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Keywords:

  • depressive outpatient;
  • medical professional–patient interaction;
  • quality of life;
  • social support

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

Abstract  Issues related to recovery of quality of life (QoL) in depressive outpatients have been raised. This descriptive correlation study investigated QoL in depressive outpatients in Taiwan. A total of 181 depressive outpatients participated in the study. Their QoL levels were measured using the Taiwanese version of the Short Form of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF). The results indicate that multiple predicting factors including marriage, less severity of depression, better social support, and better medical professional–patient interaction are associated with better QoL in depressive outpatients in the physical, psychological, social relationship, and environmental domains. QoL and its correlation with depressive outpatients must be emphasized in order to develop appropriate strategies to improve QoL and treatment efficacy.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

Various studies on the prevalence of depression suggest a rate of 2–5%, but the prevalence increases to around 10% among people who contact their general health services.1 The World Health Organization's Psychological Problems in General Health Care Study collected data in 15 countries and found that a mean of 10.4% suffered from depressive disorders. There were wide variations, from 30% in Santiago, Chile, to 2.6% in Japan, to 8.8–16.8% in Taiwan (DasGupta R, Guest JF, unpubl. data 2001).2,3 Quality of life (QoL) represents a functional index of the behavioral and cognitive impacts on depression. The outcome measure is sensitive to differences as a function of depressive characteristics, and has proved to be a useful assessment tool in evaluating treatment efficacy.4 QoL 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 QoL refers to a subjective evaluation that is embedded in a cultural, social, and environmental context.5 The WHO questionnaire on the Quality of Life, Short Form (WHOQOL-BREF) has been recently found to be an adequate measure for assessing QoL at the domain level in a population of adult psychiatric outpatients.6

Depressive illness is associated with several functional disturbances and impairment of several aspects of QoL that reflect patient's health status and treatment efficacy.4 The National Institutes of Mental Health (NIMH) Epidemiological Catchment Area Program7 showed that patients with major depressive or subsyndromal depression had higher levels of household strain, social irritability, financial stress, limitations in occupational functioning, poor health status,8 and days lost from work.9 Also, women with major depressive disorder were found to have more impairment in familial, marital, and occupational and leisure activities.10 A number of studies demonstrate that mental illness has a significant negative effect on the QoL,11 especially on the QoL of people with depression.12–14 Studies have shown that better QoL may be facilitated by lower depression level, positive social support, and better medical professional–patient interaction among depressive patients.15–18 Although studies of QoL in depressive patients have been reported, most of them were conducted among Western populations and only few involved depressive outpatients in eastern societies. Also, few studies have explored QoL in depressive outpatients for psychiatric nursing. Therefore, further study is necessary to examine the factors that influence QoL in depressive outpatients in Taiwan so as to develop appropriate strategies to improve QoL and treatment efficacy. The purpose of the present study was to identify factors that influence QoL in depressive outpatients, including severity of depression, social support, and medical professional–patient interaction.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

Subjects and setting

A total of 181 depressive outpatients volunteered as study participants from two medical centers in northern and southern Taiwan with a cross-sectional research design from August 2004 to July 2005. Participants, whose ages ranged from 18 to 65 years old, were diagnosed with either dysthymic disorder or major depressive disorder, but without personality disorder on axis II by psychiatrists using the DSM-IV criteria. All participants were followed in outpatient services at a department of psychiatry.

Procedures

The study was approved by the hospital institutional review boards of Kaohsiung Chang Gung Memorial Hospital and Cheng Hsin Rehabilitation Medical Center in Taiwan. All participants were referred by their psychiatrists and agreed to this study with informed consent by participants. Two of the researchers, who were psychiatric nurses in both medical centers, explained the purpose of the study and the risks and benefits of participation, including the right to refuse to participate without jeopardizing treatment, to each participant. Data were collected through interviews or participants' self-report by one-to-one interview.

Instruments

Specific questionnaires were used for research domains of QoL, severity of depression, social support, medical professional–patient interaction, and sociodemographic variables.

Quality of life

The Taiwanese version of the WHOQOL-BREF, which has 28 items, was used. The WHOQOL-BREF was developed by WHO for the purpose of evaluating health-related QoL and making cross-cultural comparisons.5 The WHOQOL-BREF Taiwanese version contains 28 5-point items from strongly satisfied to strongly unsatisfied. For the purpose of cross-cultural comparisons, the first 26 items were the same as the standard WHOQOL-BREF, which was developed from global studies. The two new local items, based on the psychometric criteria proposed by the WHOQOL Group, were added to form the WHOQOL-BREF Taiwan version.19 The first new added item is ‘Do you feel respected by others?’ which was included in the ‘being respected/accepted facet’. The second one was ‘Are you usually able to get the things you like to eat?’, which was included in the ‘eating/food facet’.19

Exploratory and confirmatory factor analyses indicated a four-factor model. The four specific domains include physical health (seven items), psychology (six items), social relationship (four items), and environment domain (nine items). The internal consistency (Cronbach's α) coefficients range from 0.70 to 0.77 for four domains. The test–retest reliability coefficients with intervals of 2–4 weeks range from 0.41 to 0.79 at item/facet level and 0.76–0.80 at domain level (all P < 0.01). Content validity coefficients are in the range of 0.53–0.78 for item-domain correlations and 0.51–0.64 for interdomain correlations (all P < 0.01). The four domains of the brief form provide 88% of the variance of the total QoL score and 60% of the variance of the Facet G score (measuring overall quality of life and general health).19 Higher scores on the WHOQOL-BREF indicate a higher perceived QoL. The transformed scores of four specific QoL domains range from 4 to 20, with Cronbach's alpha from 0.68 to 0.84 in the present study.

Severity of depression

Previous report suggested that QoL is a more patient-centered measure so that life satisfaction is more correlated with a self-rating (Beck Depression Inventory, BDI) than with an observer rating (Hamilton Depression Rating Scale) depression scale.20 The present study used the Chinese version of the BDI to assess severity of depression. The Chinese version of the BDI includes 21 4-point-item questions with a score of 0–3 for each item, and a score of 0–63 for total items.21 The questions of the Chinese-version BDI containing depressive mood, frustrated feeling, crying, and social withdrawal etc. have been demonstrated to have good predictive validity and internal consistency, with Cronbach's α of 0.80.21,22 Evaluation of depression was based on the method suggested by Lu et al.: a total score of ≤16 indicates normal, 17–22 represents mild depression, 23–30 indicates moderate depression, and a score of ≥31 represents severe depression.23

Social support

A structured questionnaire of social support with 12 5-point questions from ‘strongly agree’ to ‘strongly disagree’ was developed based on Liu.24 The original questionnaire in Liu was used for the study of chronic illness with elder patients.24 It had 13 4-point questions including two reverse questions, with a total score from 13 to 52 (mean, 38.67 ± 5.25), internal consistency (Cronbach's α) coefficients of 0.81–0.97, and retest reliability coefficients with an interval of 1 week of 0.85–0.89.24 The content includes physical assistance, emotional sharing, acceptance and respect, and applications of health-care resources. This questionnaire also had been used in diabetic outpatients in Taiwan.25 The present study deleted one question about elders to adapt to depression patients' issues. The construct validity of the questionnaire analyzed by factor analysis showed that Kaiser–Meyer–Olkin (KMO) value was 0.82 and Bartlett test of sphericity (BT) was 815.37 (P < 0.001).

To analyze the total variation of the questionnaire, questions with eigenvalue >1.0 were first selected using principal components analysis. Through varimax rotation, there were three questions chosen with a factor loading >0.6, resulting in a total variance of 60%. The questionnaire showed stabilized internal consistency with Cronbach's α of 0.86. Details of the questionnaire in the present study are shown in Appendix I.

Medical professional–patient interaction

A structured questionnaire of medical professional–patient interaction with 21 5-point questions from ‘strongly agree’ to ‘strongly disagree’ was developed according to Lai et al.26 The original questionnaire had 16 5-point questions in the ambulatory setting. There are seven domains, including overall satisfaction (two items), empathy (five items), competence (four items), respect (two items), confidence (one item), carelessness (one item), and time issues (one item) in the original scale. The six domains of the original questionnaire provided 3.4%−37.3% of variance, with a Cronbach's α for internal consistency of 0.89.26

The present study added five more questions to address depressive patients' concerns. The content included listening, empathy and respectful behavior by the medical professionals when explaining medication effects/side-effects, treatment strategies, and educating patients in the symptoms of depression. The construct validity of the questionnaire on factor analysis showed that KMO value was 0.90 and BT was 1916.61 (P < 0.001). To analyze the total variance of the questionnaire, questions with eigenvalue >1.0 were first selected using principal components analysis and screen plot. Through varimax rotation, there were 14 questions chosen with a factor loading >0.6, resulting in a total variance of 64%. The questionnaire also had stable internal consistency, with a Cronbach's α of 0.92. Details of the questionnaire are shown in Appendix II.

Data analysis

Descriptive statistical method was used to analyze sociodemographic variables and independent variables of severity of depression, social support, and medical professional–patient interaction. Pearson correlation was used to explore the relationships between demographic variables and independent variables on four QoL domains. Conditional index (CI) was then used to test the multicolinearity. The results showed that interaction between independent variables was <20. Finally, multiple linear regression was used to explore predictors on QoL among depressive patients. The significant level of 0.05 was established for all statistical tests.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

Participant age ranged from 18 to 65 years; 72.9% were female, 80.1% had completed at least junior-high school education, and 63.0% were Buddhists. Also, 54.1% of participants were unemployed, 53.6% were married, and 56.4% had a stable income. The mean values of QoL scores on physical, psychological, social relationship and environment domains on WHOQOL-BREF ranged from 10.16 to 12.03. The mean score of social support was 7.96 ± 2.73 with a range of 3–15; the mean of the medical professional–patient interaction was 16.96 ± 4.11 with a range of 0–21; and the mean of the BDI total score was 20.72 ± 12.83 with a range of 0–60. A total of 39.8% of participants had BDI score ≤16; 19.9% had BDI score 17–22; 18.2% had BDI score 23–30, and 22.1% had BDI score 31–63.

To analyze QoL variables and their influencing factors, multiple liner regression was performed. Results are shown in Table 1. The major factors influencing QoL in the physical and psychological domains are social support and severity of depression, which account for 38% and 51% of the variance, respectively. Also, the major factors influencing QoL in the social relationship domain, which account for 45% of the variance, are social support, medical professional–patient interaction, and severity of depression. Marital status, social support, and severity of depression, accounting for 35% of the variance, are major factors influencing QoL in the environmental domain. In the present study, however, sociodemographic variables such as gender, education, occupation, and income were not associated with any QoL domains.

Table 1.  Multiple linear regression on predicting quality of life (n = 181)
 Physical βPsychological βRelationship βEnvironment β
  • *

     P < 0.05;

  • **

     P < 0.01;

  • ***

     P < 0.001.

Demographic variables
 Gender−0.0040.01−0.110.002
 Education−0.03−0.03−0.020.07
 Occupation0.04−0.050.01−0.006
 Religion−0.0030.04−0.030.01
 Marital status0.040.04−0.030.13*
 Income0.070.070.060.002
Social support0.12*0.21***0.30***0.26***
Professional–patient interaction0.110.090.17**0.11
Severity of depression−0.56***−0.61***−0.49***−0.44***
R0.640.730.690.62
R20.410.530.480.39
Adjust R20.380.510.450.35
F13.47***21.59***17.47***11.94***

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

A study conducted in Western Europe found that the degree of disability was directly related to severity of depression in depressive patients.27 Results from both epidemiological and clinical studies show that patients with depressive illness have a substantially lower subjective QoL than healthy subjects, and QoL is severely affected by a number of life domains as well as being associated with a decreased functioning in various external life conditions.11,12,16,28 Researchers have also found that severity of illness is most consistently predictive of QoL.4,12 In the present study we found that the severity of depression is most consistently associated with influential factors in various dimensions of QoL. Those participants with higher BDI scores on depression have poorer QoL in the physical, psychological, social relationship, and environmental domains, which is consistent with previous studies.4,12,29 Thus, medical professionals must communicate with patients about the impact of their levels of depression on QoL and well-being in order to increase depressive outpatients' motivation, and enhance their confidence to receive and maintain their treatment course.

Participants with depression are vulnerable to a numbers of stressors, for example, decreased social and physical functioning, financial and living condition difficulties, and decreased ability to meet obligations. In the present study we found that better social support improves QoL in physical, psychological, social relationship, and environmental domains. Also, marriage improves QoL in the environmental domain. Therefore, better social support and marriage may help depressive outpatients to stabilize role functioning and relationships, and to restore their QoL, especially given that Chinese society has transformed from big families to small families in recent years. This finding provides not only benefits in role identity but also a structure concept for personal meaning and belonging. Previous studies have also produced similar findings.29–31 Thus, caregivers need to be cognizant of the valuable roles that they play in patients' education, and in providing psychological support and adjustment for their patients.

The present study also found that better medical professional–patient interaction improves QoL in the social relationship domain. The medical professional–patient interaction belongs to a social system in which medical professionals and patients have their own roles and should respect each other. Previous studies found that on average patients asked medical professionals three questions, but only half of their questions were answered. At least 50% of patients could not be compliant with their medications because they could not understand the prescriptions.32,33 Therefore, bad medical professional–patient interaction will impede treatment and result in illness episode or deterioration. In ambulatory setting, caregivers must understand that the medical professional–patient interaction and social support can affect the QoL of depressive outpatients.

Even some early studies pointed out that correlation of sociodemographic variables, such as gender, education, occupation, and income may be related to QoL in depressive patients.7,9,10,29,34 The present study found no influence or predictive correlation for QoL in a Taiwanese sample. This may be due to the fact that the present subjects were outpatients who were in a relatively stable clinical condition. Future studies will need more detailed sociodemographic variables to further elucidate demographic meanings.

Limitation

The present study was a cross-section investigation of subjects aged 18–65 years with either dysthymic disorder or major depressive disorder, but without personality disorder, regardless of different components of QoL and different stages or course of depression. Therefore, the results may not reflect the complete QoL in depressive outpatients during various stages and courses of depression. Further research should include longitudinal study to assess the overall impact between QoL, age at onset, medical treatment, and stage of illness.

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

The present study found that multiple predicting factors, including marriage, social support, medical professional–patient interaction, and severity of depression, are associated with QoL in depressive outpatients. The results will allow caregivers to integrate these findings in future intervention, to provide education and psychological support, in order to assist depressive outpatients in improving and maintaining their own QoL.

ACKNOWLEDGMENT

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

This research was supported by Taiwan Chang Gung Institute of Technology grant 092-111-027 to Mei-Yu Yeh.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices
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    Cummins AR. Objective and subjective quality of life: An interactive model. Soc. Ind. Res. 2000; 52: 5572.
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    Koivumaa-Honkanen H, Honkanen R, Antikainen R et al. Self-reported life satisfaction and recovery from depression in a 1-year prospective study. Acta Psychiatr. Scand. 2001; 103: 3844.
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    Kuehner C. Subjective quality of life: Validity issues with depressed patients. Acta Psychiatr. Scand. 2002; 106: 6270.
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    Yen CF, Tsai JJ, Lu PL et al. Quality of life and its correlates in HIV/AIDS male outpatients receiving highly active antiretroviral therapy in Taiwan. Psychiatry Clin. Neurosci. 2004; 58: 501506.
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    Yao G, Chung CW, Yu CF, Wang JD. Development and verification of validity and reliability of the WHOQOL-BREF Taiwan version. J. Formos. Med. Assoc. 2002; 101: 342351.
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    Demyttenaere K, Fruyt JD, Huygens R. Measuring quality of life in depression. Curr. Opin. Psychiatry 2002; 15: 8992.
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    Ko HC, Lu RB, Ko YH. Cognitive dysfunction in melancholia and non-melancholia prior to and following medication therapy. Taiwanese J. Psychiatry 1990; 4: 129135 (in Chinese).
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    Yeh MY, Hwu HG, Lin SM, Lee S. A study of depression in alcoholic patients. Nurs. Res. 2000; 8: 241248 (in Chinese).
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    Lu ML, Che HH, Chang SW, Shen WS. Reliability and validity of the Chinese version of the Beck depression inventory-II. Taiwanese J. Psychiatry 2002; 16: 301310 (in Chinese).
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    Liu SJ. An exploration of the drug compliant behaviors and associated factors of elderly people with chronic disease. Nurs. Res. 1999; 7: 581593 (in Chinese).
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    Liu SJ. Self-management of health and its related factors for diabetic outpatients of municipal hospital in Taipei. VGH Nurs. 1999; 16: 286298 (in Chinese).
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    Lai WA, Chang SK, Chang WD, Wang YS, Lan CF. Development of a questionnaire to assess ambulatory patient satisfaction with physician. Chin. J. Fam. Med. 1997; 7: 3342 (in Chinese).
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    Lepine JP, Gastpar M, Mendlewicz J, Tylee A. Depression in the community: The first pan-European study depression research in European society. Int. Clin. Psychopharmacol. 1997; 12: 1929.
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    Hansson L. Quality of life in depression and anxiety. Int. Rev. Psychiatry 2002; 14: 185189.
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    Jho MY. Study on the correlation between depression and quality of life for Korean women. Nurs. Health Sci. 2001; 3: 131137.
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    Angermeyer MC, Holzinger A, Matschinger H, Stenger-Wenzke K. Depression and quality of life: Results of a follow-up study. Int. J. Soc. Psychiatry 2002; 48: 189199.
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Appendices

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENT
  9. REFERENCES
  10. Appendices

APPENDIX I

Social support scale
  • 1
    Someone can listen to you and empathize with you.
  • 2
    Someone can talk with you.
  • 3
    Someone can encourage and praise you.
  • 4
    Someone can care about your physical condition.
  • 5
    Someone can take care of your living.
  • 6
    Someone can accompany you.
  • 7
    Someone can provide financial support.
  • 8
    Someone can go with you to outpatient department.
  • 9
    You feel your opinions are respected by others.
  • 10
    When you want to do something, someone can help you.
  • 11
    When you want to do something, no one will care about you.
  • 12
    Someone is impatient with you.

APPENDIX II

Medical professional–patient interaction scale
  • 1
    You feel your medical professionals can understand your needs.
  • 2
    You feel your medical professionals can direct you to express your feeling and thinking.
  • 3
    You feel your medical professionals can lessen your symptoms.
  • 4
    You feel your medical professionals can increase your confidence of returning to work.
  • 5
    You feel confident in your medical professionals' treatments.
  • 6
    Medical professionals can pay attention to listening to your opinions about your illness.
  • 7
    Medical professionals can understand your suffering.
  • 8
    Medical professionals can pay attention to your illness history or physical condition.
  • 9
    Medical professionals can explain related illness or treatment actively to you or your family.
  • 10
    Medical professionals respect your privacy.
  • 11
    Medical professionals display passive attitude to your concerns.
  • 12
    You feel satisfied with medical services of depression treatment.
  • 13
    Medical professionals are responsive.
  • 14
    Medical professionals can explain the reasons for medication taking or methods of treatments.
  • 15
    Medical professionals can explain choices of treatments before making decisions.
  • 16
    Medical professionals can do their best to confirm you or your family's concern.
  • 17
    You feel disappointed about medical services of depression.
  • 18
    Medical professionals present an empathetic attitude during examination.
  • 19
    Medical professionals can understand your thinking.
  • 20
    Medical professionals will actively make the next appointment with you.
  • 21
    Medical professionals present their professional knowledge and attitude.