Elsevier

General Hospital Psychiatry

Volume 26, Issue 1, January–February 2004, Pages 13-17
General Hospital Psychiatry

Original article
Quality of life assessments in major depressive disorder: a review of the literature

https://doi.org/10.1016/j.genhosppsych.2003.07.004Get rights and content

Abstract

According to the DSM-IV classification, a diagnosis of Major Depressive Disorder (MDD) is possible only when there is evidence of significant inference with functioning. However, despite the high prevalence of MDD in the general population [1], it is uncommon for clinicians to assess overall functioning in a systematic way before making such diagnosis. An important correlate of functioning is quality of life, which is typically defined as “patients' own assessments of how they feel about what they have, how they are functioning, and their ability to derive pleasure from their life activities” [2]. In the present article, we review studies focusing on the relationship between depression and quality of life, particularly focusing on the impact of the treatment of depression on quality of life. Studies focusing on the quality of life in MDD are reviewed. Candidate studies published between 1970 and recently were initially identified by Pubmed and Ovid search cross-referencing the terms “quality of life,” “psychosocial functioning” with “major depression” and “treatment.” A number of studies report poorer quality of life in MDD patients compared to controls. Several studies also report an improvement in quality of life measures during various phases of treatment with antidepressants and/or psychotherapy. However, trials comparing the role of newer psychopharmacologic agents in the acute phase of treatment, and the role of newer psychotherapies in the continuation and maintenance phases of treatment in restoring psychosocial functioning and improving the quality of life in MDD are lacking. Exploring the impact of these modalities on psychosocial function and quality of life in MDD are necessary to help translate clinical response into restoration of psychosocial function and to thus further improve the standard of care.

Introduction

Unipolar depression is currently the leading cause of disability in developed countries [3], and the fourth leading cause of disability worldwide [4]. Projections estimate that Major Depressive Disorder (MDD) will rise to be the second leading cause of disability worldwide by the year 2020 [5]. MDD has also been shown to account for a 23-fold increase in social disability, even after controlling for physical disease [6], as well as an almost 5-fold increase in short-term work-disability days [7]. Patients with MDD were found to score lower than those with a number of medical conditions on physical functioning, role functioning and emotional functioning [8]. Patients with Major Depression were also found to have long-lasting decrements in psychosocial functioning that were equal to or greater than those of patients with chronic medical illness such as diabetes and osteoarthirtis [9]. In a study of 11242 outpatients in three health care provision systems, Wells and colleagues reported worse physical, social, and role functioning in MDD patients than patients with no chronic conditions [10]. A large study of 25916 primary care patients from 14 countries revealed that patients with MDD were more likely to report disability than those without, controlling for the severity of physical disease [11]. In a similar study conducted in Western Europe, the degree of disability was found to be directly related to severity of depression in patients with MDD [12]. This may account for the fact that individuals with a history of a depressive episode are also at increased risk for chronic financial stress [13]. The presence of less severe depressive disorders such as sub-syndromal depression has also been shown to have a negative impact on psychosocial functioning [14]. Finally, the annual cost of depression to society in the US has been estimated at 44 billion dollars [15]. Of this amount, $23.8 billion represent costs stemming from the impact of depression in the workplace [15]. These estimates include costs associated with MDD, bipolar depression, and dysthymia but not minor depression.

Perhaps the most disabling aspect of depression is it's adverse impact in psychosocial functioning and quality of life. A number of studies have compared MDD patients with normal controls on several aspects of social functioning. Women with MDD were found to have more impairment in familial, marital, and occupational roles that nondepressed women [16]. A study comparing social functioning in outpatients with MDD, bipolar depression, or dysthymia revealed disturbances in most areas of functioning, predominantly occupational and leisure activities [17]. Fredman and colleagues [18] reported poorer intimate relationships and less satisfying social interactions in patients with MDD compared to those without in a community sample of nearly 5000 patients. Results stemming from the National Institutes of Mental Health (NIMH) Epidemiological Catchment Area Program [19] revealed that subjects with Major Depression or subsyndromal depression had higher levels of household strain, social irritability, financial strain, limitations in occupational functioning, poor health status [14], and days lost from work [20] than subjects without any depressive disorder or symptoms. Finally, data stemming from the National Comorbidity Survey [21] revealed that patients with depression (defined as either MDD, bipolar depression, or dysthymia) were less likely to complete high school or college [22]; more likely to experience teenage pregnancy [23] and more likely to experience divorce [24] than nondepressed subjects. While patients with MDD were less likely to be satisfied with their marriage [25], and more likely to report poorer quality of interpersonal relationships [26] than subjects without MDD.

Section snippets

The impact of treatment on quality of life in MDD

Although it is widely assumed that the improvement in depressive symptoms during treatment leads to an improvement in the quality of life and a decrease in disability, few antidepressant trials focus on the impact of treatment on quality of life and disability. In the language of the World Health Organization (WHO), health is defined as “a state of complete physical, mental, and social well-being and not merely the absence of infirmity” [27]. From this standpoint, clinical response, and

Conclusion

A number of large, epidemiologically based studies suggest that MDD is associated with significant disability and poorer quality of life. Studies focusing on the impact of the acute phase of treatment on quality of life suggest that antidepressant treatment may lead to significant improvement in quality of life measures. Studies focusing on the maintenance and continuation phase of treatment show a less dramatic improvement in psychosocial function over time for pharmacotherapy compared to

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