Layout 1 Integrating psychological assessment in achalasia management Eur J Transl Myol 34 (3) 12727, 2024 doi: 10.4081/ejtm.2024.12727 Achalasia is a rare primary esophageal motor disorder, occurring with an annual incidence rate of 1-5 cases and a prevalence rate of 7-32 cases per 100,000 people. Ho- wever, determining the true global prevalence of achalasia is challenging due to the limited availability of advanced diagnostic criteria and technology.1,2 This clinical condition impacts both sexes equally and shows no preference for any particular racial group. It can also occur at any age but is more common in older adults, typically diagnosed between ages 30 and 60.1 The cause of achalasia remains unidentified.3 Extensive and varied research indicates that the primary cause of achalasia is neurodegeneration occurring at the Lower Esophageal Sphincter (LES). This neurodegeneration involves the spe- cific loss of inhibitory neurons within the myenteric plexus located at the lower end of the esophagus. Several factors may contribute to this neurodegeneration, including genetic predispositions and environmental triggers that initiate in- flammatory and immune responses.2,3 The determination of the condition relies on the patient’s medical history, a barium esophagogram, and tests of esophageal motility.4 Advanced diagnostic techniques like high-resolution manometry are instrumental in forecasting treatment outcomes in achalasia by analyzing esophageal pressure topography, which delineates three distinct acha- lasia phenotypes (I-III). Research indicates that phenotypes I and II exhibit a more favorable response to treatment com- pared to phenotype III.5 While achalasia is not curable, over 90% of patients experience significant improvement fol- lowing treatment.6 The therapeutic approaches, including pneumatic dilation, both endoscopic and surgical myotomy, and pharmacological treatments (e.g., calcium channel Abstract Achalasia is a chronic esophageal disorder with a generally favorable prognosis; however, approximately 20% of patients experience persistent or recurrent symptoms despite therapeutic interventions. These ongoing symptoms can significantly diminish both disease-specific and overall quality of life. Although the physical manifestations of achalasia, such as regurgitation, dysphagia, chest pain, and weight loss, are well-documented and assessed using the Eckardt score, the psychological burden of the disease remains underexplored. Individuals with achalasia are at an increased risk of mental health issues, including depression, anxiety, and somatization, exacerbated by the emotional strain and social limitations imposed by the disease. Despite this, psychological impacts are often overlooked in clinical settings, leading to inadequate mental health support for these patients. This article underscores the necessity for prompt psychological assessments during the diagnosis of achalasia to better address these mental health challenges and improve overall patient care. Key Words: achalasia, mental health, patients. Eur J Transl Myol 34 (3) 12727, 2024 doi: 10.4081/ejtm.2024.12727 Integrating psychological assessment in achalasia management: addressing mental health to enhance patient outcomes Mohsen Khosravi,1,2 Ahoora Kavoosi,3 Rafat Rezapour-Nasrabad,4 Melody Omraninava,5 Alireza Nazari Anamagh,6 Seyed Teymur Seyedi Asl7 1Department of Psychiatry, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran; 2Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran, Zahedan University of Medical Sciences, Zahedan, Iran; 3Department of Clinical Psychology, Science and Research Branch, Islamic Azad University, Tehran, Iran; 4Department of Psychiatric Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 5Hospital Administration Research Center, Sari Branch, Islamic Azad University of Medical Sciences, Sari, Iran; 6Department of Humanities and Social Sciences, Science and Research Branch, Islamic Azad University, Tehran, Iran; 7Department of Psychology, Mohaghegh Ardabili University, Ardabil, Iran. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. - 8 - Non -co mmerc ial us e o nly Integrating psychological assessment in achalasia management Eur J Transl Myol 34 (3) 12727, 2024 doi: 10.4081/ejtm.2024.12727 blockers, nitrates, sildenafil, and terbutaline), focus on de- creasing LES pressure to aid in the gravitational and hydro- static movement of food and liquids through the esophagus.7 Initial treatment recommendations, whether opting for graded pneumatic dilatation or laparoscopic sur- gical myotomy accompanied by partial fundoplication, should consider factors such as the patient’s age, gender, preferences, and the expertise available at the treating in- stitution.8 While the prognosis for individuals with achalasia is generally favorable, symptoms may persist or recur in about 20% of patients despite therapeutic efforts. This prob- lem can lead to significant long-term reductions in both dis- ease-specific and overall quality of life.9 Nonetheless, there is a limited amount of research exploring the psychological burden of achalasia, specifically concerning depression, anxiety, and somatization.9 Several factors can heighten the likelihood of mental health issues in individuals diagnosed with achalasia. Those afflicted with this chronic illness are at an increased risk of experiencing depression, anxiety, and somatization.9-11 The emotional strain from the symptoms, coupled with social and functional limitations, often ex- acerbates feelings of depression, anxiety, and somatiza- tion. In this respect, many achalasia patients have noted that their disease interferes with their social engagements, relationships, and recreational pursuits.9-11 Nevertheless, the Eckardt score remains the predominant benchmark for assessing the severity of achalasia symptoms, concentrat- ing on four primary indicators: regurgitation, dysphagia, chest pain, and weight loss.12 In contrast to these physical symptoms, the psychological impacts and burdens asso- ciated with achalasia frequently receive less attention and are underappreciated. The lack of detailed assessments for specific mental health issues reduces their clinical impor- tance and limits healthcare providers’ ability to rec- ommend targeted interventions. Therefore, it is crucial to perform a prompt psychological assessment during the diagnosis of achalasia.12,13 However, Hanschmidt et al.9 discovered that the incidence rates of depression and anx- iety among female achalasia patients were significantly higher, ranging from 3.04 to 7.87 times and 3.10 times re- spectively, compared to the general population. Such dis- parities were not observed in male patients, suggesting that being female may increase the susceptibility to psy- chological distress associated with achalasia. Con- sequently, it is imperative to focus more on the psychological well-being of female patients with achalasia in medical settings and to explore additional risk factors in future studies. Psychological evaluation is significant in diagnosing acha- lasia for four primary reasons. First, psychological distress may impact the effectiveness of treatment adherence and monitoring in achalasia, potentially influencing the clinical outcomes for patients. When the primary objective in man- aging achalasia is to enhance quality of life, it is crucial not to overlook the provision of psychological support. Greater focus should be directed towards addressing the psycholog- ical manifestations associated with achalasia.13 Second, while treatments like per-oral endoscopic myotomy can en- hance the psychological well-being of individuals with achalasia, the potential for postoperative gastroesophageal reflux introduces a psychological strain that warrants con- sideration. On one side, the reduced quality of life stem- ming from gastroesophageal reflux may lead to psychological distress; conversely, the emergence of such distress can exacerbate the underlying esophageal symp- toms.13 Recent studies have established that psychological factors, rather than physiological ones, play a pivotal role in determining the severity of symptoms in patients suffer- ing from persistent heartburn and reflux issues.14 These psy- chological factors encompass general psychological distress, including depression and state anxiety; health-re- lated psychological distress, involving visceral and pain anxiety; and esophageal-specific psychological distress, such as esophageal hypervigilance. Consequently, it is cru- cial to monitor the psychological state of individuals with achalasia not only prior to treatment but also throughout the progression of the condition.13,14 Third, achalasia could po- tentially be influenced by psychological factors such as anx- iety and depression.15-17 The severity of swallowing difficulties, or dysphagia, is often linked to concurrent psy- chological disorders, particularly esophageal hypervig- ilance and visceral anxiety related to the severity of dysphagia.18 While it is plausible that anxiety and depres- sion might also impact the symptoms of achalasia, there is currently limited solid evidence to confirm this connec- tion.15-18 Fourth, patients with achalasia often experience so- cial isolation due to their symptoms. The fear of eating in public or the embarrassment of regurgitation can lead to avoidance of social situations. This isolation can further contribute to feelings of depression and anxiety.19 Address- ing the psychological mechanisms that influence a patient’s personal experience of their illness, including their coping mechanisms, psychological adaptability, and control of emotions, could enhance patient outcomes in achalasia. Es- tablished psychological treatments like cognitive behavioral therapy have demonstrated effectiveness in reducing de- pression and anxiety among those with chronic diseases. Additionally, newer methods such as acceptance and com- mitment therapy could be especially effective in alleviating the distress associated with chronic conditions.20-22 In conclusion, integrating psychological considerations into the management of achalasia is essential for a holistic ap- proach to patient care. By addressing the mental health as- pects alongside the physical symptoms, healthcare providers can offer more comprehensive and effective treat- ment. This integrated approach not only alleviates the phys- ical discomfort associated with achalasia but also enhances the overall quality of life for patients, helping them to lead more fulfilling lives despite their condition. List of acronyms LES: Lower esophageal sphincter. Contributions MK, conceptualization, investigation, writing-original draft preparation, writing-review and editing; AK, RRN, - 9 - Non -co mmerc ial us e o nly Integrating psychological assessment in achalasia management Eur J Transl Myol 34 (3) 12727, 2024 doi: 10.4081/ejtm.2024.12727 MO, ANA, STSA, writing-review and editing. The au- thors have read and agreed to the published version of the manuscript. Conflict of interest The author declares that he has no known competing fi- nancial interests or personal relationships that could have influenced the work reported in this paper. Funding This article did not receive any specific grant from fund- ing agencies in the public, commercial, or not-for-profit sectors. Ethics approval and consent to participate Not applicable. Corresponding author Mohsen Khosravi, Department of Psychiatry, School of Medicine, Zahedan University of Medical Sciences, Postal Code: 9813913777, Zahedan, Iran. Tel.: +98-5433522636 - Fax: +98-5433518352. ORCID ID: 0000-0003-2970-6309 E-mail: dr_khosravi2016@yahoo.com Ahoora Kavoosi ORCID ID: 0000-0003-4324-7014 E-mail: ahoora.kavoossi@yahoo.com Rafat Rezapour-Nasrabad ORCID ID: 0000-0002-7157-586X E-mail: rezapour.r@sbmu.ac.ir Melody Omraninava ORCID ID: 0000-0002-2322-6243 E-mail: omraninavamelody@gmail.com Alireza Nazari Anamagh ORCID ID: 0000-0001-5898-9593 E-mail: alirezanezeri@gmail.com Seyed Teymur Seyedi Asl ORCID ID: 0000-0001-7559-0533 E-mail: teymur.psychology@gmail.com References 1. Jia X, Chen S, Zhuang Q, et al. Achalasia: the current clinical dilemma and possible pathogenesis. J Neuro- gastroenterol Motil 2023;29:145-55. 2. Furuzawa-Carballeda J, Barajas-Martínez A, Olguín- Rodríguez PV, et al. 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Early access: 22 July 2024. - 11 - Non -co mmerc ial us e o nly