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Autistic symptoms represent a frequent feature in schizophrenia spectrum disorders (SSD). However, the prevalence and the cognitive and functional correlates of autistic symptoms in unaffected first-degree relatives of people with SSD remain to be assessed.
A total of 342 unaffected first-degree relatives related to 247 outpatients with schizophrenia were recruited as part of the multicenter study of the Italian Network for Research on Psychoses (NIRP). Autistic features were measured with the PANSS Autism Severity Scale. Three groups of participants, defined on the presence and severity of autistic symptoms, were compared on a wide array of cognitive and functional measures.
Of the total sample, 44.9% presented autistic symptoms; 22.8% showed moderate levels of autistic symptoms, which can be observed in the majority of people with SSD. Participants with higher levels of autistic symptoms showed worse performance on Working Memory (p = 0.014) and Social Cognition (p = 0.025) domains and in the Global Cognition composite score (p = 0.008), as well as worse on functional capacity (p = 0.001), global psychosocial functioning (p < 0.001), real-world interpersonal relationships (p < 0.001), participation in community activities (p = 0.017), and work skills (p = 0.006).
A high prevalence of autistic symptoms was observed in first-degree relatives of people with SSD. Autistic symptoms severity showed a negative correlation with cognitive performance and functional outcomes also in this population and may represent a diagnostic and treatment target of considerable scientific and clinical interest in both patients and their first-degree relatives.
Deficits in social cognition (SC) are significantly related to community functioning in schizophrenia (SZ). Few studies investigated longitudinal changes in SC and its impact on recovery. In the present study, we aimed: (a) to estimate the magnitude and clinical significance of SC change in outpatients with stable SZ who were assessed at baseline and after 4 years, (b) to identify predictors of reliable and clinically significant change (RCSC), and (c) to determine whether changes in SC over 4 years predicted patient recovery at follow-up.
The reliable change index was used to estimate the proportion of true change in SC, not attributable to measurement error. Stepwise multiple logistic regression models were used to identify the predictors of RCSC in a SC domain (The Awareness of Social Inference Test [TASIT]) and the effect of change in TASIT on recovery at follow-up.
In 548 participants, statistically significant improvements were found for the simple and paradoxical sarcasm of TASIT scale, and for the total score of section 2. The reliable change index was 9.8. A cut-off of 45 identified patients showing clinically significant change. Reliable change was achieved by 12.6% and RCSC by 8% of participants. Lower baseline TASIT sect. 2 score predicted reliable improvement on TASIT sect. 2. Improvement in TASIT sect. 2 scores predicted functional recovery, with a 10-point change predicting 40% increase in the probability of recovery.
The RCSC index provides a conservative way to assess the improvement in the ability to grasp sarcasm in SZ, and is associated with recovery.
Schizophrenia spectrum disorders are among the most debilitating mental disorders and has complex pathophysiological underpinnings. There is growing evidence that brain-derived neurotrophic factor (BDNF) can play a role in its pathogenesis. The present study investigated the longitudinal variation of serum BDNF levels in a 24-month observational prospective cohort study of Sardinian psychotic patients and its relationship with psychopathological and cognitive changes. Furthermore, we examined whether genetic variation within the BDNF gene could moderate these relationships.
Every 6 months, 105 patients were assessed for their BDNF serum levels, as well as for a series of psychopathological, cognitive, and social measures. We performed a targeted analysis of four tag single nucleotide polymorphisms within the BDNF gene that were selected and analyzed using polymerase chain reaction. Longitudinal data were analyzed using mixed-effects linear regression models.
We observed a declining longitudinal trajectory of BDNF levels in psychotic patients in general, and in relation to the severity of depressive and negative symptoms. BDNF serum levels also declined in patients scoring lower in cognitive measures such as attention and speed of information processing and verbal fluency. The rs7934165 polymorphism moderated the significant association between verbal fluency and BDNF levels.
These findings in patients from real-world settings suggest a plausible role of peripheral BDNF levels as a marker of illness burden in schizophrenia spectrum disorders.
While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.
We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.
SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.
The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.
Resilience is defined as the ability to modify thoughts to cope with stressful events. Patients with schizophrenia (SCZ) having higher resilience (HR) levels show less severe symptoms and better real-life functioning. However, the clinical factors contributing to determine resilience levels in patients remain unclear. Thus, based on psychological, historical, clinical and environmental variables, we built a supervised machine learning algorithm to classify patients with HR or lower resilience (LR).
SCZ from the Italian Network for Research on Psychoses (N = 598 in the Discovery sample, N = 298 in the Validation sample) underwent historical, clinical, psychological, environmental and resilience assessments. A Support Vector Machine algorithm (based on 85 variables extracted from the above-mentioned assessments) was built in the Discovery sample, and replicated in the Validation sample, to classify between HR and LR patients, within a nested, Leave-Site-Out Cross-Validation framework. We then investigated whether algorithm decision scores were associated with the cognitive and clinical characteristics of patients.
The algorithm classified patients as HR or LR with a Balanced Accuracy of 74.5% (p < 0.0001) in the Discovery sample, and 80.2% in the Validation sample. Higher self-esteem, larger social network and use of adaptive coping strategies were the variables most frequently chosen by the algorithm to generate decisions. Correlations between algorithm decision scores, socio-cognitive abilities, and symptom severity were significant (pFDR < 0.05).
We identified an accurate, meaningful and generalizable clinical-psychological signature associated with resilience in SCZ. This study delivers relevant information regarding psychological and clinical factors that non-pharmacological interventions could target in schizophrenia.
Previous researches highlighted among patients with schizophrenia spectrum disorders (SSD) a significant presence of autistic traits, which seem to influence clinical and functional outcomes. The aim of this study was to further deepen the investigation, evaluating how patients with SSD with or without autistic traits may differ with respect to levels of functioning, self-esteem, resilience, and coping profiles.
As part of the add-on autism spectrum study of the Italian Network for Research on Psychoses, 164 outpatients with schizophrenia (SCZ) were recruited at eight Italian University psychiatric clinics. Subjects were grouped depending on the presence of significant autistic traits according to the Adult Autism Subthreshold Spectrum (AdAS Spectrum) instrument (“AT group” vs “No AT group”). Other instruments employed were: Autism Spectrum Quotient (AQ), Specific Levels of Functioning (SLOF), Self-Esteem Rating scale (SERS), Resilience Scale for Adults (RSA), and brief-COPE.
The “AT group” reported significantly higher scores than the “No AT group” on SLOF activities of community living but significantly lower scores on work skills subscale. The same group scored significantly lower also on SERS total score and RSA perception of the self subscale. Higher scores were reported on COPE self-blame, use of emotional support and humor domains in the AT group. Several correlations were found between specific dimensions of the instruments.
Our findings suggest the presence of specific patterns of functioning, resilience, and coping abilities among SSD patients with autistic traits.
Autism spectrum disorders (ASDs) and schizophrenia spectrum disorders (SSDs), although conceptualized as separate entities, may share some clinical and neurobiological features. ASD symptoms may have a relevant role in determining a more severe clinical presentation of schizophrenic disorder but their relationships with cognitive aspects and functional outcomes of the disease remain to be addressed in large samples of individuals.
To investigate the clinical, cognitive, and functional correlates of ASD symptoms in a large sample of people diagnosed with schizophrenia.
The severity of ASD symptoms was measured with the PANSS Autism Severity Scale (PAUSS) in 921 individuals recruited for the Italian Network for Research on Psychoses multicenter study. Based on the PAUSS scores, three groups of subjects were compared on a wide array of cognitive and functional measures.
Subjects with more severe ASD symptoms showed a poorer performance in the processing speed (p = 0.010), attention (p = 0.011), verbal memory (p = 0.035), and social cognition (p = 0.001) domains, and an overall lower global cognitive composite score (p = 0.010). Subjects with more severe ASD symptoms also showed poorer functional capacity (p = 0.004), real-world interpersonal relationships (p < 0.001), and participation in community-living activities (p < 0.001).
These findings strengthen the notion that ASD symptoms may have a relevant impact on different aspects of the disease, crucial to the life of people with schizophrenia. Prominent ASD symptoms may characterize a specific subpopulation of individuals with SSD.
Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions.
Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression.
After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms.
In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.
A clinical and psychosocial follow-up study of a cohort of 85 patients affected by panic disorder (PD) with or without agoraphobia was performed an average of 40 months after initial observation and following a mean duration of illness of 8 years.
Eighty-five out of 130 patients affected by PDs with or without agoraphobia according to DSM-III R criteria, examined between 1990 and 1995 at an outpatient clinic were re-examined in 1997/1998 using the same standardized clinical evaluation performed on admission. Patients also underwent a structured diagnostic interview (Mini International Neuropsychiatric Interview, MINI) and psychosocial evaluation (Scale of Sheehan’s Disability Scale, DISS, Baker and Intagliata’s Satisfaction with Life Domains Scale, SLDS).
At follow-up, the percentage of patients who had either improved or were in remission was considerably higher among those initially diagnosed as PD with respect to those diagnosed as panic disorder with agoraphobia (PDA): Thirty-eight percent of PD and 20.6% of PDA patients were in clinical remission. Mild panic symptoms and phobic avoidance were found in the majority of patients who were still symptomatic (respectively 71% and 57%). Approximately 60% of patients reported a significant difficulty in performing daily activities and 40% expressed dissatisfaction in at least 50% of life domains considered. Seventy-two percent of subjects examined were still undergoing pharmacological treatment at the time of follow-up.
The findings of the study are suggestive of a chronic illness with a significant impact on everyday quality of life of patients.
Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment.
On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified.
The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, “dual roles” enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided.
Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions.
Schizophrenia is a leading cause of disability. People living with schizophrenia (PLWS) present unemployment, social isolation, excess mortality and morbidity, and poor quality of life. Early recognition and appropriate treatment reduce the risk of chronicity and comorbidity. Personalization and integration of pharmacological and psychosocial interventions, as well as accurate identification and management of psychiatric and somatic comorbidities, can significantly improve mental and physical health of PLWS, promoting recovery.
A three-step Delphi approach was used to explore consensus on the essential components of early recognition and intervention, personalization, and integration of care to improve schizophrenia outcome, and on barriers and challenges to close treatment gaps. The consensus involved 8 Italian experts of schizophrenia, 100 psychiatrists from academic and nonacademic settings, including representatives of Italian Society of Psychiatry, and 65 trainees in psychiatry.
A strong consensus (from mostly agree to totally agree) emerged on the importance of early diagnosis (97%), standardized assessments (91%), correct management of somatic and psychiatric comorbidities (99%), and personalization and integration of care (94%). Lack of time, human resources, and training were identified as the main barriers and challenges to the translation of knowledge into clinical practice.
The results of this Delphi study demonstrated a strong consensus on main components of schizophrenia care, as well as on unmet needs to promote best practice and gaps between knowledge and clinical practice. The involvement of a large group of professionals and trainees in this in-depth consensus process might contribute to raise awareness and stimulate innovative strategies to improve the outcome of PLWS.
Objective – Many different factors, both related to the individual and illness (“intrinsic” factors) and to the environment (“extrinsic” factors), contribute in different ways to the development of disability. Basing on data of literature, this review focuses the main “intrinsic” factors predicting disability in schizophrenia. Method – A systematic search on Mediline of all papers published during the period 1965-2001 was performed, using “schizophrenia”, “outcome”, “psychosocial outcome”, “social disability” and “social adjustment” as key words. Only papers reporting specifically data about predictive factors and psychosocial outcome variables were considered; prospective follow-up studies were considered, but retrospective and cross-sectional studies were also taken into account when data deriving from prospective studies were inconsistent. Results – Male sex predicts a higher disability among demographic factors; lower social and occupational adjustment are premorbid personality factors associated with higher disability; among factors related to illness, younger age at onset of illess, “nuclear”, “non paranoid” and in particular “deficit” forms of schizophrenia seem to predict more disability. The latter seems to be predicted also by higher levels of negative symptoms and neuropsychological deficits ; the role of depressive symptoms seems to be less supported by follow-up data; a continuous course of the illness predicts more disability, although some evidences show a progressive reduction of disability, at least in the long term. Conclusions – Disability shows a largely autonomous course respect to symptoms and has to be considered an independent parameter of outcome. Few intrinsic factors show a predictive role also in the long term.
Aims - To present the results of an epidemiologic research about psychotropic drug use inSardinia. Methods - Cross-sectional study on a sample of 1040 subjects randomly selected from registers. Setting - Community survey on three areas of Sardinia region. Evaluation: interviews carried out byphysicians by means of Italian version of the Composite International Diagnostic Interview Simplified.Drug consumption was evaluated concerning last week before the interview. Main Outcome Measures: point prevalence. Results - The rate of adults of the general population that consumed benzodiazepines was 10.1%, antidepressants 4.2%, 14.7% of the sample was using psychotropic drugs. 60% of subjects with diagnosis of ICD-10 Depressive Episod did not have the right pharmacologic treatment. A relevant proportion of subjects without lifetime psychiatric diagnosis (anxiety and/or depression) used antidepressants (0.8%). The pharmacologic therapies were managed by psychiatrics in 44.2% of cases, antidepressants were managed by general practitioners in 31.8% of subjects. Conclusions - The research underlines an increase of meet needs in subjects affected by depressive episodes against a previous Sardinian survey carried out over ten years ago. This change is parallel to a more frequent management of therapies by general practitioners. Their role seems to become more relevant in treating depressive illness.
Declaration of Interest
Mauro Giovanni Carta has received grants and research support from Regione Autonoma della Sardegna, Council of the European Union, European Union DGXII, GlaxoSmithKline, Pfizer, Lundbeck, Pharmacia, Recordati. Maria Carolina Hardoy has received grants and research support from University of Pisa, GlaxoSmithKline, Pfizer, Farmades. Bernardo Carpiniello has received grants and research support from GlaxoSmithKline, Pfizer, Recordati, Janssen Cilag, EliLilly, Astra Zeneca.
Objective – The aim of the study was to investigate the attitudes in the decision making process for admitting patients compulsorily under the Italian Law 180/78. Setting – A group of psychiatrists (n=81) working in the area of Cagliari (Sardinia, Italy). Main outcome measures – Three case–vignettes describing different hypothetical clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. Each vignette was followed by a list of 11 factors reported in the literature as important in the decision to admit compulsorily (current mental state, severity of the disease, dangerousness to self or others, psychiatric history, likely response of the mental state to the medical treatment, age and gender of the patient, owning a home, occupational status, social support available). Psychiatrists were asked: a) whether they would admit the patient compulsorily; and b) to rate 11 factors from the most to the least important in their decision.
Aims — Patients with chronic viral hepatitis suffer from a high prevalence of psychiatric problems. Furthermore, the treatment for chronic viral hepatitis, with interferon (IFN) alpha, induces the occurrence of further psychopathological symptoms. The autors examined whether patients with a pre-existing psychiatric diagnosis had more severe IFN alpha-induced psychiatric adverse effects, and whether they were more likely to interrupt the IFN alpha therapy, compared with control patients with no pre-existing psychiatric diagnosis. They also examined the psychopharmacological management of the interferon-alpha-induced psychiatric side effects. Methods — The authors studied prospectively 60 patients with chronic hepatitis B or C in Cagliari, Italy. Patients underwent psychiatric assessment before starting interferon alpha and monthly throughout the therapy. Results — After adjusting for the baseline psychopathology, there was no statistically significant difference in interferon-alpha-induced psychiatric adverse effects between patients with a pre-existing psychiatric diagnosis and controls. There was also no evidence that psychiatric cases were more likely than controls to interrupt the IFN alpha therapy because of psychiatric side effects. Moreover, there was no difference in the psychiatric adverse effects severe enough to require psychopharmacological treatment. Finally, psychopharmaco-logical management successfully treated psychiatric symptoms induced by the IFN alpha. Conclusions — Patients with a pre-existing psychiatric diagnosis do not have a specific vulnerability to interferon-alpha-induced psychiatric adverse effects.
Declaration of Interest: none of the authors have conflict of interests in writing this paper; CM. Pariante is funded by the UK Medical Research Council and by the NARSAD and the Guy's and St Thomas Charity
Based on the findings of previous studies carried out by our group, which will be briefly summarised, the present paper puts forward several hypotheses to account for the evolution of depressive symptoms and the possible increase observed in risk of depression subsequent to social changes. The particular mood disorders presented by Senegalese emigrants and several protective factors which appear to determine a low risk in these populations, such as a strong social support, will be examined. Based on a previous investigation carried out by our group, which seems to indicate the presence of depressive pictures among poorly westernised populations such as the Peul nomads or Dogon farmers from the Sub-Saharian regions, the hypothesis that “westernalisation” (considered as the loss at an individual level of traditional ways of life, working habits, cultural patterns and languages in favour of different attitudes influenced by western culture) may represent a risk factor for depressive illness, in its clinical expressions commonly observed in western contexts, has been considered. In these populations, with the exception of educated individuals, the albeit rare depressive symptoms appear to be secondary to serious somatic disorders. Research performed identified two well-defined means of clinical expression, which has been termed, respectively, “western style” or “guilty” and “traditional” or “dislocation from the group”. Further studies carried out in rapidly changing areas seem to indicate how environmental factors are able to influence the evolution of depressive symptoms from the first form to the latter and to modify the threshold of onset of emotive, behavioural and depressive patterns. It has been hypothesised that rapid changes in the social organisation tend to exacerbate attitudes of “compulsive hyper-responsibilisation”, a cognitive set of basic assumptions which may be considered at the same time both as a product of “westernalization” at an individual level and a risk factor for depression. Individuals who possess these basic characteristics, subsequent to the opportunities afforded by the social changes, tend to develop new complex systems of interpreting reality, causality, controlling of events and ways of expressing emotions. Accordingly, we herewith propose a reviewal of the entire threshold concept and provide a means of interpreting the transformation in depressive phenomena in view of the fact that, although the new levels of knowledge and learning better equip subjects to face the new situations, they also render them more vulnerable to depression.
Aims – Media reports related to people suffering from mental illness appear to deal prevalently with acts of violence and crimes. The present study focused on all newspaper reports relating to homicides, suicide, and other acts of violence, in an attempt to ascertain whether a different pattern emerged in some Italian newspapers in describing deeds committed by the mentally ill. Materials and methods – All articles published over a six–month period in the two main national and two main regional newspapers relating to homicides, suicides, and other acts of violence were selected. A comparison of reports regarding events attributed to mentally ill people was performed according to quantitative parameters. Results – 2279 articles were considered; 54% regarded homicides, 8.2% suicides and attempted suicides, 2.1% homicides/suicides; the remaining 35.8% regarded other acts of violence. A significantly higher number of words, accompanying photos and a more stigmatizing language were used in reporting deeds when attributed to mentally ill people. Conclusion – An excessive emphasis on deeds related to a psychopathological condition still emerged in media reports, almost as though acts of violence committed by the mentally insane should be viewed in a different light. These findings support the hypothesis that media portrayal mirrors the enduring stereotype of “diversity” of the mentally ill.
Declaration of Interest: no conflict of interest declared.
Aims – The study aims to evaluate the frequency of association between Axis I and II disorders according to DSMIVTR criteria and obesity, and use of mental health services in a clinical sample of patients attending a centre for the diagnosis and treatment of Obesity. Methods – 150 consecutive patients (32 Males, 118 females, mean age 44.614.3 yrs; mean BMI 35.46.2) were interviewed by means of SCID I and SCID II. Results – Lifetime Prevalence of Axis I disorders was 58% (males 50%; females 61%); the highest prevalence rate was found for Anxiety Disorders (approx 35%), whilst 30% of subjects were affected by Mood disorders, chiefly Major Depression (20%), and 18% by Eating Disorders. 28% of obese patients presented a Personality Disorder, 23% of patients being affected both by an Axis I and Axis II disorder. Mood Disorders, in particular Major Depression, were significantly prevalent among female obese. 50% of females and approx 37% males included in the sample had contacted mental health units for treatment. Conclusion – Data obtained in the present study confirm the high prevalence rates of mental disorders in obese patients seeking treatment. Specialist units should therefore include thorough psychiatric evaluation of patients as a routine practice.
Declaration of Interest: The study was supported by a research grant by University of Cagliari (ex 60% funding, financial year 2006); the authors declare no conflict of interest.
Se llevó a cabo un estudio de seguimiento clínico y psicosocial de una cohorte de 85 pacientes afectados por trastorno de angustia (TA) con o sin agorafobia una media de 40 meses después de la observación inicial y después de una duración media de la enfermedad de 8 años.
Ochenta y cinco de los 130 pacientes afectados por TA con o sin agorafobia según los criterios del DSM-III-R, examinados entre 1990 y 1995 en una clínica ambulatoria, fueron examinados de nuevo en 1997/1998 utilizando la misma evaluación clínica estandarizada realizada en la admisión. Los pacientes recibieron también una entrevista diagnóstica estructurada (Mini Entrevista Neuropsiquiátrica Internacional, MINI) y una evaluación psicosocial (Escala de Discapacidad de Sheehan, DISS; Escala de Satisfacción con los Dominios Vitales de Baker e Intagliata, SLDS).
En el seguimiento, el porcentaje de pacientes que había mejorado o estaba en remisión era considerablemente más alto entre aquellos a los que se diagnosticó inicialmente con TA en relación con los diagnosticados con trastorno de angustia con agorafobia (TAA): El 38% de los pacientes con TA y el 20% de los pacientes con TAA estaban en remisión clínica. Se encontraron síntomas de angustia y evitación fóbica leves en la mayoría de los pacientes que tenían síntomas todavía (71 y 57%, respectivamente). El 60% aproximadamente de los pacientes comunicó una dificultad significativa en la realización de las actividades diarias y el 40% expresó insatisfacción en un 50% al menos de los dominios vitales considerados. El 72% de los sujetos examinados recibía todavía tratamiento farmacológico en el momento del seguimiento.
Los hallazgos del estudio son sugestivos de una enfermedad crónica con un efecto significativo en la calidad de vida cotidiana de los pacientes.
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