int j psychiatry med 2012 winter 35 49(1)

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INTL. J. PSYCHIATRY IN MEDICINE, Vol. 43(1) 35-49, 2012

HEALTH-RELATED QUALITY OF LIFE AND ITS

DETERMINANTS IN THE URBAN RUSSIAN

POPULATION WITH MAJOR DEPRESSIVE

DISORDER: A CROSS-SECTIONAL STUDY

YAROSLAV WINTER, MDPhilipps-University Marburg, Germany

NATALIA EPIFANOVA-BERTSCHI, MD

Psychiatric Hospital Sanatorium Kilchberg, Switzerland and

Sklifosovski Research Institute, Moscow, Russia

ROMAN SANKOWSKI, MSCI

Philipps-University Marburg, Germany

TATYANA V. ZHUKOVA, MSCI

Sklifosovski Research Institute, Moscow, Russia

WOLFGANG H. OERTEL, MD

RICHARD DODEL, MD, MPH

Philipps-University Marburg, Germany

ALEXEI KORCHOUNOV, MD

Marienhospital Kevelaer, Germany

ABSTRACT

Objective:Depressive disorders pose a major challenge to healthcare in the

countries of the former Soviet Union. The objective of the current study was

to evaluate health-related quality of life (HrQoL) and its determinants in

outpatients with major depressive disorder in an urban Russian population.

35

2012, Baywood Publishing Co., Inc.

doi: http://dx.doi.org/10.2190/PM.43.1.c

http://baywood.com


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Methods: We consecutively recruited 100 urban Russian outpatients with

major depression and 100 non-depressed controls who were matched for age

and sex. The severity of their depression was assessed using the Hamilton

Depression Rating Scale (HDRS). HrQoL was evaluated using the EuroQol

(the EQ-5D and the visual analogue scale, EQ VAS). Independent deter-

minants of HrQoL were identified using multiple regression analysis.Results:

The mean EQ VAS score was 43.0 27.4 in patients with depression

compared to 81.4 14.7 in the controls (p < 0.01). Out of the domains of

the EQ-5D, anxiety/depression, usual activities, and self-care were the

most impaired. Independent determinants of reduced HrQoL were: severity

of depression according to the HDRS; violent suicide attempts; suicide

attempts in the past; and drug addiction.Conclusions:HrQoL is considerably

reduced in Russians with major depression. The disease-specific patterns

of HrQoL impairment and the independent determinants of HrQoL identi-fied in our study could be addressed in focused healthcare programs and

clinical trials. Comorbid drug addiction as a determinant of HrQoL should

receive greater attention in the management of depressive disorders in urban

Russian populations.

(Intl. J. Psychiatry in Medicine 2012;43:35-49)

Key Words: major depression, health-related quality of life, determinants, drug addiction,Russia

INTRODUCTION

Affective disorders, and particularly depression, are the most prevalent mental

disorders and are a major contributor to the worlds health burden [1-3]. Major

depression is associated with excessive mortality, a loss of productivity,

unemployment, the deterioration of the sufferers social and health status, and

may lead to suicide [3]. In recent decades, Russia has undergone major economic

and social changes, which have contributed considerably to changes in the preval-

ence of affective disorders in the Russian population [4]. According to various

estimations, the prevalence of major depression in Russia is between 7000

and 10,000 per 100,000 [1, 4], which is considerably higher than in Western

European countries (3000 per 100,000) [2]. Furthermore, these estimations are

higher than in some Eastern European countries that used to be part of the Soviet

Union, such as Estonia (5600 per 100,000) [5]. Depressive disorders are likelyto be underdiagnosed in the Russian population, and the actual number of

people with major depression may be as high as 14,000,000 [4].

Depression is a major factor of influence in respect to health-related quality

of life (HrQoL) and has become an important area of research. Several studies

have investigated HrQoL in patients with depressive disorders in recent years.

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These studies have revealed an association between the severity of depression and

the level of HrQol impairment [6, 7]. In the WHO World Health Survey, depres-

sion had the greatest negative influence on mean HrQoL scores in comparison

to the other chronic diseases which were assessed [8]. Only a few studies have

investigated the determinants of HrQoL. Recently, HrQol in people with depres-

sion and its determinants have been investigated across 12 European countries

as part of a larger multicenter study [9]. This information provided not only

diagnosis-specific determinants (e.g., the number of previous episodes of depres-

sion, duration of the current depressive episode, severity of depression, somatic

comorbidity, educational and occupational status), but also country-specific deter-

minants of HrQoL in depression (e.g., the negative influence of psychiatric

comorbidities on EQ-5D and VAS scores in Italian patients). Russia, however,

did not participate in this study.Although depressive disorders are one of the major challenges facing the

Russian healthcare system, data on the HrQoL of patients with major depression

in Russia are scarce, and no studies have yet investigated the determinants

of HrQoL in the Russian population. The objective of the current study was to

evaluate HrQoL and its determinants in people with major depressive disorder

in the urban Russian population.

METHOD AND PATIENTS

Study Design

This study was performed according to a cross-sectional design. The study

population (n= 200) consisted of 100 consecutive outpatients with major depres-

sive disorder and 100 non-depressed regional controls from the general popu-

lation, matched for age and sex. Depression was diagnosed according to the

criteria of the Diagnostic and Statistical Manual of Mental Disorders IV

(DSM-IV) for major depressive disorder [10]. The outpatients with depression

were consecutively recruited from the Department of Mental Health and Psycho-

somatic Disorders of the Sklifosovskiy Research Institute, Moscow, Russia

between July 1, 2008 and December 31, 2008. This specialized center is a

reference facility for a large district of Moscow with a population of approxi-

mately 500,000. The sample size was calculated based on the assumption that

there would be at least 10% difference in HrQoL values between patients and

controls (power of 80% and significance level of 0.05 for a two-sided test).The inclusion criteria were:

1. a clinical diagnosis of major depressive disorder;

2. the patient was aged 18 or over; and

3. the patient was not simultaneously taking part in any other study.

URBAN RUSSIAN POPULATION WITH MAJOR DEPRESSIVE DISORDER / 37


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Regional controls were matched for age and sex from a database of approximately

2500 participants in an ongoing population-based study of HrQoL in general

population. At the time point as our study with depressed patients was performed,

the recruitment for the population-based study in general Russian population

was completed only in Moscow. Therefore, we used only controls recruited in

Moscow for matching. In order to provide a sample representative for general

population, participants of the population-based study were chosen at random

in each of ten administrative divisions (districts) of Moscow [11]. This study was

approved by the local ethics committee and all patients gave their informed

consent prior to their participation.

Clinical Evaluation

All patients were examined by a psychiatrist with 10 years of experience in

affective disorders. The severity of depression was assessed using the Hamilton

Depression Rating Scale (HDRS) [12]. In addition, the following data were

collected using standardized case-report forms (CRF): age; sex; family status;

severity of depression; age at onset of depression; severity of suicidal behavior;

suicide attempts in the past; drug addiction and alcohol dependence; and treatment

using antidepressants. Alcohol dependence was defined according to the DSM IV

diagnostic criteria for alcohol dependence [10], while drug addiction was defined

based on the DSM IV diagnostic criteria for substance dependence [10]. The

patients with a drug addiction used illegal drugs, such as marijuana, cocaine,

amphetamines, and heroin.

Assessment of HrQoL

HrQoL was assessed using the standardized and validated EuroQol instrument,

which consists of a questionnaire (the EQ-5D) and a visual analogue scale (the

EQ VAS) [13]. EuroQol is a widely accepted measure of health status, which

is used to assess generic HrQoL. It enables comparisons of HrQoL between a

study population and the general population, or those with other diseases. The

rationale to use the EuroQol in this study instead of more comprehensive generic

HrQoL-instrument, such as the SF-36, was as follows:

1. in comparison to the SF-36, the EuroQol is a more compact questionnaire

consisting of only five items and is more convenient to use in patients

with severe depression (27% in our cohort);

2. it has a visual analogue scale, which can be rated a separate scale; and

3. The EQ-5D is also commonly used in health-economic evaluations.

The first part of the EuroQol is a five-item questionnaire (the EQ-5D), which

covers the following dimensions of life: mobility, self-care, usual activities,

pain/discomfort, and anxiety/depression. The index score of the EQ-5D (health

index) was calculated according to the algorithm of the EuroQol Group [14]. No

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published studies which evaluate this algorithm in a Russian population are

available to date. The index score declines as the quality of life decreases. The

second part of EuroQol is the EQ VAS, a visual analogue scale which is a

vertical 20 cm health thermometer ranging from 0 to 100 points. On the

thermometer, 0 indicates the worst state of health imaginable and 100 indicates

the best state of health imaginable.

Statistical Analysis

Statistical analysis was performed using SPSS version 15.0 (SPSS Inc.,

Chicago, IL, USA). The data are presented as mean values with standard

deviations. We used the Kolmogorov-Smirnov test to test the normality of the

distribution. The t-test was applied to the group comparison in the event of anormal distribution. For variables which did not show a normal distribution,

the Mann-Whitney U-test (for two independent variables) or the Kruskal-Wallis

test (for more than two independent variables) was applied. Statistical sig-

nificance was assumed for values with p < 0.05. Independent determinants of

HrQoL were evaluated using multiple regression analysis with forward selection.

The variables included in the multiple regression analysis were chosen according

to the results of the univariate analysis (inclusion criterion: p < 0.1). The R2

method was used to explore the variability which was accounted for by indi-

vidual determinants [15].

RESULTS

Demographic and Clinical Characteristics

Out of 100 patients with depression who were initially recruited, 18 were

excluded from the analysis because they either withdrew their informed consent

during the data collection process (n = 10) or because their records were

incomplete (n= 8). There were no significant differences in age, sex, or disease

severity between those who dropped out and those who completed the study.

Eighty-two patients and 100 controls completed the study. The mean age was

34.3 12.9 for the patients and 35.0 10.9 for the control group (p= 0.89). The

demographic and clinical characteristics of the study participants are presented

in Table 1. Fifty-four patients (65.9%) reported that they had experienced suicidal

intentions or attempted suicide at least once during their current depressive

episode. The mean duration of their current depressive episode was 10 23 weeks.Thirty-eight patients (46.3%) were experiencing their first episode of depression.

The distribution of somatic comorbidities was as follows: two (2.4%) patients had

cardiovascular disorders; two (2.4%) had gastroenteral disorders; two (2.4%)

had pulmonological disorders; six (7.3%) had neurological disorders; and 10

(12.2%) patients had orthopedic or surgical disorders.



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Social Status of Subjects and Controls

Seventeen of the patients (20.7%) lived alone. Thirty-two patients (39.0%)

were married, 10 (12.2%) were divorced, two (2.4%) were widowed, and 28(46.3%) were single. For 26 patients (31.7%), depression had led to changes in

their employment situation: 10 (12.2%) had reduced their working hours; two

(2.4%) had moved to another job; and 14 (17.1%) had become unemployed. The

average length of unemployment due to a depressive disorder was 4.5 2.3 years.

In the 12 months preceding this study, 20 of the patients (24.4%) had needed to

40 / WINTER ET AL.

Table 1. Demographics and Clinical Parameters

Patients with

depression

(n= 82)

Non-depressed

controls

(n= 100)

Age (years), mean SD

Gender,n (%)

Men

Women

Marital status,n (%)

MarriedNot married

HDRS, mean SD

Drug addiction,n (%)

No

Yes

Alcohol dependence,n (%)

No

Yes

Antidepressant therapy,n (%)

SSRIsSNRIs

TCAs

Combinations

34.3 13.0

54 (65.9%)

28 (34.1%)

32 (39.0%)50 (61.0%)

20.9 7.7

66 (80.5%)

16 (19.5%)

54 (65.8%)

28 (34.2%)

44 (53.7%)24 (29.3%)

4 (4.9%)

10 (12.2%)

35.0 10.9

68 (68.0%)

32 (32.0%)

53 (53.0%)47 (47.0%)

100 (100.0%)

0 (0.0%)

100 (100.0%)

0 (0.0%)

Abbreviations: HDRS, Hamilton Depression Rating Scale; SSRIs, selective serotoninreuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors; TCAs, tricyclicantidepressants.


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take sick leave at least once because of their depression. The average length of sick

leave due to depression was 74 54 days per year (range: 3-180, median: 20).

HrQoL

In comparison to the non-depressed controls, HrQoL in patients with depression

was reduced by 19-38%. The mean EQ VAS score was 43.0 27.4 for the patients

compared to 81.4 14.7 for the control group (p< 0.01). The EQ-5D index score

was 0.61 0.29 for the patients and 0.81 0.12 for the controls (p< 0.01).

In patients with major depression, HrQoL was reduced in all domains of

the EQ-5D (Table 2). The domains anxiety/depression, usual activities, and

self-care were the most impaired. In comparison to the controls, patients

HrQoL in these domains decreased by 44%, 32%, and 27% respectively.


Table 2. Impairment of the Health-Related Quality of Life

in Different EQ-5D Dimensions

EQ-5D dimensions

Study

participants

(%)

Control

population

(%) p-Value

Mobility

No problems

Moderate problems

Severe problems

Self-care

No problems

Moderate problems

Severe problems

Usual activities

No problems

Moderate problems

Severe problems

Pain/discomfort

No problems

Moderate problems

Severe problems

Anxiety/depression

No problems

Moderate problems

Severe problems

63.4

19.5

17.1

68.3

22.0

9.7

51.2

26.8

22.0

39.0

43.9

17.1

24.3

54.5

21.2

74.0

26.0

0.0

95.0

4.0

1.0

83.0

16.0

1.0

58.0

42.0

0.0

68.0

31.0

1.0

< 0.01

< 0.01

< 0.01

< 0.01

< 0.01


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Determinants of HrQoL

The results of the univariate analyses are presented in Table 3. We found an

inverse association between HrQoL and the severity of depression according to

the HDRS (p < 0.01). Furthermore, HrQoL showed an inverse association with

the severity of suicidal behavior (p< 0.01), a positive history of suicide attempts

(p < 0.01), and drug addiction (p< 0.05). Somatic comorbidities were not asso-

ciated with HrQoL in our patients.

The results of the multiple regression analysis are shown in Table 4. Demo-

graphic and clinical parameters with p < 0.05 were considered as independent

determinants of HrQoL. We identified the following independent factors, which

reduced the values of the EQ-5D index: severity of depression according to

the HDRS; severity of suicide attempts; suicide attempts in the past; and drugaddiction. These four parameters explained 54.4% of the variance in the EQ-5D

index scores (R2 method). Independent determinants of reduced values on the

EQ VAS were severity of depression according to the HDRS and severity of

suicide attempts, which explained 53.0% of the variance in the EQ VAS scores.

DISCUSSION

To our best knowledge, this is the first study to evaluate HrQoL and its

determinants in patients with major depression in Russia. We used a generic

HrQoL instrument (EuroQol) in order to provide data that can be used for

comparisons with the general population or those with other diseases. Our results

show that depression has a substantial impact on patients HrQoL. HrQoL was

reduced by 19-38% in patients with major depression in comparison to non-

depressed controls. This reduction in HrQoL was observed despite treatment

using antidepressants. For people with depression who were not being treated

with antidepressants, an even larger reduction in EQ-5D index scores has been

reported (60%) [16]. Burstrom et al. evaluated the EQ-5D index in the general

population and showed that the presence of mental disorders, and particularly

depression, was associated with the lowest HrQoL scores, which were similar

to those of patients with angina pectoris [17].

The EuroQol has not been used widely for the evaluation of HrQol in patients

with major depression. In a Swedish primary care study, patients with depression

attained EQ VAS values which were similar to those in our study (44.8 and 43.0

respectively) [16]. Comparable EQ VAS scores (40.0) were also reported in a

recent large multicenter European study (factors influencing depression endpointsresearch (FINDER) study) [9]. All of the patients in our study population were

receiving stable antidepressant therapy. The mean EQ-5D index score (0.61) was

comparable with the mean EQ-5D index score reported for depressed patients

treated with antidepressants in other studies (0.63-0.69) [16, 18]. In cases of

untreated depression, these values can be up to 36% lower [9, 16]. The impact of

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Table 3. Results of the Univariate Analyses in Patients

with Major Depression

Demographic and clinical

parameters

EQ-VAS

Mean SD p-Value

EQ-5D-Index

Mean SD p-Value

All patients (n= 82)

GenderMen (n= 54)Women (n= 28)

Age groups< 30 years (n= 32)30-39 years (n= 24)

40 years (n= 26)

Marital statusMarried (n= 32)Not marrieda(n= 50)

Age at disease onset< 20 years (n= 20)20-39 years (n= 36)40 years (n= 24)

Hamilton Depression Rating Scale< 14 (n= 22)14-17 (n= 48)17 (n= 12)

Suicidal attemptsb (n= 42)

Not violent (n= 9)Violent (n= 33)

Prior suicide attemptsNo (n= 48)Yes (n= 34)

Episode durationc

< 23 days (n= 41)23 days (n= 41)

Drug addictionNo (n= 66)Yes (n= 16)

Alcohol dependencyNo (n= 54)

Yes (n= 28)

43.0 27.4

42.1 26.544.9 29.9

38.7 29.750.4 29.7

41.5 22.6

42.5 31.443.4 25.2

35.1 32.547.1 29.044.6 21.6

63.3 22.256.7 23.135.3 26.0

43.8 12.240.0 14.1

70.0 20.044.2 26.6

63.18 31.1758.84 28.41

52.2 31.641.6 24.1

43.5 31.5

39.5 25.9

0.65

0.58

0.97

0.48

0.002

0.23

0.007

0.78

0.04

0.68

0.61 0.29

0.63 0.300.58 0.27

0.67 0.330.56 0.28

0.59 0.27

0.60 0.330.62 0.28

0.75 0.270.52 0.300.64 0.27

0.84 0.240.65 0.290.57 0.29

0.72 0.370.60 0.32

0.75 0.190.59 0.31

0.51 0.280.45 0.25

0.59 0.300.44 0.32

0.62 0.36

0.58 0.28

0.42

0.55

0.84

0.17

0.001

0.008

0.002

0.053

0.02

0.25

aNot married = single, divorced, or widowed.bSuicidal attempts during current depressive episode.cDuration of the current depressive episode was dichotomized using the median split

approach (median: 23 days).Abbreviations: EQ-VAS, EuroQol visual analogue scale


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Table4.

IndependentDeterminantsofHrQoLinMultipleRegressionAnalysis

EQ-5D

-Index

EQ-VAS

B

95%

CI

p-Value

B

95%

CI

p-Value

Gender

Age

Maritalstatus

Ageatdiseaseonset

HDRS

Severesuicide

Priorsuicideattempts

Drugaddiction

Alcoholdependency

0.0

5

0.0

1

0.1

5

0.0

1

0.1

2

0.1

5

0.0

5

0.1

7

0.2

7

0.3

8;

0.2

7

0.0

4;

0.0

2

0.1

3;

0.4

3

0.0

2;

0.0

5

0.2

5;0.0

2

0.2

1;0.0

4

0.1

5;0.0

6

0.3

4.7

2;0.0

1

0.51

;0.1

1

R2=0

.544

0.7

29

0.5

49

0.2

72

0.4

7

0.0

05

0.0

23

0.0

43

0.0

37

0.1

65

12.9

9

0.6

3

2.5

1

0.2

6

4.0

7

18.4

11.0

4

5.2

4

18.7

4

11.5

1;37.4

8

1.9

8;3.2

3

23.7

5;18.7

4

2.8

1;2.2

8

6.3;0.8

4

6.5

7;0.7

8

30.9

2;52.9

9

22.5

4;33.0

2

47.0

9;9.8

4

R2=

0.5

30

0.2

79

0.6

19

0.8

06

0.8

3

0.0

02

0.0

34

0.5

88

0.6

97

0.1

37

Abbreviations:

HrQoL,

health-relatedqualityoflife;B,non-standardizedregressioncoefficients;CI,co

nfidenceinterval;EQ-VAS,

EuroQolvisual

analoguescale;H

DRS,

HamiltonDepressionRatingScale.

Following

varia

blesentered

the

multiple

regression

ana

lysis:age,gender,maritalstatus,ageof

disease

onset,HDRS,severe

suicides,

priorsuicideattem

pts,

drugaddiction,alcoholdependency,

durationofdepressiveepisode,antidepressanttherapy,priordepressiveepisode,

worksituation,

inc

ome,personsinhousehold,comorbidity.

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depression on HrQoL is comparable with the impact of disabling conditions such

as severe strokes or advanced neurodegenerative diseases [19-21]. Haacke

et al. reported a mean EQ VAS value of 45.9 in stroke patients with severe

disabilities (Modified Rankin Scale 3-5), which is comparable with the mean

EQ VAS score of our patients with depression (43.0) [19]. A comparable EQ VAS

score of 41.5 was also found in patients with advanced Parkinsons disease

with a Unified Parkinsons Disease Ranking Scale (UPDRS) value >60 [22].

In comparison, the HrQoL of patients with epilepsy which has better thera-

peutic options than the aforementioned neurological disorders, is, on average,

better than those with depression (EQ-5D index: 0.80 in epilepsy versus 0.61

in depression) [23, 24].

The analysis of different domains of the EQ-5D revealed a disease-specific

pattern of HrQoL impairment in patients with major depression. The domains ofthe EQ-5D with the largest HrQoL reduction were anxiety/depression, usual

activities, and self-care. In contrast, patients with schizophrenia exhibit a

different pattern of HrQoL impairment, with severe problems more likely to

occur in the domains anxiety/depression and pain/discomfort, followed by

usual activities [25, 26]. Another disease-specific HrQoL impairment pattern

is present in patients with chronic neurological disorders, such as Parkinsons

disease or amyotrophic lateral sclerosis, which are often accompanied by

depressive symptoms. In these disorders, mobility, usual activities, and

pain/discomfort are the domains with the most considerable reduction in

HrQoL [11, 22, 27, 28]. Our findings are in accordance with a recent Swedish

study by Sobocki et al. [16] which investigated HrQoL in patients with major

depression and found the lowest scores in the domains anxiety/depression

and usual activities. In contrast to our study, the scores in the self-care domain

were higher than in the pain/discomfort domain. This could be explained by

the fact that Sobocki et al. exclusively studied patients in primary care, while

our study was performed in a secondary care setting and included patients with

more advanced diseases.

Determinants of HrQoL in patients with major depression have been investi-

gated in several studies. However, only a few of these studies have provided

multiple regression models for the EQ-5D [9, 16, 18, 29]. Similarly to the results

of these studies, the severity of depression was identified as an independent

predictor of decreased HrQoL in our study [9, 16, 18, 29]. Sobocki et al. found

an inverse association between suicidal tendencies and HrQoL [16]. In line

with this finding, our analysis identified violent suicidal behavior and previous

suicide attempts as independent determinants of reduced HrQoL. Interestingly,drug addiction was identified as a predictor of reduced HrQoL. The influence

of drug addiction was also evaluated in the FINDER study, which did not report

it among the HrQoL determinants in Western European countries [29]. This

finding of our study may be specific to Russian patients with depression. The

prevalence of drug addiction in Russia is higher than in Western Europe and



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constitutes an important social and economic problem. The proportion of patients

with comorbid substance dependence was three times higher than in studies

conducted in Western Europe [16].

Studies which have evaluated the role of demographic variables have produced

inconsistent results. In our study and in studies with fewer than 1000 participants,

no significant associations were found between the scores on the EQ-5D and

the EQ VAS [16]. An inverse association between age and the EQ-5D index scores

was reported in the FINDER study [9], which included 2230 patients with

depression from 12 European countries in the multiple regression analysis. This

study also found a weak association between the female sex and better values

on the EQ VAS.

Despite careful planning, our study carries the following limitations:

1. Russia has a large geographic territory (17.1 million square kilometers

crossing 11 time zones) and a population of approximately 142 million

citizens, representing more than 100 ethnic backgrounds. It is difficult to

draw a population sample that would be representative of the entire country.

The demographic structure of our study population is only representative

of an urban Russian population. However, the urban population comprises

73% of the general Russian population [30, 31]. As there is a considerable

difference in economic status, infrastructure, and the quality of healthcare

between the western and eastern parts of Russia, and as our single-center

study was limited to Moscow, geographical distinctions and disparities

may not be adequately reflected in the results. Due to the worse economic

situation and quality of healthcare in comparison to Moscow, we would

expect a lower HrQoL and social factors to have a greater influence in

patients with depression in eastern parts of Russia. Future multicenter

studies should address the regional differences within Russia.

2. Due to the cross-sectional design, we could not provide data on changes

in HrQol over time.

3. The EQ-5D is a measure of health status. Similarly to other measures of

health status (e.g., the SF-36), it is commonly used to evaluate generic

HrQoL. Sobocki et al. applied the EQ-5D in order to assess HrQoL in

patients with depression [16]. However, the EQ-5D is not appropriate

for evaluating the overall quality of life. In such cases, an instrument for

measuring the quality of life, such as the WHOQOL, is required.

4. HrQoL was evaluated using a generic instrument. Therefore, it is possible

that some disease-specific aspects of HrQoL in patients with depressionmay have escaped our analysis. The aim was to provide HrQoL values

for comparisons with controls and patients with other diseases. The use of

disease-specific instruments was beyond the scope of the present study.

5. We obtained moderateR2 values and cannot exclude residual confounding

by unmeasured variables in the multiple regression analysis, as 46.6% of

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the variance in EQ-5D scores and 17% of the variance in EQ VAS scores

remained unexplained. However, these R2

values are similar to or even

higher thanR2 values reported in other HrQoL-studies [16, 19, 21, 22].

6. Our study population was not large enough to perform subgroup analyses

for different age groups. For example, studies which focus on HrQoL in

elderly Russian people are required to provide data on the role of somatic

comorbidities in these patients.

7. The 1:1 match was enough to perform an analysis of the determinants of

HrQoL. However, additional information could have been gathered by a

match of 1:2 or 1:3.

In conclusion, the HrQoL of patients with major depression is considerably

reduced. The disease-specific pattern of HrQoL impairment found in our studyconsists of a predominant reduction of HrQoL scores in the domains anxiety/

depression, usual activities, and self-care. The independent determinants of

HrQoL in patients with major depression which were identified in our study

should be considered in healthcare programs and clinical trials. In particular,

comorbid drug addiction as a country-specific determinant of HrQoL should

receive greater attention in the management of depressive disorders in urban

Russian populations.

ACKNOWLEDGMENTS

The authors would like to thank the staff of the Department of Mental Health

and Psychosomatic Disorders at the Sklifosovski Research Institute, Moscow,Russia for their assistance in the patient recruitment process. We also gratefully

acknowledge the support of Prof. Christopher Goetz (Rush University Medical

Center, Chicago, Illinois), who critically reviewed this article.

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Direct reprint requests to:

Yaroslav Winter, MD

Dept. of NeurologyPhilipps-University Marburg

Baldingerstrasse

D-35043 Marburg, Germany

e-mail: [email protected]


int j psychiatry med 2012 winter 35 49(1)

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