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Quality of Life
Expanding the Scope of Clinical Significance
Madeline M. Gladis
Department of Psychiatry
Elizabeth A. Gosch
Department of Psychiatry
Nicole M. Dishuk
Department of Psychiatry
Department of Psychiatry
Clinical researchers have turned their attention to quality of life assessment as a means of
broadening the evaluation of treatment outcomes. This article examines conceptual and
methodological issues related to the use of quality of life measures in mental health. These
include the lack of a good operational definition of the construct, the use of subjective versus
objective quality of life indicators, and the nature of the relationship between symptoms and
quality of life judgments. Of special concern is the ability of quality of life measures to detect
treatment-related changes. The authors review the application of quality of life assessment
across diverse patient groups and therapies and provide recommendations for developing
comprehensive, psychometrically sophisticated quality of life measures.
Preparation of this article was funded in part by Grants P50-MH-45178, K02-MH00756, and R01-
MH40472 from the National Institute of Mental Health.
We thank Peter Bachman for his research assistance and help in preparing this article.
Correspondence may be addressed to Madeline M. Gladis, Department of Psychiatry, Center for
Psychotherapy Research, University of Pennsylvania, 3600 Market Street, Suite 768, Philadelphia,
Electronic mail may be sent to firstname.lastname@example.org
Received: August 24, 1998
Revised: December 7, 1998
Accepted: December 9, 1998
In their attempts to evaluate the full range of effects of health care interventions, clinical researchers have
broadened their definition of clinical outcome to include a concern for the patient's psychological, social, and
material well-being. The enormous appeal and, one would hope, utility of assessing "quality of life" is
reflected in the literature on the topic and the development of hundreds of measures over the past 2 decades.
It has been noted that interest among psychologists and psychiatrists in quality of life as a distinct, measurable
entity has lagged behind that of their counterparts in medicine (for reasons to be described later). This
Journal of Consulting and Clinical Psychology
June 1999 Vol. 67, No. 3, 320-331
© 1999 by the American Psychological Association
For personal use only--not for distribution.
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situation appears to be changing rapidly as quality of life instruments are adapted, or created, for use with
different psychiatric populations and for evaluation of diverse therapies. Because of the problems that
continue to plague quality of life research, this can be viewed as a mixed blessing. The purpose of this article
is to review the conceptual and methodological issues that need to be addressed to ensure the appropriate
and successful use of quality of life measures in the evaluation of psychological treatments.
The current enthusiasm for quality of life measures is not ill-founded. Although symptom relief remains a
major goal of treatment efforts, there are many reasons to expand outcome assessment to include other, less
familiar parameters of clinical progress or decline. These rationales have been detailed by a number of
authors (see Frisch, 1998 ; Hunt, 1998 ; Katschnig, 1997 ), who have pointed out that a fundamental
problem with the symptom-focused approach is that it is based on a narrow, outdated notion of health and
disease. Modern conceptions of health can be traced back to the World Health Organization's (WHO)
definition of health as "a state of complete physical, mental, and social well-being and not merely the absence
of disease" ( WHO, 1948 , p. 1). This definition has, in turn, given rise to theoretical and philosophical ideas
of what constitutes mental health and to arguments for assessing positive as well as negative outcomes. In
some circles, mental health is synonymous with "happiness" and "well-being" ( Frisch, Cornell, Villañueva, &
Retzlaff, 1992 ). A number of studies have shown that it is the patients' subjective well-being, rather than
objective medical condition, that determines their treatment-seeking behavior, their compliance, and their
evaluation of treatment ( Hunt & McKenna, 1993 ). Presenting complaints of patients do not always
conform to Diagnostic and Statistical Manual of Mental Disorders categories ( Strupp, 1996 ); further,
there is evidence that these target complaints shift during the course of treatment ( Sorenson, Gorusch, &
Mintz, 1985 ). The need to look beyond symptoms also comes from empirical data on the pervasive and
pernicious effects of mental illness on psychological state, role functioning, and social and economic status
( Broadhead, Blazer, George, & Tse, 1990 ; Greenberg, Stiglin, Finkelstein, & Berndt, 1993 ; Hays, Wells,
Sherbourne, Rogers, & Spritzer, 1995 ; Ormel et al., 1994 ; Sherbourne, Wells, & Judd, 1996 ). Many
mental health disorders, even those that are less severe, can be viewed as "lifetime" or chronic illnesses that
have long-term effects despite extended periods of symptom remission. Consequently, to fully evaluate the
effectiveness of an intervention means to document its broad effects on all domains, taking into account not
only the clinician's subjective perspective but those of the patient and other involved parties as well. The use
of quality of life measures can therefore be viewed as an alternative to statistical approaches of defining
clinical significance that are applied to traditional symptom-based measures ( N. S. Jacobson, Follette, &
Revenstorf, 1984 ; N. S. Jacobson & Truax, 1991 ; Kendall & Grove, 1988 ). Although it is important to
know whether a clinically significant reduction in symptoms has occurred, it is also of central clinical
significance to determine whether the patient's quality of life has improved.
The changing structure of health care in the United States is also a factor in the popularity of quality of life
measures. Managed care providers are developing their own criteria for mental health and are keen on
exploring a wide array of indicators of mental health status, many of which bear the quality of life label. On
an individual level, these are used to determine length and type of treatment; on a system level, programs will
be required to prove their cost-effectiveness using these indexes. The mandate of federal funding agencies
(such as the National Institute of Mental Health) for a shift from efficacy to effectiveness studies, with an
"inclusive concept of treatment" and "broadly construed outcomes" ( Lebowitz & Rudorfer, 1998 ), requires
refinement of the many constructs and measures currently under the quality of life umbrella: life satisfaction,
functioning, morbidity, social relationships, work performance, and adverse effects of treatment.
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The task of developing useful quality of life measures for mental health would be easier if the extensive use of
such instruments in the medical arena lent some clarity to the concept of quality of life. In fact, nearly all
authors reviewing the quality of life literature have commented on the absence of a good, consensual
definition ( Leplège & Hunt, 1997 ; Muldoon, Barger, Flory, & Manuck, 1998 ), with some noting the
contrast between the conceptual problems and the psychometric sophistication or statistical elegance of
several measures ( Gill & Feinstein, 1994 ). In their evaluation of the face validity of 159 uses of quality of
life measures in 75 studies, Gill and Feinstein found that quality of life was defined in only 15% of the articles
and that reasons for using a particular instrument were stated in only 36%. Perhaps the best summary of the
current status of work in this area is provided by Katschnig (1997 ), who wrote that the term quality of life
refers to "a loosely related body of work on psychological well-being, social and emotional functioning,
health status, functional performance, life satisfaction, social support, and standard of living, whereby
normative, objective, and subjective indicators of physical, social and emotional functioning are all used" (p.
Despite the conceptual confusion, a taxonomy of quality of life instruments based on theory does exist. Most
instruments used in medicine today were developed from one of two frameworks: generic quality of life or
health-related quality of life. Generic quality of life measures have their roots in classic sociological research
on work, family life, and well-being as seen through the lens of middle America (see Katschnig, 1997 ;
Stedman, 1996 ). These measures can be applied to both healthy and ill individuals and focus on aspirations,
goals, and a sense of how one is doing relative to both internal standards and an external comparison group.
As expected, they contain a predominance of items focusing on subjective perceptions and experience and
may include domains whose connection to health are not particularly obvious, such as income, housing, and
social support. Measures of well-being and life satisfaction fall into this category. In contrast, the purpose of
health-related quality of life measures is to document the burden associated with illnesses and interventions.
Of these, some can and have been used across diagnostic groups (e.g., the Short Form Health Survey [SF-
36; Ware, 1993 ] and the Sickness-Impact Profile [ Bergner, Bobbit, Carter, & Gilson, 1981] ), whereas
others are remarkable in their specificity (e.g., the Angina Pectoris Quality of Life Questionnaire [ Wiklund,
Comerford, & Dimenas, 1991 ] and the Inflammatory Bowel Disease Symptoms Questionnaire [ Mitchell et
al., 1988] ). Health-related quality of life instruments also cover various life domains and may even include an
item or two assessing "overall quality of life" or "life satisfaction"; however, their emphasis is typically on
symptoms, impairment, functioning, and disability. Having drawn this distinction between the two types of
instruments, it is important to consider the following points: Some instruments reflect a combined approach,
some researchers include several quality of life measures in their assessment battery, and, finally, there is no
shortage of criticism on conceptual and methodological grounds leveled at both generic and health-related
approaches (a complete review of which is beyond the scope of this article).
Although the central issue remains the same (i.e., how to define quality of life, conceptually and
operationally), the direct application of this work to mental disorders and treatments is complicated by a
number of factors. First, mental health practitioners have always been concerned with the psychological and
social well-being of their patients. In the therapist's office, clinical significance has long been interpreted to
encompass problems in daily functioning, difficulty handling life events and stresses, and even existential
crises. For the clinician and researcher alike, it might be difficult to see quality of life issues as distinct from
the feelings, thoughts, and behaviors that are the focus of treatment. One argument is that psychologists have
been studying quality of life variables for years but that these variables have gone by different names, such as
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social support, burden, and life events ( Katschnig, 1997 ). However, a review of 897 psychotherapy trials
conducted by Grawe, Donati, and Bernauer (1994 ) indicated few attempts to look at variables other than
symptoms, personality factors, and interpersonal relations; none of these trials used specific quality of life
instruments (see Lenz & Demal, 1997 , for a more complete discussion of this study). This finding is
consistent with the attraction of psychotherapy researchers to what is called clinical significance
methodology –statistical methods using the scores of normative samples on standard symptom measures to
define clinical improvement.
Along the same lines, a second factor that might account for the oversight of quality of life among mental
health researchers is that assessment of psychological symptoms has become a key feature of quality of life
measures. This practice is so common in medicine that it has given rise to the concern that psychiatric
syndromes will be overlooked–mistaken instead for manifestations of "poor quality of life" ( A. M. Jacobson,
de Groot, & Samson, 1997 ; Katschnig & Angermeyer, 1997 ). In any event, this practice does question
whether the use of these measures is redundant in the mental health field and creates problems for the
development of a quality of life measure that is independent of symptoms and psychological state.
Finally, psychologists bring to quality of life research a unique understanding of the complexity of the
construct. Quality of life is best thought of as an emergent variable, one not definable or measurable in the
way that other psychological constructs, such as personality traits or emotions, are defined or measured
( Kaplan, 1985 ). For that reason, psychologists speak of features or indicators of quality of life, and the
proposed models of quality of life do not define the construct as much as emphasize one feature over
another. The absence of a good working definition of quality of life is nonetheless frustrating and creates
problems for theoretical and methodological tests of the models.
From a number of possible approaches to quality of life in mental health, two dominant and competing
models have emerged. These models, described by Angermeyer and Kilian (1997 ), offer somewhat
different responses to the considerations outlined above. As the name suggests, the Satisfaction Model
derives from generic framework of quality of life in medicine. The Three Component Model, with its more
inclusive definition of quality of life, can be viewed as a refinement of the health-related framework.
The Satisfaction Model is an outgrowth of both sociological and psychological approaches to examining
personal happiness and well-being (see Diener, 1984 , for a review of this literature). In this model, quality of
life is equated with one's satisfaction with various life domains that are personally important. More
specifically, it is based on a comparison between aspirations and the degree to which these needs and wishes
are fulfilled. Overall level of satisfaction is then reflected in a sense of subjective well-being or a sense of
discontent. The assumptions underlying this model are that quality of life is inherently subjective, that global
satisfaction is the sum of satisfactions across distinct domains, and further, that satisfying areas of life
compensate for unsatisfying areas ( Baker & Intagliata, 1982 ; Frisch et al., 1992 ; Lehman, Ward, & Linn,
1982 ). Proponents of this model admire its independence from implicit or explicit value judgments about
what makes for a "good" quality of life and for its merging of the cognitive (the comparison of aspirations and
achievements) and the affective (the sense of happiness or unhappiness generated by these comparisons).
Life satisfaction is typically measured on a Likert-type scale. Respondents are asked to rate their level of
satisfaction and sometimes their level of importance for a number of life domains, the content and range of
which are somewhat different across instruments. Despite the emphasis on the subjective nature of quality of
life, earlier operationalizations of the Satisfaction Model, namely Lehman's Quality of Life Interview
( Lehman, 1988 ), include subjective and objective indicators of other components of quality of life, such as
functioning and access to resources and opportunities (e.g., income and housing). It also includes an item that
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assesses global well-being. More recent measures of life satisfaction vary in the extent to which they
incorporate these other aspects of quality of life into a life satisfaction rating; the Quality of Life Enjoyment
and Satisfaction Scale (Q—LES—Q; Endicott, Nee, Harrison, & Blumenthal, 1993 ) does, whereas the
Satisfaction with Life Scale ( Diener, Emmons, Larsen, & Griffin, 1985 ) and the Extended Satisfaction with
Life Scale ( Alfonso, Allison, & Dunn, 1992 ) do not.
Perhaps the "purest" life satisfaction measure is the Quality of Life Inventory (QOL Inventory; Frisch et al.,
1992 ). It is based on Frisch's theory that life satisfaction judgments are cognitively mediated and that
objective characteristics, such as functional ability, medical and psychological symptoms, and objective life
circumstances, influence these judgments only in terms of how they are perceived and valued. These other
nonsubjective components are therefore excluded from the quality of life construct. Frisch's QOL Inventory
measures satisfaction and importance of 17 life domains and has been applied to both clinical and nonclinical
populations. In addition, Frisch has developed a quality of life intervention aimed at increasing life satisfaction
and subjective well-being through cognitive restructuring ( Frisch, 1998 ; Grant, Salcedo, Hynan, Frisch, &
Puster, 1995 ).
Criticism of the Satisfaction Model has been directed primarily at this narrower interpretation of quality of
life. Although there is consensus that a quality of life measure needs to tap patients' perceptions, there are
questions about the exact nature of the relationship between cognitive evaluations of life satisfaction and
more general feelings of well-being, as well as doubts about the wisdom of relying on the subjective
perspective alone. As alluded to earlier, the specific problem that this presents for psychology and psychiatry
is the effect of psychological state on perceptions of well-being. If we regard quality of life judgments as
consisting only of these perceptions, then quality of life will probably not prove to be that distinct from
symptom status. Those who prefer to keep the two constructs distinct argue that depressed mood, and even
momentary affective states, not only influence but also "distort" judgments about life satisfaction ( Katschnig,
1997 ). Depressed patients, for example, judge their functioning and satisfaction with living conditions more
negatively than do independent raters, other patient groups scoring lower on objective indicators of quality of
life, and the patients themselves after recovery ( Atkinson, Zibin, & Chuang 1997 ; Morgado, Smith,
Lecrubier, & Widlocher, 1991 ). Atkinson and Caldwell (1997 ) found that the quality of life domains from
Frisch's QOL Inventory that were most highly correlated with mood were also ranked the most important,
suggesting to the authors the activation of depressogenic self-appraisal schema and further evidence of bias.
This phenomenon poses a challenge to the notion of independence of positive and negative affect, and it
would not be unreasonable to speculate that it might be widespread: If depression affects life satisfaction
ratings in this way, then so might personality disorders and even personality or cognitive styles, although this
has not been well studied ( Muldoon et al., 1998 ). Finally, the cognitive mediation hypothesis itself suggests
different interpretations of high satisfaction ratings. Patients, especially those with chronic psychiatric illness,
may resolve the discrepancies between what they want and what they have by devaluing specific life
domains. Angermeyer and Kilian (1997 ) stated that "in this case, the apparent satisfaction really represents
resignation" (p. 20).
Regardless of how one chooses to understand the relationship between symptoms and life satisfaction, a
troubling aspect of the Satisfaction Model is that it omits two components: functioning and social—material
conditions. These elements seem essential, if only for their role in determining aspirations, achievements, or
how one perceives the match between the two. Historically, quality of life has been tied to economic and
social factors ( Andrews & Withey, 1976 ; Campbell, Converse, & Rodgers, 1976 ), and positive change in
any of these areas during the course of treatment (e.g., a patient finding a job) is typically viewed as a
consequence or an indication of clinical improvement. If one aim of developing quality of life measures is to
broaden assessment of outcomes, then it seems counterproductive to use a restrictive or narrow model. An
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excellent example of an inclusive definition of quality of life, one that acknowledges both the primacy of
subjective perceptions and the role of objective or contextual factors, was proposed by the WHOQOL
group: "Quality of life is the individual's perception of their position in life in the context of culture and value
systems in which they live and in relation to their goals, expectations, standards, and concerns" ( Harper &
Power, 1998 , p. 551). The work group used this definition to develop a measure that includes
environmental and social domains (e.g., physical safety, financial resources, and social support) as well as
psychological ones. The inclusion of an objective component finds support in Strupp's (1996 ) tripartite
model of mental health that details the three vantage points, or "interested parties," from which a person's
mental health may be judged: society (including significant others), the individual patient, and the clinician. He
explained that these three judgments may be discrepant, as in the case of someone who conforms to social
standards but is in psychic distress, but that evaluations of treatment effects must be comprehensive, taking
into account all three perspectives. It is not a big leap from this model to quality of life measures that include
the subjective perspective of the patient along with more objective or external indicators of functioning and
In point of fact, many of the quality of life measures used in mental health today are based on a broad
definition of quality of life and some do attempt to measure all three, or at least two of the three, components:
satisfaction, functioning (role performance), and social—material conditions (employment, income, housing,
etc.). As noted earlier, even some of the instruments with the satisfaction label actually cover all three
components. The earliest of the instruments that combined measures of general well-being with measures of
functioning were developed for research on the burden of somatic diseases. With their emphasis on physical
disability and symptoms, these health-related quality of life instruments are not very appropriate for
psychiatric populations, although at least one (the SF-36; Ware, 1993 ) has been used in treatment studies
of depression and anxiety. Several new measures used in psychiatry, like the Disability Profile for Social
Phobia ( Schneier et al., 1994 ), are similar to health-related quality of life scales in their disease specificity
and their combination of ratings of symptoms and functional impairment. Perhaps the biggest impetus for the
development of more comprehensive quality of life instruments came from work with chronically and
severely mentally ill persons. The need to document the full effects of these disorders on sense of self, role
functioning, interpersonal relationships, employment and financial status, and living conditions, as well as to
demonstrate the impact of community-based treatments on these areas, resulted in the creation of several
ambitious measures. In these, both content and method of gathering information have been extended.
Inclusion of "objective" measures of functioning and standard of living (e.g., frequency of family contacts and
employment status) was deemed necessary because of concerns about the ability of schizophrenic patients to
make accurate subjective assessments of their quality of life. Unfortunately, few comprehensive instruments
have been developed for use with other less severe psychiatric disorders, even though the disabling effects of
some of these disorders, such as chronic major depression, have been shown to be great.
There are a number of obstacles to the development of multidimensional models and measurements of quality
of life. For example, one might wonder whether reducing quality of life to more familiar "components," such
as psychological status and role functioning, will detract from the meaningfulness and utility of the construct.
Further, if quality of life as an emergent variable is made up of features or components, how should these be
combined or weighted to produce a score that reflects overall quality of life? Finally, the inclusion of social
and environmental factors demands consideration of cultural issues in quality of life research. As described
by Hunt (1998 ), these range from the philosophical (e.g., the universality of quality of life as a concept) to
the mundane (e.g., the complexities of questionnaire translation). Interestingly, Hunt took the position that the
subjective factors (psychological states and emotional experiences), rather than the objective ones, are most
problematic for the design of cross-cultural measures because of the powerful effect of culture on the labeling
and expression of emotion. She argued, however, for the cultural relevance of all quality of life domains and
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careful scrutiny of their normative implications.
The methodological requirements for a useful quality of life instrument are that it be reliable, valid, sensitive to
change, and relatively brief (assuming that it will be part of a larger battery of assessments). Whether or not
the ideal instrument is one that is suitable for different patient groups depends on the feasibility of developing
a measure that is broad enough to be widely applied yet specific enough to be sensitive to the effects of
particular treatments. At this time, no single instrument has been tested across diverse patient samples. Table
1 provides a brief description of the most current measures, and Table 2 reviews their psychometric
characteristics. There is evidence of convergent or discriminant validity, or both, for all measures listed.
Because many of the measures are new, these data have been presented as preliminary, with ongoing efforts
to include a larger number of participants and to establish norms for several groups. (For a review, the
reader is directed to the work of Alfonso, 1995 , and Lehman, 1997. ) Initial applications of quality of life
measures (to be reviewed in the next section) indicate that they can be successfully used with a range of
psychiatric patients, including the most chronically and severely ill. Of greater methodological concern for
quality of life researchers are the larger issues related to validity of self-report, discriminant validity, and
sensitivity to change.
The limitations of self-report are certainly not unique to quality of life measures. However, because even the
most well-defined of constructs can suffer in the translation to paper-and-pencil measures, there are doubts
about whether so elusive a concept as quality of life can be adequately captured in a questionnaire format
and then consistently interpreted by patients. In this regard, quality of life research is in a bit of a conundrum,
forced to weather criticism from two camps: those who believe that quality of life is inherently so subjective
and personal that it is almost unmeasurable (the existentialist approach; see Leplège & Hunt, 1997 ) and
those who would like verification of questionnaire responses in the form of corroborating reports from others
who are assumed able to judge the patient's quality of life. From a practical perspective, it is difficult to
satisfy either group. The trend has been to universalize rather than individualize the facets of life or human
concerns deemed important enough to include in the construction of a quality of life measure. The
WHOQOL group ( Szabo, 1996 ) did improve on existing methodology by using focus groups in 15
international centers to generate 24 life facets to be included in a questionnaire that could be applied cross-
culturally. However, this resulted in a 100-item questionnaire that might be judged unwieldy by investigators.
The briefer, 26-item version is more user-friendly, but the coverage of important domains is probably
compromised by the omission of 74 questions. It has been suggested that instruments include a qualitative
component by providing participants the opportunity to list the factors that they consider personally relevant
that may have been omitted ( Gill & Feinstein, 1994 ). Unfortunately, as researchers are well aware, it is
difficult to know how to handle write-in responses in otherwise quantitative research.
Attempts to corroborate self-report data by interviewing significant others have not been particularly
successful. There is a fairly large body of evidence that points to discrepancies between patient and
informant in their reports on patients' symptoms, level of psychopathology, and functioning in very specific
areas ( Katschnig, 1997 ; Strupp, 1996 ). When it comes to quality of life, it is difficult to make the case that
the clinician's judgment should be considered the gold standard. In addition, unless one is dealing with
severely mentally ill individuals, in which case there is often an identified caregiver, it can be difficult or
awkward to enlist the cooperation of family and friends. So although quality of life researchers might support
Strupp's call for incorporating the perspective of significant others in judging outcomes–and more information
is always better than less–interviewing informants is not an uncomplicated or easy way to improve the quality
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or validity of self-reports. Researchers of quality of life will no doubt come to rely on the tried and true
methods of improving self-report procedures used in other areas of psychological assessment–clear
instructions, concise items, the opportunity for respondents to ask for assistance, use of multiple methods to
obtain information, and experimentation with new procedures. Regarding the last, there is promising work on
the use of the time-sampling techniques for the investigation of quality of life at the level of daily life
experience ( Barge-Schaapvelk, Nicolson, Delespaul, & deVries, 1997 ).
One reason that self-report ratings of quality of life have been questioned is that they appear to be dependent
on affective state. The value of the quality of life construct lies in its distinctiveness from other constructs
already routinely measured in clinical trials, such as symptoms. Establishing the discriminant validity of quality
of life measures is, therefore, an important methodological task. One would not expect to find evidence for
discriminant validity in the comparison of symptom measures and quality of life measures that have symptom
ratings embedded in them. It is less clear how to interpret the high negative correlations between symptom
measures and subjective quality of life measures (i.e., well-being or life satisfaction scales) that do not include
symptom items. As noted earlier, level of symptomatology influences judgments. Frisch's QOL Inventory, for
example, was found to be significantly negatively correlated with scores on the Beck Depression Inventory
(BDI; − .44 and − .51), the Millon Clinical Multiaxial Inventory–II Anxiety subscale ( − .41 and − .39), and
the Symptom Checklist—90 (SCL-90) Global Severity Index ( − .45 and − .48) in both an inpatient and
undergraduate sample, respectively ( Frisch et al., 1992 ). All eight summary scale scores and the single
rating of overall enjoyment and satisfaction in the Q—LES—Q were negatively correlated with Hamilton
Rating Scale for Depression (HRSD; up to − .61), SCL-90 (up to − .74), and BDI scores (up to − .73;
Endicott et al., 1993 ). The correlations varied quite a bit depending on the domain, indicating that some
domains were more reflective of affective status than others ( Endicott et al., 1993 ). Measures of symptom
change have also been shown to correlate with change in quality of life ratings ( Endicott et al., 1993 ; Frisch
et al., 1992 ).
Quality of life researchers have used the wide range and modest (though statistically significant) correlations
between life satisfaction ratings and ratings of mood and mood change to argue that their scales are not
redundant with symptom measures. Although this may be true, it is incumbent on these researchers to
acknowledge the need to know more about the relationship between quality of life and symptoms and to
examine more carefully the statistical relationship between the two. It has been suggested that mood be
statistically controlled (covaried) when looking at the effects of treatment on quality of life ratings so that the
impact of treatments on the component of quality of life that is independent of mood, or symptom status, can
be ascertained. In longitudinal designs involving multiple assessments, mood can be included as a time-
varying covariate when examining change in quality of life over time.
Another methodological issue involves the ability of quality of life measures to reflect treatment-related
changes. This criterion is important for the utility of quality of life measures, and there are concerns that some
operationalizations will not be as sensitive to therapeutic change as one might want or need them to be. One
problem is that, because little is known about how people form judgments about their level of satisfaction
and well-being, it is difficult to predict how internal and external changes will affect these judgments. For
example, there is reported to be only a modest relationship between measures of life satisfaction and
objective indicators of quality of life, such as socioeconomic status ( Barry, 1997 ; Frisch, 1998 ; Skantze,
Malm, Dencker, & May, 1990 ; Skantze, Malm, Dencker, May, & Corrigan, 1992 ). Some studies indicate
that life satisfaction judgments remain fairly stable over time and fluctuate only briefly in response to life
events and that this is as true for chronically mentally ill individuals as it is for the general population
( Angermeyer & Kilian, 1997 ). However, these findings appear to be at odds with what is known about the
relationship between life satisfaction and affective state, and the good news is that initial studies using life
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satisfaction measures in clinical trials indicate that they do change along with other measures of clinical
improvement. Clearly, more research needs to be done by scale developers and by those who have begun
to use quality of life measures to evaluate interventions. Studies reporting pre—post changes in quality of life
ratings generally note that they are sensitive to changes in clinical state, but to date there is little effort
directed at more sophisticated approaches–for example, determining factors, other than symptom relief, that
may lead to improvements in quality of life (i.e., to what extent do changes in quality of life ratings during
treatment occur independent of changes in mood?) or examining quality of life as a prognostic or moderating
variable. Questions also remain about whether the different components of multidimensional models can be
expected to change at the same rate and whether they will be equally sensitive to the type of intervention
studied (long term vs. short term, medication vs. psychotherapy; Barry, 1997 ; Cheng, 1988 ; Katschnig,
1997 ; Muldoon et al., 1998 ).
Finally, it is important to consider the interpretation and presentation of quality of life data. Because many of
the instruments currently in use are new, the scores or units of change are unfamiliar and it is extremely
difficult to evaluate the magnitude of these changes in terms of their clinical relevance. In addition, some
multidimensional measures yield not one but many summary scores, resulting in a rather complicated pattern
of results. It has been suggested that researchers pay more attention to the descriptive statistics of the quality
of life variable, both baseline and change scores, to assist in the interpretation of the findings ( Lydick &
Yawn, 1998 ). If published, these data would serve to familiarize the reader with the instrument and,
ultimately, to establish benchmarks for clinically significant improvement.
Both pharmacological and psychotherapeutic strategies are hypothesized to enhance quality of life, however
broadly or narrowly that concept is defined. Whereas psychotherapy might be more likely to target quality of
life issues, it is well known that psychotropic drugs act directly on mood and functioning and may play a
more indirect role in changing the patient's social and material conditions ( Angermeyer & Katschnig, 1997 ).
Pharmacological researchers, eager to demonstrate these effects and attuned to cost-effectiveness
considerations, have in fact taken the lead in quality of life work in psychiatric disorders. The development of
suitable instruments in this area must take into account the impact of side effects on compliance and overall
quality of life, as well as the brevity of most medication trials. Although there may be special considerations
for quality of life in psychotherapy research as well, we can anticipate future studies comparing the
differential effects of medications and psychotherapies on quality of life dimensions. Therefore, the challenge
will be to design quality of life measures that are appropriate for a number of different interventions. In this
section, we describe uses of quality of life instruments as outcome measures in the evaluation of treatments
for different disorders. Methodological problems unique to each area are highlighted.
Chronic and Severe Mental Illness
As mentioned earlier, the most comprehensive quality of life measures were developed for research on
chronic mental illness. These measures were originally developed to evaluate the mental health programs that
sought to provide deinstitutionalized patients with the skills needed to live successfully in the community
( Becker & Diamond, 1997 ). Although a number of instruments have been created, as Bobes and Gonzalez
(1997 ) have pointed out, only a few of them meet the standard of having a conceptual model, published
psychometric properties, and cultural adaptations. Three noteworthy instruments are Lehman et al.'s Quality
of Life Interview (QOL Interview; Lehman, Postrado, & Rachoba, 1993 ; Lehman et al., 1982 ), the
Quality of Life Questionnaire (QLQ; Bigelow, Brodsky, Stewart, & Olson, 1982 ; Bigelow, Gareua, &
Page 10 of 19
Young, 1990 ), and the Quality of Life Index of Mental Health (QLI—MH; Becker, Diamond, & Sainfort,
Lehman et al.'s QOL Interview addresses "objective" components (i.e., what individuals actually do and
experience) and "subjective" components (how satisfied individuals are with their experiences). The eight
main life domains assessed by the QOL Interview include living situation, family relations, social relations,
leisure activities, finances, safety and legal problems, work and school, and health. Both a core version and a
short version of this structured self-report interview have been developed. The core version consists of 143
items and requires 45 min to administer, whereas the short version consists of 78 questions taken from the
full version and takes 16 min to administer. Moderate to high internal consistency and test—retest reliabilities
have been found for both versions. Construct and predictive validity also appear to be adequate ( Lehman,
Possidente, & Hawker, 1986 ; Lehman et al., 1993 ). Research on the QOL Interview focuses primarily on
individuals with severe mental disorders.
In an effort to assess the effects of community mental health programs on quality of life for patients with
chronic mental illness, Bigelow et al. (1990) designed the QLQ. The 263-item interview uses patients'
reports of satisfaction and performance across 14 domains to measure their community adjustment. The
interviewer's observations and clinical judgment may also be used to establish ratings, as may additional
information from family, clinicians, and landlords. Internal consistency data vary from low to high for the
various scales, and good evidence of predictive and discriminant validity support the use of the QLQ for
assessing quality of life as an outcome improved by mental health services ( Bigelow, McFarland, & Olson,
Based on a number of established scales, the QLI—MH ( Becker et al., 1993 ) is a self-report
questionnaire that consists of 113 items and requires approximately 20 min to complete. Versions for
patients, families, and clinicians have enabled comparisons of quality of life ratings from different raters. The
QLI—MH assesses various aspects of life circumstances, including life satisfaction, occupational activities,
psychological well-being, physical health, activities of daily living, social relationships, economics, symptoms,
and goal attainment. Initial psychometric data are encouraging with the report of good test—retest reliability,
concurrent validity, and criterion validity ( Becker et al., 1993 ).
Most of the instruments used to assess quality of life rely on a single respondent. A major methodological
issue for quality of life measures in people with schizophrenia is the degree to which these patients can be
counted on to provide valid and consistent reports of their quality of life. A few studies have begun to
address the issue of concordance between different raters (e.g., patients, clinicians, and family; Sainfort,
Becker, & Diamond, 1996 ). Although it is clear that symptoms can, and often do, affect the accuracy of
patients' perceptions, there is agreement that patients' subjective experience of quality of life remains an
important construct to assess. In their work with patients with schizophrenia, Skantze et al. (1990 , 1992 )
found that patients' reports depended more on their internal experience of the world than on their real
experiences. Because of this discrepancy, they recommended examining subjective quality of life within the
context of an individual's "objective" standard of living (e.g., an observer's evaluation of the patient's life
situation). However, other researchers have found similarities between observer ratings and self-reports on
quality of life measures (e.g., Lehman et al., 1982 ). Sainfort et al. (1996 ) found moderate agreement
between patient and provider reports on symptoms and functioning but little agreement on social relations
and occupational functioning. Although it appears that multiple informants may provide the most accurate
picture of quality of life for individuals with severe mental illnesses, it brings us back to the previously noted
problem of how to combine discrepant information.
Page 11 of 19
Bobes and Gonzalez (1997 ) reported a number of findings that have emerged across studies of patients with
schizophrenia. These patients rate their quality of life lower in comparison with the general population and
other physically ill patients. Young people, women, married individuals, and less educated individuals with
this illness report a better quality of life. Quality of life is negatively associated with duration of the illness and
symptom severity, particularly negative symptoms. It has been shown that the combination of
psychopharmacological and psychotherapeutic treatment improves quality of life and that the level of
medication side effects also plays a role in patient satisfaction. Finally, patients integrated into community
support programs demonstrate a better quality of life than do institutionalized patients. In summary, research
on the quality of life of individuals with severe mental illnesses has yielded important preliminary data that
inform treatment and policy decisions. The use of multiple raters and objective indexes, as well as subjective
self-reports, is recommended with this population.
Quality of life measures used in "nonchronic" populations tend to be disorder-specific and focus primarily on
functioning. The assessment of role performance is not new to depression research. The Social Adjustment
Scale (SAS; Weissman, Klerman, Paykel, Prusoff, & Hanson, 1974 ), developed over 20 years ago, has
been used extensively to document reduced functioning in depressed patients as well as improved functioning
after treatment. The SAS contains both "instrumental" and "affective" items, with the latter tapping emotional
states associated with poor functioning, such as shame, distress, and inadequacy. Because these can be
construed as symptoms of depression, they have been treated separately from the more behavior-based
functioning items by some researchers ( Mintz, Mintz, Arruda, & Hwang, 1992 ; Stewart et al., 1988 ). The
SAS has never been viewed as more than what it is–a measure of role functioning or "social adjustment."
More recent instruments developed specifically as quality of life measures for use with depressed patients
include the Quality of Life in Depression Scale ( Hunt & McKenna, 1992a , 1992b ) and the SmithKline
Beecham Quality of Life Scale ( Stoker, Dunbar, & Beaumont, 1992 ). They are both brief instruments that
assess some combination of symptoms, functioning, and well-being. It is difficult to evaluate their utility
because, to date, their use has been limited. Other studies of depression have used health-related measures
borrowed from work on somatic disease. The emphasis on physical symptoms and physical functioning
found in instruments like the SF-36 may have its advantages for documenting the extent of disability and
impairment caused by depression; however, it also makes these instruments less appropriate for evaluating
broader quality of life changes in psychiatric patients.
Two measures that have the potential for more widespread application in affective disorders are the Q—
LES—Q and Frisch's QOL Inventory. Unfortunately, although the QOL Inventory was validated on two
samples of psychiatric inpatients, there is little evidence to date documenting its ability to reflect change
brought about by standard depression treatments. The advantage of the Q—LES—Q is that it contains
measures of both functioning and life satisfaction and therefore does not rely exclusively on ratings that may
be dependent on mood state. The Q—LES—Q is a 93-item self-report questionnaire yielding eight
summary scale scores corresponding to different life domains. Respondents are asked to rate their degree of
satisfaction and enjoyment on a 5-point scale. Its use in medication trials has so far produced intriguing
results. In an 8-week study comparing the efficacy of a selective serotonin reuptake inhibitor (SSRI) with a
tricyclic antidepressant in a sample of depressed outpatients, there was greater improvement in quality of life
ratings for the SSRI group, although ratings of depression (based on the HRSD [ Hamilton, 1960 ] and the
BDI [ Beck, Ward, Mendelson, Mock, & Erbaugh, 1961] ) indicated that the treatments were equivalent
( Lydiard, Stahl, Hertzman, & Harrison, 1997 ). Another study comparing two antidepressants ( Wheatley,
Van Moffaert, Timmerman, Kremer, & Mirtazapine—Flouxetine Study Group, 1998 ) pointed to a
Page 12 of 19
disjunction between symptoms and quality of life ratings. There was evidence for the superiority of one drug
over another on the basis of standard symptom ratings, but the Q—LES—Q ratings, though significantly
improved at posttest, showed no between-groups differences. Taken together, these results indicate that
quality of life ratings, as measured by the Q—LES—Q, are sensitive to treatment-related change, even in the
short term; moreover, despite significant correlations between its subscales and symptom measures, the Q—
LES—Q appears to be tapping something other than symptom change. There is much more to be learned
from this research about the relationship between mood and quality of life judgments. In addition, because it
has been suggested that the degree of functional impairment may depend more on the duration of depression
than the severity ( Katschnig & Angermeyer, 1997 ), it is important for quality of life researchers to examine
these measures in the context of longer treatments and follow-up and to consider including items assessing
the changes in material and social status (i.e., the third component of quality of life) that may be a result of the
long-term improvement or decline.
It is for the anxiety disorders, more so than for either depression or schizophrenia, that quality of life has
become synonymous with functioning. The majority of studies documenting impairment in patients diagnosed
with anxiety disorders–panic disorder, agoraphobia, obsessive—compulsive disorder, and social phobia–
have used health-related scales, such as the SF-36 ( Ettigi, Meyerhoff, Chirban, Jacobs, & Wilson, 1997 ;
Hollifield et al., 1997 ; Koran, Thienemann, & Davenport, 1996 ; Sherbourne et al., 1996 ). Even new
measures developed specifically for these populations have focused on social and occupational impairment
to the exclusion of other aspects of well-being. For example, the Sheehan Disability Scale (SDS; Sheehan,
1986 ) contains items for rating work, social, and family functioning in patients with panic disorder and other
anxiety disorders. The Leibowitz Self-Rated Disability Scale ( Schneier et al., 1994 ) has been used in
conjunction with the clinician-rated Disability Profile ( Schneier et al., 1994 ) to document at least moderate
functional impairment across six areas in more than half of social-phobic patients. Measures of functional
impairment are generally sensitive to treatment-induced change, and the literature indicates that patients with
anxiety disorders experience improved functioning with treatment. For example, panic disorder patients who
received cognitive—behavioral therapy showed significantly less impairment at posttreatment, as measured
by the SAS and the SDS, compared with a delayed-treatment control group ( Telch, Schmidt, Jaimez,
Jacquin, & Harrington, 1995 ). Overall, the restricted content of these measures suggests that the assessment
of quality of life per se has not received much attention in treatment studies of anxiety. One exception is a
study of cognitive—behavioral group treatment of social phobia that used Frisch's QOL Inventory as an
outcome measure ( Safren, Heimberg, Brown, & Holle, 1996—1997 ). Life satisfaction judgments, as
measured by the QOL Inventory, were negatively correlated with symptom severity, varied according to
subtype and presence of avoidant personality disorder, and improved after therapy.
Participants at a National Institutes of Health conference on panic disorder recommended that measures of
quality of life be included in a standard assessment package for panic disorder research ( Shear & Maser,
1994 ). Assuming that a broader conceptualization of quality of life will ultimately be adopted by anxiety
researchers and that measures like the Q—LES—Q and Frisch's QOL Inventory will be tested in
medication and therapy trials for panic disorder, social phobia, and obsessive—cumpulsive disorder,
comorbidity within anxiety disorders and with other Axis I disorders will continue to pose a methodological
problem. For example, how are anxiety researchers to estimate the separate effects of generalized anxiety,
panic symptoms, and depressed mood on perceived well-being? It might not be possible to tease this apart
empirically, but Schneier (1997 ) has recommended dealing with this by accurately defining the sample–that
is, assessing both current and lifetime comorbid disorders before making attributions regarding the cause of
poor quality of life. The high rate of comorbidity in anxiety disorder populations also argues against the use of
Page 13 of 19
Older Persons and Children
Research with older persons and children faces the challenge of incorporating normal developmental changes
into evaluations of the quality of life. Particularly with these populations, it is necessary to distinguish age-
related patterns of quality of life from quality of life patterns attributable to mental disorders ( Gurland &
Katz, 1997 ). This issue is further complicated by ambiguity in the concept of quality of life at different ages.
Before gains can be made in this field, research must clarify the concept of quality of life across the life span.
At present, these inquiries lack age-related, longitudinal, population-based information on quality of life
issues as individuals age. A few studies have evaluated normative quality of life in older persons, but no
studies are available with children. More normative data are needed to better understand quality of life
constructs in children and older persons.
Several studies have examined the impact of dementia and the impact of depression on older persons' quality
of life ( Gurland & Katz, 1992 ; Gurland et al., 1997 ). A number of instruments have been developed to
measure functional abilities of older patients with dementia, many of them consisting of interviews with an
informant or behavioral observation of the patient with dementia (see Kluger & Ferris, 1991 ). In light of
these methods, the subjective experience of the patient tends to be overlooked. Researchers who use these
instruments compare quality of life with population norms, premorbid performance of the individual, or
defined stages of impairment associated dementia ( Gurland & Katz, 1997 ). There is a focus on the patient's
ability to perform basic activities of daily living; however, there needs to be a greater emphasis on mobility,
self-care, and home management in quality of life concerns. Gurland and Katz (1997 ) have developed a
comprehensive framework for conceptualizing quality of life in older persons. They proposed that quality of
life be considered across 19 domains, with each domain representing a challenge to adaptation and sets of
responses an older person may make to meet this challenge. They suggested different grades of functioning
based on the severity of impairment but have not yet developed a standardized quality of life instrument
based on their framework.
To date, research on quality of life in children has been limited to illnesses thought to have psychosomatic
components (e.g., allergies and asthma) and to cancer (for a review, see Ivan & Glazer, 1994 ; Pal, 1996 ).
There is no well-established quality of life instrument that measures the impact of mental health problems on
children's life circumstances ( Schmeck & Poustka, 1997 ). As with older persons or individuals with severe
mental illness, there exists some concern regarding children's report of life circumstance information. Children
with mental disorders frequently participate in treatment at the request of their parents and may deny
problems in quality of life. Moreover, children's reports may not be stable over time because of normal
limitations in children's cognitive abilities and experience of time. By virtue of questions regarding the
reliability and validity of youth reports, it appears necessary to clarify the life picture with the inclusion of
parent and teacher reports. Given the influence of the family environment on child and adolescent functioning,
an understanding of family functioning is also important in evaluating a child's quality of life ( Schmeck &
Poustka, 1997 ). These factors complicate attempts to design a simple, straightforward method of measuring
quality of life in this population.
Quality of life shows some promise as a useful and measurable construct capable of reflecting clinically
significant change. There appears to be theoretical and empirical justification for a broad definition of quality
Page 14 of 19
of life (encompassing satisfaction, functioning, and objective life circumstances) and the development of
multidimensional instruments that can be applied to different disorders and across different treatments. In this
endeavor, mental health researchers can draw on lessons learned from the use of quality of life measures in
other medical specialties, where idiosyncratic definitions and ultraspecific measures have limited the
cumulative impact of the quality of life construct. There are few studies in which quality of life is more than a
secondary outcome variable, and the space allotted to the discussion of quality of life results in published
reports is invariably small. The WHO, in response to the problem, is promoting the use of its own quality of
life instrument, the WHOQOL-100 ( Harper & Power, 1998 ). Based on a broad view of quality of life (as
"a subjective evaluation embedded in a cultural, social, and environmental context"), the WHOQOL-100
was designed to be comprehensive and widely applied. Apart from its inclusion of a psychological domain
that may be confounded with mood state (and this can be explored statistically), there is no reason that this
instrument cannot be tested in psychiatric populations. We also recommend more extensive use of other
nonspecific measures, like the Q—LES—Q, in a wide range of treatment studies. It is only through this kind
of testing that we can define the relationships between quality of life and symptoms and between quality of
life and other outcomes, as well as assess the ultimate value of the quality of life construct. Finally, it is natural
that, as psychologists, we want to know more about the determinants and mediators of quality of life
judgments. How, exactly, do people with mental illness appraise their well-being? Do other psychological
constructs, like self-efficacy, perceived control, and autonomy, play a role in quality of life judgments, as has
been suggested by Barry (1997 )? Qualitative research into these questions could be fruitful.
Although there is evidence for the utility of quality of life measures as outcome variables in psychotherapeutic
and psychopharmacologic treatment, there is some danger, for researchers and patients alike, in expecting
too much. Some wonder whether we should be in the business of assessing aspects of life that bear no
obvious connection to a disorder or its treatments, especially when managed care is demanding briefer and
more focused interventions, with treatment rationed according to "medical necessity." Should clinicians and
their patients feel that the job is not done (or not done well) if symptoms are alleviated but other areas of the
patient's life are not fully satisfying? Others worry that quality of life cannot be reduced to a single score or
set of scores in that the unique and changeable set of everyday experiences that gives rise to feelings of well-
being or discontent (like the companionship of a pet, a bad commute, or noisy neighbors) cannot be
captured by a scale, however comprehensive. These legitimate concerns do not outweigh the need to
broaden our view of clinical significance, but they should be kept in mind as, hopefully, we pick up the pace
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Table 1. Descriptive Characteristics of Quality of Life Measures
Table 2. Psychometric Characteristics of Quality of Life Measures