RESEARCH
Quality of life and functional impairment among depressive patients in a psychiatric outpatient setting in India
R Sreevani, K Reddemma1
M Sc in Psychiatric Nursing, Prof and HOD, Dept of Psychiatric Nursing, Sri Devaraj Urs College of Nursing, Tamaka, Kolar, 1Ph D in Nursing, Prof and HOD, Dept of Nursing, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
Abstract
Background: Major depression is an important public health problem associated with high levels of disability, impairment of quality of life and decreased work performance. Depressive disorder negatively impacts different aspects of an individual’s life leading to grave impairments in quality of life (QOL). This study analyses the interaction between depressive symptom severity, functional impairment and QOL in outpatients with depressive disorder.
Materials and methods: This cross-sectional study was conducted with 100 consecutive outpatients seeking treatment for depressive disorder at an urban hospital-based outpatient clinic from January to August 2010. This study utilises the following measures: (a) Depressive symptom severity: Beck Depression Inventory II (BDI II); (b) Functional impairment: Work and Social Adjustment Scale (WSAS); (c) QOL measure: World Health Organization QOL BREF instrument (WHO QOL BREF).
Results: QOL is significantly impaired in severely depressed patients. Depression is negatively correlated with QOL and positively correlated with functional impairment.
Conclusion: The results suggest the need to utilise not only symptom severity scales, but also functional impairment and QOL measures in the assessment and treatment of depressive patients.
Sreevani R, Reddemma K. Quality of life and functional impairment among depressive patients in a psychiatric outpatient setting in India. Dysphrenia. 2013;4:132-7.
Keywords: Disability. Antidepressant. Age. Residence. Sex.
Correspondence: sreevani.phd@gmail.com, ambati.giri@gmail.com
Received on 24 December 2012. Accepted on 2 February 2013.
Introduction
In a study of 160 patients diagnosed with organic mental disorders, seizure disorder represented maximum number of cases.[1] Among 70% patients with epilepsy, causative factors are head trauma, malformation of brain, brain tumours, stroke, cerebral haemorrhage, lack of oxygen during birth, encephalitis, post encephalitic sequelae, or other physical and chemical insult.[2] High proportions of post encephalitis sequelae are resistant to medical treatment. The possible underlying causes can be (i) decrease numbers of gamma aminobutyric acid (GABA)-ergic neurons, (ii) increase secretion of glutamate in degenerative area of brain, (ii) changes in intrinsic properties of aberrant neurons, and (iv) aberrant connection of degenerative neurons have high propensity to develops epilepsy. Higher metabolism of diseased area in brain is related to continuous epileptic activity.[3] About 30% of patients do not become seizure free with antiepileptic drug (AED) therapy and are considered refractory or drug resistant patients.
Major depressive disorder (MDD) is the fourth leading disease causing functional impairment, disability and workforce loss worldwide.[1] Considering that the life-long prevalence of depression is between 16 and 20%,[2] MDD is expected to be the most frequent cause of work absenteeism[3] among psychiatric diseases. Moreover, predicting the further increase in this ratio, the World Health Organization (WHO) has reported that in 2020 MDD will be the second after ischaemic heart diseases among diseases that lead to disability.[4,5]
Psychiatric illnesses are strongly associated with impairment in quality of life (QOL), frequently at levels that are equal to or exceed those of medical illnesses.[6] MDD negatively impacts a myriad of facets of an individual’s life including functioning, satisfaction with work, relationships, leisure, physical health, sexual functioning, sleep patterns, future outlook and overall sense of fulfillment or contentment with one’s life.[7] Studies have demonstrated that patients with MDD have significant impairments in QOL.[6-9] An analysis from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study revealed that severity of depressive symptoms was significantly associated with poor health-related QOL.[10] Rapaport et al.[11] demonstrated significant impairments in QOL in subjects with a broad array of different depressive and anxiety disorders entering clinical trials.
Depression, a common and debilitating condition, is negatively influencing QOL of patients such as functioning by affecting psychological, physical and social areas of life and has been the object of intense research over the last few years.[7] Several studies have investigated these aspects in recent years. A large study of 25 916 primary care patients from several countries revealed that patients with major depression reported higher levels of disability than those without depression.[12] In a different study carried out in Europe, Lepine et al.[13] found that the degree of disability was related to severity of depression in patients with MDD.
Despite the extensive literature investigating QOL in psychiatric disorders, a detailed examination is needed for the interaction between depressive symptom severity, functional impairment and QOL in treatment seeking outpatients with depressive disorder. The aim of this study is to investigate the relationship between symptom severity, functional impairment and QOL among depressive patients.
Material and methods
Subjects
The sample comprised of 100 depressive patients, who were recruited from the outpatient department of psychiatry at Sri Narasimha Raja (SNR) District Hospital, Kolar, Karnataka, India. Inclusion criteria were: (a) diagnosed with depressive disorder according to International Classification of Diseases, Tenth Revision (ICD-10); (b) aged between 20 to 40 years; (c) recommended antidepressant treatment by the treating psychiatrist. Subjects with psychotic symptoms, severe life threatening illnesses, or current drug or alcohol related disorders were excluded.
Assessment
Data was collected on the basis of a single cross-sectional interview of the subjects who fulfilled the inclusion, exclusion criteria and provided written informed consent. Subjects were free to withdraw from the study at any time for any reason. All consenting adults who fulfilled the inclusion criteria were administered the sociodemographic proforma, Beck Depression Inventory II (BDI II), Work and Social Adjustment Scale (WSAS) and WHO QOL BREF scale.
Sociodemographic proforma: It includes questions on their age, gender, marital status, occupation, religion, type of family, area of residence, mean monthly income, suicidal attempts, previous depressive episodes and mean duration of present illness.
BDI II: This scale was developed by Aaron T Beck, a self-administered four point Likert scale containing 21-items, designed to assess the severity of the symptoms of depression. Statement denotes symptom severity along with an ordinal continuum from absent (scored as zero) or mild (scored as one) to severe (scored as three). The responses are summed to determine possible scores ranging from zero to 63, with higher scores indicating a greater level of symptoms. The total scores of the BDI II classify as four levels of depression: zero to 13=minimal depression; 14–19=mild; 20–28=moderate; 29–63=severe depression. In Indian studies, the BDI indicated high internal consistency (Cronbach’s alpha 0.96).[14]
WSAS: It is a self-report scale of functional impairment. It was developed by James C Mundt, Isaac M Marks, M Katherine Shear, John M Greist. It comprises five questions on a zero to eight scale. Cronbach’s measure of internal scale consistency ranged from 0.70 to 0.94. Test-retest correlation was 0.73. The range of the total score is zero to 40, with lower scores indicating higher functioning. A WSAS score >20 suggests at least moderately severe functional impairment. Scores between ten and 20 indicate measurable functional impairment but less severe clinical symptomatology.[15]
WHO QOL BREF: QOL assessment was done with WHO QOL BREF Kannada version. This scale was chosen because it is a generic scale, developed simultaneously in 15 field centres around the world (India was one of the participating countries). It is a subjective assessment for adults with a reading age of eight years and above and can be completed with interviewer assistance. This 26-item self-administered scale measures four domains of QOL. They are physical health (item nos. 3, 4, 10, 15-18) psychological health (item nos. 5-7, 11, 19, 26), environment (item nos. 8, 9, 12-14, 23-25) and social relationships (item nos. 20-22). Item numbers 1 (QOL) and 2 (QOL) reflect a general factor named ‘general wellbeing’ which is not considered a specific domain. The items are scored from one to five with total scores ranging from 26 to 130, higher scores indicating better QOL in each domain and in total score. The psychometric properties of WHO QOL BREF have been found to be comparable with those of the full version of WHO QOL 100. High correlation of domain scores (0.89 or above) for the two scales has been obtained using a four domain structure. This scale has shown good discriminant validity, content validity, internal consistency and test-retest reliability.[16]
Statistical analysis
Statistical Product and Service Solutions (SPSS) software (version 15) was used to analyse the data. Descriptive statistics were used for all variables. Pearson’s analysis was used for the correlation between depressive scores, functional impairment and QOL scores. QOL and functional impairment score of mild, moderate and severe patients were compared using analysis of variance (ANOVA) test. Quantitative data are represented as the mean±standard deviation (SD) and the level of significance was accepted as p<0.05.
Results
Demographic and clinical characteristics of the study sample
The demographic and clinical characteristics of the study population are presented in Table 1. Mean age of the sample was 30.21±7.49 years. Subjects were predominantly women (60%). Sixty two percent of the subjects were married, majority (78%) belonged to Hindu religion. The largest proportion (85%) of participants belonged to nuclear family. More than half of the subjects (64%) were residing in rural area. Half of the sample was employed. Mean monthly income of the sample was Rs. 6120±4077.80. Eleven per cent of the sample had a history of suicidal attempts. A quarter (25%) of the population suffered with at least one previous episode of depression. Mean duration of present illness was 11.88±8.45 months. Mean depressive scores of the subjects was 29.58±11.71 indicating moderate to severe level of depression, nearly half of the sample (48%) was suffering with severe depressive symptoms. The mean functional impairment was 30.33±8.88 suggestive of major functional impairment. The mean QOL scores were 64.83±12.06.
aSeverity of depression level is determined by Beck Depression Inventory II (BDI II) scale cutoff points according to Beck et al.[13] as follows: zero to 13=minimal depression; 14–19=mild; 20–28=moderate; 29–63=severe depression.
bLevel of functional impairment is determined by Work and Social Adjustment Scale (WSAS). WSAS score >20 suggests at least moderately severe functional impairment. Scores between ten and 20 indicate measurable functional impairment but less severe clinical symptomatology.[15]
Impact of demographic factors on functional impairment and QOL among depressive patients
Table 2 describes impact of demographic factors on depression, functional impairment and QOL scores. Twenty to 30 years age group subjects have significantly higher depressive scores and lower QOL scores compared to 31-40 years age group depressive subjects (p<0.05). Subjects residing in rural area had significantly higher depressive scores compared to subjects residing in urban area (p<0.05). Subjects with no previous history of depressive episode have significantly lower depressive scores than who had previous depressive episode (p<0.001). Results showed no statistically significant differences in mean outcome measures among sex, categories of marital status, religion, occupation, history of suicidal attempts and type of family measures.
Impact of depressive symptom severity on QOL and functional impairment
There were statistically significant differences in mean QOL scores between all of the various groups of depression severity (Table 3). The mean QOL score for patients in minimum to mild depression was 77.26 (SD=67.62) as compared to 57.19 (SD=11.06) in moderate and 9.64 (SD=7.32) in severe depression. QOL scores decreased as severity of depression increased. There were statistically significant differences in mean functional impairment scores between all of the various groups of depression severity. The mean functional impairment scores for patients in minimum to mild depression was 26.30 (SD=9.33) as compared to 27.45 (SD=8.55) in moderate depression and 34.00 (SD=7.40) in
|
Table 1. Demographic and clinical characteristics of the study population (total n=100) |
|
|
Characteristics |
Nos./ Mean±SD/n |
|
Age in years Women Marital status - Single/Separated/Widow - Married Religion - Hindu - Muslim Type of family - Nuclear - Joint Area of residence - Urban - Rural Occupation - Employed - Unemployed Monthly income in rupees Suicidal attempts - Yes - No Previous depressive episodes - Yes - No Duration of present illness in months Depressive scores Level of depressiona - Minimum to mild - Moderate - Severe Functional impairment score Level of functional impairmentb - Major functional impairment - Significant functional impairment Quality of life score |
30.21±7.49 60
38 62
78 22
85 15
36 64
50 50 6 120.00±4 077.80
11 89
25 75 11.88±8.45 29.58±11.71
23 29 48 30.33±8.88
80 20 64.83±12.06 |
|
SD=standard deviation. |
|
|
Table 2. Impact of demographic factors on depression, functional impairment and quality of life scores among depressive patients (total n=100) |
|||||||||
|
Characteristic |
Depression scores |
Functional impairment scores |
Quality of life scores |
||||||
|
Mean±SD |
t |
p |
Mean±SD |
t |
p |
Mean±SD |
t |
p |
|
|
Age 20 - 30 (51) 31 - 40 (49) |
31.86±10.99 27.20±12.07 |
2.02 |
.046* |
31.25±8.93 29.37±8.81 |
1.06 |
.290 |
62.04±11.41 67.73±12.14 |
-2.42 |
.017* |
|
Gender Males (40) Females (60) |
28.60±9.95 30.23±12.79 |
-.716 |
.476 |
30.35±8.62 30.32±9.12 |
.018 |
.985 |
64.08±11.70 65.33±12.37 |
-.509 |
.612 |
|
Marital status Single/Separated/ Widow (38) Married (62) |
28.35±9.15 30.48±13.02 |
-.954 |
.343 |
29.78±8.90 30.79±8.92 |
-.544 |
.588 |
65.38±12.59 64.34±11.84 |
.413 |
.681 |
|
Religion Hindu (78) Muslim (22) |
29.99±11.76 28.14±11.67 |
.653 |
.515 |
29.71±9.41 32.55±6.31 |
-1.655 |
.104 |
64.85±12.43 64.77±10.91 |
.025 |
.980 |
|
Type of family Nuclear (85) Joint (15) |
29.95±11.78 27.47±11.44 |
.757 |
.451 |
30.00±9.04 32.20±7.90 |
-.884 |
.379 |
64.75±11.54 65.27±15.14 |
-.151 |
.880 |
|
Area of residence Urban (36) Rural (64) |
26.50±12.22 31.31±11.14 |
-2.00 |
.048* |
30.54±8.90 30.20±8.92 |
.190 |
.850 |
67.00±13.34 63.61±11.20 |
1.355 |
.178 |
|
Occupation Employed (50) Unemployed (50) |
28.48±11.86 30.68±11.57 |
.939 |
.350 |
29.12±9.05 31.54±8.62 |
1.369 |
.174 |
65.72±11.76 63.94±12.40 |
-.736 |
.463 |
|
Suicidal attempts - Yes (11) - No (89) |
35.80±11.80 29.30±11.50 |
-1.79 |
.077 |
34.36±7.00 29.83±8.99 |
-1.61 |
.110 |
59.70±9.13 65.50±12.30 |
1.50 |
.138 |
|
Previous depressive episodes - Yes (25) - No (75) |
36.84±10.99 27.69±10.96 |
-3.61 |
.001** |
33.00±7.40 29.44±9.19 |
-1.76 |
.082 |
62.92±11.58 65.47±12.22 |
.914 |
.363 |
|
SD=standard deviation. *Significant at 0.05 level, **Significant at 0.001 level. |
|||||||||
severe depression. Functional impairment scores increased as severity of depression increased.
The relationship between depression, functional impairment and QOL in depressive disorder patients
Pearson’s correlation was calculated to examine the relationships between the depressive scores, functional impairment scores and QOL scores (Table 4). The depressive scores and functional impairment scores were positively correlated (r=.417), indicating that as the depressive scores increased functional impairment scores also increased. QOL scores were negatively correlated with depressive scores and functional impairment scores (r=-.688 and -.528), indicating that as severity of depression increased QOL decreased; and also as the functional impairment increased QOL decreased.
Discussion
The present study carried out among 100 treatment seeking depressive patients in psychiatric outpatient department. Subjects were assessed by using BDI II, WSAS and QOL scales. In general, the patients were moderately depressed and had major functional impairment and poor QOL scores. QOL is significantly impaired in severely depressed patients. Depression is negatively correlated with QOL and positively correlated with functional impairment. The present study indicates that depressive patients experience a poorer QOL and major functional impairment.
|
Table 3. Relationship between level of depression with functional impairment and quality of life among depressive patients (total n=100) |
||||||||
|
Variable |
Level of depression |
F |
‘p’ |
|||||
|
Min-Mild (n=23) |
Moderate (n=29) |
Severe (n=48) |
||||||
|
Mean |
SD |
Mean |
SD |
Mean |
SD |
|||
|
Quality of life |
77.26 |
67.62 |
57.19 |
11.06 |
9.64 |
7.32 |
40.86 |
.001 |
|
Functional impairment |
26.30 |
9.33 |
27.45 |
8.55 |
34.00 |
7.40 |
9.35 |
.001 |
|
SD=standard deviation. |
||||||||
Goldney et al.,[17] studying a large sample of the Australianpopulation, found that all the dimensions of QOL, as measured by the 36-item Medical Outcome Short-Form Health Survey (SF-36), were poorer among patients with depression with respect to the non-depressed general population, with the poorest level reached by patients with major depression. Data indicating that the severity of
|
Table 4. Correlation between depression, quality of life, and functional impairment among depressive patients (total n=100) |
|||
|
Variables |
Depression |
Functional impairment |
Quality of life |
|
Depression |
1 |
|
|
|
Functional impairment |
.417* |
1 |
|
|
Quality of life |
-.688* |
-.528* |
1 |
|
*Correlation is significant at the .001 level (2-tailed). |
|||
depression was significant in negatively influencing QOL of patients has been confirmed by Trompenaars et al.,[18] who showed lower levels of QOL among patients with major depression with respect to those with dysthymia and adjustment disorders.
The present study findings are consistent with other studies showing significant impairment of QOL in MDD patients such as STAR*D trial,[10] the European Factors Influencing Depression Endpoints Research (FINDER) study[19] and another International six country study.[20] The literature investigating potential sex differences in MDD are quite extensive, but the literature investigating differences in QOL is sparse.[21] In the present study no differences in the measurement of QOL or functional impairment are based on sex.
Limitations
There are several limitations in this study. First, the sample size is small. In addition, QOL and functional impairment measures were self-reported. This study did not include a control group, for example a group of general population to compare QOL and functional impairment. This study observed that patients had poor QOL and severe functional impairment; a long observation period might be needed to assess whether these patients may reach to general population norms after treatment with antidepressants. Finally, this study used a sample of convenience of individuals who had consented to participate in the study. However, in spite of these limitations, the main results seem to be clear and relevant.
Conclusion
Patients who are suffering with severe depression will have poor QOL and severe functional impairment. However, replication of the findings of this study in larger and cross-cultural samples is required. The results suggested the need to consider not only symptom severity, but also functional impairment and QOL measures in the assessment and treatment of depressive patients.
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