【作者】 吴红花；

【导师】 张洪波； 刘健；

【作者基本信息】 安徽医科大学 ， 儿少卫生与妇幼保健学， 2008， 硕士

【摘要】 目的调查了解女性类风湿关节炎(rheumatoid arthritis, RA)住院病人焦虑和抑郁症状的流行状况以及生活质量状况;探讨身体疲劳、社会支持、应对方式及婚姻调适度等因素与女性RA住院病人焦虑和抑郁症状及生活质量的关系;探讨认知行为干预方法对降低女性RA住院病人焦虑抑郁症状,提高其生活质量的有效性和可行性。方法定性研究现场为安徽省中医院风湿科,以安徽省中医院2006年8月1日至2006年9月30日在风湿科住院的女性RA病人为研究对象,应用个人深入访谈的方法,对20例符合临床诊断标准的女性RA住院病人按照统一的访谈提纲进行访谈。调查员在调查对象签署知情同意书之后,遵循自愿、保密和匿名的原则,由经过培训的专业人员按照统一制定的访谈提纲进行个人深入访谈并录音。访谈内容包括RA疾病的发生、发展状况及病人的社会支持状况、病人的心理健康状况及对心理健康服务需求的内容和形式、对不良情绪的调节能力、临床服务的内容和方式。每次访谈时间大约1小时。资料经访谈员整理后由另一名访谈员核对原始录音和整理后的文本,确定两者之间的一致性。资料的整理和分析步骤:①阅读原始资料并熟悉资料内容,将访谈的文本资料按访谈提纲问题进行编码;②为分析资料设立统一的选择标准,进行“目的性抽样”,根据访谈的线索和反映的主要内容,选取能说明研究问题的内容;③拟定分析条目,归纳出访谈对象对该条目给出的所有答案,形成结果报告。以安徽省中医院、安徽医科大学第一附属医院和安徽省立医院为研究现场,进行女性RA住院病人心理健康和生活质量状况的横断面研究。以2007年1月1日至5月31日在三家医院住院部风湿科住院的女性RA病人为研究对象,采用无记名调查问卷的方式,应用焦虑自评量表(self-rating anxiety scale,SAS)和抑郁自评量表(self-rating depression scale, SDS)、WHO生活质量量表中文简表(quality of life questionnaire for world health organization-bref, WHOQOL-BREF),对研究对象进行焦虑和抑郁症状评定及生活质量评定,并对身体疼痛、身体疲劳、社会支持、应对方式和婚姻调适等因素进行调查。以焦虑、抑郁和生活质量评分作为应变量,应用相关分析、χ2检验、多元非条件Logistic回归分析,探讨以上因素与患者的焦虑和抑郁状况及生活质量的关系。以安徽省中医院住院部风湿科为研究现场,以2007年6月1日至8月31日入院的女性RA病人为干预对象,以9月1日至12月31日入院的女性RA病人,按照年龄相差在2岁,病程相差在1年以内的原则进行1:1配比,共选出60人作为对照对象。对照对象按照常规的药物治疗和护理。干预对象除常规的药物治疗和护理外,应用认知行为干预的方法在两个星期内进行4次干预活动。分别在干预前、后采用无记名问卷的方式对干预对象进行健康状况调查。对照病人分别在入院时和住院治疗2周后进行健康状况问卷调查。用配对t检验比较干预病人和对照病人的焦虑和抑郁症状评分、生活质量评分和应对方式的变化。结果定性访谈结果表明多数女性RA住院病人在发病初期并未引起重视,情绪也比较稳定;随着病情的进展,大部分病人出现情绪波动,出现焦虑和抑郁情绪;病人在住院期间社会支持水平低,缺乏应对不良情绪的能力;医疗服务的内容主要是以疾病治疗为中心,无任何心理健康干预措施。横断面调查结果显示,女性RA住院病人焦虑症状、抑郁症状的检出率分别为37.5%和72.7%。文化程度在初中及以下、居住在农村、家庭人均月收入在800元以下、关节功能在2级及以上、关节有畸形、晨僵时间大于半小时的病人比文化程度在高中及以上、居住在城市、家庭人均月收入在800元以上、关节功能为1级、关节无畸形、晨僵时间小于半小时的病人焦虑和抑郁症状检出率均高(P<0.05)。年龄在49岁以上、既往无正规治疗的病人抑郁症状检出率分别高于年龄在49岁以下、既往有正规治疗的病人(P<0.01)。焦虑和抑郁症状均与疼痛、应对方式、婚姻调适、身体疲劳及社会支持相关联(P<0.01)。经多元非条件Logistic回归分析发现,进入焦虑症状方程的变量为屈服应对方式、身体疲劳。居住在农村、文化程度在初中及以下、晨僵时间在半小时以上、屈服性应对方式、婚姻调适度差和社会支持差可增加病人抑郁症状的危险性。女性RA住院病人生活质量各领域评分均低下。单因素分析表明,影响病人生活质量的因素有病人的文化程度、婚姻状况、关节有无畸形、既往有无正规治疗,目前关节功能分级、目前居住地。病人的身体疼痛、身体疲劳、应对方式、社会支持及婚姻调适度和生活质量相关联(r=-0.307/-0.516/0.378/0.262/-0.588/0.433/0.528, P<0.01)。经多元非条件Logistic回归分析,进入生活质量方程的变量有病人的文化程度、关节功能分级、屈服性应对方式、关节畸形和社会支持。干预研究结果表明,采用配对T检验的方法比较时,干预对象与其配对的对照的焦虑症状评分、抑郁症状评分、生活质量各领域评分以及面对应对方式、回避应对方式和屈服应对方式评分,结果显示差异无统计学意义(P>0.05)。干预对象基线时焦虑症状和抑郁症状评分与评估时评分差值的均数分别为6.47±7.81和8.00±10.79,其对照基线时的焦虑症状和抑郁症状评分与评估时评分差值的均数分别为1.35±8.46和1.93±11.84,经配对T检验,结果显示差异有统计学意义。生活质量评定结果表明,干预对象基线时生理和社会关系领域评分与评估时评分差值的均数分别为-2.98±3.26和-0.87±2.42,低于其对照相应的评分差值的均数(0.44±3.08和0.65±2.67);干预对象心理领域基线评分与评估评分差值的均数为-0.86±3.65,低于其对照基线与评估评分差值的均数(0.46±3.09);干预对象环境领域基线时评分与评估时评分差值的均数为-3.58±9.71,低于其对照相应评分差值的均数(1.15±8.76)。有关应对方式评分的配对T检验表明,干预对象基线时面对和回避方式评分与评估时评分差值的均数分别为-3.35±3.21和-2.85±3.26,低于其对照相应的评分差值的均数(-0.33±3.23和-0.20±3.37);干预对象屈服方式基线评分与评估评分差值的均数为1.83±2.68,高于其对照的相应评分差值的均数(-0.32±2.75)。结论女性RA住院病人心理健康问题严重,生活质量低。病人对疾病采取的应对方式和自我感觉的身体疲劳程度与病人的焦虑症状相关联;病人的抑郁症状受到目前居住地、文化程度、晨僵时间、屈服应对方式、婚姻调适度和社会支持的影响;病人的文化程度、医疗费用支付方式、关节功能分级、屈服性应对方式、婚姻调适度和社会支持影响到自身的生活质量。认知行为干预能有效地降低患者的焦虑和抑郁症状,促进病人的生活质量。这提示在临床工作中不仅仅要关注患者临床症状的缓解,还要关注她们的情绪状态,应重视提高患者生活质量为目的。更多还原

【Abstract】 Objectives To know the content and pattern of medical service and to explore their demand for mental health service;To determine the Anxiety and Depression symptom and Quality of life of women who suffered from Rheumatoid Arthritis in hospital and to develop effective mental healthy promoting methods for the women.Methods The qualitative study was conducted in Hospital of Anhui Chinese medicine. The women who suffer from Rheumatoid Arthritis and stayed in the hospital during August 2006 to October were invited to be as subjects. After informed consent, the in-depth interview was used to interview twenty participants who met the clinical diagnosis standards. The participants were interviewed followed the outline of interview and the interviewing. The contents of the interview involved the development and treatment of Rheumatoid Arthritis, social support, mental health, the needs of social and psychological support services, as well as the skills of dealing with negative emotion and the demand for mental health services. Each interview round lasted about one hour. To be sure of the consistency between the original records and finishing texts, the record of the interviews was transformed into word file by one investigator and was checked by another investigator. The criterion was established for data selection, and then“sampling purposes”was used to choose the targeting content based on interview clues.The cross-section study was conducted in the hospital of Anhui Chinese medicine, the first affiliated hospital of Anhui medical university and Anhui provincial hospital. The subjects were women who suffered from Rheumatoid Arthritis and stayed in the three hospitals during January 2007 to June. Anonymous questionnaires were finished by 240 participants. Anxiety rating, depression rating, quality of life were done by using SAS, SDS and WHOQOL-BREF respectively and social support, marriage adjustment, coping behavior were also investigated. The patients completed the questionnaires independently. The Chi square test was used to determine the relationship between socio-demographic characteristics and women’s anxiety, depression and quality of life with Rheumatoid Arthritis. The relationship between social support, marital adjustment, fatigue and patient’s anxiety, depression and quality of life were found out by correlate anynasis. The multiple non-conditional Logistic regression analysis was conducted to know the factors of anxiety, depression and quality of life among participants.The congnitive behavior intervention was conducted in Anhui Chinese medicine hospital. The women who suffered from Rheumatoid Arthritis and stayed in the hospital during June 2007 to December were invited to be as intervention subjects and those who stsyed in the hospital from June 1st 2007 to August 31st 2007, were selected to be control matching by age no more than 2 years and disease lasting time course no more than 1 year. The participants in intervention were received two-week cognitive behavioral intervention based on routine clinical therapy and nursing. The participants in control were only received routine clinical therapy and nursing. To assess the effects of the intervention, the questionnaire of health status was conducted at baseline and two weeks later. Paired-Samples T test was used to test the changes score of anxiety and quality of life between the two groups’subjects.Results Most of the patients in their early stages of Rheumatoid Arthritis didn’t pay enough attention to disease, and their emotion is relatively stable. With the progress of the disease developing, most patients had emotional fluctuations, anxiety and depression symptoms and had low level of social support. The patients were leak of shill of dealing with emotional problem. It was found that the medical service concentrated on disease treatment and mental health intervention was neglected.The rate of anxiety was 37.5% and that of depression was 72.7% among women suffered from RA in hospital. The rate of anxiety and depression was significantly difference between variety of education level, living in location, the month’s earning, the body condition, the joints function, the joints abnormality, and the morning stiffness. The rate of depression was significantly higher among women with RA who are at least 49 years old and had no formal therapy. Both the anxiety and depression were correlated with pain, coping behavior, marriage adjustment, fatigue and social support. By Logistic regression analysis, submission of coping style and fatigue were associated with anxiety; living in rural, under the education of middle school, suffering from the morning lasting over half an hour, submission of coping style, lack of skill of marriage adjustment and social support could increase the risk of depression. The score of quality of life among Rheumatoid Arthritis women was low. The factors were sociated with quality of life, included the patient’s education level, marital status, joint deformities, formal treatment previous, current physical functional status, place of residence. The variable of patient’s education level, body function classification, Passive approach, joint deformities and social support enter the equation of quality of life by means of Logistic regression analysis.There were no statistically differences between participants in intervention and in control among anxiety score, depression score, quality of life score and coping score at baseline. The mean scores of deviation of anxiety and depression between baseline and assessment of participants in intervention were 6.47±7.81 and 8.00±10.79 respectively, and those in control were 1.35±8.46 and 1.93±11.84 accordingly. The results showed that these differences were significant by using paired-samples T test. Regarding to quality of life, the mean scores of deviation among the physical and social field between baseline and assessment of the participants in intervention were -2.98±3.26 and 0.87±2.42 respectively, which were lower significant than those in control (0.44±3.08 and 0.65±2.67). In other word, the mean scores of deviation of the psychological and environment field between baseline and assessment of the participants in intervention were -0.86±3.65 and -3.58±9.71 respectively, which were lower significantly also than those in control (0.46±3.09 and 1.15±8.76). With the respect of coping skill, the mean scores of deviation of confrontation and obviatation between baseline and assessment of the participants in intervention were -3.35±3.21 and -2.85±3.26 respectively, which were lower significantly than those in control (-0.33±3.23 and -0.20±3.37); The mean score of deviation of submission between baseline and assessment of the participants in intervention was 1.83±2.68, and higher significantly than that in control (-0.32±2.75).Conclusions The development of Rheumatoid Arthritis disease makes negative impact on patients’physical, psychological and all social aspects. Health care workers should not only concern with the elimination and improvement of patients’somatic symptoms but also should pay attention to patients with psychological problems during their medical care activities and psychological intervention should be up with the clinical treatment so as to improve the quality of life of Rheumatoid Arthritis hospital women. Cognitive behavioral intervention could promote the mental health and improve the quality of life of women who suffered from Rheumatoid Arthritis.更多还原