Medical Journal of Dr. D.Y . Patil University July-September 2013 Vol 6 Issue 3 229Address for correspondence: [611265]

Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3 229Address for correspondence:
Dr. Daniel Saldanha, Department of Psychiatry, Dr. DY Patil Medical College, Pimpri, Pune, India. E-mail: [anonimizat]
Quality of Life: The Concept
The quality of a person’s life may be considered in terms of
its richness, completeness, and contentedness. The concept Quality of life impairment in depression and
anxiety disorders
Neha Pande, Vishu Tantia1, Archana Javadekar, Daniel Saldanha
Department of Psychiatry, Padmashree Dr. D.Y . Patil Medical College, Hospital and Research Centre, Dr. D.Y . Patil Vidyapeeth, Pimpri, Pune,
1Psychiatrist, Shree Ganganagar, Rajasthan, India
ABSTRACT
Background: Most common mental disorders (CMDs) such as
anxiety disorders and depressive disorders run a persistent and
long course. This results in significant impairment of quality
of life (QOL) of patients and their families. Evidence‑based
psychosocial interventions using findings in our own socio‑cultural
context would help clinicians in holistic management.
Objectives: To document illness profile, treatment satisfaction,
and QOL in various domains of life in study population and
normal controls. Study Design: Cross‑sectional analytical
study of patients group and their normal family members
as a comparison group. Materials and Methods: A total of
100 consecutive patients of depressive disorders and anxiety
disorders (ICD‑10 clinical diagnosis) attending outpatient clinic
of the medical college hospital and their age‑ and gender‑matched
relatives as the control group were recruited. Socio‑demographic
profile was documented along with illness parameters: Severity
of illness, treatment satisfaction, and QOL was measured using
semi‑ structured interview, HAM, Beck’s depression Inventory,
and WHO‑QOL scale. Results: The study group measured
significantly low on QOL than the comparison group. The two
groups differed significantly on the paired “ t” test of significance
and the variation had a genuine assignable cause. Notwithstanding
some variables having a confounding effect and the limitations of
a cross‑sectional study, the study was conclusive in demonstrating
statistically significant impairment of QOL of patients with
CMDs, making a strong case for clinicians to pay attention to
holistic management of patients. The study has generated QOL
data on a small but significant normative population which may
serve purpose in future QOL studies.
Keywords: Anxiety, common mental disorders, depression,
quality of lifeAccess this article online
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DOI:
10.4103/0975-2870.114640Original Article
of quality of life (QOL) was introduced in 1975 in medical
indices and its systematic study started in early 1980s mainly
within oncology.
World Health Organization (WHO) defines QOL as
individuals’ perception of their position in life in the context
of culture and value systems in which they live and in
relation to their goals’ expectations, standards, personal
health, psychological state, and concerns.[1]
QOL reflects a growing appreciation of importance of how
patients feel and how satisfied they are with treatment,
besides the traditional focus on disease outcome.[2]
Health‑related QOL is a multidimensional concept that
encompasses the physical, emotional, and social components
associated with an illness or treatment,[3] and the impact
of health conditions on function, but include social role,
suggesting that health‑related QOL may be independent of
QOL relevant to work setting, housing, or similar factors.[4]
According to Patrick and Erickson, life has two dimensions:
Quantity and quality.[5] Quantity of life is expressed in
terms of “hard” biomedical data such as life expectancy or
mortality rates. QOL describes subjective evaluation of life
in general.
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230 Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3
Pande, et al. : Quality of life impairment in depression and anxiety disordersThe WHO has projected that by the year 2020, depression
would reach 2nd place, next to diabetes as contributor
to global burden of diseases (GAD).[6] The high lifetime
prevalence of depression and high disability induced
by depression exceeding that of diseases, such as pain,
hypertension, diabetes, and coronary heart diseases, call for
understanding of impact of this condition on people’s life.[7]
The core symptoms of depression include anguish, sadness,
mournfulness, irritability, deep sense of futility, diminished
ability to experience pleasure, slowing or decrease in almost
all aspects of emotions and behavior: Thought, speech,
energy, sexuality and physical “neuro‑vegetative” functions
such as eating, sleeping, and grooming.[8]
The lifetime prevalence of anxiety disorders is almost 25%,
and description of which date back to 4th century B.C. in the
writings of Hippocrates.[9] The term anxiety means, experience
of excessive worry and apprehension and undue pessimism.
Somatic symptoms include palpitations, tachycardia, and
shortness of breath, lightheadedness, dry mouth, nausea,
diarrhea, and perspiration. Anxiety and depression often
coexist. These disorders have a considerable impact on QOL
on account of high levels of distress and suffering.
The present article is based on a study of significant clinical
interest to examine the contribution of symptom severity,
the presence of psychiatric co‑morbidity, the duration
of illness, and demographic variables to QOL and its
dysfunction.
Materials and Methods
The study was conducted at the Department of Psychiatry
of a 750 bed, general hospital affiliated to medical college.
Around 40 patients attend outpatient services daily and
approximately 50% of them comprise of anxiety and
depressive disorders.
All consecutive adult patients of depression and anxiety
disorder attending the outpatient and inpatient departments
diagnosed by two qualified psychiatrists using ICD‑10
clinical diagnostic criteria constituted the study group.
Primary diagnosis of bipolar disorder, psychotic disorders,
and serious general medical condition were excluded.
The comparison group comprised of age‑ and gender‑matched
healthy adult family members residing with the patients in
the same house. For augmentation of the sample, age‑ and
gender‑matched relatives of medical outpatients were also
recruited. The comparison subjects having current or past
history of mental illness were excluded.A total of 100 consecutive patients and matched controls
were recruited between the periods of October 2007 and
May 2009.
A specially designed pro‑forma was used to document
socio‑demographic profile, illness and treatment details,
etc. Hamilton Rating Scale for Depression and Hamilton
Rating Scale for Anxiety were used for the assessment of
severity of illness.
The QOL questionnaire of WHO was chosen for the
assessment of QOL. A semi‑structured interview using
operationalized, pilot‑tested questionnaire was conducted. In
essence, all the four domains of the tool WHOQOL‑BREF[10]
were incorporated. The format of interactive, conversational
yet comprehensive assessment has enhanced the richness of
the narrative. Informed consent was obtained from all the
subjects in both the groups. Approval of institutional ethical
committee was obtained before commencement of the study.
The results of the descriptive analysis of illness variables,
symptom variables, functionality, relationship, money
matters, physical environment, leisure and enjoyment, and
overall satisfaction with life have been tabulated. Quantitative
analysis was done by as per the WHOQOL‑BREF manual
for scoring.
Results
The socio‑demoraphic profile has been presented in Table 1.
The profile of both the groups did not show statistically
significant difference.
ICD‑10 classification categories of depressive disorders are
F‑32, F‑33, and F‑44.
66% of the study group had a diagnosis of depressive disorders
and 34% had anxiety disorders (F‑41 of ICD‑10) [Table 2].
Illness Profile
60% patients had illness of more than 6 months duration.
91% had continuous course of illness and only 9% had
episodic illness.
About 1 in 5 patients reported co‑morbid medical condition,
while 34% in the comparison group reported medical illness
such as hypertension, diabetes, asthma, cardiac problems,
etc.
Symptom Profile [Table 3]
Neuro‑vegetative symptoms of both the conditions cause
considerable distress and contribute to dysfunctionality.
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Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3 231
Pande, et al. : Quality of life impairment in depression and anxiety disordersOnly 1 in 4 reported optimal total duration of sleep (6‑8 h),
the proportion for the same in the comparison group was 3
in 4. Other sleep parameters such as difficulty in initiation of
sleep, sleep maintenance, freshness in the morning, energy
levels and fatigue in the two groups have been presented
in Table 3. The two groups measured highly significantly
different on the entire symptom profile.Functionality Profile [Table 4]
The regularity of daily routine is known to offset effects
of dysfunctionality. Depression and anxiety have direct
effects on work and daily routine. Again, the two groups
have highly significant difference on functionality
parameters such as daily routine, regularity at work, and
work satisfaction.
Table 1: Socio‑demographic profile
Study
group
N=100 Comparison
group
N=100 Chi
square P Value
Age (years)
Mean 35 40 11.19 0.004 NS
Gender
Male 46 42 0.183 0.669 NS
Female 54 58
Marital status
Single 19 14 2.856 0.563 NS
Married 79 83
Separated/divorced 1 0
Widowed 1 3
Education
Illiterate 16 13 4.075 0.130 NS
Upto HSc 77 71
Above HSc 7 16
Religion
Hindu 91 88 3.317 0.190 NS
Muslim 14 11
Employment
Unemployed 20 16 0.602 0.740 NS
Gainfully employed 51 52
Homemakers/students 29 32Table 2: Illness profile
(N=100)
Diagnosis (ICD‑10)
Depressive episode (F‑32) 48
Recurrent depressive disorder and dysthymia (F‑33 and F‑44) 18
Other anxiety disorders (F‑41) 34
Duration of illness
Upto 6 months 40
6 months to 1 yr 20
More than 1 yr 40
Course
Continuous 91
Episodic 9
Medications
Antidepressant 17
Antianxiety 11
Antidepressant+antianxiety 56
Polypharmacy 12
ECTs 4
Hospitalization
Ye s 36
No 64
Satisfaction with treatment
Y es 61
Table 3: Symptom profile
% Distribution
Study group Comparison group Chi square P Value
Sleep duration
Upto 6‑8 hrs 95 93 0.089 0.766 NS
More than 8 hrs 5 7
Ye s No Ye s No
Initiaion difficulty 77 23 12 88 82.923 0.000 HS
Maintenance difficulty 42 58 2 98 44.318 0.000 HS
Early morning awakening 55 45 5 95 57.167 0.000 HS
Freshness in the morning 21 79 91 9 96.611 0.000 HS
Concentration 20 80 85 15 82.125 0.000 HS
Energy 10 90 79 21 83.613 0.000 HS
Severity of symptoms
HAM‑A N=16 N=100
No anxiety 0 82 0.004 0.847 NS
Clinical anxiety 37.5 14
Significant anxiety 62.5 4
HAM‑D N=84 N=100
No depression 0 0
Mild to moderate depression 51.2 0
Severe depression 48.8 0
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232 Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3
Pande, et al. : Quality of life impairment in depression and anxiety disordersSupport systems modulate the impact of illness. Practical as
well as emotional support comes from the primary family.
The two groups did not differ significantly. The married
in the study group ( n = 79) were not satisfied in sexual
relationships compared to 11% ( n = 83) in the comparison
group, highly significant statistically. Financial condition
as affected by the illness, savings, assets, and loans as
an additional burden, in both the groups, did not have
significant difference.
Housing, sanitation, infrastructure facilities, etc., have an
effect on QOL [Table 4].
Participation in cultural and religious events, festivals,
pilgrimage, etc., confers inclusiveness. Some depressed
individuals may shun social contact, whereas anxious
people may feel sense of belonging. 92% respondents used
to participate in cultural events before illness, whereas
currently only 61% do so. Thus, a shift of 53% indicates the
effect of illness on this variable. 30% men and women would
watch movies and 72% would go on outing for enjoyment
before illness. Only 5% reports to watch movies currently,
while 15% said they still enjoyed outings, a sharp decline
in leisure and enjoyment behaviors.
Overall Satisfaction with Self
76% of the study respondents reported in negative about
overall satisfaction with self, while 76% in the comparison
group reported satisfaction with self, the difference is highly
significant.Quantitative Global Assessment of QOL
Conversion of raw scores into transformed scores for each
of the domain questions was done in adherence to the
WHOQOL‑BREF manual.[10] In the study group, the range
of scores obtained was 30 to 140 and the mean score was
66 (Graph 1). In the comparison group, the range was 38–180
and the mean score was 149.
Within the study group (intra group), analysis of relationships
between illness and symptom parameters with QOL, severity
of illness, functionality and QOL, spousal relationship,
financial status, and overall satisfaction with self and QOL
was carried out [Table 5]. 80% of the respondents with
severe anxiety and 87.7% with severe depression reported
lower than average QOL as compared to mild depression.
Continuous illness seems to have correlation with less than
average QOL (62.6%), but not the duration of illness.
Respondents dissatisfied with the treatment and those with
side effects of drugs, measured to have the less than average
QOL (82.11% and 60.9%).
68.4% subjects with less than average QOL reported
dissatisfaction with sleep, poor concentration (71.3%), and
low energy (64.4%) than respondents with above average
QOL.
In the study group, 71.7% whose daily routine was affected,
90% with absenteeism at work, and 70% with dissatisfaction
at work reported lower QOL.Table 4: Dimensions of quality of life
Functionality % Distribution
Study group ( n=100) Comparison group ( n=100) Chi square P Value
Daily routine
Disturbed 39 4 34.247 0.000 HS
Work Working ( n=51) Working ( n=52)
Absenteeism 39 0 110.15 0.000 HS
Dissatisfied 78 4 25.273 0.000 HS
Leisure Literate ( n=84) Literate ( n=87)
Newspaper reading 35 52 14.395 0.003 NS
Watch television 60 79
Support system
Practical (primary family) 82 96 0.050 0.823 NS
Emotional (primary family) 87 95
Spousal sexual relationship (n=79) (n=83)
Dissatisfied 64.6 13.3 46.124 0.000 HS
Financial condition
Affected 66 Na
Housing: Adequate space 52 70 7.096 0.119 NS
Safety 82 79 2.429
Transport (public) 47 59 52.020 0.000 HS
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Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3 233
Pande, et al. : Quality of life impairment in depression and anxiety disordersDissatisfaction with spousal relationships was associated
with below average QOL in 74.5%. Similarly, respondents
with financial status affected due to illness reported low
QOL (65.6%). The overall satisfaction with self showed
positive and linear correlation with QOL scores.
The implications of intra‑group comparisons and Table 5: Corelational analysis
% Distribution as per mean QoL
Scores in the study group
Less than or=66 >66 Chi square P Value
HAM‑A
Clinical anxiety 33.3 66.7 1.77 0.18 NS
Significant anxiety 80 20
Depression
Mild 8.3 91.6 24.75 <0.001 HS
Moderate 45.1 54.8
Severe 82.9 17
Duration of illness
Upto 6 months 60 40 0.002 0.96 NS
>6 months 58 42
Course of illness
Continuous 62.6 37.3 3.986 0.03 NS
Episodic 22.2 77.8
Satisfaction with treatment
Ye s 44.3 55.7 12.52 <0.001 HS
No 82.1 17.9
Sleep <6 hrs 62.3 37.7 0.619 0.02 S
>6 hrs 51.6 48.4
Satisfaction with sleep
Ye s 23.8 76.1 11.82 0.002 HS
No 68.4 31.6
Concentration
Normal 10 90 22.34 <0.001 HS
Poor 71.3 28.7
Energy low 64.4 35.6 8.89 <0.017 S
Normal 10 90
Functionality
Daily routine affected 71.7 28.3 3.50 0.02 S
Not affected 10 90
Work status
Regular 51.6 48.4 6.42 0.01 S
Absenteeism 90 10
Work satisfaction
Ye s 36.4 63.6 2.86 0.09 NS
No 70 30
Spousal sexual relations
Satisfactory 21.4 78.6 18.54 <0.001 HS
Not satisfactory 70 30
Financial status
Affected 65.6 34.4 0.42 0.14 NS
Not affected 45.8 54.2
Overall satisfaction with self
Y es 12.5 87.5 25.75 <0.001 HS
No 73.7 26.3comparison of both the groups in totality have been
discussed next.
Discussion
The concept of “quality of life”, developed in the social
sciences, was first applied in medical practice in 1980 with
cancer patients. In doing so, first step was taken in the
direction of measurement of aspects of human sufferings
which until 30 years ago was considered non‑measurable.[11]
This concept is better approached as multidimensional
construct, covering a number of conventionally defined
domains.[12] Mauro and Stein[9] have quoted, “it is recommended
that we avoid the vagaries of abstract and philosophical
concepts and concentrate on aspects of personal experience that
are related to health and healthcare (health related QOL)”.[13]
Initiative of WHO to develop the QOL assessment arose from
a need for a genuinely international measure of QOL and
promotion of a holistic approach to health and healthcare.
The definition of QOL adopted by WHO reflects and focuses
upon respondents “perceived” QOL. The recognition of the
multi‑dimensional nature of QOL is reflected in the tool
used for the present study, WHOQOL‑BREF.
The invisible suffering on the account of impact of the
anxiety and depression on every aspect of life compromises
the QOL of patients not only during the active symptomatic
state but often beyond symptomatic recovery. Our findings
are discussed below in the light of the literature referenced.
QOL is a dependent variable and hence context specific. The
present study has generated data on QOL of relatives of patients
who had comparable living conditions and environment.
Demographic characteristics were comparable too, as discussed
earlier, without any statistically significant differences with
the study population [Table 1]. The comparison group is not
a control group in strict methodological sense neither is it a
community sample as they were hospital attendees for the
index patients but without a mental illness. But it has served the
purpose of generating some normative data for bench marking.
The scores on WHOQOL for this comparison group were
in the range of 38‑180 and the mean score was 149. There
were 34% respondents even in this group who reported to
have medical illness. This may have contributed to the lower
end of the scatter on the values of QOL.
Study group, with highest score of 140, was below the mean
score of the comparison group indicative of much lower
QOL on the account of impact of illness in comparison with
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234 Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3
Pande, et al. : Quality of life impairment in depression and anxiety disordershealthy adult relatives (Graph 1). The study group showed
skewed distribution to the left while the comparison group
showed skew toward the right.
Intra‑group Analysis of Association
Within the study group, the comparison of respondents scoring
less than mean values on QOL ( ≥66) with those scoring more
than mean values was undertaken. A significant association
emerged between study variables and QOL [Table 5].
Continuous illness had a significant association with lower
QOL than with episodic illness. Pyne et al.[14] in their study
over 3 years reported similar findings about duration of
illness impacting QOL. Severely depressed subjects in the
study group scored low on QOL, but not moderately and
mild depressed ones. The inverse relationship between the
severity and QOL in this study was in keeping with results
of Pyne et al.[15] and Skevington et al.[16] In their study of
elderly patients, Chachamovich[17] reported that even milder
depressions were associated with poor QOL. Our study
did not find the same as ours was predominantly young
population (48% were less than 30 years old).
In the anxiety subgroup, the association between severity
and QOL could not be tested statistically as this subgroup
was small. Menlowicz,[18] Koran et al.,[19] Hollifield et al.,[20]
and Warshaw[21] have reported a significant association
between severity of anxiety and QOL. Patients in their study
had severe form of anxiety, namely OCD, panic disorder,
and PTSD’s crippling symptoms.
No significant association was found between presence
of side effects, co‑morbidity and QOL. Highly significant
association was found between dissatisfaction with
treatment and poor QOL. Chan et al .,[22] observed linear
relationship between improvements in QOL of depressed
patients following treatment. Individual symptoms and
QOL has shown significant association [Table 5]. Those
that slept poorly, didn’t feel fresh in the morning, had
poor concentration and low energy levels had linear and
statistically significant association with QOL.
Among the parameters of functionality, work status and
work days missed due to illness have been studied by
Simon[23] and Broadhead et al .,[24] the latter study was
conducted on a large sample of 2980 participants. This
prospective epidemiologic survey reported that depression
raised 4.78 times more risk of work‑related disability than
asymptomatic individuals.
In our own study, overall 39% of the working population
reported absenteeism and in this group 90% of the absentees scored poor QOL, this association being statistically
significant. Depression is associated with significant
reduction in work capacity and thus affects the QOL.
Significant linear association was found between low QOL
and disturbed daily routine [Table 5].
Highly significant linear association was found between
unsatisfactory spousal sexual relationship and poor QOL.
The association was bidirectional, namely satisfactory
spousal relationship correlated with better QOL. Our
findings are in keeping with those of Katherine et al .[25]
and Oatman.[26] which was an in‑depth qualitative study of
10 patients and former was of 204 women. Massion et al.
in their prospective, naturalistic, longitudinal, multicenter
study of 357 subjects used modified short form health
survey for assessment of QOL and reported poor marital
relationship in 20% subjects of panic disorder and GAD.
66% respondents in study group reported affected financial
status in comparison with the same before illness, its
correlation with QOL was not of statistical significance.
The composite dimension of overall satisfaction with self
had been highly significant and the correlation with QOL
was bidirectional.
The cross‑sectional design of our study does not permit
analysis of cause and effect relationships. Also, although
both depression and anxiety and QOL are distinct
concepts,[27] there is obvious and considerable overlap
between them.
For quantifying the cause of variation in study and
comparison groups (normal adults), the paired “ t” test
of significance was applied based on standard normal
variants (distribution). It yielded highly significant
variation in the two groups (z > 3, P = 0.001 at 99% level of
significance). It can be safely inferred that the two groups
differ from each other and the quantum of variation had a
genuine assignable cause.
Similarly, in spite of the considerable overlap between
variables under study, the present study has been found
conclusive about effects of anxiety and depression
disorders on the QOL of patients and has brought home the
importance of these findings to the clinician for better and
holistic management of patients.
Acknowledgement
Dr. L. Bhattacharya, Professor and Head of the Department
of Psychiatry, Padmashree Dr. D Y Patil Medical College and
Research Centre (Dr. D Y Patil Vidyapeeth, Pune).
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Medical Journal of Dr. D.Y . Patil University | July-September 2013 | Vol 6 | Issue 3 235
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How to cite this article: Pande N, Tantia V, Javadekar A, Saldanha
D. Quality of life impairment in depression and anxiety disorders. Med
J DY Patil Univ 2013;6:229-35.
Source of Support: Nil. Conflict of Interest: None declared.
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