Bir Site

Etiket: And

  • Alerjik astım ve cinsel yaşam

    Alerjik astım ve cinsel yaşam

    Cinsellik yaşamın doğal bir parçasıdır. Cinsel sağlık ve davranışı; aile, arkadaşlar, eğitim, kültür ve çevre gibi birçok etken belirler. Fakat, bazı hastalıklar cinsel sağlığı ve ilişki sırasında gösterilen eforu etkileyebilir hatta bozabilir. Astım, cinsel yaşam açısından, hastaların yaşam kalitesi algılamalarını önemsenmeye başlandığından bu yana üzerinde durulan bir konudur. Temel bilgi olarak astım toplumun %5’ini etkileyen, trakeo-bronşial ağacın terminal dallarının yaygın daralması ve obstrüksiyonu ile karakterize, bronkokonstrüksiyon ve mukus üretiminin aracılık ettiği kronik inflamatuvar, dönemsel, yaygın bir hastalıktır.

    Hastalık ataklar şeklinde gelişir ve bu atakları enfeksiyonlar, alerjenler, çeşitli egzersizler ve duygusal stres tetikleyebilir. Sonuç olarak kişilerin fiziksel aktiviteleri kısıtlanır, çalışma performansları düşer, gece uykuları bölünür, sıklıkla medikal tedavi almaları ve bazen de hastanede yatmaları gerekir. Yaşam kalitesi, genel olarak kişinin hastalığı ile ilgili olarak fiziksel, psikolojik ve sosyal fonksiyonlarına olan etkisini tanımlayan bir terimdir. Astımın yaşam kalitesi parametelerini etkilediğine dair hem jenerik hem de hastalık özgül anket formlarının kullanılarak elde edilen bir çok veri vardır (1,2).

    Hastalığın yaşam kalitesi parametrelerini ne denli etkilediğini inceleyen hem jenerik hem de hastalığa özgül anketler vardır (1,3,4). Astım, hastaların hayatını fiziksel, emosyonel ve sosyal açılardan etkileyen kronik bir hastalık olup son yıllarda hastalığın bu yönüyle de değerlendirilmesi oldukça ilgi çekici bir alan yaratmıştır. Seksüel yaşam da kişilerin normal hayatının doğal ve önemli bir parçası olup, birçok hastalıktan etkilenmektedir. Seksüel yaşama ait veriler yaşam kalitesi verilerinin önemli parçalarını oluşturmaktadır. Birçok hastalığın yaşam kalitesi parametreleri dışında kişilerin seksüel kalitelerini de etkilediğine dair çalışmalar mevcuttur (5,6). Son yılların ilgi çeken alanlarından olan yaşam kalitesi, seksüel yaşam kalitesi ve bunların hastalıklarla ilgisini değerlendiren çalışmalar giderek artmaktadır. Seksüel aktivite (koitus) astımı değişik yollarla tetikleyebilir.

    Kimi hastalarda seksüel heyecan ile birlikte anksiyetenin eşlik ettiği astım ve rinit atakları gelişir, nadiren de bazı hastalarda tek başına insan seminal sıvı alerjisine bağlı (HSPA=Human Seminal Plasma Allergy) (7,8) ya da kondom kullanımı sırasında görülen lateks alerjisi (7.9,10) kaynaklı aşırı duyarlılık reaksiyonları görülebilir. Postkoital astım “sexercise induced asthma (SIA)” ise seksüel heyecan dışında herhangi bir sebepten kaynaklanan astım atağıdır (11). Hasta ve partnerlerinin baskın özelliği anksiyete ve endişedir. Koital astımın aksine akut ataklar yerine koitus sonrası 4-6 saat sonra görülen geç astım yanıtlarıyla karakterizedir (11). SIA, egzersizin indüklediği bir astım şekli değildir. Seksüel aktivitenin ilk dakikalarından itibaren hastaların PEFR (peak expiratory flow rates) değerleri bariz bir şekilde düşerken merdiven çıkma egzersizindeki (ki bu egzersiz seks sırasında harcanan enerjiye denk olan bir egzersizdir) PERF değerlerinde bir düşüş görülmemektedir (12). Seksüel aktivite sırasında oluşan yoğun duygusal uyaranlar otonom sinir sitemi üzerinde parasempatik yönde bir dengesizliğe yol açarak mast hücrelerinden medyatörlerin salınmasına sonuç olarak hastada postkoital astım ya da rinit gelişmesine neden olur (11). Koitus ile ilişkili astım durumları iyi tanımlanmalı ve ayrılmalıdır.

    HSPA, kondom kullanımı ve SIA; koitus ile ilişkili olan ancak her biri farklı tedavi yaklaşımları gereken durumlardır. HSPA, vulvovajinit ile kolayca karıştırılabilirken, kondomun yol açtığı lokal belirtiler ve astım durumu, spesifik olmayan postkoital semptomlarla karışabilir. Kolayca tanı konulabilecek çoğu vaka hastaların utangaçlığı, çekinmeleri ya da klinisyenlerin yoğun poliklinik tempoları sırasında dikkatsizlikleri nedeniyle gözden kaçmaktadır.

    Ancak; tüm bunlarda en önemli çözümün, hasta değerlendirme esnasında son derece derin ve ayrıntılı bir anamnez almak olduğu aşikardır. Astımda cinsel hayatı etkileyebilen bir diğer neden de depresyondur. Hipoksi, sınırlı akciğer fonksiyonu gibi organik değişiklikler hastalığın ileri aşamalarında belirgin hale gelirken, depresif ruh hali ve sosyal faaliyetlerde kısıtlanma erken fazda görülür. Depresyon astımlı hastalarda semptomları ağırlaştırır, düşük libido, erektil disfonksiyon gibi cinsel fonksiyon bozukluklarına yol açar (13-16). Nefes darlığı ve boğulma hissi korkusu yaşayan hastalar cinsel temastan kaçınabilir ve sonuç olarak eşler arasında uyum sorunları oluşabilir (16,17). Fizyolojik olarak astım, kronik obstrüktif akciğer hastalığı (KOAH) ile benzer şekilde gonadal steroidleri etkileyebilir. Hipoksi, libido ile ilişkili temel hormon olan testesteron düzeylerinde düşüklüğe neden olur.

    Hipoksinin diğer bir etkisi, Nitrik oksit (NO) sentezi ve kavernöz dokuda cGMP aktivitesi için gerekli olan moleküler oksijen düzeylerini etkilemesidir ki bu yolla erektil disfonksiyona neden olabilir (18). Etkilenen sistem bakımından yakınlık gösteren KOAH gibi hastalıkların cinsel yaşam üzerine etkileri belgelenmiş olmasına rağmen astım için yeterince çalışma yapılmamıştır (19). Oysa ki cinsel efor düşünüldüğünde bu tür durumların astımlı bir hastanın cinsel yaşamını olumsuz yönde etkileyeceği aşikardır. Kaba bir yaklaşımla astımdan primer olarak etkilenen popülasyon %5 iken sekonder olarak etkilenen eş, ebeveyn ve çocuk popülasyonu hesaba katılacak olursa bu oran %10 ila 25 arasında dramatik bir değişim gösterebilir. Etkilenecek kişilerin muazzamlığı dikkate alınırsa konuya ciddi bir yaklaşım gerekmektedir. Gerek kapalı gerekse modern toplumlarda, hasta ve hekimler cinsel yaşam hakkında konuşmayı rahatsız edici bir konu olarak bulmaktadır (20). Kronik hastalığı olan kişiler sadece hastalıkları ile ilgili değil ayrıca cinsel yaşamları hakkında konuşmaya da teşvik edilmeli, tıp eğitimi içine hastalara cinsel konularda nasıl yaklaşılacağı konusunda pratik uygulamalar eklenmelidir (21,22). Astım tedavisinin uygun yönetimi için yaşam kalitesi ve dolayısıyla cinsel fonksiyonlar da önemlidir ve cinsel hayatlarında sınırlamaları olan hastaların astım kontrolünün iyi olduğunu söyleyemeyiz. Tüm bu veriler ele alındığında astımlı bir hastayı değerlendirirken son derece derin ve ayrıntılı bir anamnez almanın gerekliliği ortaya çıkmaktadır. Hekimlerin bu görüşme esnasında hastasının özellikle cinsel yaşamla ilgili kısıtlanmaları ve diğer yaşam kalitesi parametrelerini mutlaka değerlendirmeye alması, yapacağı tedaviye buna göre değerlendirmesi gerekmektedir. Bunun dışında astım için uygulanan tedavilerin hastanın cinsel yaşam kalitesi üzerine olumlu veya olumsuz etkileri her vizite mutlaka değerlendirilmelidir. Tüm hastalıklarda olduğu gibi astımlı hastalar da bir bütün olarak ele alınmalıdırlar.  

    Kaynaklar: 1- Wilson SR, Rand CS, Cabana MD, Foggs MB, Halterman JS, Olson L, Vollmer WM, Wright RJ, Taggart V. Asthma outcomes: Quality of life. J Allergy Clin Immunol. 2012;129(3 Suppl):88-123. 2- Braido F, Baiardini I, Balestracci S, Fassio O, Ravera S, Bellotti M, Canonica GW. The relationship between asthma control and quality-of-life impairment due to chronic cough: a real-life study. Ann Allergy Asthma Immunol. 2008;101:370-4. 3- Ware JE, Sherbourne CD, Davies AR, et al. A short-Form Health Survey (SF-36) I. conceptual framework and item selection. Med Care. 1992;30:473-83. 4- Juniper EF, Guyatt GH, Ferrie PJ, Griffith LE. Measuring quality of life in asthma. Am Rev Respir Dis. 1993;147: 832-8. 5- Kirmaz C, Aydemir O, Bayrak P, Yuksel H, Ozenturk O, Degirmenci S. Sexual dysfunction in patients with allergic rhinoconjunctivitis. Ann Allergy Asthma Immunol. 2005;95:525-9. 6- Tristano AG. The impact of rheumatic diseases on sexual function. Rheumatol Int. 2009;29:853-60. 7- Kuna P, Kupczyk M, Bochenska-Marciniak M. Severe asthma attacks after sexual intercourse. Am J Respir Crit Care Med. 2004;170:344-5. 8- Shah A, Panjabi C. Human seminal plasma allergy: a review of a rare phenomenon. Clin Exp Allergy. 2004;34:827-38. 9- Turjanmaa K, Reunala T. Condoms as a source of latex allergen and cause of contact urticaria. Contact Dermatitis. 1989;20:360-64. 10- Kawane H. Coitus-induced asthma or condom-induced asthma? Chest. 1992;102:327-28. 11- Shah A, Sircar M. Postcoital asthma and rhitinis. Chest. 1991;100:1039-41. 12- Andrews JL (Jr). Sex and asthma. In : Weiss EB, Segal MS, Stein MS, ed Bronchial Asthma; 2nd edn. Boston : Little Brown & Co. 1985;932-33. 13- Kullowatz A, Kanniess F, Dahme B, Magnussen H, Ritz T. Association of depression and anxiety with health care use and quality of life in asthma patients. Respir Med. 2007; 101:638-44. 14- Casper RC, Redmond DE Jr, Katz MM, Schaffer CB, Davis JM, Koslow SH. Somatic symptoms in primary affective disorder: Presence and relationship to the classification of depression. Arch Gen Psychiatry. 1985;42:1098–110. 15- Nicolosi A, Moreira ED Jr, Villa M, Glasser DB. A population study of the association between sexual function, sexual satisfaction and depressive symptoms in men. J Affect Disord. 2004;82:235–43. 16- Başar MM, Ekici A, Bulcun E, Tuğlu D, Ekici MS, Batislam E. Female Sexual and Hormonal Status in Patients with Bronchial Asthma:Relationship with Respiratory Function Tests and Psychologial and Somatic Status.Urology. 2007;69:421-5. 17- Brown ES, Khan DA, Mahadi S. Psychiatric diagnoses in iner city outpatients with moderate to severe asthma. Int J Psychiatry Med. 2001;30:319–27. 18- Cellek S, and Moncada S: Nitrergic neurotransmission mediates the non-adrenergic non-cholinergic responses in the clitoral corpus cavernosum of the rabbit. Br J Pharmacol. 1998;125: 1627–9. 19- Fletcher EC, Martin RJ. Sexual dysfunction and erectile impotence in chronic obstructive pulmonary disease. Chest. 1982;81:413-21. 20- Basson R, Weijmar Schultz W. Sexual sequelae of general medical disorders. Lancet. 2007;369:409–24. 21- Svartberg J, Aasebø U, Hjalmarsen A, Sundsfjord J, Jorde R. Testosterone treatment improves body composition and sexual function in men with COPD, in a 6-month randomized controlled trial. Respir Med. 2004;98:906–13. 22- Blackstock F, Webster KE. Disease-specific health education forCOPD: a systematic review of changes in health outcomes.Health Educ Res. 2007;22:703–17. Sağlıklı günler dileğiyle… Prof. Dr. Cengiz KIRMAZ

  • Depression and anxiety symptom severity in a group of children with epilepsy and related factors].

    OBJECTIVE:

    The aim of this study was to assess the anxiety and depression symptom severity in a group of epileptic children and compare the results to healthy controls. Additionally, the frequency of psychiatric disorders in epileptic children was also assessed.

    METHOD:

    The study compared 30 children, ranging in age from 8 to 16 years with epileptic disorder who attended a children’s neurology clinic, with healthy controls using the State-Trait Anxiety Inventory and Children’s Depression Inventory scores and suicidal ideation. The MINI was administered to epileptic patients to determine the frequency of psychiatric disorders in this clinical group.

    RESULTS:

    State anxiety scores of the epilepsy group were significantly higher compared to controls. No significant differences were found between patients and controls in terms of trait anxiety and depression scores. In all 3 scales boys scored significantly higher than girls. No significant relationships were found between symptom severity, duration of epilepsy, age of seizure onset and depression and anxiety scores. Psychiatric assessments with the MINI identified psychiatric disorders in 26.7% of epileptic patients. Two epileptic patients reported past suicidal attempts however, only 2 patients were receiving psychiatric treatment.

    CONCLUSION:

    Psychiatric disorders were frequently observed in the group of epileptic patients. Psychiatric disorders occurred more frequently in boys compared to girls in this group. Clinicians should be more aware of accompanying psychiatric symptoms in epileptic patients and take the necessary precautions in the early period of the illness in an effort to prevent future mental health problems.

  • Sociodemographic and clinical factors associated with compliance to methylphenidate treatment in children with attention deficit hyperactivity disorder].

    OBJECTIVE:

    The present study aimed to determine the rate of treatment compliance in children with attention deficit hyperactivity disorder (ADHD) that were newly prescribed methylphenidate, and to evaluate the associated clinical and sociodemographic factors, as well as parental concerns about drug treatment.

    METHOD:

    The sample of this prospective and observational study consisted of 238 children aged 7-18 years with ADHD diagnosed according to DSM-IV criteria. At the end of the first year, the study sample was splitted into 2 groups; compliant and non-compliant. Parental attitudes toward drug therapy, and clinical and sociodemographic characteristics of the 2 groups were compared. A clinician rated parental concerns about drug treatment 4-6 weeks after the interview that was conducted in order to inform them about methylphenidate therapy. Regarding a minimum requirement of 5 days weekly dosage and drug holidays, cases that took more than 70% of the recommended methylphenidate dose at the end of the first year were described as compliant.

    RESULTS:

    At the end of the first year of treatment, the drug compliance rate was 80.3% (n= 191). The non-compliant group consisted of older children. A significant difference was observed between the compliant and non-compliant groups in terms of parental approach toward drug treatment. Children in the non-compliant group had parents that had doubts about pharmacotherapy and these children were less compliant with methylphenidate treatment.

    CONCLUSION:

    Parental concerns about methylphenidate treatment in ADHD may influence treatment compliance. Additionally, it is suggested that developmental psychological characteristics associated with adolescence may also be important.

  • Impaired verbal memory and otherwise spared cognition in remitted bipolar patients on monotherapy with lithium or valproate.

    OBJECTIVES:

    Patients with bipolar disorder have been reported to have neurocognitive deficits; however, it is not known whether the cognitive dysfunctions are state-dependent or a stable trait. Lithium and valproate, 2 of the most widely used mood stabilizers in the treatment of bipolar disorder, have also been associated with cognitive impairment. However, the degree and pattern of neurocognitive impairment in euthymic bipolar patients on either monotherapy with lithium or valproate have not been compared before in depth.

    METHODS:

    We compared 17 euthymic outpatients with bipolar disorder (BD) on lithium monotherapy to 11 euthymic outpatients with BD on valproate monotherapy and 29 comparison subjects using tests measuring immediate verbal memory and executive functions in addition to 3 subtests of the Wechsler Adult Intelligence Scale Revised. The groups were similar in terms of level of education, duration and severity of illness, and gender distribution. Patients on lithium monotherapy were older than patients on valproate and healthy controls. Mood symptoms as assessed by standardized scales were mild to non-existent in both patient groups.

    RESULTS:

    Immediate verbal memory was impaired in both patient groups compared to controls, where the main effect of age was not significant. No significant differences could be found on the other cognitive measures.

    CONCLUSIONS:

    Both lithium and valproate may be associated with immediate verbal memory impairment, sparing other cognitive functions. Presence of a similar verbal memory deficit in the lithium and valproate groups suggests that this deficit might be intrinsic to BD or that the 2 medications influence immediate verbal memory similarly. Larger samples of remitted bipolar patients on monotherapy should be studied for more precise conclusions.

  • Psychiatric symptoms and health-related quality of life in children and adolescents with psoriasis.

    Information about the relationship between psoriasis and psychiatric morbidity and quality of life in children and adolescents is limited. We aimed to examine the symptoms of depression and anxiety and health-related quality of life levels in children and adolescents with psoriasis. Forty-eight outpatients with psoriasis aged 8 to 18 years are included in this study. Child Depression Inventory (CDI), State-Trait Anxiety Inventories for Children (STAI-C) and Pediatric Quality of Life Inventory Parent and Child Versions (PedQL-P and C) were applied to both patient and control groups. Psoriasis symptom severity was measured by the Psoriasis Area Severity Index (PASI). Both study and control groups were divided into two age groups, child (8-12 yrs) and adolescent (13-18 yrs), to exclude the effect of puberty on psychological condition. The mean CDI score was higher, and PedQL-C psychosocial and total scores were lower in the children compared with controls. Duration of psoriasis had an increasing effect on physical-health and total scores of PedQL-C in the child group and all PedQL-C scores in the entire sample. Psoriasis severity showed a negative correlation with psychosocial and total scores of PedQL-P in the adolescent group and PedQL-P physical-health scores in the entire sample. Psoriasis is related to depression and impaired quality of life in children. The depressive symptoms in children with psoriasis should not be overlooked and psychiatric assessment of these children should be provided.

  • Use of complementary and alternative medicine in children with autism spectrum disorders: a multicenter study.

    INTRODUCTION:

    This study examined the prevalence of the use of different complementary and alternative medicine (CAM) strategies, families’ attitudes and belief systems about the use of these strategies, and the economic burden of these strategies placed on family income in families of children with autism spectrum disorders (ASD).

    METHOD:

    A questionnaire survey concerning the use of CAM in children with ASD was administered to parents in the five different geographic locations in Turkey.

    RESULT:

    Of the 172 respondents, 56% had used at least one CAM therapy. The most frequently used CAM intervention was spiritual healing. Among the most reported reasons for seeking CAM were dissatisfaction with conventional interventions and a search for ways to enhance the effectiveness of conventional treatments. The most frequently reported source of recommendation for CAM was advice from family members. The mean economic burden of the CAM methods was a total of 4,005 Turkish lira ($2,670) in the sample using CAM. The CAM usage rate was lower in parents who suspected genetic/congenital factors for the development of ASD.

    CONCLUSION:

    This study observed the importance of socioeconomic and cultural factors as well as parents’ beliefs about the etiology of ASD in treatment decisions about CAM.

  • The relationship between psychological symptoms, lung function and quality of life in children and adolescents with non-cystic fibrosis bronchiectasis.

    OBJECTIVES:

    The aim of this study was to evaluate the relationship between psychological symptoms and quality of life (QOL) and clinical variables in a cohort of children and adolescents with non-cystic fibrosis (non-CF) bronchiectasis.

    METHODS:

    Seventy-six patients (aged 8-17years) participated in this study. Questionnaires were used to evaluate the psychological status and QOL of the patients and healthy controls. The patient and control groups were divided into child and adolescent groups to exclude the effect of puberty on psychological status.

    RESULTS:

    No significant difference was found between patient and control groups for mean depression and trait anxiety scores. Only the child-rated physical health QOL scores were significantly lower for patients than the controls. Also, excepting physical health scores in adolescent group, all of the parent-rated QOL scores were significantly lower in both group and total subjects. Regarding determinants of QOL, age of children and FEV1/FVC percent predicted had positive effects, while dyspnea severity and trait anxiety had negative effects, for the sample as a whole.

    CONCLUSIONS:

    Non-CF bronchiectasis is associated with poorer QOL in childhood. The impact of the disease on QOL occurs through both clinical and psychological variables.

  • Autistic trait, empathy, and attention-deficit/hyperactivity symptoms in women with ıdiopathic hirsutism.

    AIM:

    Many psychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD), disruptive behavioral disorders, autism spectrum disorders, and some psychiatric characteristics, such as poor empathizing, are regarded to be related to elevated levels of androgens or androgen sensitivity. Thus, numerous studies have investigated the potential association between androgen-related physical diseases and these psychiatric conditions. Idiopathic hirsutism (IH) is a disease characterized by an increased sensitivity of the pilosebaceous unit to circulating androgens in women. The purpose of this study was to examine whether IH has a relationship with androgen-related psychiatric conditions.

    MATERIALS AND METHODS:

    Totally 37 females with IH and 33 healthy female controls were included in this study. Childhood and present ADHD symptoms of the participants were assessed using the Wender Utah Rating Scale (WURS) and the Adult ADHD Self-Report Scale, respectively. The Autism-spectrum quotient and the interpersonal reactivity index were used to assess autistic traits and different aspects of empathy. Hirsutism severity was measured using the Ferriman-Gallwey scoring system.

    RESULTS:

    No significant difference was found between the patients and controls on psychiatric questionnaire scores, except for a trend for subjects with IH to show higher levels of the school-associated problems than controls according to WURS. The severity of hirsutism was strongly correlated with the WURS irritability and behavioral problems/impulsivity subscores and WURS total score, and moderately correlated with the WURS attentional deficit subscore.

    CONCLUSIONS:

    This study provides preliminary evidence that common etiological factors may be involved in both the severity of IH, ADHD, and coexisting disruptive behavioral problems.

  • Relationships among depression, anxiety, anxiety sensitivity, and perceived social support in adolescents with conversion disorder.

    OBJECTIVE:

    This study aimed to assess the relationships of depression, anxiety, anxiety sensitivity, and perceived social support with conversion symptoms in adolescents with conversion disorder (CD).

    METHODS:

    Fifty outpatients, aged 8-18 years, who had been diagnosed with CD and members of a control group were assessed using the psychological questionnaires.

    RESULTS:

    Compared with controls, adolescents with CD scored higher on the Child Depression Inventory (CDI), Screen for Child Anxiety-related Emotional Disorders (SCARED), Childhood Anxiety Sensitivity Index (CASI) total, CASI physical and cognitive subscales, and Multidimensional Scale of Perceived Social Support family subscale. Multiple regression analysis showed that CDI, CASI total, and CASI cognitive scores predicted the Somatoform Dissociation Questionnaire (SDQ) scores and that CDI and CASI total scores predicted the Children’s Somatization Inventory (CSI) scores of subjects.

    CONCLUSIONS:

    This study suggest that adolescents with CD had poor psychosocial well-being, and depression, global anxiety sensitivity and anxiety sensitivity cognitive concerns are related to conversion symptoms.

  • Impact of end-stage renal disease on psychological status and quality of life

    BACKGROUND:

    The aim of this study was to assess depression, anxiety, and quality of life (QOL) in a cohort of children and adolescents with end-stage renal disease (ESRD), to compare these findings with healthy controls, and to evaluate the association between these psychological symptoms, QOL, and clinical variables related to ESRD.

    METHODS:

    Thirty-two children and adolescents 8-18 years of age were enrolled in the study. The sociodemographic data were evaluated. Questionnaires were used to evaluate the psychological status and QOL of the patients and healthy controls.

    RESULTS:

    There was a significant difference in mean depression score, which was significantly higher for the ESRD patients. Mean state anxiety score was significantly lower for ESRD patients than for controls. Regarding QOL score, there were significant differences between the ESRD patients and control groups for both child-rated and parent-rated QOL scores, which were significantly lower for ESRD patients. Trait anxiety was a negative predictor of all subscales of the Pediatric Quality of Life Inventory 4.

    CONCLUSIONS:

    End-stage renal disease was related to significant morbidity and poorer QOL. The assessment and enhancement of QOL and comorbid psychiatric disorders in ESRD should be a part of disease management.