肝癌病患確診後合併焦慮症、憂鬱症、醫療資源利用與存活分析之研究-以全國人口為基礎

研究背景與動機癌症病患罹患憂鬱症是一般人的三倍，約有20~25%的癌症病患曾經有憂鬱的情況發生，隨著疾病的發展過程，其憂鬱症盛行率會增加至77%。更有研究指出憂鬱症在肝癌病患中的發病率明顯高於一般人及一般慢性疾病患者(包括其他癌症類別之患者)，約有83%肝癌病患在疾病過程中，曾產生憂鬱的狀態，顯示肝癌病患之憂鬱發生率相當高。而肝癌患者所經歷之疾病症狀與癌症相關治療，以及未來可能面臨復發與死亡的威脅，都會造成心理的壓力，此外，癌症病患若合併憂鬱的症狀，亦會影響其存活率，由此可見，肝癌與精神疾病之相關議題，相當值得研究與探討。研究目的一、探討肝癌病患確診後有無合併焦慮症、憂鬱症與其人口學特性、臨床特性之相關因子。二、探討肝癌病患確診後有無合併焦慮症、憂鬱症，對於醫療資源利用之差異。三、探討肝癌病患確診後有無合併焦慮症、憂鬱症，對於存活情形之差異。研究方法本研究採用次級資料分析法，以回溯性縱貫研究(Longitudinal study)，根據1996年至2010年全民健康保險研究資料庫-百萬抽樣歸人檔，研究對象為CD檔及DD檔ICD-9-CM前三碼為155者，篩選出之原發性肝癌病患，依所需資料根據1996年至2010年全民健康保險研究資料庫-百萬抽樣歸人檔之門診處方及治療明細檔(CD檔)、住院醫療費用清單明細檔(DD檔)、承保資料檔(ID檔)、醫事機構基本資料檔(HOSB檔)、醫事人員基本資料主檔(PER檔)之資料庫進行串聯，最後利用SPSS 19.0版統計套裝軟體，進行統計分析，以SAS 9.3版進行研究樣本傾向分數配對。研究結果研究對象總共10,025人，其中焦慮症組為2,686人、憂鬱症組為35人、焦慮&憂鬱症組為223人，和無精神疾病組為7,081人。一、年齡(OR=1.01，p<0.001)與有無化療(OR=1.45，p<0.001)與焦慮症呈現正相關，性別(OR=0.52，p<0.001)、合併症嚴重度指數(OR=0.93，p<0.001)、有無肝硬化(OR=0.67，p<0.001)、有無呼吸系統疾病(OR=0.78，p=0.019)、以及有無症狀_徵兆和不明原因(OR=0.78，p=0.001)與焦慮症呈現負相關。人口學特性、臨床特性與發生憂鬱症未存有相關性。性別(OR=0.55，p<0.001)、合併症嚴重度指數(OR=0.88，p=0.015)以及有無肝硬化(OR=0.65，p=0.004)，與焦慮&憂鬱症呈現負相關。二、門診次數部分，與無精神疾病組相較之下，焦慮症組患者一、三、五年門診次數分別顯著多20次、38次、52次；憂鬱症組患者一、三、五年門診次數分別顯著多19次、31次、33次；焦慮&憂鬱症組患者一、三、五年門診次數分別顯著多46次、75次、88次。在門診費用部分，焦慮症組患者一、三、五年門診費用分別顯著多15,659元、31,949元、46,303元；憂鬱症組患者一、三、五年門診費用分別顯著多85,293元、126,417元、139,889元；焦慮&憂鬱症組患者一、三、五年門診費用分別顯著多50,803元、89,624元、102,024元。三、住院天數部分，與無精神疾病組相較之下，憂鬱症組患者一、三、五年住院天數分別顯著多28天、33天、34天；焦慮&憂鬱症組患者一、三、五年住院天數分別顯著多10天、14天、17天。在住院費用部分，憂鬱症組患者一、三、五年住院費用分別顯著多110,857元、151,821元、159,958元；焦慮&憂鬱症組患者一、三、五年住院費用分別顯著多47,275元、58,007元、63,405元。四、總醫療費用部分，與無精神疾病組相較之下，焦慮症組患者一、三、五年總醫療費用分別顯著多15,605元、35,171元、55,531元；憂鬱症組患者一、三、五年總醫療費用分別顯著多198,229元、278,802元、298,654元；焦慮&憂鬱症組患者一、三、五年總醫療費用分別顯著多92,019元、147,720元、165,242元。五、經傾向分數配對後，焦慮症組與焦慮&憂鬱症組一年、三年、五年整體存活(月數)、整體存活率等變項均顯著性高於無精神疾病組。無精神疾病組與憂鬱症組兩組中，一年、三年、五年整體存活(月數)、整體存活率等變項均未達顯著性差異。結論與建議一、建議臨床醫師及護理人員應在第一線照顧病患時，培養對癌症患者焦慮症及憂鬱症的敏銳度，特別是針對年紀較年長者、女性、有接受化療治療的癌症病患，提供對於焦慮症及憂鬱症相關衛教和情緒支持，提供適當的轉介，讓精神科醫師做完整的評估，以免延遲病患接受治療的時機。二、除了培養對病患焦慮症、憂鬱症的敏銳度之外，為減少轉診精神科的困難，建議醫護人員在與病患溝通時，減少如憂鬱症、精神病等敏感用語，建議可考慮如：治療失眠、治療緊張、治療記憶力減退等用詞，以提高病患就診意願，使其能即時接受到適當的治療，提高其存活率。三、建議針對所有初診斷及復發的癌症病患，都應安排初步的心理評估，已篩選出有心理問題的病患，及早介入心理輔導或治療，如此應可改善癌症病患的心理健康，甚至進一步找出有自殺傾向的高危險病患，以減少家庭、社會的損失。關鍵詞：肝癌、焦慮症、憂鬱症、醫療資源利用、存活分析

關鍵字

肝癌；焦慮症；憂鬱症；醫療資源利用；存活分析

並列摘要

Background The incidence of cancer patients with depression is three times than the normal population. About 20~25% cancer patients have experienced depressed mood. The incidence of depression in hepatocellular cancer (HCC) patients is higher than that in normal population and patients with chronic diseases (including other cancer types). About 83% HCC patient developed depression, which revealed the high incidence of depression. The symptoms and treatments of the disease and death lead to the stress of HCC patients. Besides, anxiety and depression are also related to the prognosis of HCC patients. Thus, the issue of the relationship between HCC and psychological disorders is interesting for further study. Purpose 1. To investigate the demographic and clinical factors related to HCC patients with or without anxiety and depression disorders; 2. To explore the difference in medical resource utilization in HCC patients with or without anxiety and depression disorders; 3. To explore the difference in survival in HCC patients with or without anxiety and depression disorders. Methods This is a population-based retrospective longitudinal study using secondary data analysis. The data is from National Health Insurance Research Database (NHIRD) during 1996 to 2010. The primary HCC patients were extracted using ICD-9-CM 155. The study parameters include outpatient prescriptions and treatments, inpatient medical cost, medical institution and physician information. The statistical analysis and propensity score method were employed by using the SPSS 19.0 and SAS 9.3 respectively. Results In the study, 2,686 patients were anxiety group, 35 were depression group, 223 were both anxiety and depression group and 7,081 were non-psychiatric group. It showed age (odds ratio OR=1.01, p<0.001), chemotherapy (OR=1.45, p<0.001), Sex (OR=0.52, p<0.001), Charlson Co-morbidity Index (OR=0.93, p<0.001), liver cirrhosis (OR=0.67, p<0.001), respiratory disease (OR=0.78, p=0.019) and clinical symptoms (OR=0.78, p=0.001) were significantly associated with anxiety disorder. Moreover, sex (OR=0.55, p<0.001), Charlson co-morbidity Index (OR=0.88, p=0.015), liver cirrhosis (OR=0.65, p=0.004) were significantly associated with both anxiety and depression disorders. Compared with non-psychiatric disease group, the clinical visits at the 1-, 3-, and 5- year were significantly higher in anxiety group (20, 38, and 52, respectively), depression group (19, 31, and 33, respectively) and both anxiety and depression group (46, 75, and 88, respectively). Besides, the outpatient costs at the 1-, 3-, and 5- year were significantly higher in anxiety group ($15,659, $31,949, and $46,303, respectively), depression group ($85,293, $126,417, and $139,889, respectively) and both anxiety and depression group ($50,803, $89,624, and $102,024, respectively). On the other hand, compared with non-psychiatric disease group, total length of stay (LOS) at the 1-, 3-, and 5-year were significantly higher in anxiety group (28 days, 33 days, and 34 days, respectively) and both anxiety and depression group (10 days, 14 days, and 17 days, respectively). Besides, total inpatient costs at the 1-, 3-, and 5- year were significantly higher in anxiety group ($110,857, $151,821, and $159,958, respectively) and both anxiety and depression group ($47,275, $58,007, and $63,405, respectively). Additionally, total medical costs at the 1-, 3-, and 5- year were significantly higher in anxiety group ($15,605, $35,171, and $55,531, respectively), depression group ($198,229, $278,802, and $298,654, respectively) and both anxiety and depression group ($92,019, $147,720, and $165,242, respectively). Finally, the cumulative survival at the 1-, 3-, and 5- year in anxiety group and in both anxiety and depression group were better than non-psychiatric disease group. No statistically significance between depression group and non-psychiatric disease group in cumulative survival and overall survival at the 1-, 3-, and 5- year. Conclusions and suggestions Firstly, physicians and nurses should pay more attention to the patients with anxiety disorder and depression disorder and should provide the related education and emotional support to the aged, female patients and those undergoing chemotherapy. Referral to psychiatrist for complete assessment is necessary in order to avoid delaying the timing of treatment. Seconsly, to decrease the difficulty in referral to psychiatrists, both physicians and nurses should use the wording, such as treatment of insomnia, tense and memory loss instead of depression and mental disorders. Then the patients will be willing to visit the psychiatrics to have adequate treatment for better prognosis. Finally, to improve the mental health of the cancer patients and to identify the high-risk patients with suicide tendency, psychological assessments should be arranged for those who were initially diagnosed or had disease recurrence to find the patients with psychiatric disease for early intervention. Key words: hepatocellular carcinoma, anxiety disorder, depression disorder, medical resources utilization, survival analysis