Changes in women’ quality of life during the outpatient treatment of depression ; Moterų gyvenimo kokybės kitimas ambulatorinio depresijos gydymo laikotarpiu
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VYTAUTAS MAGNUS UNIVERSITY Klaudija Pauliukevičiūtė CHANGES IN WOMEN’ QUALITY OF LIFE DURING THE OUTPATIENT TREATMENT OF DEPRESSION Summary of the Doctoral Dissertation Social Sciences, Psychology (06S) Kaunas, 2010 The right of doctoral studies was granted to Vytautas Magnus University jointly with Klaipėda University on October 7, 1992 by the decision No. 739 of the Government of the Republic of Lithuania, (renewed jointly with Klaipėda University on April 14, 1998 by the decision No. 457 of the Government of the Republic of Lithuania), and restored on October 31, 2007 by the decision No. 1155 of the Government of the Republic of Lithuania. The dissertation was carried out at Vytautas Magnus University in 2000 – 2004. External defense Scientific supervisor: Prof. Dr. Habil. Antanas Goštautas (Vytautas Magnus University, biomedical sciences, medicine – 07 B, psychiatry – B 650; social sciences, psychology – 06S) Council of defense of the doctoral dissertation: Chairperson: Prof. Dr. Habil. Vytautas Gudonis (Academician of the Academy of Education and Social Sciences of Russia, Academician of New York Academy of Sciences, Siauliai University, social sciences, psychology – 06S, education science – 07S) Members: Assoc. Prof. Dr. Loreta Gustainienė (Vytautas Magnus University, social sciences, psychology, 06S) Prof. Dr.
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01 janvier 2010
VYTAUTAS MAGNUS UNIVERSITY Klaudija Pauliukevičiūtė CHANGES INWOMEN’ QUALITY OF LIFE DURING THE OUTPATIENT TREATMENT OF DEPRESSION Summary of the Doctoral Dissertation Social Sciences, Psychology (06S) Kaunas, 2010
The right of doctoral studieswas granted to Vytautas Magnus University jointly with Klaipėda University on October 7, 1992 by the decision No. 739 of the Government of the Republic of Lithuania, (renewed jointly with Klaipėda University on April 14, 1998 by the decision No. 457 of the Government of the Republic of Lithuania), and restored on October 31, 2007 by the decision No. 1155 of the Government of the Republic of Lithuania. The dissertation was carried out at Vytautas Magnus University in 2000–2004. External defense Scientific supervisor: Prof. Dr. Habil. Antanas Goštautas(Vytautas Magnus University, biomedical sciences, medicine–07 B, psychiatry–B 650; social sciences, psychology–06S) Council of defense of the doctoral dissertation: Chairperson: Prof. Dr. Habil. Vytautas Gudonis(Academician of the Academy of Education and Social Sciences of Russia, Academician of New York Academy of Sciences, Siauliai University, social sciences, psychology– education 06S, science–07S) Members: Assoc. Prof. Dr.Loreta Gustainienė(Vytautas Magnus University, social sciences, psychology, 06S) Prof. Dr. IraydaJakušovaitė(Kaunas University of Medicine, biomedical sciences, public health–10B) Prof. Dr. (HP)Irmina Matonytė(Lithuanian Social Research Center, social sciences, sociology–05S) Assoc. Prof. Dr. Ina Pilkauskienė(Vytautas Magnus University, social sciences, psychology, 06S) Opponents: Prof. Dr. Habil. Algirdas Dembinskas(Vilnius University, biomedical sciences, medicine–07B, psychiatry–B650) Assoc. Prof. Dr. NidaŽemaitienė(Kaunas University of Medicine, biomedical sciences, public health–10B, social sciences, psychology, 06S) The public defense of the dissertation’s will be held at2 pm on June 29, 2010 in the auditorium 322 at Vytautas Magnus University. Address: Daukanto st. 28, LT-44246, Kaunas, Lithuania. Summary of the dissertation was sent out on May 29, 2010. The dissertation is available at the library of Vytautas Magnus University and at Martynas Mazvydas National Library of Lithuania.
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VYTAUTO DIDŽIOJO UNIVERSITETAS Klaudija Pauliukevičiūtė MOTERŲ GYVENIMO KOKYBĖS KITIMAS AMBULATORINIO DEPRESIJOS GYDYMO LAIKOTARPIU Daktaro disertacijos santrauka Socialiniai mokslai, psichologija (06 S) Kaunas, 2010
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Doktorantūros teisėVytauto Didžiojo universitetui suteikta kartu su Klaipėdos universitetu 1992 spalio 7 d. Lietuvos Respublikos vyriausybės nutarimu Nr. 739, (atnaujinta kartu su Klaipėdos universitetu 1998 balandžio 14 d. Lietuvos Respublikos vyriausybės nutarimu Nr. 457), atkurta 2007 m. spalio 31 d. Lietuvos Respublikos vyriausybės nutarimu Nr. 1155. Disertacija parengta 2000-2004 metaisVytauto Didžiojo universiteto Socialinių mokslų fakulteto Teorinės psichologijos katedroje. Disertacija ginama eksternu. Darbo vadovas: Prof. habil. dr. Antanas Goštautas(Vytauto Didžiojo universitetas, biomedicinos mokslai, medicina–07 B, psichiatrija–B 650; socialiniai mokslai, psichologija, 06S) Disertacija ginama VytautoDidžiojo universiteto Psichologijos mokslo krypties taryboje: Pirmininkas: Prof. habil. dr. Vytautas Gudonis(Šiaulių universitetas, socialiniai mokslai, psichologija 06S, edukologija 07S, Rusijos pedagoginių ir socialinių mokslų akademijos akademikas, Niujorko mokslų akademijos narys) Nariai: Prof.dr. Irayda Jakušovaitė(Kauno Medicinos universitetas, biomedicinos mokslai, visuomenės sveikata 10B) Doc. dr. Loreta Gustainienė(Vytauto Didžiojo universitetas, socialiniai mokslai, psichologija 06S,) Doc. dr.Ina Pilkauskienė(Vytauto Didžiojo universitetas, socialiniai mokslai, psichologija 06S) Prof. dr.(HP) Irmina Matonytė(Lietuvos socialinių tyrimų centras, socialiniai mokslai, sociologija 05S) Oponentai: Prof. habil. dr. Algirdas Dembinskas(Vilniaus universitetas, biomedicinos mokslai, medicina–07B, psichiatrija–B650) Doc. dr. NidaŽemaitienė Medicinos universitetas, biomedicinos (Kauno mokslai,visuomenės sveikata –10B, socialiniai mokslai, psichologija, 06S) Disertacija bus ginama viešame doktorantūros tarybos posėdyje 2010 m.birželio29 d. 14 val. Vytauto Didžiojo universitete, auditorijoje 322 Adresas:Donelaičio 52, LT-44246, Kaunas, Lietuva Disertacijos santrauka išsiųsta 2010 m.gegužės 29 d. Su disertacija galima susipažinti Lietuvos nacionalinėje M. Mažvydo ir Vytauto Didžiojouniversiteto bibliotekose.
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TABLE OF CONTENTS
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1. INTRODUCTION World Health Organization (WHO) defines health as “ a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO:Constitution of the World Health Organization. Basic documents, 1948 (WHO, 1991:5). Nowadays health institutions usually apply the“health model based on biological assumption what health is” (Ryff, Singer, 1998:2). Psychologists underline that such a health model lacks psychological aspects of health and illnes because it stresses onlynegative aspects of the emotional status related to illness. “A positive health model should be based on the answers to the philosophical questions: “What the QoL is” and “What is cause of health and well-being“ Singer, 1998: (Ryff, 3). The authors analyzing the meaning of “good life” suggest defining health as multidimensional wellness or quality of life (QOL). The WHO uses the definion ofquality of life as “ an individual’s perception of their postion in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standarts and concerns” (WHO, 1993 (WHO: WHOQOL Study Protocol: Division of Mental Health (MNH/PSF/93.3), 1993). Thus, the WHO proposes that the positive health model should not be separated from the subjective individual understanding of wellness or subjective quality of life. Depression is one of the most wide-spread emotional illness (Ayuso-Mateos et al., 2001). Its prevalence is almost twice as high in female population then among male (Zilinskas et al., 1999; Kuehner, 2003; Stewart et al., 2004). For women depression starts in younger age, its duration is longer, it tends to be repeated and has more severe harmful impact then for men (Berndt et al., 2000). Medical treatment of depression at least takes 6 months (Kaplan, Sadock, 1991; Wittchen, 2006). Effectiveness of the treatment is evaluated by vanishing and disappearing of the symptoms, return of the patient to his/her ordinary state. However, changes of the symptoms of depression take place in the background of the health phenomenon. B.M. Booth et al. (1997) suggest that in the depression treatment it is important not only evaluate how medical treatment impacts symptoms of the illness, but also to understand what happens withpatient’shealth in general which could be measured along mulpiple indicators of the QoL.
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Research of the QoL of the consumers of the mental health service in Lithuania is scarce,even though “indicators of QOL as subjective health measure become more dominant in health services” (Kalediene, 1999).Yet, existing research crucially lacks longitudinal surveys on dynamics occurred in the QoL during treatment of various illnesses, including depression. Changes of the QoL among depressive women during three year of treatment in out-patient settings is examined in this study. This study analyzes the question how socio-demographic and health factors are related to the QoL and its changes. We suggest that orientation to subjective wellness or the QoL based on personal assessment can help to improve work of mental health centers, enhance positive achievements of intervention or rehabilitation models on the individual, systematic or community level, it can also contribute to better planning and provision of psychological support and assure successful long-term impact strategies in treatment of depression. The object of research is women’QoL and its changes during the out-patient treatment of depression. Previous research shows that low evaluation of the QoL and social adjustment might indicate that recovery is incomplete and depression might possibly recur in future despite temporal disappearance of depression symptoms (Ravindran, 2002). It is important to pay attentyion not only to changes in the symptoms of depression, but also to focus on changes in the general health status using the QoL indicators in the depression treatment process. The Biopsychosocial Model is used in this study to broadly evaluate the QoL by physical functioning, environmental, social and psychological components as it mostly corresponds to the nature of the work of primary mental health centers. Self-reported evaluation of the QoL and its changes are concurrent with cognitive and affective elements of mind and subjective experience of individual. According to R. W. Lent (2004) social cognitive theory combines three factors (behavior, cognition and environment) into one unit– functioning. psychosocial Therefore quality of life as subjectively evaluated well-being also conveys quality of psychological adaptation and psychosocial functioning.
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1.1. Scientific novelty of the study In order to increase effectiveness of support for the users of mental health services during the reform of health care system in Lithuania mental health centres have been established. Main functions of these entities are related to complex psychiatric, psychological and social support. Most of the consumers of these centres are women with depression. In Lithuania studies of the QoL of the users of mental health services started only recently. There is some research made in the QOL of the patients with ischemic heart disease, neurological or other somaticillness (Podlipskytė et al, 2004; Valeikienė and Juozulynas, 2004; Mereckas and Alekna, 2006; Staniute and Brozaitiene, 2008) and old people (Jurgelenas et al, 2007). Yet there is a lack of longitudinal studies of the QOL dynamics of the patients with various illnesses including depression. Analysis of the three years dynamic of the QOL of women with outpatient treatment of depression is performed in this research. It attempts to better disclose the context of this disease: special attention is paid to the complexity of factors related to the clinical passage of depression and social influences. Another novel aspect of this study is related to the selection of a specific group of respondents (women in out-patient treatment of depression; most of them had never underwent the inpatient treatment). 1.2. Theoretical and practical significance of the dissertation This study enhances more nuanced understanding of the relations between health measured by the QoL indicators and clinical peculiarities of depression, social and demographic factors. The study design is longitudinal and directed to examine dynamics in the QoL of patients with diagnosis of depression. WHOQOL-100 (The QoL questionnaire) standartised by WHO has been used for evaluation of the QoL. This method is suitable to use in different cultures and results of our research can be compared with results from other countries. Integrated evaluation of clinical condition of depression, mental health status during the treatment process and social demographic indicators extend the context of changes of the QoL during the outpatient ttreatment of depression. Usually clinical assessment of decrease of depressive symptoms orients towards inducing changes in the main indicators of depression (changes of energy decline, sadness and other similar symptoms) and it is widely used in public health institutions; while health might also be measured by multiple indicators of physical,
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mental and social functioning, as it is the QoL. Accordingly, this study broadens horizons of relevant profeesional analysis and provides additional information about health status of women with depression for mental health services workers (doctors, psychologists, social workers). This knowledge might be useful for evaluation of patient’s level and devising of efective strategies for psychosocial support, recovery rehabilitation and health improvement process. 1.3. The aim and objectives of the research The aims of the study are: (a) to evaluate the peculiarities of changes of women’ QoL during the three years outpatient treatment of depression; (b) to assess the importance of condition of clinical depression and mental health status, in line of socio-demographic factors, for prediction of plausible changesin the individual’s the QoL. In line with the aims, the following objectives have been set for the research: 1. To assess how the QoLof women’ with outpatient treatment of depression is related to indicators of condition of clinical depression (recurrence of depression episodes, number of episodes, duration of the episodes, inpatient treatment of depression, suicidal ideation, co morbidity of somatic illness, age of onset) and socio-demographic factors. 2. To evaluate and analyze peculiarities of changes of the QoL of women during three years of outpatient treatment of depression. 3. importance of mental health status during one year outpatientTo determine treatment (continuing depression or recovery), indicators of condition of clinical depression (recurrence of depression episodes, number of episodes, duration of the episodes, inpatient treatment of depression, suicidal ideation, co morbidity of somatic illness, age of onset) and socio-demographic factors, related with changes of the QoL during three years of outpatient treatment of depression. 1.4. Theses to be defended On the basis of the research presented in the dissertation, the following theses have been set for defense: 1. Higher the QoL of women with depression is related to the smaller number of or less intensively expressed indicators of clinical depression (smaller number of episodes, shorter duration of episodes, no inpatient treatment, no suicidal
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ideation thoughts, and no co morbidity of somatic illness, older age of the onset) and the following socio-demographic factors: younger age, higher level of education, living in marriage or cohabitation, having a paid job. 2. Positive changes of the QoL occur during one and during three years of outpatient treatment of depression. 3. Positive changes of the QoL which occur during three years of outpatient treatment of depression are related to the improvement of mental health status (recovery after one year of depression treatment), smaller number or less intensively expressed indicators of clinical depression (smaller number of episodes, shorter duration of episodes, no inpatient treatment, no suicidal ideation thoughts, and no co morbidity of somatic illness, older age of the onset) and the following socio-demographic factors: younger age, higher level of education, living in marriage or cohabitation, having a paid job. 1.5. The structure of the dissertation The dissertation consists of theoretical and empirical parts. Three chapters of the academic literature review provide background for the hypotheses for this research. The empirical part consists of chapters with research methods, results of the research, discussion, and conclusions. The results are presented in 15 tables and 17 figures. The results of statistical analysis are provided in 3 appendixes. The list of references consists 229 items in Lithuanian and English languages. 2. CONTENT OF THE DISSERTATION 2.1. Theoretical issues Firstly, we discuss peculiarities and psychosocial context of women’ depression, relationships between depression and illness or disability, psychosocial aspects of depression treatment. Further conception of the QoL, the main models of the QoL applied in mental health sector, links between the QoL and clinical indicators of depression, relationships between the QoL and socio-demographical factors related with depression are discussed. In the end, changes in the QoL and clinical indicators of depression, as though as importance of social and demographical factors in prediction of changes in the QoL of women with depression are presented. The main ideas revealed from the literature analysis are used to develop our hypotheses.
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2.2. Research methods WHOQOL-100 was used for measurement of QOL (WHOQOL Group, 1994). Standardized clinical interview (CIDI-2) was used for measurement of depression. All other data were collected from the documentation in Sanciai Mental health centre. 2.2.1. The QOL assessment instrument WHOQOL-100 (WHOQOL Group, 1994) was used for evaluation of QOL. The Lithuanian version of the instrument was prepared in2000 by N. Goštautaitė-Midttun (Vilnius University, Psychiatric Clinic) and A. Goštautas (Vytautas Magnus University, Department of Psychology). Psychometric analysis of the instrument revealed that WHOQOL-100 is a reliable and valid instrument, and could be used in different clinical groups and cross-culturally (general internal consistency reliability is high: Cronbach alpha - 0.84 (WHOQOL Group, 1998)). In this study– general Cronbach alpha 0.96, for separate domains– from 0.82 to 0.93, for separate ranges facets–from 0.56 to 0.94. WHOQOL-100 measures 25 aspects (facets) of QOL. 24 facets are grouped into six domains: physical health, psychological health, levels of independence, social relationships, environment, spirituality, religion and personal beliefs. 25th is a facet general facet assessing overall health and general QOL.Physical health is domain based on first three facets: (1) pain and discomfort, (2) energy and fatigue, (3) sleep and rest.olchsyPalicog is based on 4-8 facets: (4) positive feelings, (5) thinking, domain learning, memory, (6) self-esteem, (7) body image and appearance, (8) negative feelings.Level of independence domain is based on 9-12 facets: (9) mobility, (10) activities of daily life, (11) dependency on medication, (12) capacity to work.Social relationshipsbased on 13-15 facets: (13) personal relations, (14) practical is domain social support, (15) sex.Environment is based on 16-23 facets: (16) physical domain safety and security, (17) home environment, (18) financial resources, (19) health and social care, (20) information and skills, (21) recreation and leisure, (22) physical environment and (23) transport.Spirituality, religion and personal beliefs is domain based on one (24) spirituality facet. Nothwidstanding that the WHOQOL-100 was not drafted specifically for mental health settings, it is a generally acknowledged as an appropriate multi-dimensional
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