The Concept Of Quality Of Life

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The concept of quality of life, as used in the literature, can best be regarded as consisting of three components: (a) subjective well-being or satisfaction with the actual life situation (whereby well-being would relate to emotions, and satisfaction to cognitions; both are subjective psychological concepts); (b) functioning in self-care and in social roles ("disability" would be a variable measuring "non-functioning" in these roles); and (c) access to environmental resources, both social (e.g. social support) and physical ("standard of living") [23]. While most instruments constructed in order to measure quality of life concentrate on subjective well-being and satisfaction, one can find all three components and their sub-aspects represented in various quality of life assessment instruments in the ever growing literature on mental health and quality of life.

Barge-Schaapveld et al. [30] have traced these three components back to three main research traditions. "Well-being" and "satisfaction" are rooted in psychology, more specifically in happiness research", which appeared first in the 1950s [31]. The component of "functioning" goes back to health status research developed by social medicine and health sociologists in the 1970s, which aimed at assessing the effect of an illness and its consequent therapy upon the patient's functioning in daily life circumstances [32]. The component of environmental resources can be traced back to social indicator research, developed in the 1960s and 1970s by economists and sociologists who were studying inequalities between different groups within a given society and also between different societies [33].

Quality of life can best be conceptualized as the result of the interplay between all three components: subjective perceptions of one's well-being, objective functioning in self-care and social roles, and environmental opportunities, both social and material. Angermeyer and Kilian [34] have provided a useful overview of the theoretical models developed so far for conceptualizing this interplay. They distinguish the "satisfaction model'' [14, 16], the combined "importance/satisfaction model'' [35] and the "role functioning model'' [15] and present their own "dynamic process model''. The "satisfaction model'' is criticized as being inconclusive about three ways to interpret "high satisfaction'' with environmental conditions: is "high satisfaction'' due to the fact (a) that there is a good fit between what people want and what they get, or (b) that the life domain in question is not important for a specific person, or (c) that people have lowered their aspiration standards over time (like the fox in the fable who cannot reach the grapes). While the combined "importance/satisfaction model'' solves the problem raised by the just mentioned second possibility (it excludes life areas which are not important to the person), it fails to account for the objective environmental conditions a person is living in. The "role function ing model" accounts for these environmental opportunities, which consist of material and social opportunities; the latter are conceived as "social roles" through which people might satisfy their psychological needs, but which are also associated with demands or performance requirements. Angermeyer and Kilian's [34] own model is based on the assumption "that subjective quality of life represents the results of an ongoing process of adaptation, during which the individual must continuously reconcile his own desires and goals with the conditions of his environment and his ability to meet the social demands associated with the fulfilment of these desires and goals. Within this model, satisfaction will not be regarded as the outcome, but rather as the steering mechanism of this process.'' In view of this complex situation, the authors conclude that quantitative research methods are of limited value in assessing quality of life in mental disorders, and that the already existing qualitative methods [36], which allow the recording of subjective meaning structures, should supplement the quantitative methods.

Existing assessment methods are usually not embedded in such a sophisticated theory and there is convergent criticism that quality of life research in general (not only in psychiatry) has so far been too concerned with measurement issues and psychometrics, at the expense of theoretical and conceptual development [37, 38]. This theory deficit becomes especially apparent when the aim is to assess quality of life in mental disorders, since the widely accepted position of concentrating on the subjective perspective of the patient within a satisfaction model [39, 40] is prone to measurement distortions. Barry [41] and Leff [42] have convincingly shown that, in psychiatry, such subjective assessment has to be complemented by objective evaluation.

Calman [43] has elegantly defined quality of life as "the gap between a person's expectations and achievements'', which is basically a subjective concept. However, "achievements" depend not only on subjective factors, but also on the environmental possibilities offered. Assessing functioning in social roles, as some assessment instruments do, takes the environment partly into consideration. What is lacking in today's quality of life research is more of the social indicator research tradition, which builds environmental factors, social and material ones, into quality of life measures.

The need to include such contextual factors into the assessment of quality of life research is especially pressing in the case of psychiatric patients, where such factors interact with the patient's disorder more than in somatic problems. Income, social support and living conditions are intimately related to psychopathology. There are signs in quality of life research of a move towards going beyond subjective well-being and satisfaction by including assessment of functional status and environmental factors [44].

However, research on quality of life, in medicine in general as well as in psychiatry, is still largely dominated by assessing subjective well-being and patients' subjective view of their functioning in and satisfaction with different life domains, as a review by Lehman [45] shows.

Katschnig and Angermeyer [46] have developed an action-oriented framework for assessing quality of life in depressed patients, which includes well-being and satisfaction as psychological dimensions, as well as functioning and contextual factors as sociological dimensions (Figure 7.1). This model can be easily applied to other diagnostic categories. They show that helping actions have to be differentiated, since some act on psychological well-being (e.g., antidepressants), some on role functioning

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