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1 한국임상약학회지제 26 권제 2 호 Korean J Clin Pharm, Vol. 26, No. 2, 2016 Original Article Korean Journal of Clinical Pharmacy Official Journal of Korean College of Clinical Pharmacy Available online at pissn: 폐암환자의항우울제처방현황과관련요인분석 성경은 1,2# 정경혜 2# 김애리 1 김은영 2 * 1 건국대학교병원약제부, 2 중앙대학교약학대학 (2016년 5월 2일접수 2016년 6월 12일수정 2016년 6월 14일승인 ) An Analysis on Prescribing Patterns of Antidepressants and Their Associated Factors in Lung Cancer Patients Kyeong Eun Sung 1,2#, Kyeong Hye Jeong 2#, Ae Ri Kim 1, and Eun Young Kim 2 * 1 Department of Pharmacy, Konkuk University Medical Center, Seoul 05030, Republic of Korea 2 College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea (Received May Revised June Accepted June ) ABSTRACT Background: Depression is the leading cause of lowering the quality of life of cancer patients and lung cancer is the most likely to cause depression. It is necessary to find out depression-related factors in lung cancer patients. Methods: The study was a retrospective cohort study using medical records, and was a non-equivalent comparison group design. It involved patients diagnosed of lung cancer at the Konkuk University Medical Center from January to December Between antidepressants prescription group and non prescription group, socio-demographic factors, clinical factors, treatment-related factors and other factors were analyzed statistically. Results: Antidepressant prescription group consisted of 23 people and non-prescription group of 206 people. Prescription rate of quetiapine was the highest 47.8% (11/23), followed by escitalopram (43.5%, 10/23), amitryptyline and trazodone (30.4%, 7/23). The prescription group was prescribed with an average of 1.9 antidepressants. Antidepressants were prescribed after average of 248 days from lung cancer diagnosis and prescription period per patient was average days. According to the result of univariate logistic regression analysis between 2 groups, factors such as number of outpatient visit, number of admission, days of hospitalization, sleep disorder, and comorbidity were found to be statistically significant (p < 0.05). However, According multivariate logistic regression analysis showed that number of admission, days of hospitalization and sleep disorder were statistically significant (p < 0.05) excluding comorbidity. Conclusion: About 10% of lung cancer patients had received a prescription for antidepressants after lung cancer diagnosis. A sleep disorder, number of hospitalization and length of stay were identified as factors influencing the prescribing antidepressants. KEY WORDS: Lung cancer, depression, antidepressants 2013년국내통계청자료에의하면암은여전히사망원인 1 위를차지하고있지만, 2002년부터 2012년까지암으로인한사망률은 age-standardized rates(asrs) 이매년 2.7% 감소하고있다. 1,2) 암질환의조기진단과치료법의발달로인해, 암환자의상대생존율은 년에 53.8%, 년에 65.1%, 최근 5년간 (2009년-2013년 ) 은 69.4% 로꾸준히증가하고있다. 3) 생존연장에중점을두었던암치료의목표가이제는연장된생존기간동안의삶의질향상도주요고려사항이 되었다. 암환자의삶의질과관련된연구에서삶의질을저하시키는가장큰변수가우울증이라는보고들이있다. 4-5) 구강인두암 (22%-57%), 췌장암 (33%-50%), 유방암 (1.5%-46%), 폐암 (11%-44%), 결장암 (13%-25%), 기타부인과암 (12%-23%), 림프종 (8%-19%) 이우울증과유의한상관관계를나타낸다고보고되었다. 6-8) 그러나암환자의우울증에대한전문적치료가제한적으로시행되어, 그결과삶의질저하, 적극적인항암치료순응도감소, 사망률증가, 추가의료비발생및치료만족 *Correspondence to: Eun Young Kim, College of Pharmacy, Chung-Ang University, Dongjak-gu, Seoul 06974, Republic of Korea Tel: , Fax: eykimjcb777@cau.ac.kr #The first and second authors contributed equally to this manuscript. 107

2 108 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 감저하를가져오는주요원인이되고있다. 9-11) 폐암의경우특별한자각이나, 적절한조기진단스크리닝검사가없으므로진단시이미진행성또는전이성단계로발견되는경우가많고, 근치적수술이가능한병기 (1기, 2기 ) 에진단된환자는약 20-25% 에불과하다. 12) 5년상대생존율또한 23.5%(91,981명, 년 ) 로췌장암 (9.4%, 22,338명, 년 ) 다음으로낮다. 1) 선행연구에서우울증유발가능성이높은암질환으로폐암 (17.6%) 을지목하고있으나, 폐암환자의우울증에대한연구는많지않은실정이며, 국내에서진행된선행연구는항암화학요법을받고있는소수의폐암환자만을대상으로진행되어, 전반적인폐암환자의우울증을이해하는데에한계가있다 ) 이에본연구에서는한대학병원에내원한전체폐암환자를대상으로항우울제처방현황을분석하고, 처방군과비처방군의인구사회학적요인, 임상적요인, 치료관련요인, 기타요인을비교하여폐암환자의우울증에관련요인을분석해보고자하였다. 연구방법 대상환자및자료수집 2012년 1월부터 12월까지 1년동안서울특별시에소재한 3차의료기관 ( 건국대학교병원 ) 에내원한환자중진단명이폐암 ( 질병분류번호 C34) 인환자를대상으로항우울제처방군과항우울제비처방군으로나누어연구대상을설정했다. 항우울제처방군은최초항우울제처방시점부터 2012년 12월 31일까지, 항우울제비처방군은 2012년 1월 1일부터 2012년 12월 31일까지를조사했다. 내원횟수가 1-2회인환자, 내원횟수가 3회이상이어도연구의료기관에서폐암치료를받지않는환자, 폐암진단전에우울증진단을받거나항우울제처방이있는환자, 폐암진단과정신건강의학과진료의시간적선후관계를명확히평가하기어려운환자, 원발성폐암이아닌폐로전이된환자, 통증, 불면, 섬망, 신경병증의이유로항우울제를처방받은환자는연구대상에서제외했다. World Health Organization(WHO) Collaborating Centre for Drug Statistics Methodology에의해관리되고있는 Anatomical Therapeutic Chemical Classification System(ATC code) 를기준으로, ATC code가 N06A(Antidepressants) 에속하며, 식품의약품안전처 ( 이하, 식약처 ) 허가사항의효능및효과가 우울장애 를포함하며건국대학교병원내 formulary에등재된약제를항우울제로정의하였다. 15) 또한 ATC code가 N05A(Antipsychotics) 에속하나, 식약처허가사항의효능및효과가 주요우울장애치료의보조요법 을포함하며, off label로 major depressive disorder 에단독요법으로사용되는 quetiapine을조사대상항우울제로선정하였다. 본연구는건국대학교병원 IRB(Institutional Review Board) 승인을득하여진행되었으며, 시험대상자동의변경또는면제가시험대상자의존엄, 권리및복지에불리하게영향을주지않아시험대상자의동의를면제받았다. 자료의수집및분석의무기록을이용한후향적코호트연구로인구사회학적요인 (Socio-demographic factors), 임상적요인 (Clinical factors), 치료관련요인 (Treatment factors), 기타요인 (other factors) 으로조사하였다. 인구사회학적요인으로성별, 연령대, 직업유무, 교육수준, 결혼상태, 종교유무, 의료보험유형을조사하였다. 16) 임상적요인으로폐암의병리학적진단, 비소세포폐암 (non-small cell lung cancer, NSCLC) 환자의경우 TNM 병기, 체질량지수 (Body mass index, BMI), 통증유무, 수면장애여부, 동반질환유무를조사하였다. NSCLC의병기는항우울제비처방군은조사기간중제일나중에기록된의무기록의진단병기를, 항우울제처방군은항우울제처방이최초있던시점의병기를조사하여진단병기와우울증과의상관성을평가해보고자하였다. 통증및수면장애와우울증과의상관성은항우울제처방군은항우울제처방이최초있었던시점의마약성진통제또는비마약성진통제처방여부및수면제처방여부를, 항우울제비처방군에서는 2012년제일나중에기록된의무기록의마약성진통제또는비마약성진통제처방여부및수면제처방여부를조사하여평가해보고자하였다. 동반질환여부는항우울제처방군의경우항우울제처방이최초있었던시점의동반질환여부를, 항우울제비처방군의경우 2012년의무기록의동반질환여부를조사하였다. 수술, 방사능치료, 항암화학요법, 경구용표적항암치료제투여, 현재치료여부, 완치, 진단후경과일수를치료관련요인으로조사하였다. 수술은전폐절제술 (pneumonectomy), 폐엽절제술 (lobectomy), 쐐기절제술 (wedge resection), 분절절제술 (segmentectomy) 수술여부를조사하였다. 항암화학요법은복지부분류 421( 항악성종양제 ), 617( 주로악성종양에작용하는것 ) 인약제중폐암에효능효과가있는주사제와, 경구용표적항암치료제 gefitinib, erlotinib, crizotinib의투여여부를조사하였다. 수술, 방사능치료여부의경우는항우울제처방군은항우울제최초처방시점이전의자료를, 항우울제비처방군은 2012년 12월 31일이전의자료를조사하였다. 항암화학요법여부, 경구용표적항암치료제투여여부의조사는항우울제처방군은항우울제최초처방시점, 항우울제비처방군은 2012년을기준으로했다. 또한연구관찰기간동안방사능치료, 항암화학요법, 경구용표적항암치료제중한가지이상받고있을경우현재치료중으로분류하였다. 기타요인으로생활습관인자인흡연력, 음주력과외래진료횟수, 입원횟수, 재원일수, 중환자실재원여부를조사하였다. 외래진료횟수, 입원횟수, 재원일수, 중환자실재원여부는항우울제처방군의경우처방

3 폐암환자의항우울제처방현황과관련요인분석 / 109 이최초있던시점이포함된년도의자료를, 항우울제비처방군은 2012년의자료를조사하였다. 자료분석방법 SPSS version 17(SPSS Inc., Chicago, IL, USA) 를이용하였으며, 항우울제처방군과비처방군의유의성을검정하기위해일반적인특성중이분변수의경우카이제곱검정 (Chi-square test) 및피셔의정확검정 (Fisher s exact test) 을, 연속변수의경우독립 t-검증 (independent t-test) 을시행하였다. 또한각요인들에대하여단변량로지스틱회귀분석 (Univariate logistic regression analysis) 을실시하여교차비 (Odds Ratio, OR) 값을확인하였으며단변량로지스틱회귀분석결과통계적으로의미있는요인들 (p < 0.05) 에대하여다변량로지스틱회귀분석 (Multivariate logistic regression analysis) 을실시하였다. 결과 연구대상자특성및항우울제처방현황 2012년 1년동안연구대상기관에 3회이상내원한폐암환자는총 299명이었다. 이중에서내원횟수가 3회이상이어도본원에서폐암치료를받지않는환자 (12명), 폐암진단전에우울증진단을받은환자 (6명), 폐암진단전에항우울제처방이있는환자 (8명), 타의료기관에서전원되어폐암진단과정신건강의학과진료의시간적선후관계를명확히평가하기어려운환자 (2명), 원발성폐암이아닌폐로전이된환자 (12명), 통증, 불면, 섬망, 신경병증의이유로항우울제를처방받은환자 (30명), 총 70명이제외되어, 229명이연구대상환자였다. 연구대상환자중항우울제처방이있는환자는 10% 이었으며연구대상환자 229명의일반적특성은 Table 1에나타냈다. 항우울제처방군 23명은우울증진단이있는환자가 7명, Adjustment disorder with depressed mood 진단환자가 1명, 정신건강의학과의사에게우울증상으로자문을구한후처방받는환자 15명이었다. 폐암환자에게실제처방된항우울제는 10개성분으로, 삼환계항우울제 (Tricyclic antidepressants: TCA) 인 amitriptyline, nortriptyline, SSRIs(Selective serotonin reuptake inhibitors) 인 escitalopram, paroxetine, sertraline, SNRIs(Serotonin norepinephrine reuptake inhibitor) 인 duloxetine, venlafaxine, 기타우울증치료제 mirtazapine, trazodone, 항정신병약제인 quetiapine이었다. 항우울제처방현황분석결과 quetiapine의처방비율이 47.8% 로가장높았으며그다음으로는 escitalopram(43.5%), amitriptyline과 trazodone(30.4%) 순이었다 (Table 2). 처방군은평균 1.9개성분의항우울제를처방받았으며한성분의항우울제를처방받은경우가 52.2% 로가장많았으며두종류, 세종류, 네종류를처방받은환자는각각 26.1%, Table 1. Basic characteristics of study patients (N = 229). Variables Descriptions N (%) Gender Age (years) Occupation Marriage status Religion Insurance Pathological diagnosis Female Male (24.4) (75.6) (54.6) (45.4) No 126 (55.0) Yes 50 (21.8) Unknown 53 (23.1) No 8 (3.5) Yes 207 (90.4) Unknown 14 (6.1) No 127 (55.5) Yes 64 (28.0) Unknown 38 (16.6) National health insurance 211 (92.1) Foreigner 3 (1.3) Medicaid recipients 15 (6.6) SCLC 22 (9.6) NSCLC 205 (89.5) Unknown 2 (0.9) No 92 (40.2) Pain Yes 137 (59.8) No 192 (83.8) Sleep disorder Yes 37 (16.2) Body Mass Index Treatment types (multiples) Current treatment Hospitalization in ICU Smoking history Antidepressant < (5.7) (61.1) (24.5) (2.2) Unknown 15 (6.6) Surgery * 103 (45.0) Radiation 12 (5.2) IV Chemotherapy 115 (50.2) Oral target agents 63 (27.5) No 85 (37.1) Yes 144 (62.9) No 174 (76.0) Yes 55 (24.0) Non-smoker 122 (53.3) Ex-smoker 44 (19.2) Current smoker 40 (17.5) Unknown 23 (10.0) No 206 (90.0) Yes 23 (10.0) N(%): The number and percentage of patients * Pneumonectomy, Lobectomy, Wedge resection, Segmentectomy ICU = intensive care unit 13.0%, 8.7% 였다 (Table 3). 폐암진단후평균 248일후에항우울제처방이시작되었으며, 환자별평균처방일수는 177.5일

4 110 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 Table 2. The frequency of the prescribed antidepressants. Class Drug N a (% b ) SSRIs SNRIs TCA Others Duration on medication Mean SD Range escitalopram 10 (43.5) paroxetine 1 (4.3) sertraline 3 (13.0) duloxetine 1 (4.3) venlafaxine 2 (8.7) amitriptyline 7 (30.4) nortriptyline 1 (4.3) mirtazapine 1 (4.3) trazodone 7 (30.4) quetiapine 11 (47.8) a The number of patients who treated with the drugs b The percentage of patients who treated with the drugs in total 23 patients treated with any antidepressant medication SD = standard deviation; SSRIs = selective serotonin reuptake inhibitors; SNRIs = serotonin norepinephrine reuptake inhibitors; TCA = tricyclic antidepressants Table 3. The number of prescribed antidepressants class. Number N = 23 (%) Class combination N = 23 (%) 1 12 (52.2) TCA 1 (4.3) Mirtazapine 1 (4.3) Trazodone 1 (4.3) SSRIs 4 (17.4) SNRIs - Antipsychotics 5 (21.7) 2 6 (26.1) TCA + SSRIs 2 (8.7) TCA + Antipsychotics 1 (4.3) SSRIs + Trazodone 2 (8.7) SSRIs + SNRIs 1 (4.3) 3 3 (13.0) TCA + Trazodone + Antipsychotics 1 (4.3) TCA + SNRIs + Antipsychotics 1 (4.3) SSRIs + Trazodone + Antipsychotics 1 (4.3) 4 2 (8.7) TCA+SSRIs+Trazodone+Antipsychotics 1 (4.3) SSRIs + SNRIs + Trazodone + Antipsychotics 1 (4.3) Total Average 1.9 SSRIs = selective serotonin reuptake inhibitors; SNRIs = serotonin norepinephrine reuptake inhibitors; TCA = tricyclic antidepressants 이었다. 폐암진단후 2012년 12월 31일 ( 사망환자의경우사망일까지 ) 까지의기간은 555.6일이었다 (Table 4). 항우울제처방군과비처방군사이의각요인에대한교차분석결과항우울제처방군의평균나이는 68.8 세, 비처방군의경우 67.0세로두군간의유의한차이가없는것으로확인되었다 (p = ). 다른인구사회학적요인인성별 (p = ), 연령대 (p = ), 직업유무 (p = ), 교육수준 (p = ), 결혼상태 (p = ), 종교유무 (p = ), 의료보험유형 (p = ) 에대한교차분석결과도두군간에통계적으로차이가없는것으로나타났다. 임상적요인에대한교차분석결과수면장애여부 (p < ) 와동반질환여부 (p < 0.05) 가통계적으로유의한차이를보였다 (Table 5). 다른임상적요인인폐암의병리학적진단 (p = ) 과, TNM 병기, 체질량지수 (p = ), 통증유무 (p = ) 는통계적으로차이가없는것으로나타났다. 치료관련요인인방사능치료 (p = ), 항암화학요법 (p = ), 경구용표적항암치료제투여 (p = ), 현재치료여부 (p = ), 완치 (p = ) 에대한교차분석결과도두군간에통계적으로차이가없는것으로

5 폐암환자의항우울제처방현황과관련요인분석 / 111 Table 4. Basic characteristics of prescribed and non-prescribed group. Variables Prescribed group Non-prescribed group N mean SD range N mean SD range p-value a Age Number of outpatient visit Number of admission Days of hospitalization BMI Treatment days b , , Time lag c Prescription days a Two-sample t-test b Period from lung cancer diagnosis until (or death date) c Period from lung cancer diagnosis until first antidepressant prescription Table 5. Results of cross analysis for clinical factors and treatment factors. Variables Descriptions Prescribed group Non-prescribed group Total N (%) N (%) N (%) p-value Pathological SCLC 2 (8.70) 20 (9.80) 22 (9.69) diagnosis NSCLC 21 (91.30) 184 (90.20) 205 (90.31) total 23 (10.13) 204 (89.87) 227 (100.00) Pain N 5 (21.74) 87 (42.23) 92 (40.17) Y 18 (78.26) 119 (57.77) 137 (59.83) Sleep disorder N 10 (43.48) 182 (88.35) 192 (83.84) (No, Yes) Y 13 (56.52) 24 (11.65) 37 (16.16) Comorbidity N 1 (4.35) 54 (26.21) 55 (24.02) (No, Yes) Y 22 (95.65) 152 (73.79) 174 (75.98) Surgery N 17 (73.91) 109 (52.91) 126 (55.02) Y 6 (26.09) 97 (47.09) 103 (44.98) Radiation therapy N 20 (86.96) 197 (95.63) 217 (94.76) Y 3 (13.04) 9 (4.37) 12 (5.24) Chemotherapy N 10 (43.48) 104 (50.49) 114 (49.78) Y 13 (56.52) 102 (49.51) 115 (50.22) Oral targeted N 15 (65.22) 151 (73.30) 166 (72.49) anticancer drugs Y 8 (34.78) 55 (26.70) 63 (27.51) Current treatment N 5 (21.74) 80 (38.83) 85 (37.12) Y 18 (78.26) 126 (61.17) 144 (62.88) Cured N 23 (100.00) 194 (94.17) 217 (94.76) Y 0 (0.00) 12 (5.83) 12 (5.24)

6 112 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 나타났다. 수술 (p = ) 은유의하지않았지만경계였다. 기타요인에대한교차분석결과외래진료횟수의경우처방군의평균은 25.65회, 비처방군의경우 15.34회로유의한차이를보였다 (p < 0.01). 입원횟수의경우에도유의한차이를보였는데, 처방군은평균 3.26회입원하였고, 비처방군은평균 2.03 회입원하였다 (p < 0.01). 재원일수또한처방군은평균 51.74일, 비처방군은 16.36일로유의한차이를보였다 (p < 0.001) (Table 4). 다른요인인중환자실재원여부 (p = ) 와흡연력 (p = ) 및음주력 (p = ) 은모두두군간에통계적으로차이가없는것으로나타났다. 항우울제처방군과비처방군사이의각요인에대한단변량로지스틱회귀분석결과각요인들이항우울제처방군과비처방군에대해미치는영향을분석하기위하여단변량로지스틱회귀분석을실시하였다. 인구사회학적요인에대한교차분석결과두군간에통계적으로차이가없는것으로나타났다. 임상적요인에대한분석결과수면장애의경우수면장애가있는군을기준으로없는군은항우울제처방가능도가 0.10배 [OR = 0.10, 95% Confidence Interval(CI): ] 로나타났다. 동반질환여부의경우동반질환이있는군을기준으로동반질환이없는군은항우울제처방가능도가 0.13배 [OR = 0.13, 95% CI: ] 로나타났다 (Table 6). 치료관련요인에대한분석결과두군간에통계적으로차이가없는것으로나타났다. 기타요인에대한분석결과외래진료횟수, 입원횟수및재원일수가유의한결과를보였다 (p < 0.05) (Table 6). Table 7. Multivariate logistic regression analysis. Variables Descriptions Odds Ratio 95% CI p-value Sleep disorder Comorbidity Number of outpatient visit Days of hospitalization Yes Ref No Yes Ref No 항우울제처방군과비처방군사이의다변량로지스틱회귀분석결과단변량로지스틱회귀분석결과통계학적으로의미가있는것 (p < 0.05) 으로확인된요인들에대해서다변량로지스틱회귀분석을실시하였다. 이는수면장애여부, 동반질환여부, 외래진료횟수, 입원횟수, 재원일수였다. 수면장애가없는경우항우울제처방가능도는 0.21배였다 [OR = 0.21, 95% CI: ]. 외래진료횟수의경우진료횟수가증가할수록항우울제처방가능도는 1.05배상승하였고 [OR = 1.05, 95% CI: ], 재원일수의경우에도재원일수가증가할수록항우울제처방가능도는 1.03배상승하였다 [OR = %, CI ]. 단변량로지스틱회귀분석에서유의하였던동반질환여부는다변량로지스틱회귀분석결과유의하지않았다 [OR = %, CI ](Table 7). 고찰 Table 6. Results of univariate logistic regression analysis. Variables Descriptions Odds Ratio 95% CI p-value Sleep disorder Comorbidity Hospitalization in ICU Yes Ref. No < Yes Ref No Yes Ref No Current smoker Ref Smoking history Non-smoker Ex-smoker History of Yes Ref Alcohol No Number of outpatient visit Number of admission Days of hospitalization < 우울증은암환자들이보편적으로겪는정신적인고통이며, 자살의위험요소가되거나, 치료순응도를낮추는요인이된다. 5,17) 암환자의우울증이환율을조사한선행연구에서는, 진단방법이다르고분류기준이다른영향으로, 암환자의주요우울장애이환율이 1% 에서 50% 까지다양하였다. 10) 2010년통계청자료를기준으로발생률이높은갑상선암, 위암, 대장암, 폐암, 간암, 유방암으로연구기관에내원한환자를대상으로한암환자의우울증진단율과항우울제및항불안제처방율에대한사전조사에서는, 우울증유병율과항우울제및항불안제의처방이폐암에서가장높았고, 폐암이우울증과관련성이가장높은암종이라는다른선행연구의결과와일치하였다. 13,18) 연구대상 229명의환자중 10% 가우울치료목적의항우울제처방이있었다. 즉폐암환자의 10% 가폐암진단후항우울제복용을시작했다. 선행연구에따르면폐암환자의우울상태는 16.3% 로, 본연구의 10% 가우울상태를치료를받고있음을적용해보면, 정신건강의학과적치료가필요한환자들중치료를받는환자는일부였음을추정할수있었다. 12) 이는심리적고통을가지고있는암환자중전문적인정신건

7 폐암환자의항우울제처방현황과관련요인분석 / 113 강의학과적치료를받는경우는치료대상중일부라는선행연구의결과와도일치하였다. 6) 현재연구에서우울증치료제로처방이된약제는 10개성분으로 SSRIs 처방환자 (60.9%, 14/23) 가삼환계항우울제처방환자 (34.8%, 8/23) 보다많았다. 이는 SSRIs가내약성이좋아서인것으로보이며 19) 우울증치료로가장많이처방되는계열이 SSRIs라는유럽 12개국에서실시된연구결과와유사했다. 20) 불면증을동반한우울증에서는 trazodone이나 mirtazapine, 또는삼환계항우울제와같이졸리는항우울제를선호하는데 19) 본연구에서도항우울제처방군중불면증이있는환자 13명중 11명은 trazodone, mirtazapine, 삼환계항우울제를처방받고있었다. 기존보고된역학연구에서여성, 낮은경제수준, 주요우울장애과거력, 뇌졸중, 치매등이우울장애, 우울증상의위험인자라고밝혔으나 21-22) 폐암환자로대상을제한했던본연구에서는항우울제처방의요인으로성별의경우는유의한요인이아니었다 (p = ). 또한 173명의남성연구대상중 20 명이, 56 명의여성연구대상중 3 명이항우울제처방군으로, 남성의경우가항우울제처방의비율이높았다. 이결과는국내일개종합병원에서지속적인외래내원폐암환자를대상으로한스티그마, 디스트레스연구에서남성이여성보다스티그마가심한것으로나타난결과와일치하였다. 12,23) 동반질환여부의경우조금더세분화하여조사하지않았기에, 뇌졸중, 치매환자에있어서의우울증상은확인할수없었다. 선행연구에따르면우울한환자에서재원일수가늘어난다는연구가있는데, 우울과재원일수증가의선행관계는일치하지않지만, 본연구에서도우울과재원일수가상관관계가있는결과가나왔다. 24) 수면장애의요인이폐암환자의삶의질과관련이있다는연구가있는데, 본연구의결과와도일치하였다. 25) 2000년한연구에따르면 SCLC환자는 NSCLC에비해우울증이 3배이상 (25% vs 9%, p <0.001) 이환된다고보고되었는데, 본연구에서는 SCLC 환자군의 9%, NSCLC 환자군의 10% 가우울증치료제처방군으로, 유의한차이를밝히지는못하였다 (p =0.865). 26) 이러한차이는선행연구에서는완화치료 (palliative care) 를받는말기환자를대상으로하였고, 본연구는모든병기의폐암환자를대상으로실시한점에서동일한결과를도출하지못한것으로평가된다. 진행성폐암에서호흡곤란, 통증과같은신체적증상과불안, 우울등의심리적증상과의관련이있다고연구된바있다. 27) 본연구에서도통증이있는환자의 13% 가처방군이었고, 통증이없는환자의 5.4% 가처방군으로통증이있는환자에서항우울제처방이높게났다 (p = ). 항암화학요법을받는경우약제의부작용과관련하여우울이증가한다고보고하고있으나, 본연구에서는항암화학요법의여부는항우울제처방에유의한요인은아니었다 (p = 0.525). 28) 외래내원폐암환자를대상으로 한스티그마, 디스트레스연구에서우울정도 (t = 3.259, p = 0.001) 는현재치료를받는경우가치료를받지않는경우보다높게나타났으나 12) 본연구에서는현재치료여부가항우울제처방에유의한요인은아니었다 (p = 0.116). 항우울제와암의상관성에대해논란이있으나 SSRIs 장기복용은폐암유발위험을감소시킬수있으며 29) 우울증은폐암환자의사망률을높이는질환이므로 30) 폐암환자의우울증치료는고려되어야한다. 본연구의경우단일기관에서진행된연구로연구결과를더큰환자군집단으로적용시주의를요한다. 연구설계상의무기록을활용한후향적연구라는제한점을배제할수없으며, 폐암진단전에우울증진단을받은환자이거나타의료기관에서전원되어폐암진단과정신건강의학과진료의시간적선후관계를판단하기어려운환자들의경우본연구에서제외되어실제우울증으로진단받은환자들은본연구의결과보다많을수있다는점을고려해야한다. 그럼에도불구하고, 본연구에서는본원에내원한모든병기의전체폐암환자를대상으로항우울제처방현황을분석하였고, 항우울제처방군과비처방군간의관련요인을비교분석한연구로의의가있다고할수있다. 결론 본연구는폐암환자에서항우울제처방현황을분석하고, 처방군과비처방군의인구사회학적요인, 임상적요인, 치료관련요인및기타요인을확인하고자하였다. 연구대상환자중약 10% 에서폐암진단이후우울증상으로항우울제를처방받고있었으며, 항우울제처방군의경우수면장애여부, 입원횟수및재원일수가폐암환자에서의항우울제처방에영향을미치는요인으로확인되었다. 폐암환자들의항암치료와더불어우울증에대한진단과치료가고려되어야한다. 참고문헌 1. Statistics Korea. Available from jsp. Accessed January 14, Jung KW, Won YJ, Kong HJ, et al. Cancer statistics in Korea: incidence, mortality, survival, and prevalence in Cancer Res Treat 2015 Apr; 47(2): National Cancer information center. Available from Accessed January 14, Smith E, Gomm S, Dickens C. Assessing the independent contribution to quality of life from anxiety and depression in patients with advanced cancer. Palliat Med 2003;17(6): Mitchell AJ, Chan M, Bhatti H, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliativecare settings: a meta-analysis of 94 interview-based studies. The Lancet Oncol 2011;12(2):

8 114 / Korean J Clin Pharm, Vol. 26, No. 2, Devlen J, Maguire P, Phillips P, et al. Psychological problems associated with diagnosis and treatment of lymphomas. I: retrospective study. Br Med J (Clin Res Ed) 1987;295(6604): Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr 2004;(32): Çavuso o glu H. Depression in children with cancer. J Pediatr Nurs 2001;16(5): Carlson LE, Bultz BD. Cancer distress screening: needs, models, and methods. J Psychosom Res 2003;55(5): Goldzweig G, Meirowitz A, Hubert A, et al. Meeting expectations of patients with cancer: relationship between patient satisfaction, depression, and coping. J Clin Oncol 2010;28(9): Pinquart M, Duberstein P. Depression and cancer mortality: a metaanalysis. Psychol Med 2010;40(11): Lee JL, Kim KS. The relationships between stigma, distress, and quality of life in patients with lung cancer. J Korean Oncol Nurs 2011; 11(3): Sellick SM, Edwardson AD. Screening new cancer patients for psychological distress using the hospital anxiety and depression scale. Psycho- Oncology 2007;16(6): Walker J, Sawhney A, Hansen CH, et al. Treatment of depression in people with lung cancer: a systematic review. Lung Cancer 2013; 79(1): Anatomical-Therapeutic-Chemical-Classification-System. ATC/DDD Index Available from: Accessed May 14, Loy JW, McPherson BD, Kenyon GS. Sport and social systems: a guide to the analysis, problems, and literature: Addison-Wesley Reading, MA; DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatmentmeta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000; 160(14): Statistics-Korea. Cancer Registration Statistics Available from: Accessed May 14, Min KJ, Kwon JS, Kim W, et al. Korean clinical practice guideline of depressive disorders. Korean J Biol Psychiatry 2006;13(1): Bauer M1, Monz BU, Montejo AL, et al. Prescribing patterns of antidepressants in Europe: results from the factors influencing depression endpoints research (FINDER) study. Eur Psychiatry 2008 Jan;23(1): Park JH, Lee JJ, Lee SB, et al. Prevalence of major depressive disorder and minor depressive disorder in an elderly Korean population: results from the Korean longitudinal study on health and aging (KLoSHA). J Affect Disord 2010;125(1-3): Djernes J. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand 2006;113(5): Cataldo JK, Slaughter R, Jahan TM, et al. Measuring stigma in people with lung cancer: psychometric testing of the cataldo lung cancer stigma scale. Oncol Nurs Forum 2011;38(1): E Kitagawa R, Yasui-Furukori N, Tsushima T, et al. Depression increases the length of hospitalization for patients undergoing thoracic surgery: a preliminary study. Psychosomatics 2011;52(5): Vena C, Parker KP, Allen R, et al. Sleep-wake disturbances and quality of life in patients with advanced lung cancer. Oncol Nurs Forum 2006;33(4): Hopwood P, Stephens RJ. Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data. J Clin Oncol 2000;18(4): Tanaka K, Akechi T, Okuyama T, et al. Factors correlated with dyspnea in advanced lung cancer patients: organic causes and what else? J Pain Symptom Manage 2002;23(6): Lee GH, Oh EH. Effect of guided imagery program on patients depression and anxiety receiving cancer chemotherapy. J Korean Acad of Psychiatr Ment Health Nurs 2004;13(2): Toh S, Rodríguez LA, Hernández-Díaz S. Use of antidepressants and risk of lung cancer. Cancer Causes Control 2007 Dec;18(10): Sullivan DR1, Ganzini L2, Duckart JP, et al. Treatment receipt and outcomes among lung cancer patients with depression. Clin Oncol 2014 Jan;26(1):25-31.

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar