| 摘要: | 背景：大腸激躁症症狀困擾嚴重干擾患者生活品質，文獻缺乏台灣地區大腸激躁症發生率趨勢之全國性大型數據資料。正念減壓療法之介入對於改善大腸激躁症症狀嚴重度及生活品質成效及患者之情緒狀態能否預測疾病症狀嚴重度有待研究證實。
目的：1.探討台灣地區大腸激躁症年發生率趨勢及後續發生器質性疾病之風險。2.探討正念減壓療法對於改善大腸激躁症症狀嚴重度、生活品質、憂鬱及焦慮之成效。3.探討焦慮與憂鬱情緒狀態與大腸激躁症患者症狀嚴重度之相關性。
方法：本論文系列研究共分三個子研究，研究一採縱貫性研究及世代追蹤研究設計，分析台灣縱貫性健康保險資料2010百萬歸人檔資料，擷取大腸激躁症診斷碼，計算2003-2013年台灣地區大腸激躁症年發生率，以多變量卜瓦松迴歸合併廣義估計方程式進行大腸激躁症10年長期發生趨勢檢定，再以多變量Cox比例風險模式驗證後續發生器質性疾病之風險，並計算風險比（hazard ratio, HR）及其九五信賴區間（95% confidence interval, CI）。研究二採隨機對照試驗研究設計，醫師轉介符合羅馬準則III之大腸激躁症患者並隨機分配至正念減壓組及支持團體組進行8週介入措施，8週課程結束、3個月及6個月進行追蹤，以「大腸激躁症症狀嚴重度量表」評估症狀嚴重度、「大腸激躁症生活品質量表」評估生活品質、「貝克憂鬱量表第二版」評估憂鬱症狀及「貝克焦慮量表」評估焦慮症狀，以廣義估計方程式驗證正念減壓療法於大腸激躁症症狀嚴重度、生活品質、憂鬱及焦慮之改善成效。研究三採橫斷式研究設計，使用研究二隨機臨床試驗之基準值進行次級資料分析，分析以羅馬準則III為診斷標準之大腸激躁症患者，「大腸激躁症症狀嚴重度量表」評估症狀嚴重度、「貝克憂鬱量表第二版」評估憂鬱症狀、「貝克焦慮量表」評估焦慮症狀，以「布里斯托大便分類紀錄」作為大腸激躁症分型依據，採線性複迴歸統計方式分析大腸激躁症症狀嚴重度之預測因子。
結果：1.2003-2013年大腸激躁症年發生率趨勢為隨著時間推移而顯著下降，校正共變項後的發生風險比為0.97（p <.001）。10年長期追蹤，罹患大腸激躁症後續器質性疾病發生之風險比HR為1.77 （95% CI = 1.63 - 1.92, p <.001）。2.研究共納入60名20-79歲符合羅馬準則III之大腸激躁症病人並隨機分配至正念減壓組與支持團體組，結果顯示正念減壓和支持團體兩組在介入後多個時間點大腸激躁症疾病症狀嚴重度、生活品質及憂鬱皆有改善，而焦慮症狀僅正念減壓組在第3及6個月追蹤有明顯改善。然而廣義估計方程式統計檢定兩組差異分析顯示正念減壓療法之成效並未顯著優於支持團體。3.共納入60名20-79歲大腸激躁症病人，複迴歸預測因子模型中校正年齡、性別、吸菸狀態、大腸激躁症次分型、藥物治療、憂鬱等因素，結果顯示焦慮狀態可顯著預測大腸激躁症病人之症狀嚴重度(p =.003)，模型解釋力為20.8%。
結論： 十年間台灣大腸激躁症的發生率有顯著下降趨勢，但罹患大腸激躁症顯著增加後續器質性病變發生風險，對於大腸激躁症患者應更多關注及積極介入，除症狀控制及追蹤健康狀態外，並應更重視患者之情緒狀態，適當給予情緒支持、同理疾病感受並給予疾病認知等，亦能使患者與疾病共存達降低症狀嚴重度及提升生活品質之成效。正念減壓介入在改善大腸激躁症患者之症狀嚴重及生活品質沒有優於護理師引導之支持團體介入，因此有待未來研究證實其特定成效。
Background: Population-based data regarding secular trends in the incidence rate of irritable bowel syndrome (IBS) among Taiwanese adults are lacking. Symptom distress adversely impacts IBS patients’ quality of life (QOL). It remains uncertain whether psychological distress is an independent predictor of symptom severity in IBS. The effects of mindfulness-based stress reduction (MBSR) on symptom severity and quality of life in the IBS population remain to be determined.
Aims: 1. To investigate the sex and age-stratified trends in the annual incidence of IBS, and the risk of selected organic diseases in patients with IBS compared with those without IBS among Taiwanese adults during 2003-2013. 2. To examine the effects of MBSR on symptom severity, QOL, anxiety and depression in participants with IBS. 3. To determine the association between psychological distress and symptom severity in patients with IBS.
Methods: Study 1: A longitudinal and cohort study design was used. Medical claims data for 1 million randomly selected beneficiaries were obtained and analyzed. IBS patients were defined using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. To test whether there was a linear secular trend in IBS incidence over time, multivariate Poisson regression with generalized estimating equation model (GEE) was conducted. The risk of selected organic diseases associated with IBS was examined using multivariate Cox proportional hazard regression. Hazard ratio (HR) and associated 95% confidence intervals (CI) were estimated. Study 2: A parallel-group, randomized controlled trial design was used. Participants were randomly assigned to either a nurse-led MBSR group or a nurse-led peer-support group. IBS symptom severity was measured using the IBS Symptom Severity Scale (IBSSSS). The Irritable Bowel Syndrome Quality of life (IBS-QOL) was used to measure QOL. The Beck Anxiety Inventory (BAI) and Beck Depression Inventory-II (BDI-II) were used to assess anxiety and depression, respectively. The effects of MBSR on symptom severity, QOL, anxiety and depression were examined using GEE. Study 3: A cross-sectional study was conducted by analyzing baseline data from Study 2. The IBSSSS was used to measure symptom severity, and psychological distress, namely depression and anxiety was determined using the BDI-II and BAI. Multiple linear regression was used to determine independent predictors of symptom severity.
Results: From 2003 to 2013, the IBS incidence rate decreased significantly over time (adjusted incidence rate ratio = 0.97, p < .001). IBS significantly associated with increased risk of organic disease during a 10-year follow-up period (HR = 1.77, 95% CI = 1.63 - 1.92, p < .001). Both the MBSR group and peer-support group reduced symptom severity, and improvement QOL and depression over time whereas the post-treatment improvement of anxiety was only observed for the MBSR group. Nevertheless, the effects of MBSR were not superior to those of the peer-support group determined by GEE analyses. After adjusting for age, gender, smoking, phenotype, use of medication and depression, anxiety significantly and independently predicted the magnitude of symptom severity (p = .003, R2=20.8%).
Conclusion: There was a decreasing trend in the incidence of IBS from 2003 to 2013 in Taiwan. IBS was found to be significantly associated with future risk of organic diseases. Emotional support, disease education, and measures to reduce anxiety should be incorporated in the symptom management regime for patients with IBS in order to improve QOL of these patients. MBSR is not superior to nurse-led peer-support in reducing symptom severity and improving QOL. Future trials are thus warranted to substantiate the specific effects of MBSR for IBS symptom management. |
