Mental symptoms and quality of life in lipoprotein apheresis patients in comparison to hemodialysis patients, platelet donors and normal population

Atherosclerosis Supplements 18 (2015) 233e240 www.elsevier.com/locate/atherosclerosis

Mental symptoms and quality of life in lipoprotein apheresis patients in comparison to hemodialysis patients, platelet donors and normal population E. Stasiewski a,1, M. Christoph b,1, A. Christoph a, A. Bittner c, K. Weidner c, U. Julius a,* a

Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universita¨t Dresden, Fetscherstr.74, 01307 Dresden, Germany b Heart Center, University Hospital Carl Gustav Carus at the Technische Universita¨t Dresden, Germany c Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus at the Technische Universita¨t Dresden, Germany

Abstract Background: Despite the fact that extracorporeal methods such as lipoprotein apheresis (LA) and hemodialysis (HD) are highly effective in improving the physical status of patients, these treatment options may possibly harm the psychological status and the health related quality of life (HRQL). Methods: The occurrences of anxiety, depression and the HRQL of 111 study participants treated with LA (n ¼ 41), HD (n ¼ 41) or undergoing plateletpheresis (PD) (n ¼ 29) were compared to the normal population (NP), using standardized questionnaires (anxiety and depression: Hospital Anxiety and Depression Scale (HADS), heart-focused anxiety: Cardiac Anxiety Questionnaire (CAQ) and HRQL: Short-Form Health Survey (SF-12)). Additionally, the subjective mental and physical stress of study participants was evaluated. Results: LA females had a significantly elevated HADS-A score compared to PD and NP. Additionally, there was a trend toward higher HADS-A scores in the LA group compared to the HD group in females. In HD males HADS-A and -D scores increased compared to PD and NP. The CAQ revealed a significant increase in the CAQ-Fear scale in LA compared to HD and PD participants. The CAQ-Avoidance score showed significantly increased scores in LA and HD patients compared to PD and NP. In the CAQ-Attention scale the LA patients also showed significantly increased scores compared to PD and NP. The increased psychological symptoms were associated with significantly lower levels of objective and subjective HRQL in LA and HD patients compared to PD and NP. Conclusions: LA and HD patients had similarly increased presence of psychological symptoms with concurrent decreased quality of life compared to PD and the normal population, which may affect the outcome of the LA patients. Therefore, early psychosomatic screening and probable psychosomatic treatment should be performed. Ó 2015 Elsevier Ireland Ltd. All rights reserved.

Keywords: Lipoprotein apheresis; Hemodialysis; Plateletpheresis; Mental disorders; Health-related quality of life; Depression; Anxiety; Psychosomatic diagnostic

1. Introduction * Corresponding author. Tel.: þ49 351 458 2306; fax: þ49 351 458 5306. E-mail addresses: [email protected] (E. Stasiewski), Marian. [email protected] (M. Christoph), Antje.Christoph@ uniklinikum-dresden.de (A. Christoph), [email protected] (A. Bittner), [email protected] (K. Weidner), [email protected] (U. Julius). 1 E. Stasiewski and M. Christoph contributed equally to writing this paper. http://dx.doi.org/10.1016/j.atherosclerosissup.2015.02.035 1567-5688/Ó 2015 Elsevier Ireland Ltd. All rights reserved.

Therapeutic extracorporeal procedures have been established as effective treatment options in patients with severe hyperlipoproteinemia (lipoprotein apheresis (LA)) and renal failure (hemodialysis (HD)) [1,2]. Additionally, an extracorporeal method is used for the plateletpheresis in healthy people (platelet donors (PD)).

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Although both LA and HD are highly effective in improving the physical status and outcome of the patients, these treatment options in and of themselves may harm patients’ psychological status and health related quality of life (HRQL) [3]. It is known that patients suffering from chronic somatic disorders have relevant psychological comorbidities like anxiety and depression [4]. Each of these disorders is associated with substantial functional impairment, increased disability days and elevated health care costs [5]. A decisive difference between the different extracorporeal methods in LA, HD and PD patients is the dependence of the people on their procedure with respect to survival. LA patients are high-risk patients suffering from accelerated atherosclerosis due to severe hyperlipoproteinemia (HLP). They suffered from potentially life-threatening events caused by cardiac disease or extracoronary atherosclerotic manifestation. In patients suffering from HLP, LA treatment reduces vascular complications and improves the outcome [6]. HD patients undergoing hemodialysis are high-risk patients suffering from acute or chronic renal failure due to different primary or secondary renal diseases. For patients with an end stage renal disease the HD is essential for surviving. In contrast, the PD do not use the extracorporeal method for their own health and outcome. Because of this important difference in procedure dependency we suspected different influences on the mental stress and quality of life caused by the extracorporeal methods. To date, some studies have shown a higher incidence of depression in HD patients compared to normal population [7e10]. However, no data comparing different extracorporeal treatment groups e especially LA patients with respect to their mental symptoms and health related quality of life e are available. Therefore, we conducted a cross-sectional registry to examine this important aspect of the general health of these individuals. 2. Material and methods 2.1. Study design The current trial was a cross sectional, single-center study performed in compliance with the guidelines for good clinical practice and the Declaration of Helsinki. All data were collected, managed and analyzed at the University Hospital Dresden, Germany. The endpoints of this study were the presence of anxiety and depression and the objective and subjective HRQL using standardized questionnaires. 2.2. Study population and protocol Eligible subjects were males or females >18 years of age who were regularly undergoing an extracorporeal procedure. No other inclusion criteria were necessary.

Prior to enrollment into the study all participants received detailed verbal and written information about the content and purpose and written informed consent was obtained. In total, 111 participants were included. The study population consisted of three different extracorporeal method groups: 1: 41 LA patients (26 men and 15 women, mean age 61 (42e76 years)) undergoing regular therapeutic LA at the Lipoprotein Apheresis Center of the Department of Internal Medicine III at the University Hospital Dresden, Germany, 2: 41 HD patients (22 men and 19 women, mean age 61 (40e77 years)) from the Dialysis Center of the Curatorium for dialysis and renal transplantation and 3: 29 PD (16 men and 13 women; mean age 35, (20e56 years)) from the Thrombocytapheresis Unit of the Department of Transfusion Medicine of the Department of Internal Medicine I at the University Hospital Dresden. A statistically based matching of all three groups was not performed. Additionally, all groups were compared to a normal population (NP) without history of extracorporeal treatment. 2.3. Questionnaires Questionnaires were distributed at the respective treatment centers and answered by the patients during treatment sessions. Socio-demographic data, somatic comorbidities, duration and frequency of the extracorporeal treatment as well as subjective self-assessment concerning the mental and physical stress caused by the undergoing procedure were documented in a nonstandardized questionnaire. The Hospital Anxiety and Depression Scale (HADS), developed to identify and quantify symptoms of anxiety and depression in patients with physical disorders, is a 14-item self-report diagnostic approach containing two subscales of anxiety (HADS-A 7 items) and depression (HADS-D 7 items). Higher scores on the subscales indicate more symptoms of anxiety or depression. We used the German version of HADS, which has been found to have good psychometric properties [11,12]. For comparison of our 3 treatment groups with normal people, the normative mean values of the Hospital Anxiety and Depression Scale of appropriate comparison groups with regard to age and gender in the general German population were used [13,14]. The Cardiac Anxiety Questionnaire (CAQ) is a 17-item self-report inventory score on a five-point Likert-type scale, anchored from 0 (never) to 4 (always) [15]. The CAQ includes 3 subscales: (a) Fear (8 items); (b) Avoidance (5 items) and (c) Attention (5 items). Higher scores on this questionnaire indicate greater anxiety. The CAQ has an adequate convergent validity with established psychiatric measures like the Anxiety Sensitivity Index [16]. Additionally, the CAQ has been used as

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a cognitive behavior-therapy outcome measure [17]. The German version of CAQ, which we used in our trial, includes just 17 items (one item of the fear subscale was skipped due to differential item functioning in German compared to English) and has shown satisfactory psychometric properties [18]. In comparison, sample subjects without a history of extracorporeal treatments were used (n ¼ 105; age, mean  SD: 56.6  14.86 years) [18]. Because of the lack of gender specific values in the normal population both genders were evaluated together in this questionnaire. 12-Item Short-Form Health Survey (SF-12) is a frequently used self-evaluation scale designed to assess quality of life in relation to physical and mental health. The SF-12 comprises two subscales: a physical impairment score and a psychological impairment score. Higher values indicate a better health status [19]. Validation by various studies in patients as well as in general populations has demonstrated this questionnaire to have good psychometric properties [20]. For comparison, nonclinical German normative samples of the same age cohort were used (normative sample with regard of LA and HD patients: n ¼ 421; age: 61e70 years; normative sample for PD: n ¼ 539; age: 31e40 years) [21].

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The participating physicians and nurses had been trained in the correct usage of the questionnaires. After data collection, all questionnaires were anonymized. 2.4. Statistical analyses All variables were analyzed with respect to normality with the graphical method of normal probabilityquantile plot in combination with the Kolmogorove Smirnov test (data not shown). Results of continuous variables are expressed as means  standard deviation (standard error (SEM) in figures). Analysis of variance (ANOVA) was used to reveal differences between all treatment groups. In case of significant differences (p < 0.005), a 2 tailed, unpaired student’s t-test followed to compare two particular groups. T-tests for single means were calculated to examine differences between the study sample and the comparison samples. Level of significance was set at p < 0.05. Categorical variables are presented as total number with comparison using chi-square statistics and Fisher exact test. Significance level was set to p < 0.05. Regression analyses were used to determine relations between mental symptoms and quality of life. Level of significance was set at p < 0.05.

Table 1 Baseline characteristics.

Number of participants [N] Age [years] (range) Gender male [N] (%) Marital Status [N] (%) Single Partnership Married Divorced Widowed Education [N] (%) No degree Secondary school degree Junior high school High school College degree Apprentice ship Other qualification Employment situation [N] (%) Self-employed Employed Pensioner EU-pensioner Unemployed Student Smoker [N] (%) Alcohol [N] (%) Diabetes [N] (%) Hypertension [N] (%) Hyperlipidemia [N] (%) Atherosclerosis [N] (%) Mean procedure duration [years] (range)

LA

HD

PD

Significance (p)

41 61 (42e76) 26 (63.4)

41 61 (40e77) 22 (53.7)

29 35 (20e56) 16 (55.2)

<0.001 0.64

1 (2.4) 1 (2.4) 34 (82.9) 3 (7.3) 2 (4.9)

5 (12.2) 0 (0) 29 (70.7) 4 (9.8) 3 (7.3)

13 (44.8) 6 (20.7) 7 (24.1) 3 (10.3) 0 (0)

<0.001

0 (0) 0 (0) 5 (12.5) 1 (2.5) 11 (27.5) 21 (52.5) 2 (5.0)

1 (2.4) 8 (19.5) 4 (9.8) 1 (2.4) 4 (9.8) 22 (53.7) 1 (2.4)

0 (0) 0 (0) 1 (3.4) 5 (17.2) 7 (24.1) 14 (48.3) 2 (6.9)

0.005

0 (0) 6 (14.6) 21 (51.2) 13 (31.7) 1 (2.4) 0 (0) 1 (2.4) 31 (79.5) 17 (14.6) 29 (74.4) 38 (100) 37 (92.5) 8.7 (0.5e20)

2 (5) 4 (10.0) 22 (55.0) 12 (30.0) 0 (0) 0 (0) 6 (14.6) 20 (50) 8 (21.6) 27 (71.1) 9 (28.1) 26 (66.7) 7.7 (0.5e22)

3 (10.3) 20 (69.0) 0 (0) 0 (0) 3 (10.3) 3 (10.3) 4 (13.8) 25 (89.3) 0 (0) 3 (10.3) 3 (10.3) 0 (0) 3.5 (0.5e13)

<0.001 0.13 0.002 <0.001 <0.001 <0.001 <0.001 0.002

EU-pensioner: premature pensioner caused by health problems.

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3. Results

LA

HD

PD

NP

2.5

p=229

p<0.001

p=0.048

3.1. Baseline characteristics

p<0.001

p<0.001

p<0.001

p<0.001

p=0.137

p=0.001

p<0.001 p=0.542

2.0

1.5

p<0.001 p<0.001

1.0

0.5

0

1.6

1.2

HD

PD

p=0.003

mean scores

HD

PD

0.4 1.0

CAQ-Attention

NP

p=0.038 p=0.011

p<0.001

p=0.919

p=0.242

1.4 1.1

p=0.029

p<0.001

p=0.706

60

P=0.009

p<0.001

p=0.043

p=0.055 p=0.001

p=0.04

p=0.127

8

p<0.001

50

p<0.001

p=0.003

p=0.001 p=0.834

p=0.155

6

40 30

4

20

2

10

0

1.1

The results of the CAQ questionnaire are shown in detail in Fig. 2. The CAQ revealed a significant increase of the CAQ-Fear scale in LA compared to HD and PD participants. Additionally, in contrast to HD and PD patients, who had significantly lower CAQ-Fear scores compared to NP, there was no difference in this scale between LA and NP. The CAQ-Avoidance score showed significantly increased scores in LA and HD patients compared to PD and NP (LA: 1.7  1.1 vs. PD: 0.5  0.6, p < 0.001 vs. NP: 1.1  0.9, p < 0.001 and HD: 1.9  1.2 vs. PD: 0.5  0.6, p < 0.001 vs. NP: 1.1  0.9, p < 0.001). The PD exhibited a significantly lower CAQ-Avoidance score compared to the NP. In the CAQ-Attention scale the LA patients also showed

mean scores

10

p=0.04

0.5

CAQ-Avoidance

3.3. Cardiac anxiety questionnaire (CAQ)

p<0.001

p=0.005

p=0.879

p=0.057

1.7 1.9

p=0.001 p=0.004

p=0.003

p=0.002

1.5

Fig. 2. CAQ. Comparison of the mean values of the subscales of the CAQ (fear, avoidance, attention) between LA, HD, PD and NP (mean values  SEM).

NP

p=0.353

0.6

CAQ-Fear

LA

LA

p<0.001 p=0.068

3.2. Hospital anxiety and depression scale (HADS) The detailed results of the HADS-A and HADS-D scale are illustrated in Fig. 1. Evaluating the HADS-A scale, male LA patients demonstrated a tendency to higher HADS-A scores compared to the PD and the NP. The male HD patients had significantly increased HADS-A scores compared to PD and NP (HD: 7.9  3.8 vs. PD: 3.8  3.5, p ¼ 0.003 vs. NP: 4.6  3.2, p ¼ 0.002). In females, the LA patients revealed significantly higher HADS-A scores in comparison to the PD and NP (LA: 7.0  3.3 vs. PD: 3.3  1.8, p ¼ 0.001 vs. NP: 5.1  3.6, p ¼ 0.04). Additionally, there was a trend to higher HADS-A scores in the LA group compared to the HD group in females. The HD group revealed no relevant differences in women compared to the normal population. Analyzing the HADS-D scale, there was a significant increase of the HADS-D score in LA males compared to PD (LA: 4.8  3.4 vs. PD: 2.5  3.6, p ¼ 0.043) but not compared to NP. The HD males had significantly higher HADS-D scores compared to PD and NP. In female patients there were no relevant differences in the HADS-D score between LA, HD and NP. Only the PD had significantly decreased HADS-D scores compared to the other groups.

p<0.001

p<0.001 p=0.011

mean scores

The baseline characteristics are described in Table 1. The mean duration of the respective procedure was 8.7  6.3 [range 0.5e20] years in LA patients, 7.7  5.8 [range 0.5e22] years in HD patients and 3.5  2.9 [range 0.5e13] years in the PD. The LA and the HD groups were well balanced with regard to the demographics and clinical baseline characteristics. In contrast, the PD were significantly younger and had significantly fewer comorbidities.

5.7 7.9 3.8 4.6

7.0 4.9 3.3 5.1

male

female HADS-A

4.8 8.1 2.5 5.6

5.8 5.5 1.2 5.4

male

female

0

37.2

35.1

54.5

44.3

Physical quality of life

49.3

48.4

54.2

53.4

Psychological quality of life

HADS-D

Fig. 1. HADS-A and HADS-D. Comparison of the mean values of HADSA and HADS-D between LA, HD, PD and NP (mean values  SEM).

Fig. 3. Health related Quality of Life. Comparison of the physical quality of life subscale and the psychological quality of life subscale of the SF-12 between LA, HD, PD and NP (mean scores  SEM).

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significantly increased scores compared to PD and NP (LA: 1.4  0.79 vs. PD: 0.4  0.4, p < 0.001 vs. NP: 1.0  0.6, p ¼ 0.001). In HD patients there were no relevant differences in CAQ-Attention compared to NP. Also in the CAQAttention scale the PD patients had significantly decreased scores compared to NP. 3.4. Health related quality of life (SF-12) Results of SF-12 are illustrated in Fig. 3. Both LA and HD patients revealed significantly decreased scores in the physical and psychological quality of life compared to PD and NP (physical HRQL: LA: 37.2  10.8 vs. NP 44.3  9.5 p ¼ 0.001; psychological quality of life: LA patients: 49.3  10.5 vs. NP 53.4  7.5, p ¼ 0.038). LA and HD patients showed similar scores in physical and mental quality of life. In contrast the PD revealed significantly higher scores on both scales of quality of life compared to the NP (physical HRQL: PD 54.5  3.8 vs. NP

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44.3  9.5, p ¼ 0.003; psychological HRQL: PD 54.2  4.6 vs. NP 53.4  7.5, p ¼ 0.019). 3.5. Patient self-assessment In the patient self-assessment, with regard to physical stress, 57.5% of LA patients indicated moderate distress and 32.5% complained of mild distress. The HD patients appeared to be the most burdened group with moderate (52.9%), marked (23.5%) and severe distress (14.7%). In contrast, 50% of PD explained not to be stressed at all and 42.9% of PD were only mildly stressed. The study groups differed significantly (Fisher exact test: p < 0.001). The mental self-assessment yielded similar significant differences (p < 0.001). HD patients reported the most stress, declaring moderate (47.1%), marked (11.8%) and severe (5.9%) distress. LA patients were not at all (25.0%), mildly (37.5%) to moderately (35.0%) stressed. None of the PD declared emotional stress.

Table 2 Regression analyses.

Predictors of physical quality of life Sex (0 male j 1 female) Age Partner (0 no j1 yes) Qualification (0 low j 1 high) Employed (0 no j 1 yes) Smoking (0 no j 1 yes) Alcohol (0 no j 1 yes) Angiopathy in the past (0 no j 1 yes) Hypertension (0 no j 1 yes) Diabetes mellitus (0 no j 1 yes) Hyperlipidemia (0 no j 1 yes) Subjective physical stress Subjective mental stress HADS-anxiety HADS-depression HAF-total score Predictors of psychological quality of life Sex (0 male j 1 female) Age Partner (0 no j1 yes) Qualification (0 low j 1 high) Employed (0 no j 1 yes) Smoking (0 no j 1 yes) Alcohol (0 no j 1 yes) Angiopathy in the past (0 no j 1 yes) Hypertension (0 no j 1 yes) Diabetes mellitus (0 no j 1 yes) Hyperlipidemia (0 no j 1 yes) Subjective physical stress Subjective mental stress HADS-anxiety HADS-depression HAF-total score

Lipoprotein apheresis

Hemodialysis

B

P

B

p

B

p

L9.409 0.104 3.64 4.855 3.363 14.802 9.776 6.276 1.324 0.493 n/a 5.54 3.455 L1.331 L1.066 L9.985

< 0.05 0.658 0.496 0.327 0.499 0.179 < 0.05 0.437 0.773 0.905 n/a 0.042 0.118 < 0.05 < 0.05 < 0.01

0.249 0.245 7.22 4.599 9.854 4.19 1.656 1.568 1.641 5.495 1.391 L6.739 L3.982 L1.178 L1.394 L8.313

0.945 0.13 0.083 0.255 < 0.05 0.351 0.639 0.675 0.701 0.192 0.73 < 0.001 < 0.05 < 0.01 < 0.01 < 0.001

0.893 L0.181 1.687 2.938 0.996 1.316 0.132 n/a 1.061 n/a 0.168 0.239 n/a L0.597 L0.619 L6.734

0.557 < 0.01 0.261 0.217 0.68 0.585 0.957 n/a 0.66 n/a 0.951 0.829 n/a < 0.05 < 0.05 < 0.05

4.206 0.104 3.373 1.871 0.324 6.131 5.89 9.034 2.85 4.292 n/a L9.091 2.173 L2.327 L1.951 4.355

0.278 0.104 0.517 0.7 0.947 0.573 0.214 0.242 0.523 0.266 n/a < 0.001 0.318 < 0.001 < 0.001 0.161

5.737 0.02 1.949 4.565 0.143 0.898 2.699 1.78 2.717 2.864 6.474 L6.492 L7.071 L1.868 L1.683 L8.865

0.119 0.907 0.661 0.279 0.976 0.849 0.462 0.643 0.541 0.519 0.109 < 0.01 < 0.001 < 0.001 < 0.001 < 0.001

0.327 0.096 3.716 2.751 0.741 L7.711 1.358 n/a 0.063 n/a 2.237 0.217 n/a L1.01 L0.983 2.822

0.858 0.261 < 0.05 0.335 0.797 < 0.01 0.638 n/a 0.983 n/a 0.518 0.884 n/a < 0.001 < 0.001 0.412

B: regression coefficient, p: level of significance. Significant values are marked in bold (p < 0.05).

Plateletpheresis

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In addition to the above-mentioned assessments, we performed a regression analysis with regard to physical and psychological HRQL, which indicated that the physical and psychological quality of life were significantly associated with psychopathological symptoms (anxiety and depression, heart-focused anxiety, subjective physical and mental distress). In contrast, socio-demographic factors or somatic comorbidities did not influence the quality of life (detailed data in Table 2). 4. Discussion Extracorporeal treatment methods such as lipoprotein apheresis, hemodialysis and plateletpheresis are associated with psychopathological symptoms and a reduced health related quality of life (HRQL). Therefore we investigated psychological symptoms and the quality of life in these three different extracorporeal procedure groups and compared them with the normal population. A special focus of the presented trial was the assessment of patients undergoing LA, because to date, no published data are available dealing with the mental status of these patients. The salient finding of the current study was that patients undergoing a therapeutic extracorporeal treatment (LA and HD, but not PD) suffer more from psychological symptoms than the normal population. These increased mental symptoms are associated with a significant reduction of the patients’ HRQL. Several studies have demonstrated that psychological disorders like anxiety and depression are frequent in patients with somatic, especially with chronic somatic diseases [22,23]. These mental symptoms are known to significantly reduce the patient’s outcome [24,25]. Additional trials have shown that quality of life is an important indicator of patient’s clinical outcomes [26]. The HADS questionnaire revealed in detail more symptoms of anxiety and depression in LA and HD patients compared to PD. These findings are consistent with previous studies, which also showed a higher incidence of depression in HD patients compared to normal population [7,9,10]. In the work of Feroze and colleagues, the prevalence for depression and anxiety was determined by 20e42% and 27e45% in patients on dialysis [7]. Preljevic et al. assessed depressive disorders in 22% and anxiety disorders in 17% of dialysis patients [9]. Zhang et al. identified 45% anxiety and 32% depression in HD patients compared to 2.5% and 5% in the normal population [10]. This high prevalence of psychological symptoms is potentially caused by the permanent HD induced somatic stress of the patients [7]. Further, Johnson and Dwyer reported that over 70% of patients on HD who had symptoms of depression or anxiety did not recognize their symptoms or did not perceive that they were in need of therapy for their mental health conditions, which could potentially increase the response of the somatic therapy and the quality of life [8].

Another interesting but unsurprising finding of our study was that the PD patients revealed fewer symptoms of anxiety and depression than the normal population. A possible explanation for this could be a selection of very healthy people (somatic and psychological), who decided to participate as thrombocyte donors and which are even more healthy than the normal population. But to date there exist no data about the mental status of these thrombocyte donors compared to the normal population. Looking at the CAQ questionnaire the heart-focused fear is not a prevalent mental symptom in LA and HD patients. Rather, these patients suffer more from avoidance behavior and self-attention compared to PD and the normal population. A possible explanation is that patients treated with extracorporeal methods are well educated about their illness including the potential dangerous cardio-vascular complications. Therefore, these patients note their heart related symptoms very accurately, even pathologically, which leads to an avoidance of physical work. Finally, evaluation of the health related quality of life demonstrated a significant reduction of the psychological and physical HRQL in LA and HD patients compared to PD and the NP. This finding of impaired HRQL in patients maintaining hemodialysis in comparison to the NP has been well documented by many studies over the years [27e29]. The negative dependence of the incidences of psychological symptoms and the HRQL is confirmed by a previous study [30]. Contrarily, PD had even a significantly better mental and physical HRQL than the NP. This is potentially caused by the above-mentioned selection of very healthy people. In the current study, the objective results of reduced HRQL were additionally confirmed by patient’s subjective self-assessment, which also revealed an increased burden of physical and psychological stress. Recent papers have shown that the prognosis of patients with psychological symptoms, including HD patients, can be improved with the help of cognitive-behavioral therapies [31,32]. Whether a psychosomatic therapy is able to decrease the psychological symptoms and improve the quality of life in LA patients remains highly speculative, since there are no data to support this. However, in other fields of medicine such as gynecology, cardiology, oncology and diabetology it has been demonstrated that psychotherapy has a positive impact on the course of depressive and anxiety symptoms in physically ill patients [33e35]. Therefore further prospective studies of the impact of psychosomatic intervention on anxiety and depression in LA patients would be desirable. Some limitations of the current study must be noted. The interpretability of the results is reduced because the health status of the participants was only measured using subjective ratings. A full psychiatric examination of the study population using a standardized Interview like SCID-I/II (Structured Clinical Interview for DSM-IV) was not performed. Although appropriate comparison groups as NP were chosen with regard to age and gender, it is certainly

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not excluded that the NP group is slightly different compared to the studied participants. Although the participation rate was very high, the potential subjects who did not reply to the study invitation could have caused a selection error. In particular, people with severe mental health problems could have chosen to participate in this survey, which would result in overestimation of mental symptoms in people undergoing extracorporeal procedures.

[7]

[8]

[9]

5. Conclusions Like HD patients, LA patients have similar increased presence of anxiety and depression with commensurate decreased quality of life when compared to PD and the normal population. Because this high incidence of psychological symptoms may affect the outcome of LA patients, an early psychosomatic screening and probable psychosomatic treatment should be performed.

[10]

[11]

[12] [13]

Conflicts of interest In the last 3 years, the corresponding author was reimbursed travel expenses by Diamed, Fresenius, and B. Braun. He was paid honoraria for lectures by MSD and Fresenius as well as for lipidologic evaluations by Fresenius. The other authors state that they do not have anything to declare. Acknowledgment Thanks to the staff of the Apheresis Center, to the staff of the Dialysis Center and to Dr. K. Ho¨lig with the staff of the Thrombocytapheresis of the Department of Transfusion Medicine.The authors are grateful to Kathy Eisenhofer for her help with the manuscript as a native speaker.

[14]

[15]

[16]

[17]

[18]

[19]

[20]

References [1] Taseva K, Fischer S, Passauer J, Weiss N, Bornstein SR, Julius U. Factors inducing cardiovascular events in patients treated by lipoprotein apheresis. Atheroscler Suppl 2013;14:45e50. [2] von Dryander M, Fischer S, Passauer J, Muller G, Bornstein SR, Julius U. Differences in the atherogenic risk of patients treated by lipoprotein apheresis according to their lipid pattern. Atheroscler Suppl 2013;14:39e44. [3] Preljevic VT, Osthus TB, Os I, Sandvik L, Opjordsmoen S, Nordhus IH, et al. Anxiety and depressive disorders in dialysis patients: association to health-related quality of life and mortality. Gen Hosp Psychiatry 2013;35:619e24. [4] Lowe B, Spitzer RL, Williams JB, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry 2008;30:191e9. [5] Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 2005;62:903e10. [6] Leebmann J, Roeseler E, Julius U, Heigl F, Spitthoever R, Heutling D, et al. Lipoprotein apheresis in patients with maximally

[21] [22]

[23]

[24]

[25]

[26]

239

tolerated lipid-lowering therapy, lipoprotein(a)-hyperlipoproteinemia, and progressive cardiovascular disease: prospective observational multicenter study. Circulation 2013;128:2567e76. Feroze U, Martin D, Reina-Patton A, Kalantar-Zadeh K, Kopple JD. Mental health, depression, and anxiety in patients on maintenance dialysis. Iran J Kidney Dis 2010;4:173e80. Johnson S, Dwyer A. Patient perceived barriers to treatment of depression and anxiety in hemodialysis patients. Clin Nephrol 2008; 69:201e6. Preljevic VT, Osthus TB, Sandvik L, Opjordsmoen S, Nordhus IH, Os I, et al. Screening for anxiety and depression in dialysis patients: comparison of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory. J Psychosom Res 2012;73:139e44. Zhang M, Kim JC, Li Y, Shapiro BB, Porszasz J, Bross R, et al. Relation between anxiety, depression, and physical activity and performance in maintenance hemodialysis patients. J Ren Nutr 2014; 24:252e60. Herrmann C. International experiences with the Hospital Anxiety and Depression Scaleea review of validation data and clinical results. J Psychosom Res 1997;42:17e41. Herrmann C, Buss U, Snaith RP. Hospital anxiety and depression scale e Deutsche version (HADS-D). Manual; 19951. Hinz A, Schwarz R. [Anxiety and depression in the general population: normal values in the Hospital Anxiety and Depression Scale]. Psychother Psychosom Med Psychol 2001;51:193e200. Hinz A, Brahler E. Normative values for the hospital anxiety and depression scale (HADS) in the general German population. J Psychosom Res 2011;71:74e8. Eifert GH, Thompson RN, Zvolensky MJ, Edwards K, Frazer NL, Haddad JW, et al. The cardiac anxiety questionnaire: development and preliminary validity. Behav Res Ther 2000;38:1039e53. Zvolensky MJ, Eifert GH, Feldner MT, Leen-Feldner E. Heartfocused anxiety and chest pain in postangiography medical patients. J Behav Med 2003;26:197e209. Eifert GH, Zvolensky MJ, Lejuez CW. Heart- Focused Anxiety and chest pain: A conzeptual and clinical review. Clin Psychol Sci Pract 2000;7:403e17. Hoyer J, Eifert GH, Einsle F, Zimmermann K, Krauss S, Knaut M, et al. Heart-focused anxiety before and after cardiac surgery. J Psychosom Res 2008;64:291e7. Ware Jr J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220e33. Gandek B, Ware JE, Aaronson NK, Apolone G, Bjorner JB, Brazier JE, et al. Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol 1998;51:1171e8. Bullinger M, Kirchberger I. SF-36. Fragebogen zum Gesundheitszustand. Handanweisung; 19981. Barth J, Martin CR. Factor structure of the hospital anxiety and depression scale (HADS) in German coronary heart disease patients. Health Qual Life Outcomes 2005;3:15. Wells KB, Golding JM, Burnam MA. Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry 1988;145:976e81. Barth J, Schumacher M, Herrmann-Lingen C. Depression as a risk factor for mortality in patients with coronary heart disease: a metaanalysis. Psychosom Med 2004;66:802e13. Watkins LL, Koch GG, Sherwood A, Blumenthal JA, Davidson JR, O’Connor C, et al. Association of anxiety and depression with allcause mortality in individuals with coronary heart disease. J Am Heart Assoc 2013;2:e000068. Chaudhury S, Srivastava K. Relation of depression, anxiety, and quality of life with outcome after percutaneous transluminal coronary angioplasty. ScientificWorld J 2013;2013:465979.

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E. Stasiewski et al. / Atherosclerosis Supplements 18 (2015) 233e240

[27] Mittal SK, Ahern L, Flaster E, Maesaka JK, Fishbane S. Selfassessed physical and mental function of haemodialysis patients. Nephrol Dial Transpl 2001;16:1387e94. [28] Nemati E, Motalebi M. The gender effect of health-related quality of life in hemodialysis patients. Nephrourol Mon 2014;6:e15934. [29] Turkmen K, Yazici R, Solak Y, Guney I, Altintepe L, Yeksan M, et al. Health-related quality of life, sleep quality, and depression in peritoneal dialysis and hemodialysis patients. Hemodial Int 2012;16:198e206. [30] Baumeister H, Balke K, Harter M. Psychiatric and somatic comorbidities are negatively associated with quality of life in physically ill patients. J Clin Epidemiol 2005;58:1090e100. [31] Cukor D, Ver Halen N, Asher DR, Coplan JD, Weedon J, Wyka KE, et al. Psychosocial intervention improves depression, quality of life, and fluid adherence in hemodialysis. J Am Soc Nephrol 2014;25: 196e206. [32] Rutledge T, Redwine LS, Linke SE, Mills PJ. A meta-analysis of mental health treatments and cardiac rehabilitation for improving

clinical outcomes and depression among patients with coronary heart disease. Psychosom Med 2013;75:335e49. [33] Tovote KA, Fleer J, Snippe E, Peeters AC, Emmelkamp PM, Sanderman R, et al. Individual mindfulness-based cognitive therapy (MBCT) and cognitive behavior therapy (CBT) for treating depressive symptoms in patients with diabetes: results of a randomized controlled trial. Diabetes Care 2014;37(9): 2427e34. [34] Tully PJ, Selkow T, Bengel J, Rafanelli C. A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discrete effects of cognitive behavioral therapy, exercise, and psychotropic medication. Disabil Rehabil 2014:1e8. [35] Weidner K, Bittner A, Junge-Hoffmeister J, Zimmermann K, Siedentopf F, Richter J, et al. A psychosomatic intervention in pregnant in-patient women with prenatal somatic risks. J Psychosom Obstet Gynaecol 2010;31:188e98.