照顧者負擔、職場壓力與生活品質關係之研究

The Study of Care Giver Burden, Occupational Stress and Quality of Life

曾冬勝(Dong-Sheng Tzeng)

指導教授 ： 楊俊毓

高雄醫學大學/健康科學院/職業安全衛生研究所/博士(2010年)

https://doi.org/10.6832/KMU.2010.00127

摘要

背景:人類的健康涵蓋生物、心理與社會三個層面的健康，本論文目的是透過三個角度來探討壓力與健康的關係。1. 透過職場上兩所醫療院所的裁撤，帶給健康照顧工作者的壓力與華人健康量表、世界衛生組織生活品質的關係。2. 從照顧精神分裂病病患之主要照顧者的角度探討與壓力相關的生活品質。3. 從生物性的角度想要探討單胺氧化脢長型與短型基因在罹患憂鬱症患者治療效果上是否有差異。

方法：1. 我們寄出1269份醫院工作同仁的問卷給三家軍醫院員工來調查裁撤前、裁撤後的員工情緒心理壓力與生活品質。2. 我們是以南台灣精神照顧衛生體系，隨機抽樣257個精神分裂病個案，是在多元化治療的模式以及247個案是在傳統的精神衛生照顧體系下，其主要照顧者的生活品質及情緒心理壓力。3. 關於單胺氧化脢基因多型性的研究，我們是以58個DSM-Ⅳ診斷為重度憂鬱症患者以Mirtazapine治療7個禮拜連續評量於第一週、第二週、第三週、第四週、第七週的漢米爾頓憂鬱量表，比較長短型兩組效果。

結果：在國軍醫院裁撤的結果，我們發現護理同仁有比較嚴重的情緒心理壓力，其生活品質在心理及環境層面上比較低，且發現年輕具有藥物使用及生活事件之員工有較高的情緒心理壓力，並且發現職業類別、生活事件、藥物使用可以預測健康量表總分，年齡跟健康量表總分可以預測生活品質；在主要照顧者情緒心理壓力研究，發現了多元化的治療組其生活品質較高，主要照顧者負擔較低。我們發現單胺氧化脢之短型這組個案比長型有顯著的治療效果。

結論：在裁撤的研究發現，我們應該要發展壓力因應的策略，提供給年輕員工來促進他們的生活品質；其次在主要照顧者壓力的研究發現，一個妥善的多元化網絡將會降低照顧者的負擔。本論文推估壓力之基因與環境多重因素，在規劃疾病防治時，宜分類與持續追蹤，方可達到健康促進之目標；單胺氧化脢多型性可能是情緒心理疾患候選基因。

關鍵字

照顧者負擔 ； 工作壓力 ； 重度憂鬱症 ； 華人健康量表 ； 世界衛生組織生活品質量表 ； 單胺氧化脢基因多型性

並列摘要

Background and objectics: this thesis composed three parts, one was the merge policy and hospital accreditation were assumed to be stressful to military health care workers, so the survey and follow up for job strain model to environmental factors about mental health and quality of life were investigated; second, the outcome measurement on quality of life and care burden from care giver in two different therapeutic mental health programs were compared; third, etiological exploration of susceptibility on MAOA gene promoter polymorphysism to mental disorder such as major depression. Method: first, we sent surveys to 1269 health care workers working in military hospitals. Participants completed structured questionnaires that included the General Health Questionnaire, and the WHO Quality of Life Questionnaire; second, 257 patients in redesigned care network, including a general hospital, a chronic ward, 10 outpatient clinics, and multialternative community programs, was compared to 247 patients in other traditional healthcare provider that were utilized as the control group; third, fifty eight major depression patients with venous blood for MAOA gene promoter polymorphysism to long and short form by PCR then were given mirtazapine for seven weeks and evaluated on days 0, 7, 14, 21, 49 using the 24-Hamilton's Depression Rating Scale (HRSD). Remission was defined as a final HRSD 10 and a 50% reduction in baseline HRSD score. The patients’ response to mirtazapine treatment was compared between those who had the long-form polymorphism in the MAOA gene promoter and the short-form polymorphism. The quality of life (QOL) questionnaire and the Chinese health questionnaire (CHQ) were used. Result: 1. Nurses had the highest GHQ scores (nurses 32.1% vs. physicians 28.3% and other 22.4%). On the WHOQOL, nurses had worse psychological and environment domain scores (12.7 and 13.1, respectively) and physicians scored the worst for the physical and social domain as compared to nurses and other specialists. The younger, hypnotic drug use and life events had higher percentage in psychological morbidity group (Odds Ratio 1.04, 12.5, 2.38; p=0.008, 0.028 and 0.014, respectively). In regression analysis, job category, life event and hypnotic drug use could predict GHQ; age and GHQ could predict QOL (p<0.001). The GHQ might be a mediating factor to QOL. 2. The controls had longer duration of illness (p=0.001) and were older (p=0.004). The average resource utilization in the study group (US$ 2737/year, per case) was higher than the control group (US$ 2041). For the study group, the average length of stay was shorter, but the admission rate was higher. The QOL of the patients in the study group was better than that of the controls (p=0.01). The family burden of the study group was lower (p=0.035) and the score of general health questionnaire higher (p=0.019). 3. The total HRSD scores after mirtazapine treatment were significantly lower than baseline (p<0.001). There were 10 cases (38.5%) in short from and 6 (18.8%) in long from group touched the remission stage. Patients with the short-form group had a greater response to mirtazapine (p<0.001) than those with the long-form polymorphism after controlling for age, sex, and apolipoprotein E genetic (APOE) polymorphism. Conclusion: 1. Programs should be developed to educate younger health care workers with psychological morbidity to adjust the stressors associated with their jobs to improve their QOL. 2. We found that patients in the redesigned care network had a better QOL, lower family burden, and the caregivers had better mental health. Although the costs were higher, the continued care network was more helpful in providing comprehensive mental illness services. 3. The genetic polymorphisms in the MAOA promoter region may be associated with treatment response to mirtazapine.

並列關鍵字

care giver burden ； GHQ ； job stress ； major depression ； MAOA gene polymorphysim ； QOL

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