【作者】 胡宓；

【导师】 肖水源；

【作者基本信息】 中南大学 ， 公共管理， 2012， 博士

【摘要】 研究背景情绪问题既包括符合DSM-IV诊断标准的心境障碍和焦虑障碍,也包括亚临床水平的抑郁和焦虑情绪,本研究将与情绪问题密切相关的自杀行为也列入情绪问题的范畴。情绪问题造成的疾病负担较高：2000年世界卫生组织报导,抑郁障碍位居全球疾病负担的第四位,预计到2020年将升高至第二位；在我国,单相重性抑郁障碍占疾病总负担的6.9%,预期到2020年将达到7.3%；自杀是我国第五位的死亡原因；自杀率在老年人中形成最高峰,且农村地区高于城市地区3-5倍；情绪问题还与躯体疾病相互作用,严重的影响着我国农村老年人的健康和生活质量。情绪问题已成为了一项突出的公共卫生问题。良好的社会联系是情绪问题的保护因素。社会联系是指个体所具有的人际关系的集合,是社会支持的基础。社会联系通过提供归属感、关爱等基本心理需求、提供社会支持、提供社会影响、社会角色等,以维护和促进心理健康。而社会孤立、社会排斥这一社会联系缺乏的极端表现,是情绪问题的重要危险因素。老年人由于配偶、朋友死亡、子女外出务工、自身活动范围缩小等原因,他们的社会联系呈现明显下降趋势。社会联系的下降给老年人的健康带来的巨大的冲击。社会联系与情绪问题的研究,由于采用健康自评问卷,社会联系概念存在分歧、且评估工具相对复杂,从而阻碍了该领域的进一步探索。目的本研究采用诊断工具SCID和自评问卷PHQ9、GAD7、自杀行为调查表对情绪问题进行评估,对农村老年人情绪问题进行全面的描述；本研究还在既往研究的基础上,明确定义了社会联系的概念、确定其测量的方法,并深入探讨农村老年人社会联系现况,分析其对情绪问题的影响；本研究还探索了躯体疾病、日常生活活动能力、生活事件及社会联系对情绪问题的影响；本研究通过对抑郁障碍患者的随访,了解了抑郁障碍患者的求助行为；最后,综合本研究的结果,提出通过提高社会联系,而降低情绪问题患病了的农村老年人社区干预模式。方法调查地点为采用多阶段整群随机抽样方法抽取的浏阳市农村地区8个自然村。调查对象为年龄60岁以上,在当地居住超过半年的老年人群。使用诊断工具SCID和自评问卷PHQ9、GAD7、自杀行为调查表进行情绪问题评估；使用日常生活活动能力评估量表和老年人生活事件量表评估情绪问题两类主要影响因素；社会联系的评估是以既往研究为基础,自行编制的由五个维度构成的社会联系评估工具；基线调查结束后一年,对调查时所诊断的重性抑郁障碍患者进行求医行为随访。结果本研究应调查941人,实际完成调查839人,应答率为89.16%。调查组与失访组在性别和年龄上差异无统计学意义。在839位完成调查的人中,男性448人(53.4%),年龄最大90岁,中位数年龄为68岁,QR=13,(P25=63,P75=76)。完成调查的839人中情绪问题现患率为17.0%(95%CI15.3%-20.4%)。其中,重性抑郁障碍的现患率为6.8%(95%CI5.1%-8.5%),抑郁症状现患率12.8%(95%CI10.5%-15.0%),焦虑症状现患率7.4%(95%CI5.6%-9.2%),1年内自杀意念和自杀未遂的发生率分别为5.6%(95%CI4.0%-7.2)和0.8%(95%CI0.2%-1.5%)。将人口学特征与情绪问题进行多因素logistic回归分析发现,情绪问题的发生随着个人年收入水平的增加而下降。社会联系包括配偶、子女、朋友、邻居和社会参与五个维度。分别以婚姻状况、是否与子女居住、好朋友个数、邻居关系程度和社会参与五个客观指标进行测量,客观真实的反应了社会联系现况。以社会支持作为社会联系评估工具的同时效度,两者呈现中度正相关(r=0.588)。社会联系作为整体与情绪问题密切相关。将情绪问题四类主要影响因素,社会联系、躯体疾病、日常生活活动能力和负性生活事件进行多因素logistic回归分析,四类因素对情绪问题均有影响。患躯体疾病(adjOR=2.203,95%CI：1.335-3.633)、较高的负性生活事件刺激(adjOR=6.564,95%CI：3.332-12.932)、日常生活活动能力的损害(adjOR=1.143,95%CI：1.090-1.198)都是情绪问题的危险因素；良好的社会联系(adjO2=0.743,95%CI：0.656-0.985)是情绪问题的保护因素。负性生活事件与社会联系对情绪问题的影响有交互作用,其交互作用超额危险度为6.502(95%CI1.221-11.783),交互作用指数为2.714(95%CI1.400-5.261)。重性抑郁障碍患者一年后随访发现,他们中无一人曾接受过专业帮助,且社会联系中无人识别该患者的情绪问题。结论1.本研究结果发现,浏阳市农村老年人情绪问题的现患率为17.0%(95%CI15.3%-20.4%)。其中,重性抑郁障碍现患率为6.8%(95%CI5.%1-8.5%),抑郁症状现患率为12.8%(95%CI10.5%-15.0%),焦虑症状现患率为7.4%(95%CI5.6%-9.2%),1年内自杀意念发生率为5.6%(95%CI4.0%-7.2%),1年内自杀未遂的发生率为0.8%(95%C10.2%-1.5%)。情绪问题发生率在个人年收入水平间分布有差异,在个人年收入低水平组显著高于的个人年收入高水平组。2.躯体疾病、日常生活活动能力、负性生活事件和社会联系是情绪问题的独立影响因素。社会联系与负性生活事件对情绪问题的影响具有交互作用。当高水平负性生活事件刺激与低水平社会联系同时存在时,患情绪问题的风险最大。3.本研究定义的社会联系由配偶、子女、亲友、邻居和社会参与五个维度组成,在此基础上形成的社会联系评估方法,经调查分析发现能够客观地反映老年人样本社会联系的现状,且与情绪问题负相关,符合本研究的理论构想。4.一年随访时间内,在完成随访调查的38名重性抑郁障碍患者中,无一人就医。更多还原

【Abstract】 BACKGROUDEmotional distress always included depression, anxiety and suicide. The definition of emotional distress in this paper involved mood disorder and anxiety disorder which meet the criteria of DSM-Ⅳ, and serious symptoms which under the diagnosis criteria. Giving the high co-current with depression and sever health outcome, suicide is also considered to be a emotional distress. Emotional distress leads to large quantity burdens of disease. WHO reported in2000, depression is the4th top global disease burden. It may rise to the2nd top till2020. In China, major depression is take6.9%total disease burden in2000. It will be up to7.3%till2020. Suicide is the5th cause of death around the China. The peak of suicide rate is around the elderly. And the suicide rate in rural area is3-5times higher than which in urban districts. Emotional distress also mutually effected physical disease which may sharply decrease the quality of life. Sum all, emotional distress become an important public health issue.With good social tie is a major protect factor for emotional distress. Social tie refer to collection of all personal relationship. Social tie is the fundamental of social support. It also provide basic psychological need for individual, namely self estimate, belonging and care. Social tie also influence the health situation through the social influence and social role. Social isolation and social exclusion is the extreme status of social tie shortage. It may lead to sever health problem such as depression and suicide. During the elderly period, social ties decrease gradually due to the physical disease and spouse passed away. Giving the social tie is a important protective factors for emotional distress, decrease of social tie is a major challenge for aged people.To explore in this field is hindered by using self rate health report, dispute about the concept and less screen tool could be used.OBJECTIVEThe objective of this research is to picture the situation of emotional distress among the eldery in rural area; to compile a tool for social ties’ evaluation and analyse the correlation between social ties and emotioal distress; to explore the correlations between emotional distress and major effect factors namely physical disease, activity ability, life events and social ties; to familiar with the help seeking behavior among the patients with major depression; and to provide scientific prevention model targeting at decreasing emotional distress among elderly in rural areas by improving the social ties based on the results of this research.METHODThe subjects of this study is residents who was no less than60years old and living no less than6months in rurual areas of Liuyang. Multistage clustered random sampling was adotped and8natural villages was selected as frame of samples. Emotional distress is evaluated by SCID, PHQ9, GAD7and Suicide screening scale. The activity ability was evaluated by ADL (Activity of Daily Life); The incidence of life evets was evaluated by LESE (Life Events Scale for the Elderly);Social ties was evaluated by self made scale with five dimesions namely spouse, child, friend, neigbor and social participation. Help seeking behavoir among patients with major depression in one year follow up study was evaluated by self made scale.RESULTThere are941induviduals meeting the enrolling cretiera and839 individuals completed the investigation. The response rate is89.16%. There is no significant difference between the lost group and completed group in gender and age. Among the839individuals who completed the interview, there are448(53.4%) males and media age is68years old (QR=13,P25=63, P75=76).Among the839individuals, the prevalence of emotional distress is17.0%(95%CI15.3%-20.4%). The prevalence of Major depression, depression symptoms, anxiety symptom, suicide ideation and suicide attempt are6.8%(95%CI5.1%-8.5%),12.8%(95%CI10.5%-15.0%),7.4%(95%CI5.6%-9.2%),5.6%(95%CI4.0%-7.2%) and0.8%(95%CI0.2%-1.5%) separately. The result of multiple logistic regression analysis indicate that with increasing of annual income, the prevalence of emotional distress decreased.Five dimensions of social ties was evaluated by marrital status, living arrangement, number of friends, relationship of neighbors and times participating the group activities. The indicators of these five dimensions reflecte the situation of social ties objectively and truly, and correlated with emotional distress. Social support as a criterion-related validation middle level correlated to social ties (r=0.588).The results of multiple logistic regression analysis indicate that physical disease (adj OR=2.203,95%CI:1.335-3.633), lower activity ability (adj OR=6.564,95%CI:3.332～12.932), negative life events (adj OR=1.143,95%CI:1.090～1.198) are risk factors of emotional distress. Adequate social ties (adjOR=0.743,95%CI:0.656～0.985) are protect factors of emotional distress. Social ties and negative life events have interaction on influence of emotional distress.One year follow up study find out that there is no one seeking the professional help in the past year among patients with major depression. CONCLUSION1. Prevalence of emotional distress among the investigated area is17.0%(95%CI15.3%-20.4%). Among them, The prevalence of Major Depression, Depression Symptom Anxiety Symptom, Suicide Ideation and Suicide Attempt are6.8%(95%CI5.%1-8.5%),12.8%(95%CI10.5%-15.0%),7.4%(95%CI5.6%-9.2%),5.6%(95%CI4.0%-7.2%) and0.8%(95%CI0.2%-1.5%) separately. Individual annual income is significantly effect emotional distress.2. Physical disease, activity ability, life events and social ties are major effect factors of emotional distress. Social ties and life events have interaction on influence of emotional distress. There are highest risk of emotional distress when negative life events and poor social ties coexisted.3. The social ties are clearly defined in this research and inclued five dimensions, spouse, child, friends, neighbors and social participation. The method of evaluation on social ties was formed basing on the definition. The results of the research indicated that the results reflects social ties objectly and truly, and middle level related to social supprt and negatively related to emotional distress. The definition fits the hypothesis of social tie.4. During an one year follow up period, there is no one has visited the doctors among the patient with Major depression.更多还原