初探个案管理对精神分裂症患者暴力行为及社会功能的干预效果.pdf

Abstract Background and Purpose: Mental illness is a group of disease with low cure rate, high recurrence and disability rate, which not only seriously affect people's health, but also bring a heavy burden for the state, society and the family. According to epidemiological survey in 1992, China's overall morbidity rate of mental illness is 13.47 ‰, there are more than 16 million persons with mental illness. The mental illness has become a serious public health issue and a prominent social problem. The community mental health services developed in 1950s have been proved to be a effective way to reduce the occurrence of mental illness and mental disability and to prevent the relapse of mental illness by most of counties in the world. Case Management is a process full of cooperation in order to meet the needs of patients in health, which includes assessment, planning, implementation, coordination, monitoring and evaluation and tries to achieve high-quality community service through a variety of communication and choice of treatment conditions. Therefore, the case management plays an important role in community mental health service, it makes the community mental health services better than before in continuity, coordination and efficiency. Moreover, the community mental health service is at an early stage in China. Many regions are exploring a effective way which is fit for the community mental health service of our country. First, we established the community case management system through studying the foreign case management models in Xinhui District, Jiangmen City, Guangdong Province. The purpose of the study is to explore the effect of case management for the patients with schizophrenia and to improve the implementation of the case management program. Objects and Methods: 30 schizophrenic patients were selected for case management treatment for one year in Shuangshui town, Xinhui District, Jiangmen City. Using the Clinical Global Impression Scale (CGI), the individual and social performance scale ( PSP), risk behavior assessment form, and Social Disability Screening Schedule (SDSS) to evaluation the patients' situation once a month. Using Positive and Negative Syndrome Scale (PANSS) and Social Support Rating Scales (SSRS) to evaluate the patients' situation once every six months.Results: 1 Through the case management the number and frequency of violence in second、third、fourth、fifth and sixth month decline than the first month (P＜0.01).2 Statistically, there is no significant difference between each month in scores of SDSS .3 There is statistical significant difference in the score of each item of PANSS between the sixth month and the joining month through the case management.4 There is statistical significant difference in the score of social support and subjective support than the norm. There is also statistical significant difference in the III score of each item of SSRS between the sixth month and the joining month. Conclusion: 1 To establish networks of mental illness and to implement case management programs in the community can effectively reduce the incidence of violence of the schizophrenic patients, improve the patient's condition and prevent the deterioration of the social functions of the schizophrenic patients. 2 We should strengthen the family intervention to improve the social support.[Key words]: Case Management, Community mental health, Schizophrenic IV 第一章 前言 1.1 社区康复的必然性 精神分裂症(schizophrenia)是一组病因未明的精神疾病，具有思维、情感、行为等多方面的障碍，以精神活动与环境不协调为特征。

通常意识清楚，智能尚好，但分患者在疾病过程中可以出现认知功能损害，多在青壮年发病，常缓慢起病，有慢性化倾向和衰退的可能[1]该组疾病是一种患病率、复发率、致残率均较高的慢性迁延性疾病，是造成精神残疾的重要原因之一[2]，精神残疾也称社会功能缺陷，患者由于社会功能的缺陷，不仅影响了自身生活、学习、就业及其家庭职能和社会职能的行使，同时也给患者、家庭和社会带来诸多的负担 20世纪50年代末，Barton和Goffman描述了长期住院引起的“住院综合征”，认为长期住院会导致患者与正常的社会生活隔绝，加重精神衰退，进而丧失劳动能力成为精神残疾有大量的实践证明，大部分精神障碍者在急性期症状控制后，只有得到相应的康复服务，才能够使其逐渐适应正常生活，达到回归社会的目的 就精神疾病康复而言，可分为社区防治康复和医院康复，这是不可分割的两个组成部分，两者相辅相成，不能偏废从国内外的发展趋势来看，精神疾病康复也像其他疾病和残疾一样，康复服务工作的重点正逐渐从医院康复向社区防治康复转移精神疾病的社区防治康复的主要目标是为社区精神疾病患者提供中间性或过渡性生活空间及相应的精神卫生与康复服务，尽量安排他们接受适应社会生活的各项训练，从而尽可能促进功能恢复而重返社会。

WHO提出:“以院所为基础的康复不可能满足绝大多数病残者的需要，而以社区为基础的康复能给至今尚未得到帮助的病残者提供基本的康复服务” [3] 1.2 国外及国内的社区康复情况： 1.2.1美国社区精神医学的发展和现状 当代社区精神医学的形成与发展主要源于美国1946年美国国会通过了国家精神保健法60年代，美国国会成立了专门委员会，通过了社区精神卫生法规，在全国各州普遍建1 立社区精神卫生中心，让住院病人重返社区，在社区中进行治疗、护理和预防精神科非住院化运动”在美国全面开展，使全美精神病床总数由56万张减至14万张，并且还在不断下降，而院外服务由22．6％上升为71．6％经过40多年的实践，社区精神卫生服务取得了良好的效果，接受社区治疗的精神病患者，每人每年的花费仅需约900美元，比住院治疗每人每年15600美元下降了94％[4] ，使精神疾病患者广泛获得了有效治疗 1.2.2英国社区精神医学的发展和现状 英国社区精神医学发展始于上世纪50年代当时英格兰、威尔士的精神病床位有148000张，约每1000人口中有床位3．2张从那以后，英国开展社区精神病治疗，床位占用率开始持续稳定下降目前，大约每1000人口中有床位0．4张。

在初建的120所精神病院中，有30所已经关闭，且计划在未来的几年中陆续关闭剩下90所[5]英国社区精神卫生服务体系是由社区精神卫生中心、综合医院的精神病床、日间医院及日间中心和病人家庭支持共同构成社区精神卫生中心是社区精神卫生服务的工作基地，它为精神病人及精神病家庭提供心理教育干预治疗和危机住院服务，中心有3～4张床位，将处于危机状态的病人收住几天，危机期度过后便出院 1.2.3瑞典社区精神医学的现状 瑞典的社区精神卫生服务是由精神保健服务所提供的，精神科门诊与具有各项规章制度的社区精神保健所相联系，社区精神保健所为所分管的居民提供一线诊疗及护理，每3万居民配备一名精神科医生，在社区各种类型的精神病患者均可得到照料医护人员为病人提供质量高、家庭氛围浓、受纪律约束的整体诊疗护理急重性患者由综合医院负责值得一提的是瑞典是一个高福利国家，在保健服务所就诊的病人每年仅需缴纳较少数量的会诊费和药费，。