臺灣失能老人的抗憂鬱藥物使用研究

Abstract

本研究目的為瞭解臺灣失能老人的重鬱症傾向分佈情形與抗憂鬱藥物使用情形，包括年使用盛行率、抗憂鬱藥物治療率、處方藥品及類別、處方科別及疾病診斷。並探討人口學背景、健康與照顧狀況及社會支持系統與重鬱症傾向者使用抗憂鬱藥物的相關情況。 研究樣本來自「全國長期照護需要評估」計畫資料中65歲以上的失能樣本，共12,030人，另以調查檔的CES-D問卷篩選出CES-D≧25分的重鬱症傾向樣本，共1,015人。由調查檔中得到樣本之性別、年齡、教育程度、籍貫、重鬱症傾向、身體功能狀況、照顧安排、社會網絡與社會支持等資訊，再連結全民健康保險資料檔，以取得個案在訪視後一年期間的抗憂鬱藥物處方及診斷資訊，進而分析整體失能老人以及重鬱症傾向失能老人的抗憂鬱藥物使用情形。 結果發現臺灣失能老人CES-D總分的平均值為13.3分，有重鬱症傾向者占12.6% (CES-D≧25分)。在雙變項分析中可發現女性、65-74歲(年輕老人)、未受正式教育、免部份負擔、居住在直轄市、有認知障礙、完全依賴、四種以上慢性疾病、居住在機構、低社會網絡、低情緒性支持、低工具性支持者有重鬱症傾向的比率較高。 臺灣失能老人抗憂鬱藥物年使用盛行率為12.5% (1,499人)，年抗憂鬱藥物處方數為10,276張，僅有31.6%用於治療憂鬱症。有重鬱症傾向者，在訪視後一年有使用抗憂鬱藥物者占17.5%；而有重鬱症傾向者，且在訪視後一年有使用抗憂鬱藥物治療憂鬱症者，僅占5.9%。總和門診和住院的抗憂鬱藥物處方(10,276張)來說，處方數目最多的是TCA類，占39.0%，接下來是Heterocyclic類，占27.3%，第三名則是SSRI類，占21.8%，最後則是MAOI類，占11.9%。而用於治療憂鬱症的抗憂鬱藥物處方中(3,244張)，第一名是SSRI類，占42.8%，接下來是Heterocyclic類，占29.8%，第三名則是TCA類，占16.8%，最後則是MAOI類，占10.6%。在雙變項分析中，藥物類別和處方診斷有顯著相關，SSRI類(62.0%)最常用以治療憂鬱症，TCA類(74.1%)、MAOI類(61.2%)及Heterocyclic類(40.0%)都最常用以治療其他疾病。不同科別的醫師常用的抗憂鬱藥物類別亦不相同，精神科醫師主要處方SSRI類，而復健科及放射線科最常處方Heterocyclic類，其他如神經科、內科、家醫科、不分科、泌尿科、骨科、神經外科及皮膚科等都最常處方TCA類。 複邏輯斯迴歸分析發現，年齡、部分負擔、照顧安排、固定就醫傾向和重鬱症傾向者是否使用抗憂鬱藥物有顯著相關。相較於85歲以上者，65-74歲(OR=2.342, 95%CI=1.173-4.674)及75-84歲(OR=2.113, 95%CI=1.089-4.099)的重鬱症傾向者使用抗憂鬱藥物的機會較高。相較於需部分負擔者，免部分負擔(OR=1.636, 95%CI=1.090-2.456)的重鬱症傾向者使用抗憂鬱藥物的機會較高。相較於居家無照顧者，有居家家庭照顧者(OR=1.482, 95%CI=0.876-2.506)或居家全職看護(OR=2.572, 95%CI=1.260-5.248)的重鬱症傾向者使用抗憂鬱藥物的機會較高。相較於固定就醫傾向者，不固定就醫(OR=3.696, 95%CI=2.191-6.236)及中度就醫傾向(OR=1.555, 95%CI=0.844-2.863)的重鬱症傾向者使用抗憂鬱藥物的機會較高。 在重鬱症傾向者使用抗憂鬱藥物治療憂鬱症的影響因素方面，複邏輯斯迴歸分析發現，部分負擔、城鄉別、照顧安排、固定就醫傾向都和重鬱症傾向者是否使用抗憂鬱藥物治療憂鬱症有顯著相關。相較於需部分負擔者，免部分負擔(OR=2.211, 95%CI=1.167-4.189)的重鬱症傾向者使用抗憂鬱藥物治療憂鬱症的機會較高。相較於居住在鄉鎮區者，居住在直轄市(OR=3.276, 95%CI=1.443-7.435)、省轄市(OR=1.496, 95%CI=0.640-3.500)、縣轄市(OR=1.178, 95%CI=0.491-2.823)的重鬱症傾向者使用抗憂鬱藥物治療憂鬱症的機會較高。相較於居家無照顧者，有居家家庭照顧者(OR=1.175, 95%CI=0.496-2.782)或居家全職看護(OR=3.250, 95%CI=1.102-9.583)的重鬱症傾向者使用抗憂鬱藥物治療憂鬱症的機會較高。相較於固定就醫傾向者，不固定就醫(OR=3.069, 95%CI=1.276-7.383)及中度就醫傾向(OR=1.189, 95%CI=0.404-3.498)的重鬱症傾向者使用抗憂鬱藥物治療憂鬱症的機會較高。 憂鬱是失能老人相當常見的問題，而失能老人有重鬱症傾向者在未來一年使用抗憂鬱藥物的比例相當低，而使用抗憂鬱藥物是用以治療憂鬱症的比例更低。藉由對失能老人重鬱症傾向者使用抗憂鬱藥物治療憂鬱症的相關分析發現，居住在鄉鎮區、居家無照顧者、需要部分負擔、固定就醫的重鬱症傾向者，使用抗憂鬱藥物治療憂鬱症的機會較低。對衛生政策及心理精神醫療服務提供者來說，如何降低老人的心理精神醫療就醫障礙，是制定老人憂鬱照護政策的重點，特別是居住在鄉村、居家無照顧者和需要部分負擔的重鬱症傾向者，而我們可利用社區式長期照護模式、部分負擔減免、照顧者的職能訓練、民眾衛教、醫事人員教育等方式，來提高大眾對於失能老人憂鬱症的辨識、診斷及治療率。

The objectives of this study were to understand the distribution of severe depressive symptoms, and antidepressant utilization among disabled elderly in Taiwan. To explore factors associated with antidepressant use in severe depressive elderly. Data were used from the ‘Evaluation of Taiwan National Requirements for Long-Term Care’, and 12,030 disabled people aged 65 years and above were enrolled in the current study. The Center for Epidemiological Studies Depression scale was used to define two groups: non-depressed (CES-D＜25) and severe depressive symptoms (CES-D≧25). Subject identification information was linked to the National Health Insurance claim database to obtain antidepressant prescription data and diagnosis, including ambulatory visits and inpatient care, from the month of interview to one year later. The prevalence rate of antidepressant utilization in the full sample (N=12,030) and the antidepressant treatment rate in the severe depressive sample were both measured. And the associations of antidepressant use with demographic, heath and care, social network and social support factors among severe depressive sample were analyzed. The results indicated that the average CES-D score of the full sample was 13.3, and 1,015 respodents (12.6%) had severe depressive symptoms. In bivariate analyses, women, 65-74 years (young old), less education, don’t requiring co-payment, living in a municipality, cognitive impairment, physically dependent, more than four chronic conditions, living in institutions, low social network, low emotional support, and low instrumental support were associated with severe depressive symptoms. The annual prevalence rate of antidepressant utilization among full sample was 12.5% (TCAs of 39.0%, Heterocyclics of 27.3%, SSRIs of 21.8%, and MAOIs of 11.9%), and the number of annual antidepressant prescriptions was 10,276. Only 3,244 (31.6%) antidepressant prescriptions were used for depression (SSRIs of 42.8%, Hetrocyclics of 29.8%, TCAs of 16.8%, MAOIs of 10.6%). Average number of antidepressant prescriptions among antidepressant users was 6.9 annually. The annual antidepressant treatment rate of severe depressive sample was 17.5%. Only 60 (5.9%) severe depressive people use antidepressant for depression. In bivariate analysis, drug category was significantly associated with diagnosis. SSRIs (62.0%) was used mostly for depression, but TCAs (74.1%), MAOIs (61.2%), and Heterocyclics (40.0%) were usedly mostly for other diseases. Different specialists’ prescription patterns were not the same. Psychiatrists prescribed SSRIs most, rehabilitation department prescribed Heterocyclics most. Others like neurologist, internist, family medicine, urologist, orthopedics, and dermatologist prescribed TCAs most. In a multiple logistic regression model, age, co-payment, care arrangement, tendency to usual healthcare sources significantly associated with antidepressant treatment of severe depressive people. Compared to 85 years and above, 65-74 years (OR=2.342, 95%CI=1.173-4.674) and 75-84 years (OR=2.113, 95%CI=1.089-4.099) severe depressive people were more likely to use antidepressants. Compared to those requiring co-payment, those don’t requiring co-payment (OR=1.636, 95%CI=1.090-2.456) were more likely to use antidepressants. Compared to those with no caregivers, those with family caregivers (OR=1.482, 95%CI=0.876-2.506), and with a full-time personal aide (OR=2.572, 95%CI=1.260-5.248) were more likely to use antidepressants. Compared to those with high tendency to usual healthcare resources, those with low tendency (OR=3.696, 95%CI=2.191-6.236), and with intermediate tendency (OR=1.555, 95%CI=0.844-2.863) were more likely to use antidepressants. In a multiple logistic regression model, co-payment, residential area, care arrangement, and tendency to usual healthcare sources significantly associated with antidepressant treatment for depression among severe depressive people. Compared to those requiring co-payment, those don’t requiring co-payment (OR=2.211, 95%CI=1.167-4.189) were more likely to use antidepressants for depression. Compared to those living in a town, those living in a municipality (OR=3.276, 95%CI=1.443-7.435), in a provincial city (OR=1.496, 95%CI=0.640-3.500), and in a county-controlled city (OR=1.178, 95%CI=0.491-2.823) were more likely to use antidepressants for depression. Compared to those with no caregivers, those with family caregivers (OR=1.175, 95%CI=0.496-2.782), and with a full-time personal aide (OR=3.250, 95%CI=1.102-9.583) were more likely to use antidepressants for depression. Compared to those with high tendency to usual healthcare resources, those with low tendency (OR=3.069, 95%CI=1.276-7.383), and with intermediate tendency (OR=1.189, 95%CI=0.404-3.498) were more likely to use antidepressants for depression. In summary, depression in disabled elderly was a quite common problem, but the antidepressant treatment rate among severe depressive people was very low. Those who lived in a small town, with no caregivers, requiring co-payment, or with low tendency to usual healthcare resources had the lowest opportunity to receive antidepressant treatment for depression. How to minimize the barrier to mental health services, especially for those living in small towns, with no caregivers, or those requiring co-payment, was the most important goal for health policy makers and mental health services providers to make elderly depression care policy. We could improve the recognition, diagnosis and the treatment rate of depression through development of community-based long-term care system, reducing co-payment, training the caregivers, provide health education lessons to the public, or further professional knowledge about elderly depression to the health providers.