Quality Of Life and Associated Factors among Patients with Major Depression on Follow Up At Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia


 Background: Patients suffering from major depression are reported to have poorer quality of life than both the general population and otherwise healthy persons with chronic diseases. The impact of major depression on quality of life is scarcely investigated in developing country.Methods : An institution based cross-sectional study was conducted from March 15 to April 16, 2017 at Amanuel Mental Specialized Hospital. 502 study participants were involved in the study. Quality of life was measured by a structured cross-cultural WHOQOL-BREF. Other tools utilized in this study were Montgomerry-Asberg depression rating scale, Oslo social support scale, and Jacoby perceived stigma scale. Multiple linear regression analysis was used to predict the effect of each factor on domains of quality of life.Result : The mean score QOL for each domain (mean± SD) was, for physical 43.5±11.9, for psychological 41.2±11.9, for social 40.7±10.6, and for environmental 41.3±9.6. Univariate analysis showed nearly half of the participants scored below the mean score quality of life (QOL). Multiple regression analysis depicted severity of depressive symptoms was strongly negatively correlated with all domains of QOL. It had predicted above 50% of the variability in each domain. Social support was also another strong predictor which was negatively correlated with all QOL domains, except environmental. It had explained above 60% of the variance in physical, and 43.3% for psychological and 44.8% for social domain.Conclusion: The results shows mean score QOL in each domain is lower compared to other studies, and even nearly half the participants are below the mean score QOL. Severity of depressive symptoms, social support, numbers of episodes in a year, duration on treatment, stigma, being single and rural residence are factors negatively correlated with at least one domain. Treating Major depression should follow a holistic approach and should aim in improving QOL. Keywords: Major Depressive Disorder , Quality of life, WHOQOL-BREF, Associated factor

In addition the study revealed stigma has no direct effect on QOL rather its effect is mediated through mastery, social support and symptom severity [21]. In contradiction to this, studies from Jordan and Czech argue stigma independently predicts lower quality of life. On the other hand, the studies maintain the effect of age, stigma, and symptom severity on QOL [16,22].
According to Diagnostic Manual from American Psychiatric Association (DSM-V) classification, a clinically significant impairment in functioning is a must criterion to diagnose MDD. Measuring QOL is important to know the effect of depression on functioning. Impaired quality of life is a significant problem for people with MDD and is often not addressed through symptom remediation alone [20].
Poor quality of life in patients with MDD is associated with high rates of relapse, significant negative impact on the ability to perform and/or enjoy occupational and social activities including family, impaired future outlook, medical complications such as heart disease, and overall increase of healthcare related costs [7,23].
In developing countries Studies done on quantifying the impact of depression on quality of life are very scarce. Most professionals tend to focus on symptom reduction, which is only a single aspect of treating patients with major depressive disorder. The issue of assessing quality of life is highly neglected in Ethiopia. Having one psychiatric specialized hospital serving the nation alarms the need to assess quality of life of patients we serve.
In Ethiopia there is no any published research done assessing quality of life especially in patients with major depressive disorder, Given the urgency and potential benefit of an evidence on quality of life in patients with MDD, so far there is no a single article on this area. The research is aimed to determine the mean quality of life of patients in physical, psychological, social, and environmental health. In addition, it also has an objective of identifying factors associated with each domain of quality of life. This study is first of its kind in Ethiopia. The results of the study will be used as baseline for further investigation. (Fig.1.)   Comorbid medical or surgical disease-is a proven or diagnosed medical or surgical problem in addition to MDD. It will be proven by reviewing patient chart and asking the patient.

Substance use; Alcohol, cannabis, cigarette
 Current use-those who use (non-medical use only) substance for the last 3 months.
 Ever use -those who ever use (non-medical use only) substance in their life.
 Stigma -based on jacoby perceived stigma scale: a score of 1 and above indicate the patient is stigmatized [26].  Training was given to data collectors. Data was collected by three psychiatric nurses and was supervised by an experienced psychiatric nurse.

Data analysis
The collected data was coded, entered in to software called EpiData version 3.1and analyzed by using SPSS version 20. Descriptive statistics Frequency, Mean, Standard deviation were used to assess Quality of life in patients. Pearson product-moment correlation, and simple and multiple linear regression analysis were used to assess the correlates of Quality of life in the participants and B coefficient with 95% confidence interval was used. The statistical significance was accepted at p value < 0.05.

Ethical consideration
Ethical clearance was obtained from Institutional review board (IRB) of University of Gondar and Ethical committee of AMSH. A formal letter of permission was obtained from AMSH.
Written consent was received from the study participants before data collection.
Confidentiality of respondents was maintained by letting participant to fill the questionnaire anonymously. Completed questionnaires and computer data were kept confidential, by password security. Written consent form and an outline of the purpose of the study were discussed with each client. The participants are aware of the right to withdraw from the interview at any time they wish. Participants were assured that if they wish to refuse to participate, their care or dignity will not be compromised in any way.
Participants also were informed that there is no expectation of additional treatment or any associated benefits and risks for them participating in the study

Result
A total of 502 participants making the response rate 100% were enrolled in the study. The mean age of respondents was 36 years with SD ±12 years and majority of the populations (52.6%) were included in the age group 18-34. About 53% of the study participants were females. About 74.5% of the participants reside in urban areas. Majority of the participants were married, orthodox followers and Amhara by ethnicity. Regarding their occupation nearly half of the participants were jobless. (Table 1)

WHOQOL-BREF Score of Respondents
The mean score quality of life in each domain was below 45, as measured in a range from 0-100 using WHOQOL-BRIEF. Nearly half of the respondents scored below the mean score quality of life in each domain. The internal consistency measured using Cronbach alpha for each domain was found to be 0.73 for physical, 0.71 for psychological, 0.56 for social and 0.68 for environmental. (Table 3)   . The study from China using WHOQOL-BREF reported a lower mean score in each domain [10]. This could be due to the study had used a large sample size (n=19,984), and also the study included first visit patients.
Consistent findings are also reported from south Africa [12] and Germany [11]. Nearly half of the participant's QOL is below the mean QOL score. Another studies found that quality of life in patients with MDD is lower than patients with other chronic conditions [2,3,23,27,28].
Participant's educational level is not a significant predictor of each domain which is a different result from studies in USA and Germany [11,14]. Possible reason could be the difference in socioeconomic status in the study participants. Single participants have a lower QOL score compared to married in the social domain which is supported by a similar study from Germany [11].
Severity of depressive symptoms is one of the strongest significant predictors of quality of life in all domains. The finding is also supported by many studies done in a different setting and country [13,14,[17][18][19][20]. and environmental health(-0.349) [11]. Lower coefficients for each domain have been reported from Taiwan [21]. The difference could be because of the tool they used to measure severity of depressive symptoms, which is CES-D or socioeconomic and cultural differences in the study populations. Higher coefficients were reported from a study done in Brazil. Difference could be because of the tool they used to measure severity which is HADS or socioeconomic and cultural differences in the study populations. [17].
Social support score is positively correlated with all domains of QOL, except environmental. The study from Taiwan had reported a relatively lower coefficients for each domain, but the study deemed social support as a strong predictor of QOL [21]. Poor social support predicts 66% of the variance for physical, above 40% of the variance for psychological and social health. The finding is congruent with studies from Germany [11].  [16]. Another study fron Czech also supports the notion stigma is a significant predictor of a lower mean score QOL [22].
Participants who came from rural areas had a QOL score reduced by 2.78 units in environmental domain compared to those who came from urban areas.
Participants who had <1 year Treatment had a lower quality of life score in the physical domain compared with those >5 years history of treatment. Duration of treatment was not a significant 15 factor for other domains. Stigma affected the physical domain but was not a significant predictor in other domains. The influence of rural residence was only seen in environmental domain.

Conclusion
The study revealed that patients with major depression have lower mean score quality of life in all domains compared to other studies. Nearly half of the study participants scored below the mean score QOL. Severe depressive symptoms predicted all of the domains strongly. Social support, number of episodes in a year, duration on treatment,, stigma, being single, living in rural were the predictors of a lower mean score quality of life in all or at least one domain of quality of life.

Ethical approval and consent to participate
Ethical clearance was obtained from Institutional review board(IRB) of University of Gondar and Ethical committee of AMSH. Written consent was received from participants prior to data collection Consent for publication "Not applicable" in this section.

Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author on reasonable request