Poor Sleep Quality in Late Life Depression Choe JY, et al 애를예측하는가장중요한예측인자로알려져있고, 노인환자의 50% 습관적인수면문제를지니고있다. 7)8) 불면증도연령이증가함에따라유병률이증가하는것으로알려져있으며, 이에따른수면

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1 online ML Comm ORIGINAL ARTICLE ISSN / eissn Korean J Biol Psychiatry 2014;21(2):74-80 분당서울대학교병원정신건강의학과, 1 제주대학교의학전문대학원제주대학교병원정신건강의학교실 2 최진영 1 박준혁 2 Poor Sleep Quality and Its Effect on Quality of Life in the Elderly with Late Life Depression Jin Yeong Choe, MA, 1 Joon Hyuk Park, MD 2 1 Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea 2 Department of Psychiatry, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, Korea ObjectivesZZMore than half of the elders suffer from chronic sleep disturbances. Moreover, sleep disturbances are more prevalent in patients with depressive disorder than in community dwelling elderly. In this study, we aim to estimate the risk factors of poor sleep quality and its effect on quality of life in patients with late life depression. MethodsZZThis study included 159 depressive patients aged 65 years or older who completed Pittsburgh Sleep Quality Index (PSQI). A global PSQI score of 5 or greater indicates a poor sleeper. Structural diagnostic interviews were performed using the Korean version of Mini International Neuropsychiatric Interview (MINI). Depression was evaluated by the Korean form of Geriatric Depression Scale (KGDS). Global cognition was assessed by Mini-Mental State Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer s Disease assessment packet. Quality of life was evaluated by the Korean version of Short-Form 36-Item Health Survey (SF-36). ResultsZZThe frequencies of poor sleepers were 90.5% in major depressive disorder, 71.8% in minor depressive disorder, 47.1% in subsyndromal depressive disorder, and 73.0% in all types of depressive disorders. Multivariate logistic regression analysis indicated that female [odds ratio (OR) = 2.83, 95% confidence interval (CI) = ] and higher KGDS score (OR = 1.13, 95% CI = ) were risk factors of poor sleep quality in patients with late life depression. In the analysis of ANCOVA adjusted for age, gender, education and KGDS score, the mean scores of vitality mental health and mental component summary of SF-36 were lower in poor sleepers than in good sleepers. ConclusionsZZPoor sleepers among patients with late life depression are very common and are associated with female and higher KGDS scores. Poor sleep quality causes a significant negative effect on mental health quality. So researchers and clinicians should be more vigilant in the evaluation and treatment of sleep disturbances in patients with late life depression. Key WordsZZLate life depression ㆍ Sleep quality ㆍ Quality of life ㆍ Poor sleeper. Received: April 23, 2014 / Revised: April 27, 2014 / Accepted: April 28, 2014 Address for correspondence: Joon Hyuk Park, MD Department of Psychiatry, Jeju National University Hospital, School of Medicine, Jeju National University, 15 Aran 13-gil, Jeju , Korea Tel: , Fax: , empath0125@gmail.com 우울증은정신과질환중에서가장흔한질환중의하나지만, 인간의삶에미치는영향은매우심각하다. 우울증은인류에게가장큰부담 (burden of disease) 을초래하는 10대질환중 4위이고, 2020년에는 2위, 2030년에는 1위가될것으로예측된다. 1)2) 특히노년기우울증은우리나라를비롯하여노 년층인구가급증하고있는아시아국가에서심각한공중보건상의문제로대두되고있다. 노인우울증에서수면장애의비율은매우높아서약 2/3 이상에서수면장애를동반하고있고, 3) 수면장애자체도인지기능과정동상태에부정적인영향을주고전반적인삶의질을떨어뜨린다. 4)5) 연령이증가함에따라수면은점점단편화되며, 야간각성및주간수면의양상을보이게된다. 6) 나이의증가는수면장 74 Copyright 2014 Korean Society of Biological Psychiatry

2 Poor Sleep Quality in Late Life Depression Choe JY, et al 애를예측하는가장중요한예측인자로알려져있고, 노인환자의 50% 습관적인수면문제를지니고있다. 7)8) 불면증도연령이증가함에따라유병률이증가하는것으로알려져있으며, 이에따른수면제의사용도연령에따라증가하는것으로알려져있다. 이러한수면장애는주요우울장애, 면역기능의감소, 심혈관계질환의증가와관련된다. 연구마다불면증의유병률은차이가나는데이는불면증의정의와조사방법의차이에기인한다. 국내의연구에의하면 65세이상노인의대략 22% 에서 57.7% 의노인에서불면증이있는것으로보고되고있다. 9)10) 우리나라노인의주요우울장애유병률은다른아시아권국가들이나서구의 2~4% 보다대체적으로높아서 5.4% 였고, 11) 한국판단축형노인우울척도 (Short form of Korean version of the Geriatric Depression Scale) 12) 점수를이용해그점수가 8점이상이우울증으로정의할때유병률은 27.7% 로다른아시아권국가들이나서구에비해서높았다. 13) 수면장애와우울장애의관계는양방향적이다. 14) 즉만성불면증은우울증발병의위험요인으로작용할뿐만아니라, 15)16) 불면증의우울장애의잔존증상으로남아있을경우향후우울증의재발의위험을높인다. 17) 또한불면증은우울장애의주요한증상중의하나로주요우울장애의 70% 이상에서동반하게된다. 3) 이전의연구들의초점은주로불면증과우울장애의연관관계나, 14) 각질환들이삶에질에미치는영향이독립적으로연구되었다. 18)19) 현재노년기우울증에동반된수면장애에대한연구는부족한실정이다. 본연구는노년기우울장애군환자를대상으로수면질저하군과수면질양호군의임상적특징을비교하고또한노년기우울장애에서수면의질저하가삶의질에저하에미치는영향을조사하고자한다. 대상자 2011 년 3월 1일 ~2012년 6월 30일까지제주대학교병원정신건강의학과에우울감을주소로외래진료를위해내원한사람중이로인하여사회적직업적활동에지장이있어치료가필요한사람을대상으로하였다. 치매환자, 청력, 시력저하로정상적인면담이불가능한사람, 우울증이외의정신과적주요정신질환을갖고있는사람은본연구에서배제하여최종적으로본연구참여한총 159명이었다. 모두서면동의를구하였고, 연구계획및피험자권익보호에대하여제주대학교병원임상시험심사위원회 (Institutional Review Board) 의심의를통과하였다. 진단모든대상자는정신건강의학과의사가 the Korean version of the Mini-International Neuropsychiatric Interview( 이하 MINI) 20) 를통하여구조화된면담을시행하였다. 주요우울장애에대해서는 Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision( 이하 DSM-IV-TR) 의진단기준을사용하였고, 경도우울장애는 DSM-IV-TR 의부록 B의연구진단기준으로진단하였다. 아증후군적우울증은주요우울장애와경도우울장애의진단에해당되지않으면서, 우울감또는흥미의상실과같은핵심증상한가지는반드시포함하고, 9개의주요우울삽화진단기준중 5개이상의증상이 2주중 1주이상과하루중 1/2 이상충족될경우로임의로정의하였다. 평가우울증상에대한평가를위해 the Korean form of Geriatric Depression Scale( 이하 KGDS), 12) 인지기능평가에대해 the Mini-Mental State Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer s Disease assessment packet( 이하 MMSE-KC) 21) 를사용하였다. 신체적및정신적삶의질에대한평가를위해 the Korean version of Short-Form 36-Item Health Survey( 이하 SF-36) 22) 를시행하였다. SF-36 은건강수준에대한자기보고식측정도구로써 8개의영역으로구분하여평가한다. 8개의영역은각각신체적기능 (Physical functioning), 사회적기능 (Social functioning), 신체적역할제한 (Role-physical), 감정적역할제한 (Roleemotional), 정신건강 (Mental health), 활력 (Vitality), 통증 (Bodily pain), 일반건강 (General health) 이며각영역당 2~ 10개의설문으로구성되어있다. 또크게신체적건강과정신적건강에대해 2개의영역으로구분하여신체요인요약점수 (physical component summary, 이하 PCS) 와정신요인요약점수 (mental component summary, 이하 MCS) 를계산하였다. 23) 수면의질은피츠버그수면질척도 (Pittsburgh Sleep Quality Index, 이하 PSQI) 로평가하였다. 24) PSQI는주관적수면의질 (Subjective sleep quality), 초기불면 (Sleep latency), 수면시간 (Sleep duration), 습관적수면효율 (Habitual sleep efficiency), 수면방해 (Sleep disturbance), 수면제사용 (Use of sleeping medication), 주간기능장애 (Daytime dysfunction) 의총 7개영역으로구성되고, 7개영역은총 18개의하부문항으로구성된다. 점수는 7개영역별로 0점에서 3점의 4점척도로재구성하여영역별점수를구하고, 7개영역점수의총합이 PSQI 총점 (Global PSQI score) 이된다. PSQI 총점범위는 0점에서 21점이며점수가높을수록수면의질이나쁜것 journal.biolpsychiatry.or.kr 75

3 Korean J Biol Psychiatry 2014;21(2):74-80 이고, 총점이 6점이상시수면질저하군 (poor sleeper) 으로분류된다. 본연구에서모든평가척도는훈련된전문연구원에의해시행되었다. 통계적분석주요우울장애, 경도우울장애, 아증후군적우울증의세군간의나이, 교육년수, KGDS, MMSE-KC, SF-36 의 PCS, MCS 점수, PSQI 총점과세부항목점수를 ANOVA 를이용하여비교하고, Bonferroni 사후검정을시행하였다. PSQI 총점이 6점이상인수면질저하군 (poor sleeper) 과 5점이하의수면질양호군 (good sleeper) 사이의임상적특징은독립변수가연속변수일경우에는 ANOVA 로, 명목변수일경우는 chi-square test를이용하여비교하였고, 또한수면질저하여부를종속변수로연령, 성별, 교육, KGDS 점수, MMSE-KC 를독립변수로하여다변량로지스틱회귀분석을이용하여우도비 (odds ratio, 이하 OR) 를구하였다. 수면질저하군과수면질양호군의삶의질의비교는 SF-36 의세부항목점수를독립변수로하여, 세부항목점수에영향을줄수있는성별, 연령, 교육정도, KGDS 점수를공변량 (covariant) 으로하여 ANCOVA 를시행하였다. 통계적분석은 Statistical Package for the Social Sciences( 이하 SPSS) 20.0(SPSS Inc., Chicago, IL, USA) 을통해이루어졌다. 대상자의인구통계학적특성 총 159 명의우울증환자가본연구에등록되었고, 대상자의 평균연령은 72.4 ± 6.8세였고, 여성의비율은 69.2% 였다. KGDS의평균점수는 19.3 ± 5.9점이었고, MMSE-KC 점수는 22.2 ± 4.5점이었다. 수면의질을나타나는 PSQI 총점은 8.7 ± 4.2점이었고, 6점이상의수면질저하군의비율은 73.0% 였다. 159명중주요우울장애로진단된환자는 42명 (26.4%), 경도우울장애는 43명 (27.0%), 아증후군적우울증은 74명 (46.5%) 이었다 (Table 1). 진단군별특징주요우울장애, 경도우울장애, 아증후군적우울장애군의군간의평균연령, 교육년수, MMSE-KC 점수는차이가없었고, 성별의비율도차이는없었다. KGDS 점수는주요우울장애군에서 23.9 ± 4.5점, 경도우울장애군에서 20.2 ± 4.8점, 아증후군적우울장애군에서 16.2 ± 5.4점으로우울증의심각도에따라서높은점수를보였고이는통계적으로도유의하였다 (p < 0.001, ANOVA). 삶의질의척도면에서는 PCS 와 MCS 모두에서주요우울장애군에서가장낮은점수를보였고, 아증후군적우울장애군간은통계적으로유의한차이를보였다 (p < 0.05, Bonferroni post hoc test). 수면의질측면에서도우울증진단별로큰차이를보였는데, 주요우울장애군은수면질저하의비율이 90.5% 로경도우울장애군 71.8%, 아증후군적우울증군 47.1% 에비해유의하게높았다 (p < 0.05, chi-square test). PSQI 총점은주요우울장애군에서 10.9 ± 4.3점으로경도우울장애군과아증후군적우울장애군에비해유의하게높았다 (p < 0.05, Bonferroni post hoc test)(table 1). 세부점 Table 1. Characteristics of the subjects with major depressive disorder (MDD), minor depressive disorder (MnDD) and subsyndromal depression (SSD) MDD MnDD SSD Statistics* Post hoc Number Age (years) 70.5 ± ± ± a = b = c Education (years) 5.0 ± ± ± a = b = c Gender (women, %) a = b = c KGDS 23.9 ± ± ± a > b > c MMSE-KC 22.2 ± ± ± a = b = c SF-36 PSQI PCS 33.0 ± ± ± a = b, a < c MCS 38.9 ± ± ± a = b, a < c Global score 10.9 ± ± ± a > b = c Poor sleeper (%) a > b = c Data are expressed as mean ± SD unless otherwise indicated. a, b and c indicate MDD, MnDD and SSD, respectively. * : F for continuous variables and chi square for categorical variables, : Bonferroni post hoc comparison for continuous variables and 2 2 chi-square test for categorical variables, : p < 0.05, : p < KGDS : Korean form of Geriatric Depression Scale, MMSE- KC : Mini-Mental State Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer s Disease assessment packet, SF-36 : Short Form 36, PCS : physical component summary, MCS : mental component summary, PSQI : Pittsburgh Sleep Quality Index 76

4 Poor Sleep Quality in Late Life Depression Choe JY, et al Table 2. Sleep quality of the subjects with major depressive disorder (MDD), minor depressive disorder (MnDD) and subsyndromal depression (SSD) MDD MnDD SSD p value* Post hoc Subjective sleep quality 1.7 ± ± ± a = b, a > c Sleep latency 2.1 ± ± ± a = b, a > c Sleep duration 1.8 ± ± ± a = b, a > c Habitual sleep efficiency 1.2 ± ± ± a = b = c Sleep disturbance 2.0 ± ± ± 0.6 < a > b = c Use of sleeping medication 0.9 ± ± ± a = b = c Daytime dysfunction 1.2 ± ± ± a = b, a > c Data are expressed as mean ± SD. a, b and c indicate MDD, MnDD and SSD, respectively. * : ANOVA, : Bonferroni post hoc comparison Table 3. Comparison of clinical characteristics between good sleepers and poor sleepers in subjects with late life depression Good sleeper (n = 43) Poor sleeper* (n = 116) Statistics Frequency (%) Age (mean ± SD, years) 72.1 ± ± Education (years) 06.5 ± ± Gender (women, %) KGDS (mean ± SD) 16.5 ± ± MMSE-KC (mean ± SD) 22.9 ± ± PSQI global score (mean ± SD) 03.9 ± ± * : score 6 on Pittsburgh Sleep Quality Index (PSQI) global score, : F for continuous variables and chi square for categorical variables, : p < 0.05, : p < KGDS : Korean form of Geriatric Depression Scale, MMSE-KC : Mini-Mental State Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer s Disease assessment packet Table 4. Multivariate logistic analysis of factors associated with poor sleepers in the depressed patients Factors OR (95% CI) p value Age (years) 1.02 ( ) Female 2.83 ( ) Education (years) 1.03 ( ) KGDS 1.13 ( ) MMSE-KC 1.01 ( ) KGDS : Korean form of Geriatric Depression Scale, MMSE-KC : Mini-Mental State Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer s Disease assessment packet, OR : odds ratio, CI : confidence interval 수별로는주요우울장애군에서주관적인수면의질, 초기불 면, 수면시간, 수면문제, 주간기능장애에서아증후군적우 울장애군보다유의하게높은점수를보였다 (Table 2). 우울장애의수면질저하군임상특징 전체우울장애환자 159 명중 116 명 (73.0%) 이수면질저하 군에속하였고, 수면질저하군과수면질양호군간의연령, 교육수준, 간이정신상태검사점수의차이는관찰되지않았 다. 수면질저하군의여성의비율 79.2% 로수면질양호군의 59.6% 보다유의미하게높은수준을보였다 (p < 0.05, chisquare test). KGDS 점수는수면질저하군이 20.5 ± 5.7 점 으로수면질양호군의 16.5 ± 5.9 점보다유의하게높은점수 를보였다 (p < 0.05, ANOVA). PSQI 의총점은당연히수면질 저하군이 10.5 ± 3.4점으로수면질양호군의 3.9 ± 3.4점에비해높은점수를보였다 (p < 0.001, ANOVA)(Table 3). 수면질저하여부를종속변수로연령, 성별, 교육, KGDS 점수, MMSE-KC 를독립변수로하여다변량로지스틱회귀분석을하였을때, 여성 [OR = 2.83, 95% confidence interval( 이하 CI) = ] 과 KGDS 점수 (OR = 1.13, 95% CI = ) 가수면질저하와유의하게연관이있었다 (Table 4). 우울장애의수면질저하군의삶의질삶의질의측면에서, 수면질저하군이수면질양호군보다정신건강의질이저하된소견을보였으나 (p < 0.05, ANCOVA) 신체건강의질은양군간의차이가없었다 (p = 0.780, AN- COVA). 수면질저하군에서활력 (Vitality), 정신건강 (Mental Health), 정신요인요약치 (Mental component summary) 항목에서수면질양호군보다는낮은점수를보였고, 신체적삶의질과연관성이높은항목인신체적기능 (Physical functioning), 신체적역할제한 (Role limitation-physical), 통증 (Bodily pain), 일반건강 (General health) 항목에서는양군간은유의한차이를보이지않았다 (Table 5). 전체 159 명의우울증환자중에서수면질저하군은주요우 journal.biolpsychiatry.or.kr 77

5 Korean J Biol Psychiatry 2014;21(2):74-80 Table 5. Comparison of quality of life between good sleepers and poor sleepers Good sleeper Poor sleeper* p value Physical function 56.9 ± ± Role limitation-physical 69.9 ± ± Bodily pain 59.5 ± ± General health 32.1 ± ± Vitality 47.3 ± ± Social function 79.1 ± ± Role of limitation-emotion 79.8 ± ± Mental health 60.0 ± ± Physical component summary 38.3 ± ± Mental component summary 47.9 ± ± Data are expressed as mean ± SD. * : score 6 on Pittsburgh Sleep Quality Index (PSQI) global score, : ANCOVA adjusted for age, gender, education and KGDS score 울장애군에서 90.5%, 경도우울장애군에서 71.8%, 아증후군적우울장애군에서 47.1%, 전체우울증군의 73.0% 였다. 본연구의주요우울장애군과경도우울장애군에서수면질저하군의비율은이전지역사회노인의수면질저하군의유병률인 41.5~47.1% 25) 보다약 2배정도의높은비율을보였고, 아증후군적우울장애군에서는지역사회노인군과비슷한비율을보여, 우울증의심각도가경도우울장애이상의경우에서만수면의질의유의한저하를보였다. 본연구에서는우울증군의범위를아증후군우울증군까지확대하였는데, 이는최근아증후군적우울증은유병률이높고, 노인의장애에대한중요한기여인자로작용한다는인식이증가하면서그임상적중요성이점점커지고있기때문이다. 26) 아증후군적우울증은유병률연구가소수에불과한데, 아증후군적우울증의유병률은 17~33% 로주요우울장애 4~7%, 경도우울장애 10~15% 와비교하여상대적으로높았고, 27) 지역사회거주노인집단에서는아증후군적우울증이 30% 에이른다는보고도있다. 26) 또한, 아증후군적우울증은자살위험의증가, 삶의질저하, 사회적서비스의과도한이용, 장애에대한사회경제적비용증가의이유로그진단과치료의중요성이강조되고있다. 28) 주관적수면의질 (Subjective sleep quality), 초기불면 (Sleep latency), 수면시간 (Sleep duration), 수면방해 (Sleep disturbance), 주간기능장애 (Daytime dysfunction) 의 5개의 PSQI 세부영역점수와 PSQI 총점에서주요우울장애군은경도우울장애또는아증후군적우울장애군에비해서유의하게높은점수를보였다. 수면의질을연속변수를이용하여평가할때도주요우울장애군은가장낮은수면의질을보였다. 우울증의심각도가심해질수록주관적수면의질이저하되는양상을확인할수있었다. 이는임상적으로주관적수면의질에대한양적, 질적평가는우울증의심각도를평가하는중요한척도로이용될수있음을시사한다. 이전의정상대조군과비교해서 19) 본연구에서삶의질을평가하는 SF-36 의 8개의소항목, MCS, PCS 점수저하가뚜렷하였고, 우울증의심각도와삶의질의저하는단계적인연관 (graded association) 이있었고, 이는이전의연구결과와는일치는하는소견이었다. 19) 본연구에서수면질저하군은여성, KGDS 점수와연관이있었고, 연령, 교육수준, 전반적인지기능과는연관이없었다. 본연구결과와는반대로이전의지역사회거주자를대상으로한연구들에서는연령이수면질저하군과연관이있음을비교적일관되게보여주는데, 6-8)25) 본연구에서연령이수면질저하와연관이없게나온이유는본연구의대상자가임상에서모집한우울증환자군이라서대상자의연령이대부분 70세전후로집중적으로분포하기때문으로생각된다. 여성이수면질저하의관계는연관이있다는연구와 7)29) 연관이없다는연구가 8)16)25) 모두존재하여일관되지않다. 여성이수면의질저하와연관이없다는연구들도단변량분석에서는성별에따라수면의질의차이가있었지만, 여러혼란변수를통제할때여성이수면질저하군의위험요인으로작용하지는않았다. 본연구와마찬가지로이전의연구에서도우울척도의점수와수면질저하와는비교적일관되게연관성이있었다. 8)30)31) 삶의질의측면에서, 수면질저하군이수면질양호군보다정신건강의질이저하된소견을보였으나, 신체건강의질은양군간의차이가없었다. 삶의질에영향을미치는나이, 성별, 교육수준, 우울증의심각도등의혼란변수를통제하고도수면질의저하는삶의질에유의미하게부정적인영향을주고있었다. 4)5)8)18) Wong과 Fielding 8) 의연구는본연구와마찬가지로수면의질저하가신체건강의질은영향을주지않고정신건강의질만유의미하게저하되는소견을보였다. 이러한결과는수면의질저하가삶의질에영향을주는경로가신체적인측면보다심리적인측면으로작용한다는것을의미한다. 78

6 Poor Sleep Quality in Late Life Depression Choe JY, et al 본연구의장점은주요우울장애, 경도인지장애뿐만아니라 역치이하의아증후군적우울장애까지수면의질과삶의질 영역에대해비교평가하였다. 이전의역치이하의우울증에 관한연구에서는대부분설문지로평가하거나, 32-36) 전문가가 아닌숙련되지못한면담자에의해구조화된면담을통해진 행되어, 37-42) 주요우울장애의부분관해, 기분부전장애또는 적응장애를역치하우울증과감별하는데어려움이있었다. 43) 본연구는정신과의사에의해구조화된면담을통해진행되 었고, 훈련된전문연구원에의해각종평가가시행되어진단 의정확성에대한문제를해결하였다. 본연구의제한점은다음과같다. 첫째, 연구에사용한아증 후군적우울장애의진단기준이비록이전진단기준의단점을 보완한기준이지만, 아직은이기준에대한타당도연구가이 루어지지않은상태로이에대한추후연구가필요한것이다. 둘째, 본연구의대상자가외래를방문한우울장애환자군으 로비우울증군의대조군으로없는연구이다. 향후연구에서성 별분포, 연령, 교육수준이비슷한비우울증대조군을포함시 킨다면본연구의목적을더명확하게확인할수있을것이다. 셋째, 본연구는임상에서우울증환자를대상으로한횡적인 연구로, 본연구의결과를일반화하고인과관계를명확히하 기위해서는지역사회에서일반노인을대상으로종적연구가 필요할것이다. 본연구는노인인구에우울장애환자군에서수면의질저 하가 70% 이상에서호발하고, 또한우울증의심각도와관련 없이정신건강의측면삶의측면을유의하게저하시키는것 을확인하였다. 그러므로임상에서접하는노인우울증을진 단하고치료할때동반된수면장애에대한평가와치료에더 많은관심과노력이필요할것이다. 중심단어 : 노년기우울증 수면의질 삶의질 수면질저 하군. Acknowledgments 이논문은 2011 년도제주대학교의학전문대학원발전기금연구비 ( 의과학연구소학술연구비 ) 의지원에의해서연구되었음. Conflicts of interest The authors have no financial conflicts of interest. REFERENCES 1) Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 1997;349: ) Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367: ) Nelson JC, Clary CM, Leon AC, Schneider LS. Symptoms of late-life depression: frequency and change during treatment. Am J Geriatr Psychiatry 2005;13: ) Schubert CR, Cruickshanks KJ, Dalton DS, Klein BE, Klein R, Nondahl DM. Prevalence of sleep problems and quality of life in an older population. Sleep 2002;25: ) Léger D, Scheuermaier K, Philip P, Paillard M, Guilleminault C. SF-36: evaluation of quality of life in severe and mild insomniacs compared with good sleepers. Psychosom Med 2001;63: ) Tractenberg RE, Singer CM, Kaye JA. Characterizing sleep problems in persons with Alzheimer s disease and normal elderly. J Sleep Res 2006;15: ) Ohayon MM, Zulley J, Guilleminault C, Smirne S, Priest RG. How age and daytime activities are related to insomnia in the general population: consequences for older people. J Am Geriatr Soc 2001;49: ) Wong WS, Fielding R. Prevalence of insomnia among Chinese adults in Hong Kong: a population-based study. J Sleep Res 2011;20(1 Pt 1): ) Yang CK, Yoo SY, Joo YH, Hahn HM. Sleep habits and sleep disorders among the elderly between years who are living in a part of Pusan. Sleep Med Psychophysiol 1997;4: ) Yoon JS, Shin IS, Kim JM, Kang SA, Ha HW, Park IS, et al. Sleep patterns and problems of the Korean elderly in urban and rural areas. Sleep Med Res 1999;1: ) Park JH, Lee JJ, Lee SB, Huh Y, Choi EA, Youn JC, 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: ) Bae JN, Cho MJ. Development of the Korean version of the Geriatric Depression Scale and its short form among elderly psychiatric patients. J Psychosom Res 2004;57: ) Park JH, Kim KW, Kim MH, Kim MD, Kim BJ, Kim SK, et al. A nationwide survey on the prevalence and risk factors of late life depression in South Korea. J Affect Disord 2012;138: ) Alvaro PK, Roberts RM, Harris JK. A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep 2013;36: ) Baglioni C, Riemann D. Is chronic insomnia a precursor to major depression? Epidemiological and biological findings. Curr Psychiatry Rep 2012;14: ) Paudel M, Taylor BC, Ancoli-Israel S, Blackwell T, Maglione JE, Stone K, et al. Sleep disturbances and risk of depression in older men. Sleep 2013;36: ) Cho HJ, Lavretsky H, Olmstead R, Levin MJ, Oxman MN, Irwin MR. Sleep disturbance and depression recurrence in communitydwelling older adults: a prospective study. Am J Psychiatry 2008;165: ) Zammit GK, Weiner J, Damato N, Sillup GP, McMillan CA. Quality of life in people with insomnia. Sleep 1999;22 Suppl 2:S379-S ) Ryu JS, Kim MD, Lee CI, Park JH. Cognitive impairment and decreased quality of life in elderly patients with subsyndromal depression. Korean J Biol Psychiatry 2013;20: ) Yoo SW, Kim YS, Noh JS, Oh KS, Kim CH, Namkoong K, et al. Validity of Korean Version of the MINI international neuropsychiatric interview. Anxiety Mood 2006;2: ) Lee DY, Lee JH, Ju YS, Lee KU, Kim KW, Jhoo JH, et al. The prevalence of dementia in older people in an urban population of Korea: the Seoul study. J Am Geriatr Soc 2002;50: ) Han CW, Lee EJ, Iwaya T, Kataoka H, Kohzuki M. Development of the Korean version of Short-Form 36-Item Health Survey: health related QOL of healthy elderly people and elderly patients in Korea. Tohoku J Exp Med 2004;203: ) Nam BH. Testing the validity of the Korean SF-36 health survey [dissertation]. Seoul: Seoul University; ) Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychi- journal.biolpsychiatry.or.kr 79

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한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -