Quality of Life Research 8: 283291, 1999. 1999 Kluwer Academic Publishers. Printed in the Netherlands.

Quality of life and depression: Symmetry concepts

N. de Leval

Faculty of Psychology and Education Science, Departement de Psychologie clinique, Unite CLES, Universite Catholique de Louvain, Place du Cardinal Mercier 10, 1348 Louvain-la-Neuve, Belgium Received 2 April 1998; accepted in revised form 18 November 1998

Abstract. From the theory of Three-Time-dimensions based on the disturbed temporal horizon of the depressed individual: Past, Present, therapeutic-Future, new concepts of phenomenological-depression and the intrinsic-quality of life have been dened, in which both are considered as the perception of a discrepancy between, on one hand, the healthy Past and Present ill-being, and on the other, the intensity of demand for recovery or a therapeutic-Future. In

order to determine the symmetry of these two concepts, the Three-Time-dimensions Synoptic Scale (3TSS) was presented to 110 subjects who had been diagnosed as suering from major primary depression. The demonstration was carried out in three stages, the rst statistical, the second mathematical, and nally, a geometrical one; it showed the importance of the temporal horizon of the depressed person in diagnosis.

Key words: Extrinsic-quality of life, ill-being, intrinsic-quality of life, phenomenological-depression, synoptic scale, Three-time-dimensions

Introduction Many studies have shown that the depressed individual has a reduced quality of life (QOL). They reveal close correlations between results obtained for depression and quality-of-life scales. QOL was negatively and signicantly associated with depression [18]. Major depression can adversely aect patients' QOL [9]. Depression and mastery had the strongest total eects on QOL [1012]. Depression is a common disorder the characteristic features of which are likely to impair QOL [13]. The QOL measures accounted for 31.5% of the variance in depression inventory scores, and QOL was the single most important predictor of depression [14]. Depression scores accounted for 49% of the variances in QOL scores and predicted each of the self-care behavior scores [15]. More specic QOL measures are needed to assess the impact of depression and its treatment [13]. The QOL measures may be sensitive to important dierences among depressed patients that are not detected by the measures usually employed [16, 17]. In a study that we carried out with 110 clinically depressed subjects, 57% considered that they had a very bad quality of life, 26% a bad one and 18% an average one. In the light of these studies what can the relationship be said to be between these two concepts of depression and QOL? From our bibliographical research we have not been able to obtain a clear demonstration of a reasoned model which might bring together the terms depression, quality of life, ill-being and the suering

specic to the depressed person. The absence of agreement about QOL and the fact that it has not been conceptualized, to some extent explains the variability of the measures used [1837]. To bring some clarity to this disparate group of scales called QOL scales, we have tried to distinguish between three large categories according to their authors and the populations they targeted. We specically do not mention the name of any scale used at present as the study of their specic qualities lies outside the scope of this article. The rst category contains QOL scales drawn up by doctors from various disciplines who have analysed the QOL of well dened pathologies: principally serious or chronic somatic problems, such as asthma, diabetes, Parkinson's disease, cardio-vascular, rheumatic, oncological conditions etc. Here the questionnaires measure the level of performance or the degree of autonomy of the patients in relation to a medical model. These scales are said to be ``specic''. In the second category we nd QOL scales drawn up by psychologists, sociologists, psychiatrists and economists. This group has created relatively large batteries covering dierent areas: functional, psychological, relational, spiritual and material of various types of populations, healthy or otherwise for example according to time of life, social situation etc. The areas measured by these scales, which are called ``generic'', may be weighted dierently. Physical and psychological items belonging to the major depression syndrome may be found here. It can be deduced

284 from this a contrario that depression or the lack of it is an important variable in the QOL. The taxonomy assay carried out for this type of scale shows that the number of areas to be included in the QOL is not only variable but also that these areas are different in order to adapt to each situation of the population targeted. In the third category are included the specic QOL scales drawn up by psychiatrists or psychologists and which, just like the scales called ``depression'' or ``ill-being'' scales, analyse the various symptoms given by the DSM-IV [38], such as mood disorders, somatic disorders, emotional and cognitive disorders. This is the category dealt with in the following sections. Concerning this topic, more information is available in the papers of the ``Journal of Quality of Life Research'', Special Issue: International Use, Application and Performance of Health-related Quality of Life Instruments, Vol. 2 (6) Dec. 1993. In this article, we will demonstrate the relationship which exists between the QOL and depression, basing our reasoning on a theory and using a new type of scale: the Three-Time-dimensions Synoptic Scale (3TSS). The paradigm on which our analysis rests is the temporal-horizon approach of the Three-Timedimensions theory. Model The term QOL, which is the subject of our discussion, led us to elaborate the Three-Time-dimensions theory. The main objective of this theory is to serve as basic reference for a taxonomy of assessment instruments of ill-being, phenomenological-depression and QOL. It denes these three concepts in terms of the dimensions past, present and future time in other words, the temporal horizon [3942]. While the temporal horizon is normally continuous, it is discontinuous for the depressed person and seems to come to a halt in a gloomy, empty and unhappy ``here and now''. For such a person time drags on interminably and the past, having become distant from the present, no longer nourishes it and in fact deprives it of energy, while the future becomes so blurred that it disappears. The obliteration, not to say total absence, of a future resulting from this situation, may reveal illness, be evidence of despair, an indication too of a desire for death. However, if he is not suicidal, the depressed person's perspective of the future is contained in one wish: to be cured, to recover his past ``when he was not ill''. To escape from his depression, he must therefore recover his past, or more exactly, that part of his past ``when he was well''. He will then be able to ``get back to'' his true future and resume the normal course of his life. The ``past to be recovered'' will therefore be his therapeutic future, a necessary and unavoidable stage on the path he must take towards healing. This new concept of a ``therapeutic-future'', a central theme of the Three-Time-dimensions theory, is an original concept which is entirely dierent from the concept of ``future'' time used by cognitivists. The cognitive theory of depression also alludes to three aspects of a depressed individual's mental life the self, the perception of the world and the future. The therapeutic-future, the key concept of the temporal approach, conveys the intensity of the demand for recovery dened by the depressed person himself. It is therefore particular to depression. In this way it dierentiates depression from other types of illness where a real future is present whether it be favourable or unfavourable that is, if the ill person is not also depressed. This schematic representation of the temporal horizon of the depressed person makes it possible to attempt a new method of dening ill-being, phenomenological-depression and the QOL. In our concept: ill-being considered in the present corresponds to the symptomatology of depression as described in the DSM-IV [38]. phenomenological-depression is the perception of a gap between a healthy past and an ill-being present. The present is depressed in relation to the past and the greater the gap between the past and the present, the greater the phenomenologicaldepression and correlatively the suering. with regard to the QOL, authors such as Calman [43], Michalos [44], Dazord [45] provide an operational denition: it can be measured by the distance between actual experience and aspirations. Using the same concepts of present and future, we dene the QOL as being ``the appropriateness of future aspirations to the present'' or in another way ``the making present of the future''. Its value is consequently inverse to the distance which separates the phenomenological present from future goals. The greater the distance between them, the lower the QOL. How can the QOL of the depressed person be dened in relation to that of the non-depressed person. At this level of analysis it is necessary to distinguish two types of QOL described in our article [41]. According to the Three-Time-dimension Model, the depressed person is characterized by present ill-being and a therapeutic-future: the distance between the two will dene the intrinsic-QOL or IQOL. On the other hand, the non-depressed person is characterized by present well-being and a real future: the gap between the two denes the extrinsic-QOL or EQOL. These two QOLs intrinsic and extrinsic are part of the same continuum, where the intrinsic-QOL is situated upstream and the extrinsic downstream, the latter being strengthened or weakened by the strength or weakness of the IQOL, which is its foundation and

285 root. The non-depressed person may therefore be described as possessing an IQOL supplemented by a fairly large EQOL: the depressed person, on the other hand, as suering from a relative absence of IQOL and a fairly large absence of EQOL. Only with his recovery will he get back his IQOL and only then will it again become possible to measure his EQOL to some extent. The QOL of the depressed person therefore cannot be discussed without specifying these characteristics. The two QOL concepts may be measured by QOL scales which comply with the criteria of the ThreeTime-dimension taxonomy: unity of time within the same item and unity of time between all the items of the same scale. The intrinsic-QOL scale specic to the depressed person measures the gap between the present which describes the syndrome of the depression and the therapeutic-future. In other words, the score obtained will position the depressed person with regard to his personal progress towards what he himself considers to be his recovery. It therefore includes two time dimensions, present and therapeutic(th)-future: in its present-time section it is a synthesis of ill-being scales and in its thfuture-time section a synthesis of scales of therapeutic expectations or despair, as their aspect is positive or negative. The extrinsic-QOL scale measures the distance between the present and the real future and explores numerous and varied domains; physical, material, social, emotional, relational, intellectual, spiritual etc. It is a synthesis of wellbeing scales with regard to the psychological aspect, life-comforts scales with regard to the material aspect in the present, and scales of wishes for the future. These two types of scale, with two time dimensions the IQOL scale, which is not an ill-being scale assessing the degree of depression with one time dimension, and the EQOL scale are therefore dierent in content. Accordingly the philosophy behind the construction of EQOL scales is dierent to that of existing QOL scales, in which the description of the depression syndrome is only one area among others and where the QOL is considered as being the sum of the scores, whether weighted or not, measuring different areas. From our point of view, the IQOL scale is the basis without which no QOL can be calculated. In other words, we determine the score of the QOL mathematically as being the product of the EQOL and IQOL [46]. In order to verify the symmetry of the two concepts, phenomenological-depression and intrinsicQOL, according to the Three-Time-dimension theory, we have constructed a battery of tests which we have called the Three-Time-dimensions Synoptic Scale (3TSS). The content of the items will be explained below. Description of The Three-Time-dimensions Synoptic Scale 3TSS Material The 30 items which make up the 3TSS were chosen in accordance with a prior analysis of the contents of existing questionnaires, in such a way as to cover the range of items usually put forward to assess depression. They were rephrased in a uniform manner and presented as simple propositions concerning how the subject feels at the moment, how he felt in the past and how he wishes to feel in the future. The originality of this scale lies in combining the time dimensions of these questions, each put successively in the present, past and future. Its synoptic arrangement aims at discerning the temporal horizon which is disturbed in the depressed person. This, according to the moments of application of the scale provide many types of information, which we will discuss below. In practice the 3TSS is auto-applicable, easy to complete and takes less than 15 min. The 30 items of which it is composed are grouped into 2 sub-tests: 15 items concerning life force or the vital feeling of depression, 15 items concerning neurotic tendencies or depressed mood. The subject must codify his answer on an 5-point intensity scale. For mathematical reasons, the scale ranges from 1 point (severe pathology) to 5 points (absence of pathology). This armation is expressed in three tenses. First the subject must assess the intensity of what he is experiencing now, in the present. Then, wording the armation himself in the past tense, he must note the intensity of what he felt before his depression. Finally, he is asked to say, with regard to this armation, what he expects in the future, in other words, his demands for recovery. Here we see the therapeutic-future. The results obtained are expressed in points and range from the score of 150 points: absence of depression to that of 30 points: maximal depression. Subjects We selected during 3 months every patient (out or in) attending a Psychiatric Section in three General Hospital with a clinical diagnosis of major primary depression made by psychiatrists following the criteria of the DSM-III-R [47]. The same psychologist applied individually the 3TSS to 110 clinically depressed patients. The sample is composed by 44 men and 66 women aged between 25 and 60, of whom the average age was 47. The malefemale distribution was the same as that given in the research literature for depression epidemiology, which gives a prevalence rate of 8.4% for men and 14.8% for women. The patients already under treatment were all receiving medication which generally included anti-depressants, anxiolytics and sleeping pills. 56% of the subjects being treated were hospitalized in dierent

286 medical institutions in the French-speaking part of Belgium, and 44% were out-patients. It should be noted that 31% of the sample were alcoholics, 38% lived alone and 48% were unemployed. These very high percentages, which are much greater than those found in the general population, may of course be taken as showing alcohol, lack of work and solitude to be factors promoting a pathology of depression quite as much as being its consequences [42]. Metrological Qualities The metrological qualities of the ``present'' dimension of the 3TSS, i.e. the ill-being scale, enable this scale to measure depression according to the DSM-III-R criteria. The statistical analysis is contained in Ref. [42]. Homogeneousness was calculated by means of the Alpha Coecient of Cronbach [48] it was 0.865. This measure of the degree of internal consistency is very high. The comparative validity in relation to the Beck Scale [49] abridged version of 13 items was calculated by means of a BravaisPearson correlation: it was 0X65. The coecient was negative because, unlike the Beck scale, in the 3TSS the lower the score the more intense the depression. The empirical validity was calculated by comparing the values obtained for the 3TSS with the clinical classication carried out by the psychiatrists. The Student t values: t (82) = 5.25, t (46) = 9.05 and t (80) = 5.68 showed that the means of the three clinically diagnosed levels of depression mild, moderate, severe all diered signicantly, p = 0.05. The classication produced by the clinical diagnoses and the 3TSS are therefore conrmed. With regard to content validity, the 3TSS is composed of two sub-tests measuring life force and neurotic tendencies. Each item is highly correlated with the sub-test to which it belongs: on the other hand the correlation of the item with the other sub-tests is weak, even not signicantly dierent to zero. This conrms the principles on which the construction of the test is based. The measurement of item discrimination or the capacity of the instrument to distinguish between dierent individuals was carried out for each of the 30 items by the F.B. Davis method [50]. For 28 of the items the scale distinguishes between very depressed and slightly depressed subjects. The ill-being scale Present-time dimension is therefore denitely a scale which measures depression. The wording of the 30 items is given in the appendix in French, which was the language in which the metrological qualities were analysed. Following this analysis of the present dimension, central axis of the three time dimensions, and in order to describe the symmetry of the two concepts: phenomenological-depression and intrinsic-QOL, we address ourselves to the two other scales designated according to the Three-Time-dimension taxonomy, ``life events scale'' for the past dimension, and ``therapeutic expectations scale'' for the therapeutic-future dimension, this with regard to the positive aspect, and ``hopelessness scale'' with regard to the negative aspect. Demonstration of the symmetry of the concepts The hypothesis based on the Three-Time-dimensions Theory concerning the present, past and therapeutic(th)-future dimensions is: the depressed person who is experiencing a state of present ill-being, now, if he is suering from major primary depression having previously experienced a certain state of wellbeing and wishes in the future to recover from his depression, i.e. to regain, to recover the well-being of the past. ``In search of time past'' [51]. For the words: Past, Present and th-Future, the initial capital letter refers to the value of the test. Without initial capital letter they means the usual sense of past, present and future. Expressed mathematically, the Past and the th-Future should have values very close to the maximum, i.e. 150 points. Moreover, these scores should have a very small spread with reduced standard deviations which would show very homogeneous distributions. This is not the case. In fact the scores for the Past have a mean of 120.80 and a very large standard deviation of 14.08 and those of the th-Future a mean of 119.8 and a standard deviation of 13.45. The Student t distribution for paired groups had a value of 0.38; df 109 and was non-signicant at a level of 0.05. The distribution of these scores is given in Table 1. The demonstration of the symmetry of the two concepts of phenomenological-depression and intrinsic-quality of life will be carried out in three stages: statistical, mathematical and geometrical. 1st Stage: Statistical demonstration In order to determine their symmetry, concordance between the scores for the two time dimensions must be shown: the Past dimension must be equal to that of the th-Future. This concordance has been demonstrated by dierent statistical methods. The BravaisPearson correlation between the score for the Past and those for the th-Future is 0.42 signicant at 0.05. Cochran's test measuring the concordances between frequencies obtained for ve distractors in the two time dimensions was 1.58, df 1; non-signicant at 0.05. The percentage of concordance of the identical responses for 30 items obtained in the 110 depressed patients is 68%. These ndings therefore clearly show the concordance between the two time dimensions so conrming the theory underlying the construction of the 3TSS.

287
Table 1. Distribution of scores of 3TSS scale in Past and th-Future Time-dimensions (N = 110) Score Past N 5155 5660 6165 6670 7175 7680 8185 8690 9195 96100 101105 106110 111115 116120 121125 126130 131135 136140 141145 146150 Mean Sigma %
cumul.

th-Future N %
cumul.

depression. We therefore demonstrate that phenomenological-depression varies symmetrically to the intrinsic-quality of life: the milder the phenomenological-depression, the better the intrinsic-quality of life and vice-versa, the more severe the phenomenological-depression, the lower the intrinsic-QOL. 3rd Stage: Geometrical demonstration We have shown above that the Past is equal to the thFuture. We can consider the gap between these and the Present as being the hypotenuses of two rightangle triangles. To show this we use a diagram Figure 1 of which the ordinate is the 3TSS scores and the abscissa the three time dimensions. The initial postulate is: the Present is situated at an equal distance from the Past and the th-Future. We have already shown that statistically the score for the Past time dimension is identical to that of the th-Future. We therefore have two right-angle triangles of which the side lengths A and AH are equal, as are B and BH , the latter giving the intersection points with the abscissa of the perpendiculars descending respectively from A and AH . C is the mid-point of the segment BBH . The segments AB, AH BH and BC, BH C being equal, it follows that the two right-angle triangles ABC and AH BH C are equal and also symmetrical with regard to each other. Taking the Present axis as the perpendicular bisector and rotating one of the two right-angle triangles by 180 , the triangles may be superimposed; their segments AC and AH C therefore are symmetrical. We have thus shown that phenomenological-depression and the IQOL are symmetrical with each other. We should make clear that the concepts involved are phenomenologicaldepression, and not ill-being, and the intrinsic-quality of life of the depressed person drawing upon the therapeutic-future, and not the extrinsic-quality of life of the non-depressed person for whom the future is real. Practical application of this symmetry It seemed of interest in a clinical perspective to verify if the symmetry between these two concepts was to be

1 1 2 2 1 4 3 2 10 12 23 23 18 6 1 1 120.34 14.08

0.91 1.82 3.64 5.45 6.36 10.00 12.73 14.54 23.64 34.54 54.54 76.36 92.73 98.18 99.09 100.00

1 1 3 3 6 8 14 10 23 13 18 4 3 3 119.80 13.45

0.91 1.82 4.54 7.27 12.73 20.00 32.73 41.82 63.64 74.54 90.91 94.54 97.27 100.00

2nd Stage: Mathematical demonstration of the symmetry between phenomenologicaldepression and the intrinsic-quality of life We have dened these two concepts as being the perception of a gap between present ill-being and the past for one of them, and between present ill-being and the therapeutic-future for the other. Mathematically it would appear incorrect to determine the values of these gaps by the dierence between the respective scores for the two time dimension poles. Such a mathematical formulation does not take account of the all-important element of the intensity of the subject's ill-being. For this reason we opted for a ratio of which the numerator was the score for the present time dimension. Phenomenological-depression is therefore measured by the ratio between the Present and the Past, while the intrinsic-QOL is measured by that between the Present and the thFuture. The numerator being the same and the denominators having the same statistically veried values, these two ratios have an identical value. While the value ``1'' of the ratio in the rst formulation signies that no phenomenological-depression exists and that the subject has not experienced a decline, in the second formulation the signicance is quite different: the intrinsic-QOL of the subject is at a maximum or, in other words, his healed ill-being has changed to well-being. The subject cured of his depression in this case sees his present state as identical with the state that he wished to recover during his

Figure 1. Application of theory of Three-Time-dimensions to 3TSS.

288 found for each of the 110 subjects diagnosed as suffering from depression. One remark must be made before dealing with this. While the BravaisPearson correlation between the scores for the Past and those for the th-Future is 0.42, the correlations were zero between the scores for the Present and those for the Past it does the same for the Present and those for the th-Future. The scores for the Past and those for the th-Future are therefore independent of the degree of severity of the depression. These ndings have an impact on the clinical interpretation of the diagnosis of depression. The practitioner analyzing the temporal horizon of the patient with this type of scale will not concentrate only on the present of the individual but will have a more holistic approach, taking account both of the past and the therapeutic expectations of the patient. The calculation of standard error of the measurement of dierence between Past and th-Future as described in Ref. [52], enables us to consider the values for the dierences between Past and th-Future which are less than 13 points as non-signicant. A categorisation of the sample of 110 depressed patients was carried out according to this criterion and gave the following results: 60% of the sample had a Past and th-Future which were equivalent, with this percentage rising when the depression was diagnosed as mild; 24% had a Past which was greater than the thFuture and 16% a Past which was less. From studies which we are carrying out at present we nd that a very low score for the past is highly correlated with severe depression, which shows that the patient who is suering in this way a fact which is well known has a tendency to darken his past while the mild or moderate depressed has a tendency to overestimate his past in comparison with a nondepressed population [53]. On the other hand, a very low score for the th-future less than Percentile 40 reveals a subject with very strong suicidal tendencies by the expression of a low level of expected recovery. This notion is analysed and conrmed in Ref. [54]. Discussion and conclusions Clinical research is looking for instruments to measure human behavior, based if at all possible, on a theory which would allow them to make valid comparisons of their clinical observations, diagnoses, prognostications and therapies. How can the subjective concepts of phenomenological-depression, ill-being and the intrinsic-quality of life be objectied? These represent three further approaches to the subject who, following the criteria of the DSMIV, is suering from depression. The medical approach can be added to and completed by a phenomenological interpretation, which demonstrates that depression is accompanied by a profound modication of the human being in his relations with the world and, most especially, with regard to time. Time stops and the present lasts interminably, the past is psychologically under- or over-estimated and the future is ``unthinkable''. In this study, psychological time outside the nosographic framework is the central notion of the model. How does the individual, as a person situated in time, experience his past and present and envisage his future? The temporal horizon supposes a memory of things. Without memory there is no past, but neither is there any future, for projects are only developed with reference to events which have already taken place. The relative importance that a subject gives to memories, projects and present life events of depends to a great extent on education, sociocultural inuences and pleasant or unpleasant personal experiences. His past consists of a vast range of temporally related memories: through these a feeling of permanence and individuality is established. His future is the world of objectives and motivation. The symmetry between the two concepts of depression and QOL to our knowledge, has never been demonstrated. While many studies reveal a relationship between these, particularly an inverse one using scales, which however, do not comply with the criteria and taxonomy of the Three-Time-dimensions. By constructing a new tool, the 3TSS, we have attempted to demonstrate the symmetry between the two new concepts phenomenological-depression and intrinsic-quality of life dened by the Three-Timedimensions theory. To this end we have used a single questionnaire in which identical items are given in a present, past and future form. This scale uses not only an inter-individual comparison between the subject's values and those of his reference group, but also an intra-individual comparison, the subject in relation to himself. But what is the relationship between the severity of the depression and the QOL? In our terminology, the QOL being the product of the EQOL and IQOL, a low or zero IQOL case of severe depression will make the QOL low or non-existent [46]. The question can therefore be couched in the following terms: is there a relationship between the level of ill-being and the IQOL? the rst being considered as a state and the second as a perception of a discrepancy between two states, one present and the other wished for. It should be remembered that a high score for the illbeing scale means mild depression, while a low score means severe depression. Let us take two extreme situations. In one, the th-Future remains the same and the degree of ill-being varies for dierent subjects or at dierent times. In the other, the degree of illbeing remains the same and the th-Future (therapeutic expectations) is variable. In the rst case, if the degree of ill-being is less the discrepancy between this state and the desired state will be less and therefore the IQOL will be

289 higher. If the IQOL is at a maximum level, i.e. equal to 1, the state of ill-being will have disappeared, the Present will have reached the desired state, Present and th-Future will be equal: there will have been a making-present of the future and therefore recovery. With the same th-Future, the severity of the depression will have an inverse relationship with the IQOL. In the case where the degree of ill-being remains stationary and the th-Future level varies, the subject, being more demanding with regard to the level of recovery that he expects, will be further removed from it and his IQOL will only depend on his thFuture score and will therefore be less than for a less demanding subject. This is particularly the case for a young subject suering from depression for whom the degree of severity of the depression may be the same as for an older subject: the former is more demanding than the latter and his IQOL will be less. The analysis of the th-Future shows up the lack of proportionality between the phenomenolgy of the depressed person and the assessment of an external observer. Consequently in this case, they are not necessarily relation between ill-being and IQOL [46]. As one of our research has showed [53], the depressed person's th-Future score, which one might have expected to be similar to the average score of a non-depressed population, is signicantly lower and is statistically equal to his Past score, which is in fact the basis of our theory. The depressed does not wish to be better than before his depression. In summary, the following practical conclusions issued from this work are: the measurement of the extrinsic-QOL is in practice only reliable if it is certain that the intrinsic-QOL exists or that the subject is not depressed. they are not necessarily a relation between ill-being and IQOL the importance of the th-Future (therapeutic expectations) it demonstrates. the analysis of temporal horizon is a very important variable in diagnosis of depressed person. the symmetry between those two concepts: phenomenological-depression and IQOL obtained by the identical items conjugated in past and future time can be found in 2 out of 3 cases of depression. The equality between Past and thFuture being more frequent, the less the feeling of ill-being is pronounced. Two facts are evident from our research with depressed subjects where this equality is to be found: 1. When the degree of ill-being is great, together with a strongly underestimated Past is a diagnosis of severe major depression with suicidal tendencies may be made; 2. When the degree of ill-being is low and equal to the Past, this is normally a case of dysthymia in which one nds a slight generalised feeling of ill-being throughout the temporal horizon. the non-equivalence between Past and th-Future found in over one out of 3 cases of depression has a particular clinical interest: 1. The depression is particularly severe if the Past is inferior to the th-Future; 2. The risk of suicidal tendencies is high if the th-Future is inferior to the Past. By applying the 3TSS to the patient, the clinician may not only measure the degree of severity of the depression, but also know where the subjects stands in his progress towards what he considers to be his recovery. The clinician can also measure the decline perceived by the patient during his painful passage from a healthy state to a depressed one, and by measuring this decline also measure to a certain extent the suering experienced by the patient. It is thus shown that for a depressed person the suering reveals a lack in his quality of life.

Appendix
Please answer ALL the questions one by one: what you feel NOW, what you felt BEFORE and what you wish to feel IN THE FUTURE by encircling the corresponding number in the scale of intensity: 1, not at all; 2, a little; 3, moderately; 4, a lot; 5, extremely. 1. Je suis dynamique 2. Je prends soin de mon apparence 3. Je suis en bonne sante 4. Je suis su r(e) de moi moire 5. J'ai une bonne me resse a ce qui se passe autour de moi 6. Je m'inte tit stable 7. J'ai un appe 8. Je fais les choses rapidement 9. J'ai l'esprit clair 10. Je travaille avec entrain ussi ma vie 11. J'ai l'impression d'avoir re 12. Je me sens utile 13. Je me sens heureux(se) 14. J'ai des plaisirs dans la vie 15. Je me sens intelligent(e) et capable 16. Je suis optimiste es obse dantes 17. J'ai des ide 18. Je me sens coupable 19. J'ai le cafard courage (e) devant la vie 20. Je suis de c 21. Je suis de u(e) par moi-me me 22. J'ai envie de mourir 23. Je me tracasse pour ma sante 24. Je me fais des reproches (e) 25. Je me sens angoisse (e) de s le matin 26. Je me sens fatigue 27. J'entreprends quelque chose avec diculte 28. Je trouve le temps interminable site a prendre une de cision 29. J'he 30. Je manque de concentration Copyright 1993, de Leval N.

290 Acknowledgements The author acknowledges the assistance of Claude Wallemacq, Doctor of Medicine.
17. new measure. Psychopharmacol Bul 1993; 29: 321 326. Gregoire J, de Leval N, Mesters P, Czarka M. Validation of the Quality of Life in Depressive Scale in a population of adult depressive patients aged 60 and above. Qual Life Res 1994; 3: 1319. Revicki DA, Kaplan RM. Relationship between psychometric and utility-based approaches to the measurement of health-related quality of life. Qual Life Res 1993; 2: 477487. Anderson RT, Aaronson NK, Wilkin D. Critical review of the international assessments of health-related quality of life. Qual Life Res 1993; 2: 369395. Naughton MJ, Woklund I. A critical review of dimension-specic measures of health-related quality of life in cross-cultural research. Qual Life Res 1993; 2: 397432. Kaplan RM, Feeny D, Revicki DA. Methods for assessing relative importance in preference based outcome measures. Qual Life Res 1993; 2: 467475. Kaplan RM, Bush JW. Health-related quality of life measurement for evaluation research and policy analysis. Health Psychol 1982; 1: 6180. Cella DF, Tulsky DS. Measuring quality of life today: Methodological aspects. Oncology 1990; 4: 2938. Jenkinson C, Wright L, Coulter A. Quality of Life Measurement in Health Care: A Review of Measures and Population Norms for the UK SF-36. Oxford: Health Services Research Unit, 1993. Bullinger M. Quality of Life: denition, conceptual or ization and implications a methodologist view. The Surg 1991; 6: 9151055. Walker SR, Rosser RM. Quality of life: Assessment and application. Lancaster: MTP Press, 1988. Hyland ME. A reformulation of quality of life for medical science. Qual Life Res 1992; 1: 267272. Hyland ME, Bott J, Singh S, Kenyon CA. Domains, constructs, and the development of the breathing problems questionnaire. Qual Life Res 1994; 3: 245256. WHO QOL Group. Study protocol for the World Health Organisation project to develop a quality of life assessment instrument (WHOQOL). Qual Life Res 1993; 2: 153159. Guyatt GH, Feeny D, Patick DL. Measuring healthrelated quality of life. Ann Intern Med 1993; 118: 622 629. Spilker B. Quality of life assessments in clinical trials, New York: Raven Press, 1990. Banta D, Luce B. Health care technology and its assessment: An international perspective. New York: Oxford University Press, 1993. Ware J, Snow KK, Kosinski M. SF-36 Health survey: Manual and interpretation guide. Boston, MA: The Health Institute, 1993. Gregoire J, de Leval N, Mesters P. Assessment of quality of life in the treatment of major depressive disorders with uoxetine 20 mg in ambulatory patients aged over 60 years. Inter Clin Psychophar 1993; 9: 47 53. Aaronson NK, Ahmed S, Bergman B. The European organisation for research and treatment of cancer QLQ C30: A quality-of-life instrument for use in international clinical trials in oncology. J Nat Canc Inst 1993; 85: 365376.

References
1. Kish GB, Moody DR. Psychopathology and life purpose. Int For Logother 1989; 12: 4045. 2. Burckhardt CS. The Ostomy Adjustment Scale: Further evidence of reliability and validity. Rehabilit Psych 1990; 35: 149155. 3. Weissman MM. Panic disorder: Impact on quality of life. Annual Meeting of the American Psychiatric Association Symposium: Panic disorder: Strategies for long-term treatment. J Clin Psych 1991; 52: 68. 4. Frisch MB, Cornell J, Villanueva M, Retzla PJ. Clinical validation of the Quality of Life Inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psych Assess 1992; 4: 92101. 5. Revicki D, Turner R, Brown R, Martindale JJ. Reliability and validity of a health-related quality of life battery for evaluating outpatient antidepressant treatment. Qual Life Res 1992; 1: 257266. 6. Sahoo FM. Bidyadhar S. The Subjective components of psychological well-being: An idiographic investigtion using the Lens Model. Psych Stud 1992; 37: 151 160. 7. Headey BW, Kelley I, Wearing AJ. Dimensions of mental health: Life satisfaction, positive aect, anxiety and depression. Soc Indic Res 1993; 29: 6382. 8. Kim S, Rew L. Ethnic identity, role integration, quality of life, and depression in KoreanAmerican women. Arch Psychia Nurs 1994; 8: 348356. 9. Turner R. Quality of life: Experience with sertraline: IX World Congress of Psychiatry Symposium: The search for the ideal antidepressant: How close are we? Int Clin Psychopharmacol 1994; 9: 2731. 10. Moody L, Mc Cormick K, Williams A. Disease and symptom severity, functional status, and quality of life in chronic bronchitis and emphysema. J Beh Med 1990; 13: 297306. 11. Kind P, Sorenson J. The casts of depression. Third International Symposium: RIMAs in subtypes of depression: Focus on moclobemide. Int Clin Psychopoharmacol 1993; 7: 191195. 12. Mechanic D, McAlpine D, Roseneld S, Davis D. Effects of illness attribution and depression on the quality of life among persons with serious mental illness. Soc Sc Med 1994; 39: 155164. 13. Beaumont G. Quality of life in primary care. Hum Psychopharmacol Clin Experim 1994; 9: 2529. 14. Godding PR, McAnulty RD, Wittrock DA, Britt DM, et al. Predictors of depression among male cancer patients. J Nerv Ment Disease 1995; 183: 9598. 15. Conn VS, Taylor SG, Wiman P. Anxiety, depression, quality of life, and self-care among survivors of myocardial infarction. Iss Ment Heal Nurs 1991; 12: 321 331. 16. Endicott J, Nee J, Harrison W, Blunenthal R. Quality of life enjoyment and satisfaction questionnaire: A

18.

19. 20.

21. 22. 23. 24.

25. 26. 27. 28. 29.

30. 31. 32. 33. 34.

35.

291
36. Kendrick A, Joyce CRB, Trimble MR, Selai CE. A new method for evaluating health-related quality of life based on repertory grid technique. Qual Life Res 1994; 3: 48. 37. Jenkinson C, Wright L, Coulter A. Criterion validity and reliability of the SF-36 in a population sample. Qual Life Res 1994; 3: 712. 38. American Psychiatric Association, Diagnostic Criteria from DSM-IV, 4th edn, Washington DC: American Psychiatric Association, 1994. orie des trois temps ou la qualite de vie 39. de Leval N. The pressif. Rev Psychol Psychom Langue Fr 1993; du de 14: 2531. chelles de de pression: 40. de Leval N. Le vaste champs des e bauche de classement en fonction de la dimension une e du temps. Langage et l'homme 1994; 1: 3747. 41. de Leval N. Scales of depression, ill-being and quality of life is there any dierence? An assay in taxonomy. Qual of life Res 1995; 4: 259269. 42. de Leval N. Theory, Taxonomy, Test: The Three Time dimensions Synoptic Scale 3TSS. Rev Psychol Psychom Langue Fr 1996; 17: 1, 525. 43. Calman KC. Quality of life in cancer patients on hypothesis. Journ of Med Ethics 1984; 10: 124127. 44. Michalos AC. Multiple discrepancies theory (MDT). Soc Indic Research 1985; 16: 347414. de vie subjective en 45. Dazord A. Evaluation de la qualite pression 1992; 16: 110. psychiatrie. Visage de la de de vie du 46. de Leval N. Approche nouvelle de la qualite pressif en fonction de l'horizon temporel: conception de et mesure. Rev Psychol Psychom Langue Fr 1997; 18, (2/3): 530. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd edn, Revised (DSM-III-R), Washington DC: 1987. Cronbach LJ. Coecient alpha and the internal structure of tests. Psychometrika 1951; 16: 297334. Beck AT. An inventory for measuring depression. Arch Gen Psychiatry 1969; 4: 561571. Davis FB. Estimation and use of scoring weights for each choise in multiple-choice test items. Educ Psychol Measm't 1959; 9: 291298. ou la qualite de Leval N. A la recherche du temps passe pressif. Submitted for publication. de vie du de orie des Trois de Leval N. Essai de validation de la the conceptuelle de la Three Temps ou mesure de la validite Time dimensions, Synoptic Scale, 3TSS. Europ Rev Applied Psychol. To be published. chelle synoptique des trois temps de Leval N. L'e a un e chantillon de 260 non-de pressifs. Subapplique mitted for publication. ation d'un nouveau type d'e chelle de Leval N. Cre diagnostiquant les tendances suicidaires chez le pressif a partir de l'horizon temporel. Submitted for de publication.

47. 48. 49. 50. 51. 52.

53. 54.

Address for correspondence: Dr. N. de Leval, Fax: +32 10 47 4834

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