Research paperPsychometric properties of the well-being index (WHO-5) spanish version in a sample of euthymic patients with bipolar disorder
Introduction
Bipolar disorder (BD) is a chronic mood disorder characterized by episodes of hypomania/ mania and depression (Grande et al., 2016). There is evidence from the literature that some patients with BD experience significant psychosocial impairment (Rosa et al., 2008, Sanchez-Moreno et al., 2009), reduced quality of life (QoL) and well-being (Dias et al., 2008, Mackala et al., 2014, Michalak et al., 2005) even during euthymia. Traditionally, treatments for BD have been focused on symptom reduction, achievement of remission and functional recovery (Bonnin et al., 2016, Torrent et al., 2013). However, to date, subjective assessments -such as QoL, well-being or life satisfaction- have received less attention in the BD field (Mackala et al., 2014, Bonnín et al., 2012), perhaps in part due to concerns about the relationship between self-report measures of well-being and mood symptoms (Anaya et al., 2016). There is also a lack of maturity and measurement precision in this field. Morton et al's (2017a) recent review highlights the broad variability of definitions and instruments to assess the subjective experience (QoL, well-being, life satisfaction…) of patients with BD. The current lack of consensus on construct definitions and the wide variability in applied measurements tools may complicate the selection of appropriate instruments. In fact, the authors point out that the term QoL is often used as a synonym for other terms such as subjective well-being, life satisfaction, health or functioning. Hence, further research is needed to clarify the definition and the boundaries of all these concepts. Lack of attention to the inclusion of self-report measures of well-being in research and clinical care in BD certainly represents a missed opportunity (Bonnín et al., 2012, Morton et al., 2017a).
This study is focused on the concept of well-being, a term that has been defined by the World Health Organization (WHO) as the individual's ability to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community (WHO, 2004). As previously stated, there is ongoing discussion about the perimeters of constructs such as well-being and QoL (Morton et al., 2017a). Within the well-being field, diverse instruments have been developed to evaluate psychological subjective well-being, or related concepts, for instance: the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS)(Tennant et al., 2007), the Satisfaction with Life Scale (Kobau et al., 2010) and The Subjective Well-being under Neuroleptic Treatment Scale (SWN) (Vothknecht et al., 2013), although the latter was developed to evaluate patients with schizophrenia receiving antipsychotics and includes items not directly related to well-being. To advance this field, the WHO developed a brief scale to assess subjective well-being, the Well-Being Index (WHO-5), a generic, self-administered 5-item Likert-response, one factor-structured scale (Hajos et al., 2013). Since the WHO considers positive well-being to be a synonymous term for mental health (WHO, 2004), this scale was created exclusively for assessing positive aspects of psychological well-being. Since the publication of the WHO-5 in 1998, it has been translated into more than 30 languages, including Spanish, and it has been used in research studies all over the world in diverse fields, including endocrinology, oncology and psychiatry. In psychiatry, most studies have been conducted in patients with unipolar depressive disorder (Arnfred et al., 2017, Bonsignore et al., 2001, Christensen et al., 2015, Lauritsen et al., 2017, Möller Leimkühler et al., 2007). In non-clinical samples, it has been used as a screening tool for depression (Heun et al., 1999); however it has also been applied as an outcome measure in some clinical trials in patients with depressive disorder (Guico-Pabia et al., 2012, Martiny et al., 2012).
To the best of our knowledge, the WHO-5 has only been used once in the BD arena (Bech et al., 2006). Even though the WHO-5 was not specifically designed to evaluate well-being in patients with BD, it may have utility and meaningfully add to the growing literature on subjective outcome assessments in patients living with BD. In contrast with other tools, the WHO-5 is a brief-scale that captures one aspect of the subjective experience in BD, which is wellbeing. Even though it is not as complete as other subjective assessments, such as QoL measures, we believe that, if it shows adequate psychometric properties, it would represent a good tool to be further implemented in study protocols and clinical practice: for instance, to assess the efficacy of psychological interventions aimed at improving subjective well-being in this population. The objective of this study was to report on the psychometric properties of this scale in a sample of euthymic patients with BD.
Section snippets
Participants
Participants with BD were enrolled from the Barcelona Bipolar Disorders Program at the Hospital Clínic (University of Barcelona). It is a University based BD program providing integrated care for difficult-to-treat patients with BD from across Catalonia, as well as care to patients with BD from a specific catchment area (Eixample Esquerra) in Barcelona (Vieta, 2011). Hence, the sample from this study was recruited in a tertiary center, including some participants who may represent a severe
Clinical and sociodemographic characteristics of the groups
A total of 149 participants were recruited for this study, 40 healthy controls and 109 patients diagnosed with BD (either type I or II). The patient group was composed mainly of participants diagnosed with BD type I (81.0%), mean age of patient group was 44 years old. Mean years of illness duration was 17.9 (12.1) and most of them were not working at the moment of the evaluation (59.6%).
Regarding the healthy control group, mean age was 42 and most of them were employed at the time of the
Discussion
This is the first study to evaluate the psychometric properties of the WHO-5 in a sample of euthymic patients with BD from Spain. The results suggest that this scale is acceptable for application in clinical and research settings to assess subjective well-being in BD, as supported by the reliability and preliminary validity tests. Regarding reliability, the Cronbach's alpha index revealed that the scale presented a good level of internal consistency; this is in accordance with previous studies
Conclusions
Despite these limitations, the primary objective of this study: to provide preliminary psychometric evaluation of the Spanish version of a scale to measure psychological well-being in a sample of patients with BD, was met. Exploration of the psychometric properties of the WHO-5 in patients with BD demonstrate that it is a reliable and unitary tool deserving for further application in this field. Other advantages include its brevity and ease-of-use. The psychometric properties of the WHO-5 and
Acknowledgements
The authors thank the support of the Spanish Ministry of Economy, Industry and Competitiveness; the CIBER of Mental Health (CIBERSAM); the Secretaria d′Universitats i Recerca del Departament d′Economia i Coneixement (2014_SGR_398) and the CERCA Programme / Generalitat de Catalunya.
Role of funding source
This study was supported by the Instituto de Salud Carlos III, the CIBER of Mental Health (CIBERSAM) (Banco de Instrumentos del CIBERSAM; http://bi.cibersam.es/proyectos-de-investigacion), the Spanish Ministry of Economy, Industry and Competitiveness (PI15/00283, PI15/00330/PI16/00187) integrated into the Plan Nacional de I+D+I y cofinanciadopor el ISCIII-Subdirección General de Evaluación y el FondoEuropeo de Desarrollo Regional (FEDER).
Dr. Bonnín would like to thank the Departament de Salut
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