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Title: 某精神醫院精神分裂症病患服用抗精神病藥物引起性功能障礙之盛行率及服藥配合度:觀察性研究
Prevalence of the antipsychotic-induced sexual dysfunction and medication adherence among psychiatric patients with schizophrenic disorders in a mental hospital
Authors: 蔡馨瑩
Tsai,Hsin-Ying
Contributors: 文榮光;黎進三;簡邦平
Wen Jung -Kwang;Lee,ChinSan
人類性學研究所
Keywords: 精神分裂症;性功能障礙;盛行率;服藥配合度;對數秩檢定法
antipsychotic drugs;sexual dysfunction;prevalence;adherence;Log-rank
Date: 2010
Issue Date: 2011-05-26 10:32:18 (UTC+8)
Publisher: 高雄市:[樹德科技大學人類性學研究所]
Abstract: 【研究目的】:探討南部某精神專科醫院精神分裂症病患服用抗精神病藥物引起性功能障礙之盛行率,進而分析性功能障礙對病患服藥配合度之影響。
【研究方法】:採立意取樣,研究方法學為調查研究法(包含問卷、訪談與觀察)。研究對象經DSM-IV-IR®診斷為精神分裂症,年齡18至65歲,男女各100名之門診、社區復健中心、康復之家、日間留院、病房及玫瑰園養護所能自由活動之病患,抗精神病藥物治療最少6個月以上,同意接受訪問之個案。
【研究工具】:
1. 正(陽)性與負(陰)性症狀量表(PANSS)為精神症狀評估工具,研究收案條件為總分小於91分。經由精神專科醫師指導完成會談訓練,其評分者間信度ICC(intraclass correlation)0.824~0.934相當良好。
2. 性功能障礙評估工具:包含亞利桑那性經驗量表-中文版(ASEX-CV),性障礙評估問卷、性功能障礙不良反應與忍受度認知問卷。
3. 服藥配合度評估工具:病患用藥行為配合度問卷與藥物治療史。
4. 泌乳激素:有89位研究對象,同意抽血進行泌乳激素值、藥物與性功能之分析。
5. 以描述性統計、卡方考驗、T檢定、F檢定、單因子變異數分析(One-way ANOVA)、無母數分析、邏輯斯迴歸(Logistic Regression)、對數秩(Log-rank)檢定法,進行問卷分析。
【研究結果】:
研究共回收有效問卷199人,38位服藥前已有性功能障礙者,將另外進行描述性統計。服藥後引起性功能障礙組共161人(男52.2%;女47.8%),平均年齡39.52歲,為主要進行分析與探討之範圍。
1. 研究結果發現ASEX-CV(中文版)量表之靈敏度及特異姓各為77.1%及72.7%,陽性預測值為91.2%,陰性預測值則為68.8%(p<.000)。ROC曲線之AUC值為0.759±0.051。真陽性及偽陽性數值的評分標準定義為(ASEX-CV總分≥17,任一題≥5,或者任三題≥4)。ASEX-CV全量表Cronbach's alpha達0.8187,顯示本問卷信度良好,適合成為臨床上精神分裂症病患性功能之評估工具。
2. 抗精神病藥物引起性功能障礙之盛行率為70.2%,男生有52人佔61.9%;女生有61人佔79.2%(p<.05)。卡方結果顯示,性別與藥物引起性功能障礙有顯著相關(p<.05)。進一步分析,ASEX-CV每題≧4 分之人數結果得知,男性以性慾望障礙的百分比最高,女性則同時有性慾望障礙、陰道潤滑障礙、性高潮障礙等性問題。進行T檢定結果顯示,性別不同,則男性較女性重視性生活的品質(p<.001);女性對性生活的滿意度則高於男性(p<.05)。
3. 進行T檢定結果顯示,性別不同對於性功能障礙之忍受程度(p<.05)與服藥配合度皆有顯著差異(p<.001)。有82.3%(男75.0%;女89.6%)可以忍受藥物引起性功能障礙,可忍受的主要原因:無性伴侶(38.9%)、精神症狀穩定最重要(32.8%)。進行T檢定結果顯示,在服藥配合度四個分項中,僅「按照醫師交代的時間吃藥」男性之配合度高於女性,有顯著差異(p<.05),其他選項則無明顯差異。整體而言,有53.5%(男51.2%;女55.8%)可以完全配合醫師指示服藥,而造成服藥配合度不好的主要原因為:忘了吃藥(51.1%)。上述研究結果顯示,女性對於性功能障礙之忍受程度高於男性,且服藥配合度較佳。
4. 進行T檢定結果顯示,性別不同之泌乳激素有顯著差異(p<.000)。男性之泌乳激素平均值為15.45 ng/ml(標準差13.65);女性之泌乳激素平均值為51.47 ng/ml(標準差50.40),女性明顯高於男性。抗精神病藥物依作用機轉分類,進行無母數檢定分析達顯著差異(p<.05),事後比較結果女性以服用SDAs(serotonin-dopamine antagonist)藥物之泌乳激素平均濃度102.84ng/ml(標準差59.71)最高,大於MARTAs(multi-acting receptor targeted agents)與合併用藥兩大類。
5. 以ASEX-CV評估無性功能障礙者,泌乳激素平均值為20.42 ng/ml(標準差23.45),有性功能障礙者之泌乳激素平均值為40.12 ng/ml(標準差46.26),泌乳激素平均值與性功能障礙,呈顯著正相關(r=.231,p<.05)。
6. 以邏輯斯迴歸進行分析,得知會自慰者之性功能障礙發生的機會比不會自慰者降低24.3%(p<.001),服用MARTAs藥物,包含Clozapine(Clozaril®)、Olanzapine(Zyprexa®)、Quetiapine(Seroquel®)、Zotepine(Lodopin®)之性功能障礙發生的機會比服用FGAs(First generation antipsychotics drug)降低26.5%(p =.063),接近統計顯著意義。不分性別,在婚姻狀況部份:分居/離婚/再婚/鰥寡者,性功能障礙發生的機會比未婚者降低15.4%(p<.05),有服用腸胃道藥物者,性功能障礙發生的機會會降低22.8%(p<.05)。
7. 以存活分析中的區間設限數據的形態進行統計分析,發現女性且年齡大於39歲,其藥物低劑量組與維持劑量組有顯著差異(p<.05)。進一步分析,在服藥第一到兩個月出現性功能障礙的機率:維持劑量組為13.5%;低劑量組為0.0%。第七個月之後,尚未出現性功能障礙的機率:維持劑量組有52.7%;低劑量組為81.0%。。比較三種藥物,雖未達顯著差異(p=.207),服用藥物第一到第五個月會出現性功能障礙的機率為risperidone(58.3%)、 olanzapine(36.0%)、 clozaril(9.5%)。
【研究結論】:
在男性與女性病患的身上,均發現性功能障礙之高盛行率。然而,女性病患對性生活的滿意度比男性病患高,且服藥配合度比男性病患佳。ASEX-CV量表能夠提供臨床醫師,精準地測量出病患之性功能障礙症狀,也將面對性問題的不舒服及難堪程度降到最低。探討性功能障礙之盛行率、發生機率、危險因子,與服藥配合度,性別差異是值得重視的一環。
【Objective】:
To investigate the prevalence of sexual dysfunction in the schizophrenic patients after antipsychotic treatments in a psychiatric hospital of southern Taiwan, and to analyze the impacts of sexual dysfunctions on patients' medication adherence.
【Method】:
The judgment sampling was used in this study. Subjects were 100 male and 100 female patients between 18 and 65 being diagnosed with schizophrenia (according to criteria of DSM-IV-IR®) and under the treatment of antipsychotics over 6 months at the outpatient service, community rehabilitation center, halfway house, psychiatric day care center, ward, or nursing home. All the patients agreed to accept the interview.
【Instruments】:
1. Positive and Negative Syndrome Scale (PANSS) to assess the psychological symptoms of patients, and the total score for each patient to enter this study should be less than 91. After a thorough review by psychiatrists, we obtain an excellent intraclass correlation (ICC) (0.824~0.934).
2. Assessments of sexual dysfunctions: Arizona Sexual Experience Scale-Chinese Version (ASEX-CV), questionnaires of sexual dysfunctions including adverse reactions and tolerance cognition.
3. Assessment of Patients' adherence: Questionnnaires of patients’ adherence and medication history.
4. Prolactin: Totally 89 patients agreed to draw their blood for level analysis.
5. Description statistics, Chi Square Test, T-test, F-test, One-way Analysis of Variances (one-way ANOVA), Nonparametric Test, Logistic Regression , and Log-rank were used to analyze the questionnaires.
【Results】:
A total of 199 participants were enrolled in the study. Among them, 38 patients had developed sexual dysfunctions prior to the study. These subjects were described in a separated chapter. The remaining 161 patients (male 52.2%; female 47.8%) with an aveage age of 39.5 were found to develop sexual dysfunctions after treatments. To investigate and analyze the questionnaires they answered is the main purpose of this study.
1. The study indicates that the sensitivity and specificity of ASEX-CV were 77.1% and 72.7% respectively; positive predictive value is 91.2% and negative predictive value is 68.8%(p<.000). The area under the ROC curve(AUC)is 0.759±0.051. The standard criteria for true and false positives includes a total ASEX-CV score ≥17, any one ASEX item with an individual score ≥5 or any three ASEX items with individual scores ≥4. The Cronbach's alpha for ASEX-CV measures 0.82 indicating that the ASEX-CV is reliable and appropriate for the clinical evaluation of schizophrenic patients.
2. Prevalence of sexual dysfunction induced by antidepressants is 70.2% including 52 males(61.9%) and 61 females(79.2%)(p<.05). The Chi Square Test result demonstrate a significant relevance between the gender and drug-induced sexual dysfunctions(p<.05). Upon further analysis of any one ASEX item with an individual score ≥4, the percentage of libodo disorders reaches the highest in males. For female patients, sexual dysfunctions,, such as the decrease of libido, vaginal lubrication and orgasm, could develop at the same time. The T-test reults demonstrate a gender difference reflecting that the quality of sexual life is more important in male patients (p < .001), and in contrast, the degree of satisfaction is more important in female patients (p < .05).
3. The T-test results also demonstrate a significant gender diffference in patients' tolearance for sexual dysfunctions (p < .05), as well as patients' adherence for medications (p < .001). About 82% of patients (male 75.0% and female 89.6%) could tolerate medication-induced sexual dysfuctions, mainly due to no sexual partners(38.9%) and stable mental status (32.8%). There are 53.4% of total patients ( male 51.2% and female 55.8% ) able to completely follow physicians' instructions to take their medications. The nonadherence is mainly attributable to patints'ata in survival anlysis for the study of time to event finds that a significant difference between the low and maintenance dose of administrations in female patients older than 39 years old. Furthermore, the incidence of sexual dysfuntion development in the first two months after maintenance dose of treatment is 13.5%, as compared to 0% for the group using the lower dose. At 7 months after treatment, the incidence of no sexual dysfunction development using a low dose regimen is 52.7%, much lower than 81% for those using maintenance dose. The distributions of the event time show no significant statistical difference among those three specified medications (Risperidone, Olanzapine, and Clozaril). However, the incidence of developing sexual dysfunction in yhe first five months after taking these three medications are 58.3, 36.0 and 9.5%, respectively.
【Discussion】:
There is high prevalence of antipsychotic-induced sexual dysfunctions in both male and female patients. In general, better sexual life satisfaction, as well as better adherence of medication were found in female patients after antipsychotic treatments.The ASEX-CV assessment will help clinicians evaluate patient's sexual dysfuctions due to antipsychotic treatments, and minimize their consequent discomfort and embarraasment. Investigations for the prevalence of antipsychotic-induced sexual dysfunctions in different genders are important for the improvement of medical adherence.
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