台灣地區抗精神病藥物使用趨勢之探討

目的：精神分裂症是二十一世紀最受醫療專家及公衛專家矚目及重視的疾病之一。精神分裂症是一種功能性精神疾病 (functional psychosis)，發病後持續而廣泛的嚴重心理障礙所引起的特殊症狀。依據世界衛生組織(WHO)的報告指出，精神分裂症的全球盛行率從 0.1 ~ 1.7%之間。美國的終生罹患率約為1%，且只有半數的精神分裂症患者尋求治療，其年發生率約為每十萬人10 ~ 58 個病例(Warner， 1995)。但據國外調查指出，在美國精神分裂症約耗費2.5%醫療資源；除此之外75%精神分裂症患者因為認知功能退化，無法穩定工作或待業中，相對地降低了國家整體生產力及競爭力(Kaplan， 2003)。也因為精神分裂症帶給患者本身莫大的痛苦，所以各國已將精神分裂症視為重要公共衛生議題(胡海國， 2002)。同時精神分裂症耗費龐大的醫療花費及社會福利的支出；因此在資源有限的情形之下，將醫療資源做最有效的分配與利用是各國共同面臨的問題(Knapp & Kavanagh， 1997)。因此本研究目的希望能探討台灣地區抗精神病藥物在各年度、不同類型醫療機構，使用藥物類型之差異。研究方法：本研究資料來源為國衛院之『全民健保研究資料庫』中之系統資料檔，資料時間為1997至2005年所有抗精神病藥物資料，藥品分類依ATC代碼篩選。針對醫院類型及用藥類型間探討藥物使用趨勢並分析。統計軟體使用SPSS for Window統計套裝軟體，連續性變項用 Independent t-test；類別變項用Chi-square及ANOVA分析；使用Linear Regression及Multiple Logistic Regression來預測影響抗精神病藥物使 III 用之因素。研究結果： 1997 至2005 年間共取得約48 萬筆Antipsychotics 處方資料，內含211 項藥品，其中典型Antipsychotics 有19 種及非典型 Antipsychotics 共9 種。分析結果發現， 1997 至2005 年期間， Antipsychotics 使用金額增加了367.78%，尤其在2000 年之後更快速成長。在藥物類型上，以非典型Antipsychotics 成長最快，並於2002 年使用金額超過典型Antipsychotics；在藥物產國別上，以國產藥物為處方大宗，以進口藥物使用金額較高。在醫院專科別；非精神專科醫院比精神專科醫院成長較快；非精神專科醫院無論在使用進口或國產、典型或非典型均高於精神專科醫院。區域醫院及地區醫院為主要使用Antipsychotics 的醫院，使用量及使用金額佔84%；這兩類醫院也使用較多的非典型及進口Antipsychotics。健保局為遏止藥費成長，對新上市藥品實施藥物使用規範及推動總額支付制度，似乎對抗精神病藥物無法達到管控藥費成長的目的，在相關政策期間，非典型及典型Antipsychotics 的月平均處方金額仍持續上升；進口及國產藥物月平均處方金額也持續上升。利用迴歸分析預測使用非典型 Antipsychotics 之因素，發現非精神專科醫院、醫學中心、區域醫院及地區醫院使用較多的非典型Antipsychotics；非精神專科醫院、醫學中心、區域醫院及地區醫院，也使用較多進口Antipsychotics。結論與建議本研究發現，1997 至2005 年抗精神病總體藥物的使用持續成長，且似乎不較受健保政策影響，特別是非典型及進口Antipsychotics；與國內及國外研究情形類似的是，精神專科醫師偏好使用非典型及進 IV 口藥物，同時也與醫院類型有關。精神疾病常有的共病現象及仿單外使用、新醫藥科技及人口和疾病結構的變化，可能是影響醫療費用成長的原因；因此建議相關單位在評估相關政策時應考量患者實際需要藥物及是否對仿單外適應症之管控。未來研究方向，可朝向分析新一代藥物是否提供精神病患有較好的預後，並探討有關抗精神病藥物醫療經濟學，以找出最佳藥物選用之治療模式。

關鍵字

精神分裂症；抗精神病藥物；盛行率；藥物流行病學

並列摘要

Purpose： Schizophrenia is one of the diseases that the medical and public health experts pay the most attention to in the 21st century. The schizophrenia is a functional psychosis, which the special symptoms are caused by sustainably and extensively severe mental disorder after the onset of disease. The global prevalence rate of schizophrenia was from 0.1% to 1.7% according to the WHO report. The lifetime incidence rate was about 1% in U.S.A. and only half of the schizophrenia patients sought treatment. The incidence rate per year was about 10 to 58 cases of every 100,000 people (Warner, 1995). According to the survey from foreign country, the schizophrenia consumed about 2.5% of the medical care resources in the United States. In addition, 75% of the schizophrenia patients were unable to work stably or unemployed because of the degradation of cognitive function, which reduced the country’s total productivity and competitiveness relatively (Kaplan, 2003). According to the economic cost analysis of the severe schizophrenia patients in Taiwan, the scholar pointed out that the productivity loss of patients themselves, the time cost of caregivers VI taking care of schizophrenia patients and the indirect cost of psychological burden accounted for about 80% of total economic costs (Ling-ling Yeh 2003). Because of the great suffering which was brought to the patients by the schizophrenia, countries around the world had considered schizophrenia as an important public health issue (Hai-gwo Hwu 2002). The schizophrenia had consumed huge expenditures of medical care costs and social welfare. Therefore, under the circumstance of limited resources, it would be the common issue faced by every country to make the most effective allocation and use of medical care resources (Knapp & Kavanagh, 1997). The purpose of this study is to discuss the difference in types of Antipsychotics use between different types of medical care institutions in different period of time in Taiwan. Method： Source of this study comes from the system data file in the 『National Health Insurance Research Database』of National Health Research Institute. The data time is from 1997 to 2005 for all Antipsychotics. Medicines are classified according to ATC code screening. The trend analysis of medicine use has been conducted VII according to the types of hospitals and the types of medicine use. The use of statistical software is “SPSS for Window” statistical software package. “Independent t-test” is conducted to analyze the continuous variables. “Chi-square” and “ANOVA” are conducted to analyze the types of variables. “Linear Regression” and “Logistic Regression” are conducted to forecast the factors of influencing antipsychotics use. Result： There are 480,000 antipsychotics prescription data obtained from 1997 to 2005, including 211 items of medicines. There are 19 kinds of atypical and 9 kinds of typical antipsychotics in total among them. The results of analysis find that the amount of antipsychotics consumption and money spent on antipsychotics increased obviously by 367.78% from 1997 to 2005, by growing faster after 2000. In terms of type of medicine, the atypical antipsychotics grew the fastest and the money spent on atypical antipsychotics exceeded that on typical antipsychotics for the first time in 2002. In terms of medicine producing country of origin, domestic medicines were prescribed mostly. In terms of hospital specialty, the consumption of antipsychotics in non-psychiatric specialty hospitals grew faster than that in psychiatric specialty VIII hospitals. The consumption of antipsychotics in non-psychiatric specialty hospitals is higher than that in psychiatric specialty hospitals, no matter for imported or domestic and atypical or typical antipsychotics. The regional and district hospitals are the main types of hospitals in which the antipsychotics are used and the consumption has accounted for 84% of the total amount used and 84% of the total money spent. These two types of hospitals consumed more atypical and imported antipsychotics as well. In order to inhibit the growth of medicine expenditures, the Bureau of National Health Insurance implemented the medicine usage guidelines for new launch products and the global budget policy, which did not seem to be able to achieve the goal of controlling the growth of medicine expenditures against antipsychotics. The monthly average cost spent on atypical and typical antipsychotics prescription increased continuously during the period, and so did the imported and domestic antipsychotics. The forecast for the factor of using atypical antipsychotics by regression analysis finds that the psychiatric specialty hospitals, medical centers, regional hospitals and district hospitals used more atypical and imported antipsychotics as well. IX Conclusion and Suggestion： The study finds that the total cost of antipsychotics was grew continuously from 1997 to 2005 and did not seem to be affected by the Health Insurance policy, especially for the atypical and imported antipsychotics. Similar results from local and worldwide researches, the psychiatrists preferred to use the atypical and imported antipsychotics which are related to the types of the hospitals at the same time. The comobidity of psychosis, off-label use, new medical technology and the structure change of population and disease may be the reasons for the growth of medical expenditures. Therefore, the patients’ needs and whether should control the off-label use should be taken into consideration when making related policy. The future study can be conducted to further understand whether the medicine of new generation can provide better prognosis to the psychotic patients and discuss the medical care economics regarding the antipsychotics in order to find out the best therapeutically method of medicine choice