Love of life and its association with well‐being in Iranian psychiatric outpatients

Abstract Aim The aims of this study were as follows: (a) to investigate the psychometric properties of the Love of Life Scale (LLS); (b) to explore sex differences in LLS scores; (c) to explore LLS correlations with spiritual health and psychological well‐being; and (d) to compare the mean LLS score with previous studies. Design A cross‐sectional study. Methods A sample of 191 Iranian psychiatric outpatients was recruited from clinics at the School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), which is affiliated with the Iran University of Medical Sciences. They responded to the Farsi versions of the LLS, the Spiritual Well‐Being Scale (SWS) and the World Health Organization‐five Well‐Being Index (WHO‐5). Results Cronbach alpha for the LLS was 0.95, and a principal component analysis (PCA) of the LLS items extracted one component labelled "Love of life." The sex difference in LLS scores was not significant. All the correlations between the scales were statistically significant and positive. Patients who had high scores for their love of life had better spiritual health and psychological well‐being. Discussion The present sample obtained a lower mean LLS score than college students from eight countries except one. Further research should explore predictors of the love of life.

Most previous studies on the LLS have been carried out using college students. Therefore, there is a need to explore the performance of the LLS with clinical cases. To the best of our knowledge, the LLS has not been administered to psychiatric outpatients.
Furthermore, the studies on the LLS using the Farsi version with Iranian participants are rare.
There are specific applications of the present study for nursing practice. Based on the statistically significant negative associations between the LLS and psychopathology, mainly anxiety, depression and suicidal ideation, the score on the LLS could be used as one of the indicators to improvement after psychological interventions for patients, particularly in psychiatric nursing, psycho-rehabilitation and mental health nursing, among other nursing branches.
Therefore, the LLS could be useful in nursing education.

| BACKG ROU N D
At a theoretical level, it is important to investigate whether the LLS behaves differently in psychiatric patients compared with university students. Because of the presence of symptoms of anxiety and depression, we hypothesize that the LLS scores of psychiatric patients would be lower than that of non-clinical persons. Individuals with anxiety disorders may suffer from specific phobias, social anxiety, panic disorder, agoraphobia and general anxiety. Individuals with specific phobias are fearful or anxious about or avoidant of circumscribed objects or situations. Individuals with general anxiety disorder have persistent and excessive anxiety and worry that the individual finds difficult to control about various domains, including work and school performance. In addition, they experience physical symptoms, including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or their mind going blank; irritability; muscle tension; and sleep disturbance (American Psychiatric Association, 2013, pp. 189-190). Because of these symptoms and complaints, the sense of subjective well-being, as well as love of life, may be negatively affected in individuals with anxiety disorders (Abdel-Khalek, 2013a. Individuals with depression suffer from some of the following symptoms: depressed mood, loss of interest or pleasure, hopelessness, changes in body weight, decrease or increase in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness, diminished ability to think and thoughts of death (American Psychiatric Association, 2013, pp. 160-161). Symptoms and complaints like these may have a negative impact on the love of life.
The aims of the present study were (a) to investigate the psychometric properties of the Farsi version of the Love of Life Scale (LLS) with psychiatric outpatients, (b) to explore sex differences in LLS scores, (c) to explore LLS correlations with spiritual and psychological well-being and (d) to compare the mean LLS scores of the present sample of psychiatric patients with the available results for the LLS in previous research by others.

| Participants
A convenience sample of 191 Iranian psychiatric outpatients was recruited from clinics at the School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), which is affiliated with the Iran University of Medical Sciences. The sample size was calculated using Cochran's formula. To estimate the sample size, three issues need to be studied (the level of precisions, confidence or risk level and the variability). The less variable (more homogeneous) a population, the smaller the sample size. For reason, the patients' population we were studying was small, we modified the sample size by using this equation: n = [n0/(1+((n0-1)/N)). The patients were invited to voluntarily participate in the study after they completed a psychiatric interview with one psychiatrist. The objective of study was explained to the patients. The scales contained a cover letter, explaining all the ethical considerations (confidentiality, anonymity, informed written consent and the right to withdraw) as well as an explanation of the research procedure. The response rate was 100%.

| The Spiritual Well-Being Scale (SWS)
The SWS, developed by Paloutzian and Ellison (1991), contains 20 items. Each item is answered on a six-point Likert-type scale. Ten items measure religious well-being (a religious element and a sign of relationship with a superior authority, e.g. God), and 10 items measure existential well-being (a psychosocial element and a sign of a person's feelings about who he/she is, what and why he/she does and where he/she belongs). The scores of religious and existential well-being subscales ranged 10-60, and total scores ranged 20-120.

| The World Health Organization-five Well-Being Index (WHO-5)
The WHO-5 has a Persian version (Dadfar,

| Data analysis
For determination of the normality of the data and equality of variances, the Kolmogorov-Smirnov test and Levene's test were used, respectively. The data were analysed with descriptive statistics (mean, standard deviations), t tests, Pearson correlation coefficients and a principal components factor analysis to identify the number of factors to be retained. The criterion of eigenvalues greater than or equal to 1.0 was followed, and the Varimax orthogonal rotation of axes was adopted. The SPSS/WIN (SPSS & Inc., 2009) 23. 0 program was used. Table 1 reports demographic and clinical characteristics of patients.   Inspection of this table indicates that the mean LLS score of the present sample is lower than that of college students in all countries except for Egyptian females.

| D ISCUSS I ON
The present study indicated that the Farsi version of the LLS is a reli- In a sample of Palestinian students, Al-Arja (2018) found that love of life was not correlated with gender or their parents' academic level.
She found also that the love of life mean score was significantly higher in Christian than in Muslim students. Students who were resident in villages had higher love of life mean score compared with those living in refugee camps. Perhaps as a result of the politically and economically unstable and harsh situations for the Palestinian students, their mean LLS score was lower than the scores of Kuwaiti and Lebanese students.

Associations between love of life and both spiritual well-being and
psychological well-being were significant and positive for the psychiatric patients in the present study. Patients who had more love of life had better spiritual health and psychological well-being. This finding is consistent with results from other studies. Abdel-Khalek (2013c, 2015 found that religious college students from Egypt and Qatar reported higher subjective well-being. In a similar vein, Atef Vahid et al. (2016) reported positive correlations between scores on the LLS and the Using the LLS and the Multidimensional Inventory for Religious

| CON CLUS ION
The current investigation has successfully achieved its objectives; that is, the LLS had good internal consistency. A factor analysis identified one factor which is consistent with some previous studies and indicates a good degree of homogeneity of the item content.
Consistent with previous findings, the sex differences were not statistically significant. The associations of LLS with spiritual well-being and general well-being were statistically significant and positive. As predicted, the mean score on the LLS among the present sample of psychiatric patients was lower than most previous studies carried out on non-clinical samples from several countries. All in all, the love of life concept may be considered one of the major constructs related to subjective well-being. Furthermore, we suggest developing a programme to promote love of life among patients. This programme would ameliorate physical and psychological symptoms and would improve their social adjustment. This proposed programme may be incorporated into psychotherapeutic procedures with patients.

ACK N OWLED G EM ENTS
We thank all the psychiatric outpatients for their participation in the study and the research assistants for helping in the collection of data.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no funding for the study and they have no conflict of interest regarding the publication of this paper.

AUTH O R CO NTR I B UTI O N S
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www. icmje.org/recom menda tions/)]: substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; and drafting the article or revising it critically for important intellectual content.