精神分裂症患者主觀照顧需求與主客觀生活品質之相關性研究—以精神科日間病房及社區復健中心病患為例

Research of the relationships between subjective needs for care and subjective/objective quality of life among the individuals with schizophrenia

蔡幸君(Hsin-Chun Tsai)

指導教授 ： 張永源

高雄醫學大學/健康科學院/行為科學研究所/碩士(2005年)

摘要

目的：
精神分裂症為一慢性嚴重精神疾患，會導致認知功能逐漸損壞進而使自我照顧、社會、職業功能損壞，其生活品質較正常人差而生活滿意度亦比較低，需要終生持續的醫療與社會照顧，回顧相關文獻，患者生活各層面的照顧需求有未滿足的狀況，且與較差的主觀生活品質有關。因此本研究目的在從病患自評的角度，探討精神分裂症患者生活各層面之照顧服務需求、主觀生活品質及客觀生活狀況、以及照顧服務需求與主觀生活品質之相關性。
方法：
使用結構式訪談問卷以病患自我報告方式，訪談67位（女性34人、男性33人）日間病房與社區復健中心的精神分裂病患，以中文版Camberwell需求量表以及台灣版Lanchcashire Quality of Life Profile，分別評估病患之主觀照顧需求以及主觀與客觀生活品質，以Global Assessment of Functioning以及簡短精神症狀量表評估病患之整體功能與精神症狀。探討社會人口學特徵以及整體功能與精神症狀等臨床因素，對需求與生活品質的影響，最後分析需求狀態與主觀生活品質之相關性。
結果：
完成全部量表評估者共65人，女性32人、男性33人，年齡從18到64歲，平均33.30±9.34歲。個案來源的差異主要在工作狀況、精神症狀與整體功能。
病患多屬未婚、無工作，半數是低社經階層。主觀生活滿意度最好的在法律與安全、宗教、休閒等層面，生活滿意度最差的在工作與經濟層面，綜合各層面的自覺生活品質與生活滿意度平均在滿意與不滿意各半。會談者外評的生活品質與患者自評的整體安適感相關因素不同，顯示會談者與病患的參考觀點不同。
需求最常見的領域是精神症狀、白天活動、社交，未滿足需求最常見的領域是親密關係、社交、心理痛苦。平均需求數5.32個，滿足需求數：未滿足需求數為4.63：0.69（＝6.71：1）。未滿足需求比例低於國外社區精神病患，需求領域則與國內外研究相似。親密關係、他人安全、自身安全、福利金、家務整理、與身體健康領域的問題是最常未被親友或醫療社會服務發現的需求。
主觀生活品質主要與精神症狀與整體功能相關，社會人口學變項與主觀生活品質有相關的很少。女性、低症狀、高功能、年齡較低、或生病時間較短，與需求或未滿足需求較少有關。
回歸分析發現，只有越多精神症狀與較多需求總數與未滿足需求數顯著相關，可解釋26.2%與17.1%的變異量。自覺生活品質與需求數及未滿足需求數有顯著負相關，但在回歸分析控制了精神症狀後未達顯著，與國外不同。
與主觀生活品質相關的是家務、社交、交通領域（社會、服務、功能類別）的需求。精神症狀是自覺生活品質的顯著預測因子，可解釋9.9%變異量。控制了精神症狀，服務類別與交通領域的需求未滿足程度分別可以解釋8.2%與5.5%的自覺生活品質。低需求總數較精神症狀更能預測好的自覺生活品質，可單獨解釋10.0%的變異量。
結論：
精神症狀是精神分裂病患主觀生活品質以及未滿足需求的共同預測因素，此外病患的主觀生活品質感受又受到服務類別、特別是交通領域需求未滿足程度的影響，需求總數越多、主觀生活品質越差，顯示評估辨認病患需求，並減少其需求數與未滿足程度有助於改善病患生活品質。雖然精神症狀是主觀需求與主觀生活品質的共同影響因素，低的回歸模式解釋變異量，表示兩者關係之間被探討的相關變項仍不足。

關鍵字

主觀照顧需求 ； 精神分裂症 ； 主觀生活品質

並列摘要

Objectives:
Schizophrenia is a chronic severe mental disorder. The schizophrenic patients have gradual deterioration of cognitive functions and then impairment of self-care, social and occupational functioning. The patients have worse quality of life and are less satisfied with their lives than normal persons. They need persistent medical and social services throughout their life. Reviewing the literatures, the schizophrenic patients have unmet needs for care in various life domains and the unmet needs are related to a poor quality of life. Therefore, the aims of the present study are to investigate patient-rated needs for care or services in each life area, subjective quality of life and the objective living situation, and the relationships between needs for care and subjective quality of life among the individuals with schizophrenia in Taiwan.

Methods:
A total of 67 (34 females, 33 males) schizophrenic patients from two psychiatric day-hospital and community mental rehabilitation center were interviewed with structured self-report interviewing questionnaires. The patients’ subjective needs for care as well as subjective and objective quality of life were assessed with the Chinese version of the Camberwell Assessment of need (CAN) and the Taiwanese version of the Lancashire Quality of Life Profile (T-LQOLP), respectively. The global functioning and psychiatric symptoms were assessed with the Global Assessment of Functioning Scale (GAF) and the Brief Psychiatric Rating Scale (BPRS). The impact of social demographic characteristics and clinical factors, the global functioning and the psychiatric symptoms, on needs and quality of life were investigated, and then the relationships between need status and subjective quality of life.

Results:
A total of 65 schizophrenic patients (32 females, 33 males) completed the entire questionnaires, with mean age of 33.30±9.34 years (from 18 to 64 years). The difference between the two sample sources mainly existed in working status, psychiatric symptoms and the global functioning.
The majority of patients were single or unmarried, and jobless. Half of patients were at lower socioeconomic status. The three life domains that demonstrated the highest level of satisfaction were law/safety, religion and leisure, and the lowest two were working and finance. The perceived quality of life demonstrated by the mean of nine domain satisfaction scores was located at “life is equally satisfied and dissatisfied”. No common associated factors between the interviewer’s quality of life rating and the patient-rated global well-being score implied the interviewer and the patients referred to difference point of views when rating the patients’ quality of life.
The most frequently detected need areas were psychotic symptoms, daytime activities, and company. The areas with the highest proportion of unmet needs were intimate relationships, company and psychological distress. The mean number of needs was 5.32 and the ratio of mean number of met needs to unmet needs was 4.63 versus 0.69 (=6.71:1). The mean number of unmet needs was lower than the community schizophrenic patients abroad. The most common need areas were similar to the foreign literature reports. Intimate relationship, others’ safety, self’s safety, benefits, housekeeping and physical health were the most common problem areas that were detected neither by relative/ friends nor by medical/social services.
Subjective quality of life was mainly related to the levels of patients’ global functioning and psychiatric symptoms. Few socio-demographic characteristics were correlated with subjective quality of life. Female, fewer symptoms, higher functioning, younger or shorter duration of illness was related with fewer needs or unmet needs.
A regression analyses showed that the higher psychiatric symptoms score was uniquely associated with more total needs and more unmet needs, accounted for 26.2% and 17.1% of explained variance in total need and unmet needs, respectively. Perceived quality of life was negatively correlated with total needs and unmet needs. However, the result of regression analysis, different from foreign literature reports, showed that perceived quality of life was not significant associated with more total needs and more unmet needs after controlling for the psychiatric symptoms.
The need areas that were correlated with subjective quality of life were housekeeping, company and transport, belonged to social, service and functioning category of needs. The psychiatric symptoms score was the significant predictor of perceived quality of life and accounted for 9.9% of explained variance in perceived quality of life. After controlling for the psychiatric symptoms score, the number of needs in social category and the need level in transport area respectively accounted for 8.2% and 5.5% of explained variance in perceived quality of life. The lower number of total needs was a stronger predictor of better perceived quality of life than the psychiatric symptoms score, and solely accounted for 10.0% of explain variance in perceived quality of life.

Conclusions:
The psychiatric symptomatology was the chief predictor of schizophrenic patients’ subjective quality of life and unmet needs. Besides, patients’ perception of subjective quality of life was affected by needs in service category and especially the need level in the transport area. The more total needs, the worse subjective quality of life. This result revealed that assessing the patients’ needs and reducing the total needs and the level of unmet needs would be helpful to improving the patients’ subjective quality of life. Although the psychiatric symptomatology was the common predictor of patients’ subjective quality of life and subjective needs for care, the low proportion of explained variance in regression model suggested that the associated factors in the relationship between the subjective quality of life and subjective needs was not explored adequately.

並列關鍵字

schizophrenia ； subjective needs for care ； subjective quality of life

參考文獻

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