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International Journal of Social Psychiatry (1999) Vol. 45 No. 4238-246.

SUBJECTIVE QUALITY OF LIFE IN FEMALE IN-PATIENTS


WITH DEPRESSION: A LONGITUDINAL STUDY

HElD! RUDOLF & STEFAN PRIEBE

SUMMARY
This study investigated Subjective Quality of Life (SQOL) in 42 women with
depression, 70 women with alcoholism, and 73 women with schizophrenia within
3 weeks after hospital admission. Twenty-eight of the depressive patients were
re-examined after 6 months. SQOL was assessed using the German version of the
Lancashire Quality of Life Profile.
On average, depressive women expressed dissatisfaction with life as a whole
and with 4 out of 8 life domains, and had a lower SQOL than the other two
diagnostic groups. Differences remain statistically significant when the influence
of age and anxiety/depression is controlled for. SQOL in depressive women
improved significantly within the follow up period. Positive SQOL change was
moderately correlated with an improvement of depressive symptoms.
The results indicate that depressive women after hospital admission express
an unusually low SQOL, which seems to have some diagnostic specificity and
improves over time. Changes in depressive symptoms do not fully explain SQOL
changes.

INTRODUCTION

Quality of life indicators were initially used in psychiatric research for evaluating different
settings and treatments for patients in long-term care. Most studies using the concept of
quality of life investigated samples with severe and chronic mental illnesses. Studies in
diagnostically homogeneous groups have usually focused on patients with schizophrenia.
In the last 10 years, there has - for various reasons - been an increasing interest in examining
quality of life in other diagnostic groups. Most notably, subjective quality of life (SQOL)
measures have been obtained in studies on patients with alcoholism (Haver, 1986; Beattie
et al. 1993;Welshet al. 1993;Longabaughet al. 1994;Schneideret al. 1995)anddepression
(Sullivan et al. 1992; Russo et al. 1997). Women with alcoholism were found to have a
particularly low SQOL regarding their social network (McLachlan et al. 1979; Gomberg &
Schilit,1985;Akerlind&H6mquist,1992)andtheirhealthstatus(Rudolfet al. 1996;Rudolf
& Priebe, 1999).
Patients with depression appear to have a lower SQOL than patients with schizophrenia
(Koivumaa-Honkanenet al. 1996;Guptaet al. 1998)and with mania (Russo et al. 1997).
Atkinsonet al. (1997)founda lowerSQOLin patientswithuni-polarand bi-polaraffective
disorders as compared with samples with schizophrenia or physical illness, even if the former
H. RUDOLF & S. PRIEBE 239

group had more favourable objective life circumstances. Within depressive samples SQOL is
-like in other samples (e.g. Priebe et al. in press) - associated with the degree of depressive
symptoms. Patients with more depressive symptoms tend to be less satisfied with their life
(Sullivan et al. 1992; Pyne et al. 1997), and SQOL may improve over the course of treatment
(Lonnqvist et al. 1994; Russo et al. 1997).
Whilst women in the general population have often been found to have a lower SQOL than
men, findings on gender differences in psychiatric patients have been inconsistent. Some
studies demonstrated little or no SQOL differences between women and men with mental
illness (Baker & Intagliata, 1982; Lehman, 1983, 1988; Huber etal. 1998; Meltzer etal. 1990;
Levitt et al. 1990). Other studies showed significant gender differences with a more (Shtasel
et al. 1992;Roder-Wanner & Priebe, 1995) or less (Briscoe, 1982) favourable SQOL in female
patients. Some of the studies that failed to identify major gender differences in the degree of
SQOL, found that different factors and domains may be relevant for SQOL in women and
men with schizophrenia (ROder-Wanner et al. 1997, Roder-Wanner & Priebe, 1998).
If SQOL measures are to be used for individual treatment planning, they may have to be
assessed in the acute stages of an illness. The purpose of this study was to investigate SQOL
in patients with acute depression who were homogenous not only with respect to diagnosis,
but also treatment situation, Le. after hospital admission, and gender, i.e. women. We
addressed two questions:
1. How is SQOL in women with depression after hospital admission as compared with
women with alcoholism and schizophrenia in the same situation?
2. How does SQOL in women with depression after hospital admission change over a 6
month follow-up period?

METHODS

One hundred and eighty-five women between 18 and 63 years of age, who were consecutively
admitted to three psychiatric hospitals in Berlin, Germany, and had a diagnosis of depression,
schizophrenia or alcoholism, were interviewed within the first three weeks of admission. The
diagnosis was made by the clinician psychiatrist according to ICD-lO (WHO, 1992) and
confirmed by a researcher who did the interviews and was not involved in treatment. The
same researcher re-interviewed the depressive patients after a 6 month follow-up.
Quality of life was assessed on the Berliner Lebensqualitiitsprofil (Priebe et al. 1995), a
German version of the Lancashire Quality of Life profile (Oliver et al. 1997). SQOL is rated
as satisfaction with life as a whole and with life domains on 7-point Likert-type scales with 1
as the negative, and 7 as the positive extreme. Psychopathology was observer rated on the
Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962).
In the depressive sample, symptoms were also assessed on the Hamilton Rating Scale for
Depression (HAMD, Hamilton, 1960), and self-rated on the Beck Depression Inventory
(BD!; Beck & Steer, 1987).

Statistical analysis
Differences between groups were analysed using chi2-tests, t-tests, and one-factorial analyses
of variance. In analyses of variances Scheffe-tests were applied a posteriori for single
240 SUBJECTIVE QUALITY OF LIFE

comparisons between two groups. When comparing SQOL in the three diagnostic groups,
analyses of variance were repeated with potentially influential variables as covariates. For
assessing the association between psychopathology and SQOL scores, as well as SQOL
changes, correlation coefficients (Pearson's r) were used.
T-tests for dependent samples were used for analysing changes over time. Correlation
coefficients (Pearson's r) were calculated as a measure of stability over time for psycho-
pathology and SQOL scores. These test-retest coefficients do not reflect the stability in
absolute terms, but the degree to which individuals maintain their relative position in the
distribution of scores. A multiple regression analysis was calculated for predicting SQOL
changes in a multivariate model.

RESULTS

According to ICD-IO, depression was diagnosed in 42 women (F31 = 1, F32= 19,


F33 = 20, F34.1 = 2), alcoholism in 70 women (FIO.l = 1, FIO.2= 24, FIO.3= 32,
FIO.4 = 9, FIO.5 = 4), and schizophrenia in 73 women (F20.0 = 65, F22 = 1, F23 = 4,
F25 = 3). Clinical and sociodemographic characteristics of the 3 groups are shown in Table 1.
The three groups show significant differences in age, monthly income and partnership
situation. Moreover, women with depression have a longer duration of illness as compared
with the schizophrenia group, and a higher degree of depressive symptoms as compared to
both other groups. Their scores on BPRS sub-scales anergia, thought disorder and hostility
are lower than in the schizophrenia group.
Table 2 summarises SQOL scores in the three groups.
Depressive women had a significantly lower satisfaction with life as a whole, with social
contacts, leisure activities and mental health than the other two groups. The mean SQOL
score was also significantly less favourable. As compared with women with alcoholism,
depressive patients were less satisfied with their financial situation and with accommodation.
In a next step we compared SQOL in the three groups when controlling for the influence
of age and BPRS sub-scale anxiety/depression. This was done because age and anxiety/
depression differed significantly between the three groups and are known to be factors of
potential influence on SQOL scores. Table 3 shows which differences were statistically
significant before and after controlling for the influence of age and anxiety/depression.
Differences in satisfaction with social contacts and with the financial situation failed to
reach statistical significance when the influence of age and anxiety/depression was controlled
for. Other differences, however, including the one in the SQOL mean score remained
statistically significant.
Within the depressive sample, the SQOL mean score was significantly correlated
with the BPRS sum score (Pearson's r: -.53, p < 0.001), with BPRS sub-scales anxiety/
depression (r: -.40, p < 0.05), activation (r: -.40, p < 0.05) and thought disorder (r: -.46,
p < 0.01). Correlations with HAMD (r: -.35, p < 0.05) and BDI (r: -.44, p < 0.01) were
also statistically significant indicating that a higher degree of symptoms was associated with
lower satisfaction scores.
At 6 month follow-up, 28 depressive women (67% of the base line sample) were
re-interviewed. 14 patients either refused a second interview or could not be traced. There
H. RUDOLF & S. PRIEBE 241

Table 1
Sociodemographic and clinical characteristics of women with depression, alcoholism and schizophrenia after
hospital admission

Women with Women with Women with Statistics


depression alcoholism schizophrenia
n=42 n=70 n=73

Age (years) 41.7 :t 11.0 43.5 :t 9.7 33.7 :t 10.5 F(2,182) = 17.6***
Job Situation ns
Employed 52% 53% 63%
Unemployed 24% 16% 15%
Housewife 7% 16% 14%
Retired 17% 16% 8%

Income (DM) 1901 :t 980 2030 :t 860 1651 :t 775 F(2,172) = 3.3*
State Benefits 21% 33% 42 ns

Partnership 67% 60% 37% X2(2,185) = 12.0**


Living Situation
Alone 36% 31% 48% ns
With partner 24% 30% 9%
With Partner & Children 28% 23% 14%
Single Parent 8% 9% 16%
With other 4% 6% 13%

Age of onset if illness (yrs) 33.9 :t 12.5 33.9 :t 10.8 30.8 :t 9.7 ns
Duration of illness (years) 7.8:t 8.6 9.6:t 6.5 3.0 :t 5.6 F(2,179) = 17.4***a
Number of previous 1.2 :t 1.8 1.8 :t 3.7 0.9 :t 2.5 ns
hospitalisations
BPRS-Sum Score 35.9 :t 6.6 32.2 :t 6.8 46.9 :t 10.7 F(2,180) = 55.5*** a
AnxietylDepression 15.0 :t 2.7 11.8 :t 3.7 11.1 :t 3.3 F(2,180) = 18.7** ab
Anergia 7.2 :t 2.8 7.1 :t 2.9 9.9 :t 3.3 F(2,180) = 18.1 *** a
Activation 5.8 :t 204 5.3 :t 2.1 7.0:t 3.1 F(2,180) = 8.2***
Thought disorder 404:t 1.0 4.5 :t lA 10.3 :t 3.9 F(2,180) = 106.9*** a

Hostility 3.5 :t 1.1 3.5 :t 0.9 8.5 :t 3.5 F(2,180) = 98.3*** a


HAMD 19.1 :t 6.9 11.0:t 6.1 - F(l,IIO) = 40.9***
BD! 23.5 :t 10.2 11.6 :t 6.7 - F(l,107) = 5404***

*p:S; 0.05, **p :s; 0.01, ***p :s; 0.001


a posteriori single comparison (Scheff6- Test p:S; 5%): adepression vs. schizophrenia group, bdepression vs.
alcoholism group

were some base-line differences between the interviewed group and the drop-outs: patients
who were followed up, lived less often in a partnership (57% versus 86%, chi2 (1,42): 3.4,
p = 0.06), and they had more previous hospitalisations (1.5 :t 2.1 versus 0.6 :t 0.7, t = 2.0,
p = 0.05).
Table 4 shows SQOL measures and psychopathology scores in the followed up group at
base line and 6 months later. The table also indicates the individual stability of scores over
time and the statistical significance of differences on a group level.
On average, patients still showed marked depressive symptoms at follow up. Yet, the
degree of observer rated and self-rated depressive symptoms was significantly lower than at
base line. Other aspects of psychopathology as assessed on BPRS sub scales did not
significantlychange. All SQOL scores improved. The differences were significant regarding
242 SUBJECTIVE QUALITY OF LIFE

Table 2
Subjective quality of life in the three groups
Satisfaction with Women with Women with Women with Statistics
depression alcoholism schizophrenia

Life as whole 2.8 :t: 1.5 4.0:t: 1.4 4.0 :t: 1.8 F(2,182) = 9.0*** ab

Family 4.5 :t: 1.8 5.1 :t: 1.6 5.0 :t: 1.2 ns
Social contacts/friends 4.3 :t: 1.4 5.2:t: 1.4 5.0 :t: 1.2 F(2,181) = 5.5** ab
Leisure Activities 3.5 :t: 1.6 4.3 :t: 1.7 4.0 :t: 1.6 F(2,182) = 8.1 *** ab
Accommodation 4.6:t: 2.0 5.8 :t: 1.6 4.3 :t: 1.9 F(2,182) = 13.1 *** b
Job Situation 3.5 :t: 2.1 4.0:t: 2.2 4.4 :t: 2.0 ns
Finances 3.6:t: 2.2 4.7:t: 2.0 4.3 :t: 1.9 F(2,182) = 3.5* b
Safety 4.1 :t: 1.7 3.8 :t: 1.7 4.1 :t: 1.6 ns
Mental Health 1.9 :t: 1.1 3.2 :t: 1.5 4.1 :t: 1.8 F(2,18l) = 23.5*** ab
SQOL mean score 3.6:t: 0.9 4.5:t: 0.8 4.5:t: 0.9 F(2,175) = 14.4*** ab

*p s 0.05, **p S 0.01, ***p S 0.001


a posteriori single comparison (Scheffe- Test p S 5%): adepression vs. schizophrenia group, bdepression vs.
alcoholism group

satisfaction with life as a whole, with leisure activities, safety, and mental health as well as
in the SQOL mean score.
Individual stability of self-rated depressive symptoms, of SQOL mean score and of
satisfaction with some life domains was relatively high. An improvement of the SQOL
mean score between base line and follow-up was significantly correlated with a reduction of
scores on HAMD (r = .49, P < 0.05) and BDI (r = .54, p < 0.01) over the same period
of time. BDI changes were the best predictor of SQOL changes. In a multivariate analysis,
this predictive value was not increased significantly when baseline data and changes in
variables other than BDI were also considered as predictors.

Table 3
Statistical significance of SQOL differences between the three groups before and
after controlling for the influence of age and anxiety/depression

Satisfaction with Before controlling for the After controlling for the
influence of age and influence of age and
anxiety/depression anxiety/depression

Life as a whole *** F(2,178) = 3.6*


Family ns ns
Social contacts/friends ** ns
Leisure activities *** F(2,178) = 3.8*
Accommodation *** F(2,178) = 6.4**
Job situation ns ns
Finances * ns
Safety ns ns
Mental Health *** F(2,178) = 13.4***
SQOL mean score *** F(2,l72) = 5.2**

*p S 0.05, **p S 0.01, ***p S 0.001


H. RUDOLF & S. PRIEBE 243

Table 4
Psychopathology and SQOL in depressive women after hospital admission
and six months later (including stability of individual score over time)
Baseline Follow-up t(27) Stability

BPRS-Sum score 35.5 :t 5.7 33.6 :t 5.7 1.5 33ns


Anxiety/depression 14.7 :t 2.8 13.5 :t 3.0 2.0* .44*
Anergia 7.3 :t 2.5 7.0:t 2.9 0.5 .3lns
Activation 5.6 :t 2.1 5.2 :t 1.9 1.0 .32ns
Thought disorder 4.3 :t 0.7 4.3 :t 0.6 004 .16ns
Hostility 304:t 1.2 3.7 :t 1.6 0.8 .40*
HAMD 19.0:t 6.7 15.6 :t 6.5 2.3* .32ns
BDI 23.6 :t 11.5 18.0:t 11.8 2.9** .66***
Satisfaction with:
Life as a whole 2.7 :t 1.5 3.9 :t 1.6 4.2*** .54**
Family 4.6 :t 1.8 4.8 :t 1.7 0.6 .74***
Social contacts/friends 4.3 :t 1.3 4.8 :t 1.2 1.9 .52**
Leisure activities 3.2 :t 1.5 4.0 :t 1.2 2.6 .31 ns
Accommodation 4.3 :t 2.1 4.7 :t 2.0 lA .69***
Job situation 3.3 :t 1.9 3.8 :t 2.0 1.0 .22ns
Finances 3.4 :t 2.1 3.7 :t 1.9 1.0 .64***
Safety 3.9 :t 1.7 4.6:t lA 3.5* .32ns
Mental health 1.9 :t 1.2 3.5 :t 1.9 4.7*** 048*
SQOL mean score 3.5 :t 0.9 4.2 :t 0.9 4.9*** .67***

*p s; 0.05. **p s; 0.01. ***p s; 0.001

DISCUSSION

Women with depression expressed a low SQOL in this study. Their SQOL scores were
clearly less favourable than those of the other two groups in the same treatment situation.
Moreover, 5 out of 9 satisfaction scores, those with life as a whole, leisure activities, job
situation, finances and mental health, indicated an explicit dissatisfaction on a group level.
This is unusual since average scores of most samples in the general population or in patient
groups are in the positive range, and since it usually is only the degree of satisfaction that
distinguishes between groups or varies over time. The average SQOL of depressive women
found at base line in this study, is one of the lowest reported in the literature using similar
assessmentmethods (Priebe et at. 1999). Finances, leisure activities and job situation can be
seenas related life domains, because a sufficiently paid job may provide the money for doing
enjoyable leisure activities. The dissatisfaction in these areas is not explained by a
particularly high percentage of unemployed patients or by an extremely low income. The
findingsare consistent with other reports in the literature (Atkinson et at. 1997) and suggest
that depressive women tend to assess objective circumstances in a specifically negative
way, because of higher expectations and aspirations or due to unfavourable comparisons
with other people and with their own past.
SQOL scores in the other two groups were also relatively low although clearly higher
than in the depressive group - indicating that hospital admission with all the preceding events
might pose a crisis situation in which patients appraise their life particularly negatively
(Priebe et al. in press). The significant improvement of SQOL scores in the follow up period
would be consistent with that assumption.
244 SUBJECTIVE QUALITY OF LIFE

Numerous studies have reported that a higher degree of depressive symptoms is asso-
ciated with lower SQOL scores (e.g. Sullivan et al. 1992, Pyne et al. 1997). Thus, it is not
surprising that a similar correlation was found for depressive women in this study. However,
it appears striking that SQOL differences between the diagnostic groups remained statis-
tically significant when the influence of depressive symptoms - and age - was controlled
for, suggesting that lower SQOL in depressive women was not due to a higher degree of
depressive symptoms. There are several possible explanations for this: the BPRS sub scale
anxiety/depression might be an insufficient measure for capturing those depressive symp-
toms, which are most influential for SQOL ratings. Alternatively, one might argue that it is
not only the quantitative degree of depressive symptoms, but rather their qualitative nature
that is relevant for satisfaction ratings. Patients with depression might have underlying
depressive cognitions that are not shared by alcoholism or schizophrenia patients with
depressive symptoms, but that do determine a particularly negative assessment of their life.
One might also speculate as to whether depressive women experience hospital admission
differently than the other two groups and respond with a more negative view of their life.
The results suggest that diagnosis is a relevant feature associated with SQOL ratings.
Diagnosis should, therefore, be assessed in studies using SQOL scores and considered a
relevant factor, the influence of which should be controlled for. This applies as long as the
precise mediating factors explaining the association between diagnosis and SQOL are not
fully understood and can, therefore, not be exactly measured. A diagnostic classification
seems necessary in addition to an assessment of depressive symptoms.
Depressive patients' SQOL did improve within the 6 month follow-up. This change on the
group level was accompanied by some individual stability of ratings over time. The findings
underline that SQOL ratings are sensitive to change and may be used as outcome criteria
in studies evaluating treatment of depression (Lonnqvist et al. 1994, Russo et al. 1997, Priebe
et al. 1999).
In line with the results of other studies, a positive change in SQOL was associated with an
improvement of depressive symptoms. The correlations were statistically significant and
substantial in size. Changes in depressive symptoms were the best predictor for SQOL
changes explaining approximately 30% of the variance. This confirms the importance of
depressive symptoms for SQOL changes, but also indicates that improvement in SQOL is not
just an epiphenomenon of positive changes in depression.
This study demonstrated a very low SQOL in depressive women after hospital admission
which is not explained by the degree of depressive symptoms as assessed in the study.
Moreover, it showed an improvement of SQOL within a 6 month follow-up period which
was moderately correlated with an improvement of depressive symptoms. The study had a
naturalistic design, and further experimental studies should be conducted to identify which
therapeutic interventions have the most positive effect on both depressive symptoms and
SQOL. Moreover, future studies might establish in which way individual SQOL ratings can
be used for designing specifically beneficial psychosocial interventions in depressive women.

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Heidi Rudolf, PhD, Research Fellow, Clinic for Psychiatry and Psychotherapy, University Hospital Aachen,
Pauwelsstrasse 30, 52074 Aachen, Germany
Stefan Priebe, MD, Professor of Social and Community Psychiatry, St Bartholomew's and the Royal London School
of Medicine and Dentistry, Queen Mary & Westfield College. University of London, UK
Correspondence to Dr. Rudolf.