Current Opinion in Psychiatry:
Personality disorders and neuroses: Edited by Charles B. Pull and Aleksandar Janca
Quality of life and mental health in Chinese culture.
Xiang, Yu-Taoa,b; Chiu, Helen FKa; Ungvari, Gabor Sa
aDepartment of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
bBeijing Anding Hospital, Capital Medical University, Beijing, China
Correspondence to Dr Yu-Tao Xiang, Research Assistant Professor, Department of Psychiatry, Shatin Hospital, Shatin, N.T., Hong Kong SAR, China Tel: +852 2636 7748; fax: +852 2647 5321; e-mail: email@example.com
Purpose of review: Quality of life (QOL) has become a standard outcome measure in psychiatry. The QOL concept is culture-dependent, which means that the results of Western studies may not be applicable to Chinese patients. The aim of this study is to summarize the recent literature on QOL and mental health in Chinese culture.
Recent findings: QOL has increasingly been used as an outcome measure of pharmacotherapeutic or psychosocial interventions in Chinese societies. Recent studies have suggested that socio-cultural factors exert an influence on the QOL of Chinese psychiatric patients. Patients with major psychiatric disorders have a poorer QOL than the general population. Socio-demographic characteristics have no, or only weak, associations with QOL in schizophrenia, whereas novel antipsychotics and antidepressants improve QOL relative to traditional psychotropic medications in the short term.
Summary: The inclusion of QOL measures in routine clinical practice and research in Chinese societies should be encouraged, and culture-sensitive QOL measures should be developed. Chinese psychiatry should also implement appropriate strategies and effective measures in line with the findings on the relationship between QOL and socio-demographic and clinical factors.
Over the past three decades, quality of life (QOL) as a concept in psychiatry has gained increasing attention because it can provide a more comprehensive view of the effectiveness of pharmacotherapeutic or psychosocial interventions and, more importantly, because it reflects respect for patients' opinions and subjective feelings by bringing their satisfaction with life into focus .
The majority of studies on QOL have focused on white populations. Preliminary evidence indicates that QOL is greatly influenced by value systems and by philosophical and cultural factors [2,3]. Thus, the results of these Western studies may not be valid in Chinese societies because of their different ethnic and socio-cultural backgrounds.
Recent epidemiological studies have revealed significant psychiatric morbidity in China. According to the country's second national psychiatric epidemiological survey , the lifetime prevalence of psychiatric disorders is 1.35%, which suggests that approximately 17 million people have psychiatric disorders at least once in their lifetime. It is very likely, however, that this figure vastly underestimates the real rate of psychiatric morbidity . A further characteristic of the Chinese mental health system is that large-scale deinstitutionalization has not yet taken place due to the particular socio-cultural context within which psychiatry operates. Hence, it is understandable that, until recently, research studies on the QOL of Chinese psychiatric patients have been few and far between. In the past few years, however, Chinese mental health professionals have become increasingly aware of the importance of the QOL concept, and research into patients' QOL using modern methods has begun in earnest. Most of these studies, however, have been reported only in Chinese-language journals. Therefore, it is important to summarize recent QOL studies for readers who cannot access the Chinese-language literature. This select review summarizes a few of the relevant studies on QOL and mental health in Chinese culture that were published between January 2008 and June 2009.
Relevant publications in both English and Chinese were identified by searching the Medline (2008-2009), EMBASE (2008-2009) and China National Knowledge Infrastructure (2008-2009) databases using the keywords 'Chinese', 'quality of life', 'well being', 'mental health', 'psychiatric disorders' and 'mental health problems'.
Definition of quality of life
In healthcare research, QOL is viewed as a broad, multidimensional term involving disease-related aspects and multiaxial functioning . The various aspects of QOL being considered should therefore be specified based on the purpose of the study. However, all but one [7••] of those reviewed here failed to elaborate on the QOL concept they had applied.
Assessment of quality of life
There is no optimal instrument for measuring QOL; suitable instruments need to be chosen based on the purpose of the given study . The instruments used to assess QOL can be classified into generic and disease-specific measures . Generic instruments are designed to measure the 'general' QOL of the general and patient populations. Examples include the MOS 36-Item Short Form Survey Instrument (SF-36)  and both the World Health Organization Quality of Life Instrument (WHOQOL scale)  and its brief version (WHOQOL-BREF) . The advantage of generic instruments is that they allow comparisons across a wide range of conditions. However, they are insufficiently sensitive to identify subtle changes in QOL. Disease-specific instruments are more sensitive, but they are restricted to measuring the QOL dimensions of the particular disease they were developed for. An example of a disease-targeted instrument is the Dementia-Quality of Life instrument (DQOL) . Generic and disease-specific QOL measures are complementary and should be used together .
In the publications under review, no study used both types of QOL measures concurrently, and a disease-specific QOL measure was used in only two of the studies. In a cross-sectional investigation conducted in Taiwan, Chiu et al. [14•] evaluated QOL in 71 patients with dementia, 27 matched controls and 51 family caregivers using the Chinese version of the DQOL, and found that the scale exhibited moderate to good reliability and validity. In a Singaporean study, Lin Kiat Yap et al.  validated the Chinese version of the Quality of Life-Alzheimer's Disease (QOL-AD) scale in 67 patients with Alzheimer's disease and 67 healthy caregivers. They found this scale to be reliable and valid for QOL assessment in dementia.
Another methodological problem is that complicated QOL measures with several items have often been used in acute psychiatric patients. For example, Guo et al.  compared the effects of different types of antipsychotics on QOL in acute patients with schizophrenia using the 100-item WHOQOL. Similarly, Shang et al.  explored the effects of atypical antipsychotics on improving QOL, as measured by the 100-item WHOQOL in acute patients with schizophrenia. Furthermore, in the two aforementioned studies, the patients' unstable mental states may also have biased the QOL ratings. Because of the nature of psychiatric disorders, the validity and reliability of QOL measures in psychiatry have been questioned . However, subsequent studies have demonstrated that the self-rated QOL of patients with mild to moderate psychiatric symptoms is valid and reliable [19,20], and that it is only severe psychopathology that distorts QOL assessment .
Several studies have found self-rated QOL scales to be more valid than observer-rated scales [22,23]. Gill and Feinstein  concluded that QOL can be measured appropriately only by patients themselves. Self-rated QOL measures were administered in all of the studies reviewed here.
Socio-demographic and clinical correlates of quality of life in the studies reviewed
A clear understanding of the relationship between socio-demographic and clinical variables and QOL could facilitate the design of more optimal clinical interventions and cost-effective strategies. Several of the studies carried out in the past year explored the influence of these variables on the QOL of Chinese patients with psychiatric disorders.
Only one of these recent studies investigated the socio-demographic and clinical correlates of QOL in Chinese patients with schizophrenia. Xiang et al. [24•] randomly selected 264 clinically stable patients with schizophrenia in Hong Kong and recruited 258 matched counterparts in Beijing. QOL was measured with the WHOQOL-BREF. Multivariate analysis revealed that depressive and positive symptoms, anxiety, the use of benzodiazepines, extrapyramidal side effects and a history of suicide attempts predicted one or more domains of QOL. No socio-demographic characteristics were significantly correlated with any of the QOL domains, a finding that is in line with Western studies [25,26]. Severe positive symptoms were found to predict the poor overall and physical domains of QOL. This finding contrasts with the widely held view that QOL is more related to negative symptoms and only weakly related to, or independent of, positive symptoms [27,28]. The authors explained the discrepancy between the literature and their findings by socio-cultural factors, that is, the influence of traditional Confucian ideas that champion modesty or 'moderation' (zhong yong zhi dao) and oppose polarity or extremes. The major limitation of the study is that it focused only on clinically stable patients with schizophrenia. Furthermore, it was cross-sectional in design, and thus the causal relationships between the demographic and clinical variables and QOL could not be explored.
Depression can cause immense suffering and be a massive economic burden to patients and their families , thereby negatively affecting QOL. There are only two recent studies on the QOL of depressed Chinese elderly subjects. In a cross-sectional study, Chan et al. [30•] selected a convenience sample of 80 depressed elderly residents in Hong Kong and 71 in Shanghai and evaluated their QOL using the WHOQOL-BREF. Severity of depression, the number of medical conditions, satisfaction with social support and functional ability were all correlates of QOL. The same researchers [31••] followed up 31 depressed elderly patients for 12 months and assessed their QOL and psychiatric status using standardized rating instruments. Severity of depression was a predictor of changes in QOL, and the level of daily functioning was a predictor of baseline QOL and changes at the 12-month follow-up. Nonrandom sampling and the small sample size constituted the major deficiencies of both of these studies.
In a longitudinal study, Wang et al.  evaluated QOL in a sample of outpatients with generalized anxiety disorder at baseline and at a 4-month follow-up using the SF-36. The patients' QOL was significantly lower than the norm for the general population at baseline, but it improved dramatically after treatment, particularly in the male patients. Similarly, patients with social anxiety disorder and panic disorder both had a poorer QOL than the general population . Again, the socio-demographic and clinical correlates of QOL were not determined in these two studies.
Alcohol dependence is a major public health problem in China, where several epidemiological surveys of its prevalence have been carried out [34-36]. The rates of such dependence have been found to range from 0.13 (Shandong Province) to 6.56% (Panzhihua City, Sichuan Province). Only one recent study has focused on QOL in alcohol dependence. Tang et al. [37••] measured QOL using the 100-item WHOQOL scale in 45 patients. These patients' QOL was significantly poorer than that of the general population. The frequency and volume of their drinking and the severity of their depressive symptoms were significantly correlated with poorer QOL. The main limitations of this study were its small sample size and cross-sectional design.
Other mental health problems
Insomnia and suicide attempts are common problems among psychiatric patients [38-40]. The impact of both on QOL has been investigated in Chinese patients with schizophrenia. Xiang et al. [7••], for example, found that the frequency of at least one type of insomnia in 505 patients with schizophrenia was 36.0% over the previous 12 months; the rates of difficulty initiating sleep, difficulty maintaining sleep and early morning awakening were 21.2, 23.6 and 11.9%, respectively. Poor sleepers had significantly poorer QOL in the physical, psychological, social and environmental domains relative to patients without insomnia. After controlling for the potential confounding effects of socio-demographic and clinical factors, the association between insomnia and the physical QOL domain remained significant.
The same team reported the lifetime prevalence of suicide attempts to be 26.7% in this sample. Patients with a history of suicide attempts scored lower in all QOL domains. Multivariate analysis found poor physical QOL to be a significant contributor to lifetime suicide attempts .
Cross-cultural differences and quality of life
Two studies explored the potential role played by socio-cultural factors in the QOL of patients with psychiatric disorders by comparing Hong Kong and Beijing. Hong Kong had been a British colony for nearly 150 years before its return to China in 1997 and it is thus quite different from other parts of China in terms of the political, economic, and socio-cultural environment and healthcare. Using the WHOQOL-BREF to compare 264 clinically stable patients with schizophrenia in Hong Kong with 258 of their counterparts in Beijing, who were matched according to a host of socio-demographic and clinical variables, Xiang et al. [24•] found that the Beijing sample scored significantly higher in the psychological, social and environmental domains of QOL. After controlling for the confounding effect of psychopathology, however, the differences between the two samples disappeared in all of these domains. The authors concluded that, despite the considerable differences between the two sites, QOL did not differ between Hong Kong and Beijing. Earlier Western studies  have also suggested that patients' QOL is independent of their living standard, as long as it reaches a certain minimum level.
Chan et al. [30•] compared the QOL of depressed elderly residents of Hong Kong and Shanghai. The Shanghai sample had a significantly better QOL in terms of the psychological, social and environmental domains than the Hong Kong sample. The older age, lower level of education and higher level of depression among the Hong Kong patients may have contributed to their poorer QOL. No multivariate analysis was performed, and thus further research into the influence of socio-cultural factors on QOL is warranted.
Pharmacotherapy, psychosocial interventions and quality of life
In recent years, the impact of psychotropic medications on QOL has been intensively explored [43,44]. However, only a few such studies have been reported from China. For example, in an 8-week, open-label randomized trial, Zhang [45•] studied the effects of citalopram and amitriptyline on QOL in 86 depressed elderly patients assessed by the Generic Quality of Life Inventory (GQOLI). This generic 64-item Chinese QOL instrument found citalopram to result in a better QOL than amitriptyline. Guo et al.  reported that patients with schizophrenia treated with quetiapine scored higher on a QOL measure than those on chlorpromazine. These two studies demonstrate the favorable short-term effects of novel psychotropic medications on QOL. Further studies with a more sophisticated design, a longer follow-up period and a larger sample size are needed.
Psychiatric rehabilitation has developed rapidly over the past few years in China [46,47]. Liu et al.  examined the impact of psychotherapy on QOL in a prospective study of 80 patients with schizophrenia using the GQOLI. The physical, psychological and social domains of QOL had significantly improved at the end of the 12-month follow-up. In a randomized controlled study comparing social skills training with routine rehabilitation services for chronic patients with schizophrenia, Chen et al.  observed significant improvement in the physical, psychological and social domains of QOL in the former group, as measured by the GQOLI.
Limitations of the recent Chinese literature on quality of life
Most of the studies reviewed in this study share a number of methodological shortcomings. Most of them fail to adequately address the conceptual issues of QOL, including its definition. In addition, most are cross-sectional in design, meaning the causality between QOL and the other variables could not be examined. The QOL measures used in these studies were adapted from Western sources. Although their validity was tested, they may not have been sufficiently sensitive to eliminate cultural bias. Culture-sensitive QOL measures should be developed in China for use in future studies. Some of the studies reviewed also failed to adequately describe the background characteristics of the participants, as well as the outcome measures, assessment and statistical analysis, thus precluding any replication of their findings.
Quality of life is a complex, multifaceted concept, and no consensus has yet been reached regarding its components and assessment . In recent years, interest in evaluating the correlates of QOL and using it as an outcome measure in psychiatry has been growing in the Chinese literature. The prominent, but still preliminary, findings of the studies reviewed here can be summarized as follows. Cultural factors play an important role in the QOL of Chinese psychiatric patients. Chinese patients with major psychiatric disorders have a poorer QOL than the general population. No socio-demographic characteristics, but a few psychiatric symptoms, are significantly correlated with QOL in Chinese patients with schizophrenia. Novel antipsychotics and antidepressants have more favorable short-term effects on QOL than do conventional drugs. Psychosocial interventions as adjuvant treatment modalities could effectively improve the QOL of patients with schizophrenia. Insomnia and suicide attempts are both associated with poorer QOL in patients with schizophrenia.
The study was supported by grants from the Direct Grant for Research from the Chinese University of Hong Kong (Project No. 2041454), the National Natural Science Foundation of China (No. 30800367) and the Beijing Nova Program of the Beijing Municipal Science and Technology Commission (No. 2008B59).
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 76-77).
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