|Year : 2016 | Volume
| Issue : 3 | Page : 193-199
The relationship between stressful life events and quality of life of adolescent patients
Sherien S.M. Mohammed1, NM Abdel Kader2
1 Mahalet Damana Secondary Nursing School, Ministry of Health, Mansoura, Dakahlia, Egypt
2 Department of Psychiatric Mental Health Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
|Date of Submission||27-Aug-2016|
|Date of Acceptance||11-Aug-2016|
|Date of Web Publication||15-Feb-2017|
Sherien S.M. Mohammed
Mahalet Damana Secondary Nursing School, Ministry of Health, Mansoura, Dakahlia, 35834
Source of Support: None, Conflict of Interest: None
The risk for psychosis increases with the number of life events experienced and is associated with impairments in quality of life (QoL) and functioning.
The aim of the present study was to assess the relationship between stressful life events and QoL of adolescent psychiatric patients.
Patients and methods
A descriptive, correlational design was used in this study. A sample of convenience of 100 adolescent psychiatric patients was recruited from the adolescents’ outpatient clinics of El-Abbassia Mental Health Hospital. Three tools were used in the present study: a sociodemographic and medical data interview, life events inventory, and QoL profile.
The results showed that more than half of the sample were girls, students, and were not working. More than two-thirds of the sample were diagnosed with conduct, depressive, and bipolar disorders, with a family medical history, and half of the sample had had sexual experience. Findings revealed highly statistically significant negative correlation between life events inventory and the QoL profile.
Most of the adolescent psychiatric patients experienced a multiple stressful life events that negatively affected their QoL. Therefore, it is recommended that psychosocial treatment should be selected and modified for patients to deal with stressful life events and building adolescents’ self-esteem. In addition to periodic check-ups, further studies for generalization should be carried out and a suitable psychotherapeutic model must be adopted.
Keywords: Adolescents psychiatric patients, life events, quality of life
|How to cite this article:|
Mohammed SS, Abdel Kader N M. The relationship between stressful life events and quality of life of adolescent patients. Egypt Nurs J 2016;13:193-9
|How to cite this URL:|
Mohammed SS, Abdel Kader N M. The relationship between stressful life events and quality of life of adolescent patients. Egypt Nurs J [serial online] 2016 [cited 2018 Dec 14];13:193-9. Available from: http://www.enj.eg.net/text.asp?2016/13/3/193/200181
| Introduction|| |
Adolescence is a specific period in the development of humans. It is a critical period of development manifested by significant changes in brain development, endocrinology, emotions, cognition, behavior, and interpersonal relations. In addition, from a mental health point of view, adolescence is important because most of the major mental illnesses begin during adolescence (Dwight and Martin, 2005). Furthermore, researches by Swanh et al. (2012) and Chau et al. (2013) have shown that many adolescents are vulnerable to a wide range of health-related challenges: poor living conditions, poor social relations, unhealthy behaviors, physical ill health, poor psychological health, suicidal attempts, and sustained violence. In their study, Dwight and Martin (2005) added that after occurring in adolescence, many chronic mental illnesses continue into adulthood, leading to ongoing significant mental disorders during the adult years. Adolescence is the developmental period between childhood and adulthood, generally the period ranging from teen years through to the 20s.
Furthermore, Ferguson (2013) and Cobb (2007) listed some stressors for today’s adolescents: school needs; negative thoughts and feelings about themselves; changes in their bodies; exploration of their own identity; problems with age group; unsafe living environment; separation/divorce of parents; chronic disease within the family; death of an intimate one; moving or changing schools; involvement in too many activities; and family monetary problems just to name a few. In addition, Shevlin et al. (2008) stated that, more than the effect of a single current life event, increased exposure to traumatic life events may increase the risk for mental disorder. A study by Adamson (2008) showed that the possibility of mental disorder increases with the number of life events experienced.
There is an increasing evidence that anxiety and affective disorders are correlated with substantial deteriorations in life quality and functioning (Rapaport et al., 2005).
In this sense, Lahana et al. (2010) noted that, subjective quality of life (QoL) can be defined as a multidimensional construct that includes one’s physical and psychological health, autonomy, social relations and relations with his/her environment, and social context. Furthermore, QoL components are affected by factors such as sex, age, socioeconomic status, and culture. On the same lines, Marwaha et al. (2008) found that age and education both negatively influence subjective QoL in outpatients with schizophrenia. Moreover, as stated by Rapaport et al. (2005), several researches report greater deterioration in QoL for major depressive disorders, whereas others report similar dissatisfaction in QoL for anxiety disorders and major depressive disorder.
Significance of the study
Adolescent mental health is partially studied by international development organizations and interventions at country level appear to be disintegrated. Interventions for the enhancement of psychosocial health and provision of mental healthcare to adolescents often have narrow focus and project-specific objectives, whereas opportunities to mainstream adolescent mental health in education, and health and child protection programs are still largely not studied (World Health Organization (WHO), 2013). Many studies have been conducted on subjective QoL in adult psychiatry, but until now little attention has been paid to subjective QoL in children and adolescents with psychiatric illness (Solanki et al., 2008). According to UNICEF (2013), Egyptian statistics for the adolescent population aged 10–19 by the year 2010 are ∼15 926 and adolescents represents 20% of the total population.
According to Vila et al. (2003), adolescents with mental disorders have a significantly poorer QoL than do adolescents with no disorders. In a study by Goppoldova et al. (2008), factors such as psychosocial factors as life events, comorbidities and psychopathology, personality-related situations, change of environment and care setting, medication, cognitive and emotional functioning, social adjustment and support network, age, education, and work status were shown to affect subjective QoL. Nevertheless, children and teens may be at particular risk for the impact of psychosocial stressors as stressful life events because of the psychosocial development that occurs during the teenage years (Andersen et al., 2008).
Psychiatric nurses are in a distinct position to assess adolescent psychiatric patients and their psychosocial care. However, there remains an obstacle to examine some of these facts of care. Nurses need to be more aware of patient’s stressful life events and their relation to QoL. Therefore, this study could provide nurses and other professionals with an in-depth understanding related to this category of population, which could be reflected positively on the QoL of adolescents. Moreover, it is hoped that findings of this study might help in improving QoL of this age group and establish evidence-based data that can promote nursing practice and research.
| Patients and methods|| |
The aim of the present study was to assess the relationship between life events and QoL of adolescent psychiatric patients at outpatient clinics.
Q1: What are the life events of adolescent psychiatric patients?
Q2: What is the relationship between life events and psychiatric adolescents’ QoL?
A descriptive, correlational design was used in this study; such a design fits the nature of the problem under investigation. This design identifies variables and relationships among them when information exists. The purpose of descriptive studies is to observe, describe, and document aspects of a situation as it naturally occurs (Marilynn and Janet, 2006).
The study was conducted at adolescents’ outpatient clinics at El-Abbassia Mental Health Hospital.
A convenient sample of 100 adolescent psychiatric patients was selected for this study. The inclusion criteria included patient age ranging from 11 to 18 years and patients diagnosed as mentally ill with different psychiatric diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. The exclusion criteria included seriously mentally disturbed and mentally retarded adolescents.
Tools for data collection
Demographic and medical history structured interview
It was designed by the investigator and it included code, age, sex, occupation, residency, diagnosis, family history, and patient’s personal history.
Life events inventory (LEI)
The LEI was developed by the investigator on the basis of the instruments developed by Holmes and Rahe (1967), Spurgeon et al. (2001), and Renner and Mackin (1998). This developed tool was used to measure life events that influence adolescents and affect their mental health. This developed tool included five subscales: family, educational, work, social, and personal events. The content validity and reliability were tested. The result of Cronbach’s α test (reliability testing) was r=0.789, which suggested high homogeneity of all items of the questionnaire. It comprised 34 items. Participants were asked to mark yes or no. The score was 1 for each answer with ‘no’ and 0 for each answer with ‘yes’, except for reverse questions. The higher the score, the lower the stressful life events. The total score was 34.
The QoL profile was developed by the investigator after reviewing the three instruments developed by Beck (1993), Frisch (1994), and Giacomuzzi (2004), respectively, and reviewing other related literatures. This developed tool was used to measure QoL of psychiatric adolescent patients. It included 12 subscales with 66 items: education and labor, leisure time, religion, finance, housing, relationship with relatives, relationship with friends, love, security and law, health, hopefulness, and self-esteem. The content validity and reliability were tested. The result of Cronbach’s α test (reliability testing) was r=0.826, which suggested high homogeneity of all items of the questionnaire.
Participants were asked different types of questions. For the first type of questions, response scores varied as follows: 0 for ‘not important’, 1 for ‘important’, and 2 for ‘very important’. For the second type of questions, the participants were asked to mark on 0 for ‘completely unsatisfied’, 1 for ‘undetected’, and 2 for ‘completely satisfied’. For the third type of questions, participants were asked to mark 1 for ‘yes’ and 0 for ‘no’. For the fourth type, participants were asked to complete and mark 1 for positive answer and 0 for negative one. For the fifth type, participants were asked to mark 0 for ‘no’, 1 for ‘I don’t know’, and 2 for ‘yes’. For the sixth type, participants were asked to choose from multiple-choice answers: the score ranged from 0 to 5. For the seventh type of questions, participants were asked to mark 0 for ‘days’, 1 for ‘months’, and 2 for ‘years’. The higher the score, the higher the QoL. The total score was 136.
Official permissions were obtained from the director of El-Abbassia Mental Health Hospital and the director of adolescent outpatient clinics before conducting this study. After the permissions were granted to proceed with the proposed study, the researcher assured voluntary participation and confidentiality of information to each participant. The purpose and the nature of the study were explained to each adolescent psychiatric patient and his or her guardian or relative and a written informed consent was obtained from them. Data were collected using the above-mentioned tools. Data collection phase lasted for 4 months, from March 2010 until June 2010. Each adolescent psychiatric patient was interviewed individually. For each patient, the interview took around 1 h.
Oral and written informed consent was obtained from the patient’s relative or guardian. The objectives and steps of the study were explained in details to the patient and their relatives or guardians. Participants were assured of no harm or risk during the study.
A pilot study was conducted on 10 cases from the sample to investigate the feasibility as well as clarity of data collection tools. All patients recruited in the pilot study met the inclusion criteria of the study and were included in the actual study as there were no modifications.
Data were double entered on a computer using office program 2007. It was analyzed using SPSS (version 17; SPSS Inc.). Cronbach’s α test was used to explore the internal consistency of all tools. Numerical data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. For quantitative data, comparison between two variables was performed using the t-test, and comparison between more than two variables was performed using the one-way test and the χ2 test for qualitative variables. Relations between different numerical variables were tested using Pearson’s correlation.
In addition, correlation coefficient was used to describe the association between LEI and QoL. Correlation coefficient (r) of 0.5 was considered fair correlation, r=0.6–0.7 was considered good correlation, and r=0.8 or higher was considered as very good correlation. P-value less than or equal to 0.05 was considered significant, and less than 0.001 was considered highly significant.
| Results|| |
The studied sample consisted of 100 adolescent psychiatric patients, with a mean age of 15.93±1.84 years. Those whose ages ranged from 11 to 13 years, from 14 to 16 years, and from 17 to 18 years represented 12, 46, and 42% of the sample, respectively. Girls represented 58% of the sample, whereas boys represented 42%. Moreover, 37% of the sample were not working and 83% resided in urban areas ([Table 1]).
|Table 1: Frequency distribution of the studied sample according to sociodemographic characteristics|
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[Table 2] shows that 29, 27, and 13% of the studied sample were diagnosed with conduct disorders, depressive disorders, and bipolar disorder, respectively. On the other hand, 69% of the sample had psychiatric patients/members in their family. Besides, 60% of the studied sample had had sexual experiences. As regards diagnosis, family history, and patient’s personal history, there were no significant differences among the subscale variables.
|Table 2: Frequency distribution of the studied sample according to clinical characteristics|
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Regarding study and labor in family environment as subscales of LEI, the results of the present study indicated that girls were affected more than males, accounting for around 30 and 40% in most aspects in this study, including events such as asked to be absent or quit the study, a sudden drop in study level, cheating in exams, having problems with colleagues or employers at school or faculty, change in work circumstances, and change in financial status. Almost similar results were obtained as regards social relations as a subscale, accounting for around 30–50% including events of making new friendship, change in social activities, change in religious or political thoughts, participation in a quarrel, and change in a health status of a friend.
Regarding education and labor, leisure and entertainment, financial status, housing, family, friends and acquaintances, love, and security, and law as subscales of QoL profile, boys and girls had unsatisfactory QoL in similar percentages for most of the aspects, but percentages for girls were slightly higher.
Our results showed statistically significant differences between sex and total LEI (t=2.000 at P=0.048) and total QoL profile (t=2.832 at P=0.006), respectively. Furthermore, mean scores of total QoL were high for both sexes (63.05±17.22 and 53.84±15.13).
[Table 3] shows statistically significant differences between the presence of psychiatric patients in the patient’s family regarding total LEI (t=−3.383 at P=0.001) and total QoL profile (t=−2.246 at P=0.027). It also shows statistically significant differences between having sexual experience regarding total LEI (t=−3.063 at P=0.003), and total QoL profile (t=−2.136 at P=0.035). Furthermore, the results indicated that total LEI had highly statistically, significant negative correlations with total QoL profile score (r=−0.410 at P=0.000).
|Table 3: Comparison between psychiatric patients/members in the family who have received psychotherapy in the patient’s family and having sexual experience regarding studied variables (n=100)|
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| Discussion|| |
Sociodemographic and clinical characteristics of the studied sample
Adolescents are the most vulnerable age group to psychological disorders, and their risk for psychiatric illness is higher than that of any other easily recognized age group in society due to severe emotions and mood swings. Results of the present study revealed that depressive and conduct disorders affected around quarter of the sample; the most affected age groups in this study were middle and late adolescence periods. A study conducted on boys of a secondary school (age range: 15–18 years) in Abha city supported these results and reported that more than one-third (38.2%) of the students had depression disorders, whereas 48.9% had anxiety and 35.5% had stress disorders (Spady et al., 2001).
Furthermore, in the present study, more than half of the sample were females. In addition, it was noticed that, depressive and conduct disorders among female patients were more than those among male patients. Because of physical appearance, sexual maturation, and menstrual period of females, they are at a higher risk for mental illness. In agreement with the results of the present study, a study by Al-Sughayr and Ferwana (2012) in National Guard Housing, Riyadh, Saudi Arabia, found that the percentage of mental diseases among female adolescents was 51%.
The majority of the patients in the present study were from urban areas. Urban living can be a stressor if one does not have a private space of their own, experiences insufficient security, or lives under changeable economic conditions. Living in an urban environment is a risk factor for psychiatric disorders such as major depression or schizophrenia. This is true even though the transportation and communication system, socioeconomic status, nutrition, and healthcare services are clearly better in urban than in rural areas. Higher stress exposure and higher stress liability play an essential role. Social stressors may be the most important factors for the increased risk for mental illness in urban areas. This goes in line with a study by Al-Sughayr and Ferwana (2012), conducted in National Guard Housing, Riyadh, Saudi Arabia, as it demonstrated urbanization to be correlated with increased psychiatric illness rates among Saudi teenagers.
In addition, the present study showed that around two-thirds of the patients had a family history of psychiatric illnesses. Having a family member with psychiatric illness puts pressure on the rest of the family and affects their adjustment, their relations, and coping behaviors. Adolescents cannot socialize as they have to care for their mentally ill parent rather than spending time with friends or playing sports, and may suffer negative feelings, including anger, fear, and grief. This was supported by the findings of previous studies such as that by Marmorstein and Iacono (2004), who demonstrated that, adolescents with a family history of depressive disorders had experienced more severe and chronic types of depression, more recurrences, psychiatric comorbidity, defective psychosocial functioning, and suicidal attempts.
The current study indicated that around two-thirds of the sample had had a sexual experience. During adolescence, sexual maturation is completed, which results in sexual exploration, sexual interest, and sexual experience. This was supported by findings of a study conducted by Finer and Philbin (2013). They showed that, only 16% of teenagers experienced sex by age 15, comparable with one-third of those by age 16, approximately half (48%) of those by age 17, 61% 18-year-olds, and 71% 19-year-olds.
Life events inventory of the studied sample
The current study showed that the majority of the sample had passed through stressful life events. Life events, whether positive or negative, are considered as stressors. Teenagers deal with the demands of going through puberty, meeting changing expectations, and coping with new emotions. In line with this, Costello et al. (2002) and Kilpatrick et al. (2003), in their respective studies, stated that, according to the data from the most recently conducted national survey of teenagers and other studies, one in four children and adolescents in the USA pass through at least one traumatic event before the age of 16. Moreover, more than 13% of the 17-year-olds (one in eight) are affected with posttraumatic stress disorder at some point in their lives.
The current study reported statistically significant difference between sex and total LEI. Female adolescents pass through life events more than males because of their social roles, responsibility, and search for a better future. In agreement with these findings, a study by Charbonneau et al. (2009) revealed that there were variations between adolescent females and males as regards the amount of stressful life events.
The finding of the present study revealed statistically significant difference between the presence and absence of family history of psychiatric illness in the patient’s family regarding total LEI. Family history of mental illness is a painful and stressful life event. In agreement with the previous results, a study by Zhou et al. (2006) revealed that psychopathology of parents, such as parental alcoholism and antisociality, causes disturbance in the family environment, which increases exposure to negative life events.
The findings of the present study showed statistically significant difference between those who having sexual experience and those who do not have sexual experience in relation to total life event inventory (LEI). Physical abuse or sexual abuse are devastating life events especially if they happen in childhood or adolescence. Today, much is known about the potential sequence of traumatic experiences in childhood and teenage years and there is clear evidence that failure to solve moderate to severe traumatic reactions result in both short-term and long-term adverse sequences. Besides, Harkness et al. (2006) had found that adolescents who had a history of child abuse and neglect were more susceptible to life events.
Quality of life profile of the studied sample
The results of the present study revealed that males and females had unsatisfactory QoL in most aspects of the profile. QoL is measured through life satisfaction, happiness, and defined behaviors. Therefore, the more the satisfaction, better the QoL. In line with this, a study by Tollefson and Andersen (1999) reported that patients with mental illnesses were less satisfied with all aspects of their QoL than were members of the general population. The present findings revealed statistically significant difference between sex and total QoL profile. Females have lower QoL than do males due to their own physical, psychological, and social developmental differences. In agreement with this interpretation, a study by Jörngården et al. (2006) on adolescents’ subjective QoL revealed that boys reported improved health-related QoL than did girls.
The results of the present study detected statistically significant difference between presence of psychiatric patients in the patient’s family regarding total QoL profile. Family history of mental disorders, personal physical or sexual abuse negatively affect the adolescents’ QoL, especially social and behavioral relationships. In agreement with this, a study by Wilkins et al. (2004) revealed that maternal depressive disorders reported at 6 months were significant negative indicators of teenage psychosocial QoL.
Besides, the present findings indicated statistically significant difference between those who having sexual experience and those who do not have sexual experience in relation to total QoL profile. In agreement with this, a research by Al-Fayez et al. (2012) reported that adolescent childhood sexual abuse was significantly correlated with parental divorce, decreased QoL and self-esteem, high scores on anxiety/depression, and difficulty with education and social relationships. The findings supported the idea that, despite the conservative culture, adolescent sexual abuse is experienced by a large number of adolescents in Arab countries.
The results of the present study revealed a negative correlation between total LEI subscales and total QoL profile. In general, adolescence is a developmental period that places distinct demands on psychosocial and occupational well-being, as well as adaptive coping skills. Adolescents have a high risk for both stressful life events and increased negative judgment of stressful experiences. Environmental factors could also play a part, such as stressful life events may affect self-esteem and QoL satisfaction during adolescence.
In their study, Bastiaansen et al. (2005) reported that the unsatisfactory global report on QoL correlated with the lack of social support, poor family function, and stressful life events. In addition, results of a study by Chappel (2011) indicated that suffering from major life events and interparental conflict were distinct predictors of life satisfaction, and, also, that all the family stress factors combined represented 37% of the variance in life satisfaction. In the same context, studies by Afifi et al. (2007) and Sunday et al. (2008) showed that the consequences of adolescents’ sexual abuse involved depression, decreased subjective QoL, decreased self-esteem, poor parental relation, and poor perception of parental harmony.
Most of the adolescent psychiatric patients experienced a multiple stressful life events in their life mainly, which negatively affected their QoL (r=−0.410 at P=0.000). 
On the basis of the findings of the present study, the following are recommended: (a) psychiatric education programs should be conducted for parents/carers on how to deal with adolescents; (b) periodical assessments should be carried out for adolescent psychiatric patients to assess the impact of life events on their QoL; (c) further studies using a large probability sample must be carried out for generalizing the results; and (d) patients should be provided with a psychotherapeutic program including a suitable psychotherapy model.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]