Mental Health and Quality of Life among Egyptian Patients with Esophageal Motility Disorders: A Psychiatric Assessment

Background and study aim: This study aimed to assess the effect of esophageal motility disorders on quality of life, anxiety, and depression among Egyptian patients. Patients and Methods: This cross-sectional study included 38 patients with esophageal dysmotility who visited GIT motility unit at Ain Shams specialized


INTRODUCTION
The most widely known and studied esophageal motility disorder is achalasia.
In spite of that, investigations and management workup for other primary esophageal motility disorders are increasing and becoming more relevant and updated [1].
Esophageal symptoms such as dysphagia, non-cardiac chest pain, and regurgitation can arise from primary esophageal motor disorders like achalasia.Yet, these symptoms can also arise from disorders of impaired relaxation across the lower esophageal sphincter (LES) and other disorders of esophageal peristalsis, in addition to other unclassified conditions with abnormal manometric findings [2].
A lot of studies have found that the motility pattern of esophageal body in GERD patients is mainly ineffective esophageal motility (IEM) [3].It has been evident that it is a significant correlation between hypomotile esophagus and GERD [4,5].
Due to the wide spectrum of esophageal motility disorders, and the long course of the disease from diagnosis to definitive management (medical, endoscopic, or surgical); Many patients are at risk of developing psychological distress and other mental health symptoms.Previous studies have focused on relation of individual motility disorders with psychological stress and mental disorders.
At the same time, psychological stress is known to play a crucial role in the pathogenesis of gut motility disorders.It was believed that stress could be a precipitating factor of gastrointestinal symptoms in patients with functional gastrointestinal disorders.However, little research has been done to evaluate the effect of stress in exacerbating the symptoms associated with gastroesophageal reflux and it is still debatable [6].
Gastroesophageal reflux disease (GERD), as considered a disorder of esophageal motility, has an evident effect on the health-related quality of life (QOL), affecting daily social activities and physical and emotional aspects of patients.It also interferes with healthy sleep and work [7,8].
The most common mental disorders known among patients with gastroesophageal reflux disease (GERD) were depression, anxiety, bipolar disorder and sleep disorders [6,9,10].Previous studies concluded that achalasia alone irrespective of other comorbidities was associated with an increased incidence of depression [9,11].It also has been observed that achalasia patients have impaired quality of life that improves generally after interventions like Heller's cardiomyotomy [12].
This study aimed to evaluate mental health outcomes and Quality of life among Egyptian patients suffering from esophageal motility disorders.

PATIENTS/MATERIALS AND METHODS
This was a cross-sectional study registered at the Faculty of Medicine Ain Shams Research Institute (MASRI) and approved by the Research Ethics Committee of the Faculty of Medicine, Ain Shams University (FMASU REC no.R48/2022).The study conducted at the department of tropical medicine, Ain Shams University Hospital, and the GIT motility unit at Ain Shams Specialized hospital, Cairo, Egypt.
Informed consent was included, explaining in details the study design and aim prior to respondents' enrollment.Participants could terminate at any time they desired.Moreover, confidentiality of information was assured, and they were informed that this study could be used for scientific publication without the disclosure of the participants' personal identity.Patients were asked to participate in psychiatric evaluation after completing the required esophageal motility studies.
Assuming the expected population standard deviation to be 10, and employing t-distribution to estimate sample size, the study would require a sample size of 19 to estimate a mean with 95% confidence and a precision of 5 [13].However, the sample size was later upgraded to 30 by the Ain Shams University reviewing board.Thirtyeight patients who visited the motility unit from April 2022 to November 2022 and accepted to participate in the study were included.The patients with previous evident psychiatric disorders and those who refused participation in the study were excluded.

Study Tools:
Full history taking (personal and history of present illness) Arabic validated version was used [15].10.Beck anxiety inventory (BAI) [16]: is a 21question multiple-choice self-report inventory that is used for measuring the severity of anxiety in adolescents and adults ages 17 and older.The score of anxiety was calculated with the sum of twenty-one items, each answer was graded either 0= no at all, 1= mild, 2= moderate, 3= severe, and so (total score from 0 to 7 was considered negative for anxiety, from 7 to 15 was considered mild anxiety, from 16-25 was considered moderate, and above is considered severe).Arabic validated version was used [17] -Quantitative data were shown as mean, SD, and range.
-Qualitative data were expressed as frequency and percent.
Analytical statistics: -Chi-square test was used to measure association between qualitative variables, while Fisher exact test was used for 2x2 qualitative variables when more than 25% of the cells have expected count less than 5.
-Student t-test was used to compare mean and SD of 2 sets of quantitative normally distributed data, while Mann Whitney test was used when this data is not normally distributed.
-Pearson's correlation was used to study correlation between two variables having normally distributed data, while Spearman's correlation was used when this data is not normally distributed.
-The Friedman test was used for one-way repeated measures analysis having quantitative not normally distributed.
-Kruskal-Wallis test was used for comparison between three or more groups having quantitative not normally distributed.
-P-value was considered statistically significant when it is less than 0.05.

Participants' Characteristics
Thirty-eight patients who visited GIT motility at Ain Shams specialized hospitals from April 2022 to November 2022, accepted to participate in the study.Mean age of the patients was 36.63 ± 9.719 years, twenty-four of them (63.2%) were males, twenty-eight (75.7%) received higher education, twenty-eight (75.7%) were from urban cities, twenty-six (70.3%) were employed (Table 1.).

Clinical symptoms of studied Egyptian patients complaining of esophageal motility disorders.
Twenty-nine (76.3%) were complaining of chest pain, twenty (52.6%) were complaining of heart burn, eighteen (47.4%) were complaining of regurgitation and vomiting, sixteen (42.1%) were complaining of dysphagia.
On the other side, thirteen (34.2%) were diagnosed to have disorders of out flow, and twenty-two (57.9%) had hypomotility peristaltic disorders (Table 1).Although the fact that there is no other statistical significance, we cannot deny the affection of all different domains of quality-of-life assessment scores.Table (3) Moreover, Environmental, and social quality of life domains were more affected in patients from rural areas, their medians scores were both 50, while Environmental and physical domain was more affected in those from urban areas their medians scores were 59.50 and 56 respectively (Table 3).

WHOQOL-BREF assessment
Physical and environmental domains were more affected in all patients regardless of the main presenting symptom.All quality-of-life domains were more affected in patients with outflow disorders than other categories (Fig. 1) (Table 3).
Patients mean age 41.6±8.43 showed statistical significance on experiencing moderate levels of severity on the BDI P value =0.031* (Fig. 1) (Table 5).

DISCUSSION
Esophageal motility disorders affect patient quality of life and are often associated with mental illness, which compounds the burden on patients and their social circles.In this study, we assessed patients with proven esophageal motility disorders for depression, anxiety, and quality of life.
To our knowledge, this is one of the earliest studies to address the issue of mental health associated with esophageal motility disorders in the Middle East and Africa.It is also one of the very few papers that have studied the quality of life and psychiatric issues associated with individual esophageal motility disorders.This includes not only achalasia but also other disorders of peristalsis such as ineffective motility and spastic disorders.
Our findings showed that, regardless of etiology, most patients with esophageal motility disorders experienced impairment across all examined domains.All but one of the subjects in our study suffered from various degrees of anxiety and depression, with a significant percentage experiencing extreme degrees of anxiety (10.5%) and depression (23.7%).Quality of life was affected in all four domains.Manometry was performed on those with abnormal results, but two patients refused.The result was that 10 of the 11 tested patients had major motor abnormalities by manometry, indicating a relationship between psychiatric problems and motor disorders [23].
The study may have had some limitations.According to the guidelines for treating such patients, the appropriate therapy should have been selected before performing invasive procedures (Upper GI endoscopy and Barium swallow).This could explain the small sample size, which was our main limitation.The patient in our low-income country could not afford the high cost of this examination.Moreover, the study did not receive any funding.However, our research's strengths were being the first center in Egypt and conducting novel research work.
Our study highlights the significant impact of esophageal motility disorders on patients' quality of life and the associated burden of depression and anxiety.These findings reinforce the importance of screening for psychological distress in patients with underlying esophageal motility disorders.Thus, proper psychological support can be provided in conjunction with medical, endoscopic, or surgical interventions.
Our results emphasize the importance of studying gastrointestinal tract motility disorders and carrying out more research in this field.Unfortunately, it is underestimated in our society.

CONCLUSION
In all our studied patients, all domains of quality of life are affected, especially physical and environmental domains, and those with outflow obstruction were more affected than others .All our studied patients had variable degrees of anxiety and depression affecting their mental health.
Our study's results are consistent with previous research, highlighting the association between esophageal motility disorders and mental healthrelated outcomes.These disorders result in a poorer quality of life for patients.

Table 1 .
Sociodemographic characteristics and clinical symptoms of studied Egyptian patients complaining of esophageal motility disorders (n=38)

Table 2 .
Descriptive presentation of WHOQOL-BREF, BAI and BDI scores of studied Egyptian patients complaining of

Table 3 :
Comparative Sociodemographic data and clinical symptoms with different domains of WHOQOL-BREF:

Wallis test -(NCCP) non-cardiac chest pain.
W, Vela M, Safder A, Hila A, Castell DO.Revised Criterion for Diagnosis of Ineffective Esophageal Motility Is Associated With More Frequent Dysphagia and Greater Bolus Transit Abnormalities.
Lee Y-S, Jang B-H, Ko S-G, Chae Y. Comorbid risks of psychological disorders and