Psychosomatics 41:377-384, October 2000
© 2000 The Academy of Psychosomatic Medicine
Emotional State, Coping Styles, and Somatic Variables in Patients With Chronic Hepatitis C
Michael R. Kraus, M.D. Ph.D.,
Arne Schäfer,
Herbert Csef, M.D.,
Michael Scheurlen, M.D., and
Hermann Faller, M.D. Ph.D.
Received September 21, 1999; revised December 1, 1999; accepted February 4, 2000. From the Medizinische Poliklinik and the Institute of Psychotherapy and Medical Psychology, University of Würzburg, Würzburg, Germany. Address reprint requests to Dr. Kraus, Medizinische Poliklinik, University of Würzburg, Klinikstrasse 6–8, 97070 Würzburg, Germany; e-mail: m.kraus{at}mail.uni-wuerzburg.de
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ABSTRACT
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The authors in a cross-sectional study examined 113 patients with chronic hepatitis C (CHC) without widely progressed or decompensated liver disease. The patients were investigated for emotional state (depression, anxiety, coping styles) and somatic/sociodemographic variables. A high percentage of patients had positive scores for depression (22.4%) and anxiety (15.2%). Mode of acquisition (e.g., former drug abuse) and histological grade of liver damage had no significant influence on emotional state or coping strategies. Older patients ( 50 years) were significantly more depressed (P=0.024). Patients with a recently diagnosed CHC (>4 weeks, <6 months) had significantly lower scores for depression (P=0.003) and anxiety (P=0.001) than the subgroup with a time interval since initial diagnosis of more than 5 years. Recently diagnosed CHC patients also showed the highest levels of problem-solving behavior. Patients who were advised not to undergo an interferon therapy were significantly more depressed (P=0.001) and anxious (P=0.028). Older patients with CHC and patients with a long period since CHC diagnosis or who were advised not to undergo interferon therapy should be carefully and regularly assessed for depression, anxiety, and inappropriate coping styles.
Key Words: Hepatitis • Depression • Anxiety
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INTRODUCTION
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Chronic hepatitis C (CHC) is one of the most frequent infectious diseases in the world. The estimated prevalence of an antibody to hepatitis C virus (anti-HCV) ranges from 15% in Egypt or Cameroon to 1.8% in the United States to 0.8% in Germany.1–3 Since the detection of the hepatitis C virus (HCV) in 1989,4 a continually rising number of patients with CHC have been diagnosed. The number of people infected with HCV has been estimated to exceed 100 million worldwide.2 Of these, approximately 70% have CHC (2.7 million persons in the United States3) and at least 20% have cirrhosis.5 The mode of transmission is often unclear (30%–40%) when typical acquisition modes (e.g., intravenous drugs and transfusions) cannot be found.2 Its frequently undetermined origin and the fact that CHC is the most frequent cause of chronic liver disease and liver cancer in the developed world often leads to a feeling of uncertainty in both patients and physicians. End-stage liver disease due to CHC is now the major indication for liver transplantation in adults in the United States, accounting for 30% of the cases.6 In addition, there is an increasing number of reports about the problem of CHC as the "new plague of humanity" or the "shadow epidemic"7 in the media and the Internet. Similar to human immunodeficiency virus (HIV) infection, patients often estimate their infectious disease as fatal and stigmatic.
The medical therapy of CHC is still unsatisfactory, although about 40%–50% of patients can reach a "sustained" (6 months after termination of therapy) virological HCV-clearance by new therapeutic strategies [interferon- alpha (IFN)/ribavirin].8,9 However, the tolerance of this medication is often poor.
For patients with CHC, quality of life is significantly reduced,10–13 even in the absence of therapy and cirrhosis.14 The concept of quality of life, aside from somatic comfort and social relations, coping styles, and emotional state, plays an important role in patients with chronic diseases.
Singh15 showed that patients with liver cirrhosis as an end stage of different liver diseases and depression had a significantly poorer perceived quality of life and poorer adaptive coping compared with nondepressed patients. They were more likely to die while awaiting transplantation. In Singh's study a significantly higher number of patients with depression had a viral hepatitis (B/C)-associated cirrhosis compared with patients without depression. The difference in mortality could not be explained by somatic factors (e.g., severity of illness variables, Child-Pugh score, or complication of liver disease).
Implications for medical care in CHC are evident; addressing psychosocial factors may have positive results on the outcome of patients with hepatitis C by improving compliance and reducing risk behavior [e.g., intravenous drug use (IVDU), alcohol abuse]. As psychiatric disorders are well-known side effects of IFN therapy, prevalence rates for emotional disorders of treatment candidates are of particular interest (see inclusion/exclusion criteria).
Taking into account this context of problems, we decided to investigate coping styles and emotional state of hepatitis C patients without a specific medical treatment at the time of assessment. Coping is viewed as a response to perceived stress; it has been defined as the "cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person."16
The objective of the present study is the descriptive analysis of coping styles and emotional state in hepatitis C patients and to evaluate the correlation between these variables and the way of acquisition (e.g., intravenous drugs, transfusions, or unknown), age, gender, time since initial diagnosis, and histology of liver. We did not analyze the duration of infection (exposure time), because in most patients the exact date of acquisition cannot be determined.
An additional aim is to evaluate coping styles and emotional state according to three different patient subgroups: patients who decided to deny, were refused (e.g., medical contraindications, unsuccessful IFN/ribavirin therapy in the past), or underwent IFN therapy after a psychometric test.
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METHODS
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Subjects
The participants were patients with CHC, referred to the Medizinische Poliklinik of the University of Würzburg from November 1996 to June 1999. At the Medizinische Poliklinik, a multispecialty group of physicians (e.g., specialists of gastroenterology/hepatology and psychosomatic medicine) cares for patients from a wide geographic radius on an in- and outpatient basis. To be included in the study, patients were required to have documented antibody to HCV and detectable HCV-RNA in the serum, using a sensitive assay that is based on reverse-transcription polymerase chain reaction. The major exclusion criteria were patients under 18 years old or above 65 years old, evidence of coinfections (e.g., HIV, HBV), previous or current malignant diseases, limited or decompensated liver function (Child-Pugh B/C), active IVDU or alcohol abuse, current IFN therapy, obvious intellectual impairment, and insufficient knowledge of the German language.
All the subjects were informed of the study's aims and gave written informed consent before enrollment. The study was approved by the Ethics Committee for Medical Research in Würzburg in accordance with the Declaration of Helsinki.
The overall number of hepatitis C patients in the center between November 1996 and June 1999 was 190; 118 patients fulfilled the criteria of the study. Five patients denied participation, and 113 patients were enrolled in the study.
Measures
Psychometric Instruments
Anxiety and depression were assessed by the well-validated Hospital Anxiety and Depression Scale (HADS, German version)17. HADS is a 14- item questionnaire with anxiety and depression dimensions. All items exclusively refer to the emotional state and do not reflect somatic symptoms. Data analysis can be performed in two different ways. In addition to a dimensional analysis, scores can be assigned to three categories: inconspicuous ( 7), doubtful (8–10), and conspicuous (11). Recently, the cut-off value for the clinically relevant depression subscale was set to 9, for anxiety 11.17
To evaluate state and trait aspects of anxiety, we used the State-Trait Anxiety Inventory (STAI, German version)18. The STAI consists of two subscales (State and Trait anxiety), each including 20 items.
Coping was evaluated by the well-validated Freiburg Questionnaire on Coping with Illness [FKV (FQCI), German version, self-report format]19–22. FKV is a 35-item questionnaire with five primary dimensions: Depressive Coping, Problem-Solving Behavior, Distraction and Self-Revalorization, Religiousness and Search for Meaning, and Cognitive Avoidance and Dissimulation. A high score in the FKV subscales means that there is a strong tendency towards the concerning coping mechanism. There are several validity studies for other chronic diseases.23
Clinical, Laboratory, and Histological Data
Blood samples were obtained during the patients' medical visits to evaluate the following parameters: HCV-RNA and virus genotype. A biopsy showed data concerning liver histology/grade of liver damage (e.g., inflammation, fibrosis, cirrhosis). Finally, information about acquisition mode, former IFN therapies, and comorbidities as well as time since initial diagnosis was documented.
Sociodemographic Factors
This category of variables includes gender, age, family status, partnership background, and employment.
Statistical Analysis
Data were registered and analyzed using the Statistical Package for Social Sciences (SPSS for Windows, German version 8.0). All tests of significance were two-tailed, P values of <0.05 were considered statistically significant. Because of the explorative character of the study, we did not consider  -adjustment in multiple comparisons. For descriptive analysis, data are expressed as median or mean±standard deviation (SD). For tests of significance, mean differences of continuous variables among subgroups were examined by analysis of variance (ANOVA procedure, followed by Scheffe test) and t-test for independent samples (comparison of two subgroups). Pearson's correlation was used when appropriate.
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RESULTS
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Demographic and Biomedical Data
The description of sociodemographic variables in our study sample (gender, age, family status, partnership background, and employment) is presented in Table 1.
With regard to probable mode of acquisition, 53 patients (46.9%) were infected through former IVDU, 28 (24.8%) through transfusion (before 1990), and in 32 patients (28.3%) it was not possible to record the cause of infection; 8 patients (7.1%) of this group worked in hospitals, and this is a possible infection mode.
In 110 patients, genotype was examined: 74 patients (65.5%) were infected with HCV genotype I, 5 (4.4%) with II, and 31 (27.4%) with III.
In 99 patients, the grade of liver damage was determined by biopsy. For histology, 58 patients (51.3%) showed chronic hepatitis, 23 (20.4%) fibrosis, and 18 (15.9%) cirrhosis.
In 40 patients (35.4%), the time between initial diagnosis of hepatitis C and psychometric evaluation was between 4 weeks and 6 months—so it could be assumed that the "acute shock phase" had already passed at the time of investigation. Fifteen patients (13.3%) had been aware of their infection for at least 5 years.
Twenty-nine patients (25.7%) had received a specific therapy with IFN previously. Indication for an IFN therapy was given in 98 patients (86.7%), 20 (17.7%) refused a recommended IFN treatment, and in 15 cases (13.3%) a physician advised the patient not to treat the hepatitis C infection with IFN because of medical reasons (e.g., comorbidities such as cardiovascular disease, autoimmune disease, depression, and low activity of hepatitis).
Emotional State (Depression and Anxiety)
Evaluation of sociodemographic variables showed no influence of gender, family status, partnership, or employment on emotional state.
In the total sample (112/113; one HADS questionnaire was not evaluable) mean scores were 5.24±4.32(SD) for depression and 6.70±3.92 for anxiety. The scores for depression were distributed as follows: inconspicuous (n=84, 75%), doubtful (n=15, 13.4%), and conspicuous (n=13, 11.6%). Twenty-five patients (22.3%) had a depression score above the cut-off value (9; healthy control subjects 3.2%).
Prevalence of anxiety scores in our total sample was inconspicuous (n=71, 63.4%), doubtful (n=24, 21.4%), conspicuous (n=17, 15.2%). Seventeen patients (15.2%) had an anxiety score above the cut-off value (11; healthy control subjects 6.8%).
The evaluation of trait and state anxiety in STAI showed a mean score of 41.36±12.24 and 41.42±12.01. (Of the healthy control subjects, 50% yielded a trait anxiety score 34.)
In patients with former IVDU, scores for depression and anxiety (trait and state) were not different from those of patients without IVDU.
In the subgroup with previous IFN therapy measures of depression (5.79±4.95 vs. 5.05±4.09) and anxiety (8.03±4,80 vs. 6.23±3.48) were increased in comparison to "IFN-naive" individuals. The observed differences were not statistically significant; however, the increase of anxiety scores reflects a trend.
As quantification of HCV load was not performed in all patients, we were not able to determine the association between HCV load and emotional state. Cirrhosis, fibrosis, and hepatitis as different grades of liver damage as well as HCV genotype had no impact on scores of depression or anxiety.
Patients older than 50 years of age had significantly higher scores of depression than younger patients (7.26±4.81 vs. 4.83±4.12; P=0.024).
Analysis of variance revealed that the main effect of the factor "time interval since initial diagnosis" was significant for both depression (P<0.01) and anxiety (P<0.01) in HADS (Figure 1).
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FIGURE 1. Subgroups according to time interval since initial diagnosis with the Hospital Anxiety and Depression Scale (HADS)
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In patients with a recently diagnosed hepatitis C (<6 months; >4 weeks), mean scores for depression (3.74±2.67 vs. 8.13±4.76; post hoc: P=0.003) and anxiety (5.67±2.95 vs. 10.27±4.40; post hoc: P=0.001) were significantly lower than in the subgroup of patients knowing of their infection for more than 5 years (linear correlation coefficients: anxiety/time interval 0.30, depression/ time interval 0.24).
STAI anxiety mean scores were significantly increased for both subscales (trait 49.3±13.85 vs. 38.51±10.17; post hoc: P=0.013; state 49.82±14.76 vs. 39.87±9.12; post hoc: P=0.022) in the subgroup with more than 5 years since initial diagnosis compared with patients with a recently diagnosed hepatitis C (<6 months; >4 weeks) (ANOVA main effects in both cases: P=0.013). Age and time since HCV notification were not significantly correlated (r=0.11; P=0.217), so this possible confounding factor can be excluded.
The subgroup of those patients who were advised not to undergo IFN treatment was significantly more depressed (8.93±5.34 vs. 4.83±3.82; P=0.001) and anxious (trait: 47.53±13.72 vs. 40.26±11.14; P=0.028) than patients with a subsequent IFN medication.
Coping Styles and Related Variables
In the total sample, the subscale problem-solving behavior (3.48±0.79) was the dominant coping mechanism next to distraction and self-revalorization (3.02±0.67), religiousness and search for meaning (2.55±0.73), cognitive avoidance and dissimulation (2.10±0.85), and depressive coping (2.08±0.80).
Sociodemographic variables (gender, family status, partnership background, and employment) had no influence on order or extent of coping styles.
In patients with former IVDU, the mean score for distraction and self-revalorization (2.90±0.60) was somewhat lower than in patients without former IVDU (3.12±0.71; P<0.1). Apart from this tendency, there were no detectable differences between the subgroups on the basis of acquisition mode.
A previous IFN therapy had no influence on the quantity (mean scores) of coping styles. Patients with cirrhosis, as grade of progressed liver damage, showed in tendency a higher mean score for religiousness and search for meaning compared with those with hepatitis or fibrosis (2.79±0.86 vs. 2.48±0.67; P=0.093).
The investigation of the relationship between age and coping mechanisms revealed only one significant correlation: religiousness and search for meaning was positively correlated with age (r=0.3; P<0.01). In patients older than 50 years of age (19/113) religiousness and search for meaning was significantly more important than in younger patients (P<0.01) (Figure 2).
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FIGURE 2. Subgroups according to the patients' age and coping styles according to the Freiburg Questionnaire on Coping with Illness (FKV)
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Problem-solving behavior (3.68±0.76) was expressed significantly more in individuals with recently diagnosed hepatitis C (>4 weeks, <6 months) than in the remaining subgroup (6 months) (3.37±0.80, P=0.05). The subgroup of patients knowing of their infection for more than 5 years showed significantly higher levels of depression (2.48±0.84 vs. 2.01±0.78; P=0.04) and lower levels of problem-solving behavior (3.05±0.85 vs. 3.54±0.77; P=0.024) (Figure 3).
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FIGURE 3. Subgroups according to time interval since initial diagnosis and coping styles according to the Freiburg Questionnaire on Coping with Illness (FKV)
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Patients with a former IFN therapy were not different in their coping styles from individuals who had had no previous IFN treatment.
In patients who denied a recommended IFN treatment, the coping mechanism religiousness and search for meaning was more expressed (P=0.1).
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DISCUSSION
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In contrast to HIV/AIDS,24–31 no research examining emotional state, psychosocial consequences, or coping in CHC has been published so far.
In this cross-sectional study, we investigated the relationship between emotional state (depression, anxiety), coping styles, and somatic variables (clinical, laboratory, and histological data) in patients with CHC. Being aware of the fact that data from screening tools are unlikely to accurately represent prevalence of DSM-IV disorders, we found out that a high percentage of patients with hepatitis C showed clinically relevant scores for depression and anxiety. Compared with healthy control subjects, prevalence rate of depression was much higher in HCV patients. This rate (22.4%) was nearly identical to the rate (24%) observed in a retrospective study by Lee et al.,32 where depression, unrelated to IFN therapy, was the most common associated disorder in CHC. However, it does not reach the prevalence of depression observed in patients with known HIV/AIDS infection.27,33,34 In a small sample of patients with CHC (n=30), the rate of psychiatric diagnoses was 36.7%, most frequently represented by anxiety disorders (20%).35 As all investigated patients with hepatitis C belong to a clinical sample, depression and anxiety may be less prevalent in a community sample.
Mean score of depression was comparable17,36 or considerably higher in patients with CHC than in patients with recently diagnosed cancer.37,38 The mean score of anxiety was higher38 or equal36 in patients with CHC compared with cancer patients, and coping styles were in a similar range.38
In the total sample, the order of coping styles corresponded with the order in other diseases like Crohn's disease,39 cancer,38 myocardial infarction, end-stage renal disease, and multiple sclerosis.23 Active coping styles like active problem-solving were predominantly used (Figure 2 and Figure 3).
Sociodemographic factors like gender, family status/ partnership background, and employment did not seem to influence emotional state or coping style in CHC. Only age turned out to be linked with several dependent variables in our study.
In our study, older patients (>50 years) were significantly more depressed. The coping mechanism of religiousness and search for meaning was also positively correlated with age (Figure 2). However, this correlation does not seem to be specific for a CHC infection. In patients with cancer or other chronic disease, a similar correlation was reported.23
Unexpectedly, the mode of acquisition and the histological grade of liver damage as a marker of severity of illness had no significant influence on emotional state and coping strategies.
The major result of this study, in our opinion, was the fact that patients with recently diagnosed hepatitis C had significantly lower scores for depression and anxiety than patients with a longer time interval since initial diagnosis (Figure 1). The last subgroup of patients shows the lowest levels of problem-solving behavior (Figure 3). A similar tendency in coping strategies was found in a sample of patients with myocardial infarction, cancer, end-stage renal disease, and multiple sclerosis.23 This may be the result of HCV-infected patients' realization that problems like development of liver cancer or failure in liver function are a "question of time." In addition, patients with a longer period since initial diagnosis are more likely to have experienced poor results and often unsatisfying tolerance of former therapy strategies. Similar to Foster et al.,14 who showed that the reduction in quality of life scores could not be attributed to the degree of liver inflammation or the mode of acquisition of the infection, our data suggest that the time of "knowledge" about hepatitis C infection seems to be one of the main variables influencing the emotional state. Additionally, in our investigation, experience of a former ineffective IFN therapy had no significant influence on emotional state or coping strategy. Patients who were advised not to undergo IFN therapy were significantly more depressed and anxious. The higher age of this subgroup explains only in part higher scores of depression but not of anxiety. Unfortunately, our cross-sectional study design does not allow us to make statements about causal relationships. It remains unclear whether elevated anxiety is a consequence of the physician's IFN therapy denial or the reason for the physician's decision.
Clinical implications of these findings in patients with CHC are apparent. First, given the relatively slow natural progression of CHC infection and the increasing but unpredictable risk of complications, regular assessment of psychosocial variables should be a mandatory component of medical care. Patients who indicate symptoms of emotional disorders or inappropriate coping styles should be referred to corresponding specialists. Individuals of older age with CHC and patients with a longer time period since HCV notification or who were advised not to undergo IFN therapy should be carefully and regularly assessed. Symptoms of depression and anxiety should be sought in patients with CHC because both are treatable disorders.
The impact of emotional state and coping styles on health outcome and tolerance/response in IFN therapy warrants further investigation in a longitudinal study design that includes assessment for DSM-IV comorbidity and the identification of the relationship between emotional state and measures of HCV activity (e.g., HCV-virus load).
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ACKNOWLEDGMENTS
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This study was supported in part by Essex-Pharma (Germany), a subsidiary of Schering-Plough (Kenilworth, NJ).
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REFERENCES
|
-
Alter MJ: Epidemiology of hepatitis C in the West. Seminars in Liver Disease 1995; 15:5–14[Medline]
-
Alter MJ: Epidemiology of hepatitis C. Hepatology 1997; 26:62S– 65S[CrossRef]
-
Alter MJ, Kruszon-Moran D, Nainan OV, et al: The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Eng J Med 1999; 341:556–562[Abstract/Free Full Text]
-
Choo QL, Kuo G, Weiner A, et al: Isolation of a cDNA clone derived from a blood-borne non-A, non-B hepatitis genome. Science 1989; 244:359–362[Abstract/Free Full Text]
-
McQuillan GM, Alter MJ, Moyer LA, et al: A population-based serologic study of hepatitis C virus infection in the United States, in Viral Hepatitis and Liver Disease, edited by Rizetto M, Purcell RH, Gerin JL, et al. Turin, Edizioni Minerva Medica, 1997, pp 267– 270
-
Hoofnagle JH: Chronic viral hepatitis C—clinical, in Association for the Study of Liver Diseases: Postgraduate Course. Chicago, IL 1998, pp 376–381
-
Williams S: Hepatitis C testing at home. Newsweek, May 24, 1999
-
McHutchison JG, Gordon SC, Schiff ER, et al: Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C. N Eng J Med 1998; 229:1485–1492
-
Poynard T, Marcellin P, Lee SS, et al: Randomised trial of interferon alpha 2b plus ribavirin for 48 weeks or for 24 weeks versus interferon alpha 2b plus placebo for 48 weeks for treatment of chronic infection with hepatitis C virus. Lancet 1998; 352:1426– 1432
-
Carithers RL, Sugano D, Bayliss M: Health assessment for chronic HCV infection: results of quality of life. Digestive Diseases Sciences 1996; 41:75S–80S
-
Bayliss MS, Gandek B, Bungay KM, et al: A questionnaire to assess the generic and disease-specific health outcomes of patients with chronic hepatitis C. Quality of Life Research 1998; 7:39–55
-
Bonkovsky HL, Wooley JM: Reduction of health-related quality of life in chronic hepatitis C and improvement with interferon therapy. The Consensus Interferon Study Group. Hepatology 1999; 29:264– 270[CrossRef][Medline]
-
Ware JE, Bayliss MS, Mannocchia M, et al: Health-related quality of life in chronic hepatitis C: impact of disease and treatment response. Hepatology 1999; 30:550–555[CrossRef][Medline]
-
Foster GR, Goldin RD, Thomas HC: Chronic hepatitis C virus infection causes a significant reduction in quality of life in the absence of cirrhosis. Hepatology 1998; 27:209–212[CrossRef][Medline]
-
Singh N, Gayowski T, Wagener MM, et al: Depression in patients with cirrhosis. Digestive Diseases and Sciences 1997; 42:1421– 1427
-
Lazarus RS, Folkman RH: Stress, appraisal and coping. New York, Springer, 1984
-
Herrmann C, Buss U, Snaith RP: HADS-D. Hospital Anxiety and Depression Scale—Deutsche Version. Ein Fragebogen zur Erfassung von Angst und Depressivität in der somatischen Medizin. Bern, Huber, 1995
-
Laux L, Glanzmann P, Schaffner P, et al: Das State-Trait-Angstinventar. Theoretische Grundlagen und Handanweisungen. Weinheim, Beltz, 1981
-
Muthny FA: Freiburger Fragebogen zur Krankheitsverarbeitung. Weinheim, Beltz, 1989
-
Buddeberg C, Wolf C, Sieber M, et al: Coping strategies and course of disease of breast cancer patients. Psychotherapy and Psychosomatics 1991; 55:151–157[Medline]
-
Buddeberg C, Sieber M, Wolf C, et al: Are coping strategies related to disease outcome in early breast cancer. J Psychosom Res 1996; 40:255–264[CrossRef][Medline]
-
Faller H, Bülzebruck H, Drings P, et al: Coping, distress and survival among lung cancer patients. Archives of General Psychiatry 1999; (in press)
-
Muthny FA, Bechtel M, Spaete M: Laienätiologien und Krankheitsverarbeitung bei schweren körperlichen Erkrankungen. Psychotherapie Psychosomatik medizinische Psychologie 1992; 42:41–53[Medline]
-
Catalan J: Psychosocial and neuropsychiatric aspects of HIV infection: review of their extent and implications for psychiatry. J Psychosom Res 1988; 32:237–248[CrossRef][Medline]
-
Miller D, Riccio M: Non-organic psychiatric and psychosocial syndromes associated with HIV-1 infection and disease. AIDS 1990; 4:381–388[Medline]
-
Wolf TM, Balso PM, Morse EV, et al: Relationships of coping style to affective state and perceived social support in asymptomatic and symptomatic HIV-infected persons: implications for clinical management. J Clin Psychiatry 1991; 52:171–173[Medline]
-
Leiberich P, Engeter M, Schumacher K, et al: Problem- und Krankheitsverarbeitung bei HIV-Positiven. AIDS-Forschung 1992; 7:575–583
-
DeGenova MK, Patton DM, Jurich JA, et al.: Way of coping among HIV-infected individuals. J Soc Psychol 1994; 134:655–663[Medline]
-
Fleishman JA, Fogel B: Coping and depressive symptoms among people with AIDS. Health Psychol 1994; 13:156–169[CrossRef][Medline]
-
Friedland J, Renwick R, McColl M: Coping and social support as determinants of quality of life in HIV/AIDS. AIDS Care 1996; 8:15–31[CrossRef][Medline]
-
Grassi L, Righi R, Sighinolfi L, et al: Coping styles and psychosocial-related variables in HIV-infected patients. Psychosomatics 1998; 39:350–359[Abstract/Free Full Text]
-
Lee DH, Jamal H, Regenstein FG, et al: Morbidity of chronic hepatitis C as seen in a tertiary care medical center. Digestive Diseases and Sciences 1997; 42:186–191[CrossRef][Medline]
-
Weimer E, Clement U, Nilsson-Schönnesson L: Depressive Reaktion und psychische Verarbeitung bei HIV-positiven homosexuellen Männern. Psychotherapie Psychosomatik medizinische Psychologie 1991; 41:107–114[Medline]
-
Perry SW, Jacobsberg L, Car C, et al: Severity of psychiatric symptoms after HIV testing. Am J Psychiatry 1993; 151:156–161[Medline]
-
Taruschio G, Santarini F, Sica G, et al: Psychiatric disorders in hepatitis C virus related chronic liver disease. Gastroenterology 1996; 110:A1342
-
Herrmann C: International experiences with the Hospital Anxiety and Depression Scale—a review of validation data and clinical results. J Psychosom Res 1997; 42:17–41[CrossRef][Medline]
-
Moorey S, Greer S, Watson M, et al: The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br J Psychiatry 1991; 158:255–259[Abstract/Free Full Text]
-
Faller H, Kraus MR, Burth EM, et al.: Emotionales Befinden, Krankheitsverarbeitung und klinischer Status bei Morbus Hodgkin-Patienten. Zeitschrift für Medizinische Psychologie 1999; 8:19–28
-
Kordy H, Normann D: Psychische und somatische Faktoren des Krankheitsverlaufs bei Morbus Crohn. Psychotherapie Psychosomatik medizinische Psychologie 1992; 42:141–149[Medline]
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Psychosomatics,
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45(1):
29 - 33.
[Abstract]
[Full Text]
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J. M. Loftis and P. Hauser
Safety of the Treatment of Interferon-Alpha-Induced Depression
Psychosomatics,
December 1, 2003;
44(6):
524 - 526.
[Full Text]
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E. Dieperink, S. B. Ho, P. Thuras, and M. L. Willenbring
A Prospective Study of Neuropsychiatric Symptoms Associated With Interferon-{alpha}-2b and Ribavirin Therapy for Patients With Chronic Hepatitis C
Psychosomatics,
April 1, 2003;
44(2):
104 - 112.
[Abstract]
[Full Text]
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S. P. Yovtcheva, M. A. Rifai, J. K. Moles, and B. J. Van Der Linden
Psychiatric Comorbidity Among Hepatitis C-Positive Patients
Psychosomatics,
October 1, 2001;
42(5):
411 - 415.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
