Course of life satisfaction in patients with depressive and addictive disorders after therapeutic intervention

Abstract

Background/Aim: To analyse the course of life satisfaction during the clinic stay of patients with depressive and/or addictive disorders.

Methods: In a cohort study, 199 patients with depressive and addictive diseases were asked to complete a series of questionnaires at the start and the end of their psychotherapeutic treatment (on average 4.2 ± 2.3 weeks later). The questionnaires were the Brief Multidimensional Life Satisfaction Scale (BMLSS), the Positive Life Construction/Contentedness/Well-Being Scale from the ERDA (Emotional/Rational Disease Acceptance) questionnaire, Beck’s Depression Inventory and the revised Symptom Checklist (SCL-90-R).

Results: The psychotherapeutic interventions improved the clinical situation of the patients and resulted in strong effects with respect to positive life construction (d = 1.07) and moderate effects on life satisfaction (d = 0.71). Stronger effects were noted in patients with depressive disorders (d = 0.80) than in patients with addictive disorders (d = 0.69). Regression analyses revealed that pre-treatment life satisfaction can be explained negatively by an escape-avoidance strategy (Escape from Illness), and positively by positive life construction. In contrast, post-treatment life satisfaction can be explained negatively by psychological distress and depression, and positively by positive life construction and living with a partner.

Conclusion: The hypothesis that life satisfaction changes are associated with the clinical situation of patients was confirmed. In particular, patients with depressive disorders profited from the psychotherapeutic interventions.

Keywords

life satisfaction depression addiction intervention disease acceptance

Background

One area of psychology analyses subjective well-being, that is, people’s cognitive and affective evaluation of their lives. This includes what one calls happiness, peace, fulfillment, and life satisfaction (Diener et al., 2003). Although personality can explain a significant amount of variability in subjective well-being, life circumstances also influence the long-term levels of subjective well-being, for example, life satisfaction (LS) (Asadi-Lari et al., 2004). LS is influenced by an individual’s awareness and acceptance of certain intrinsic aspects of life (attitudes, self-expectancies, personality) and extrinsic aspects (relationships, work, social support). The importance of these different aspects may vary between individuals.

One has to differentiate patient satisfaction with medical care and service quality, which are more specifically defined as the extent to which general healthcare needs and condition-specific needs are met (Asadi-Lari et al., 2004), and life satisfaction, which is a broader concept. Even patients with an impaired perception of health status, who may have more social needs, can have high satisfaction with various dimensions of life concerns (Büssing et al., 2009). In fact, although cancer patients experience traumatic stress, in several cases they also experience personal growth (Jim and Jacobsen, 2008).

Borg et al. (2008) have noted that overall health, self-esteem and feelings of worry rather than activities of daily living capacity, were significantly associated with LS. The findings indicate the importance of taking not only the reduction in functional capacity into account but also the individual’s perception of health and self-esteem. Personal rather than environmental factors are important for LS among people with reduced daily living capacity.

However, in most cases of chronic illness, there is no option of healing in terms of full physical and psychical restoration. Thus, one has to assess the underlying aspects of LS to identify specific (existential) needs of patients which should not been regarded as ‘defective’ just because of the persistence of symptoms. These symptoms may impact health-related needs and quality of life as suggested by Pfingsten (2009), because chronic illness affects not only physical and mental functioning, but also the working abilities, employment and financial situation of the patient. In addition, there must also be an impact on family life, friendships and so forth.

In patients with cancer, LS has a strong negative correlation with depression (r = −0.64), anxiety (r = −0.54), and a moderate negative correlation with fatigue (r = −0.43) and SF-12’s mental component (r = −0.42) (Büssing et al., 2009). The highest LS scores were found in healthy individuals, and the lowest in patients with chronic pain conditions and depressive disorders (Büssing et al., 2009). Thus, depressive symptoms obviously impair various aspects of life, including satisfaction with family life, friendships, oneself, future perspectives and other. Ghubach et al. (2010) confirmed that depressive disorders were significantly associated with reduced LS, and Daig et al. (2009) showed that depressive symptoms significantly explained the variance of LS domains. LS is also of relevance in patients with addictive disease because it may predict remission (Laudet et al., 2009).

Because several of these studies were cross-sectional, we investigated the course of LS during the clinic stay of patients with depressive and/or addictive disorders. It was not the aim to verify the effectiveness of the respective treatments but to analyse whether LS, as measured with the Brief Multidimensional Life Satisfaction Scale (BMLSS), might change in response to the psychotherapeutic intervention. It was hypothesized that improving the clinical situation of the patients through therapeutic interventions would significantly increase their LS (i.e. self, future prospects, overall life), which is not explicitly health related.

Materials and methods

Patients

All individuals in this multi-centre, prospective cohort study were informed of its purpose, were assured of confidentiality, and gave informed consent to participate. The study was approved by the ethical commissions of the University Witten/Herdecke (#115/2007) and the Medical Chamber Baden-Württemberg (#B-2008-070-f).

Participants were 199 patients who received the anonymous questionnaires at the start and at the end of their treatment in the Oberberg clinics in Schwarzwald, Weserbergland or Berlin/Brandenburg (on average 4.2 ± 2.3 weeks). Inclusion criteria were being 18–75 years of age, of legal competence and giving consent to participate.

Inpatient treatment

The Oberberg clinics offer comprehensive medical and psychotherapeutic treatment for about 150 individuals suffering from emotional, psychosomatic and psychiatric illness such as depression, anxiety, burnout or addiction. The intensive inpatient treatment (on average four to six weeks) includes daily individual and group therapy sessions. This enables an intensive therapeutic process, especially on an emotional level, to improve the emotional potential of the patient’s personality with respect to self-efficacy, self-awareness and changing dysfunctional aspects of personality. Mind-body-orientated awareness treatments, such as relaxation and meditation techniques like autogenic training, breathing exercises or body scan, cranio-sacral therapy, psychotherapeutic arts therapy and so forth, were also added to intensive conventional psychotherapeutic inpatient treatment.

Measures

LS was measured with the eight-item BMLSS (Büssing et al., 2009), which is based on the work of Huebner and colleagues (Huebner et al., 2004; Zullig et al., 2005) and was recently validated in a sample of adults, both healthy and with chronic diseases (Büssing et al., 2009). The items of the BMLSS refer to intrinsic (Self, Overall Life), social (Friendships, Family Life), external (Work, Where I Live) and the perspective (Financial Situation, Future Prospects) aspects of LS. Reliability analysis indicated a good internal consistency (Cronbach’s α = 0.87) and a single-factor structure which explained 53% of variance (Büssing et al., 2009). Patient satisfaction was measured with three additional items: health situation, effectiveness of treatment and own abilities to deal with daily life. Each item was introduced by the phrase ‘I would describe my satisfaction with…’, and scored on a seven-point scale from dissatisfaction to satisfaction (0 = Terrible, 1 = Unhappy, 2 = Mostly dissatisfied, 3 = Mixed (about equally satisfied and dissatisfied), 4 = Mostly satisfied, 5 = Pleased, 6 = Delighted). The BMLSS total score was transformed to a 100% level (transformed scale score).

As an additional external measure, the Positive Life Construction/Contentedness/Well-Being Scale from the ERDA (Emotional/Rational Disease Acceptance) questionnaire was used to measure an emotional style of disease acceptance (Büssing et al., 2008). The items had a good internal consistency (Cronbach’s α = 0.92) (Büssing et al., 2008) and were scored on a five-point scale from disagreement to agreement. Again, the respective score was transformed to a 100% level (transformed scale score). Scores above 60% indicate a high level of agreement or usage of the respective acceptance style, while scores below 40% represent a low level, and scores of 40%–60% an intermediate level of agreement (indicating neutrality).

To assess psychiatric symptoms three instruments were used: the German version of Beck’s Depression Inventory (BDI), a self-report instrument intended to assess the existence and severity of symptoms of depression (Beck et al., 1961, 1974; Beck and Steer, 1984); the German version of the 90-item revised Symptom Checklist (SCL-90-R), designed to measure overall psychological distress (Schmitz et al., 2000) with its Global Severity Index (GSI); and the three-item Escape From Illness Scale, which measures an attitude of passive escape-avoidance (Büssing et al., 2006).

Patients completed all study questionnaires at the start and at the end of their hospital stay.

Statistics

All statistical analyses were performed using SPSS 17.0 for Windows. The level of significance was taken as p < 0.05.

To assess the sensitivity of the BMLSS scale to treatment effects, data from the start and end of the hospital stay were compared using Wilcoxon’s signed rank test, and the effect sizes were estimated, expressed as an equivalent to Cohen’s d (Cohen, 1988). According to Cohen (1988) and Wolf (1986), values above 0.80 were taken to indicate large effects, and 0.50–0.80 as moderate effects.

Results

Demographic characteristics of patients

Of the participants, 58% were men, their mean age was 50.0 ± 9.2 years, most had a high school education and were living with a partner (Table 1). As primary diagnoses, based on the ICD-10 Classification of Mental and Behavioral Disorders, 44.9% had depressive disorders, 41.4% addictive disorders and 13.6% other psychiatric disorders, including phobia/anxiety.

Table 1.

Demographic and psychometric data

Mean age (years)	50.0 ± 9.2
Gender (%)
male	58
female	42
Family status (%)
married	60
living with partner not married	11
divorced	11
alone	18
Educational level (%)
secondary (Hauptschule)	5
junior high school (Realschule)	17
high school (Gymnasium)	70
other	9
Denomination (%)
Christian	58
other	10
none	32
Underlying disease (%)
depressive disorders	44.9
addictive disorders	41.4
other psychiatric disorders	13.6
Mean duration of treatments (weeks)	4.2 ± 2.3
Overall psychological distress (SCL-90-R GSI)	62.9 ± 11.1
Depression (BDI)	17.6 ± 9.9

Results are mean values or relative proportions, respectively, of patients at the start of their hospital stay

Treatment effects

Initially, patients had moderate BMLSS scores, which increased significantly by the end of the hospital stay (from 62.4 ± 18.2 to 74.4 ± 15.6, p < 0.001) (Table 2). In line with the improvement of the LS sum score, the overall psychological distress (SCL-90-R GSI), depression (BDI) and Escape from Illness scores were significantly lower at the end of the hospital stay (p < 0.001), while Positive Life Construction was higher (p < 0.001).

Table 2.

Life satisfaction, patient satisfaction and mental health affection in all patients

	Pre-treatment		Post-treatment		Wilcoxon’s signed rank test		Effect size (Cohen’s d)
	M	SD	M	SD	Z	p	MD	PV	ES
Life Satisfaction
LS Sum Score (%)	62.4	18.2	74.4	15.6	−9.6	0.000	12.0	16.9	0.71
Family Life	3.42	1.65	4.26	1.39	−6.9	0.000	0.84	1.52	0.55
Friendships	3.91	1.46	4.41	1.28	−5.2	0.000	0.50	1.37	0.36
Work	3.46	1.82	3.81	1.63	−3.1	0.002	0.35	1.73	0.20
Self	2.89	1.43	4.38	1.25	−10.0	0.000	1.41	1.34	1.11
Where I Live	4.36	1.52	4.79	1.18	−4.3	0.000	0.43	1.35	0.32
Overall Life	3.62	1.37	4.46	1.09	−7.4	0.000	0.84	1.23	0.68
Financial Situation	4.11	1.53	4.48	1.39	−5.1	0.000	0.37	1.46	0.25
Future Perspectives	3.53	1.52	4.36	1.22	−7.7	0.000	0.83	1.37	0.61
Employment	3.91	1.68	4.18	1.53	−2.7	0.007	0.27	1.61	0.17
Patient Satisfaction
Health Situation	2.71	1.62	4.07	1.46	−9.1	0.000	1.36	1.54	0.88
Treatment Efficacy	3.58	1.35	4.93	1.15	−9.2	0.000	1.35	1.25	1.08
Ability to Manage Daily Life	3.49	1.48	4.60	1.15	−8.8	0.000	1.11	1.32	0.84
Escape	48.66	26.45	32.01	24.48	8.26	0.000	17.65	25.48	0.69
SCL-90-R GSI	62.95	11.06	50.42	10.17	11.16	0.000	12,53	10.62	1.18
BDI Score	17.59	9.93	6.91	7.32	10.61	0.000	1.68	8.63	1.24
Positive Life Construction	50.33	20.72	71.15	18.03	−10.5	0.000	2.82	19.38	1.07

SD: standard difference, MD: mean difference, PV: pooled variance, ES: effect size (Cohen’s d)

Effect sizes > 0.8 were judged as indicators of large effects, and 0.5–0.8 of moderate effects; effect sizes > 0.5 were regarded as clinically relevant, and thus highlighted

The therapeutic interventions were strongly effective with respect to depression, overall psychological distress, Positive Life Construction, and patient satisfaction, while the effects on LS were moderate (d = 0.71). With respect to the underling LS aspects, strong effects were observed for satisfaction with self (d = 1.11), and moderate effects for Future Perspectives, Living Area and Family Life satisfaction.

The effects on patient satisfaction and LS were strong in participants with depressive disorders; by contrast, only satisfaction with treatment efficacy was strong in patients with addictive disorders (Table 3).

Table 3.

Life satisfaction and patient satisfaction in patients with depressive and addictive disorders

	Depression			Addiction
	MD	PV	ES	MD	PV	ES
Life Satisfaction
LS Sum Score (%)	13.76	17.20	0.80	11.05	16.58	0.69
Family Life	0.91	1.68	0.54	0.87	1.34	0.65
Friendships	0.47	1.36	0.36	0.68	1.35	0.50
Work	0.46	1.79	0.26	0.26	1.52	0.17
Self	1.69	1.30	1.30	1.44	1.36	1.06
Where I Live	0.43	1.49	0.29	0.41	1.22	0.34
Overall Life	0.90	1.28	0.70	0.81	1.19	0.68
Financial Situation	0.43	1.40	0.31	0.32	1.59	0.20
Future Perspectives	1.07	1.40	0.77	0.63	1.31	0.48
Employment	0.29	1.65	0.18	0.34	1.54	0.22
Patient Satisfaction
Health situation	1.54	1.44	1.07	1.21	1.61	0.75
Treatment efficacy	1.41	1.25	1.12	1.33	1.23	1.08
Ability to manage daily life	1.27	1.25	1.01	1.01	1.28	0.79
Escape	21.3	25.07	0.85	13.60	24.86	0.55
SCL-90-R GSI	14.50	1.70	1.36	1.80	1.02	1.08
BDI Score	13.80	8.30	1.66	7.50	8.37	0.90
Positive Life Construction	24.50	18.70	1.31	18.20	19.80	0.92

MD: mean difference, PV: pooled variance, ES: effect size (Cohen’s d)

Effect sizes > 0.8 were judged as indicators of large effects, and 0.5–0.8 of moderate effects; effect sizes > 0.5 were regarded as clinically relevant, and thus highlighted

Next the patients were categorized with respect to low (BDI < 12), intermediate (BDI = 12–24) and high (BDI > 24) depression scores, and their Escape from Illness, Positive Life Construction and LS scores were analysed. Patients with high depression scores had a mean LS score of 51.2 ± 18.4, indicating that they were equally satisfied and dissatisfied (‘undecided’), while patients with BDI score < 12 had high LS scores (73.2 ± 14.2) indicating that they were mostly satisfied or even pleased (Table 4). In line with this increase of LS along with decreasing depression and Escape from Illness scores, there was an increase in Positive Life Construction (Table 4).

Table 4.

Patients with high, intermediate and low depression scores (pre-treatment)

		BDI	Escape	PLC	BMLSS
All	M	17.56	48.63	50.50	62.44
	SD	9.90	26.60	20.67	18.17
BDI low (< 12)	M	6.40	32.34	65.89	73.19
	SD	3.01	22.90	19.06	14.26
BDI intermediate (12–24)	M	17.57	51.26	48.47	61.57
	SD	3.56	24.61	17.28	16.25
BDI high (> 24)	M	30.70	63.33	35.81	51.24
	SD	5.37	24.05	15.22	18.43
F (df 2,192)		508.5	23.6	41.7	24.8
p		< 0.0001	< 0.0001	< 0.0001	< 0.0001

BDI: depression, PLC: Positive Life Construction, BMLSS: life satisfaction

Life satisfaction predictors

To analyse which variables predict LS at the start and end of the therapeutic intervention, regression analyses were performed with the following variables: Positive Life Construction, Escape from Illness, depression, overall psychological distress (SCL-90), gender, age, and family status (living with/without partner).

Pre-treatment life satisfaction was predicted negatively by Escape from Illness (β = −0.35, p < 0.0001) and positively by Positive Life Construction (β = 0.22), and living with a partner (β = 0.13) (Table 5). In contrast, post-treatment life satisfaction was predicted by Positive Life Construction (β = 0.35), negatively by psychological distress (β = −0.27) and depression (β = −0.21, p < 0.0001), and positively by living with partner (β = 0.20).

Table 5.

Predictors of pre-/post-treatment life satisfaction (regression analyses)

Included variables	Pre-treatment			Post-treatment
	β	T	p	β	T	p
(constant)		5.265	0.000		7.163	0.000
Age	0.104	1.771	0.078	0.078	1.544	0.124
Female	0.119	1.916	0.057	0.079	1.546	0.124
Living with partner	0.134	2.328	0.021	0.199	3.939	0.000
Psychological distress (SCL – GSI)	−0.069	−0.862	0.390	−0.271	−4.148	0.000
Depression (BDI)	−0.137	−1.649	0.101	−0.208	−3.240	0.001
Escape from Illness	−0.346	−4.913	0.000	−0.023	−0.365	0.716
Positive Life Construction	0.220	2.781	0.006	0.347	4.994	0.000
R²	0.442			0.602

Dependent variable: life satisfaction (BMLSS)

Discussion

Therapeutic interventions may have an impact on symptoms, either directly or indirectly, by a change in patient behaviours and/or attitudes. This may subsequently effect other variables, such as life satisfaction. On the other hand, one could also suggest that the relevance of distinct resources of support (family, friends, and so on) or potentials of personality may change during the course of treatment. This study shows that psychotherapeutic interventions during the hospital stay significantly changed the clinical situation of the patients, indicated by strong effect sizes for overall psychological distress and depression, and also for the emotional disease acceptance style, Positive Live Construction. Similarly, interventions have improved patient satisfaction, as measured by satisfaction with health situation, treatment efficacy and ability to manage daily life. With respect to LS, the stabilization of the clinical situation resulted in beneficial effects (i.e. strong effect sizes with respect to Self, and moderate effect sizes with respect to Overall Life, Future Perspectives, and Family Life and Friendships). In particular, patients with depressive disorders showed strong effects. Similar differences were observed with respect to patient satisfaction and the clinical situation. One may thus suggest that patients with depressive disorders improved more than those with addictive disorders; however, one has to account for the fact that the depressive state strongly affected patient satisfaction with various aspects of life. In fact, those with high depression scores had low LS scores, while patients with low BDI scores had high LS scores in the same range as healthy individuals (77 ± 13). In addition, the post-treatment BMLSS scores were in the range of healthy individuals, indicating that an effective psychotherapeutic treatment has an impact on LS too.

The primary aim of the (psychotherapeutic) interventions was to strengthen the patients’ emotional acceptance of disease (and of course, treatment of depressive symptoms). It is known that the unconscious emotional non-acceptance of disease, such as denial, guilt, fighting against or escape of the disease, are believed to be significant risk factors for relapse even if the patient is able to accept the disease rationally (Gottschaldt, 1997; Mundle et al., 2008; Mundle and Gottschaldt, 2007). With emotional acceptance, one will see disease as a medical condition rather than personal failure, and thus be able to accept the necessary treatment and deal effectively with difficulties caused by the disease. Thus, the improvement of LS and patient satisfaction is a consequence of a patient’s mental improvement with subsequently more positive attitudes and views – or (new) appreciation of distinct resources (i.e. family and friendships) in terms of a response shift – and (conscious) appreciation of all potentials of personality in terms of dealing with the disease and also with new inner and outer relations. In fact, Escape from Illness, which can be regarded as a passive escape-avoidance strategy, and Positive Life Construction were the best predictors of pre-treatment life satisfaction, while the post-treatment predictors were Positive Life Construction, psychological distress, depression, and living with a partner who keeps the patient grounded. With the exception of Positive Life Construction, which deals also with contentedness and well-being and thus correlates well with LS, it became evident that the LS predictors strongly differ between pre- and post-treatment.

Although there are hints that women and men with depressive and anxiety disorders use different coping strategies (Kelly et al., 2008), in this analysis only Positive Life Construction was somewhat higher in men than in women, while there were no significant gender-specific differences with respect to LS. Other groups have confirmed that depressive disorders, and also anxiety and hypochondrial disorders, were significantly associated with reduced LS (Ghubach et al., 2010). In this study, psychological distress and depression were post-treatment predictors, while pre-treatment Escape from Illness was of major relevance. Daig et al. (2009) found that low levels of LS were found particularly in the elderly (> 85 years) and individuals living alone, and suggested that ‘lack of meaning and worries are more detrimental to life satisfaction than physical frailty’. In the present sample, age was not of outstanding relevance, but living with a partner (whether married or not) who may support the patient was. Previous data support that individuals who live alone or are divorced had the lowest LS scores, compared to those living with a partner or widowed (Büssing et al., 2009).

Previous findings that depression and conscious living were the strongest predictors of LS (Büssing et al., 2009) are in congruence with findings of Daig et al. (2009), suggesting that depressive symptoms significantly explain the variance of LS aspects. However, now we have hints that psychological distress and depression are negative post-treatment predictors of LS. An effective treatment first should aim to decrease psychological stress, and second strengthen emotional disease acceptance, particularly Positive Life Construction, even after the hospital stay. Stable self-awareness of intrinsic factors of life (i.e. self-esteem or potentials of own personality) and a stable partnership can contribute to increased LS. In terms of a positive feedback loop, improved emotional acceptance of disease, patient’s personality and satisfaction with life concerns could further stabilize the treatment effects. Multidisciplinary approaches are thus required.

Conclusion

This study confirms that the BMLSS is sensitive to psychotherapeutic treatment effects and that LS changes are associated with a clear perception and acceptance of disease and life situation. In line with these changes, patients with depressive disorders in particular profited from the interventions as shown by strong positive effects on LS. Although LS is conceptually distinct from quality of life, it is nevertheless of outstanding relevance for patients with depressive disorders because several aspects of life concerns are important to them to provide support during the clinical stay (i.e. family life, friendships and so forth).

Footnotes

Acknowledgements

The authors would like to thank Judith M. Fouladbakhsh, Wayne State University, Detroit, for critical comments and valuable suggestions.

The authors have no connection with the tobacco, alcohol, pharmaceutical or gaming industries, and are not funded by any of these organizations. To evaluate the data, the University Witten/Herdecke received funding from the Oberberg Foundation Matthias Gottschaldt, a non-profit, non-governmental private organization. There were no contractual constraints on publishing imposed by the funder.

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