OR I GI NAL AR T I C L EHealth-related quality of life and
symptom severity in Chinesepatients with major depressive
disorderYuping Cao1MD PhD, Wen Li2MD, Jingjin Shen1,3MD, Robert T.
Malison4MD, Yalin Zhang1MD PhD &Xingguang Luo4MD1 Mental Health
Institute, Second Xiangya Hospital, Central South University,
Changsha, China2 Department of Psychosomatics, Hunan Mental
Hospital, Changsha, China3 Department of Psychiatry, Shenzhen Sixth
Hospital, Shenzhen, China4 Department of Psychiatry, Yale
University School of Medicine, New Haven, CT, USAKeywordsChinese,
correlation, health-related quality oflife, major depressive
disorder, symptomseverityCorrespondenceYalin Zhang MD PhD, Mental
Health Institute,Second Xiangya Hospital, Central SouthUniversity,
Changsha, Hunan 410011, China.Tel: +86 731 85292159Fax: +86 731
85362586Email: [email protected] 5 March 2012Accepted
4 December 2012DOI:10.1111/appy.12059AbstractIntroduction: Patients
sufferingfrommajor depressivedisorder (MDD)have been reported to
have substantial long-lasting limitations in multipledomains of
health-related quality of life (HRQoL). The thoughtful assess-ment
of HRQoLandtheimpact of treatment responseonHRQoLareemerging as
important issues in the care of patients with major
depressivedisorder.Methods:
OnehundredandthreepatientsmeetingDiagnosticandSta-tisticalManualofMentalDisorders(DSM-IV)criteriaforMDDtooku-oxetine(20
mg/d)for6weeksandwereassessedbytheShortForm36Health Survey (SF-36),
the 17-item Hamilton Depression Rating (HAMD-17) and the Clinical
Global Impression (CGI) scales. Relationships betweenSF-36 scores
and depressive symptom severity and early change of thesesymptoms
were tested.Results: SF-36component scoresat
week6werehigherthanthoseatbaseline (all P 0.0058). Scores for
general healthwere signicantlyhigher in responders than
non-responders (P = 0.0009). The
overallHAMD-17andCGIscoresat2-and6-weekfollow-upweresignicantlylower
thanthose at baseline (P 0.0001). Higher scores for
anxiety/somatizationweresignicantlyassociatedwithpoorer SF-36scores
atbaseline(P =
0.0001);role-physicalscoresatweek6werepositivelycor-relatedwithreductionrateofanxiety/somatizationin2-weekfollow-up(P
= 0.0002).Discussion:
DepressivesymptomseveritywasassociatedwithHRQoLinpatients with MDD.
HRQoL may vary with severity of depression
and/oranxiety-somatization at baseline.IntroductionDepressionis
amongthemost prevalent of medicalillnesses, and has become the
fourth leading cause ofglobal disabilityadjustedlifeyears(DALYs),
andtheleading cause indeveloped countries (Murray andLopez, 1997a).
Depression is also projected to
becomethesecondleadingcauseofglobaldisabilityby2020accordingtotheWorldHealthOrganization(WHO)(Murray
and Lopez, 1997b). Thus, many nations nowacknowledge the importance
of recognizing andtreating depression both for the benet of
patients andfor society.WHO dened health as a state of complete
physi-cal, mental, and social well-being and not merely
theabsenceof diseasein1948. Thisconcepthasresur-faced as an
important touchstone for the evaluation
ofbothmentalandphysicalhealthtreatmentoutcomes(Rapaportet al.,
2005). Health-relatedqualityoflife,referring to the perceptions of
daily function andwell-being in physical, social, and
psychologicaldomains,canhelpdoctorsbetterunderstandhowanbs_bs_bannerOfcial
j ournal of thePacicRim College of PsychiatristsAsia-Pacific
Psychiatry ISSN 1758-5864276 Asia-Pacific Psychiatry 5 (2013)
276283Copyright 2013 Wiley Publishing Asia Pty Ltdillness or its
treatment affects a persons life(Endicott et al., 1993).Patients
suffering fromMDDhave beenreported tohavesubstantial
long-lastinglimitations inmultipledomains of health-related quality
of life (HRQoL),when compared to the general population (Pyne et
al.,1997) or tothose whosuffer fromother commonchronic medical
illnesses such as diabetes, arthritis orcardiovascular diseases
(Wells et al., 1989; Ormel et al.,1994;Hayset
al.,1995;WellsandSherbourne,1999;Saarijarvi et al., 2002). Thus,
the thoughtful assessmentof HRQoLandtheimpact of treatment
responseonHRQoL are emerging as important issues in the care
ofdepressed patients. In fact, reports in the literature
innon-Chinese populations have suggested that depres-sionseverity
is associated withhealth-related quality oflife (Rapaport et al.,
2005; Aydemir et al., 2009;Patten et al., 2009; ten Doesschate et
al., 2010).To our knowledge (by searching English[lan-guage],
(severity OR early improvement), health-related quality of life,
Chinese, depression inPubMed), no literature inany international
journal hasreported the relationship between the severity
ofsymptomsortheirearlyimprovement(intherst2weeks (Quitkinet al.,
1984; Bech, 2001) ) andtheHRQoL improvement in Chinese MDD
patients.However, basedonprior workinthenon-Chinesepopulations
(Quitkin et al., 1984; Bech, 2001;Rapaport et al., 2005; Aydemir et
al., 2009; Patten et al.,2009; tenDoesschateet al., 2010),
wehypothesizedthat such an association might also exist in the
Chinesepopulation. The current study employed a xed, open-label
trial of antidepressant medication (uoxetine) for6 weeks in Chinese
MDD patients in order to explorethis hypothesis. We assessed
health-related quality oflife (HRQoL) among Chinese patients with
majordepressivedisorder (MDD) usingstandardizedmea-sures and
investigated its correlations with depressivesymptomseverity and
with early change of thesesymptoms after antidepressant
intervention. These cor-relations were investigated within the same
subjects; inother words, HRQoL and depressive symptom severitywere
assessed under the same conditions. This study isimportant for us
toknowif HRQoLcanserveas apotential supplemental outcome
measurement inclini-cal treatment trials in Chinese MDD
patients.MethodsSubjectsTheMental
HealthInstituteofSecondXiangyaHos-pital andtheHunanMental
HealthHospital
aretwoprovince-runpsychiatricinstitutes/hospitalsinSouthChina.Theyaretwoofthetoppsychiatricinstitutes/hospitals
in China. Consecutive outpatients
fromthesetwoinstitutes/hospitalswereinvitedtopartici-patefromJanuarytoJuly2006.Theinclusioncrite-riawereasfollows:
(i)all
participantsagedbetween1865years;(ii)allparticipantsmetDSM-IVcriteriafor
MDD; (iii) Hamilton Depression Rating
forDepression17-item(HAMD-17)totalscoreswerenoless than 16; and
(iv) all participants were free of anyantidepressant and
antipsychotic within 1 monthbeforetrial.The exclusioncriteria
included(i) a historyofdysthymia, mania, hypomania, bipolar
disorder ordepression secondary to a known substance or
generalmedicalcondition;(ii)adrugallergyorclinicallysig-nicant
laboratory abnormality; (iii) active suicidalideation, comorbid
mental disorders, catatonic fea-tures, and/or severe psychomotor
retardation thatmadeinterviewdifcult; (iv)activesubstanceabuse;(v)
historyof braininjuryor other severemedicalcomorbidity, such as
stroke, diabetes or
cardiovasculardisease;(vi)currentmedicationthatmightinuencemoodorthecentralnervoussystem;(vii)pregnancyor
breastfeeding; or (viii) current use of other antide-pressants or
electroconvulsive
therapy.Subjectswerediagnosedbytwoseniorpsychia-trists. These
psychiatrists were trained before study toassure they used the
tools consistently. The inter-raterreliability of the assessment of
the measurements was97% for assessing ten patients. Each patient
was ratedby the same clinician each time. This study wasapproved by
the Medical Ethics Committee of SecondXiangya Hospital of Central
South University inChina. All patients provided written informed
consentprior to their participation in the study.MeasurementsShort
Form 36 Health Survey Questionnaire(SF-36) (Ware and Sherbourne,
1992)TheChineseversionofSF-36(FangandHao,2001),developedbytheMedical
Outcomes Study(MOS),wasusedtoassesshealth-relatedqualityoflife.
TheSF-36 is a self-rated instrument consisting of ninedomains:
physical functioning, role-physical,
bodilypain,generalhealth,vitality,socialfunctioning,role-emotional,mentalhealthandreportedhealthtransi-tion.SF-36hasbeenclaimedtohavegoodreliabilityand
validity for assessment in major depressivepatients (Zhanget al.,
2006). Ahigher scoreontheSF-36 represents a better health-related
quality of life.Y. Cao et al. Quality of life and severity of
symptoms277 Asia-Pacific Psychiatry 5 (2013) 276283Copyright 2013
Wiley Publishing Asia Pty Ltd17-Item Hamilton Depression Rating
Scale(HAMD-17) (Hamilton, 1967)The Chinese version of the HAMD-17
(Zhu andZhang, 1998), whichis the most
widelyemployedinstrumentforassessingMDD, wasappliedtoassessseverity
of depressive symptoms. It consists of 17items that evaluate
functioning inve areas (sub-scales): cognitive impairment,
retardation, anxiety/somatization, sleepdisturbance, andweight
change.Higher scores indicatemoreseveredepression.
ThereliabilityoftheChineseversionoftheHAMD-17is0.880.99.Clinical
global impression (CGI)The Chinese version of the CGI (Wu, 1998)
was usedto assess severity of depressive symptoms. Higherscores
represent more severe symptoms.ProceduresAll patients met DSM-IV
criteria for major depressivedisorder. They were assessed by SF-36
at baseline andat the end of the 6th week after taking
antidepressant.HAMDandCGIforthesepatientswereevaluatedatbaseline,
2-week and 6-week follow-up. Symptomseveritychangewas
measuredbyachangeintotalHAMD-17 score. Responders were dened as
patientswith a 75% or greater improvement in symptoms
andnon-responders as those with less than 75% improve-ment in
symptoms.One hundred and twenty-eight patients wereenrolled in this
study. All patients were given a xeddosageof 20 mg/dof
uoxetinehydrochloridefor6weeks. One hundredandthree patients
completedboththe2-weekand6-weekfollow-upevaluations.Eighteen(14.1%)patientswithdrewfromthestudyduetotravel/inconvenience,lackoftime/availabilityorbeingunsatisedwithantidepressant
response; 2(1.6%)patientswereunabletotolerateside-effects,such as
severe nausea, vomiting, anxiety, insomnia orweakness; 5 (3.9%)
patients were non-compliant withresearchprocedures.
15ofthe103(14.6%)patientshad ever taken estazolam or nitrodiazepam
to alleviatesevere insomnia.Statistical analysisSPSS version 15.0
was used for analyses. Paired t-testswere usedfor withinsubject
comparisons betweenbaseline and either 2-week or 6-week
follow-upassessments. Two-sample (unpaired) t-tests were usedfor
comparisons of responders andnon-responders.Pearsoncorrelationtest
wasusedtoassesstherela-tionshipsbetweenHRQoLanddepressivesymptomsandbetweenHRQoLandsymptomseveritychange.Multiple
testing was accounted for by
Bonferronicorrection.ResultsDemographic characteristicsA total of
103 patients completed the
6-weekfollow-upandwereincludedforstatistical
analyses,including45men(43.7%)and58women(56.3%).The mean age was
(34.4 12.7) years (ranging from18 to 63 years). The duration of
illness ranged from 2to77weeks, withanaverage of 12.0weeks.
Theaverageeducationlevel was(11.1 3.1)years. Theresponse rate of
antidepressant intervention was 34%(threshold for improvement:
75%).Comparisons of scores for the SF-36 at baselineand week 6As
showninTable 1, scores for all domains of theSF-36 were nominally
higher at week six as comparedTable 1. Six-week follow-up and
baseline comparisons of scores of SF-36 (M SD)SF-36 Baseline 6-week
follow-up t P-valuePhysical function 80.73 18.92 92.86 8.90
-7.226
