1999 - Subjective Quality Of Life In Female In-patients

International Journal of Social Psychiatry (1999) Vol. 45 No. 4238-246.

SUBJECTIVE QUALITY OF LIFE IN FEMALE IN-PATIENTS WITH DEPRESSION: A LONGITUDINAL STUDY

HElD! RUDOLF & STEFAN PRIEBE

SUMMARY This study investigated Subjective Quality of Life (SQOL) in 42 women with depression, 70 women with alcoholism, and 73 women with schizophrenia within 3 weeks after hospital admission. Twenty-eight of the depressive patients were re-examined after 6 months. SQOL was assessed using the German version of the Lancashire Quality of Life Profile. On average, depressive women expressed dissatisfaction with life as a whole and with 4 out of 8 life domains, and had a lower SQOL than the other two diagnostic groups. Differences remain statistically significant when the influence of age and anxiety/depression is controlled for. SQOL in depressive women improved significantly within the follow up period. Positive SQOL change was moderately correlated with an improvement of depressive symptoms. The results indicate that depressive women after hospital admission express an unusually low SQOL, which seems to have some diagnostic specificity and improves over time. Changes in depressive symptoms do not fully explain SQOL changes.

INTRODUCTION Quality of life indicators were initially used in psychiatric research for evaluating different settings and treatments for patients in long-term care. Most studies using the concept of quality of life investigated samples with severe and chronic mental illnesses. Studies in diagnostically homogeneous groups have usually focused on patients with schizophrenia. In the last 10 years, there has

-

for various reasons - been an increasing interest in examining

quality of life in other diagnostic groups. Most notably, subjective quality of life (SQOL) measures have been obtained in studies on patients with alcoholism (Haver, 1986; Beattie et al. 1993;Welshet al. 1993;Longabaughet al. 1994;Schneideret al. 1995)anddepression (Sullivan et al. 1992; Russo et al. 1997). Women with alcoholism were found to have a particularly low SQOL regarding their social network (McLachlan et al. 1979; Gomberg & Schilit,1985;Akerlind&H6mquist,1992)andtheirhealthstatus(Rudolfet al. 1996;Rudolf & Priebe, 1999). Patients with depression appear to have a lower SQOL than patients with schizophrenia (Koivumaa-Honkanenet al. 1996;Guptaet al. 1998)and with mania (Russo et al. 1997). Atkinsonet al. (1997)founda lowerSQOLin patientswithuni-polarand bi-polaraffective disorders as compared with samples with schizophrenia or physical illness, even if the former

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group had more favourable objective life circumstances. Within depressive samples SQOL is -like in other samples (e.g. Priebe et al. in press) - associated with the degree of depressive symptoms. Patients with more depressive symptoms tend to be less satisfied with their life (Sullivan et al. 1992; Pyne et al. 1997), and SQOL may improve over the course of treatment (Lonnqvist et al. 1994; Russo et al. 1997). Whilst women in the general population have often been found to have a lower SQOL than men, findings on gender differences in psychiatric patients have been inconsistent. Some studies demonstrated little or no SQOL differences between women and men with mental illness (Baker & Intagliata, 1982; Lehman, 1983, 1988; Huber etal. 1998; Meltzer etal. 1990; Levitt et al. 1990). Other studies showed significant gender differences with a more (Shtasel et al. 1992;Roder-Wanner & Priebe, 1995) or less (Briscoe, 1982) favourable SQOL in female patients. Some of the studies that failed to identify major gender differences in the degree of SQOL, found that different factors and domains may be relevant for SQOL in women and men with schizophrenia (ROder-Wanner et al. 1997, Roder-Wanner & Priebe, 1998). If SQOL measures are to be used for individual treatment planning, they may have to be assessed in the acute stages of an illness. The purpose of this study was to investigate SQOL in patients with acute depression who were homogenous not only with respect to diagnosis, but also treatment situation, Le. after hospital admission, and gender, i.e. women. We addressed two questions: 1. How is SQOL in women with depression after hospital admission as compared with women with alcoholism and schizophrenia in the same situation? 2. How does SQOL in women with depression after hospital admission change over a 6 month follow-up period? METHODS One hundred and eighty-five women between 18 and 63 years of age, who were consecutively admitted to three psychiatric hospitals in Berlin, Germany, and had a diagnosis of depression, schizophrenia or alcoholism, were interviewed within the first three weeks of admission. The diagnosis was made by the clinician psychiatrist according to ICD-lO (WHO, 1992) and confirmed by a researcher who did the interviews and was not involved in treatment. The same researcher re-interviewed the depressive patients after a 6 month follow-up. Quality of life was assessed on the Berliner Lebensqualitiitsprofil (Priebe et al. 1995), a German version of the Lancashire Quality of Life profile (Oliver et al. 1997). SQOL is rated as satisfaction with life as a whole and with life domains on 7-point Likert-type scales with 1 as the negative, and 7 as the positive extreme. Psychopathology was observer rated on the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962). In the depressive sample, symptoms were also assessed on the Hamilton Rating Scale for Depression (HAMD, Hamilton, 1960), and self-rated on the Beck Depression Inventory (BD!; Beck & Steer, 1987). Statistical analysis Differences between groups were analysed using chi2-tests, t-tests, and one-factorial analyses of variance. In analyses of variances Scheffe-tests were applied a posteriori for single

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comparisons between two groups. When comparing SQOL in the three diagnostic groups, analyses of variance were repeated with potentially influential variables as covariates. For assessing the association between psychopathology and SQOL scores, as well as SQOL changes, correlation coefficients (Pearson's r) were used. T-tests for dependent samples were used for analysing changes over time. Correlation coefficients (Pearson's r) were calculated as a measure of stability over time for psychopathology and SQOL scores. These test-retest coefficients do not reflect the stability in absolute terms, but the degree to which individuals maintain their relative position in the distribution of scores. A multiple regression analysis was calculated for predicting SQOL changes in a multivariate model.

RESULTS According to ICD-IO, depression was diagnosed in 42 women (F31 = 1, F32= 19, F33 = 20, F34.1 = 2), alcoholism in 70 women (FIO.l = 1, FIO.2= 24, FIO.3= 32, FIO.4 = 9, FIO.5 = 4), and schizophrenia in 73 women (F20.0 = 65, F22 = 1, F23 = 4, F25 = 3). Clinical and sociodemographic characteristics of the 3 groups are shown in Table 1. The three groups show significant differences in age, monthly income and partnership situation. Moreover, women with depression have a longer duration of illness as compared with the schizophrenia group, and a higher degree of depressive symptoms as compared to both other groups. Their scores on BPRS sub-scales anergia, thought disorder and hostility are lower than in the schizophrenia group. Table 2 summarises SQOL scores in the three groups. Depressive women had a significantly lower satisfaction with life as a whole, with social contacts, leisure activities and mental health than the other two groups. The mean SQOL score was also significantly less favourable. As compared with women with alcoholism, depressive patients were less satisfied with their financial situation and with accommodation. In a next step we compared SQOL in the three groups when controlling for the influence of age and BPRS sub-scale anxiety/depression. This was done because age and anxiety/ depression differed significantly between the three groups and are known to be factors of potential influence on SQOL scores. Table 3 shows which differences were statistically significant before and after controlling for the influence of age and anxiety/depression. Differences in satisfaction with social contacts and with the financial situation failed to reach statistical significance when the influence of age and anxiety/depression was controlled for. Other differences, however, including the one in the SQOL mean score remained statistically significant. Within the depressive sample, the SQOL mean score was significantly correlated with the BPRS sum score (Pearson's r: -.53, p < 0.001), with BPRS sub-scales anxiety/ depression (r: -.40, p < 0.05), activation (r: -.40, p < 0.05) and thought disorder (r: -.46, p < 0.01). Correlations with HAMD (r: -.35, p < 0.05) and BDI (r: -.44, p < 0.01) were also statistically significant indicating that a higher degree of symptoms was associated with lower satisfaction scores. At 6 month follow-up, 28 depressive women (67% of the base line sample) were re-interviewed. 14 patients either refused a second interview or could not be traced. There

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Table 1 Sociodemographic and clinical characteristics of women with depression, alcoholism and schizophrenia after hospital admission Women with depression n=42

Women with alcoholism n=70

Age (years) Job Situation Employed Unemployed Housewife Retired

41.7 :t 11.0

43.5 :t 9.7

Income (DM) State Benefits

1901 :t 980 21%

Partnership

67%

Statistics

Women with schizophrenia n=73 33.7 :t 10.5

F(2,182) = 17.6*** ns

63% 15% 14% 8%

53% 16% 16% 16%

52% 24% 7% 17%

= 3.3*

1651 :t 775 42

F(2,172)

60%

37%

X2(2,185)

36% 24% 28% 8% 4%

31% 30% 23% 9% 6%

48% 9% 14% 16% 13%

ns

Age of onset if illness (yrs) Duration of illness (years) Number of previous hospitalisations BPRS-Sum Score AnxietylDepression Anergia Activation Thought disorder Hostility HAMD

33.9 :t 12.5 7.8:t 8.6 1.2 :t 1.8

33.9 :t 10.8 9.6:t 6.5 1.8 :t 3.7

30.8 :t 9.7 3.0 :t 5.6 0.9 :t 2.5

ns F(2,179) = 17.4***a ns

35.9 :t 15.0 :t 7.2 :t 5.8 :t 404:t 3.5 :t 19.1 :t

32.2 :t 11.8 :t 7.1 :t 5.3 :t 4.5 :t 3.5 :t 11.0:t

46.9 :t 11.1 :t 9.9 :t 7.0:t 10.3 :t 8.5 :t

BD!

23.5 :t 10.2

Living Situation Alone With partner

With Partner & Children Single Parent With other

6.6 2.7 2.8 204 1.0 1.1 6.9

2030 :t 860 33%

6.8 3.7 2.9 2.1 lA 0.9 6.1

11.6 :t 6.7

*p:S; 0.05, **p :s; 0.01, ***p :s; 0.001 a posteriori single comparison (Scheff6- Test p:S; 5%): adepression alcoholism group

-

10.7 3.3 3.3 3.1 3.9 3.5

vs. schizophrenia

ns

= 12.0**

F(2,180) = 55.5*** a

F(2,180) = 18.7** ab F(2,180) = 18.1 *** a F(2,180) = 8.2*** F(2,180)

F(2,180)

= 106.9***

= 98.3***

a

a

F(l,IIO) = 40.9*** F(l,107) = 5404***

group, bdepression

vs.

were some base-line differences between the interviewed group and the drop-outs: patients who were followed up, lived less often in a partnership (57% versus 86%, chi2 (1,42): 3.4, p

= 0.06),

and they had more previous hospitalisations

(1.5 :t 2.1 versus 0.6 :t 0.7, t

= 2.0,

p = 0.05). Table 4 shows SQOL measures and psychopathology scores in the followed up group at base line and 6 months later. The table also indicates the individual stability of scores over time and the statistical significance of differences on a group level. On average, patients still showed marked depressive symptoms at follow up. Yet, the degree of observer rated and self-rated depressive symptoms was significantly lower than at base line. Other aspects of psychopathology as assessed on BPRS sub scales did not significantlychange. All SQOL scores improved. The differences were significant regarding

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OF LIFE

Table 2 Subjective quality of life in the three groups Satisfaction

with

Women

with

depression

Women with alcoholism

schizophrenia

4.0:t: 1.4 5.1 :t: 1.6 5.2:t: 1.4 4.3 :t: 1.7 5.8 :t: 1.6 4.0:t: 2.2 4.7:t: 2.0 3.8 :t: 1.7 3.2 :t: 1.5 4.5:t: 0.8

4.0 :t: 1.8 5.0 :t: 1.2 5.0 :t: 1.2 4.0 :t: 1.6 4.3 :t: 1.9 4.4 :t: 2.0 4.3 :t: 1.9 4.1 :t: 1.6 4.1 :t: 1.8 4.5:t: 0.9

2.8 :t: 1.5 4.5 :t: 1.8 4.3 :t: 1.4 3.5 :t: 1.6 4.6:t: 2.0 3.5 :t: 2.1 3.6:t: 2.2 4.1 :t: 1.7 1.9 :t: 1.1 3.6:t: 0.9

Life as whole Family Social contacts/friends Leisure Activities Accommodation Job Situation Finances Safety Mental Health SQOL mean score

Women

Statistics

with

F(2,182) ns

= 9.0***

F(2,181)

= 5.5** ab

F(2,182)

= 8.1 *** ab

F(2,182)

= 13.1 *** b

ab

ns F(2,182) = 3.5* b ns F(2,18l) = 23.5*** ab F(2,175) = 14.4*** ab

*p s 0.05, **p S 0.01, ***p S 0.001 a posteriori single comparison (Scheffe- Test p S 5%): adepression vs. schizophrenia alcoholism group

group, bdepression vs.

satisfaction with life as a whole, with leisure activities, safety, and mental health as well as in the SQOL mean score. Individual stability of self-rated depressive symptoms, of SQOL mean score and of satisfaction with some life domains was relatively high. An improvement of the SQOL mean score between base line and follow-up was significantly correlated with a reduction of scores on HAMD (r = .49, P < 0.05) and BDI (r = .54, p < 0.01) over the same period of time. BDI changes were the best predictor of SQOL changes. In a multivariate analysis, this predictive value was not increased significantly when baseline data and changes in variables other than BDI were also considered as predictors.

Table 3 Statistical

significance of SQOL differences between the three groups before and after controlling for the influence of age and anxiety/depression

Satisfaction

with

Before controlling for the influence of age and anxiety/depression

Life as a whole Family Social contacts/friends Leisure activities Accommodation Job situation Finances Safety Mental Health SQOL mean score

*p S

0.05, **p S 0.01, ***p S 0.001

*** ns ** *** *** ns * ns *** ***

After controlling for the influence of age and anxiety/depression F(2,178)

= 3.6*

ns ns F(2,178) F(2,178)

= 3.8* = 6.4**

ns ns ns F(2,178) = 13.4*** F(2,l72) = 5.2**

243

H. RUDOLF & S. PRIEBE Table 4 Psychopathology and SQOL in depressive women after hospital admission and six months later (including stability of individual score over time) Baseline

Follow-up

t(27)

Stability

BPRS-Sum score Anxiety/depression Anergia Activation Thought disorder Hostility HAMD BDI

35.5 :t 14.7 :t 7.3 :t 5.6 :t 4.3 :t 304:t 19.0:t 23.6 :t

5.7 2.8 2.5 2.1 0.7 1.2 6.7 11.5

33.6 :t 13.5 :t 7.0:t 5.2 :t 4.3 :t 3.7 :t 15.6 :t 18.0:t

5.7 3.0 2.9 1.9 0.6 1.6 6.5 11.8

1.5 2.0* 0.5 1.0 004 0.8 2.3* 2.9**

33ns .44* .3lns .32ns .16ns .40* .32ns .66***

Satisfaction with: Life as a whole Family Social contacts/friends Leisure activities Accommodation Job situation Finances Safety Mental health SQOL mean score

2.7 :t 4.6 :t 4.3 :t 3.2 :t 4.3 :t 3.3 :t 3.4 :t 3.9 :t 1.9 :t 3.5 :t

1.5 1.8 1.3 1.5 2.1 1.9 2.1 1.7 1.2 0.9

3.9 :t 4.8 :t 4.8 :t 4.0 :t 4.7 :t 3.8 :t 3.7 :t 4.6:t 3.5 :t 4.2 :t

1.6 1.7 1.2 1.2 2.0 2.0 1.9 lA 1.9 0.9

4.2*** 0.6 1.9 2.6 lA 1.0 1.0 3.5* 4.7*** 4.9***

.54** .74*** .52** .31 ns .69*** .22ns .64*** .32ns 048* .67***

*p s; 0.05. **p s; 0.01. ***p s; 0.001

DISCUSSION Women with depression expressed a low SQOL in this study. Their SQOL scores were clearly less favourable than those of the other two groups in the same treatment situation. Moreover, 5 out of 9 satisfaction scores, those with life as a whole, leisure activities, job situation, finances and mental health, indicated an explicit dissatisfaction on a group level. This is unusual since average scores of most samples in the general population or in patient groups are in the positive range, and since it usually is only the degree of satisfaction that distinguishes between groups or varies over time. The average SQOL of depressive women found at base line in this study, is one of the lowest reported in the literature using similar assessmentmethods (Priebe et at. 1999). Finances, leisure activities and job situation can be seenas related life domains, because a sufficiently paid job may provide the money for doing enjoyable leisure activities. The dissatisfaction in these areas is not explained by a particularly high percentage of unemployed patients or by an extremely low income. The findingsare consistent with other reports in the literature (Atkinson et at. 1997) and suggest that depressive women tend to assess objective circumstances in a specifically negative way, because of higher expectations and aspirations or due to unfavourable comparisons with other people and with their own past. SQOL scores in the other two groups were also relatively low although clearly higher than in the depressive group

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indicating that hospital admission with all the preceding events

might pose a crisis situation in which patients appraise their life particularly negatively (Priebe et al. in press). The significant improvement of SQOL scores in the follow up period would be consistent with that assumption.

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Numerous studies have reported that a higher degree of depressive symptoms is associated with lower SQOL scores (e.g. Sullivan et al. 1992, Pyne et al. 1997). Thus, it is not surprising that a similar correlation was found for depressive women in this study. However, it appears striking that SQOL differences between the diagnostic groups remained statistically significant when the influence of depressive symptoms

-

and age

-

was controlled

for, suggesting that lower SQOL in depressive women was not due to a higher degree of depressive symptoms. There are several possible explanations for this: the BPRS sub scale anxiety/depression might be an insufficient measure for capturing those depressive symptoms, which are most influential for SQOL ratings. Alternatively, one might argue that it is not only the quantitative degree of depressive symptoms, but rather their qualitative nature that is relevant for satisfaction ratings. Patients with depression might have underlying depressive cognitions that are not shared by alcoholism or schizophrenia patients with depressive symptoms, but that do determine a particularly negative assessment of their life. One might also speculate as to whether depressive women experience hospital admission differently than the other two groups and respond with a more negative view of their life. The results suggest that diagnosis is a relevant feature associated with SQOL ratings. Diagnosis should, therefore, be assessed in studies using SQOL scores and considered a relevant factor, the influence of which should be controlled for. This applies as long as the precise mediating factors explaining the association between diagnosis and SQOL are not fully understood and can, therefore, not be exactly measured. A diagnostic classification seems necessary in addition to an assessment of depressive symptoms. Depressive patients' SQOL did improve within the 6 month follow-up. This change on the group level was accompanied by some individual stability of ratings over time. The findings underline that SQOL ratings are sensitive to change and may be used as outcome criteria in studies evaluating treatment of depression (Lonnqvist et al. 1994, Russo et al. 1997, Priebe et al. 1999). In line with the results of other studies, a positive change in SQOL was associated with an improvement of depressive symptoms. The correlations were statistically significant and substantial in size. Changes in depressive symptoms were the best predictor for SQOL changes explaining approximately 30% of the variance. This confirms the importance of depressive symptoms for SQOL changes, but also indicates that improvement in SQOL is not just an epiphenomenon of positive changes in depression. This study demonstrated a very low SQOL in depressive women after hospital admission which is not explained by the degree of depressive symptoms as assessed in the study. Moreover, it showed an improvement of SQOL within a 6 month follow-up period which was moderately correlated with an improvement of depressive symptoms. The study had a naturalistic design, and further experimental studies should be conducted to identify which therapeutic interventions have the most positive effect on both depressive symptoms and SQOL. Moreover, future studies might establish in which way individual SQOL ratings can be used for designing specifically beneficial psychosocial interventions in depressive women. REFERENCES AKERLIND, I. & HORNQUIST, 1.0. (1992) Loneliness and alcohol abuse: A review of evidences of an interplay. Social Science and Medicine, 34, 405-414.

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Heidi Rudolf, Pauwelsstrasse

PhD, Research Fellow, Clinic for Psychiatry 30, 52074 Aachen, Germany

and Psychotherapy,

University

Hospital

Aachen,

Stefan Priebe, MD, Professor of Social and Community Psychiatry, St Bartholomew's and the Royal London School of Medicine and Dentistry, Queen Mary & Westfield College. University of London, UK Correspondence

to Dr. Rudolf.