Psychosocial functioning of the adult with congenital heart disease: a 20-33 years follow-up.

AIMS: Since knowledge about the psychosocial function of adult patients with congenital heart disease is limited, we compared biographical characteristics, and emotional and social functioning of these patients with that of the reference groups. METHODS AND RESULTS: Patients with congenital heart disease (N=362, aged 20-46 years), belonging to five diagnostic groups, were subjected to extensive medical and psychological examination, 20-33 years after their first open heart surgery. All the patients were seen by the same psychologist, who examined their psychosocial functioning using a structured interview and questionnaires. The majority (78%)was living independently and showed favourable outcome regarding the marital status. Among married/cohabitant patients, 25-39-year-olds showed normal offspring rates. None of the 20-24-year-old patients had any children. The offspring rate dropped after the age of 40. The proportion of adult patients with a history of special education was high (27%). Accordingly, patients showed lower educational and occupational levels compared to reference groups. As regard to the emotional and social functioning (leisure-time activities), the sample showed favourable results. CONCLUSIONS: Overall, this sample of patients with congenital heart disease seemed capable of leading normal lives and seemed motivated to make good use of their abilities.     

心血管内科门诊患者合并心理问题的现状分析

目的 了解心内科门诊患者合并心理问题的现状及临床特点.方法 采用抑郁自评量表(SDS)、焦虑自评量表(SAS)、汉密尔顿抑郁量表(HRSD)、汉密尔顿焦虑量表(HAMA)对2005年10月至2006年11月在北京大学人民医院心内科门诊就诊的所有347例患者进行评估.结果 单纯躯体疾病所占比例为52.4%,单纯心理疾病占12.7%,躯体疾病与心理疾病共病占27.7%.其中心理问题主要表现为抑郁31例(8.9%)、焦虑62例(17.9%)、抑郁焦虑混合状态28例(8.1%).单纯心理疾病患者既往多诊断为心血管疾病、功能性疾病或消化系统疾病,并且大部分患者不认为自身有心理问题.结论 心内科门诊患者中心理问题和躯体疾病共病常见,单纯心理问题容易被误诊为心血管疾病.     

Prevalence of Probable Mental Disorders Among Pediatric Asthma Patients in an Inner-City Clinic

Objective. To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. Method. In this pilot study, a consecutive sample of pediatric asthma patients aged 5-11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. Results. Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. Conclusions. These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.     

Actualización 2013 en cardiopatías congénitas,cardiología clínica e insuficiencia cardiaca y trasplante

This article presents the most relevant developments in 2013 in 3 key areas of cardiology: congenital heart disease, clinical cardiology, and heart failure and transplant. Within the area of congenital heart disease, we reviewed contributions related to sudden death in adult congenital heart disease, the importance of specific echocardiographic parameters in assessing the systemic right ventricle, problems in patients with repaired tetralogy of Fallot and indication for pulmonary valve replacement, and confirmation of the role of specific factors in the selection of candidates for Fontan surgery. The most recent publications in clinical cardiology include a study by a European working group on correct diagnostic work-up in cardiomyopathies, studies on the cost-effectiveness of percutaneous aortic valve implantation, a consensus document on the management of type B aortic dissection, and guidelines on aortic valve and ascending aortic disease. The most noteworthy developments in heart failure and transplantation include new American guidelines on heart failure, therapeutic advances in acute heart failure (serelaxin), the management of comorbidities such as iron deficiency, risk assessment using new biomarkers, and advances in ventricular assist devices.     

Psychiatric disorders in older primary care patients

OBJECTIVE: Most older people with psychiatric disorders are never treated by mental health specialists, although they visit their primary care physicians regularly. There are no published studies describing the broad array of psychiatric disorders in such patients using validated diagnostic instruments. We therefore characterized Axis I psychiatric diagnoses among older patients seen in primary care. DESIGN: Survey of psychopathology using standardized diagnostic methods. SETTING: The private practices of three board-certified general internists, and a free-standing family medicine clinic. PARTICIPANTS: All patients aged 60 years or older who gave informed consent were eligible. MEASUREMENTS AND MAIN RESULTS: For the 224 subjects completing the study, psychiatric diagnoses were based on the Structured Clinical Interview for DSM-III-R. Point prevalence estimates used weighted averages based on the stratified sampling method. For the combined sites, 31.7% of the patients had at least one active psychiatric diagnosis. Prevalent current disorders included major depression (6.5%), minor depression (5.2%), dementia (5.0%), alcohol abuse or dependence (2. 3%), and psychotic disorders (2.0%). Dysthymic disorder and primary anxiety and somatoform disorders were less common and frequently comorbid with major depression. CONCLUSIONS: Mental disorders, particularly depression, are common among older persons seen in these primary care settings. Clinicians should be particularly vigilant about depression when evaluating older patients with anxiety or putative somatoform symptoms, given the relatively low prevalences of primary anxiety and somatoform disorders.     

Pediatric cardiology and congenital heart disease: from fetus to adult

This article contains a review of some of the most important publications on congenital heart disease and pediatric cardiology that appeared in 2010 and up until September 2011. Of particular interest were studies on demographic changes reported in this patient population and on the need to manage the patients' transition from the pediatric to the adult cardiology department. This transition has given rise to the appearance of new areas of interest: for example, pregnancy in women with congenital heart disease, and the effect of genetic factors on the etiology and transmission of particular anomalies. In addition, this review considers some publications on fetal cardiology from the perspective of early diagnosis and, if possible, treatment. There follows a discussion on new contributions to Eisenmenger's syndrome and arrhythmias, as well as on imaging techniques, interventional catheterization and heart transplantation. Finally, there is an overview of the new version of clinical practice guidelines on the management of adult patients with congenital heart disease and of recently published guidelines on pregnancy in women with heart disease, both produced by the European Society of Cardiology.     

Aortic coarctation repair--lost and found: the role of local long term specialised care

BACKGROUND: Aortic coarctation is associated with significant abnormalities of the underlying vasculature. Surgical repair, although relieving obstruction, is not a cure; patients continue to have a high risk of complications with a significantly reduced life expectancy. It has become increasingly apparent that they require regular specialised follow up lifelong. However provision of such services is limited particularly for patients living some distance from the largest cities where specialised adult congenital heart disease services tend to based. We carried out a notes-based study to look at the adequacy of long term follow up in such patients and to assess the role of a local specialist cardiology service in managing these patients. METHODS: We carried out a notes-based study of 55 patients with aortic coarctation referred to a new specialist grown up congenital heart disease clinic based in a large district general hospital over 100 miles from the nearest surgical centre specialising in adult congenital heart disease. RESULTS: A significant proportion of the patients in this study had already suffered major complications by the time of referral. Despite this, nearly half had, at some stage, been lost to follow up and a third had been referred from the community with new complications. 52% of the women had produced children often with little cardiological support. Few patients had had any specialised imaging. At initial review in the clinic, 41% had significant hypertension, although only a small proportion were on antihypertensives. Following initial review in the specialist GUCH clinic, new medications were initiated in 55%, mostly for hypertension; aortic imaging was performed in 94%; and 22% were referred for further specialist investigation or invasive treatment. CONCLUSIONS: This study demonstrates that many patients with previous repair of aortic coarctation have not received optimal long term care. Many had been lost to regular cardiology follow up and, even amongst those who had been seen in cardiology clinics, there was a high frequency of poorly treated or unsuspected complications. The provision of local expert care from a cardiologist specialising in congenital heart disease allows earlier and more aggressive treatment of complications and may also improve compliance. Where a localised specialist is not available, general cardiologists need to work to protocol-driven care pathways with easy access to specialist support.     

Prevalence of Probable Mental Disorders Among Pediatric Asthma Patients in an Inner-City Clinic

Objective. To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. Method. In this pilot study, a consecutive sample of pediatric asthma patients aged 5–11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. Results. Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. Conclusions. These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.     

Biomedical and Psychosocial Evaluation of “Cured” Adults with Congenital Heart Disease

As a result of significant advances in diagnostic, surgical, interventional, and pharmacological approaches, up to 95% of infants born with a congenital heart defect now survive into adulthood and there are at least 800 000 adult congenital heart disease patients living in the United States. Unfortunately, many of these individuals consider themselves “cured” or “fixed” and might have the misperception of a cure for a variety of reasons. The “cured” label is problematic and congenital heart disease is most accurately considered a chronic condition. This article outlines the concerns associated with the cured label. This is followed by the presentation of 4 illustrating case studies. Members of an adult congenital cardiology healthcare team must be prepared to address the full spectrum of concerns faced by patients who experience unexpected health deterioration. This spectrum includes both biomedical and psychosocial factors.     

The effect of major depression on functional status in patients with coronary artery disease

OBJECTIVE: To examine the effect of major depression on reported functional status in a group of patients with coronary artery disease (CAD). SETTING: An inpatient cardiology service. PARTICIPANTS: Three hundred thirty-five inpatients with coronary artery disease who were free of dementia, Parkinson's disease, and other primary neurological illnesses. MEASUREMENTS: Duke Depression Evaluation Schedule, a structured psychiatric interview which included the Diagnostic Interview Schedule depression subscale, the Cumulative Illness Rating Scale, and two scales for measuring instrumental and self-maintenance activities of daily living. RESULTS: Twenty-seven subjects met DSM-IV criteria for major depression. Compared with subjects without major depression, depressed subjects were more than twice as likely to report a self-maintenance ADL deficit and were significantly more likely to report an IADL deficit than were nondepressed subjects (93 vs 71%). In regression models, female gender, older age, greater medical illness severity, and presence of major depression were significant predictors of self-maintenance ADL disability; and female gender, older age, greater medical severity, and presence of major depression significantly predicted greater IADL impairment. CONCLUSION: The presence of major depression was associated with functional disability in patients with CAD. Further research is needed to clarify whether antidepressant treatment significantly impacts both affective symptoms and functional status in patients with coronary heart disease.     

Cardiología pediátrica y cardiopatías congénitas: del feto al adulto

This article contains a review of some of the most important publications on congenital heart disease and pediatric cardiology that appeared in 2010 and up until September 2011. Of particular interest were studies on demographic changes reported in this patient population and on the need to manage the patients’ transition from the pediatric to the adult cardiology department. This transition has given rise to the appearance of new areas of interest: for example, pregnancy in women with congenital heart disease, and the effect of genetic factors on the etiology and transmission of particular anomalies. In addition, this review considers some publications on fetal cardiology from the perspective of early diagnosis and, if possible, treatment. There follows a discussion on new contributions to Eisenmenger's syndrome and arrhythmias, as well as on imaging techniques, interventional catheterization and heart transplantation. Finally, there is an overview of the new version of clinical practice guidelines on the management of adult patients with congenital heart disease and of recently published guidelines on pregnancy in women with heart disease, both produced by the European Society of Cardiology.     

Frustration and body image in children with and without congenital cardiopathy]

The aim of the present study was to determine the existence of differences on the type of response to frustration and disintegration of body image among children with congenital heart diseases (hospitalized and out patients) with or without symptomatology and children without heart disease. The study was performed in the outpatient clinic and the pediatric cardiology ward of the Instituto Nacional de Cardiología "Ignacio Chávez". Two tests were used: The Rosenzweig picture frustration test for children (PFT) and the human figure drawing (HFD) of Elizabeth Koppitz. No differences were found regarding the type of response to frustration, differences between groups were present in only two emotional items of the HFD. We conclude that children with congenital heart disease have special capabilities that enable them to respond to illness in adaptative ways.     

综合医院门诊冠心病患者精神卫生现状及心理干预的效果

目的：探讨综合医院门诊冠心病患者的精神卫生状况以及心理干预的临床效果。方法：采用精神卫生症状自评量表（SCL-90）对门诊确诊的87例冠心病患者进行心理卫生状况评定，找出患者存在的心理卫生问题，根据患者存在的问题进行心理疏导治疗。心理治疗采用以个体为对象，以心理疏导为主。对治疗前后的SCL-90各因子分进行比较。结果：综合医院门诊冠心病患者存在较多的心理卫生问题，主要是焦虑（78．2％）、抑郁（54．0％）、恐怖（33．3％）、强迫（33．3％）。给予心理疏导治疗后可明显地改善患者的心理卫生问题，治疗前后SCL-90各因子分比较，抑郁、焦虑、恐怖、强迫、人际敏感有显著好转（P〈0．01）。结论：冠心病患者存在焦虑、抑郁等心理卫生问题，恰当的心理治疗对冠心病患者的情绪状态有明显的治疗效果。     

Predictors of anxiety and depression in Egyptian thalassemic patients: A single center study

Thalassemic patients are vulnerable to emotional and behavioral problems. Each patient age group exhibits problems unique to that stage of development, and although up to 80 % of thalassemic patients are likely to have psychological disorders, e.g., anxiety and depression, predictors of these disorders remain poorly understood. The present study was designed to assess the prevalence of anxiety and depression in a sample of Egyptian thalassemic patients and to identify predictors of these psychiatric disorders. A case–control study was conducted in 218 thalassemic patients, with 244 healthy subjects as a control. All patients and control subjects were subjected to thorough evaluation of medical history and clinical examination, and examined by a psychiatrist using the clinician version of the structured clinical interview for DSM-IV (SCID-CV), hospital anxiety and depression scale and Coopersmith self-esteem inventory. Abnormal and borderline anxieties were reported by 36.7 and 20.6 % of thalassemic patients, respectively, while abnormal and borderline depressions were reported by 32.1 and 16.1 % of patients, respectively. Hospitalization, low self-esteem, diabetes mellitus and heart failure were independent predictors of anxiety. The independent predictors of depression were heart failure, hospitalization, diabetes mellitus, short stature and delayed puberty. Thalassemic patients were more vulnerable to anxiety and depression, indicating that screening and management for such psychiatric disorders should be considered in treating all such patients.     

Antisocial personality disorder is associated with increased severity of gambling, medical, drug and psychiatric problems among treatment-seeking pathological gamblers

AIMS: To evaluate systematically whether pathological gamblers with antisocial personality disorder (ASPD) experience increased severity of gambling, medical, psychiatric, substance use and psychosocial problems compared to pathological gamblers without ASPD. PARTICIPANTS, DESIGN AND MEASUREMENTS: Pathological gamblers (n = 237) entering an out-patient treatment study for pathological gambling completed the ASPD section of the Structured Clinical Interview for Diagnostic and Statistical Manual version IV (DSM-IV) Personality Disorders, California Psychological Inventory-Socialization Scale, Addiction Severity Index (ASI), Brief Symptom Inventory (BSI) and gambling questionnaires. SETTING: Pathological gambling research clinic. FINDINGS: Thirty-nine (16.5%) pathological gamblers met DSM-IV diagnostic criteria for ASPD. Compared to pathological gamblers without ASPD, pathological gamblers with ASPD were younger, more likely to be male and divorced/separated, and had fewer years of education. They also began gambling earlier in life, reported increased severity of gambling, medical and drug problems, and scored higher on the paranoid ideation, somatization and phobic anxiety subscales of the BSI. Further, logistic regression identified male gender, history of illicit drug use and severity of gambling and medical problems as independent predictors of ASPD. CONCLUSIONS: These results underscore the importance of assessing a wide range of behaviors and personality indices, including ASPD, among treatment-seeking pathological gamblers.     

Evaluation of congenital heart disease in adults

Improvements in the diagnosis and surgical treatment of congenital heart disease during infancy and childhood have resulted in an outstanding increase in the prevalence of these entities during adulthood. Congenital heart disease in the adult represents a new diagnostic challenge to the consultant cardiologist, unfamiliar with the anatomical and functional complexities of cardiac malformations. Assessment of adult congenital heart disease with imaging techniques can be as accurate as in children. However, these techniques cannot substitute for a detailed clinical assessment. Physical examination, electrocardiography and chest x-rays remain the three main pillars of bedside diagnosis. Transthoracic echocardiography is undoubtedly the imaging technique which provides most information, and in many situations no additional studies are needed. Nevertheless, ultrasound imaging properties in adults are not as favorable as in children, and prior surgical procedures further impair image quality. Despite recent advances in ultrasound technologies such as harmonic or contrast imaging, other diagnostic procedures are sometimes required. Fortunately, transesophageal echocardiography and magnetic resonance imaging are easily performed in the adult, and do not require anaesthetic support, in contrast to pediatric patients. These techniques, together with nuclear cardiology and cardiac catheterization, complete the second tier of diagnostic techniques for congenital heart disease. To avoid unnecessary repetition of diagnostic procedures, the attending cardiologist should choose the sequence of diagnostic techniques carefully; although the information this yields is often redundant, it is also frequently complementary. This article aims to compare the diagnostic utility of different imaging techniques in adult patients with congenital heart disease, both with and without prior surgical repair.     

Progress in pediatric cardiology and congenital heart defects

We present a review of progress reported in the fields of pediatric cardiology and congenital heart disease between July 2004 and July 2005. The review covers diagnosis, medical treatment, interventional cardiology, and surgery. Among advances in diagnosis, we highlight new diagnostic imaging methods such as three-dimensional echocardiography, magnetic resonance imaging, CT angiography, and tissue Doppler imaging. In the area of fetal cardiology, we focus on advances in fetal interventions, such as percutaneous aortic valvuloplasty, percutaneous pulmonary valvuloplasty, and intact or restrictive atrial balloon septostomy. In interventional cardiology, we highlight advances in the application of percutaneous techniques to adult congenital heart disease to help solve problems resulting from previous surgery, and we review new devices for enabling the percutaneous closure of muscular and membranous ventricular septal defects. In cardiac surgery, a number of developments in valved conduits and in aortic translocation in patients with complex transposition of the great arteries are of particular interest.     

Long-term statin use and psychological well-being

OBJECTIVES: We sought to study the effect of long-term statin use on psychometric measures in an adult population with underlying coronary artery disease (CAD). BACKGROUND: Previous studies have suggested associations between cholesterol lowering and psychological well-being. METHODS: Study subjects were recruited from an outpatient cardiology clinic. Psychological well-being was assessed at baseline and annually during follow-up. The exposure of interest was long-term statin use and the outcomes of interest were depression, anxiety, and hostility. We estimated the odds ratios (ORs) and 95% confidence intervals (CI) that represented the strength of association between statin use (vs. no use of any cholesterol-lowering drug) and the risk of having abnormal depression, anxiety, and hostility scores. RESULTS: Study subjects had an average follow-up of four years and maximum of seven years. Comparing the 140 patients who had continuous use of statins with the 231 patients who did not use any cholesterol-lowering drugs, statin use was associated with lower risk of abnormal depression scores (OR 0.63, 95% CI 0.43 to 0.93), anxiety (OR 0.69, 95% CI 0.47 to 0.99), and hostility (OR 0.77, 95% CI 0.58 to 0.93) after adjustment for the propensity for statin use and potential confounders. The beneficial psychological effects of the statins appeared to be independent of the drugs' cholesterol-lowering effects. CONCLUSIONS: Long-term use of statins among patients with CAD appeared to be associated with reduced risk of anxiety, depression, and hostility.     

Needles in Hay: Chest Pain as the Presenting Symptom in Children with Serious Underlying Cardiac Pathology

Introduction. Chest pain in children is common, but rarely heralds serious underlying cardiac pathology. Despite this, the anxiety of missing a potentially life threatening condition creates a large burden of referrals and diagnostic testing. We evaluated patients diagnosed with 1 of 9 serious cardiac diseases and detailed the clinical signs and symptoms of the patients presenting with chest pain. Methods. Patients diagnosed between the ages of 7 and 21 years from January 2000 to December 2009 at Children's Hospital Boston (CHB) were identified from a database using diagnostic and billing codes for aortic dissection, coronary anomalies, dilated cardiomyopathy, hypertrophic cardiomyopathy, myocarditis, pericarditis, pulmonary embolus, pulmonary hypertension, and Takayasu arteritis. Patients with previously diagnosed congenital or acquired heart disease were excluded. Results. Four hundred eighty-four patients were included and 35% presented with chest pain. Forty-one (24%) of these patients with chest pain were diagnosed in the outpatient cardiology clinic, while the remaining 130 patients (76%) were diagnosed in the emergency department (ED) or inpatient setting. Coronary artery anomalies were the most common diagnosis made in cardiology clinic, and 16 of the 23 (70%) patients with serious coronary anomalies had exercise-induced chest pain. Patients presenting to the ED or inpatient units tended to have other important nonspecific symptoms (35–44%), high-risk past medical histories (12%), physical examination findings (32%), and electrocardiogram (ECG) abnormalities (78%) that heighten clinical suspicion of cardiac disease. Conclusions. Identifying underlying cardiac pathology in the CHB outpatient cardiology department in patients presenting with chest pain is rare, with only 41 cases over a 10-year period. The presence of exertional chest pain was important in identifying patients with coronary artery anomalies. A detailed history and physical examination, along with a critical review of an ECG, seem to identify those patients with rare diseases who need further diagnostic testing.     

The association of comorbid anxiety and depression with asthma-related quality of life and symptom perception in adults

Background and objective:   There are limited data on the association and interaction between anxiety and depression comorbidity and asthma-related quality of life (AQOL) and symptom perception. This study evaluated these associations in patients subsequent to an emergency department (ED) visit for asthma.
Methods:   This was a cross-sectional study of 110 (38 male) adult asthma patients (mean age 42 years), who had visited an ED in the previous 18 months. Participants completed the hospital anxiety and depression scale, measures of AQOL and the asthma symptom checklist.
Results:   Depression symptoms independently showed a significant negative association with AQOL after controlling for depression/anxiety, age, gender, smoking status and ED visits in the previous 12 months (ED-12). Overall, anxiety and depression symptoms accounted for 28.3% of the variance in AQOL. Greater anxiety was associated with increased perception of asthma-specific panic-fear and hyperventilation symptoms during an asthma attack, irrespective of depression status. Categorical analyses of groups of patients, differentiated by psychometric properties on the hospital anxiety and depression scale (anxiety vs normal, anxiety and depression vs normal depression) confirmed most results. However, for the anxiety group there was a significant association with the AQOL domains of emotional functioning and response to environmental stimuli, after controlling for depression symptoms.
Conclusions:   The negative association of depression symptom scores with AQOL and of anxiety with increased panic-fear and hyperventilation symptoms suggests a potential role for interventions addressing this psychological comorbidity, in order to improve AQOL.