mental health

1. The MGH Psychiatry Academy Frontiers of Psychiatric Treatment Series
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Nhi-Ha Trinh MD MPH
Director of Multicultural Studies and Clinical Services
Depression Clinical and Research Program
Director, Department of Psychiatry Center for Diversity
Massachusetts General Hospital (MGH)
Assistant Professor of Psychiatry, Harvard Medical School
Optimizing quality of life in the treatment of depression

2. The MGH Psychiatry Academy Frontiers of Psychiatric Treatment Series
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Disclosures
Neither I nor my spouse has a relevant financial
relationship with a commercial interest to disclose.
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3. The MGH Psychiatry Academy Frontiers of Psychiatric Treatment Series
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Learning Objectives
At the end of this presentation, participants will be able to:
1. Define the term Quality of Life and describe how it is
measured;
2. Describe two effects of Depressive disorders on patient
Quality of Life;
3. Apply three strategies to engage patients regarding
their Quality of Life.
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Overview
• Background: Depression and Quality of Life
• Impact of Depressive Disorders on Quality of
Life
• Interventions to improve Quality of Life in
patients with Depressive Disorders
• Clinical Recommendations
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Depression: Global Burden of Disease
• Depression is a very common mental illness, affecting an
estimated 350 million people worldwide;
(WHO 2012)
• The clinical course of the disorder is highly recurrent;
only 20% of patients recovering and remaining
continuously well, 80% have at least one recurrence
during their lifetime;
(Burcusa and Iacono, 2007).
• Given its prevalence, highly recurrent nature, and multi-
level impairments, major depressive disorder (MDD) is a
leading cause of disability worldwide.
(WHO 2012)
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Depression: Clinical Challenges
• The core features of MDD include emotional, somatic,
and functional impairments.
• Functional impairments associated with MDD result in
social and occupational impairments that disrupt work,
school, leisure, family life activities, and family
responsibilities.
• Patients also experience reduced quality of life (QoL)
and difficulty with interpersonal relationships.
(APA 2013, Sheehan et al 2017)
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Quality of life: What is it?
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https://ec.europa.eu/eurostat/web/gdp-and-beyond/quality-of-life/data

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Quality of life: What is it?
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(Verghese L. 2017)

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Quality of Life: Definition
According to the World Health Organization
(WHO), Quality of Life is defined as:
“the individual’s perception of their position in life
in the context of the culture and value systems in
which they live and in relation to their goals,
expectations, standards and concerns.”
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https://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/; accessed June 2, 2020

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Quality of Life: Definition (cont.)
Quality of life (QoL) “is a broad ranging concept
affected in a complex way by the person's physical
health, psychological state, personal beliefs, social
relationships and their relationship to salient
features of their environment.”
Health related QoL (HRQoL) is an evaluation of
QoL and its relationship with health.
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https://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/; accessed June 2, 2020

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Quality of Life versus Functioning
• QoL is often used interchangeably with functioning,
functional impairment, or considered a distinct, albeit
related, concept.
• Functioning refers to one’s performance in activities
such as work, love, and play (as rated by self or
observers);
• QoL refers to one’s satisfaction with the above
activities and one’s perception of health, among other
domains, by self-report.
(IsHak et al. 2011)
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Quality of Life: “The Ultimate Outcome Measure”
• Quality of life measures assess well-being across
several domains.
• Disease-specific measures of severity of illness may not
accurately represent the overall treatment effect.
• There is a growing recognition of the importance of
patient-defined outcomes and the need to involve people
with lived experience in research and clinical practice.
(IsHak et al. 2011)
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Quality of Life: Measures
The Quality of Life Enjoyment and Satisfaction
Questionnaire, Short Form (Q-LESQ-SF)
– 16-item self-report measure designed to quantify satisfaction and
enjoyment in various domains of functioning: physical health,
feelings, work, household duties, school/work, leisure time
activities, social relations, and general activities.
– 5-point Likert scale that indicates the degree of enjoyment or
satisfaction achieved during the past week (1= very poor to 5 =
very good)
– The total score is calculated by summing the scores on the first
14 items. Higher scores represent greater life enjoyment and
satisfaction.
– Internal consistency and test–retest reliability have been
established. (Endicott et al., 1993)
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Quality of Life Enjoyment and Satisfaction Questionnaire, Short Form (Q-LES-Q-SF)
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GENERAL ACTIVITIES OVERALL LEVEL OF SATISFACTION
Taking everything into
consideration, during the past
week how satisfied have you
been with your ...
Very Poor Poor Fair Good Very
Good
… physical health? 1 2 3 4 5
… mood? 1 2 3 4 5
… work? 1 2 3 4 5
… household activities? 1 2 3 4 5
… social relationships? 1 2 3 4 5
… family relationships? 1 2 3 4 5
… leisure time activities? 1 2 3 4 5
… ability to function in daily
life?
1 2 3 4 5
… sexual drive, interest
and/or performance?*
1 2 3 4 5
… economic status? 1 2 3 4 5
… living/household
situation?*
1 2 3 4 5
.. ability to get around
physically without feeling
dizzy or unsteady or falling
1 2 3 4 5
… your vision in terms of
ability to do work or
hobbies?*
1 2 3 4 5
… overall sense of well being? 1 2 3 4 5
… medication? (if not taking
any, check here ______ and
leave item blank)
1 2 3 4 5
How would you rate your
overall life satisfaction and
contentment during the past
week?
1 2 3 4 5
(Endicott et al., 1993)

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Quality of Life: Measures
• The Short Form Health Survey 12 (SF-12)
– The SF-12 is a self-report measure of perceived health status,
with 12 questions on subjects ranging from general health to
physical limitations to the amount of energy one has.
– Some items are scored as absent/present while others are
scored on a Likert scale, with ranges varying from item to item.
– Two scores are generated: a physical health factor score and a
mental health factor score. Each score has a possible range
from 0 to 100, with a higher score indicating better function.
– The scales have been constructed so the population norm for
each score is 50.
– The measure has been shown to be valid and has test–retest
reliability.
(Ware et al 1996)
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The Short Form Health Survey 12 (SF-12)
This information will help your doctors keep track of how you feel and how well you are able to do your usual
activities. Answer every question by placing a check mark on the line in front of the appropriate answer. If you
are unsure about how to answer a question, please give the best answer you can and make a written comment
beside your answer.
1. In general, would you say your health is: Excellent (1) Very Good (2) Good (3)Fair (4) Poor (5)
The following two questions are about activities you might do during a typical day. Does YOUR HEALTH NOW
LIMIT YOU in these activities? If so, how much?
2. MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf: Yes,
Limited A Lot (1) Yes, Limited A Little (2) No, Not Limited At All (3)
3. Climbing SEVERAL flights of stairs: Yes, Limited A Lot (1) Yes, Limited A Little (2) No, Not Limited At All (3)
During the PAST 4 WEEKS have you had any of the following problems with your work or other regular
activities AS A RESULT OF YOUR PHYSICAL HEALTH?
4. ACCOMPLISHED LESS than you would like: _____ Yes (1) _____ No (2)
5. Were limited in the KIND of work or other activities: _____ Yes (1)_____ No (2)
(Ware et al 1996)
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The Short Form Health Survey 12 (SF-12) cont.
During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS A
RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?
6. ACCOMPLISHED LESS than you would like: _____ Yes (1) _____ No (2)
7. Didn’t do work or other activities as CAREFULLY as usual: Yes (1) No (2)
8. The PAST 4 WEEKS, how much did PAIN interfere with your normal work (including both work the
home and housework)? Not At All (1) A Little Bit (2) Moderately (3) Quite A Bit (4) Extremely (5)
The next three questions are about how you feel and how things have been DURING THE PAST 4
WEEKS. For each question, please give the one answer that comes closest to the way you have been
feeling. How much of the time during the PAST 4 WEEKS –
9. Have you felt calm and peaceful?
10. Did you have a lot of energy?
11. Have you felt downhearted and blue?
12. During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR EMOTIONAL
PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)?
All of the Time (1) Most of the Time (2) A Good Bit of the Time (3) Some of the Time (4) A Little of the
Time (5) None of the Time (6)
(Ware et al 1996)
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18. The MGH Psychiatry Academy Frontiers of Psychiatric Treatment Series
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Impact of Depression on Quality of Life
“Quality of life is neither the opposite of
depression, nor is euthymia a synonym of
QoL.”
(da Rocha et al 2009)
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Impact of Depression on Quality of Life
• In treating depression, the optimal treatment outcome
has long been recognized as full remission of depressive
symptoms and improvements in psychosocial
functioning.
(Cho et al 2019)
• Partial remission and residual depressive symptoms
have been associated with impaired quality of life, and
subsequently, burden in healthcare and social welfare.
(Keller et al 2003)
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Impact of Depression on Quality of Life
• Multiple domains of QoL are significantly impaired in
MDD.
• Research has consistently demonstrated that depressed
patients’ QoL is significantly lower than that of healthy
individuals, and often even those with chronic medical
illnesses such as hypertension, cancer, or chronic pain.
• When depression is comorbid with other medical and
psychiatric illnesses, the deterioration in QoL is
compounded.
(Ishak et al 2011)
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Impact of Depression on QoL
• Although depression severity is correlated with QoL
impairment, changes in QoL are not fully accounted for
by changes in depression symptoms.
• QoL changes more slowly than depressive symptoms.
(Judd, et al., 2000; Hirschfeld, et al., 2002; Trivedi, 2006)
• Treatments that reduce depression symptoms do not
necessarily result in improved QoL;
• Two meta-analyses demonstrated that while clinician
ratings of depressive symptoms may decrease with
pharmacotherapy, patients’ ratings of QoL did not exhibit
improvement. (Spielmans et al, 2013 and 2014)
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Impact of Depression on Quality of Life
• Although QoL impairments are seen to persist even
following successful treatment of depressive symptoms;
• QoL has been shown to be a better predictor of
sustained remission than symptom resolution;
• QoL may serve as a protective factor against future
depressive episodes.
(Ishak et al 2011)
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Impact of Depression on Quality of Life
• In addition, improved QoL is associated with improved
adherence and response to treatment in patients with
depression.
(Pyne et al 2001)
• Health-related QoL (HRQoL) has been known to be an
independent factor affecting various medical outcomes,
such as death or re-admission, and is an important
consideration for health care interventions.
(Dominick et al 2002)
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Interventions to Improve QoL: Psychotherapy
(Cuijpers 2020)
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Interventions to Improve QoL: Pharmacotherapy
• Meta-analyses have demonstrated that pharmacotherapy (SSRIs)
are also associated with significant improvements in QoL
(Hofmann et al 2017; Kamenov et al 2017)
• CBT may improve QoL primarily by reducing symptoms of
depression, while SSRIs are more broad-band therapies that target
a multitude of psychiatric problems, including anxiety and stress.
(Hofmann et al 2017)
• Combined treatment appears to be superior, but psychotherapy and
pharmacotherapy alone are also efficacious for improving
functioning and QoL; adjusting for publication bias, psychotherapy
appears to be more efficacious than pharmacotherapy for QoL.
(Kamenov et al 2017)
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Interventions to Improve QoL: Promising interventions
• A meta-analysis of exercise interventions suggested exercise
(defined as a planned, structured, repetitive and purposive physical
activity) significantly improved physical and psychological domains
and overall QoL in patients with MDD; (Schuch et al 2016)
• A meta-analysis of mindfulness meditation programs showed small
improvements in the mental health component of health-related QoL
for patients with anxiety and depression symptoms;
(Goyal et al. 2014)
• Complementary Alternative Medicine (CAM) has some data to
suggest efficacy in reducing symptoms in MDD; limited data on QoL.
(Haller et al, 2019)
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Future Directions: Quality of Life
• More studies are needed to examine the effect of individual patient
demographics, pre-morbid AND co-morbid clinical variables that
account for poor QoL in patients with MDD.
• More emphasis needs to be placed, not just on symptom severity
and functional status, but also on QoL as measured by the patient’s
self-reported level of satisfaction and perceptions.
• Assessments of outcome for MDD treatment—including medication,
psychotherapies, and alternative treatments—need account for
symptom severity, functioning, and QoL.
(IsHak et al 2011)
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Recommendations: Quality of Life
“Research shows that patients find symptom reduction a very important
goal of therapy, but it is certainly not the only goal. What patients want
is very personal and depends on their current situation.”
“Apart from symptom reduction, it is well-known to clinicians that
patients want, for example to be able to go back to work, have a more
fulfilling life, solve conflicts with partners, other close relatives, friends,
want to learn to live with the chronic disorder they recently developed,
learn to handle a trauma, recent or in the past.”
(Cuijpers 2020)
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Recommendations: Quality of Life
https://www.verywellmind.com/tips-for-living-with-depression-1066834
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Recommendations: Quality of Life
• Engage patient in goal-setting for QoL:
“What would satisfaction and enjoyment in [health,
feelings, work, household duties, school/work, leisure time
activities, social relations, and general activities] look like
for you?”
• Share what we know: Interventions and QoL.
• Don’t be afraid to think outside the box!
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Discussion
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References
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