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The Effects of Restricted Physical Activity on Health-Related Quality of Life in Adult Patients with Depression

Objectives The objective was to identify restricted physical activity in patients with depression, and to determine the effects of that restricted activity, on their health-related quality of life (HRQOL). Methods Data was analysed from Year 1 of the 7th Korea National Health and Nutrition Examination Survey (KNHANES VII-1). From a total sample of 8,150 subjects, 277 adults aged ≥19 years who were diagnosed with depression were selected. The results were derived using restricted activity and HRQOL data measured from the subjects. Results Most of the participants were females ≥ 50 years old. HRQOL scores were high in the “self-care” dimension and low in the “pain/discomfort” and “anxiety/depression” dimensions. Their restricted activity due to illness in the past year, led to increases in participants being bedridden or absent from work. Many participants reported being bedridden for more than 3 months. A higher number of absences owing to illness in the past year, and longer durations of being bedridden, had a negative impact on HRQOL. Age, marital status, educational level, income level, and occupation were the sociodemographic variables that had an impact on HRQOL. Conclusion Patients with depression experiencing stress in their daily lives should take measures to avoid illness and pain that may lead to them becoming bedridden, and employ lifestyle habits with support from families and community health promotion centres, where mental health counselling can be accessed.


Introduction
Depression is a common mental health disorder, with a worldwide lifetime prevalence in adults of 5%-12% in males, and 10%-25% in females [1]. Depression contributes to the development of chronic diseases, such as heart disease and diabetes causing serious functional impairment for the individuals concerned, and increases utilisation of health care services and public health burden [2].
Patients with depression often lack confidence, have a noticeable pattern of wanting to be alone, and may lose the will to live. Moreover, because of clear physical symptoms, such as weight loss, loss of appetite, digestive impairment, headaches, and sleep impairment, patients have a difficult time concentrating on any tasks at hand [1]. In addition, people with depression have a negative image of themselves, and have negative thoughts about their future [3]. An increase in the severity of depression can lead to suicide from repeated thoughts about death [4]. Furthermore, depressive episodes can cause problems in maintaining social relations, and hinder effective job performance, ultimately leading to a decline in the quality of life (QOL) [5].
Various activities, including social activities, are known to have a positive impact on mental health. By engaging in activities of different kinds, humans find their identity, maintain social relations, and feel a sense of belonging and self-efficacy [6]. One of the theories about behaviours that cause a recurrence of depression is "learned helplessness." According to Seligman [7], depression is caused by a sense of helplessness in controlling the outcome of a situation.
Depression causes limitations in activities, and the inability to perform activities causes the person to perceive him/herself as helpless, which, in turn, causes the person to fall further into depression. Ultimately, restricted activity creates a vicious cycle that prevents the person from recovering from depression, which consequently leads to a decline in QOL.
The World Health Organization defines QOL as "an individual's perception of their position in life in the context of their culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns." It is a broad concept that is affected in various ways by an individual's physical health, mental state, level of independent living, social relations, and relationship with the environment [8]. QOL is directly linked to one's happiness and achievement of life goals, and it is very important in identifying success in the life of an individual. In other words, it can be viewed as having the utmost importance in the general well-being of an individual [9]. In particular, health-related QOL (HRQOL) is used as an indicator of health and well-being which directly impacts on the physical, psychological, social, and mental health of an individual [10]. years who had been diagnosed with depression were selected.

HRQOL
The instrument used to measure HRQOL was the EuroQol-5D (EQ-5D) Index, which is a multidimensional preference-based HRQOL measure. It is a useful instrument with objectivity and reliability for measuring HRQOL that can be used in various situations. It shows the tested results as a simple health profile, or a numerical utility value [11,12]. The EQ-5D Index consists of items that ask about current health status in 5 dimensions; mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each of the dimensions has 3 levels: 1 point for "no problem," 2 points for "some problems," and 3 points for "serious problems." The present study calculated the scores using the estimated weight for Koreans presented by the Korea Center for Disease Control and Prevention. The calculated scores represented the overall HRQOL whereby lower scores indicated a higher HRQOL [13].

Activity limitation
The present study used survey data on whether current health problems caused any limitations in daily and social activities.
The items surveyed included being bedridden owing to illness in the past month, the number of bedridden days owing to illness in the past month, being bedridden owing to illness in the past year, the number of bedridden days owing to illness in the past year, being absent from work owing to illness in the past month, the number of absences owing to illness in the past month, being absent from work owing to illness in the past year, and the number of absences owing to illness in the past year.

Statistical analysis
Collected data were analysed using SPSS 21.0 (IBM Corp., Armonk, NY, USA). The sociodemographic characteristics and restricted activity of the patients with depression were analysed by descriptive statistics. The effects of general characteristics and restricted activity on HRQOL were analysed using multiple regression analysis. Statistical significance was set at p < 0.05.

Participant characteristics
There were more females (78.0%) than males (22.0%), while the highest number of participants according to age group were ≥ 70 years (24.2%), 50-59 years (22.0%), and 60-69 years (20.6%). For educational level, "primary school graduate or lower" (34.3%) was the most common response, followed in order by "high school graduate" (27.8%) and "college graduate or higher" (22.0%). For occupation, "unemployed, including homemaker" (68.2%), was the most common response, followed in order by "manual labourer" (8.3%) and "service/ sales worker" (7.9%). With respect to income level, the incidence of lower income participants was 33.2% and lowermiddle was 24.9%, showing that those with an income level below middle, accounted for more than half of the sample.
For marital status, living with a spouse (59.9%) was the most common response, followed in order by widowed (17.0%), divorced (11.2%), and single (11.2%). For subjective health status, those who perceived their health to be poor or very poor (54.9%) accounted for more than half of the sample (Table 1) income level (β = 0.288, p < 0.001), and occupation (β = -0.218, p < 0.001) were found to have an impact on HRQOL (Table 4).

Discussion
The present study used KNHANES VII-1 (2016) data to examine restricted activity in adult patients with depression, and analysed the effects of such restricted activity on HRQOL.
With respect to the general characteristics, there were 3 times as many females as males who were diagnosed with depression. The lifetime prevalence of depression has been reported to be higher in females, increasing in incidence after menopause [14]. In the present study, more than half of the subjects were 50 years or older, and it was determined that the incidence of adult depression was high among women, especially those aged 50 years or older. Those women whose education level were "Primary school graduate or below" were the most common, while "unemployed, including homemaker," was the most common response for occupation.
With respect to income level, more than half of the subjects gave the response of "lower" or "lower-middle" income level.
A study by Kim [15]

Status of suicidal ideation and restricted activity in patients with depression
The status of restricted activity in patients with depression was as follows. There were 63 subjects (22.7%) with experience of being bedridden owing to illness in the past month, among whom being bedridden for < 3 days (49.2%) was the most common response. There were 119 subjects (43.0%) with experience of being bedridden owing to illness in the past year, among whom being bedridden for < 7 days (42.0%) was the most common answer, while many also responded with "8-30 days" (29.4%) and "> 90 days" (15.2%). Meanwhile, only 5.4% of the subjects responded "Yes" to being absent from work owing to illness in the past month, with most indicating < 3 days of absence. There were 35 subjects (12.6%) with experience of being absent from work owing to illness in the past year and their most common response was being absent for < 7 days (65.7%).
The proportion of those who had planned suicide in the past year was 10.1%, while the proportion of those who actually attempted suicide was 5.4%. The proportion of whole study population who had received psychiatric counselling in the past year was 38.3%, which was lower than the proportion of those who had not (Table 3).

Effects of restricted activity and sociodemographic characteristics on HRQOL
The main objective was to examine the effects of restricted activity on HRQOL, while sociodemographic characteristics were additionally examined to provide further details into   The limitations of the present study include the following.
Since the only data used were from 2016, they did not reflect recent trends. In addition, since only previously assessed results were used, the study could not examine more dimensions associated with HRQOL. However, the study identified the status of restricted activity in patients with depression and how it affects HRQOL. Therefore, the present study may have significant value in establishing future national and community-based strategies for managing the health of patients with depression.

Conclusion
HRQOL scores were high in the self-care dimension and low in the pain/discomfort and anxiety/depression dimensions.
Examination of the effects of restricted activity on HRQOL showed that being bedridden owing to illness in the past year, being absent from work owing to illness in the past year, a higher number of absences owing to illness in the past year, and longer durations of being bedridden or being absent from work owing to illness, all had an impact on HRQOL. For patients with depression to continue to manage stress in their daily lives, not becoming bedridden because of illness, and preventing pain, may require constant support from family and the community to help change their lifestyle habits.
Moreover, they should not pay attention to prejudices about mental health counselling and visit counselling agencies, such as community health promotion centres, to prevent extreme situations, such as suicide owing to depression.

Conflicts of Interest
The author has no conflicts of interest to declare.