Psychiatric Times October 2005 Vol. XXII Issue 11

Health-related quality of life (HRQOL) can be defined as a broad array of outcomes that go beyond syndrome-specific symptoms or mortality and can include satisfaction and competence in primary life role (e.g., student, homemaker or breadwinner), satisfaction and competence in relationships, freedom from pain and mental anguish, energy, and other broad and subjective psychosocial constructs affected by one's health. Health-related quality of life is part of the larger concept of QOL, which includes some aspects of living that, while important, do not necessarily directly reflect health per se, such as spiritual satisfaction, lack of crowding and availability of a stimulating environment. Of necessity, HRQOL must be defined with reference to the patient's values (Asadi-Lari et al., 2004) and cannot always be subjected to external validation, in contrast to more objective measures of function such as activities of daily living, which can be validated by direct observation (McCall et al., 2002).

Why is HRQOL important to psychiatry and, more specifically, to the practice of electroconvulsive therapy? The Institute of Medicine quality improvement blueprint calls for care that is both evidence-based and customized based upon patient needs and values (Committee on Quality Health Care in America, 2001). In a world with limited resources for the treatment of disease, HRQOL is a useful means of contrasting the overall impact of different diseases on patients' lives. For example, HRQOL creates a common language that allows a comparison of the impact of problems as disparate as orthopedic problems and cancers. Similarly, treatments of different diseases can be contrasted for their relative value in improving HRQOL. Going further, the relative cost of a unit of improvement in HRQOL for different treatments of different diseases can be compared, facilitating optimal allocation of scarce health resources.

Health-related quality of life can also assist in determining the relative health benefits of treatments that have both high efficacy and significant side effects. In the example of cancer, HRQOL can simultaneously take into account the therapeutic action of chemotherapy and its adverse effects, giving some sense of the overall net impact of chemotherapy on health.

HRQOL and Depressive Illness

In the same vein, HRQOL can provide a simultaneous and net assessment of the therapeutic and adverse effects of psychiatric treatments. Major depressive disorder (MDD) has been identified as the candidate for the second leading cause of poor HRQOL in the world by the year 2020 (Murray and Lopez, 1996). This phenomenon is predicted by both the high world prevalence of MDD as well as the greater negative impact of MDD on HRQOL as compared with the impact of other common conditions, such as arthritis, diabetes or coronary disease (Wells et al., 1989). Within samples of patients with depression, severity of depression is related to the extent of HRQOL deficits, and the type of deficit depends in part upon the age of the patient with depression (McCall et al., 1999a).

Therefore, antidepressant treatments, including ECT, would be expected to have the potential for producing large improvements in HRQOL that would be of relevance to public health. Indeed, successful treatment of depression is associated with improvements in HRQOL (McCall et al., 2001). Conversely, partial antidepressant response and failure to achieve a complete remission, leaving the patient with ongoing residual symptoms, is associated with worse HRQOL (Zimmerman et al., 2004).
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