Quality of Life and Functioning Impairments Across Psychiatric Disorders in Adults Presenting for Outpatient Psychiatric Evaluation and Treatment

Psychiatric disorders affect nearly one out of three people in the United States, and contribute equally or more to global disability than physical medical conditions (1, 2). There is evidence to suggest that psychiatric disorders are strongly associated with quality of life (QOL) and social/occupational Functioning, frequently at levels that are equal to or exceed those of medical illness (3, 4).

QOL is a core health measure (5), and Functioning is a core diagnostic criterion of psychiatric disorders (6). Poor QOL and low Functioning in psychiatric disorders are implicated in increased relapse rates (7), decreased productivity (8), medical complications such as heart disease (9), and increased overall costs to society and individuals (1, 10). While impaired Functioning is required for any DSM‐5 diagnosis, the severity level of such impairments varies widely and is of high clinical importance as self‐reported by patients (11). It is true that some Functioning and QOL may improve after symptom remission, but several studies have shown that Functioning and QOL do not typically follow suit after symptom remission and may need more targeted interventions (11, 12, 13). In fact, these impairments may not just be a result of psychiatric symptoms but also connected to the underlying disease process or the patient's psychosocial situation (13). Yet, significant questions remain unanswered about the extent to which QOL and Functioning impairments vary across psychiatric disorders.

Recent literature has suggested that there are significant differences across psychiatric disorders in the extent to which they affect QOL and Functioning, but the extent of this remains unanswered. Major depressive disorder (MDD) (14, 15, 16), which was particularly true in older adults (17, 18). Even among patients diagnosed with schizophrenia or another mood disorder, depression symptoms or diagnosis were independently associated with a decreased QOL (19, 20, 21). Other psychiatric disorders have also been implicated in decreased QOL and Functioning, including other mood disorders like anxiety and bipolar disorder, though potentially to a lesser extent than MDD (22, 23). Functional impairment is also prominent among patients with psychotic disorders, resulting from deficits in a variety of psychopathological domains (20, 21). Patients at high risk of psychosis experience impaired QOL and Functioning, and those who go on to develop psychosis experienced further impairments in both (24). QOL and Functioning were also impaired in other psychiatric conditions, including somatoform disorders and pathological gambling, though the extent of the effect of each on QOL and Functioning remains unclear (17, 19).

In the current study, we utilized data collected over a 7‐year period from an outpatient psychiatric treatment facility to examine QOL and Functioning impairment across psychiatric conditions at the point of presenting for evaluation and treatment. We assessed the degree of QOL and Functioning impairments across psychiatric disorders seen in a general outpatient psychiatry setting, including mood disorders (MDD, dysthymic disorder, and bipolar disorder, manic, depressed, and mixed), anxiety disorders (generalized anxiety disorder [GAD], panic disorder, obsessive‐compulsive disorder, posttraumatic stress disorder, and the phobias), psychotic disorders (schizophrenia and schizoaffective disorders), substance use disorders (alcohol, opioid, and cannabis abuse and dependence), adjustment disorders and attention deficit hyperactivity disorder. We assessed these patients before outpatient treatment. Based on past findings in the scientific literature, we hypothesized the following:

Hypothesis 1

Mood disorder patients would experience worse QOL and/or Functioning at entry into psychiatric outpatient treatment compared to other psychiatric disorders, as measured by mean scores, percentage of patients with severe impairments, and percentage of patients with normal QOL and/or Functioning.

Hypothesis 2

Severe impairments in QOL and/or Functioning at entry to outpatient treatment would be experienced by the majority (≥70%) of patients with psychiatric disorders, and normal QOL and/or Functioning would be seen in a minority (≥30%) of patients in treatment for their psychiatric condition(s).

METHODS

Population and Recruitment Methods

Patients presenting for psychiatric evaluation and treatment at Cedars‐Sinai Medical Center (CSMC), a tertiary medical center located in an ethnically and socioeconomically diverse area of Los Angeles, California, were enrolled in the Cedars‐Sinai Psychiatric Treatment Outcome Registry (CS‐PTR). This research study tracked the outcomes of psychiatric interventions in a naturalistic clinical setting using measurement‐based care from 2005 to 2012. The Institutional Review Board at CSMC approved the current study.

Clinical Measures

We assessed patients using the Mini International Neuropsychiatric Interview (MINI) (25), which assessed for diagnoses (e.g., mood, anxiety, and substance use disorders) from the Fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV). Psychiatric residents, psychology interns and social work interns who had undergone a course on the MINI performed the evaluations. A faculty‐supervising psychiatrist monitored each interview through a one‐way mirror with patient consent. Final diagnoses were confirmed using consensus techniques by a team with a senior faculty member. All data were de‐identified and entered into a secure database maintained by a data manager who monitored data completeness and integrity.

Patients provided self‐report data on the following measures:

1. QOL: The Short‐Form QOL, Enjoyment, and Satisfaction Questionnaire (Q‐LES‐Q) (26), contains 16 items rated on a 5‐point Likert‐type scale. In the first 14 items, the patient rates their satisfaction with physical health, mood, work, household activities, social relationships, family relationships, leisure time activities, ability to function in daily life, sexual drive/interest/performance, economic status, living/housing situation, ability to get around physically, vision and overall sense of wellbeing. The total score is calculated and converted to a percentage where 100 is the best and 0 is the worst. The Q‐LES‐Q has previously demonstrated strong psychometric properties, with a Cronbach's alpha of 0.90 and a test‐retest reliability of 0.74 (26). Severe impairment in QOL was defined as a score of 2 or more standard deviations below the community normal mean, that is, a score <55.7 (27). Normal QOL was defined as a score within 1 standard deviation below community norms, or higher, that is, a score of 67 or more (28) (see Table 1).

2. Functioning:

   1. The Work and Social Adjustment Scale (WSAS) (29) was utilized to measure Functioning by patient report. The WSAS is a 5‐item survey. It assesses Functioning in the areas of work, home management, private leisure, social leisure, and relationships. Patients who reported scores >20 (on a 40‐point scale) were considered severely impaired in Functioning and those who scored below 10 were considered to have normal Functioning (29) (see Table 1). The WSAS has fairly strong psychometric properties, with a Cronbach's alpha ranging from 0.70 to 0.94 and a test‐retest reliability of r = 0.73.

   2. The Sheehan Disability Scale (SDS) (30) contains 3 items with total scores that range from 0 to 30 points, where 0 represents no impairment and 30 represents maximum impairment. This scale is used to assess the degree to which symptoms have disrupted work, social and family responsibilities. It has no severity cutoffs (30).

   3. The Endicott Work Productivity Scale (EWPS) (31) is a 25‐item measure, with total scores ranging from 0 to 100, where 0 is best and 100 is worst. This scale was only given to patients who reported employment at entry to the study and it has no published severity cutoffs or norms (31).

3. Depressive Symptom Severity: The Quick Inventory of Depressive Symptomatology‐Self Report (QIDS‐SR) (32) was used to measure depressive symptom severity in all patients, even those without a diagnosis of depression. The measure consists of 16 items, scaled 0–3, with total scores ranging from 0 to 27, where 0 is best and 27 is worst. As detailed by Rush and colleagues (32), data from the QIDS‐SR can be used to assess depression status as follows: remission (score 0–5), mild (score 6–10), moderate (score 11–15), severe (score 16–20), or very severe (score >20) (see Table 1). Remarkably, this scale is highly correlated with the widely utilized clinician‐rated Hamilton Rating Scale for Depression (HRSD or HAMD, with three versions—HAM‐D 17, 21, and 24), the Montgomery Asberg Depression Rating Scale and the Beck Depression Inventory (33, 34, 35).

Statistical Analysis

To report demographic and clinical data we computed means and standard deviations for continuous variables (age, and scores on clinical measures). We recorded counts and percentages for proportional frequency data (race/ethnicity, gender, employment, and principal diagnosis). To examine variations in clinical measures by diagnosis, we selected diagnoses for which more than 25 patients provided data. We then examined all clinical measures within each diagnostic category (16 in total).

We used analysis of variance (ANOVA) to compare patients with a principal diagnosis of mood disorder (single episode or recurrent MDD; Bipolar Disorder, all types; Dysthymic Disorder; and Mood Disorder due to a general medical condition) to all other psychiatric outpatients on continuous outcome measures. The continuous outcome measures data were normally distributed and the levels of variance in each group were roughly equal.

We used Pearson's Chi‐Square tests to compare patients with a principal diagnosis of mood disorder to those without on binary outcome measures, such as presence or absence of severe impairment in QOL. Any valid data point was utilized in calculations per measure, and all percentages reflect the number of valid cases within each variable (i.e., listwise deletion was not used). Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 24.0 by IBM Corporation and SAS 9.4.

RESULTS

Demographic and Clinical Characteristics

We collected data for 2114 adults who presented for initial outpatient evaluations between 2005 and 2012. The demographic and clinical characteristics of the study population are presented in Table 2. Patients were predominately female (n = 1152, 54.5%) and Caucasian (n = 1477, 69.9%), and reported a mean age of 44.7 years (SD = 16.9). Approximately half of the patients (n = 1066, 50.4%) were employed.

The top five diagnoses most commonly encountered in the whole sample in descending order include Recurrent MDD (n = 838, 39.6%); Single Episode MDD (n = 135, 6.4%); GAD (n = 131, 6.2%); Bipolar I Disorder, Manic (n = 115, 5.4%); Bipolar I Disorder, Depressed (n = 91, 4.3%). Mood Disorders totaled 61.7% of the whole sample (n = 1304). There were no differences with regards to gender or employment across disorder groups.

QOL and Functioning at Baseline

Table 3 displays the means and standard deviations for all clinical outcome assessments, by principal diagnosis. In general, patients who carried a principal diagnosis of mood disorder scored lower on all outcome measures. In ANOVA analyses at entry into treatment (see Table 3), patients with a principal diagnosis of mood disorder reported significantly lower QOL (Q‐LES‐Q mean difference = −8.9, p < 0.001); WSAS mean difference = 4.8, p < 0.001; EWPS mean difference = 4.4, p < 0.005; SDS mean difference = 3.2, p < 0.001, and higher levels of depressive symptoms (QIDS‐SR mean difference = 3.3, p < 0.001), as shown in Table 4.

Severe Impairment in QOL and Functioning at Baseline

Overall, we observed 70.6% of patients reported severe impairment in QOL measured by the Q‐LES‐Q, while 59.6% of patients reported severe impairment in Functioning as assessed by the WSAS (see Table 5).

Patients with Recurrent MDD had the highest frequency of severely impaired QOL (82.6%), followed by patients with Bipolar II Disorder (77.4%), Mood Disorder due to a general medical condition (77.4%), Dysthymic Disorder (75.0%), Single Episode MDD (74.8%) and Bipolar I Disorder, Depressed (73.6%).

Patients with Bipolar I Disorder, Depressed had the highest frequency of severely impaired Functioning on the WSAS (74.7%), followed by patients with Recurrent MDD (68.4%), Bipolar II Disorder (66.1%), and Single Episode MDD (57.5%).

Normal QOL and Functioning at Baseline

Few patients entered outpatient treatment with normal levels of QOL or Functioning. Overall, only 14.1% of patients reported normal levels of QOL on the Q‐LES‐Q, and 16.8% of patients reported normal Functioning on the WSAS (see Table 6). Only 5.5% of patients with Recurrent MDD reported normal QOL at baseline.

Comparison of Patients with a Principal Diagnosis of Mood Disorder Versus Patients with a Principal Diagnosis of Other Disorders on Severity of QOL/Functioning

In general, patients who carried a principal diagnosis of mood disorder, more frequently reported severe levels of impairment in QOL and Functioning (see Table 6). Patients with a principal diagnosis of mood disorder more frequently reported severe impairment in QOL on the Q‐LES‐Q (χ² = 103.7, p < 0.001). They also showed more frequent impairments in terms of Functioning, as measured by self‐report on the WSAS (WSAS χ² = 74.8, p < 0.001).

Similarly, patients with a principal diagnosis of mood disorder were less likely to report normal QOL and Functioning on entry into outpatient treatment compared to patients without such a diagnosis, on the Q‐LES‐Q (χ² = 52.7, p < 0.001), and on the WSAS (χ² = 29.6, p < 0.001) (see Table 7).

DISCUSSION

The World Health Organization defines Health as “a state of complete physical, mental and social well‐being and not merely the absence of disease or infirmity” (36). Hence, restoration of health, as evidenced by improvements in QOL and Functioning, should be a major goal of clinical interventions (37, 38). Psychiatric disorders frequently cause a significant burden, both to individuals and to society, as they include four out of the 10 most disabling conditions in the world (39). Psychiatric disorders were strongly associated with poor quality of life (QOL) (40), and impairment in occupational and/or social Functioning (41). In fact, QOL of patients, with psychiatric disorders, especially depression, has been shown to be worse than the QOL of patients with medical disorders (42, 43).

The current assessment of patients entering an outpatient treatment program for a variety of psychiatric conditions revealed that, at entry into treatment, these patients were significantly impaired in both QOL and Functioning. In addition, very few patients reported normal levels of QOL or Functioning, which was to be expected, given that these patients were entering treatment.

In general, with regard to QOL, patients were as impaired as predicted; wherein more than 70% of patients across diagnoses reported severely impaired QOL on the Q‐LES‐Q. However, only approximately 60% of these patients reported severely impaired Functioning on the WSAS, which was generally consistent with our second hypothesis. Exceeding our initial predictions, only around 15% of patients reported QOL and Functioning within normal ranges at the entry into treatment. This is understandable, as patients were seeking treatment of their own accord due to psychiatric symptoms. Yet, these patients were far worse off than we had originally anticipated.

Consistent with our first hypothesis, patients with a principal diagnosis of mood disorder were significantly more impaired in terms of Functioning and QOL across measures compared to patients without a principal diagnosis of mood disorder. Importantly, patients with a principal diagnosis of anxiety disorder were consistently the least likely to report severe impairments in QOL or functioning at entry to treatment. It follows that these patients may have less risk of endorsing impairments in functioning or QOL compared to individuals with a principal diagnosis of mood disorder. Assessed as a continuous variable, or in terms of the numbers of patients who reported severe impairment versus normal QOL or Functioning, patients with a principal diagnosis of mood disorder reported much worse QOL and Functioning. Although these differences corresponded with small effect size (after controlling for demographic variables), these differences are noteworthy, and imply that treatment efforts should be targeted, in particular, at patients who meet criteria for a principal diagnosis of mood disorder.

Consistent with findings in the present study, several studies have demonstrated that MDD can have a substantial negative impact on QOL and on the ability to function (44, 45, 46, 47, 48, 49). The reason that depressive symptoms across psychiatric conditions lead to greatest impairment in QOL and Functioning remains unclear, though it is likely related to mediating constructs such as degree of self‐efficacy and subjective perception of health (50, 51). Mood disorders like MDD, have consistently shown the highest negative impact on QOL and Functioning (52). Our finding that patients with bipolar disorder endorse significant impacts on QOL and Functioning align with the literature, though the extent to which this is linked to depressive symptoms is unclear (53). Interestingly, the fact that Bipolar Disorder, Depressive Type had the greatest impact on QOL and Functioning does suggest a link to a combination of depressive symptoms with residual symptoms such as impulsivity, irritability, or insomnia, which are more highly associated with bipolar disorders (54).

A careful examination of the methodology of treatment outcome assessment of psychiatric disorders reveals that there is significantly more emphasis on measuring and reducing symptom severity as the primary outcome, rather than improvements in QOL and Functioning (55, 56). Although psychiatric treatments aimed at alleviating suffering from symptoms was thought to eventually lead to overall improvement, evidence has shown that even after responding to treatment, patients often continue to experience impairments in QOL and Functioning (57, 58). Which, in consequence, can negatively impact an individual, their family, their work and productivity, or even society at large. Outcome assessments in both clinical and research settings should go beyond focusing primarily on changes in symptom severity. Tracking QOL and Functioning may serve as an important metric in assessing patients' recovery as they progress through treatment. Although symptom remission has become a widely accepted goal of treatment, improving, and restoring QOL and Functioning would need to be the ultimate goals (59).

Limitations and Strengths

Limitations

There was no control group that could permit comparing QOL and Functioning to medical patients or normal controls. However, the use of validated scales with community norms could be helpful as an initial exploration of QOL and Functioning in psychiatric patients. Although self‐report measures can carry the risk of minimization or magnification of rated items, the ones used in the current study have previously demonstrated high correlations with clinician‐rated scales and have been validated in other scientific studies (29, 35, 43). Findings from the present study may not be applicable to patients in an inpatient setting, patients with significant medical or psychiatric co‐morbidities, or patients that belong to certain ethnic groups such as Asian Americans or Native‐Americans, as there was a minimal number of subjects from these ethnic groups included in the study sample. In addition, the study may not reflect community‐dwelling individuals who are not treatment‐seeking, as these individuals may have different clinical or demographic features. Thus, future studies should aim at applying our research methodology and testing findings of the present study with those particular populations.

Strengths

This study is unique in that it uses a naturalistic longitudinal outpatient dataset to analyze QOL and Functioning data from treatment‐seeking patients with diverse demographic, clinical, and diagnostic backgrounds. Of note, innovative features of the study included the fact that while QOL and Functioning have been examined in different disorders, they have not been systematically studied and compared in outpatient treatment settings across diagnostic categories. This study launched a concerted effort to compare QOL and Functioning in different psychiatric disorders using the same set of measures, in a naturalistic treatment‐seeking outpatient population, rather than convenience samples, community populations, or ad‐recruited research subjects. The patients in the study sample had diverse demographics and clinical presentations with regard to assessment and treatment. These factors suggest that our patient population is more reflective of the general population seen in mental health outpatient facilities, and thus, the conclusions in this study are likely generalizable in outpatient settings.

CONCLUSION

Patients with psychiatric conditions overwhelmingly reported severely impaired QOL and Functioning upon presentation to outpatient evaluation and treatment. Patients with mood disorders were especially impacted, as these patients report greater impairments in QOL and Functioning compared to those with other psychiatric diagnoses, at entry into outpatient treatment. Findings from the present study suggest that future treatment efforts should focus on developing specific interventions to restore QOL and Functioning in psychiatric patients in general, and in patients with a principal diagnosis of mood disorder in particular. As such, QOL and Functioning need to be considered in conjunction with symptom remission, particularly in patients with mood disorders, as these might not always improve spontaneously following symptom improvement. Clinicians may need to regularly measure these constructs alongside symptoms, monitor them over time, and then implement interventions that directly target QOL and Functioning.