫情期間更為顯著。所有兒科精神病患中青少年(13-18歲)佔71.78% ，女性患者居多。疾病診斷以憂鬱症、躁鬱症、自殺為前三名，其累積成長率皆超過100%。不同年齡及性別的精神疾病診斷有顯著分布差異。而所有病患中僅28.9%患者接受精神科醫師會診，18.6%有社工介入。相較於非精神疾病診斷的病人，精神病患在急診留滯時間顯著較長，一年內返診頻率也較高。兒童精神病患的離院動態，住院比例約增加兩倍，離院及安排門診追蹤之比例則相對穩定。 結論及建議： 急診是兒童精神病患及其家庭相當重要的醫療資源和社會支持介入節點，也是後續能否得到適當治療處置的關鍵。研究結果顯示，罹患精神疾患並有治療需求的兒童和青少年有逐年增加之勢，但目前急診的環境設備和人力配置還無法給予相應的回饋與照護。此議題尚須醫療機構及政策制定單位多方檢討、合作，針對精神科專業人員配置、高風險病患篩檢系統建立、急診室環境和處置流程改善等面向努力，才能提升兒童精神病患的整體醫療與生活品質。

Background and objectives Steep rise of mental disorders among children had become a major child public health concern that reflected the urgent but unmet demand of psychiatric health care. Pediatric emergency departments (PED) are usually the first checkpoint of entry into health system for the newly diagnosed patients or disease crisis. Timely recognition and properly management are crucial for stabilizing clinical condition, arranging future treatment outside of PED, and optimizing the prognosis. To improve pediatric PED settings for children seeking psychiatric services in Taiwan, a more accurate and contemporary description of current epidemiology and characteristics should be demonstrated. Our objectives are to explore (1) trend and demographic characteristics of PED visits of children with mental disorders; (2) distribution of psychiatric diagnoses during study period; (3) medical need and utilization of mental health PED visits. Methods This was a secondary data analysis of clinical data retracted from National Taiwan University Hospital Hisn-Chu Branch from January 2015 to December 2021. Every visitor aged 0-18 years old having mental disorder diagnosis were recruited. Analyses were conducted to present the trend of PED utilization and the association between different demographic and clinical factors. Results Over the 7-year study period, a total of 105976 PED visits were identified, with 925 (0.87%) had mental health diagnosis. Despite the annual visits decreased gradually, the proportion of psychiatric requested reached a tenfold increase. The surge was heavily driven in 2020, when COVID-19 started raging. Youths 13-18 years of age accounted for 71.78% of the visits, and female preponderance was found. Depressive disorder, anxiety disorder, and suicide attempt remained the leading diagnosis and their cumulative growth increased by more than 100%. The diagnoses differed across gender and age with significance. Only 28.9% psychiatric visits received evaluation by psychiatrists, and 18.6% of them were contacted by social workers. Compared to patients with other chief complaints, mentally ill children had longer length of stay at PED (p<0.05) and more frequent return. Their admission rate almost doubled during study period while the discharge rate remained relative stable. Conclusions PED is an important community resource for helping children and family get through psychiatric crisis and bridging them into appropriate psychiatric treatment, particularly with the relative shortage of outpatient and other supportive setting. The multidisciplinary cooperation focusing on psychiatric manpower relocation, risk screening system buildup, process and environment refinement at PED must be engaged in order to provide comprehensive, equitable, and timely access to pediatric mental health care.