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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 36  |  Issue : 2  |  Page : 125-129

Quality of life among patients with depression: Impact of self-stigma


Department of Psychiatry, Government Medical College and Rajindra Hospital, Patiala, Punjab, India

Date of Submission10-May-2019
Date of Decision09-Jul-2019
Date of Acceptance22-Oct-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Dr. Rohit Garg
Department of Psychiatry, Government Medical College and Rajindra Hospital, Patiala - 147 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_32_19

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  Abstract 


Background: Health-related quality of life (QoL) is an important aspect in the recovery of mental illness. There is ample research evidence that evaluates the reduced QoL and stigma in the various mental illnesses, but there has been paucity of the literature exploring the impact of self-stigma and its correlation with QoL in patients with depression. Aim of the Study: This study aims to find the impact of self-stigma on QoL of patients with depression and also find the correlates of QoL. Methods: A total sample of 150 patients was recruited from the outpatient department of psychiatry of a tertiary care medical college and hospital in North India in August and September, 2018. The patients recruited were in symptomatic remission and were assessed on Hindi versions of WHOQOL Bref and self-stigma scale. Results: After the statistical analysis, it was revealed that majority of the sample were young (47.33%), urban (54%), females (57.33%) who were married (52%), and living in joint families (59.33%). Most affected domain of QoL was satisfaction with psychological health with score 39.62 ± 10.29 and the least affected was satisfaction with environment with score 58.23 ± 14.90. Significant correlation was found between the sociodemographic factors, self-stigma, and QoL. Younger patients had a better QoL on psychological domain. Female patients had a better overall QoL (Q1) and better satisfaction with psychological health and satisfaction with environment. Conclusion: Depression has a significant correlation with the deterioration in QoL of patients. The burden of self-stigma further significantly deteriorates the QoL of patients with depression.

Keywords: Depression, quality of life, stigma


How to cite this article:
Garg R, Kaur H. Quality of life among patients with depression: Impact of self-stigma. Indian J Soc Psychiatry 2020;36:125-9

How to cite this URL:
Garg R, Kaur H. Quality of life among patients with depression: Impact of self-stigma. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Nov 29];36:125-9. Available from: https://www.indjsp.org/text.asp?2020/36/2/125/288110




  Introduction Top


Health-related quality of life (QoL) is an important component of outcome and recovery in mental disorders as these disorders reduce the QoL of the affected individual.[1] Many recent studies have identified that QoL of persons suffering from depression is lower than general population.[2],[3] Depression has a significant negative impact on patients' overall QoL, physical and psychological health, social relations, marital relations, occupational functioning, and self-esteem which can all diminish QoL.[2] Factors associated with poor QoL in patients with depression are symptoms severity, social support, medication side effects, low social support, comorbid conditions, problems in employment, and associated anxiety.[3],[4]

Self-stigma reduces hope, QoL, self-esteem, self-efficacy, and empowerment of persons with mental disorders. Stigma and depression are closely related. Depression leads to self-stigma. Hopelessness and low self-esteem due to stigma further cause depression and increase suicidal risk.[5] Recently, it has been identified that self-stigma is a significant contributor to poor QoL among persons with psychiatric disorders.[6] Self-stigma results when the affected person accepts and endorses the public stereotypes related to mental disorders, considers the stereotypes as relevant to self and stigmatizes self.[1],[5] However, almost all the research on impact of stigma on QoL has been conducted in schizophrenia and bipolar disorder. There is a glaring lack of research on the impact of self-stigma on QoL of patients with depression. The present study aims to find the impact of self-stigma on QoL of patients with depression and also find the correlates of QoL.


  Methods Top


It was a cross-sectional, descriptive study, carried out in the outpatient department (OPD) of psychiatry of a tertiary care medical college and hospital in North India.

Study duration

Two months (August and September, 2018).

Sample population

One hundred and fifty consecutive patients diagnosed as depression by two qualified psychiatrists as per the DSM 5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) criteria.

Inclusion criteria

Patients aged more than 18 years, of both genders, and willing to participate in the study were recruited. Patients should have been in symptomatic remission at the time of study.

Exclusion criteria

Patients with comorbid physical, medical, neurological, or any other stigmatizing disorder like HIV, leprosy, tuberculosis, etc., that could affect QoL and stigma were excluded. Patients with family history of psychiatric disorder, uncooperative patients (who refused to give written informed consent), having psychotic symptoms, or any other comorbid psychiatric disorder were excluded. Patients having substance dependence except nicotine and caffeine were also excluded.

Tools

Sociodemographic and clinical pro forma

A semistructured pro forma was prepared to record age, gender, education, occupation, marital status, family type, monthly family income, locality, and total duration of illness.

WHO quality of life Bref Hindi version

WHO QoL Bref Hindi version was used to measure subjective health-related QoL.[7] The 26 items are further divided into four domains (satisfaction with physical health, psychological health, social relations, and environment) and two general questions related to satisfaction with overall QoL and overall health. This is one of the most commonly used scales to measure QoL and has excellent reliability and validity.

Stigma scale (in Hindi)

The Hindi self-stigma scale previously standardized in India was used for the study.[1] It is a 28-item self-rated instrument with a Likert-type scoring (agree, neither agree nor disagree and disagree). Each item is rated from 0 to 2. The 28 items are divided into three domains, namely discrimination (13 items), disclosure (ten items) and positive aspects of stigma (five items). Higher score on each domain and the total scale score denotes higher stigma. Negatively worded items are reverse scored. The scale has been previously standardized in India on a variety of patients with mental illnesses and was found to have good internal consistency and test–retest reliability.

Study protocol

All the patients attending the psychiatry OPD of the institute were screened by the researchers. The patients having a diagnosis of depression according to DSM 5 and fulfilling inclusion and exclusion criteria were invited to participate in the study. The patients were explained the purpose of the study, and written informed consent was obtained. After obtaining the written informed consent, the rating scales were applied by the researchers. About 40–50 min were taken to assess each patient.

Ethical considerations

All the ethical guidelines were adhered to. The study was approved by ethics committee of the institute. Written informed consent was taken from all the patients. The Indian Council of Medical Research ethical guidelines for biomedical research on human participants were adhered to.

Statistical analysis

Continuous data (Qol and other variables), assumed to be normally distributed, was written as in the form of mean and standard deviation. When it was skewed, it was written in the form of median and interquartile range. The normality of quantitative data was checked by measures of Kolmogorov–Smirnov tests of normality. For normally distributed data, Student's t-test was applied to compare 2 groups. Spearman or Pearson correlation coefficients were calculated to see relationship of different variables with WHO-QoL. All the statistical tests were two sided and were performed at a significance level of α = 0.05. Analysis was conducted using IBM SPSS Statistics (version 22.0). (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp).


  Results Top


The study sample comprised of 150 remitted patients with depression. [Table 1] shows the sociodemographic and clinical parameters of the participants and their correlation with QoL. Majority of the patients were females (57.33%; N = 86), in the young age group (47.33%; n = 0 71), and had more than 12 years of formal education (56.67%; n = 85). Most of the patients were married (52%; n = 78) and hailed from urban locality (54%; n = 81) and joint families (59.33%; n = 89). The mean duration of illness was 43.46 ± 22.503 months (range 2–180), and majority of the patients were never hospitalized (76%; n = 115). Seventy-nine (52.67%) patients had episodic illness while 71 (47.33%) had a continuous illness.
Table 1: Sociodemographic and clinical variables and their correlation with quality of life (n=150)

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Younger patients had a better QoL on psychological domain. Female patients had a better overall QoL (Q1) and better satisfaction with psychological health and satisfaction with environment. The other sociodemographic variables such as education, marital status, family type, and locality had no significant impact on the QoL of the individuals.

[Table 2] shows the scores on the WHO-QoL Bref Hindi scale. As can be seen from [Table 2], the most affected domain of QoL was satisfaction with psychological health and the least affected was satisfaction with environment.
Table 2: Quality of life scores of the participants (n=150)

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[Table 3] shows the correlation of QoL with stigma and duration of illness. Total stigma and discrimination were significantly negatively correlated with 3 domains of WHO QoL. The correlation with satisfaction with social relations was also negative, though not significant. The correlation of QoL with stigma of disclosure and positive aspects of stigma were negative, although they did not reach statistical significance. Duration of illness also had a negative impact on all the domains of QoL, although the correlation achieved statistical significance for satisfaction with psychological health only.
Table 3: Correlation of quality of life with self.stigma, duration of illness, severity of illness, and insight (n=150)

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  Discussion Top


The notion of self-stigma gained the glare of publicity since 2000, and all through this time, the sum of qualitative and quantitative research has been presented in various sample populations. This study highlights the impact of self-stigma on the QoL in the patients with depression. To the best of our knowledge, this is the first Indian effort to study impact of self-stigma on QoL of patients with depression.

Socio-demographics and clinical history

Our study asserts that the younger population has higher psychological satisfaction and females had overall better QoL. This correlation is in accordance with the landmark UK the Factors Influencing Depression Endpoints Research Trial which was a prospective and observational research to estimate QoL in patients with a clinical diagnosis of depression.[8] However, our findings are in contrast to some studies that comment that there is no correlation, positive or negative, between any sociodemographic factors and QoL.[2],[3] In the current study, the satisfaction with the psychological health decreased as the duration of illness increased. This finding is in accordance with the current literature that explains the shoddier overall QoL which may be associated with higher disability in family, work, and social life.[9]

Most affected domain – Satisfaction with psychological health

We found that the most affected domain of QoL among patients with depression is “satisfaction with psychological health.” The psychological satisfaction domain is principally concerned with the self-contentment, sense of life, and degree to which a person is able to enjoy life apart from sadness and anxiety. The negative impact on the psychological satisfaction can be contributed by psychological consequences such as guilt, self-blame, stigma, reduced hope, self-efficacy, and self-esteem. Our findings are in accordance to the previous research conducted regarding this aspect.[2]

Least affected – Satisfaction with the environment

Regarding the satisfaction with the environment, domain scores were higher as compared to other domains in our study. The possible elucidation can be provided on the behalf of higher proportion of patients belonging to urban areas with higher educational qualifications, married, and living in a joint set up which could have preserved their environmental QoL to some extent. Furthermore, these patients included treatment-seeking population in remission who are more stable than patients in the community. Our findings are in the accordance with the previous studies.[2]

Brunt of self-stigma and quality of life

Our study highlights that self-stigma has a negative impact on subjective QoL in the patients with depression. Stigma causes a significant reduction in hope, self-esteem, socio-occupational functioning, life opportunities resulting in shame, guilt, social isolation, and segregation. All these factors have a significant adverse impact on the subjective QoL.[10],[11] This finding of stigma having a negative impact on QoL and is clearly similar to the evidence present in the literature.[10],[12],[13]

Self stigma – Just a depressive cognition?

The research evidence states that cognitive schemas in the patients suffering from depression do affect the self-stigma, which in turn worsens depressive symptomatology. This is a vicious cycle which includes many variables and factors but taking the self-stigma completely as a depressive cognition is not recommended.[14]

Strengths and limitations

Strengths of the study include the stringent inclusion and exclusion criteria, implementation of standardized instruments in the local language (Hindi), and adequate sample size. However, a few limitations are noteworthy while interpreting the results. The limitations include the lack of comparison group as the study was conducted in treatment-seeking population and difficulty in generalization of the results.


  Conclusion Top


It can straightforwardly be concluded that depression has a correlation with deterioration in QoL of patients with rather questionable correlation with sociodemographic factors. The burden of self-stigma further significantly deteriorates the QoL of patients with depression. Therefore, management of patients with depression should include a routine assessment of QoL as well as self-stigma. Since QoL is an important outcome variable, there is dire need of integration of intervention aimed at enhancing the QoL, in the management plan for patients with depression. Finally, it will be in good sense to combine the interventions aiming at enhancement of QoL and reduction of self-stigma altogether.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garg R, Arun P, Chavan BS. Reliability of the stigma scale in the Indian setting. Indian J Soc Res 2013;54:267-76.  Back to cited text no. 1
    
2.
Matovic S, Jankovic S. Quality of life among patients with depression. Ser J Exp Clin Res 2015;16:151-6.  Back to cited text no. 2
    
3.
Sivertsen H, Bjørkløf GH, Engedal K, Selbæk G, Helvik AS. Depression and quality of life in older persons: A review. Dement Geriatr Cogn Disord 2015;40:311-39.  Back to cited text no. 3
    
4.
Brenes GA. Anxiety, depression, and quality of life in primary care patients. Prim Care Companion J Clin Psychiatry 2007;9:437-43.  Back to cited text no. 4
    
5.
Arun P, Garg R. Stigma of mental illness. In: Chadda RK, Kumar V, Sarkar S, editors. Social Psychiatry: Principles and Clinical Perspectives. New Delhi: Jaypee Publishers; 2018. p. 409-25.  Back to cited text no. 5
    
6.
Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Soc Sci Med 2010;71:2150-61.  Back to cited text no. 6
    
7.
Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. World Health Organization quality of life. Natl Med J India 1998;11:160-5.  Back to cited text no. 7
    
8.
Lenox-Smith A, Macdonald MT, Reed C, Tylee A, Peveler R, Quail D, et al. Quality of life in depressed patients in UK primary care: The FINDER study. Neurol Ther 2013;2:25-42.  Back to cited text no. 8
    
9.
Dell'Osso B, Benatti B, Buoli M, Altamura AC, Marazziti D, Hollander E, et al. The influence of age at onset and duration of illness on long-term outcome in patients with obsessive-compulsive disorder: A report from the international college of obsessive compulsive spectrum disorders (ICOCS). Eur Neuropsychopharmacol 2013;23:865-71.  Back to cited text no. 9
    
10.
Vrbova K, Prasko J, Ociskova M, Kamaradova D, Marackova M, Holubova M, et al. Quality of life, self-stigma, and hope in schizophrenia spectrum disorders: A cross-sectional study. Neuropsychiatr Dis Treat 2017;13:567-76.  Back to cited text no. 10
    
11.
Mashiach-Eizenberg M, Hasson-Ohayon I, Yanos PT, Lysaker PH, Roe D. Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope. Psychiatry Res 2013;208:15-20.  Back to cited text no. 11
    
12.
Picco L, Pang S, Lau YW, Jeyagurunathan A, Satghare P, Abdin E, et al. Internalized stigma among psychiatric outpatients: Associations with quality of life, functioning, hope and self-esteem. Psychiatry Res 2016;246:500-6.  Back to cited text no. 12
    
13.
Yen CF, Chen CC, Lee Y, Tang TC, Ko CH, Yen JY. Association between quality of life and self-stigma, insight, and adverse effects of medication in patients with depressive disorders. Depress Anxiety 2009;26:1033-9.  Back to cited text no. 13
    
14.
Shimotsu S, Horikawa N. Self-stigma in depressive patients: Association of cognitive schemata, depression, and self-esteem. Asian J Psychiatr 2016;24:125-9.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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