Adult outpatients with depression: worse quality of life than in other chronic medical diseases in Argentina

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Abstract

Current research into the impact of major depressive illness on society goes beyond estimating its prevalence, complications or comorbidity patterns, to include research that seeks to establish how this disorder affects individuals’ daily functioning and well-being. However, it is unclear whether depression affects such broadly defined quality of life (QOL) outcomes to a similar or an even greater extent than chronic physical illness. The present study assessed QOL in a sample of 48 ambulatory depressed patients who sought psychiatric assistance at a centre in La Plata, Argentina, during a 15-month period. All of them met DSM-IV criteria for current major depression, as diagnosed by clinicians. For the purposes of comparison, we also evaluated the QOL of additional samples of persons who were healthy or who had chronic physical illness. QOL was assessed with the WHOQOL-100, a generic and transcultural instrument developed simultaneously in 15 centres, by the World Health Organization (WHO). Results indicated that QOL was significantly poorer in depressed persons than in either healthy persons or individuals with other frequent chronic pathologies in Argentina. The impact of depression was also found to be related to the seriousness of the episode. We suggest that it is important to include QOL assessments of patients with depressive disorders when evaluating the course and progress of their treatment. Such assessments can be used in health care decision making and resource allocation.

Introduction

Major depressive illness is a type of disease that can have a marked impact in many areas of an individual’s life. Current research on the impact of major depressive illness, therefore, goes beyond estimating its prevalence, complications and comorbidity patterns to include research that seeks to establish how the disorder affects the daily performance and well-being of the population (Pyne et al., 1997, Kocsis et al., 1997). This subjectively perceived well-being, which is summarized in the concept of quality of life (QOL), is among the patients’ and their relatives’ main concerns; health care providers should also consider it as a major treatment outcome.

Primary care physicians often assume that mood-related complaints such as depression are less significant for the patient’s general well-being than many other medical conditions that give rise to consultation. Nonetheless, those who are in daily contact with depressed patients are acquainted with the serious repercussions of depression on the individual’s well-being; repercussions that in turn give rise to physical disability and reduce one’s functional capacity to work (Mintz et al., 1992, VonKorff et al., 1992, Bruce et al., 1994). Depression is often accompanied by impairment in role functioning in non-work domains as well (Katschnig & Angermeyer, 1997). It is therefore reasonable to expect depression to have a significantly negative effect on patients’ more broadly defined QOL.

Is it reasonable, however, to expect the magnitude of the depression–QOL relation to be as great as that observed in chronic physical conditions? This is one of the central issues examined in the present paper. Existing studies of this issue have been carried out almost exclusively in North American or Western European samples (Ormel et al., 1993, Hays et al., 1995, Ormel et al., 1998). For example, in perhaps the largest study to date, QOL was assessed in over 11,000 patients under treatment in the United States for chronic medical conditions such as hypertension, diabetes, arthritis, advanced heart disease and depression (Wells, Steward & Hays, 1989). Data from the Medical Outcome Study’s 36-item Short-Form Health Survey SF36, which measures QOL in eight role and function domains, indicated that patients with depression scored as poorly as patients with other chronic conditions in comparison with healthy community controls.

Whether these findings may be generalized to other countries and populations is unclear. One cross-cultural report suggests that depression and psychopathology in general may exert an even greater impact on QOL than that attributable to chronic physical illness (Ormel, VanKorff, Ustun, Pini, Korten & Oldehinkel, 1994). However, the central limitation in every study to date is that the QOL assessment instruments are either limited in scope, or have not been developed and validated for cross-cultural use.

The present study assesses QOL in patients with depression in a Latin American country, Argentina, using a QOL instrument developed and validated at a local level with procedures that follow international scientific standards. Specifically, we employed the WHO transcultural QOL measure, the WHOQOL (The WHOQOL, 1994, The, 1999). The WHOQOL resulted from a WHO initiative to develop a QOL instrument simultaneously in a diverse group of countries, among them Argentina. The goal of this initiative was to facilitate the direct comparison of the results of similarly designed studies among these countries.

We administered the Argentine versions (Bonicatto, Soria & Tagliero, 1996; Bonicatto & Soria, 1998) of both the long form (WHOQOL-100) and the short form of the WHO instrument (WHOQOL-BREF), as well as other clinical measures, to: (a) a group of patients with diagnosed depression, (b) a matched sample of non-depressed physically healthy persons and (c) groups of patients with one of three chronic medical conditions: lumbalgia, hypertension or breast cancer. We hypothesized the following: (1) patients with clinical depression would show a significant impairment of their QOL when compared with healthy individuals; (2) QOL would be as negatively affected, and possibly more affected, in cases of depression compared with other chronic severe pathologies (Bonicatto, Zaratiegui & Lorenzo, 1998a); (3) among depressed persons, greater severity of depressive symptoms would be associated with greater decrements in all QOL domains.

Section snippets

Patients with depression

Between March 1997 and May 1998, all newly diagnosed depressed patients (n=48) attending the outpatient offices of a private psychiatric assistance centre in La Plata, Province of Buenos Aires, were enrolled in the study. No one declined to participate in the study. Each had been diagnosed by an experienced clinician with a major depressive episode in accordance with DSM-IV criteria (American Psychiatric Association, 1994). The sociodemographic characteristics of the patients are shown in Table

Results

Reliability: The internal consistency reliabilities for the six domains and for the scale as a whole are shown in Table 2. The alpha coefficients are 0.69 or greater for all the domains, indicating a high level of reliability (Nunnaly, 1970). The facet–domain correlations also proved generally satisfactory, although they tended to be lower within the environment domain than in other domains. This may be due to the fact that, while all of the facets in the domain concern elements of the

Discussion and conclusions

Significantly reduced QOL has been previously demonstrated among depressed people primarily in English-speaking countries, using a variety of measurement instruments in these populations (Bech, 1996). The present study provided one of the first opportunities to consider the WHOQOL-100 as an instrument specifically designed to facilitate cross-cultural comparisons of QOL. The careful development and validation of this instrument made it an ideal choice for comparing QOL in depressed persons in

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