憂鬱症在慢性阻塞性肺病(COPD)病患之盛行率及其對COPD病患急性發作及死亡之影響

The prevalence of depressive disorder and its effect on acute exacerbation and mortality in patients with chronic obstructive pulmonary disease (COPD)

傅彬貴(Pin-Kuei Fu)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2015年)

https://doi.org/10.6342/NTU.2015.00289

摘要

背景：慢性阻塞性肺病(COPD)是一個病情複雜、病程較長且合併許多共病症(Comorbidities)的慢性病。自2011年起，共病症已列入COPD治療指引以強調其重要性。然而，憂鬱症對於COPD急性發作及死亡之影響，本土資料仍顯不足。
目的：本研究目的為探討憂鬱症共病症在台灣COPD患者的盛行率及其對於COPD急性發作以及死亡之影響。
材料與方法：本研究為固定世代追蹤研究，資料來源為全民健康保險研究資料庫之「2005年百萬承保抽樣歸人檔(LHID2005)」。COPD之診斷必須符合在2005.1.1至2007.12.31當中，至少【兩次門診就診】或【至少一次住院】之出院診斷前三碼有ICD9-CM code: 491,492,496或A323；排除年紀在40歲以下或120歲以上、排除掉同時合併有氣喘之診斷【ICD-9CM code: 493, 至少兩次門診或一次以上住院診斷前三碼】以及排除掉在2008年1月1日以前死亡之個案。憂鬱症(Depression)共病症的診斷包括輕度憂鬱症及重度憂鬱症， ICD9-CM code：輕度憂鬱症(Minor depression)：300.4,309.0,309.1,311 以及重度憂鬱症(Major depression)：296.2,296.3。共病症之診斷時間為2007.1.1 -2007.12.31期間有門診三次以上或住院一次以上。觀察指標為：有無憂鬱症共病症對於【急性發作(2008.1.1-2008.12.31期間)】以及【死亡(2008.1.1-2011.12.31期間)】之影響。本研究亦使用不同的COPD用藥分組作為校正COPD疾病嚴重度模型，以探討憂鬱症在不同嚴重度的COPD對急性發作以及死亡之影響。整體資料以SAS 9.3版套裝軟體進行資料處理及統計分析。
結果：台灣地區憂鬱症共病症在COPD患者盛行率約為4.1%，遠低於目前大多數文獻研究報導的20-25%，且盛行率並未隨疾病嚴重度增高而上升。憂鬱症的有無並與急性發作之風險(adjusted HR=1.02, 95% CI, 0.77-1.35, p=0.909)以及死亡發生的風險(adjusted HR=1.07, 95% CI, 0.92-1.23, p=0.386)均未達顯著相關，在校正COPD疾病嚴重度後，憂鬱症仍未與急性發作或死亡發生具有顯著相關。
結論：相較於其他COPD常見的共病症，台灣COPD憂鬱症共病症診斷率遠低於其他國家，存在被低估的可能性，因此憂鬱症對於急性發作以及死亡之影響也可能因此而被低估。未來需要進一步結合醫院臨床診療系統進行前瞻性研究，並將憂鬱症評估納入COPD病患常規照護流程。

關鍵字

慢性阻塞性肺病 ； 共病症 ； 憂鬱症 ； 急性發作 ； 死亡

並列摘要

Backgroud: Chronic obstructive pulmonary disease (COPD) is a chronic and complicated disease, which has a longer course and ofen merges many comorbidities. Since 2011, an additional chaper of comorbidities has been included in the COPD treatment guidelines in order to emphasize its importance. However, the impact of depression for COPD acute exacerbations and survival is still insufficient in Taiwan.
Purpose: The purpose of current study is to investigate the prevalence of depressive disorder and its influence on the acute exacerbation and survial in patients with COPD in Taiwan.
Materials and Methods: From Taiwan’s National Health Insurance Research Database, the Longitudinal Health Insurance Database (LHID) 2005, we collected data from 4 925 patients, including 985 COPD patients with depressive disorder and 3 940 age- and gender- matched (1:4) control COPD subjects without depressive disorder. Patients newly diagnosed as COPD (with more than 2 times of ambulatory visits diagnosed as COPD【ICD-9-CM: 491, 492, 496 or A323】or 1 times hospitalization with major diagnosis of COPD in 2005-2007 were included in the study. COPD patients aged younger than 40 years old or elder than 120 years old and those who have diagnosed as asthma at the same time were excluded. The comorbidity of depressive disorder included major【ICD-9-CM: 296.2,296.3】and minor depression【ICD-9-CM: 300.4, 309.0, 309.1, 311】were identified during the period of 1 Jan to 31 Dec in 2007. The severity of COPD was adjusted by the different formula of prescriptions. Cox proportional hazards model was performed to evaluate whether depressive disorder was the independent risk factors for acute exacerbation (in 2008) and survival (during 2008-2011) in patients with COPD.
Results: The prevalence of depression comorbidity in patients with COPD is about 4.1%, which is far below most of the previous study reported in 20-25%. Meanwhile, the prevalence of depression was not in propotional to the severity of COPD. The findings of our study showed that the risk of acute exacerbation in COPD did not reach significant difference between depression and non-depression group (adjusted HR=1.02, 95% CI, 0.77-1.35, p=0.909). In addition, the results alos showed no significant difference in survival in COPD between depression and non-depression group (adjusted HR=1.07, 95% CI, 0.92-1.23, p=0.386). After adjusting the confounding factor of COPD severity, the influence of depressive disorder on the acute exacerbation and survial in COPD still not reached statistical significance.
Conclusion:
In comparision to the other common comorbidites in COPD, the prevalence of depressive comorbidity in Taiwan is far lower than other countries. COPD with depressive comorbidity did not increase the risk of acute exacerbation and death even adusting the severity of COPD. Whether this result is contributed to be underestimated of depressive comorbidity in COPD in Taiwan remans uncertain. Further investigation may be needed to corroborate the true prevalence of depressive comorbidity and its influence on COPD through intergrated COPD care process.

並列關鍵字

COPD ； Comorbidity ； Depressive disorder ； Acute exacerbation ； Mortality

參考文獻

台灣胸腔暨重症加護醫學會. (2014). 慢性阻塞性肺病2014診治指引. Chronic Obstructive Pulmonary Disease. 台北市.

廖浩欽, 胡百敏, 吳清平, 陳淑芳, & 廖訓禎. (2011). 以健保資料庫資料探究40歲以上慢性阻塞性肺部疾病和支氣管性氣喘病人之診斷與處置. [Using the National Health Insurance Database to Analyze Diagnoses and Treatment Procedures in Chronic Obstructive Lung Disease and Bronchial Asthma in Patients Over 40 Years Old]. 台灣急診專科醫師期刊, 3(4), 105-111.

Kuo, L. C., Yang, P. C., & Kuo, S. H. (2005). Trends in the mortality of chronic obstructive pulmonary disease in Taiwan, 1981-2002. J Formos Med Assoc, 104(2), 89-93.

Sarkar, M., Bhardwaj, R., Madabhavi, I., & Khatana, J. (2015). Osteoporosis in chronic obstructive pulmonary disease. Clin Med Insights Circ Respir Pulm Med, 9, 5-21.

Aaron, S. D. (2014). Management and prevention of exacerbations of COPD. BMJ, 349, g5237.