Research Article
J Fam Med. 2015;2(3): 1027.
Relationship of Depression, Disability and Quality of Life in Depressive Patients-A Case Control Study
Jaiswal P, Dalal PK*, Tripathi A, Singh S and Jain S
Department of Psychiatry, King George’s Medical University UP, India
*Corresponding author: Dalal PK, Department of Psychiatry, King George’s Medical University UP, India,
Received: March 18, 2015; Accepted: May 15, 2015; Published: May 18, 2015
Abstract
Aim: To assess quality of life, disability and burden on spouse of depressed patients.
Methods: The sample size taken for the study is 151 married patients of the depression and similar number of healthy controls. Case group include first two patients registered on specific days aged 18-60 of each week in the adult general psychiatric OPD, King George’s Medical University (K.G.M.U.), Lucknow and for the controls a geographically urban and rural area were identified with the help of NGO (samajdarshan) Lucknow who had close liasoning with the people of the community. The diagnosis was made using DSM-IV-TR criteria. Assessment of quality of life was done by WHO Quality Of Life Scale (WHOQOL), disability with WHO disability assessment schedule (WHODAS) and burden of care with burden assessment schedule (BAS).
Results: In the enrolled cases, 72 (47.68%) patients were male and 79 (52.31%) were female. Among the controls 70 (46.35%) were male and 81 (53.64%) were female. The mean age of cases and controls was 35.93±9.1 and 35.1±9.2 respectively. Depression was analyzed with Hamilton depression scale -21 in the cases and the mean HAM-D-21 score was 17.79±6.10. The domains of QOL was also significantly (P<0.0001) different between cases and controls, representing poor physical health, psychological condition, social relations and poor environmental condition of depressed patients. As per WHO Disability assessment schedule disability was assessed in both cases and controls significantly (P<0.0001) higher disability was observed in depressed patients group. The range is from 12-60. In addition to scales burden on the spouse of depressed patients was assessed and the mean of burden assessment schedule observed was 39.29±4.24.
Conclusion: The findings of this study suggest that quality of life deterioted in patients of depression than controls. There was more disability found in case group than control and significant burden was also seen in spouses of patients of depression.
Keywords: Depression; Disability; Quality of life; Relation; India
Introduction
Depression is recognized as one of the major health threats in the 21st century. Research suggests that unipolar depression is the most prevalent of all mental disorder. Depression is not only a common, often chronic and recurrent disorder, but it is cardinally associated with significant impairment in work and daily social and psychological well-being [1]. Major depressive disorder (MDD) is the fourth leading cause of disability worldwide [2] and is predicted to become the second leading cause by the year 2020 [3]. The Medical Outcomes Study [4] found that depressed individuals have comparable or worse physical, psychosocial, and role functioning than those who have chronic medical conditions. Similarly, the World Health Organization (WHO) Collaborative Study on Psychological Problems in General Health Care [5] reported increased functional disability, even after controlling for physical disease severity among patients with depression. Furthermore, the longer a patient remains symptomatic, the lower the chances of a complete recovery, [6] and thus greater dysfunction.
Quality of life is defined by the World Health Organization Quality of Life (WHOQOL) Group as individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. This definition reflects the view that quality of life refers to a subjective evaluation that is embedded in a cultural, social and environmental context. The Quality of Life in depression scale is a disease specific patient-reported outcome which assesses the impact that depression has on a patient’s quality of life. Healthrelated quality of life (HRQOL) in depression involves at least 3 specific domains of health—physical, psychological, and social—and each can be measured by either objective assessment or subjective perception. Furthermore, there are many components within each domain (eg, symptoms, ability to function, and disability). Whereas disease-specific instruments focus on the domains most relevant to the disease or condition under study, both generic and diseasespecific instruments of HRQOL have often been used in general populations to assess a wide range of domains applicable to health states, conditions, and diseases [7,8].
Studies comparing and contrasting the relative quality of-life dysfunction for major depressive disorder and anxiety disorders have yielded equivocal findings. Several studies report greater impairment in quality of life for major depressive disorder [9], whereas others report comparable deficits in quality of life for anxiety disorders and major depressive disorder [10]. The proposed study included the quality of life, disability and burden on spouse of depressed patients, the concerning domains of quality of life and its relation with severity of depression. There is extensive review on the family related variables but as cultural difference plays an important role we have thought to throw light on the Indian scenario comparing it with the healthy control.
The extensive and in-depth study will help in the treatment of the patient and formulating psychosocial management programs suitable for the Indian set up. It would also help in directing clinical intervention. Therefore, researches in these fields are required.
Material and Methods
Sample
The sample size taken for the study are 151 married patients of the depression and similar number of healthy controls meeting the inclusion exclusion criteria as shown in Figure 1. The procedure used in this study is shown in Figure 2.
Figure 1: Inclusion and exclusion criteria.
Figure 2: Flowchart showing the procedure of the study.
Cases: For case group first two patients registered on specific days aged 18-60 of each week in the adult general psychiatric OPD, King George’s Medical University (K.G.M.U.), fulfilling the selection criteria was included in this study.
Controls: For the controls urban and rural area were identified with the help of NGO (samajdarshan) Lucknow who works on the areas of education, sanity, women empowerment etc as they had close liaising with residents there. The NGO had detailed demographic details of the residents. One to one matching was done for age, sex and domicile.
Informed consent was taken from both cases and controls.
Tools used
Hamilton depression scale: To assess the symptoms of depression and severity of depression [11] (HAM-D-24) - The Hamilton Psychiatric rating scale is most widely used depression scale. It is a 24 item scale each item is rated in either 3 or 5 rating steps. Rating is based on clinical interview and observation made by the clinician.
W.H.O. quality of life scale: It is to measure the quality of life of the plan individual. The WHOQOL – BREF an abbreviated 26 item version of the WHOQOL-100 was developed using data from the field trial version of the WHOQOL-100. The items are distributed into 4 domains (physical. psychological, social and environmental health) and 25 facets. The WHOQOL instrument can be used in particular cultural settings, but the same time results are comparable across cultures. WHOQOL-BREF has shown to display good discriminant validity, content validity and test retest validity [12].
The burden assessment schedule (B.A.S.) [13]: The instrument is based on extensive ethnographic with affected families in an effort to gauge the meaning of giving care to a chronic psychotic person. The items are distributed into factorial configuration. (1) Impact on well being (2) marital relationship (3) Appreciation for caring (4) Impact on relation with others (5) Perceived severity of diseases.
W.H.O. disability assessment schedule [14]: A series of systematic field studies was studied to determine the schedules cross cultural applicability reliability and validity as well as utility of health service research. WHODAS 2.0 of is a practical generic assessment instrument that can measure health and disability at population level or in clinical practice. WHO captures the level of functioning in six domains of life? 1-cognition-understanding and communicating. 2-Mobility - moving and getting around. 3-Self care-attending to ones hygiene, dressing, eating and staying at home. 4-Getting along - interaction with others. 5-Life activities - domestic responsibilities, leisure, work and school. 6-Participation - joining in community activities, participating in society. It provides a common metric of impact of health condition in terms of functioning. The range is from 12-60.
Standardization of tools
Three translators who were well versed in English and Hindi translated the original version into Hindi independently. They discussed and compared their versions and drafted a final version by consensus. This version was tested on 20 literate and 20 illiterate people from the community for simplicity, clarity, understanding and precision. Changes were made accordingly. Two bilingual experts translated back the Hindi version into English to establish meaning equivalence. The primary translators and the back translators discussed questionnaire item by item to ensure that the translations were approximate as closely as possible.
Procedure
The assessment was completed on the same day or after appointment on a mutually convenient day. Information regarding details of identification data, demographic details, history of present and past illness was recorded on a semi structured Performa.
The diagnosis was made by consensus between the investigator and the chief supervisor or the co-supervisor. The diagnosis was made using DSM-IV-TR criteria. Assessment of functioning and expressed emotions of family of depressed patients was done by applying WHODAS, WHOQOL and BAS on spouse of depressed patients. For the control group a geographically defined area was identified, door to door survey was done. Control group was matched on age. Sex, educational and family income and those fulfilling the inclusion, exclusion criteria formed the sample of the study.
Data management and analysis
Data were expressed as proportion, % or mean + SD as appropriate. The test on the proportions between groups was performed using Chisquare test or Fisher’s exact test. For comparison between groups, Student unpaired t test and One-Way analysis of variance (ANOVA) was performed. Correlation analysis was performed using Pearson correlation test. P value less than 0.05 is considered as statistically significant.
Results
In the enrolled cases, 72 (47.68%) patients were male and 79 (52.31%) were female. Among the controls 70 (46.35%) were male and 81 (53.64%) were female. The mean age of cases and controls was 35.93±9.1 and 35.1±9.2 respectively.
Further cases and controls were compared in terms of education, number of married years, occupation, patient’s income, and family income, number of family members, domicile and type of family. It was found that there was no significant difference between cases and controls in the above mentioned parameters.
Depression was analyzed with Hamilton depression scale -21 in the cases and the mean HAM-D-21 score was 17.79±6.10. The range of score is from 0-84. The domains of QOL was also significantly (P<0.0001) different between cases and controls, representing poor physical health, psychological condition, social relations and poor environmental condition of depressed patients (Table 1). The range is 26-130.
Cases (n=151)
Control (n=151)
Χ2/t
d.f.
p-value
No.
%
No.
%
Age in years
35.93±9.18
35.12±9.28
0.76
300
0.44
Gender
Male
72
47.7
72
47.7
0.99
300
1.00
Female
79
52.3
79
52.3
Education
Schooling (Middle /High /Intermediate)
81
53.6
84
55.6
0.12
1
0.72
College (UG/PG /Professional)
70
46.4
67
44.4
Occupation
Unemployed
50
33.1
48
31.8
2.36
6
0.88
Unskilled
20
13.2
20
13.2
Semiskilled
8
5.3
14
9.3
Skilled worker
38
25.2
37
24.5
Clerk, farm owner, shop keeper
26
17.2
26
17.2
Semi professional
7
4.6
5
3.3
Professional
2
1.3
1
0.7
Religion
Hindu
133
88.1
135
89.4
1.06
2
0.59
Muslim
17
11.3
16
10.6
Sikh
1
0.7
0
0.0
Type of family
Joint
73
48.3
84
55.6
1.60
1
0.20
Nuclear
78
51.7
60
44.4
Number of family members
Upto 5
66
43.7
59
39.1
0.67
1
0.41
Above 5
85
56.3
92
60.9
Patient’s income (in Rs.)
7017.8±9114.1
8035.09± 10708.84
0.89
300
0.37
Family income (in Rs.)
12404.6± 10898.41
11549.00±10634.33
0.69
300
0.49
Family income categorical (in Rs.)
Less than 1520
4
2.6
4
2.6
5.11
6
0.53
1521-4555
31
20.5
38
25.2
4556-7593
27
17.9
37
24.5
7594-11361
30
19.9
25
16.6
11362-15187
22
14.6
16
10.6
15188-30374
21
13.9
14
9.3
More than 30375
16
10.6
17
11.3
Domicile
Rural
73
48.3
80
53.0
0.65
1
0.42
Urban
78
51.7
71
47.0
Social economic status
Upper
9
6.0
1
0.7
8.34
4
0.08
Upper middle
47
31.1
44
29.1
Lower middle
48
31.8
46
30.5
Upper lower
35
23.2
47
31.1
Lower
12
7.9
13
8.6
Years of Marriage
14.6±10.4
15.6±10.6
0.82
300
0.41
Table 1: Socio-demographic Characteristics of Case and Control.
WHODAS (World Health Organization Disability Assessment Schedule)
As per WHO Disability assessment schedule disability was assessed in cases the mean score 32.38±73.3 (Table 2&3). The range is from 12-60. Thereby the patients of depression face moderate disability (24- mild, 36- moderate, 48-severe, 60-v.severe).
QOL (QUALITY OF LIFE) & Their domains)
Mean ± SD in cases group
Mean &SD in Normal healthy control
p-value
95 % CI
TOTAL QOL
68.33±13.51
101.4±12.11
< 0.0001*
-36.05 to -30.23
PHYSICAL HEALTH
18.11±5.58
28.14±3.09
< 0.0001*
-11.09 to -9.03
PSYCHOLOGICAL
15.69±3.9
24.21±3.9
< 0.0001*
-9.51 to -7.76
SOCIAL RELATIONSHIP
8.5±2.57
12.94±2.35
< 0.0001*
-4.98 to 3.87
ENVIRONMENT
21.94±4.6
28.19±4.8
< 0.0001*
-7.31 to -5.18
Values are given as mean ± SD. Differences were tested by the Student t test for mean ± SD. (*, p value <0.05 considered statistically significant; SD, Standard Deviation.
Table 2: Quality of life and their domains.
WHODAS & Their domains
Mean & SD in cases group
Range of scale
Subjective range
WHODAS TOTAL
32.38±73.3
12-60
13-42
Values are given as mean ± SD. Differences were tested by the Student t test for mean ± SD. (*, p value <0.05 considered statistically significant; SD, Standard Deviation)
Table 3: WHODAS.
In addition to scales burden on the spouse of depressed patients was assessed and the mean of burden assessment schedule observed was 39.29±4.24. The range of score is from 20-60 (Table 4).
BAS components
Mean ±SD
Appreciation for caring
7.17±1.42
Impact on relation with others
8.13±1.59
Marital relationship
7.94±1.42
Impact on well being
7.62±1.66
Perceived severity of depression
7.40±1.94
Total
38.25±4.27
Table 4: Burden assessment schedule and its domains.
Discussion
Depression is a mental disorder characterized by depressed, low, or “blue” mood that lasts more than a few days. Depressed people often lose interest in activities they formerly found pleasant, feel hopeless and sad, and suffer from low self-esteem.
The term quality of life (QoL) is used by various segments of society. It covers subjective and objective aspects and denotes the need for humans to seek internal and external equilibrium. According to the World Health Organization (WHO), QoL is the “individual’s perception of their position in life, in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns. The domains of QOL were also significantly different between cases and controls, representing poor physical health, psychological condition, social relations and poor environmental condition of depressed patients. Angermeyer MC et al. Had been reported based on the objective assessment of quality of life, namely that depression implies a persisting impairment of social functioning and living conditions, can be replicated to some extent from the point of view of the patients themselves [15]. Similarly Lehman reported females found to have lower QOL than males [16]. In addition Jho [17] discovered a negative relationship between depression and QOL in a Korean study. Health problems interfered negatively in all domains of QoL [18].
Information on disability is an important component of health information, as it shows how well an individual is able to function in general areas of life. Depression plays an important role in determining the disability and quality of life. As per WHO Disability assessment schedule disability was assessed in both cases and controls significantly (P<0.0001) higher disability was observed in depressed patients group.
The depressed spouse will experience less happiness, satisfaction and contentment in the marriage. At the same time, the partner will struggle with handling the increased isolation and social withdrawal of the depressed spouse, the loss of emotional intimacy (and often sexual intimacy as well), and the prevalent negativity in the relationship. When one spouse is depressed, the depression colors everything in the relationship. The depressed spouse sees the world through a darkened lens that limits his or her perspective. Any negative events are interpreted even more negatively; neutral events are also interpreted negatively, and the positive happenings are often overlooked. The depressed spouse often loses interest in activities that used to bring pleasure and may experience fatigue and listlessness. In addition to scales burden on the spouse of depressed patients was assessed and the mean of burden assessment schedule observed was 39.29±4.24. Lessening the burden of spouses of depression may help the improvement of depressed patients [19]. In general, the spouses living with depressed patients encounter enormous emotional burden when their spouses suffer from depression. Some research has shown the quality of life for the family members and caregivers was influenced by mental disorders such as depression and schizophrenia [19] and the quality of life for the partner could play a significant role in the prognosis of depression [19]. Considerable research has demonstrated there was strong association between depression and marital relationship. When one family member suffers from depression, the quality of life for the spouses was influenced. Our results showed the quality of life and social support for the spouses of depressed patients were poorer than the married community controls, consistent with previous study in mood disorders [20]. Obviously, when one family member suffered from depression, the spouse of depressed patients needed to take care of the patient and bear more emotional and economic burden, less social support especially from the family. Additionally, women reported better quality of life than men [21] which suggests when wife in the family suffered from depression; their husbands were exposed to higher burden and showed lower quality of life. One possible explanation could be women tend to seek more support and more social networks.
The study is important as we can clearly predict which variable of quality of life is an important predictor of depression and thereby when we formulate programs to help patients of depression the study finding can play an important role.
Limitations of the Study
Rural and urban matching was difficult in a larger sample would give better understanding about all the psychological aspects involved in the study.
Ethical Approval
The King George’s Medical University ethics committee specifically approved this study, via the university ethics committee wide letter no-4070/R-Cell-12. Ref. code: 60th E.C.M.II B/P1.
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