Mental health and quality of life in liver transplant and cirrhotic patients with various etiologies

Int J Clin Health Psychol, Vol. 12. Nº 2 MEDINA-PRADAS et al. Emotional theory of mind in eating disorders 203 ISSN 1697-2600 print ISSN 2174-0852 online 2012, Vol. 12, Nº 2, pp. 203-218 © International Journal of Clinical and Health Psychology Mental health and quality of life in liver transplant and cirrhotic patients with various etiologies1 María Ángeles Pérez-San-Gregorio2 (Universidad de Sevilla, Spain), Agustín Martín-Rodríguez (Universidad de Sevilla, Spain), Elisabeth Domínguez-Cabello (Universidad de Sevilla, Spain), Eduardo Fernández-Jiménez (Universidad de Sevilla, Spain), Mercedes Borda-Más (Universidad de Sevilla, Spain), and Ángel Bernardos-Rodríguez (Hospital Universitario Virgen del Rocío, Spain) ABSTRACT. In this study we aimed to: 1) examine whether there were differences in mental health and quality of life of liver transplant recipients according to etiology that led to transplantation (alcoholic cirrhosis, Hepatitis B/C Virus, hepatocellular carcinoma and others); and 2) to compare mental health and quality of life between liver transplant and cirrhotic patients, according to etiologies that most often lead to liver transplantation (alcoholic and Hepatitis C Virus). Two patient groups participated: 168 transplant recipients and 63 cirrhotic patients. Mental health was assessed by the Hospital Anxiety and Depression Scale and quality of life by the SF-36 Health Survey. We found the following results: 1) statistically significant differences were found in anxiety, depression, general health, and vitality; in all of them, transplant patients due to Hepatitis C Virus showed the highest impairment and transplant patients due to alcoholic cirrhosis showed the lowest deterioration; 2) cirrhotic patients, compared to transplanted, and patients with Hepatitis C Virus, compared to alcoholic liver patients, were the groups with greater biopsychosocial impairment. In the absence of interactive effects between factors groups and etiology, Hepatitis C Virus patients had higher biopsychosocial impairment than alcoholic liver patients, regardless of whether or not they underwent transplant. 1This investigation was financed by the Ministry of Science and Innovation of Spain (Register PSI2009-07713). 2Correspondence: Departamento de Personalidad, Evaluación y Tratamiento Psicológicos. Facultad de Psicología. Universidad de Sevilla. C/ Camilo José Cela, s/n. 41018 Sevilla (Spain). E-mail: [email protected] Int J Clin Health Psychol, Vol. 12. Nº 2 204 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients KEYWORDS. Biopsychosocial well-being. Liver transplantation. Liver cirrhosis. Etiologies leading to transplant. Ex post facto study. RESUMEN. En este estudio se plantea: 1) analizar diferencias en salud mental y calidad de vida entre trasplantados hepáticos en función de la etiología desencadenante del trasplante (etílica, Virus de la Hepatitis B/C, hepatocarcinoma y otras), y 2) comparar la salud mental y la calidad de vida entre trasplantados hepáticos y enfermos cirróticos en función de las etiologías que con más frecuencia desencadenan el trasplante hepático (etílica y Virus de la Hepatitis C). Se seleccionaron dos grupos: 168 trasplantados y 63 cirróticos. Se empleó la Escala Hospitalaria de Ansiedad y Depresión y el Cuestionario de Salud SF-36. Los resultaron indicaron: 1) diferencias significativas en las variables ansiedad, depresión, salud general y vitalidad; en todas ellas el mayor deterioro correspondió a trasplantados con el Virus de la Hepatitis C y el menor a etílicos, 2) enfermos cirróticos versus trasplantados hepáticos, y enfermos con el Virus de la Hepatitis C versus etílicos, fueron los grupos con mayor deterioro biopsicosocial. Ante la inexistencia de efectos interactivos entre los factores grupo y etiología, se concluye que los pacientes con Virus de la Hepatitis C presentan mayor deterioro biopsicosocial en comparación con pacientes etílicos, independientemente de que hubieran sido o no trasplantados. PALABRAS CLAVE. Bienestar biopsicosocial. Trasplante hepático. Cirrosis hepática. Etiologías desencadenantes del trasplante. Estudio ex post facto. Liver transplantation is a completely consolidated therapy that improves patients’ quality of life, although they do not achieve the same levels as the general population (Karam et al., 2003; Sumskiene, Sumskas, Petrauskas, and Kupcinskas, 2006; Taylor, Franck, Gibson, and Dhawan, 2005). Thus, for example, in a study that analyzed healthrelated quality of life in three groups (cirrhotic patients who presented diverse levels of severity -mild, moderate, and severe-, liver transplant patients, and healthy population), it was found that the quality of life of the transplant recipients did not reach the levels of the healthy population, although it was significantly better than that of the cirrhotic patients, especially compared to those who were in advanced stages of the liver disease (Pantiga et al., 2005). Similarly, another study that compared the same groups also found that the best functioning corresponded to the healthy people and the worst to the transplant candidates. In comparison to the last group, the liver transplant recipients had fewer limitations in their psychosocial functioning, but in comparison to the control group, some aspects of their functioning were worse, especially the physical and social dimensions (O’Carroll, Turner, Flatley, McGregor, and Hayes, 2008). The quality of life of liver transplant recipients may be conditioned by the diverse etiologies that lead to transplantation, with alcoholic cirrhosis and cirrhosis associated with Hepatitis C Virus (HCV) being the main indications. In the same vein, most of the investigations report that the quality of life of HCV transplant recipients is worse than that of other transplant recipients: poorer physical functioning (Feurer et al., 2002; Paterson et al., 2000), higher presence of anxious-depressive symptomatology (De Bona Int J Clin Health Psychol, Vol. 12. Nº 2 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients 205 et al., 2000; Dwight et al., 2000; Paterson et al., 2000), fibromyalgia (Goulding, O’Connell, and Murray, 2001) and fatigue (Kallman et al., 2007). In general, the studies conclude that alcoholic cirrhotic patients have better quality of life than cirrhotic patients with HCV, both before and after the transplant (Burra et al., 2005). Nevertheless, other studies reach different, and even contradictory, conclusions: transplant recipients with alcoholic cirrhosis or cryptogenic cirrhosis have worse quality of life than patients with autoimmune hepatitis or viral hepatitis (Aadahl, Hansen, Kirkegaard, and Groenvold, 2002); HCV transplant recipients have worse quality of life than patients with hepatocellular carcinoma or primary biliary cirrhosis (Estraviz et al., 2007); and alcoholic cirrhotic patients display worse psychological functioning in comparison to HCV-infected patients (Minazzato et al., 2009). Likewise, regarding the studies focused on analyzing the influence of the etiology of cirrhosis on the biopsychosocial well-being of patients who are candidates for a liver transplant, the conclusions are also contradictory: cirrhotic patients with Hepatitis B Virus (HBV) have better quality of life than cirrhotic HCV patients or than patients with primary biliary cirrhosis (Bondini et al., 2007); patients with autoimmune hepatitis display higher levels of clinical anxiety in comparison to patients who suffer alcoholic cirrhosis or hepatocellular carcinoma (Santos et al., 2010), and the etiology of the cirrhosis does not determine the quality of life (Jurado et al., 2011). In view of the relevance of this topic in clinical practice, the scarcity of this topic in Spain, and of the controversial results of previous investigations, we aimed to continue to analyze the differences between pre- and posttransplant liver patients as a function of etiology of liver disease in the Spanish population. Therefore, in the present ex post facto study (Montero and León, 2007), we proposed two main goals: 1) firstly, to determine whether there are any differences in mental health and quality of life of liver transplant recipients as a function of the etiology of the disease that led to the transplant (alcoholic, HBV, HCV, hepatocellular carcinoma, and others), and 2) secondly, to compare the mental health and quality of life between liver transplant recipients and cirrhotic patients who are potential transplant candidates as a function of the etiologies that most frequently lead to liver transplant (alcoholic and HCV). Likewise, we aimed to control demographic and clinical parameters as covariables, in order to highlight in the analysis the influence of factors groups (liver transplant recipients and cirrhotic patients) and etiology (alcoholic and HCV). Method Participants To carry out this study, two groups of patients were selected: 168 liver transplant recipients and 63 patients with hepatic cirrhosis. The group of transplant recipients was made up of 126 men and 42 women, mean age 50.42 years (SD = 10.57 years). They all had received a first liver transplant five years ago, on average, proceeding from a donor who had died from the following causes: cerebrovascular accidents (60.5%), craneoencephalic traumas (34.1%), and others (5.4%). This group was divided into five Int J Clin Health Psychol, Vol. 12. Nº 2 206 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients subgroups as a function of the etiology of the disease that led to the transplant: alcoholic (n = 59), HCV (n = 40) hepatocellular carcinoma (n = 28), HBV (n = 14), and others (n = 27). The group of cirrhotic patients was made up of 58 men and 5 women, mean age 56.16 years (SD = 7.72 years). This group was divided into two subgroups depending on the etiology of the disease: alcoholic cirrhosis (n = 38) and HCV (n = 25). Instruments – Clinical variables. In the case of the transplant recipients, we collected the following clinical data related to the diverse stages of the transplant: a) preoperative: etiology of the disease that led to transplant (alcoholism, HBV, HCV, hepatocellular carcinoma, and others), scores on the Child-Pugh scale (mild, moderate, and severe) and on the Model for End-stage Liver Disease (MELD) scale; b) perioperative: quality of the graft implanted (optimal or suboptimal); and c) postoperative: complications of the function of the graft (rejection), complications of the depressed immune system (Epstein Barr Virus - EBV- and cytomegalovirus -CMV), hospital admissions due to medical problems after transplant, and type of immunosuppressive medication prescribed (cyclosporine, tacrolimus, micophelonate, cyclosporine + micophelonate, and tacrolimus + micophelonate). In the case of the cirrhotic patients, we collected the same data as for the transplant recipients in the preoperative stage: etiology of the liver pathology and scores on the Child-Pugh and MELD scales. – Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith, 1983). This instrument has 14 items, 7 of depression and 7 of anxiety, in which patients indicate how they felt during the past week, selecting one of four response options. The test provides two scores, one for anxiety and the other for depression. According to Herrero et al. (2003), the optimal cut-off point for the screening of depressive disorders is 5 and is 8 for the screening of anxiety disorders in several clinical populations in Spain. In Spanish studies, Cronbach’s alpha values range between .80 and .90. We used the version developed by Caro and Ibáñez (1992). This questionnaire has been described as one of the most commonly used in liver transplantation, as well as, has shown suitable psychometric properties in this clinical population (Jay, Butt, Ladner, Skaro, and Abecassis, 2009). – SF-36 Health Survey (Alonso, Prieto, and Antó, 1995). This is made up of 36 items, each one with various response alternatives that provide a health status profile. The test explores eight dimensions: physical functioning, role limitations due to physical problems (physical-role), bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems (emotionalrole), and general mental health. In each dimension, a score ranging from 0 (worse health status) to 100 (better health status) is obtained. Alonso et al. studied the psychometric properties of this test in Spanish population and found that internal consistency (Cronbach’s alpha) of the diverse dimensions ranged between .45 and .94, with a mean value of .78, and always above the value of .70, except for the dimension social functioning, which did not exceed .45. For test-retest reliability, the correlation coefficients ranged between .51 and .85. Int J Clin Health Psychol, Vol. 12. Nº 2 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients 207 Procedure Before beginning the psychological assessment of the participants of the study, they were informed about the study, their doubts were clarified, and written informed consent was obtained, emphasizing that their participation was voluntary and they could leave the study at any time, without having to offer any explanation and without this having any negative effects on their medical care. In the two groups (liver transplant recipients and cirrhotic patients), we took the following inclusion criteria into account: being over 18 years of age, having a reading/ writing level that allowed them to complete the diverse scales employed, not presenting any incapacitating state (severe encephalopathy, coma, etc.) to understand items of questionnaires at the moment of assessment, and giving their written informed consent to participate in the investigation. Other specific inclusion criteria were: in the transplanted group, having received a first liver transplant (retransplant recipients were excluded) proceeding from a deceased donor; and in the group of cirrhotic patients, being admitted in the Digestive Diseases Unit with alcoholic cirrhosis or cirrhosis associated with HCV, for a medical study to determine their inclusion on the waiting list for subsequent liver transplant (possible recipients of a combined liver-kidney transplant were excluded) proceeding from a deceased donor. Both groups of patients were selected from the University Hospital Virgen del Rocío of Seville, taking into account that the Ethics and Health Research Commission had previously approved the adequacy and implementation of this investigation. Once we had received approval, the medical data of the patients were obtained through the Hepatic-Biliary-Pancreatic Surgery and Liver Transplant Unit and from the Digestive Diseases Unit. To select the group of transplant recipients, we started with a clinical population made up of all the patients in Seville who had received a liver transplant from a deceased person during the 1990-2007 interval. During this time interval, 662 liver transplants were carried out in adults, of whom 236 died. Of the 426 living transplant recipients, 28 could not be located and 230 did not meet the following inclusion criteria: not being able to read or write, not wishing to participate, and having been retransplanted. We finally assessed 168 patients. To select the group of cirrhotic patients, we started with all the patients who, during a 2-year interval (2009 and 2010), had been scheduled for admission in the Digestive Diseases Unit in order to undergo a pre-liver transplant study due to the advanced state of their hepatic pathology. During this time interval, 83 patients were admitted; we excluded 20 of them because they did not meet the following inclusion criteria: not being able to read or write, not wishing to participate, suffering very uncommon etiologies -HBV, autoimmune and cryptogenic- and being under study for a liver-kidney transplant. We finally assessed 63 patients. Data analyses All the analyses were performed with the SPSS 19.0 statistical package. To compare the categorical variables in the diverse groups, we used Pearson’s chi-square statistic, and to compare the continuous variables among the five subgroups of transplant Int J Clin Health Psychol, Vol. 12. Nº 2 208 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients recipients with different etiologies, we used the Kruskal-Wallis statistic (with post hoc analysis by means of the Mann-Whitney U statistic). We also applied Analysis of Covariance (ANCOVA), to analyze the influence of two independent variables with two levels in each variable: groups (liver transplant recipients and cirrhotic patients) and etiology (alcoholic and HCV). This analysis allowed us to control the possible influence of clinical (MELD and Child-Pugh scores) and demographic variables (age and gender). Results Firstly, we compared the clinical data of the liver transplant recipients taking into account the five types of etiologies that determined the transplant (see Table 1). We found no statistically significant differences in variables such as MELD scores (p = .07), quality of the graft (p = .26), rejection of the graft (p = .52), presence of EBV (p = .44), and hospital admissions due to medical complications after the transplant (p = .07). Other clinical variables (Child-Pugh, CMV, and type of immunosuppressive medication) could not be compared because there was a very small number of patients in some levels. TABLE 1. Comparisons in clinical data among liver transplant patients. Etiology leading to transplant MELD Mean (SD) Graft quality (%) Graft rejection (%) Presence of EBV (%) Hospital Admissions (%) Alcohol (n = 59) 17.24 (3.96) Optimal: 69.5 Suboptimal: 30.5 Yes: 22 No: 78 Yes: 67.8 No: 32.2 Yes: 10.2 No: 89.8 HCV (n = 40) 17.69 (3.84) Optimal: 80 Suboptimal: 20 Yes: 25 No: 75 Yes: 65 No: 35 Yes: 25 No: 75 Hepatocarcinoma (n = 28) 16 (3.51) Optimal: 57.1 Suboptimal: 42.9 Yes: 21.4 No: 78.6 Yes: 78.6 No: 21.4 Yes: 14.3 No: 85.7 HBV (n = 14) 18.69 (2.68) Optimal: 78.6 Suboptimal: 21.4 Yes: 35.7 No: 64.3 Yes: 50 No: 50 Yes: 35.7 No: 64.3 Others (n = 27) 17.52 (4.82) Optimal: 77.8 Suboptimal: 22.2 Yes: 37 No: 63 Yes: 70.4 No: 29.6 Yes: 29.6 No: 70.4 Intergroup comparisons H (4,168) = 8.61 (p = .07) Ȥ 2 = 0.56 (p = .26) Ȥ 2 = 3.18 (p = .52) Ȥ 2 = 3.74 (p = .44) Ȥ 2 = 8.58 (p = .07) Upon comparing mental health and quality of life among the five subgroups of liver transplant recipients of various etiologies, we found statistically significant differences in the variables anxiety (p = .05), depression (p = .04), general health (p = .004), and vitality (p = .03; see Table 2). In all of these variables, we found the same results, that is, the subgroup of HCV transplant recipients showed greater impairment, and the subgroup of alcoholic transplant recipients enjoyed greater well-being. Int J Clin Health Psychol, Vol. 12. Nº 2 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients 209 TABLE 2. Comparisons in mental health (HADS) and quality of life (SF-36) among liver transplant patients with various etiologies. Etiology leading to transplant Psychological variables Alcohol (n = 59) M (SD) HCV (n = 40) M (SD) Cancer 1 (n = 28) M (SD) HBV (n = 14) M (SD) Others (n = 27) M (SD) Contrast statistic p HADS 2 Anxiety 3.76 (3.05) 6.48 (4.77) 5.54 (4.18) 5.71 (4.26) 6.11 (4.96) 9.505 .05* Depression 3.42 (3.05) 5.40 (4.14) 3.93 (4.24) 4.43 (3.10) 3.56 (4.19) 9.659 .04* SF-36 3 Bodily pain 74.84 (26.66) 62.07 (31.69) 62.39 (33.10) 65.35 (29.49) 72.29 (27.72) 6.898 .14 Physical-role 77.54 (24.43) 68.59 (32.87) 58.03 (36.35) 66.96 (28.84) 75.46 (26.34) 7.176 .12 Mental health 77.11 (19.01) 62.87 (26.30) 76.07 (20.69) 70.71 (17.19) 72.22 (21.36) 8.811 .06 General health 73.77 (17.81) 56.00 (24.94) 62.85 (24.33) 57.21 (19.64) 65.07 (26.22) 15.619 .004** Vitality 72.19 (21.49) 57.81 (24.86) 64.73 (23.94) 59.82 (24.35) 65.41 (22.96) 10.459 .03* Social functioning 77.96 (23.36) 68.75 (31.52) 69.19 (28.76) 69.63 (31.65) 75.00 (29.41) 2.777 .59 Emotional-role 80.08 (22.37) 63.95 (34.56) 69.34 (30.76) 79.16 (25.89) 78.08 (24.80) 5.954 .20 Physical functioning 72.71 (25.19) 64.12 (28.30) 66.42 (26.27) 76.78 (22.32) 79.25 (24.12) 8.274 .08 Note: 1Hepatocarcinoma; 2the higher score, the worse mental health; 3the lower score, the worse quality of life; * p < .05, ** p < .01 From the post hoc analyses with these four variables, statistically significant differences were found among the following subgroups: alcoholic transplant recipients and HCV transplant recipients, in the variables anxiety (p = .006), depression (p = .009), general health (p < .001), and vitality (p = .002). Significant differences were found between the HCV transplant recipients and those who suffered from other etiologies in the variable depression (p = .013); and between the alcoholic transplant recipients and the HBV transplant recipients, in the dimension general health (p = .007). In the latter two comparisons, the transplant recipients with chronic viral hepatitis (B and C) suffered greater impairment too (see Table 3). TABLE 3. Intergroup comparisons between liver transplant patients with various etiologies. Variables Alcohol and HCV Alcohol and cancer 1 Alcohol and HBV Alcohol and others HCV and cancer 1 HCV and HBV HCV and others cancer 1 and HBV cancer 1 and others HBV and others Contrast statistic (p) HADS: Anxiety -2.73 (.006**) -1.89 (.05) -1.54 (.12) -1.90 (.05) -0.62 (.53) -0.56 (.57) -0.35 (.72) -0.18 (.85) -0.29 (.76) -0.16 (.86) Depression -2.59 (.009**) -0.03 (.97) -1.22 (.22) -0.70 (.48) -1.94 (.05) -0.37 (.70) -2.47 (.01*) -0.98 (.32) -0.48 (.62) -1.29 (.19) SF-36: General health -3.61 (< .001**) -1.78 (.07) -2.70 (.007**) -1.48 (.13) -0.98 (.32) -0.35 (.72) -1.58 (.11) -0.96 (.33) -0.43 (.66) -1.06 (.28) Vitality -3.04 (.002**) -1.36 (.17) -1.87 (.06) -1.53 (.12) -0.98 (.32) -0.37 (.73) -1.29 (.19) -0.55 (.58) -0.26 (.79) -0.77 (.43) Note: 1Hepatocarcinoma; * p < .05, ** p < .01. Int J Clin Health Psychol, Vol. 12. Nº 2 210 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients In the Analysis of Covariance (ANCOVA), we used two factors (groups and etiology) with two levels in each factor: liver transplant versus cirrhotic patients (groups), and alcohol versus HCV (etiology). The scores in the MELD and Child-Pugh scales, age, and gender were defined as covariates (see Table 4). TABLE 4. Comparisons in clinical and demographic data among the groups under study. * p < .05, ** p < .01. Regarding the interactive effects analyzed with the ANCOVA between the factors groups and etiology, no statistically significant relationships were found in any of the variables studied (see Table 5). These results indicate that the effects that exert each one of these factors (groups and etiology) on the variables related to mental health and quality of life are independent of each other. It could be said that the HCV patients presented greater biopsychosocial impairment than the alcoholic liver patients, independently of whether or not they had been transplanted (see Figures 1 and 2). Groups MELD Mean (SD) Child-Pugh (%) Age Mean (SD) Gender (%) Liver transplant patients (n = 99) 17.44 (3.89) Mild: 4.2 Moderate: 44.2 Severe: 51.6 53.24 (7.58) Men: 76.8 Women: 23.2 Cirrhotic patients (n = 63) 15.53 (5.02) Mild: 19 Moderate: 46 Severe: 35 56.16 (7.72) Men: 92.1 Women: 7.9 Intergroup comparisons F (1,160) = 7.28 (p = .008**) Ȥ2 = 16.60 (p = .005**) F(1,160) = 5.39 (p = .02*) Ȥ2 = 5.27 (p = .02*) Etiology MELD Mean (SD) Child-Pugh (%) Age Mean (SD) Gender (%) Alcohol (n = 97) 16.77 (4.72) Mild: 8.4 Moderate: 44.2 Severe: 47.4 55.06 (6.93) Men: 91.8 Women: 8.2 HCV (n = 65) 16.46 (4.19) Mild: 12.7 Moderate: 46 Severe: 41.3 53.35 (8.77) Men: 69.1 Women: 30.9 Intergroup comparisons F(1,160) = 0.44 (p = .50) Ȥ2 = 1.02 (p = .59) F(1,160) = 1.76 (p = .18) Ȥ2 = 12.27 (p < .001**) Int J Clin Health Psychol, Vol. 12. Nº 2 PÉREZ-SAN-GREGORIO et al. Quality of life in liver transplant and cirrhotic patients 211 TABLE 5. Comparisons in mental health (HADS) and quality of life (SF-36) between liver transplant and cirrhotic patients as a function of etiology. Note: 1The higher score, the worse mental health; 2the lower score, the worse quality of life; * p < .05, ** p < .01. Groups Etiology Main Effects Interactive effects Variables Liver transplant (n = 99) M (SD) Cirrhotic patients (n = 63) M (SD) Alcohol (n = 97) M (SD) HCV (n = 65) M (SD) Groups F(1,160) (p) Etiology F(1,160) (p) F(1,160) (p) HADS 1 : Anxiety 4.86 (4.04) 8.40 (4.90) 5.49 (4.40) 7.34 (4.96) 21.23 (< .001**) 4.73 (.03*) 1.39 (.24) Depression 4.22 (3.64) 6.87 (4.61) 4.64 (3.83) 6.17 (4.66) 10.82 (.001**) 6.24 (.01*) 0.87 (.35) SF-36 2 : Bodily pain 69.68 (29.33) 59.87 (32.88) 70.80 (29.43) 58.50 (32.12) 4.62 (.03*) 3.29 (.07) 0.04 (.82) Physicalrole 73.92 (28.33) 45.83 (35.33) 67.26 (33.08) 56.63 (34.69) 28.03 (< .001**) 3.43 (.06) 0.36 (.54) Mental health 71.36 (23.20) 58.96 (23.57) 71.54 (20.55) 59.07 (26.96) 10.49 (.002**) 7.59 (.007**) 0.34 (.55) General health 66.59 (22.63) 37.06 (18.16) 61.46 (23.38) 45.63 (25.61) 74.36 (< .001**) 20.54 (< .001**) 0.35 (.55) Vitality 66.32 (23.89) 43.94 (24.64) 63.15 (24.87) 49.32 (26.81) 35.07 (< .001**) 10.40 (.002**) 0.003 (.96) Social functioning 74.24 (27.18) 57.33 (30.49) 72.67 (25.59) 60.19 (33.57) 13.67 (< .001**) 9.64 (.002**) 0.09 (.76) Emotionalrole 73.56 (28.89) 62.83 (32.98) 75.60 (26.92) 60.12 (34.18) 3.33 (.07) 7.79 (.006**) 0.002 (.96) Physical functioning 69.24 (26.69) 47.38 (30.91) 64.69 (28.68) 54.84 (31.79) 26.95 (< .001**) 5.00 (.02*) 0.19 (.66) Int J Clin Health Psychol, Vol. 12. 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