|Year : 2013 | Volume
| Issue : 3 | Page : 229-235
Quality of life impairment in depression and anxiety disorders
Neha Pande1, Vishu Tantia2, Archana Javadekar1, Daniel Saldanha1
1 Department of Psychiatry, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, India
2 Psychiatrist, Shree Ganganagar, Rajasthan, India
|Date of Web Publication||5-Jul-2013|
Department of Psychiatry, Dr. DY Patil Medical College, Pimpri, Pune,
Source of Support: None, Conflict of Interest: None
Background: Most common mental disorders (CMDs) such as anxiety disorders and depressive disorders run a persistent and long course. This results in significant impairment of quality of life (QOL) of patients and their families. Evidence-based psychosocial interventions using findings in our own socio-cultural context would help clinicians in holistic management. Objectives: To document illness profile, treatment satisfaction, and QOL in various domains of life in study population and normal controls. Study Design: Cross-sectional analytical study of patients group and their normal family members as a comparison group. Materials and Methods: A total of 100 consecutive patients of depressive disorders and anxiety disorders (ICD-10 clinical diagnosis) attending outpatient clinic of the medical college hospital and their age- and gender-matched relatives as the control group were recruited. Socio-demographic profile was documented along with illness parameters: Severity of illness, treatment satisfaction, and QOL was measured using semi- structured interview, HAM, Beck's depression Inventory, and WHO-QOL scale. Results: The study group measured significantly low on QOL than the comparison group. The two groups differed significantly on the paired " t" test of significance and the variation had a genuine assignable cause. Notwithstanding some variables having a confounding effect and the limitations of a cross-sectional study, the study was conclusive in demonstrating statistically significant impairment of QOL of patients with CMDs, making a strong case for clinicians to pay attention to holistic management of patients. The study has generated QOL data on a small but significant normative population which may serve purpose in future QOL studies.
Keywords: Anxiety, common mental disorders, depression, quality of life
|How to cite this article:|
Pande N, Tantia V, Javadekar A, Saldanha D. Quality of life impairment in depression and anxiety disorders. Med J DY Patil Univ 2013;6:229-35
|How to cite this URL:|
Pande N, Tantia V, Javadekar A, Saldanha D. Quality of life impairment in depression and anxiety disorders. Med J DY Patil Univ [serial online] 2013 [cited 2021 Apr 20];6:229-35. Available from: https://www.mjdrdypu.org/text.asp?2013/6/3/229/114640
| Introduction|| |
Quality of Life: The Concept
The quality of a person's life may be considered in terms of its richness, completeness, and contentedness. The concept of quality of life (QOL) was introduced in 1975 in medical indices and its systematic study started in early 1980s mainly within oncology.
World Health Organization (WHO) defines QOL as individuals' perception of their position in life in the context of culture and value systems in which they live and in relation to their goals' expectations, standards, personal health, psychological state, and concerns. 
QOL reflects a growing appreciation of importance of how patients feel and how satisfied they are with treatment, besides the traditional focus on disease outcome. 
Health-related QOL is a multidimensional concept that encompasses the physical, emotional, and social components associated with an illness or treatment,  and the impact of health conditions on function, but include social role, suggesting that health-related QOL may be independent of QOL relevant to work setting, housing, or similar factors. 
According to Patrick and Erickson, life has two dimensions: Quantity and quality.  Quantity of life is expressed in terms of "hard" biomedical data such as life expectancy or mortality rates. QOL describes subjective evaluation of life in general.
The WHO has projected that by the year 2020, depression would reach 2 nd place, next to diabetes as contributor to global burden of diseases (GAD).  The high lifetime prevalence of depression and high disability induced by depression exceeding that of diseases, such as pain, hypertension, diabetes, and coronary heart diseases, call for understanding of impact of this condition on people's life. 
The core symptoms of depression include anguish, sadness, mournfulness, irritability, deep sense of futility, diminished ability to experience pleasure, slowing or decrease in almost all aspects of emotions and behavior: Thought, speech, energy, sexuality and physical "neuro-vegetative" functions such as eating, sleeping, and grooming. 
The lifetime prevalence of anxiety disorders is almost 25%, and description of which date back to 4 th century B.C. in the writings of Hippocrates.  The term anxiety means, experience of excessive worry and apprehension and undue pessimism. Somatic symptoms include palpitations, tachycardia, and shortness of breath, lightheadedness, dry mouth, nausea, diarrhea, and perspiration. Anxiety and depression often coexist. These disorders have a considerable impact on QOL on account of high levels of distress and suffering.
The present article is based on a study of significant clinical interest to examine the contribution of symptom severity, the presence of psychiatric co-morbidity, the duration of illness, and demographic variables to QOL and its dysfunction.
| Materials and Methods|| |
The study was conducted at the Department of Psychiatry of a 750 bed, general hospital affiliated to medical college. Around 40 patients attend outpatient services daily and approximately 50% of them comprise of anxiety and depressive disorders.
All consecutive adult patients of depression and anxiety disorder attending the outpatient and inpatient departments diagnosed by two qualified psychiatrists using ICD-10 clinical diagnostic criteria constituted the study group. Primary diagnosis of bipolar disorder, psychotic disorders, and serious general medical condition were excluded.
The comparison group comprised of age- and gender-matched healthy adult family members residing with the patients in the same house. For augmentation of the sample, age- and gender-matched relatives of medical outpatients were also recruited. The comparison subjects having current or past history of mental illness were excluded.
A total of 100 consecutive patients and matched controls were recruited between the periods of October 2007 and May 2009.
A specially designed pro-forma was used to document socio-demographic profile, illness and treatment details, etc. Hamilton Rating Scale for Depression and Hamilton Rating Scale for Anxiety were used for the assessment of severity of illness.
The QOL questionnaire of WHO was chosen for the assessment of QOL. A semi-structured interview using operationalized, pilot-tested questionnaire was conducted. In essence, all the four domains of the tool WHOQOL-BREF  were incorporated. The format of interactive, conversational yet comprehensive assessment has enhanced the richness of the narrative. Informed consent was obtained from all the subjects in both the groups. Approval of institutional ethical committee was obtained before commencement of the study.
The results of the descriptive analysis of illness variables, symptom variables, functionality, relationship, money matters, physical environment, leisure and enjoyment, and overall satisfaction with life have been tabulated. Quantitative analysis was done by as per the WHOQOL-BREF manual for scoring.
| Results|| |
The socio-demoraphic profile has been presented in [Table 1]. The profile of both the groups did not show statistically significant difference.
ICD-10 classification categories of depressive disorders are F-32, F-33, and F-44.
66% of the study group had a diagnosis of depressive disorders and 34% had anxiety disorders (F-41 of ICD-10) [Table 2].
60% patients had illness of more than 6 months duration. 91% had continuous course of illness and only 9% had episodic illness.
About 1 in 5 patients reported co-morbid medical condition, while 34% in the comparison group reported medical illness such as hypertension, diabetes, asthma, cardiac problems, etc.
Symptom Profile [Table 3]
Neuro-vegetative symptoms of both the conditions cause considerable distress and contribute to dysfunctionality.
Only 1 in 4 reported optimal total duration of sleep (6-8 h), the proportion for the same in the comparison group was 3 in 4. Other sleep parameters such as difficulty in initiation of sleep, sleep maintenance, freshness in the morning, energy levels and fatigue in the two groups have been presented in [Table 3]. The two groups measured highly significantly different on the entire symptom profile.
Functionality Profile [Table 4]
The regularity of daily routine is known to offset effects of dysfunctionality. Depression and anxiety have direct effects on work and daily routine. Again, the two groups have highly significant difference on functionality parameters such as daily routine, regularity at work, and work satisfaction.
Support systems modulate the impact of illness. Practical as well as emotional support comes from the primary family. The two groups did not differ significantly. The married in the study group (n = 79) were not satisfied in sexual relationships compared to 11% (n = 83) in the comparison group, highly significant statistically. Financial condition as affected by the illness, savings, assets, and loans as an additional burden, in both the groups, did not have significant difference.
Housing, sanitation, infrastructure facilities, etc., have an effect on QOL [Table 4].
Participation in cultural and religious events, festivals, pilgrimage, etc., confers inclusiveness. Some depressed individuals may shun social contact, whereas anxious people may feel sense of belonging. 92% respondents used to participate in cultural events before illness, whereas currently only 61% do so. Thus, a shift of 53% indicates the effect of illness on this variable. 30% men and women would watch movies and 72% would go on outing for enjoyment before illness. Only 5% reports to watch movies currently, while 15% said they still enjoyed outings, a sharp decline in leisure and enjoyment behaviors.
Overall Satisfaction with Self
76% of the study respondents reported in negative about overall satisfaction with self, while 76% in the comparison group reported satisfaction with self, the difference is highly significant.
Quantitative Global Assessment of QOL
Conversion of raw scores into transformed scores for each of the domain questions was done in adherence to the WHOQOL-BREF manual.  In the study group, the range of scores obtained was 30 to 140 and the mean score was 66 (Graph 1). In the comparison group, the range was 38-180 and the mean score was 149.
Within the study group (intra group), analysis of relationships between illness and symptom parameters with QOL, severity of illness, functionality and QOL, spousal relationship, financial status, and overall satisfaction with self and QOL was carried out [Table 5]. 80% of the respondents with severe anxiety and 87.7% with severe depression reported lower than average QOL as compared to mild depression. Continuous illness seems to have correlation with less than average QOL (62.6%), but not the duration of illness.
Respondents dissatisfied with the treatment and those with side effects of drugs, measured to have the less than average QOL (82.11% and 60.9%).
68.4% subjects with less than average QOL reported dissatisfaction with sleep, poor concentration (71.3%), and low energy (64.4%) than respondents with above average QOL.
In the study group, 71.7% whose daily routine was affected, 90% with absenteeism at work, and 70% with dissatisfaction at work reported lower QOL.
Dissatisfaction with spousal relationships was associated with below average QOL in 74.5%. Similarly, respondents with financial status affected due to illness reported low QOL (65.6%). The overall satisfaction with self showed positive and linear correlation with QOL scores.
The implications of intra-group comparisons and comparison of both the groups in totality have been discussed next.
| Discussion|| |
The concept of "quality of life", developed in the social sciences, was first applied in medical practice in 1980 with cancer patients. In doing so, first step was taken in the direction of measurement of aspects of human sufferings which until 30 years ago was considered non-measurable. 
This concept is better approached as multidimensional construct, covering a number of conventionally defined domains.  Mauro and Stein  have quoted, "it is recommended that we avoid the vagaries of abstract and philosophical concepts and concentrate on aspects of personal experience that are related to health and healthcare (health related QOL)".  Initiative of WHO to develop the QOL assessment arose from a need for a genuinely international measure of QOL and promotion of a holistic approach to health and healthcare.
The definition of QOL adopted by WHO reflects and focuses upon respondents "perceived" QOL. The recognition of the multi-dimensional nature of QOL is reflected in the tool used for the present study, WHOQOL-BREF.
The invisible suffering on the account of impact of the anxiety and depression on every aspect of life compromises the QOL of patients not only during the active symptomatic state but often beyond symptomatic recovery. Our findings are discussed below in the light of the literature referenced.
QOL is a dependent variable and hence context specific. The present study has generated data on QOL of relatives of patients who had comparable living conditions and environment. Demographic characteristics were comparable too, as discussed earlier, without any statistically significant differences with the study population [Table 1]. The comparison group is not a control group in strict methodological sense neither is it a community sample as they were hospital attendees for the index patients but without a mental illness. But it has served the purpose of generating some normative data for bench marking.
The scores on WHOQOL for this comparison group were in the range of 38-180 and the mean score was 149. There were 34% respondents even in this group who reported to have medical illness. This may have contributed to the lower end of the scatter on the values of QOL.
Study group, with highest score of 140, was below the mean score of the comparison group indicative of much lower QOL on the account of impact of illness in comparison with healthy adult relatives (Graph 1). The study group showed skewed distribution to the left while the comparison group showed skew toward the right.
Intra-group Analysis of Association
Within the study group, the comparison of respondents scoring less than mean values on QOL (≥66) with those scoring more than mean values was undertaken. A significant association emerged between study variables and QOL [Table 5].
Continuous illness had a significant association with lower QOL than with episodic illness. Pyne et al.  in their study over 3 years reported similar findings about duration of illness impacting QOL. Severely depressed subjects in the study group scored low on QOL, but not moderately and mild depressed ones. The inverse relationship between the severity and QOL in this study was in keeping with results of Pyne et al.  and Skevington et al.  In their study of elderly patients, Chachamovich  reported that even milder depressions were associated with poor QOL. Our study did not find the same as ours was predominantly young population (48% were less than 30 years old).
In the anxiety subgroup, the association between severity and QOL could not be tested statistically as this subgroup was small. Menlowicz,  Koran et al.,  Hollifield et al.,  and Warshaw  have reported a significant association between severity of anxiety and QOL. Patients in their study had severe form of anxiety, namely OCD, panic disorder, and PTSD's crippling symptoms.
No significant association was found between presence of side effects, co-morbidity and QOL. Highly significant association was found between dissatisfaction with treatment and poor QOL. Chan et al.,  observed linear relationship between improvements in QOL of depressed patients following treatment. Individual symptoms and QOL has shown significant association [Table 5]. Those that slept poorly, didn't feel fresh in the morning, had poor concentration and low energy levels had linear and statistically significant association with QOL.
Among the parameters of functionality, work status and work days missed due to illness have been studied by Simon  and Broadhead et al.,  the latter study was conducted on a large sample of 2980 participants. This prospective epidemiologic survey reported that depression raised 4.78 times more risk of work-related disability than asymptomatic individuals.
In our own study, overall 39% of the working population reported absenteeism and in this group 90% of the absentees scored poor QOL, this association being statistically significant. Depression is associated with significant reduction in work capacity and thus affects the QOL. Significant linear association was found between low QOL and disturbed daily routine [Table 5].
Highly significant linear association was found between unsatisfactory spousal sexual relationship and poor QOL. The association was bidirectional, namely satisfactory spousal relationship correlated with better QOL. Our findings are in keeping with those of Katherine et al.  and Oatman.  which was an in-depth qualitative study of 10 patients and former was of 204 women. Massion et al. in their prospective, naturalistic, longitudinal, multicenter study of 357 subjects used modified short form health survey for assessment of QOL and reported poor marital relationship in 20% subjects of panic disorder and GAD.
66% respondents in study group reported affected financial status in comparison with the same before illness, its correlation with QOL was not of statistical significance.
The composite dimension of overall satisfaction with self had been highly significant and the correlation with QOL was bidirectional.
The cross-sectional design of our study does not permit analysis of cause and effect relationships. Also, although both depression and anxiety and QOL are distinct concepts,  there is obvious and considerable overlap between them.
For quantifying the cause of variation in study and comparison groups (normal adults), the paired "t" test of significance was applied based on standard normal variants (distribution). It yielded highly significant variation in the two groups (z > 3, P = 0.001 at 99% level of significance). It can be safely inferred that the two groups differ from each other and the quantum of variation had a genuine assignable cause.
Similarly, in spite of the considerable overlap between variables under study, the present study has been found conclusive about effects of anxiety and depression disorders on the QOL of patients and has brought home the importance of these findings to the clinician for better and holistic management of patients.
| Acknowledgement|| |
Dr. L. Bhattacharya, Professor and Head of the Department of Psychiatry, Padmashree Dr. D Y Patil Medical College and Research Centre (Dr. D Y Patil Vidyapeeth, Pune).
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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