Antipsychotics reduces mortality in patients with neuropsychiatric systemic lupus erythematosus: a retrospective study of psychiatric consultation cases.

Objective: This study aimed to identify the presence of psychiatric comorbidities as well as investigate the relationship between psychiatric interventions for mental symptoms and mortality in patients with systemic lupus erythematosus (SLE). Method: We retrospectively evaluated the records of 160 inpatients with SLE who required psychiatric consultation for further therapeutic intervention from 2013 to 2020 in a tertiary general hospital. We collected clinical data, including diagnoses, medications, and mortality rate. We compared clinical characteristics among the diagnosis groups and correlations between variables. Results: A total of 138 (86.3%) patients met the diagnostic criteria for at least one mental disorder, with the most common being delirium (54.4%). The average Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score significantly differed among the diagnosis groups (p = 0.003). The mortality rate among patients with delirium was significantly higher than that in the other patient groups (x2 = 12.967, p = 0.024). SLEDAI-2K score was not significantly correlated with mortality (r = 0.123, p = 0.087). Antipsychotics use was associated with mortality (odds ratio 0.053, p = 0.021). Conclusion: Antipsychotic use may decrease death risk for patients with NPSLE. Early psychiatric consultation is necessary for patients with SLE who have developed or have suspected psychiatric symptoms in order to establish a comprehensive intervention plan.

Differential impact of resilience on demoralization and depression in Parkinson disease.

Objectives: The objective of this study was to study the interrelations of demoralization, depression, and resilience in patients with Parkinson disease, and, more specifically, to determine if higher resilience in patients with Parkinson disease is associated with lower demoralization, lower depression, or both. Methods: Outpatients with Parkinson disease (N = 95) were assessed for demoralization, depression, and resilience, as well as sociodemographic, clinical, and treatment-related variables. Bivariable associations, standard regressions, linear regression with copula correction, and correspondence analysis were used to analyze the data. Results: Although the bivariable association between resilience and depression was statistically significant, the association ceased to be significant when demoralization was taken into consideration in both standard regressions and linear regression with copula correction. By contrast, the association between resilience and demoralization was significant when depression was not taken into consideration and continued to be significant when depression was taken into consideration. Correspondence analysis revealed that low resilience was strongly related to demoralization combined with depression, whereas normal resilience was closely correlated with depression without demoralization. Conclusion: These results expand our understanding of resilience by suggesting that it is a mechanism evolved to reduce or prevent demoralization and not just depression. Reducing demoralization and strengthening resilience as part of a comprehensive treatment plan are likely to improve the prognosis of Parkinson disease.

Promoting weight loss and psychological well-being in patients with obesity: A sequential combination of behavioural lifestyle intervention and well-being therapy.

Behavioural lifestyle interventions focused on diet and physical activity are a cornerstone for the treatment of obesity. However, their effects vary substantially across individuals in terms of magnitude and durability. Personalized approaches that target psychological well-being may be promising to facilitate healthy behaviours and sustained weight loss. This preliminary study aimed to explore whether the sequential combination of behavioural lifestyle intervention (BLI) and well-being therapy (WBT) may result in more favourable outcomes than BLI alone in promoting weight loss (primary outcome) and improving psychological well-being, distress, dietary behaviours and physical activity (secondary outcomes). A total of 83 patients with obesity were randomly assigned to BLI/WBT (N = 38) or BLI group (N = 45). The BLI group received a 12-week behavioural weight loss programme, whereas the BLI/WBT group received the same programme followed by an additional 4-week WBT, adapted for group interventions. Data were collected at pretreatment (baseline, T1), at the end of BLI/WBT (T2), at 6-month (T3) and 12-month (T4) follow-ups. There was a significant weight loss in both treatment groups at T2, T3 and T4. The BLI/WBT group showed greater improvements in depressive symptoms at T3 and T4, in autonomy at T2, in personal growth at T4 and in global well-being at T4 compared with BLI group. WBT yielded no additional effect on weight loss. However, the secondary outcomes indicate that WBT may have enduring effects that reduce vulnerability to psychological distress in patients with obesity. In order to confirm these preliminary findings and explore whether a more intensive and individualized WBT can foster sustained weight loss, future studies are needed.

Eczema as a protective factor for brain cancer: a meta-analysis.

BACKGROUND: Brain cancer is one of the most aggressive cancer types owing to poor treatment effects. Epidemiological studies have demonstrated that allergies may increase the disease risk. Therefore, this study evaluated the association between eczema and the risk of various brain cancers. METHODS: We systematically searched the PubMed and Embase databases from their inception until June 23, 2022. Two reviewers independently reviewed and screened the articles, extracted data, assessed the study quality, and pooled the results. Stata software was used to generate pooled odds ratios and 95% confidence intervals (CIs). RESULTS: We included 20 studies comprising 5,117,222 patients that investigated the relationship between eczema and brain cancer. Eczema was significantly inversely associated with the risk of brain cancer (odds ratio [OR], 0.82; 95% CI, 0.77-0.87), glioma (OR, 0.53; 95% CI, 0.14-2.02), meningioma (OR, 0.74; 95% CI, 0.66-0.84), and acoustic neuroma (OR, 0.60; 95% CI, 0.41-0.88). Interesting, The strong correlation between eczema and the reduced risk of brain cancer was observed in people over 16 years old (OR, 0.79; 95% CI, 0.71-0.88), but not in those under 16 years old (OR, 0.94; 95% CI, 0.79-1.11). In addition, subgroup analyses found that eczema significantly decreased the glioma risk in Europeans (OR, 0.73; 95% CI, 0.65-0.82) but not Australians (OR, 0.53; 95% CI, 0.14-2.02) or Americans (OR, 1.01; 95% CI, 0.69-1.46). CONCLUSION: Eczema may be considered as a potential protective factor of brain cancer in population aged over 16 years. However, this relationship requires verification using large-scale clinical data.

Well-Being Therapy and Lifestyle Intervention in Type 2 Diabetes: A Pilot Randomized Controlled Trial.

OBJECTIVE: This pilot randomized controlled trial evaluates the preliminary efficacy of a 4-month well-being therapy (WBT) and lifestyle intervention among adults with type 2 diabetes and overweight/obesity. METHODS: Fifty-eight patients were recruited from two outpatient clinics and randomized to receive the WBT-lifestyle intervention or the lifestyle intervention alone. Data were collected at baseline (T0), immediate postintervention (T1), 6-month follow-up (T2), and 12-month follow-up (T3). Primary efficacy outcomes included changes in weight, psychological distress, and well-being, whereas secondary efficacy outcomes included changes in lifestyle and physiological parameters. RESULTS: Compared with the lifestyle-alone intervention, the WBT-lifestyle intervention showed greater improvements in depression (p = .009, d = -0.6), hostility (p = .018, d = -0.6), and personal growth (p = .026, d = 0.5) at T1, in self-reported physical activity at T2 (p = .013, d = 0.7) and T3 (p = .040, d = 0.5), and in triglycerides (p = .019, d = -1.12) at T3. There were no differences between treatment groups in weight and other physiological parameters. CONCLUSIONS: These findings suggest that WBT may be a valuable addition to lifestyle interventions for improving short-term psychological outcomes and promoting long-term healthy changes in physical activity, with a potential impact on physiological outcomes.Trial Registration:ClinicalTrials.gov identifier: NCT03609463.

A pooled analysis of the association between sarcopenia and osteoporosis.

BACKGROUND: Sarcopenia is a progressive generalized skeletal muscle disorder that causes the accelerated loss of muscle mass and function. Osteoporosis is a systemic condition of the skeleton that results in low bone mass and quality. Several studies have suggested that osteoporosis and sarcopenia are interrelated; however, a few studies indicate the lack of a significant association between sarcopenia and osteoporosis. We aimed to evaluate the association between sarcopenia and osteoporosis via a systematic review and pooled analysis. METHODS: From the inception of the PubMed and Embase databases until September 2022, we conducted a systematic search for studies evaluating the relationship between sarcopenia and osteoporosis. Study appraisal and synthesis methods: We included observational studies that provided 95% confidence intervals (CIs) and risk estimates. Two reviewers independently extracted data and assessed the quality of the research. The random-effects model was applied to the pool analysis, and the odds ratios (ORs) and 95% CIs were finally calculated. RESULTS: The primary statistic was the mutual risk between sarcopenia and osteoporosis. According to the inclusion criteria, 56 studies (796,914 participants) were finally included. Sarcopenia was significantly correlative to the risk of osteoporosis (OR, 3.06; 95% CI, 2.30-4.08), and each standard deviation increase in relative appendicular skeletal muscle mass was significantly related to a decreased risk of osteoporosis (OR, 0.65; 95% CI, 0.56-0.75). Osteoporosis observably referred to a higher risk of sarcopenia (OR, 2.63; 95% CI, 1.98-3.49). CONCLUSION: Our research indicated that sarcopenia and osteoporosis are highly positively correlated. Osteoporosis is closely associated with the risk of sarcopenia. Our finding highlights the importance of sarcopenia screening for those at risk of osteoporosis, and vice versa. However, heterogeneity was noted among the studies, and this might have influenced the accuracy of the results. Therefore, the results of our study should be interpreted with caution.

A 4-factor perspective of the patient-practitioner orientation scale (PPOS): a deeper understanding of patient-centredness.

BACKGROUND: Although patient-centred medical services are widely recognized and accepted, how to define and evaluate them remains a controversial topic. OBJECTIVES: This study attempts to evaluate the underlying structure of the Patient-Practitioner Orientation Scale (PPOS) with a homogenous population and clarify the connotation of patient-centredness. METHODS: In this cross-sectional study, 279 7th year Chinese medical students in were selected to examine the internal structure of the PPOS by means of internal consistency, exploratory, and confirmatory factor analyses. RESULTS: Both the two-factor model and the four-factor model showed acceptable internal consistency and structural validity. The four-factor model that endorsed the implicit attitude towards the doctor-patient relationship outperformed the two-factor model in terms of adaptability. CONCLUSIONS: The PPOS has good psychometric attributes, as evaluated by Chinese medical students. This article attempts to explore patient-centredness from the perspective of implicit attitudes that affect the doctor-patient relationship and resummarizes the four factors. These four dimensions may suggest a deeper attitude towards the doctor-patient relationship, while "sharing information" or "caring about" the "patient" is the behaviour and preference expressed on the basis of these four attitudes, which is the result rather than the cause. PRACTICE IMPLICATIONS: Understanding the underlying attitudes towards the doctor-patient relationship can help to construct a patient-centred medical service concept and improve the doctor-patient relationship in medical education courses and the system design of medical activities.

Identification of key genes related to skin burns based on bioinformatics analysis.

To further understand the regulatory network and molecular mechanisms of gene expression after skin burns, we performed bioinformatics analysis of gene expression profiles of skin burn samples and identified key genes associated with skin burns. The GSE8056 dataset and GSE139028 dataset was downloaded from the Gene Expression Omnibus (GEO) database for analysis and validation. The limma package was used to screen for differentially expressed genes (DEGs). Gene ontology (GO) and pathway enrichment analyses (KEGG) were then performed. Subsequently, LASSO regression analysis was performed on DEGs and a regulatory network map of skin burn-related genes was constructed. Finally, the infiltration of immune cells was calculated and co-expression network maps of immune-related key genes and skin regeneration genes were constructed. Analysis of the GSE8056 dataset showed that 432 genes were upregulated and 351 genes were downregulated. The DEGs were mainly focused on immune response and skin regeneration. Meanwhile, these two groups of pivotal genes were significantly associated with abnormal infiltration of 9 immune cells. GSE139028 validation revealed that 3 hub genes associated with skin burn immunity were differentially expressed, except for S100A8, while only the DPT gene was differentially expressed among the seven hub genes associated with skin regeneration. In short, the effect of skin burn on patients is to regulate the expression of immune-related genes UPP1, MMP1, MMP3 and skin regeneration-related gene DPT, which may be the key target for the treatment of skin burn.

From Perceived Stress to Demoralization in Parkinson Disease: A Path Analysis.

Objectives: The objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence. Methods: Ninety-five consecutive outpatients with Parkinson's disease were evaluated for perceived stress, depression, anxiety, subjective incompetence, and demoralization using reliable and valid scales. Inclusion criteria were ages 40-90, intact cognition, and no current history of substance use. The setting was a Movement Disorders Clinic at a university-affiliated hospital. The outcome variable was demoralization, selected a priori. Mediators between perceived stress and demoralization were examined using path analysis. Results: Depression, anxiety, and subjective incompetence were mediators between perceived stress and demoralization. Among all variables, subjective incompetence was the largest contributor to demoralization. Depression connected to demoralization indirectly via subjective incompetence (ß = 0.25, p < 0.001), whereas anxiety bypassed subjective incompetence (ß = -0.01, p = 0.882), connecting directly to demoralization (ß = 0.37, p = 0.008). Conclusion: Early treatment and reversal of subjective incompetence and anxiety could potentially prevent the escalation of demoralization and the associated disruption in health-related quality of life and eventual suicide.

Efficacy of group biofeedback treatment on hyperemesis gravidarum with psychosomatic symptoms diagnosed with the revised version of Diagnostic Criteria for Psychosomatic Research (DCPR-R): study protocol for a randomised controlled trial.

INTRODUCTION: Hyperemesis gravidarum (HG) is a condition characterised by dehydration, electrolyte imbalance, lack of nutrition and at least 5% loss in body weight, occurring in the first half of pregnancy. The aim of this trial is to examine the efficacy of group biofeedback treatment on patients with HG with psychosomatic symptoms, which will be evaluated through the revised version of Diagnostic Criteria for Psychosomatic Research (DCPR-R). METHODS AND ANALYSIS: In this single-blinded randomised controlled clinical trial, 68 patients with HG diagnosed with at least one psychosomatic syndrome according to DCPR-R and aged 18-40 years, will be recruited in a Chinese Maternal and Child Health Hospital. The sample will be randomised (1:1) into two arms: experimental group, which will undergo group biofeedback treatment, psycho-education and treatment as usual (TAU); and control group, which will undergo psycho-education and TAU only. The primary outcomes will be reduction of the frequency of psychosomatic syndromes, severity of nausea/vomiting, quality of life and heart rate variability. The secondary outcomes will include days of hospitalisation, repeated hospitalisation and laboratory investigations. ETHICS AND DISSEMINATION: This study has received ethical approval from the Nanjing Medical University (No. 2019/491, granted 22 February 2019). All participants will be required to provide written informed consent. Study outcomes will be disseminated through peer-reviewed publications and academic conferences, and used to confirm a tailored biofeedback intervention for patients with HG with psychosomatic symptoms. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry (ChiCTR2000028754).

The Role of Psychological Well-Being in Weight Loss: New Insights from a Comprehensive Lifestyle Intervention / El papel del bienestar psicológico en la pérdida de peso: nuevos conocimientos acerca de una intervención integral en el estilo de vida

Background/Objective: Although the literature suggested that impaired psychological well-being (PWB) is associated with obesity, evidence on the role of PWB in weight outcomes is limited and inconclusive.This research aimed to investigate the joint role of PWB in achieving clinically significant weight loss (CWL; loss of 5% of the initial weight) through a comprehensive lifestyle intervention for obesity using a broad-based evaluation. Method: This study is a prospective cohort of 96 patients with obesity attending a comprehensive lifestyle intervention for weight loss. Data on weight, lifestyle, PWB, and distress, were collected before and after the intervention. Results: 30.5% of the participants achieved CWL at the end of treatment. A more pronounced increase in autonomy (odds ratio = 0.80 [95% CI: 0.68, 0.93], p ≤ .01) and somatization (odds ratio = 0.83 [95%CI: 0.70, 0.98], p ≤ .05) from pre- to post-treatment were independently associated with a lower probability of CWL. Conclusions: Unbalanced dimensions of PWB, in particular exceedingly high autonomy, may contribute to a poor weight loss outcome. This study paves the way for the addition of psychotherapeutic strategies geared to euthymia in comprehensive lifestyle intervention.

Antecedentes/Objetivo: Aunque la literatura sugiere que el deterioro del bienestar psi-cológico (BP) está asociado con obesidad, la evidencia sobre el papel del BP en el peso es limitada. Se investiga el papel del BP en el logro de pérdida de peso clínicamente signi-ficativa (PPCS; pérdida del 5% del peso inicial) a través de una intervención integral sobre el estilo de vida con respecto a la obesidad. Método: Cohorte prospectiva de 96 pacientes con obesidad que asisten a una intervención integral sobre el estilo de vida para la pér-dida de peso. Se recolectaron datos sobre peso, estilo de vida, BP y angustia, antes y después de la intervención. Resultados: El 30,5% de los participantes lograron pérdida de peso al final del tratamiento. Mayor aumento de autonomía (razón de momios = 0,80 [ICdel 95%: 0,68, 0,93], p ≤ 0,01) y somatización (razón de momios = 0,83 [IC del 95%: 0,70, 0,98], p ≤ 0,05) de antes a después del tratamiento se asociaron de forma independiente con menor probabilidad de PPCS. Conclusiones: Las dimensiones desequilibradas del BP, en particular la autonomía excesivamente alta, pueden contribuir a una pérdida de peso insuficiente. Se allana el camino para añadir estrategias psicoterapéuticas orientadas a la eutimia en la intervención integral en el estilo de vida.

The Role of Psychological Well-Being in Weight Loss: New Insights from a Comprehensive Lifestyle Intervention.

BACKGROUND/OBJECTIVE: Although the literature suggested that impaired psychological well-being (PWB) is associated with obesity, evidence on the role of PWB in weight outcomes is limited and inconclusive. This research aimed to investigate the joint role of PWB in achieving clinically significant weight loss (CWL; loss of 5% of the initial weight) through a comprehensive lifestyle intervention for obesity using a broad-based evaluation. METHOD: This study is a prospective cohort of 96 patients with obesity attending a comprehensive lifestyle intervention for weight loss. Data on weight, lifestyle, PWB, and distress, were collected before and after the intervention. RESULTS: 30.5% of the participants achieved CWL at the end of treatment. A more pronounced increase in autonomy (odds ratio = 0.80 [95% CI: 0.68, 0.93], p ≤ .01) and somatization (odds ratio = 0.83 [95% CI: 0.70, 0.98], p ≤ .05) from pre- to post-treatment were independently associated with a lower probability of CWL. CONCLUSIONS: Unbalanced dimensions of PWB, in particular exceedingly high autonomy, may contribute to a poor weight loss outcome. This study paves the way for the addition of psychotherapeutic strategies geared to euthymia in comprehensive lifestyle intervention.

CONTEXTO/OBJETIVO: Aunque la literatura sugiere que el deterioro del bienestar psicológico (BP) está asociado con obesidad, la evidencia sobre el papel del BP en el peso es limitada. Se investiga el papel del BP en el logro de pérdida de peso clínicamente significativa (PPCS; pérdida del 5% del peso inicial) a través de una intervención integral sobre el estilo de vida con respecto a la obesidad. MÉTODO: Cohorte prospectiva de 96 pacientes con obesidad que asisten a una intervención integral sobre el estilo de vida para la pérdida de peso. Se recolectaron datos sobre peso, estilo de vida, BP y angustia, antes y después de la intervención. RESULTADOS: El 30,5% de los participantes lograron pérdida de peso al final del tratamiento. Mayor aumento de autonomía (razón de momios = 0,80 [IC del 95%: 0,68, 0,93], p ≤ 0,01) y somatización (razón de momios = 0,83 [IC del 95%: 0,70, 0,98], p ≤ 0,05) de antes a después del tratamiento se asociaron de forma independiente con menor probabilidad de PPCS. CONCLUSIONES: Las dimensiones desequilibradas del BP, en particular la autonomía excesivamente alta, pueden contribuir a una pérdida de peso insuficiente. Se allana el camino para añadir estrategias psicoterapéuticas orientadas a la eutimia en la intervención integral en el estilo de vida.

COVID-19 pandemic: study on simple, easy, and practical relaxation techniques while wearing medical protective equipment.

BACKGROUND: No studies have reported on how to relieve distress or relax in medical health workers while wearing medical protective equipment in coronavirus disease 2019 (COVID-19) pandemic. The study aimed to establish which relaxation technique, among six, is the most feasible in first-line medical health workers wearing medical protective equipment. METHODS: This was a two-step study collecting data with online surveys. Step 1: 15 first-line medical health workers were trained to use six different relaxation techniques and reported the two most feasible techniques while wearing medical protective equipment. Step 2: the most two feasible relaxation techniques revealed by step 1 were quantitatively tested in a sample of 65 medical health workers in terms of efficacy, no space limitation, no time limitation, no body position requirement, no environment limitation to be done, easiness to learn, simplicity, convenience, practicality, and acceptance. RESULTS: Kegel exercise and autogenic relaxation were the most feasible techniques according to step 1. In step 2, Kegel exercise outperformed autogenic relaxation on all the 10 dimensions among the 65 participants while wearing medical protective equipment (efficacy: 24 v. 15, no space limitation: 30 v. 4, no time limitation: 31 v. 4, no body position requirement: 26 v. 4, no environment limitation: 30 v. 11, easiness to learn: 28 v. 5, simplicity: 29 v. 7, convenience: 29 v. 4, practicality: 30 v. 14, acceptance: 32 v. 6). CONCLUSION: Kegel exercise seems a promising self-relaxation technique for first-line medical health workers while wearing medical protective equipment among COVID-19 pandemic.

Demoralization and Quality of Life of Patients with Parkinson Disease.

INTRODUCTION: Demoralization is quite prevalent in patients with Parkinson disease (PD). Unrecognized or untreated, demoralization may progress, at times, to demands for euthanasia and the desire for suicide. Typically, patients with PD do not complain of being "demoralized"; rather, they report disruptions in the quality of their lives. Hence, early identification of disruptions in health-related quality of life (HRQoL) specifically associated with demoralization may prompt earlier recognition and treatment. Published data on such associations, however, could not be found. Alleviation of demoralization in PD is likely to improve treatment outcomes. OBJECTIVE: This research aimed at identifying the disruptions of HRQoL specifically associated with the demoralization of patients with PD. METHODS: Consecutive general hospital outpatients with PD (n = 95) were assessed for: demoralization, with the Diagnostic Criteria for Psychosomatic Research Demoralization Scale (DCPR-D) and the Demoralization Scale (DS); depression, with the Patient Health Questionnaire-9 (PHQ-9); HRQoL, with the Parkinson Disease Questionnaire-Short Form (PDQ-8); sociodemographic variables; medical comorbidities; PD severity; and types of treatment. RESULTS: The prevalence of demoralization was 19%. Regression analyses showed that demoralization was significantly more likely to be experienced by participants who had difficulty with mobility and felt embarrassed in public due to having PD. Demoralization explained HRQoL over and above depression. CONCLUSIONS: Stigma and perceived difficulty with mobility are associated with demoralization of PD patients, and they may signal the need for psychotherapeutic and behavioral interventions to prevent the progression to helplessness, hopelessness, demands for euthanasia, and desire for suicide.

Post-COVID-19 Epidemic: Allostatic Load among Medical and Nonmedical Workers in China.

BACKGROUND: As the fight against the COVID-19 epidemic continues, medical workers may have allostatic load. OBJECTIVE: During the reopening of society, medical and nonmedical workers were compared in terms of allostatic load. METHODS: An online study was performed; 3,590 Chinese subjects were analyzed. Socio-demographic variables, allostatic load, stress, abnormal illness behavior, global well-being, mental status, and social support were assessed. RESULTS: There was no difference in allostatic load in medical workers compared to nonmedical workers (15.8 vs. 17.8%; p = 0.22). Multivariate conditional logistic regression revealed that anxiety (OR = 1.24; 95% CI 1.18-1.31; p < 0.01), depression (OR = 1.23; 95% CI 1.17-1.29; p < 0.01), somatization (OR = 1.20; 95% CI 1.14-1.25; p < 0.01), hostility (OR = 1.24; 95% CI 1.18-1.30; p < 0.01), and abnormal illness behavior (OR = 1.49; 95% CI 1.34-1.66; p < 0.01) were positively associated with allostatic load, while objective support (OR = 0.84; 95% CI 0.78-0.89; p < 0.01), subjective support (OR = 0.84; 95% CI 0.80-0.88; p < 0.01), utilization of support (OR = 0.80; 95% CI 0.72-0.88; p < 0.01), social support (OR = 0.90; 95% CI 0.87-0.93; p < 0.01), and global well-being (OR = 0.30; 95% CI 0.22-0.41; p < 0.01) were negatively associated. CONCLUSIONS: In the post-COVID-19 epidemic time, medical and nonmedical workers had similar allostatic load. Psychological distress and abnormal illness behavior were risk factors for it, while social support could relieve it.