Quality of life: concepts, needs, psychometric measurement, factors associated and treatment responsiveness in depression disorder

INTRODUCTION

The concept of quality of life (QOL) has long been recognized as a crucial component in psychiatry. According to World Health Organization, QOL is an individual’s perception of their situation in life concerning their objectives, standards, prospects, and concerns as well as the culture and value systems in which they live.¹ The idea of quality of life seems to revolve around a sense of well-being. The perception and response to health issues and other non-medical aspects of one’s life is notorious as QOL.² Hence, QOL is determined from the patient^'s outcomes from psychiatric patients. Researchers^' views on how extensively the ideas of QOL should be applied have also varied. Quality of life (QOL) impairment is significantly correlated with psychiatric disorders, recurrently comparable to or greater than those of medical disorders.³

METHODS

The review article aimed to identify the evidence to explore and understand the concepts, needs, psychometric measurement, and factors associated with and treatment responsiveness of QOL in depression disorder in narrative forms obtained from the last three decades to 2022 on the evidence from the studies published in English databases from extensive electronic database using PubMed, SCOPUS, PsychINFO, ScienceDirect, SpringerLink, and Google Scholar. The significant findings from books, journals, and grey literature were also included. The significant articles were searched by using keywords: “quality of life”, “needs of quality of life”, “quality of life and depression disorder”, “psychometric properties and quality of life”, “treatment response and quality of life” and “treatment modalities in depression disorder and quality of life”. The findings of the narrative review on evolved concepts are discussed under the following headings.

DISCUSSION

Concept of quality of life in depression disorder

Depression is the largest contributor to disability, which also significantly contributes to the overall global burden worldwide. 322 million people are suffering from depression worldwide (WHO,2017).⁴ Depressive disorder is the highest prevalence among all mental disorders in India. Furthermore, it contributed to 33.8% of disability-adjusted life-years of the total mental disorders.⁵ The depressive disorder negatively impacts a person’s life such as functioning, job satisfaction, enjoyment of one's work pattern, relationship status, physical health, sexual function, sleep patterns, outlook on the future, and a general sense of fulfillment.⁶

The different facets of QOL are significantly correlated with major depressive disorder. Shak et al revealed that QOL is significantly impaired in major depressive disorder with a mean QOL score of 39.8% (SD=16.9). The study also concluded intensity of depressive symptoms and disability were found to have a substantial impact on QOL.⁷ The STARD study’s analysis revealed a substantial relationship between the intensity of depressive symptoms and low health-related QOL.⁸ However, an improvement in QOL is not always associated with an improvement in life expectancy. This is why it is suggested that all health professionals pay attention to the QOL among patients.⁹

Need of restoring quality of life in depression disorder

Quality-of-life screening and enhancement have been recognized as crucial in depression disorder. The assessment of QOL is becoming a standard element of comprehensive clinical evaluation of patients that can have a detrimental impact on all facets of life. The specific therapeutic intervention involves not only precise diagnosis of the disease and implementation of effective pharmacotherapy but also accurate evaluation of all the essential components of QOL and the satisfaction level of patients in mental, emotional physical, and social needs.¹⁰ The need for evaluating QOL in a patient with depressive disorder comprises: The practice of QOL in the concept of quality-adjusted life years to analyse the particular intervention is cost-effective. Tracking QOL as the key performance indicator for treatment effectiveness in depression disorder. QOL outcomes beyond symptom scales guide clinicians to pay attention to holistic management, and it is employed as a complementary outcome measure. QOL is used as a therapeutic tool and is greatly affected by depression which is directly attributable to mood disturbance. Symptom-focused interventions may direct a misleading treatment protocol that patients have recovered, hence, emphasizing QOL. Due to scarce resources, there is rising attention to disease prioritization within the growing arena of health economics. Hence, generic measurements such as QOL are needed. QOL measures are patient-centered outcomes that put the consumer in the middle. Determine if a certain treatment modality just reduces symptoms or also increases subjective wellbeing. Direct policymakers to take interest in stakeholders and provide appropriate treatment.^11-19

Factors associated with Quality of life in depression disorder

Improving the quality of life is a vital goal in enhancing long-term results and lowering impairments in depressive disorder. Recognizing the variables that affect patients with depressive disorders delivers clinicians and policymakers a clinical picture and aids in establishing a guideline for a long-term management strategy for these patients. Evidence from various population-based studies concluded that poor QOL in depressive disorder associated with: older age of respondents, lower socio-economical status, the intensity of the depressive symptoms, a lower level of education, worse subjective perception of health, unemployment, obesity, living arrangement, perceived stigma, social support, and lower degrees of resilience.^19-23

The studies also conclude that positive enhancements in all aspects of QOL could be accomplished through comprehensive intervention such as strengthening the social support system, early recognition and treatment of disease, and reducing stigma, as well as suggest decision-makers should focus their attention to provide appropriate management for disorder with improving QOL.^19-22

Psychometric measurements of QOL in depression disorder

The fact that existing quality of life measurements fall short of accurately capturing comprehensive output and the value of benefits of mental healthcare interventions..²⁴ A multidimensional psychometric measurement is very essential to ensure that the tools utilized are comprehensive and psychometrically sound to properly quantify and value these benefits of QOL. In literature variety of instruments in existence to measure QOL, in which some investigators, particularly apply a single domain while other investigators tap into a series of domains. These scales will differ in their level of depth, with some drilling down to evaluating QOL in various categories while others acting as a more succinct, specific, and overall assessment. A large number of QoL measurements have been used in depression disorder. These include, but are not limited to:

WHOQOL BREF

The WHO collaborated with 15 international field centers to develop the WHOQOL-100 QOL evaluation. An abbreviated version consists of a 26-item questionnaire that assesses four different elements of life quality (i.e., physical, social, psychological, and environmental). High scores indicate good QOL, which is determined by respondents’ ratings of the items on a 5-point Likert scale over the past two weeks. It has been demonstrated that WHOQOL-BREF exhibits strong discriminant validity, content validity, and test-retest validity.²⁵ The domains of QOL by the World Health Organization (WHO) are illustrated in (Figure 1).

Quality of life in depression scale (QLDS)

The QLDS, a disease-specific tool used to evaluate QOL in depressive patients, was first proposed by Sonja Hunt and Stephen McKenna. The 34 items on the QLDS, a self-administered questionnaire, each describes one of the essential physical and psychological demands of clients with depression disorder. The QLDS reacts quickly to changes in QOL. It was discovered to be highly reliable and internally consistent in its original form.^26,27

Quality of life enjoyment and satisfaction questionnaire (Q-LES-Q)

It is a self-applicable tool designed to gauge how content and satisfied people are with many areas of daily life. Despite not being created especially for depressive patients, the Q-LES-Q was initially tested on a group of depressed individuals and has been applied with this goal. It has 93 items total, 91 of which are arranged into 8 sub-scales. The respondent rates their level of satisfaction with the items using a Likert-type scale with five options. All Cronbach's alpha coefficients in the instrument's original form are above 0.90, demonstrating the instrument's strong internal consistency.²⁸

SmithKline Beecham quality of life scale (SBQOL)

Although the SBQOL makes use of three fixed elements- the self as it is now, the ideal self, and the sick self- and 23 preset constructs. The scores are given on a scale of one to ten, with a very positive anchor point on one side and a very negative anchor point on the other. The questionnaire inquires about social relationships, work/job, religion, finances, work/religion, activities/hobbies, humor, sexual function, and psychological and physical well-being. The SBQOL showed sufficient internal consistency. The SBQOL showed sufficient internal consistency.²⁹

Short form (SF-36)

SF-36 health survey is a global measure of health-related QOL. The SF-12 is a condensed version that has 12 items instead of 36. Eight scaled scores make up the SF-36. On the premise that each item is assigned an equal weight, the scale is directly translated into a 0-100. The lesser the impairment, the higher the score. Except for social function and mental health, six of the eight SF-36 dimensions had internal reliability values greater than 0.7.³⁰

Treatment Responsiveness of QOL in depression disorder

The diminished quality of life is a significant concern for individuals with depression disorder and is often not addressed by symptom relief alone. The QOL is affected differently by various treatment techniques for depressive disorder.

Psychoeducation

The information on mental illness, signs and symptoms, medication and treatment, self-esteem, social skill training, assertiveness, negative, rational thinking, and relaxation training is useful in improving QOL. Farkhondeh et al concluded that psychoeducational was effective in 8 domains of QOL in the intervention group. All of the domains showed a significant difference at p<0.001.³¹

Multimodal and community-based lifestyle intervention

The multimodal, system-wide approach to health care that promotes changes in the environment, diet, behavior, and psychological habits to improve physical and mental well-being. An RCT by Sherwin et al concluded that a multimodal, community-based lifestyle intervention has been shown to enhance depressed symptoms and improve QOL in people with depression disorder.³²

Pythagorean Self-awareness intervention

PSAI compresses diaphragmatic breathing, progressive muscle relaxation, and psychoeducation. A randomized control trial by Psarraki et al demonstrated significantly greater reductions in depressive symptoms and QOL among participants.³³

Body-mind-spirit interventions

Interventions associated with body, mind, and spirit play a significant role in enhancing the QOL. A RCT concluded that body-mind-spirit intervention was found to significantly improve well-being and QoL scores throughout the 6-month trial period by Rentala et al.³⁴

Cognitive-behavioral therapy (CBT)

The psychosocial intervention, which reduces the symptoms of various mental illnesses and enhances the QOL, especially in anxiety and depression disorders. A meta-analysis conducted by Hofmann et al concluded that those who received CBT and SSRIs both saw moderate QOL gains, although these effects may have been brought about by distinct causes.³⁵ While an RCT by Asarnow et al demonstrated that quality improvement interventions (particularly CBT and antidepressant medication) resulted in a significant decrease in depression symptoms, an improvement in mental health QOL, and improved satisfaction with mental health care.³⁶

Group therapy

Group therapy interventions are effective measures to decrease depression and create a goal and improve the QOL in depression disorder. A comparison of two types of mental health nurse follow-up programs revealed that group therapy and telephone counselling were effective in improving the QOL for these patients (p=0.813 and p=0.792) respectively.³⁷

Mental health promotion intervention

The intervention includes collaboration within an interprofessional team consisting primary care physician, a registered nurse, and other care providers. The registered nurse offered intense case management, behavioral activation, community navigation, advocacy, psychosocial support, and harmonized communication between the patient, their family caregiver, and agencies across the care continuum. Markle-Reid et al concluded a nurse-led mental health promotion intervention was efficacious in enhancing the QOL for patients while they were hospitalized at a six-month follow-up.³⁸ Even other shreds of evidence from significant studies reveal early intervention to minimize stress in treating depression disorder is very essential in enhancing QOL.³⁹

Recent trends showed there has been a shift in mental health treatment approach policy from prominence on treatment that reduces symptoms and understanding of illness of pathology to a more holistic approach that takes into account well-being, social functioning, recovery, and QOL.¹⁸

CONCLUSION

The QoL is an important concept related to a patient’s well-being in the field of psychiatry, particularly patients with depressive disorder. The concern of QoL in the psychiatry field is to not only understand particular treatments in alleviating symptoms but also improve subjective well-being. In the past few decades, the study of QoL and the emphasis on patients’ subjective feelings of well-being have gained professional attention. Moreover, numerous studies have shown that individuals with depression disorders have a particularly poor QOL. From the aforementioned, it is worthy to draw the attention of psychiatrists, mental health nurses, and other mental health professionals on treatment as well as a social intervention to involves not only accurate diagnosis of the disease, implementation of effective psychotherapy and pharmacotherapy but also correct evaluation of all the components of QOL and satisfaction of patients’ various need including mental, physical, emotional and social needs. Among the different QoL measures used today, patient-reported outcome measures represent a significant improvement as a tool for use in routine clinical management for patients and clinical research. Through the development of therapy plans that go beyond symptom relief, additional research may enhance treatment outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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