2002 - Subjective Quality Of Life And Depressive Symptoms In Women With Alcoholism During Detoxification Treatment

DRUE dnd^ALC(HU(@ DEENIEIE,E ELSEVIER

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Subjectivequality of life and depressive symptomsin womenwith alcoholismdurins detoxificationtreatment Heidi Rudolf " *. Stel'anPriebeb ' Ih..dat rhnln.t stih|ry. 1li.d".t:txt\s. 2. 1s181 ,|h.rr an n.r tuhr, G(r,wt\ r' St Rdrlholant\'s dnl Rordl Lanlan S'haal ot MAnm ,l Dutti!l\'. .f t..nln,. I rntun. I:K Quan Mutt d,tl tr'ltlficltt C.t.Et, I.inrir Reer\ed :8 November:000: rccepled:0 Jul) l00l

T|e stndy investieat.dwhclhcr subjcclivcqualil) of lilc (SQOL) diffcrs in alcoholic{,oncn wilh and without depre$ive symplomsbcirg in dctoxiication treatment.Mofcorcr. wc tcsrcd *hclhcr dcpressiveslmptoms were cdfelated irith otber subjeltire claluarion crireria.SQOI. nnd psychoparhology sere obkined in r0 aicoholicwofren during fteatment.Alcoholic woDrenrvith deprcssive s)nptoms showeda bwer SQOI- rcgardingsc!€rallilc dohanrs.in particnlartheir inmily situalion.and life as a whole Addiltunall). they retorted more needsl-or suppon and more negatileconsequerces of rlcoholi$. Thc fiDdings underlinerhe rclevanceof qualiq of lifc mtings iI dctoxilic.tion trc.tmcnt rtrd ihci lssocidliof rvi(h dc!.es\i!e slmptons o 2002Elsclicr Scicncclreland I td. All .ights rcscrlcd. (.Ln,L1\ subjecrr!e qualil] .l llir

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l. Introduction Alcoholismoften occuN alongsidcothcr ncntal dis eases.e.g. anxiety disordcr. dcprcssionor pefsoDalilr.| disodcr {sccrelie$ in Wcllcrlurg(1999)).Elpccialll in womcn. alcohol dcpcndenc],is frequenll) associaled $ith depression.Both fomrs, alcohol use as a consequenceof a depressi\€disorder (primary depression) and depressionoccurringlviih pre-exisringalcoholism (secondarJdepression) halc bccDlbund in scvcfalsrud' ies (Halcr and Dahlgrcn. 1995).Dcprcssivccomorbid ity rn alcoholicwomcnhasbeenreporledlo rangc liom 25 to 66N,(Schuckir.1986).The tiguresvary depending on how depressivesympromshave beentlssessed. e.g. $ \ ( r h L r a r i r ' !. ( r l < . , ' r J i r g r r ^ l r \J l . , * i 5 ( a r i o\n) , rcrr, hn!e hc(r ,r..J Denresiolanneir. r^ hc t. fl ru larly common durxrg and following detoxification (Beck et al.. 1993;Behar et a1.. 1984;Turnbull and Gomber-q, 1988). NC l r r e \ p o n d n gr u t b o r .T e l . + 1 9 1 0 8 4 8 . 1 1 1 5l5i r: : + J 9 1 0 8 l,arl

a/.t.$r [.idi rudolf,i.tlonlinede (H. Rndoll)

Various nudics inlcsligaled rhe prognosdc significance of depressionin alcoholism with inconclusi!c lindnrg!.Sonicsludiesreporledlower relapseratesand a more favourableoutcon€ for depressive fenalc alco holics (Kmnzler ei al. 1996:Rounlaville el al.. 1987) and cspcciall) lbr wonien with a primary depressive disorder (Schuckitrnd Winokur. 1972).Ye!. ,n olhcr studiesa depreslioDdiso.dcr in ,ilcoholism$as correlalcd wilh a higher propensityto return to drinking (Greenfieldet a1..1998:Miller er al.. 1996).Morcovcr. rclap!c! ollcn appcarcharrcterisedby a neganle mood and an occurrenceof depressive symptoms(Connorset a1.,1998). Thcrc is .t growing interestin investigatingalcoholic patients-viewsand subjeciivecritefia both a\ rnodcrat nrg lari.rblcsfor outcomeand as an outcomecritenon in iheir own right (Beattieei al.. 1993:Longabaughct al.. 1994).Subjectiveeval ation criteria direcrlymirfor starementsby pati€ntsand can be usedibr evalualing (drc rpflebeer at.. aoi. toqSrTh..rrrnrr..;rngrm1.ranccrellecls\!idespreadcallsfor userinvolvemeniand a partnershipmodel of carc iu which !icw! ol pa licnls and not onlr- thoseof cliniciansand experrs are taken seriouslvand consideredas relerant.

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A high degreeof depressionseenNcorrelated$ith a 1owsubjectirequality oflife (SQOL; P,\neet rl.. 1997; Sullilan et al.. 1992).The family. ffiendships.leisure activitiesand mental health .rre domrins. ihere especiall] alcoholic lvomen report problemsor thal rhev assess as haling a lo$ SQOL (Akeflind and H.irnquist. 1992;Gombergand Schilii.1985:Rudolf et al., 1996). In our own sludy.rhe struciureof SQOL wasr suitable critcdon lbr separatinganrorg alcoholi! wonen. Dif' lcrcnt prolllcs d SQOL of four subgroups{crc co.rc lared with different forms of the objccrilc living-situation.$ith the degreeof ps,lchoprthologl and $ith ihe clinical prognosis(Rudolf and Priebe. 1999a). This papcr rcpor!5!hc dcgrccol dcprcssi!cs!Dlptoms in alcoholicrvomcnand its .rssocialidrwilh SQOL aDd other subjectiveelaluation criteria.i.e. selt'-raled sr-mp toms. needsfor support and vie$s on the effeds of driDking. Based on the litc.aturc, one lrlay e)tpecta gcncralh lowcr SQOL litr alcoholic women wirh marked dcprcssilcs,""mpton]s. Ycl. i1 is lcss slcar prc cisell rhar lilc donrnrs alcoholic$omcn rlith doprc! sion arc lcsssalislledwilh aDdwhclhcf they diiltr liom Don dcprcss{jd pa!icn!! in mbjcctivccrilcria other than SQOL as wcll. Thc rclalion!lip bclwcclr dcprcssive symplomalolog), on lhc one h,rndand SQOL and other subjeciivee\alualion criteria on the orhcr i\ lubjcct ol thrs paper.

2. N{ethod ).1. Subi(r!.' Thc lubjecis lvere 70 alcdroli! women bet\reen:3 and 6:l ,""cars ol agljwho wcrc consccutirelradmittedio thrcc holpilals in Bsrlin. Ccrmanr-.lbr detorilicaiion lionl alcohol.Thc diagDosiswas nradcb) the clinician pslchiatrisl accordingro ICD-ll) (World Hcalth Org.l nization. 1992).Women who fulfilled lhc crilcria ol F10.2 of ICD-10 were first approached br- thcir doctor and asked fof participation in the sludy. In case ih€y agreed, thel were contacied by a researcher.Paficiparion or noD-participationdid not havean,"-effectson the treatnrentthe patienisreceiled. Inlbrmcd conscntwa! obtaincd lion dll patients.The inlcrvicwed during llrc sccond wcck " . r e r . , l m i . . i o n b ) . , r e . e a r ( h e$rh o \ a . n ' r r l volled in ireatment,and none of the informatlon as in the intcrlicw! was passcdon to the treat a$scs$cd ncnl !c.m. This was n naluralinic study and all rvomenlool parl in thc routinc lrcirtmcnl progfamme of the gjven hospitrl. The inpatient trcahcnt pro grammefor addiction in the selectedhospiralsusuall] lastedI weeksand includedphysicalwithdrawal.sporl and sociotherapeuticaciivities. and participation in

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meetingsof the .rlcoholicsanonymous.Treatnent Iocussedon ph]sical rvithdrawal.If fufiher lreaimentlor depressionor anolher menial disorder .|ras neecled. -( (rr(d ..' .fe.ifr ort. .'e|L nariefr' \(re trngrammesfollo\,!hg hospitalisationsuch rs individual

Ps!choparhdogjcals)mptoms wcrc rLlcd oD !hc HamiltonDcp.clrjionScalc(HAMD: Halnilton.l9fd)l and the Brief PsychiatricRaling Scale(BPRS:Overall and Gorhan, 1962)b-vthe intervje$er,r researchps-vchologisi rvith clinical qu.rlification$ho Nas trained rnd experienced in applyingthe rssessnentscales.Depressile symptoms were assessedreg.rrdle\! of their Thi5wasbcciuscNc aimcdat diignosticclassilicrlioli. in\csligalingthc rolc ol dcprc\si\cslnploms \.\ilhout limitrrion as serb,\ the conceptsof cxrrent nosological iypoiogy. tof distinguishingbet$eenalcoholrc$omen with and withoui depressileslmptoms $e used.r cuioll poinr of 11 on the H,A.IUD.A IIAMD scorcof 1l or higher is to be considefed.rs .r mod€ratedegreeof groups are depressives)mploms .rnd non-depressive assumedro show a scofe of ten or lolver (Robbins e1 al.. 1985).Thi$-two \lomen were classiliedas belorginr to tbe non-deprcssilcgfoup ( ND : IIAMD < l0). 18 worncn 1(r lhc dcp.cssilc group l'D: H A N { D> l l ) . i Q r , l \ 1 . . \ 1 n r r . J r ' r r ! . r . ( ' . 1 n o r\ f r . r o f (Berliner Lebensqualitiitsprofil; Priebeet al.. i995) of ihe LancashireQualit,vof Lil-e-Pfofile(Oliver. 1991: Olilcr e1 al.. l99l). TD the BerlincfLebcnlqualita! sprolil.SQOL is r.tlcd as s.ttislaclion$i1h life in general and \rith difi-erentlife domains:family, sociri relations, l , e " l r hl .e i , I e r c . ' ! i r i e .J. i n . . , c e\ so.f k . i ' i n ! . ' , U : , r i o n r n d : e c u r i r \s i r i . t u . r i o Ii . r a r e db \ r h ep " . i e n . o. r . l Liker'l] pe-scale rnngxrgfrom one (mostxnsatisfied)to selen (nost satisfied)$ith four being ihe n€utral nrid dlc point. Seleralsludiesusingthe BerlinerI-ebensqual itril\prolil dcnrorstrulcdSQOI- as a suit,rblccralualion crirerion distinguishingbc!sccn dillcrcn1 diagnoslics groupsof menrallyill patients{Kaiseret al.. 1997: Priebeet a1.. 1998;Rdder-wanner and Priebe. 1995: Rudoli and Priebe.1999b). Self-ratedsymptoms$ere obtainedon the tseckDepressionInventory(BDI: Beck and Steer.1987)and the Von ZcfsscnComplaiDts Chccklist(BLi CIPS. 1986). Needs$ere sell'-ratedon rhe Berlin NeedsAssessmenl Schedule.which obrains paiients vieq on their needs for help or support m 16 domanrs (Hoffmann and Priebe.1996:Priebeet al.. 1998). IllDess and ireatneni'relared data lverc assessed iDtcr\icw.TDaddition.thc $olncn lhrougha structurcd \\crc askcdabou! thcir subicclivc!ic$ on posililc and negati!easteclsof lheir drinking.

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2.3. Stdtitti(trl dnaltsit Conprisons bcl{een the txo group! (womenrrthout and siih dcprcssiles,vnpromi) wcrc nade uslng 7r-rests.r tcstsand non-paramel.iclosts(Mann whltner. M W). Pearsoncofr€latiolrssere calculatedfof .rDaly\ingrhe relationshipbct{ccn SQOL and soctod.'mographic and clirical dala. A discrinlnanl anal,rsrs $as carriedout for separalmgrhe depressileand non dcpressilegroup br SQOL ralirgs.

3. Rcsults Table I sho\rs the sociodcnographicrnd clinical ol the t$o groups.Depresslveand non ch:rraclerislics depressive $omen dillcrcd onl] in a fe\Lvariablcs:Thc quallliwomcnhad a bettefprolissional non-depressi'e calion. mon ol lhem reportcd ha\n]g lilends. The $onrcn sirh depressi\,e s,rnlplomshad beenhospilalised lbr $ilhdrawal mofe frcqucnll) and had more selere gcncral psychopathology.Thcsc differencesdrd not hdd allcf Bonltroni adjustnent. Dcprcssileand ronJ < f ( , r \ c \ o r r . n d i | l e r e n. r< | | h rIrn J p e, r ro n . e r u f i l duralioi ol alcoholism. Thc rcsuhsof the discrimnrant.tnalysisaccordingto

thc 1$o groups sho$ lhc largest dillercncc berween rn satrss-r'mptoms $omcn sith and $ithorl| dcpressl\'e faclion rlilh rheir tumilr".Faclor loading ]s .rboul | = 0.83 (Trblc l). Oihef donrins of SQOL {hich dislinguishedbetweenthe 1$o groups are soci.rlrclariolls. nental he.rlrh.lili ill ge eral and leisurcactrvrtics. wonen $ithoul dcpressllesymptom! rq)oried :r highcr SQOL in most d the raied domajns. SQOL rarings alone cone!tl,"-classit',\7,1%of lhc sarnplein 'depressileand non depressile. ln agreemcnr{ilh the observcrralcd sererityof dc pression.thc degreeof self'ratcdmental .rnd ph,"-sical sr-nrplonswashigherin lhc dcprcssivegroup (Tablc l). Nccds for help ruted on the Berlin Needs Asscssment were reportcdnainly wrlh respect1(l support Schedr.rle nccdedfor coping !vi!h alcoholism(86'f ol the total sample).Man,"'womcn staledther"needcdsuppofi con(l8l). cerningihci. mcnLalhealth(51'/r.iob sirLralion ph,"'!icnlhc.rllh {2lDr) and inlinrn.trn aboui ihei. ill Womcn wilh ncssand specifictreahent opllons(2tlL),i,). symptomsrcporlcd ore needsihan non-dedcpressive prc\sivewomendid. Thc range$as liom 2lo 9 lirr the deplcssircgroup and from 0 to 6lor the other group. Espcciallyconcerningmenlal health. social contacls. housc\rork and food. morc women with deprcssrre n a t r . . n r ' c o m p r f e J. ' l l ^ c \ \ r h ' u . d < p r e " i , cr n n -

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loms ralcd a nccd lbr supporl. Yc!. rhis diference Iailed to rcrch statisticalsigniiicance. Most of the total sanrplereporiednegativeconsequences of their drinking: |he most frequentlymentioneddomainsw€re the lamil,""{41'lt. job+ituation (26'I) ard physical and rr.nil hralrl l'6 ) W.'r.r ir rh( Jrtrj*i!e rronp $ere mo-e c^ncerrcd abJrr rhe,e repari\. c,.n.. qu€nces of alcoholism and reporred more aspecls they $€re lvorried aboul, but there ivas no singlc do main that $as predominmily emphasisedin €ither of thc ls'o groups.Manr- women also expressed concerns irboul rhcir iob situalion (ld)i ol lhc rdal sample).health (3404 and famjl-vor part ership. respectivelt(23%).Addiiionall]. 49% oI the \romen mentioncd positive efttcis ol thcir alcoholism. The nl(xt-feported aspectsdeall wilh shon-ierm consequcnc€!: laeling self-conlldentand nrcre competent (18'ri,).bccomingmorc soci,tblc(10'l'")and beingableio ..t. $rr\ rrrn.,l L.'nfrI),\. . I rdurng rnri
(6,r,).

Correlationswithio rhe sxbgroupsbet\reen SQOL the one hand and socirl and clinical critefia on the orher, releal only a fe$ significant associationswithin boih groups: SQOL is positivel-v corrclatcdwiih age (ND: r:0.46. P{0.01: D: r: (ND: | :0.17. P < 0.05;D: 0.52.P < 0.01).occupalion :0.,10, f P<{).05). age at onsetof alcoholismlNDl /:0.52. P<0.01; D: r=0.38, P<0.01). Being ddcr. halinga iob and onsc!ol alcoholism rt a higher agc arc corrclalcd Nilh a highcr SQOI-. Degrce of psychopnlhobgicalsyrnplomsas obscrvcrratcd oD the BPRS is ncgali!cl) correlrred wilh SQOL in the no -depressivc-qroup.A higher degrcc of srni|lolns correlateswith a lower SQOL (BPRS:r: 0.,16.P { 0.01).

,1. Discussion The resxlts of this study reveal a high extent ol depressive sympromsin alcoholicr\'omenduring deto)tification. More than half of the sample was ar least modentel,vdepressive. Regardlessof origin and e\aci (Beharei al.. 198,1: Ilavef diagnosis ol the depfessnrr and D.rhlgrcn. 1995tSchucki!. I980. dcprcsscdalco holic womcn rcportcd a much lowcr SQOL lhan thc womenwithoul depressive symptons.This finding.thar depr€ssionls negativeltcorrelaled\,!ith SQOL, is consistentwith the results of orher reports (Pyne el ai.. 1997iRudoll and Pricbc.1999b:Sullilancl rl.. 1992). As a lbrmer stud) demonstrated. SQOL $as a convenient marker for disiinguishxrgsubgroupsof alcoholic women under treatmenr(Rudolt and Priebe. 1999a). The rnalysisreportedin this papersho$sthat alcoholic womenwith aDd!rithout depressiles,vmpronN differ in someNpects ol SQOL. The more private aspects.e.g. pefsoral relntionsand menial health,seemto be of a parlicular rclcvancc.This might poinl a1 tbc impor ta ce of familt inlohcmcnl and pslchological trealments rather than con\'cnlr()nalsocial $ork focussing on accommodationand emplor-lnen1. patientsalso sho\,!ed Depressiveand non-depressive dilTerences in oihef subjectiveevaluationcriteria: deprclsivcwomcDhad a highcrdcgrccol sclf ralcd symp toms and complaints-and reported more needs for .uppo|| in d lTefenrr-eJ. of iie .'nd rnorereg.'tire coNequencesof alcoholisn. In contrastto SQOL ratiDgs.which differed overall as well .rs in speciiiclife domains.depressilewomen reported in generalmore ncedsand negalire coDsequences d driDking.bul nol wilh rcspcc!to spcciliclilc domnins.This may bc duc !o i rQ { ) l r a r r r p r n . . f i p h c r . . n ! r r ' r . \' . l J ' . n r a nr l 1 c ( r fS

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comparcdto ratings of needsand ncgaliveeffecrsof drinkrng. ln line wilh resulisof Priebeet al. (1998),the lindinss slrggclla strong link bet\leendiffcrcnl subjectrve cnieri,r and obser\€r-ratedpsychopalhdogy.llowever. correlalions betweenSQOL and somc objectivecriteria. lilc agc.job-srtuationand age al onsetof alcoholism. sholr that low SQOL is iikely no1 10 be a mereconsequenceol depression.bui also associalcdwith orher Observcrralcd depressionand parienrs rated QOL reveal overlapping.but not identical inlbrmation. To someextenl.thc rssocialiors,ith obserlerrateddcprc! sioD nighi be seenas a lalidatiolr of the satisfacrion ralings thar form the SQOL scorcs.Sinle boih assessmerrtsarc rclativell simpleio obtain. thcy may become part ol roulinc aslcllm€nt and providecomplcnrcntary lnibrmarion. luiure researchmight rnlcstignie as to what exlcn! thc prognosticvalueof deprcssionrn atcoholism is rncdialcdand erplainedby paticnb' SQOL. Assuming that Dore of the two lactors ncilher depfessionnor SQOL is a mere function of thc olher. both phenomcnam,ry bc important for treahcn!. Managementof depressbnand plychosocialintervcn tions t.rgering arcas ol dissatislaction(Prieb€ c! al.. 1999)ma,v ha\'c 1(] bc cornbinedin a comprehcnsilc cafc package.ln lhis case..tsscssments of depiession and SQOL will havea placein diagnollic proceduresas nell as in outcomemeasurement.In bclwccn I and 2 weeksafter thc bcginningof detoxiflcaiionmight be a good point of iime lbr palienls10corNidertheir life and rate SQOL. even if sonc ol- them are likely 1() bc dcpressed. Ant rnterprelalionoI SQOL scoresin thcsc ,ho rld c.,n\iderrl'( l.\(l ul Jepfes:i\e{rrl fdriJnr. !o s but. vice versa.inlirnnation on parienrs SQOL mighl al!o be important when consideringtherapeurlc implicationsof depressive symptoms.

This srud! \!as supporiedb) the wonlen rescarcll program e'ol rhe BerlinSenate( l r a n l n u m b c r : P - 2 1 9 l ' l l r 9 : l9 5 .

AkcfliDd. I, Hijrnqui!. JO.. 1r)9: Lonelinc$ rrd al.obol rbu\e . revrewof cvidcn.csofai i.rerrl{!. Sor Sci Med 11..105.11.1 B . a r 1 r €N. l C . . L o n s l b a u e hR . , L l l i . t . c . S l o u l ,R . E . F ! v a . J . No.l. \ F, l99i Fllect of the social cr\ir.nrncrt on rlcohol nrvolr€mcntand brccti!. sell be,ngpnor lo alcohox$ trlrt r$1 J Slud. Alcohol 54. 281 196 BecL. A.l. Stc* R/\ l9li.1 Rech Depressior l.v.nbry Tl[ P\lchologrcrlCorporrlio.. San r\nr.nl. Bcck. T. Wrrghl.F.D.. Ne$mxn, C.l. . Licsc.B S 199:l(ognrlr\e Ihcrap) or SubnaDoeAbuse.Tbe Cuilford Prcs, Nc$ Yorr. Behar.D.. \\l.okur. (;. Berg,C.J.. 1981.Depressiorin thc abn ..r r l c o h o l i cA. m . J P s l t h i a t l 4 l , l l 0 - r l l 0 ? . ( lPS. l9E6 InlernllionaleStal.n dcr Psr-chialrleBell/. $Jenhem C o r D o 6 . ( ; . 1 -I , l r r ! 1 oS . . A . Z y w i a k .W l l 1 9 9 3M l l c a n d l l m r l e dl.oholi.s alftlbltnhs rcgrrdnrg rhe onserand tcfmDaion oi re[pses and the man]lcMn.c .f,hstinence J Subn Abuse 10. Conbcre. L s L , schili! R.. 1985 Socul rclxtior and fassllily of roner alcoholi.s Al..hol Alcobol. 20. lll :11,1. Greenlicld.S F.. Wens. R.D. Vncn/. I .R , v.se, L M., Kell_v. J.1... -Ihc Bcll., r-.R.. Mrcb.el. J.. 1998 cfcct ofdcr,rcssi.no. rerum to drnrkire Arch (;en Ps)-chinr. 55. 159 265. Hrnnllon. Nf. 1960 A ratine scrl. f.r depr€\rn J \eud NeuroHarer, 8.. Dahlgrc.. L. 1995 Elrll lreatnent of somen with alcoh.l ddiclion (EwA): a compchcnsir. .vrlua!.n dnd oul comc rnd! I Parremsol Dslcbrrric c.m.rbidi$ !r rntnke. Addrtr.n 9i). l0l ll)9 Hollnrnn. K.. Pficbc,s 1996 Needslbr belp.nd rrppon in thc \rer or schizophrenic lore rcrn f,aricn( and o Lhentherapins l.oits.hr \eui(n Psyc 6.1..1?l 481 in c.rmrn K r r f r . \ . . P r i . b c .s . B ! r . w , H o l i m . n n . K . I s e m r a n DN. i . RiiderVxnner. U.ll.. llu{1.}. P. 1997 Prolilesof sublcctilc

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Robbnr. D R.. Alessi.N.l . Coliir. M V. Yanchlshln. ('.$ . l9ll5 lrsc of the Hlnilron hhtrg scrle lor depre$ion.nd th. (rarroll sclf{atin-rscalein ldolescetrls.PsrcbuL Re\. l.l, ll:l 129 Rdde.1\'!nner.L -U . lneb€, S. 1995 Schi/othreniaa.d qualilt .f l e se\ spec ic n\Fcls Forlrhr \.urol Pit. 61. l9l 401 nr

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P r i . b . .S ( i r u ) r e r T . u c i n z c .M . l l o l f n a n n .C . . h k c l ^ . 1 9 9 5 Subteclnecnleria lo. c!!lurl$n ol Dychrlln. c!re: helhodr lo. a$c$mcnt ir rcscdch and routinecxre Psl-Ichkt.Prax ll. 140 Pyne.J M.. hnerson, T.L . Krplan. R \t . G,llnr. J.C., (oct. w I .. 6rant. 1.. 1997.AsessneDlof rhe quahlr oflfe of paients rvith n'ai.f d.tarlon Psr'.hian Ser .18.21.1 ll0

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