邵曉麗，江錦芳

癌癥病人心理痛苦篩查與干預(yù)研究進(jìn)展

邵曉麗，江錦芳

摘要：介紹了心理痛苦篩查工具、心理痛苦干預(yù)的研究進(jìn)展以及我國(guó)癌癥病人心理痛苦篩查與干預(yù)現(xiàn)狀,提出要真正實(shí)現(xiàn)對(duì)所有癌癥病人的心理痛苦篩查、干預(yù)并形成實(shí)踐指南。

關(guān)鍵詞:癌癥病人；心理痛苦；篩查工具；干預(yù)

AbstractIt introduced the research progress on psychological distress screening tool and the psychological distress intervention，and the status quo of psychological distress screening and intervention for cancer patients in China.It put forward that the psychological distress screening and intervention should be achieved truly for all cancer patients，and to form the practical handbook.

中圖分類號(hào)：R473.73

文獻(xiàn)標(biāo)識(shí)碼：碼：A

doi:10.3969/j.issn.1009-6493.2015.28.005

文章編號(hào)：號(hào)：1009-6493(2015)10A-3469-05

作者簡(jiǎn)介邵曉麗,護(hù)師,碩士研究生在讀,單位：530021,廣西醫(yī)科大學(xué)附屬腫瘤醫(yī)院；江錦芳(

通訊作者)單位：530021,廣西醫(yī)科大學(xué)附屬腫瘤醫(yī)院。

收稿日期:(2014-10-10;修回日期:2015-07-15)

Research progress on psychological distress screening and intervention of cancer patients

Shao Xiaoli,Jiang Jinfang(Affiated Cancer Hospital of Guangxi Medical University，Guangxi 530021 China)

Key wordscancer patient;psychological dietress;screening tool;intervention

心理痛苦在癌癥病人中非常常見(jiàn),癌癥的診斷、疾病本身及治療都可引起病人心理痛苦[1]。國(guó)外報(bào)道癌癥病人心理痛苦發(fā)生率為34.3%～65.9%[2-6],我國(guó)癌癥病人心理痛苦發(fā)生率為24.2%～73.4%[7-12]。美國(guó)國(guó)家癌癥綜合協(xié)作網(wǎng)(National Comprehensive Cancer Network,NCCN)1999年就發(fā)布了癌癥病人心理痛苦篩查與管理指南,并且每年都對(duì)指南進(jìn)行了更新。而我國(guó)在癌癥病人心理痛苦方面的研究還處于起步階段。本文就癌癥病人心理痛苦篩查與干預(yù)研究進(jìn)展綜述如下。

1心理痛苦

NCCN(2013)對(duì)心理痛苦定義如下：由多種因素引起的不愉快的情感體驗(yàn),包括心理(認(rèn)知、行為、情感)、社會(huì)和(或)精神實(shí)質(zhì)上的體驗(yàn),這些體驗(yàn)可能會(huì)影響病人有效地應(yīng)對(duì)癌癥、身體癥狀及治療的能力；心理痛苦持續(xù)存在,既包括感情脆弱、悲傷和害怕等常見(jiàn)心理感受,也包括抑郁、焦慮、恐懼、社會(huì)孤立感及精神危機(jī)等嚴(yán)重的心理障礙。心理痛苦作為第六生命體征已經(jīng)得到研究者們廣泛認(rèn)同[13-17],同時(shí)也被國(guó)際腫瘤心理協(xié)會(huì)[18]、NCCN[19]、癌癥委員會(huì)[20]、加拿大腫瘤護(hù)士協(xié)會(huì)[21]以及加拿大認(rèn)證部[22]采納。心理痛苦會(huì)嚴(yán)重影響癌癥病人生活質(zhì)量、疾病康復(fù)、生存期且有焦慮、抑郁高風(fēng)險(xiǎn)[2,23,24]。NCCN自1999年起,就建議對(duì)癌癥病人進(jìn)行心理痛苦篩查及管理；美國(guó)癌癥外科學(xué)院委員會(huì)要求自2015年起對(duì)所有癌癥病人進(jìn)行心理痛苦篩查[25]。

2心理痛苦篩查工具的研究進(jìn)展

目前,用于評(píng)定癌癥病人心理痛苦問(wèn)題的評(píng)估工具多達(dá)33種[26],然而,這些量表在使用過(guò)程中存在一些共性問(wèn)題：①對(duì)于心理痛苦概念的界定存在差異,在有的研究中,用單純的焦慮、抑郁情緒代替癌癥病人的心理困擾[27]；②評(píng)估量表多為一些普適量表,缺乏針對(duì)癌癥病人的特異性量表,比如常用的醫(yī)院焦慮抑郁量表(Hospital Anxiety and Depression Scale,HADS)、簡(jiǎn)明癥狀問(wèn)卷(Brief Symptom Inventory,BSI)、癥狀自評(píng)量表(SCL-90)、簡(jiǎn)明心境問(wèn)卷(Profile of Mood Scale,POMS)等；③一些評(píng)估量表沒(méi)有很好地報(bào)告其心理測(cè)量屬性,因而也限制了其臨床使用價(jià)值；④有些量表?xiàng)l目過(guò)長(zhǎng),且使用了過(guò)多的負(fù)性條目,容易引起病人的抵觸情緒,從而限制了量表的使用,同時(shí),填寫需要花費(fèi)太多的時(shí)間。腫瘤護(hù)理協(xié)會(huì)要求癌癥相關(guān)心理痛苦篩查所用工具必須是準(zhǔn)確有效的[28]；此外,所用篩查工具必須是簡(jiǎn)短、病人容易完成的[29]；NCCN推薦使用心理痛苦管理篩查工具(Distress Management Screening Measure,DMSM)進(jìn)行心理痛苦程度及其相關(guān)因素的篩查。DMSM工具簡(jiǎn)單、易操作,包括兩部分: 心理痛苦溫度計(jì)(Distress Thermometer,DT)和問(wèn)題列表(Problem List,PL)。1998年由Roth等[30]開(kāi)發(fā)并首次運(yùn)用于前列腺癌病人,NCCN在DT基礎(chǔ)上增加了問(wèn)題列表,并推薦其作為心理痛苦篩查工具。①DT,以0～10刻度數(shù)字表示心理痛苦程度,0表示無(wú)心理痛苦,10表示極度心理痛苦； ②PL,包括5大方面：實(shí)際問(wèn)題、家庭問(wèn)題、情緒問(wèn)題、軀體方面問(wèn)題及精神宗教信仰問(wèn)題,共39個(gè)具體問(wèn)題。參與調(diào)查的病人根據(jù)過(guò)去的1周心理痛苦狀況選擇DT上的一個(gè)合適數(shù)字,然后用“是”或“否”回答39個(gè)具體問(wèn)題,其中精神宗教信仰方面是沒(méi)有具體問(wèn)題的。DMSM在多國(guó)、多癌癥病種使用都經(jīng)驗(yàn)證具有良好的信度、效度及診斷準(zhǔn)確性[8,31]。不同國(guó)家的研究報(bào)道,包括美國(guó)、日本、土耳其、荷蘭、法國(guó)、英國(guó)、意大利、丹麥、中國(guó)、澳大利亞、以色列、冰島、愛(ài)爾蘭,其檢驗(yàn)參照標(biāo)準(zhǔn)主要為住院病人焦慮和抑郁量表及18項(xiàng)簡(jiǎn)明癥狀問(wèn)卷,其AUC值在0.66～0.89；中重度心理痛苦的截?cái)嘀翟?分～7分,NCCN建議的截?cái)嘀禐?分[32]；敏感性在0.60～0.99,特異性在0.49～0.93。研究結(jié)果的差異性可能與參照標(biāo)準(zhǔn)量表的選擇、癌癥種類、治療及處理方式、人口學(xué)差異等因素有關(guān)。

3心理痛苦干預(yù)的研究進(jìn)展

目前簡(jiǎn)單并有效的痛苦篩查工具已經(jīng)具備,且癌癥病人的心理痛苦篩查也是現(xiàn)實(shí)可行的,在這種情況下,如何將所測(cè)得的心理痛苦分?jǐn)?shù)轉(zhuǎn)變?yōu)榕R床實(shí)踐,即如何對(duì)心理痛苦病人采取有效的干預(yù)措施,已經(jīng)成為迫切需要解決的問(wèn)題[33-35]。

3.1心理痛苦干預(yù)的領(lǐng)導(dǎo)者心理痛苦護(hù)理被公認(rèn)為是高質(zhì)量的腫瘤護(hù)理不可分割的一部分[36,37]。系統(tǒng)進(jìn)行心理痛苦篩查被認(rèn)為是醫(yī)療理念的重大轉(zhuǎn)變,其目的是實(shí)現(xiàn)以病人為中心的護(hù)理[38]。NCCN(2007)[39]提出,腫瘤護(hù)士應(yīng)是癌癥病人心理痛苦篩查的領(lǐng)導(dǎo)者：腫瘤護(hù)士是腫瘤治療小組中最重要的成員,與病人接觸時(shí)間長(zhǎng),在工作中能夠發(fā)現(xiàn)病人的心理問(wèn)題并且能夠自然地表達(dá)對(duì)病人的關(guān)心和同情；腫瘤護(hù)士的目標(biāo)是要識(shí)別病人的心理痛苦并在疾病的全程篩查痛苦水平。同時(shí),NCCN(2007年)還指出,腫瘤護(hù)士不僅要對(duì)癌癥病人的心理痛苦進(jìn)行篩查,還要采取相應(yīng)的干預(yù)措施。目前，國(guó)外癌癥病人心理痛苦篩查及干預(yù)的已有的相關(guān)報(bào)道中,心理痛苦篩查及干預(yù)也主要是由腫瘤護(hù)士在領(lǐng)導(dǎo)實(shí)施。最新觀點(diǎn)明確提出[40],在癌癥病人心理痛苦篩查與干預(yù)中,腫瘤護(hù)士起主導(dǎo)作用,腫瘤護(hù)士有義務(wù)找到一個(gè)有效的工具評(píng)估癌癥病人的心理痛苦,并循證找出有效的干預(yù)措施來(lái)緩解癌癥病人的心理痛苦。

3.2心理痛苦干預(yù)手段

3.2.1認(rèn)知行為療法(cognitive behavior therapy,CBT)CBT是由A.T.Beck在60年代發(fā)展出的一種有結(jié)構(gòu)、短程、現(xiàn)在取向的心理治療方法,主要針對(duì)抑郁癥、焦慮癥等問(wèn)題以及修正功能障礙的想法與行為,以其科學(xué)、高效和相對(duì)較低的復(fù)發(fā)率被大多數(shù)臨床心理學(xué)家所接受和使用,是目前應(yīng)用最廣泛的心理治療方法。其實(shí)施方式可分為個(gè)人與小組,內(nèi)容包括放松技術(shù)、壓力管理、問(wèn)題解決及認(rèn)知重建。See等[41]認(rèn)為,CBT非常適用于癌癥病人；還有大量研究表明CBT對(duì)改善癌癥病人的心理痛苦效果顯著,研究主要集中于CBT對(duì)癌癥病人焦慮、抑郁情緒及身體癥狀的改善,如改善失眠[42]、緩解壓力及情緒困擾[43,44]。

3.2.2支持性心理療法(supportive-expressive therapy,SET)支持性心理治療起源于20世紀(jì)初,通過(guò)利用建議、勸告和鼓勵(lì)等方式來(lái)對(duì)心理嚴(yán)重受損的病人進(jìn)行治療,目標(biāo)是維護(hù)或提升病人的自尊感,盡可能減少或者防止癥狀的反復(fù),以及最大限度地提高病人的適應(yīng)能力,基本原則是二元治療,一是直接改善癥狀;二是維持、重建自尊或提高自信、自我功能和適應(yīng)技能。支持性心理療法運(yùn)用于乳腺癌病人較為成熟,通過(guò)隨機(jī)對(duì)照研究試驗(yàn),發(fā)現(xiàn)支持性小組療法可以改善乳腺癌病人的情緒及減輕疼痛[45]、提高病人生存質(zhì)量及減輕癌癥相關(guān)疲乏和應(yīng)對(duì)癌癥策略[46],但不能延長(zhǎng)病人生存期[45,47]。

3.2.3夫妻情感療法(emotionally focused couple therapy)癌癥嚴(yán)重影響病人及其配偶的情緒調(diào)節(jié),導(dǎo)致夫妻間的親密程度、相互支持及凝聚力降低,婚姻矛盾增加。近年來(lái),夫妻情感療法在癌癥病人中運(yùn)用逐漸增多。實(shí)施夫妻情感療法可以減少回避、減輕病人的心理痛苦[48],同時(shí)還可以改善夫妻間的關(guān)系及婚姻狀態(tài)[49]。

3.2.4正念減壓療法(mindfulness-based stress reduction,MBSR)MBSR于1979年由美國(guó)麻省大學(xué)醫(yī)學(xué)中心Jon Kabat-zinn博士所創(chuàng)立,其目的是在教導(dǎo)病人運(yùn)用自己內(nèi)在的身心力量,為自己的身心健康積極地做一些他人無(wú)法替代的事——培育正念,即以中立的態(tài)度刻意每時(shí)每刻的自我關(guān)注,來(lái)處理壓力、疼痛和疾病。過(guò)去的十多年來(lái),MBSR已經(jīng)成為減輕癌癥病人心理痛苦的一種有效療法。目前“正念”主要與以下4種意思相關(guān)：傳統(tǒng)的冥想練習(xí)、現(xiàn)代的臨床干預(yù)、瞬間的狀態(tài)及外在特征。研究證實(shí),MBSR可以提高積極的情緒調(diào)節(jié)策略、自我同情水平、減少沉默及回避經(jīng)歷,這將減輕臨床病人的心理痛苦及抑郁水平、提升積極情緒[50]。Schellekens等[51]設(shè)立隨機(jī)對(duì)照試驗(yàn)研究,對(duì)110例肺癌病人實(shí)施為期8周的正念減壓療法,結(jié)果顯示該療法可以顯著減輕病人的心理痛苦。

3.2.5意義為中心小組干預(yù)療法(meaning-centered group psychotherapy,MCGP)MCGP由Breitbart于2002年研發(fā),主要用于幫助癌癥病人提升對(duì)生命意義、目的及祥和的認(rèn)識(shí),并坦然面對(duì)死亡。能夠充分理解生命及患病經(jīng)歷意義的癌癥病人能夠有較好的自我調(diào)節(jié)能力、心理功能及生存質(zhì)量,并能阻止或減少心理痛苦[52]。

3.2.6其他干預(yù)手段有研究認(rèn)為,瑜伽可以減輕癌癥病人心理痛苦,Vadiraja等[53]對(duì)88例乳腺癌病人實(shí)施每周3次,每次1 h,為期6周的瑜伽作為干預(yù),結(jié)果表明瑜伽活動(dòng)可以有效減輕乳腺癌病人的心理痛苦。有研究認(rèn)為,芳香療法同樣有作用,Serfaty等[54]對(duì)39例淋巴瘤及骨髓瘤病人進(jìn)行每周8次、為期3個(gè)月的芳香療法,研究結(jié)果顯示其較認(rèn)知療法能夠更好地減輕病人的心理痛苦。Jennifer等[55]對(duì)40例乳腺癌病人實(shí)施每天20 min～30 min的步行療法,每周5次,為期12周,結(jié)果顯示可以顯著減輕其心理痛苦。Aranda等[56]對(duì)192例存在心理痛苦的乳腺癌病人提供信息干預(yù),如化療前提供相關(guān)信息、治療過(guò)程中面對(duì)面的課程教育、電話隨訪等,結(jié)果顯示可以顯著減輕病人的心理痛苦。此外,放松訓(xùn)練可以緩解癌癥病人心理痛苦,Elyse等[57]對(duì)274例確診期的乳腺癌病人實(shí)施放松訓(xùn)練干預(yù),每次30 min,共3次,結(jié)果顯示病人的心理痛苦程度可以明顯降低。

4我國(guó)癌癥病人心理痛苦篩查與干預(yù)現(xiàn)狀

4.1我國(guó)癌癥病人心理痛苦篩查現(xiàn)狀我國(guó)2007年引入DMSM并在北京腫瘤醫(yī)院運(yùn)用,經(jīng)檢驗(yàn)信效度較好,由此推薦該篩查工具可以在全國(guó)腫瘤臨床大力推廣使用。目前DMSM在我國(guó)仍處于臨床探索試驗(yàn)階段,心理痛苦篩查并未納入臨床腫瘤常規(guī)治療與護(hù)理。目前已有的研究顯示,我國(guó)癌癥病人心理痛苦發(fā)生率為24.2%～73.4%[7-12]；中重度心理痛苦DMSM最佳截?cái)嘀祬⒄諒埲~寧[8]的研究結(jié)果及NCCN的建議定為4,未見(jiàn)有進(jìn)一步的驗(yàn)證研究,由于最佳截?cái)嘀悼赡芘c參照標(biāo)準(zhǔn)量表的選擇、癌癥種類、治療及處理方式、人口學(xué)差異等因素有關(guān),故最佳截?cái)嘀瞪行柽M(jìn)一步研究。

4.2我國(guó)癌癥病人心理痛苦干預(yù)現(xiàn)狀通過(guò)對(duì)癌癥病人心理痛苦的篩查,可以分析出影響病人心理痛苦的因素。胡君莉等[9]研究顯示,癌癥病人心理痛苦的影響因素主要包括身體問(wèn)題中的乏力、進(jìn)食困難及疼痛,情緒問(wèn)題中的擔(dān)憂、抑郁及緊張,實(shí)際問(wèn)題中的經(jīng)濟(jì)問(wèn)題。但目前關(guān)于心理痛苦的干預(yù)措施多關(guān)注于健康教育、心理輔導(dǎo)方面,癥狀困擾問(wèn)題的干預(yù)多停留在減輕最常發(fā)生的癥狀方面,而癌癥病人經(jīng)常發(fā)生的癥狀并不代表是最需解決的問(wèn)題。建立適合癌癥病人心理痛苦的臨床干預(yù)模式已迫在眉睫。

5小結(jié)

癌癥病人心理痛苦普遍存在,心理痛苦作為第六生命體征,其重要性必須得到認(rèn)可,臨床醫(yī)務(wù)工作者應(yīng)該像監(jiān)測(cè)其他生命體征一樣,對(duì)病人的心理痛苦進(jìn)行常規(guī)監(jiān)測(cè)與干預(yù)處理。雖然多項(xiàng)研究表明有效的干預(yù)措施可以減輕病人的心理痛苦,但是可以在臨床推廣的干預(yù)措施,其實(shí)施結(jié)果必須是可以評(píng)價(jià)的,可以考慮采用運(yùn)動(dòng)干預(yù)如瑜伽、步行、放松訓(xùn)練,也可考慮用系統(tǒng)療法如認(rèn)知療法、正念減壓療法、支持療法等。癌癥病人心理痛苦管理包括5個(gè)階段[58]：第一階段主要是選擇合適的工具篩查癌癥病人的心理痛苦情況；第二階段主要對(duì)有心理痛苦的癌癥病人采取干預(yù)措施,干預(yù)措施主要從NCCN提供的問(wèn)題列表5方面來(lái)進(jìn)行；第三階段是通過(guò)循證形成心理痛苦篩查與管理指南；第四階段是將指南在世界范圍內(nèi)傳播、擴(kuò)散并真正實(shí)施運(yùn)用；第五階段是評(píng)價(jià)心理痛苦篩查與管理指南的實(shí)施對(duì)癌癥病人的影響。目前，我國(guó)關(guān)于癌癥病人心理痛苦的管理僅處于第一至第二階段,要真正實(shí)現(xiàn)對(duì)所有癌癥病人的心理痛苦篩查、干預(yù)并形成實(shí)踐指南,任重而道遠(yuǎn)。

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(本文編輯孫玉梅)