DEPRESSION

AND

ANXIETY 26:10331039 (2009)

Research Article
ASSOCIATION BETWEEN QUALITY OF LIFE AND
SELF-STIGMA, INSIGHT, AND ADVERSE EFFECTS OF
MEDICATION IN PATIENTS WITH DEPRESSIVE
DISORDERS
Cheng-Fang Yen, M.D. Ph.D.,1,2 Cheng-Chung Chen, M.D. Ph.D.,13 Yu Lee, M.D.,4 Tze-Chun Tang, M.D.,2
Chih-Hung Ko, M.D.,2 and Ju-Yu Yen, M.D.2,5

Background: The aims of this study were to examine whether different domains
of quality of life (QOL) are differently affected by depressive disorders by
comparing QOL of subjects with and without depressive disorders, and to
examine the association of QOL with self-stigma, insight and adverse effects of
medication among subjects with depressive disorders. Method: The QOL on the
four domains of the WHOQOL-BREF Taiwan version were compared between
the 229 subjects with depressive disorders and 106 control subjects. Among the
depressive subjects, the association between the four QOL domains and subjects
self-stigma, insight, and adverse effects of medication were examined using
multiple regression analyses by controlling for the influence of depression, sociodemographic and clinical characteristics and family function. Results:
Depressive subjects had poorer QOL on the physical, psychological and social
relationship domains than the non-depressive control group. The depressive
subjects who had more severe self-stigma had poorer QOL on all four domains.
The depressive subjects who perceived more severe adverse effects from
medication had poorer QOL on the physical, psychological and environmental
domains. However, insight was not associated with any domain of QOL in
patients with depressive disorders. Conclusions: The results of this study
demonstrate that different domains of QOL are differently affected by depressive
disorders, and that clinicians must consider the negative influences of selfstigma and adverse effects from medication on QOL of subjects with depressive
disorders. Depression and Anxiety 26:10331039, 2009. r 2009 Wiley-Liss, Inc.
Key words: quality of life; depression; stigma; insight; adverse effects of
medication

1
Department of Psychiatry, Faculty of Medicine, College of
Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
2
Department of Psychiatry, Kaohsiung Medical University
Hospital, Kaohsiung, Taiwan
3
Department of Psychiatry, TsyrHuey Mental Hospital, Kaohsiung, Taiwan
4
Department of Psychiatry, Chang Gung Memorial HospitalKaohsiung Medical Center, Chang Gung University College of
Medicine, Kaohsiung, Taiwan
5
Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang
Hospital, Kaohsiung, Taiwan

r 2009 Wiley-Liss, Inc.

Correspondence to: Dr. Cheng-Chung Chen, M.D., Ph.D.,

Department of Psychiatry, Kaohsiung Medical University, No.

100 Tzyou 1st Road, Kaohsiung City, Taiwan 807.
E-mail: ccchen@mail.khja.org.tw
Received for publication 16 June 2007; Revised 11 September
2007; Accepted 19 September 2007
DOI 10.1002/da.20413
Published online 15 March 2009 in Wiley InterScience (www.
interscience.wiley.com).

1034

Yen et al.

INTRODUCTION

The quality of life (QOL) is a broad-ranging concept,

incorporating in a complex way the persons physical

health, psychological state, level of independence,
social relations, personal beliefs, and relationship to
salient features of the environment.[1] Depressive
disorders have long courses, a high tendency to relapse,
and adverse impacts on multiple dimensions of
functioning. Assessment of the impact of depressive
disorders on QOL is important in deciding how
aggressively the disorders should be treated and for
how long, measuring outcomes, assessing the health
needs of patients, and allocating resources.[2] Patients
with depressive disorders have been found to have
poorer subjective QOL than healthy control subjects,[3,4] subjects with schizophrenia, and subjects with
physical illness.[5] However, there are different concepts of subjective QOL in depression. Some have
argued that subjective QOL in depression is tautological because of the concepts of QOL and depression
and because of the negative influence of a depressed
mood on the perception of oneself and the environment,[6] whereas others suggest that judgments about
QOL involve not only an evaluation of internal states,
including mood, but are also affected in a complex way
by the environment, situation, or events experienced.[7]
Several instruments, including the World Health
Organization questionnaire on quality of life [WHOQOL[1]], have been developed to evaluate multiple
domains of QOL. Further research is needed to
examine whether the adverse impact of depression
varies in the different domains of QOL.
Previous studies have found that the severity of
depression,[8] age,[9] family and social support,[10,11]
and sex[12] are associated with the QOL of patients
with mental illnesses. Except for the sociodemographic
characteristics and severity of psychopathology, it is
noteworthy to examine whether patients subjective
attitudes toward their mental illness and experience of
treatment have an impact on the level of QOL. From
the consumer-oriented and holistic view of health care,
the patients subjective attitudes and experience should
be highly respected. The associations of QOL with
three categories of patients subjective attitudes and
experience, including self-stigma, insight, and experienced adverse effects of medication, were examined in
this study. Stigma is an important psychosocial factor
that affects people adversely through mechanisms of
direct and structural discrimination and social psychological processes that involve the stigmatized persons
perceptions.[13] Stigma has been found to negatively
influence the QOL of patients with severe mental
illnesses.[14] Although stigma is widespread among
depressed patients,[15] little research has focused on
patients with depressive disorders.
Insight has been considered a predictor of clinical
outcomes for mental illnesses.[16,17] However, contradictory findings have been reported regarding the
Depression and Anxiety

relationship between insight and subjective QOL in

patients with psychiatric disorders.[9,11,1820] Different
measures of insight, heterogeneous samples, and
whether to consider insight a single or multidimensional concept may account for the controversy. To our
knowledge, no study has examined the association
between QOL and each dimension of insight evaluated
by a standard multidimensional measure in a homogenous group of patients with depressive disorders.
Subjective QOL is negatively influenced by the side
effects of treatment in schizophrenic patients.[2123] and
in patients with panic disorders.[24] A variety of
antidepressants can improve depressive symptoms.
However, antidepressants have different adverse effects
on several organs and systems.[25] Little is known about
the impacts of the adverse effects of pharmacotherapy
for depressive disorders on QOL.
This is the first study to examine the association
between QOL and self-stigma, insight, and adverse
effects of medication among patients with depressive
disorders by controlling for sociodemographic characteristics and family function. The aims of this study
were (1) to examine whether different domains of QOL
are differently affected by depressive disorders by
comparing the QOL of subjects with and without
depressive disorders, as well as the moderating effects
of sociodemographic characteristics and family support
on the association between QOL and the diagnosis of
depressive disorders and (2) to examine the association
of QOL with self-stigma, insight, and adverse effects of
medication among subjects with depressive disorders.

MATERIALS AND METHODS

PARTICIPANTS
A group of 247 subjects diagnosed with depressive disorder
according to the Diagnostic and Statistical Manual of Mental
Disorders-IV [DSM-IV] criteria [APA,[26]] were recruited from
outpatient psychiatric settings in three general hospitals in southern
Taiwan. Those with intellectual disability, comorbid substance use
disorders, and psychotic disorders were excluded. The demographic
and clinical characteristics of these subjects had been described in
previous studies.[27,28] The sociodemographic and clinical data,
stigma, insight, adverse effects of medication, family function, and
QOL of the 229 subjects who received antidepressant treatment at
the time of recruitment were analyzed in this study. Of these, 155
subjects (67.7%) were diagnosed with major depressive disorder, 45
(19.7%) with dysthymic disorder, and 29 (12.7%) with a depressive
disorder not otherwise specified.
To recruit subjects for the control group, we posted an
advertisement in the hospital and in newspapers to invite participation in the study. A total of 157 persons responded to the
advertisement. A psychiatrist assessed all the responders systematically to determine whether they had any mood or psychotic
disorders using the structured mini-international neuropsychiatric
interview.[29] Those who had any mood or psychotic disorders, drank
alcohol more than once per month, used any illicit drugs, or had low
mentality were excluded. A total of 106 subjects conformed to the
criteria and were recruited as the control group.

Research Article: Quality of Life in Depressive Disorders

SURVEY INSTRUMENTS
World Health Organization Questionnaire on Quality
of Life: Short FormTaiwan version. The World Health
Organization questionnaire on quality of life, short formTaiwan
version (WHOQOL-BREF Taiwan version) was developed by the
WHO to evaluate health-related QOL and to make cross-cultural
comparisons.[1] The WHOQOL-Taiwan group adapted the WHOQOL-BREF for use in Taiwan.[30] The WHOQOL-BREF Taiwan
version contains 28 5-point items that assess general (2 items) and
four specific domains of QOL, including 7 items in physical health, 6
in psychological, 4 in social relationships, and 9 in environmental
domains, with well-established validity and reliability.[30] The
transformed scores of the four QOL domains range from 0 to 100.
Higher scores on the WHOQOL-BREF Taiwan version indicate a
higher perceived QOL.

The Taiwanese Version of the Self-Stigma Assessment

Scale. The Taiwanese version[27] of the Self-Stigma Assessment

Scale [SSAS;[31]] is an 8-item five-point scale assessing participants

attitudes toward their own mental illnesses, including whether they
agree that, because of mental illnesses, they are morally weak, are
unable to care for themselves, cannot handle responsibility, are
dangerous, and are unworthy of respect. The Cronbachs a for the
SSAS was 0.803.[27] Possible total scores on the SSAS range from 8 to
40, with higher scores indicating greater self-stigma.
The Mood Disorders Insight Scale. The Taiwanese
version[27,28] of the Mood Disorders Insight Scale [MDIS;[32] is an 8item scale that measures three dimensions of insight, awareness of
illness (2 items), attribution of symptoms (3 items), and the
participants belief in the necessity of treatment (3 items). The MDIS
items are presented as a series of statements, read by two research
assistants, and the participants are asked if they agree, disagree, or are
unsure. For example, the first item in the dimension necessity of
treatment is I need to be seen by a psychiatrist (or doctor). If the
subject disagrees or is unsure, they are further asked whether they
agree with the item that there was a time when I needed to be seen by
a psychiatrist (or doctor). The original total scores were adjusted to a
range from 0 to 12. In this study, the Cronbachs a for the MDIS was
0.679. Higher MDIS scores indicate greater insight.

The Center for Epidemiological Studies Depression

Scale. The 20-item Center for Epidemiological Studies Depression Scale (CES-D) is a self-administered four-point scale assessing
frequency of depressive symptoms in the preceding week, with scores
ranging from 0 (never or rarely) to 3 (always).[33] The Taiwanese
version of the CES-D has been used for studying depression in
Taiwan for many years,[34] and the possible total scores on the CES-D
range from 0 to 60, with higher scores indicating more severe
depression. In this study, the Cronbachs a for the CES-D was 0.931.
A score Z17 is classified as obvious depression.[33]

Questionnaire on Adverse Effects of Medication for

Depression. The questionnaire on adverse effects of medication
for depression is adapted from the questionnaire on adverse effects of
medication for panic disorder, which has been found to have good
reliability and validity.[24] It contains 16 items to evaluate the patients
perceived adverse effects induced by antidepressants used for treating
depressive disorders in the preceding 2 weeks. The Cronbachs a of
the questionnaire on adverse effects of medication for depression in
this study was 0.845. The positive items are summed up to represent
the total severity of adverse effects of medication.
Family APGAR Index. The Taiwanese version of family
APGAR[35] is based on the original version developed by Smilkstein.[36] The five-point response scales reflect frequency ranging
from never to always. High scores indicate good family support.
When the APGAR score is 6 or less, the family is considered as
providing low support.[37]

1035

PROCEDURE AND STATISTICAL ANALYSIS

The protocol was approved by the Institutional Review Board of
Kaohsiung Medical University. Informed consent was obtained from
all the subjects before commencement of the study. Two research
assistants evaluated the insight of depressive subjects using the MDIS
and explained how to complete the self-administered questionnaires.
If the participants had difficulty in understanding the contents of the
questionnaires due to a low level of literacy, the researchers read out
the questions to them to maximize comprehension and reliability.
The sociodemographic characteristics and family support on the
APGAR Index among the subjects in the control group were also
collected.
Among the subjects in the depressive and control groups, the
influences of the diagnosis of depressive disorders on the four QOL
domains on the WHOQOL-BREF Taiwan version were examined
using full enter multiple linear regression analyses by controlling for
sex, age, education, marriage, and family support. If the diagnosis of
depressive disorders, sociodemographic characteristics, and family
support were significantly associated with QOL, the interactions of
the diagnosis of depressive disorders with sociodemographic characteristics and family support were further selected into the analysis
model to examine the moderating effects of sociodemographic
characteristics and family support on the association between QOL
and the diagnosis of depressive disorders.
Among the subjects in the depressive group, the association
between the four QOL domains and the subjects self-stigma, insight,
and adverse effects of medication were examined using full enter
multiple linear regression analyses by controlling for the influence of
depression, sex, age, education, marriage, and family support. A twotailed P-value less than 0.05 was considered statistically significant.

RESULTS
The sociodemographic characteristics, family function on the APGAR, and the QOL on WHOQOLBREF Taiwan version of the subjects in the depressive
and control groups are shown in Table 1. More subjects
in the depressive group were married (w2 5 13.768,
Po0.001), and the depressive subjects were older than
those in the control group (t 5 8.098, Po0.001). No
differences were found in the sex, social status, age, and
family function between the depressive and control
groups.
The influences of the diagnosis of depressive
disorders on the four QOL domains were examined
using multiple linear regression analysis by controlling
for sociodemographic characteristics and family function and the results are shown in Table 2. The results
found that subjects in the depressive group had poorer
QOL in the physical, psychological, and social
relationship domains than those in the control group
after controlling for the influences of other factors.
However, no difference was found in the environmental domain between the depressive and control
groups. The moderating effects of sociodemographic
characteristics and family support on the association
between the diagnosis of depressive disorders and
QOL in the physical, psychological, and social
relationship domains were further examined. The
results indicated that the interaction between the
diagnosis of depressive disorders and family support
Depression and Anxiety

1036

Yen et al.

TABLE 1. Sociodemographic and survey data

Depressive group (N 5 229)

Sociodemographic characteristics
Age (years)
Education (years)
Gender: female
Married
Family function on the APGAR
CES-DZ17
Duration of illness (months)
Self-stigma scores on the SSAS
Insight on the MDIS
Adverse effects of medication on the QAEM-D
Quality of life on WHOQOL-BREF Taiwan version
Physical
Psychological
Social relationship
Environment

Mean (SD)

Range

43.8 (14.2)
11.8 (3.9)

1577
019

Control group (N 5 106)

N (%)

Mean (SD)

Range

33.8 (8.1)
12.0 (1.1)

1850
916

141 (61.6)
97 (42.4)
13.9 (4.0)

N (%)

55 (51.9)
38 (35.8)

520

14.3 (3.2)

520

166 (72.5)
54.6
19.6
9.0
5.0

(70.1)
(5.2)
(2.5)
(3.9)

1372
832
012
014

49.3
41.4
53.1
55.1

(17.0)
(20.2)
(16.3)
(16.1)

688
094
081
694

70.5
54.1
61.7
51.6

(11.9)
(12.3)
(13.4)
(16.1)

3894
2581
2594
1975

APGAR, Family APGAR Index; CES-D, The Center for Epidemiological Studies Depression Scale; MDIS, Mood Disorders Insight Scale;
QAEM-D, Questionnaire on Adverse Effects of Medication for Depression; SSAS, Self-Stigma Assessment Scale; SSRS, Social Status Rating
Scale; WHOQOL-BREF Taiwan version, World Health Organization Questionnaire on Quality of Life, Short Form Taiwan Version.

TABLE 2. The effect of the diagnosis of depressive disorders on quality of life by controlling the effects of family
function, age, sex, education, and marriage in multiple linear regression analyses
Physical
b
Having depressive disorder
Total APGAR scores
Age
Female
Education
Married
Adjusted R2
F value

0.550
0.254
0.070
0.059
0.009
0.028

Psychological
t

11.515
5.516
1.2457
1.288
0.186
0.545
0.361
32.316

b
0.380
0.351
0.221
0.023
0.049
0.058

7.530
7.208
3.723
0.480
0.955
1.070

0.288
23.489

Social relationship
t

b
0.320
0.364
0.133
0.187
0.070
0.110

6.350
7.469
2.2480
3.830
1.357
2.021

0.288
23.469

Environment
t

b
0.041
0.439
0.237
0.071
0.061
0.014

0.807
8.871
3.932
1.439
1.166
0.259
0.266
21.074

Po0.05; Po0.001.

APGAR, Family APGAR Index.

was neither associated with QOL in the physical

(b 5 0.047,
t 5 0.226)
and
psychological
(b 5 0.060, t 5 0.272) nor the social relationship
domain (b 5 0.112, t 5 0.493). The interaction between
the diagnosis of depressive disorders and age was
neither associated with the QOL in the psychological
(b 5 0.360, t 5 1.387) nor the social relationship
domain (b 5 0.528, t 5 1.855). The interactions between the diagnosis of depressive disorders and sex
(b 5 0.001, t 5 0.012) or marriage (b 5 0.079,
t 5 0.679) were not associated with the QOL in the
social relationship domains. These results indicated
that sociodemographic characteristics and family support had no significant moderating effect on the
association between the diagnosis of depressive disorders and QOL.
Depression and Anxiety

The associations between QOL and self-stigma,

insight, and adverse effects of medication were
examined using multiple linear regression analysis
among the subjects in the depressive group (Table 3).
The results indicated that by controlling for the
influence of the severity of depression, sociodemographic and clinical characteristics, and level of family
function, the depressive subjects who had a more severe
self-stigma had poorer QOL on all four domains of the
WHOQOL-BREF. Self-stigma accounted for 3.9, 2.0,
1.3, and 1.9% of the variance in the physical,
psychological, social relationship, and environmental
domains of QOL, respectively. The depressive subjects
who perceived more severe adverse effects of medication had poorer QOL on the physical, psychological,
and environmental domains. Perceived adverse effects

Research Article: Quality of Life in Depressive Disorders

1037

TABLE 3. Variables associated with quality of life among patients with depressive disorders in multiple linear
regression analyses
Physical
T

b
Self-stigma scores on the SSAS
Insight on the MDIS
Adverse effects of medication on the QAEM-D
CES-D Z17
Total APGAR scores
Age
Female
Education
Married
Duration of illness
Adjusted R2
F value

Psychological

0.209
0.059
0.357
0.326
0.087
0.002
0.054
0.021
0.010
0.066

3.823

1.089
6.367
5.579
1.487
0.030
1.006
0.353
0.167
1.242
0.478
20.196

b
0.115
0.010
0.184
0.448
0.196
0.157
0.032
0.088
0.014
0.005

2.181

0.185
3..412
7.957
3.488
2.511
0.615
1.542
0.242
0.096
0.515
23.300

Social relationship
t

b
0.128
0.070
0.085
0.283
0.266
0.116
0.179
0.091
0.070
0.060

2.123

1.175
1.381
4.378
4.136
1.622
3.040
1.386
1.056
1.022
0.363
12.969

Environment
t

2.644
0.087
2.390
7.524
5.400
2.241
1.880
1.191
0.670
0.006
0.532
24.824

0.137
0.004
0.127
0.416
0.298
0.138
0.095
0.067
0.038
0.001

Po0.05; Po0.01; Po0.001.

APGAR, Family APGAR Index; CES-D, The Center for Epidemiological Studies Depression Scale; MDIS, Mood Disorders Insight Scale;
QAEM-D, Questionnaire on Adverse Effects of Medication for Depression; SSAS, Self-Stigma Assessment Scale.

of medication accounted for 12.1, 3.0, and 1.4% of the

variance in the physical, psychological, and environmental domains of QOL, respectively. However, the
level of insight on the MDIS was not associated with
any domain of QOL on the WHOQOL-BREF.

DISCUSSION
This study found that patients with depressive
disorders had a poorer QOL on the physical, psychological, and social relationship domains than the nondepressive control group, which further shows that
depression negatively influences the conditions that are
essential for maintaining good QOL in these three
domains. On the other hand, some items in the
psychological and physical WHOQOL-BREF domains
cover criterion symptoms of depressive syndromes,
which might partially account for the differences in
these two domains in QOL between depressive and
non-depressive subjects. Previous studies assumed that
depression is related to a negative cognitive set of
viewing the self, the world, and the future,[38] and the
formation of assessment of QOL faces interference
from problematic information processing caused by
depression.[22] On the basis of this theoretical framework, depressed patients should have poorer subjective
QOL in all QOL domains than non-depressed ones.
However, no difference in the environmental QOL
domain was found between these two groups. The
results of this study demonstrate that different domains
of QOL are differently affected by depressive disorders,
which is in line with the findings of Kuehner.[3]
This study found that a high level of self-stigma was
associated with a poor QOL in subjects with depressive
disorders, which indicates that the compromising
effects of stigma on QOL are seen not only in patients
with schizophrenia[39] and bipolar disorder[40] but also

in those with depressive disorders. Self-stigma may

damage ones self-concept and lead to self-deprecation,
which in turn compromises feelings of mastery over
ones lifes circumstances.[41,42] People who worry
about stigmatization are also more likely to withdraw
from social contacts,[40] choosing a more isolated
existence above the risk of rejection or discrimination,
which may result in further demoralization, lower
income, unemployment, and restricted social networks.[43] The results of this study further support
the importance of reducing stigma and discrimination
against people with depressive disorders.
The results of this study found that adverse effects of
medication were associated with poor QOL in the
physical, psychological, and environment domains. As
seen in the treatment of schizophrenia[2123] and panic
disorders,[24] antidepressants might be a two-edged
sword in the QOL of patients with depressive
disorders. In line with the results of other studies,[8,44]
we found that subjects who were in obvious depression
had poorer QOL in all four domains than those in
remission. Improving the level of depression using
antidepressants seems to be the first and most reliable
step in improving QOL. On the other hand, intolerable
adverse effects of antidepressants may compromise
patients QOL, which may further compromise their
treatment adherence. Poor medical adherence results
in the recurrence of depressive illnesses, which
adversely influences the patients QOL in a vicious
cycle. The findings of this study indicate that clinicians
must help patients with depressive disorders to identify
and manage the adverse effects of therapy. Frequent
discussions with patients may encourage them to
continue treatment and to accept the balance of
benefits and adverse effects of treatment.
Previous studies have hypothesized the association
between insight and QOL in patients with mental
Depression and Anxiety

1038

Yen et al.

illnesses. First, stigma elicited by the psychiatric

diagnosis can make acceptance of the diagnosis
especially distressing.[45] Second, persons who accept
their diagnosis of a mental illness may modify their
expectations concerning lifes goals and acceptable
psychosocial circumstances, which may reduce their
subjective QOL.[44] However, in this study, insight was
not associated with QOL in patients with depressive
disorders. We analyzed the correlation between insight
and QOL by Pearsons correlation and found that
insight was negatively associated with the QOL in the
physical (r 5 0.233, Po0.001), psychological
(r 5 0.244,
Po0.001),
social
relationship
(r 5 0.263, Po0.001), and environment domains
(r 5 0.200, Po0.01). However, the correlations
became nonsignificant in the multiple regression
analyses. We hypothesized that the correlation between
insight and QOL may be partially accounted for by
other factors. This is the first study to examine the
association between insight and QOL in a homogenous
group of patients with depressive disorders, and further
studies are needed to examine this issue.
A strength of our study is that the WHOQOLBREF is a transcultural instrument, the results of
which have a high face and construct validity within the
specific cultural setting.[46] However, some limitations
of this study must be taken into account. First, the
cross-sectional study design restricts the drawing of
causal inferences between QOL and psychosocial
factors, such as stigma. Although it seems plausible
that a lower QOL would be an outcome of stigma,
stigma could also conceivably result from a poor QOL.
Additional longitudinal studies are needed to further
examine the temporal relationships among these
phenomena. Second, the sample size of the control
group was smaller than that of the depressive group.
Meanwhile, the subjects in the control group were
recruited into this study by an advertisement, and the
potential selection bias should be taken into account.
Third, further studies are needed to examine whether
the level of self-stigma is higher in this study than that
in Western countries and whether the role of selfstigma on the QOL is different between Asian and
Western populations. Asian people may have a higher
level of stigma toward mental illnesses. For example, a
previous study has considered that severe stigma
toward mental illnesses was one of the explanations
for the marked underdiagnosis of depression in
Japanese communities.[47] Fourth, to examine how
self-stigma negatively influences the QOL of patients
with depressive disorders may need further quantitative
and qualitative studies.

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