Psychotropic medication use is widely implicated as a risk factor for injuries, and it is believed that the adverse effect profiles of these medications are exacerbated by the consumption of alcohol. The objectives of this study are (a) to examine the associations between the use of specific classes of psychotropic medications and injuries among elderly participants of the National Population Health Survey (NPHS), and (b) to determine whether and how associations between psychotropic medications and injuries are modified by the consumption of alcohol. Data from Cycles 1 (1994/95), 2 (1996/97), and 3 (1998/99) of the NPHS household longitudinal file were used in this study, selecting community-dwelling participants aged 65 years of age and older in 1994/95. Among antidepressant medications, the magnitude of the risk of injuries was higher for users of tricyclic derivatives (OR=1.4; 95%CI: 0.7 – 2.9) than SSRIs (OR=0.3; 95%CI: 0.1 – 1.0). Benzodiazepine use for any indication increased the risk of injuries, but that effect was not consistent across indications. The use of benzodiazepine antianxiety medications resulted in an increased risk of injuries (OR=2.0; 95%CI: 1.3 – 3.1), but there were no significant effects on the injury risk among benzodiazepine hypnotic and sedative users (OR=0.8; 95%CI: 0.4 – 1.7). Results pertaining to the second objective of this study raised as many questions as they resolved. Alcohol consumption decreased the odds of injury among hypnotic and sedative users, but otherwise, no consistent results were observed. Findings from this study underscore the importance of identifying appropriate alcohol measures for research among elderly populations. They also stress the need to separately consider the impact of different classes of psychotropic medications on injuries (tricyclic antidepressants separate from SSRI antidepressants and antianxiety benzodiazepines separate from hypnotic and sedative benzodiazepines).

研究目的：失眠影響國人身心健康甚多，藥物取向治療為當代最廣泛的失眠治療方式。研究顯示許多失眠患者，可藉由短期服用助眠藥物改善失眠，避免個體失眠慢性化，且於停藥後未有任何藥物副作用困擾。然而，臨床上仍觀察到不少個案，對助眠藥物產生依賴，需長期服用助眠藥物，此舉不僅造成醫療資源之浪費，其安全性與有效性仍受爭議。而心理因素在藥物依賴扮演重要的角色，同樣是長期服用助眠藥物，不同的助眠藥物使用者卻可能存有相異的用藥心態，因此助眠藥物使用者的用藥行為以及用藥相關心態，可能會組合成不同的用藥型態，而探討助眠藥物之不同使用型態與其心理機轉，有助於進一步瞭解助眠藥物使用現象。故本研究旨在用量化方法探討助眠藥物使用型態之差異，試圖將不同的助眠藥物使用型態進行分群，並提出可能影響助眠藥物使用型態的相關因子。 研究方法與結果：本研究招募了272名曾經或目前正在服用助眠藥物的使用者填寫研究問卷，透過對兩個外顯用藥行為變項（用藥總時間、用藥頻率）與六個用藥相關心理變項（對助眠藥物的渴求程度、對助眠藥物的正、負向態度、主觀規範、以及促進、抑制之知覺控制）的集群分析，我們將助眠藥物使用型態分為「慣性使用」、「矛盾依賴」、「控制使用」以及「輔助使用」四種型態。在外顯用藥行為方面，「慣性使用」集群與「矛盾依賴」集群皆展現較長的用藥時間與高頻率的使用，「控制使用」群集與「輔助使用」群集則展現較短的用藥時間與低頻率的使用。然而，四組群集皆展現其獨特的心理特徵。「慣性使用」群集對助眠藥物的渴求程度最強，正向態度比負向態度高，主觀認為重要他人支持自己服用助眠藥物，傾向持續服用助眠藥物；「矛盾依賴」群集呈現對助眠藥物正向與負向態度皆高的矛盾狀態，且主觀認為自己無法控制藥物之使用；「控制使用」群集雖也對助眠藥物出現正向、負向態度皆高的表現，但其可對藥物使用進行控制；「輔助使用」群集的個案對於助眠藥物的負向態度高於正向態度，藥物渴求程度低，且傾向避免使用助眠藥物。多項式邏輯斯回歸的分析結果則進一步顯示年齡較大、失功能睡眠信念問卷分數較高的個案，較容易落入「慣性使用」組；被診斷過情緒疾患、失眠時間較長、睡前激發程度問卷分數較高的個案，較容易落入「矛盾依賴」組；受教育年限較高的個案，較傾向落入「控制使用」組；最後，年紀較輕、失功能睡眠信念問卷分數較低的個案，則容易落入「輔助使用」組。 結論：本研究結果顯示相似的用藥行為仍有相異的用藥相關心理狀態，且部分心理相關變項可能會影響助眠藥物之使用型態，故推測用藥心理與助眠藥物使用者的特質扮演影響用藥型態的重要因素。此結果可提供臨床工作者，初步了解助眠藥物使用之心理機轉，亦能將其運用於協助不同類型的安眠藥物使用者擬訂減藥處遇。 / Purpose：Insomnia has great impact on people's health in Taiwan. Pharmacological approaches are the most commonly used treatment for insomnia. Although short-term hypnotic use could improve sleep, however some patients use hypnotics for a prolonged period of time and have difficulty to discontinue using them. This would lead to great cost of the individuals and societies. Psychological factors have been found to play an essential role in the long-term use of other substances. Clinical observation also showed that there were individual differences in the psychological aspects of medication use in spite of similar medication use behaviors. Therefore, it is possible to use hypnotic-related behaviors and psychological factors to categorize hypnotic users in order to further the understanding the mechanism underlying chronic hypnotic use. The purpose of this research is to identify hypnotic use patterns by exploratory quantitative method and the characteristics associated with different hypnotic usage patterns. Methods and Results: 272 previous or current hypnotic users were recruited to complete a package of questionnaires. Through cluster analysis with two explicit medication behavior variables (total duration of hypnotic use, frequency of hypnotic use) and six hypnotic-related psychological variables (craving for hypnotic, positive and negative attitudes towards hypnotic, subjective norm, facilitating and inhibiting perceived behavioral control), four hypnotic usage patterns were identified, which were “habitual use”, “paradoxical dependence”, “controlling use”, and “supplementary use”. In terms of explicit medication behaviors, “habitual use” and “paradoxical dependence” clusters both show longer time and higher frequency of hypnotic use. On the other hand, “controlling use” and “supplementary use” clusters showed similar medication use behaviors with shorter duration and lower frequency of hypnotic use. In addition, the four clusters exhibited different psychological profiles. Users in “habitual use” cluster have strongest craving for hypnotic, higher positive than negative attitude toward hypnotic use, and believe that significant others support their medication behavior. Users in “paradoxical dependence” cluster showed paradoxical attitude toward hypnotics, and reported less control over their hypnotic use. Users in “controlling use” cluster also had paradoxical attitude toward hypnotic, but their craving level of hypnotic was lower than users in “paradoxical dependence” cluster. In addition, users in “controlling use” cluster feel they can control their hypnotic use. Users in “supplementary use” cluster had lowest craving level, higher negative attitude toward hypnotic, and tend to avoid taking hypnotic when possible. Multiple logistic regression further showed that (1) people with older age or higher score on the Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS) tend to classified into “habitual use” cluster; (2) people with mental disorder diagnosis, long history of insomnia, or higher score in Pre-Sleep Arousal Scale (PSAS) tend to be classified into the "paradoxical dependence " cluster; (3) patient with more years of education more likely fall into “controlling use” cluster, finally, (4) the hypnotic users who are younger or lower score in DBAS are easier classified into the “supplementary use ” cluster. Conclusions：The results of the current study indicates that similar medication behavior could have different hypnotic-related psychological status. Therefore, psychological factors are needed to be assessed in order to understand the process of long-term hypnotic use. The results provides a further understanding of the psychological mechanisms of hypnotic use, and also help clinician in related-field to develop insomnia treatment plan or hypnotic discontinuation program based on insomniacs’ characteristics and their psychological variable toward hypnotic use.

研究目的：失眠盛行率高，且容易發展為慢性化的問題，目前多以助眠藥物作為失眠的治療，短期使用雖可幫助緩解失眠症狀，但長期使用的有效性及安全仍有較大爭議，且容易發展出依賴性及耐受性的問題。然而失眠患者中仍有相當高的比例在對藥物療效不滿意的情況下，使用遠超過臨床指引建議的期間，許多失眠患者亦表達出對助眠藥物使用的矛盾心態，顯示助眠藥物的使用仍受其他心理因素影響。過去研究指出計劃行為理論能有效預測及幫助探討物質使用相關行為的認知因素，但助眠藥物的使用除了認知因素的影響外，也會出現較為衝動及難以控制的渴想狀態。因此本研究目的是在於了解長期助眠藥物使用的心理因素，探討助眠藥物使用行為的認知因素，以及在計劃行為理論的架構下，失眠患者對於助眠藥物使用的認知因素是否會受到渴想的影響。 研究方法與結果：本研究以21名失眠患者進行開放式訪談後編制助眠藥物使用之計劃行為理論問卷，招募失眠且有助眠藥物使用經驗的受試者填寫助眠藥物使用計劃行為理論問卷以及助眠藥物渴想量表，並於施測後一個月及三個月的時間點，以電話追蹤其助眠藥物使用狀況，一個月及三個月有效問卷分別為143及139份。結果顯示知覺行為控制為行為意圖的主要預測因子，行為意圖及知覺行為控制能預測一個月及三個月時的藥物使用行為，且行為意圖為使用行為的最佳預測因子；助眠藥物使用行為意圖對一個月及三個月時的助眠藥物使用情況的預測力會受到渴想的負向調節。 結論：本研究結果顯示助眠藥物使用的行為意圖是行為出現與否的主要決定因素，說明失眠患者的確會在認知決策後選擇使用助眠藥物，也會在知覺到較多促進助眠藥物使用之情境或因素時產生助眠藥物使用的行為意圖或直接出現助眠藥物的使用行為，顯示助眠藥物使用行為上外在情境及因素的重要性。此外，本研究結果也顯示助眠藥物使用的行為意圖會受到渴想的干擾，當渴想程度愈高時行為意圖對於實際行為的預測力愈低，而渴想程度愈低時行為意圖對實際行為的預測愈高。此研究結果幫助了解長期助眠藥物使用的心理因素，亦可將其用於幫協助擬定助眠藥物減藥策略。 / Insomnia has high prevalence and is prone to develop into a chronic problem. Hypnotics are the most common choice of treatment for insomnia. Although short-term usage is effective in relieving insomnia, the safety and efficacy of long-term usage are still in controversy. Long-term usage has also been reported to increase risks of tolerance and dependence. Even though the efficacy of hypnotics is not always satisfying, the duration of hypnotics use in insomnia patients is often longer than clinical recommendation. This may be influenced by some psychological factors. The theory of planned behavior has been demonstrated to be able to predict cognitive factors of substance use behaviors. It can therefore possibly be used to model hypnotic use behavior. In addition to cognitive factors, craving that is associated with losing control over drug use may also play a role in the use of hypnotics. The purpose of current study is to 1) explore the cognitive factors of long-term hypnotics use based on the theory of planned behavior, and 2) understand whether the cognitive factors would be influenced by the craving state. Method and result: We first conducted a semi-structured interview with 21 insomnia patients to develop the questionnaire of the theory of planned behavior of hypnotics use and a hypnotic craving scale. The insomnia patients who had used or are currently using hypnotics were recruited to complete the questionnaires. They were contacted by telephone at 1-month and 3-month follow-ups. Total number of valid questionnaires of 1-month and 3-month follow-ups were 143 and 139, respectively. We found that behavior intention could be predicted by perceived behavior control, but not attitude and subjective norms. Frequency of hypnotics use at 1-month and 3-month follow-ups could be predicted by behavior intention and perceived behavior control, and behavior intention was the best predictor. Craving has a negative moderating effect on the relationship between behavior intention and the hypnotics use behavior at both 1-month and 3-month follow-ups. Conclusion: The findings of current study show that behavior intention is the most crucial cognitive factor to predict hypnotics use behavior. It indicates that insomnia patients may have higher behavior intention and are more likely to use hypnotics when they perceive more situational factors that lead to drug use. In addition, our study indicates the association between behavior intention and actual hypnotic use behavior can be moderated by craving. The higher the craving state the lower the predictability of hypnotic use by behavior intention, and vice versa. Our study helps understand the psychological factors of long-term hypnotics use, and assists in developing the tapering interventions.

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