Meniere's disease is frequently associated with psychogenic comorbidities such as anxiety, depression, and persistent dizziness in the sense of "persistent postural perceptual dizziness" (PPPD) or reactive psychogenic dizziness. The current meta-analyses on anxiety and depression and the consequences for otorhinolaryngology are presented and discussed. The aim is to raise awareness of psychogenic comorbidity and to encourage helpful approaches in diagnosis and treatment.

Objective: A previous placebo-controlled crossover study of intratympanic latanoprost—a drug commonly used for glaucoma treatment—showed positive effects on hearing, tinnitus, and vertigo in patients with long-standing Ménière disease (MD). We aimed to test the safety and efficacy of intratympanic treatment with latanoprost 0.0005% versus placebo in patients with active MD concerning speech discrimination in noise, hearing, tinnitus, and vertigo. Study design: A prospective, randomized, double-blind, placebo-controlled study over 3 months in patients with active stage II to III MD. Setting: Twelve otolaryngology referral centers across Sweden. Intervention: Patients were allocated to intratympanic injection of latanoprost 0.0005% administered as a single injection on day 1, or 3 injections over 3 consecutive days, or placebo administered as a single injection or 3 injections over 3 consecutive days. Main outcome measures: The primary outcome was change in speech discrimination in noise, assessed using phonetically balanced monosyllabic Swedish words (PB S/N+4dB), from baseline (day 1) to day 14. Secondary outcomes were change in pure tone average measured at 0.25, 0.5, 1, 2, 3, 4, 6, and 8 kHz, tinnitus according to the Tinnitus Handicap Inventory (THI) score and vertigo measured at 2, 4, 6, and 8 weeks after the first injection. Hearing, tinnitus, and vertigo were also assessed according to a Likert scale scored from 0 to 10. Days with vertigo attacks lasting ≥20 minutes were registered twice a week by patients. LS means were compared for each outcome measure. Results: When comparing latanoprost (1 or 3 injections) with placebo (1 or 3 injections), no statistically significant difference was seen for the change in speech discrimination in noise from baseline to day 14, 0.4 (95% CI: −4.5; 5.3), P =0.88. None of the secondary efficacy measures showed a statistically significant difference between latanoprost and placebo. Latanoprost treatment was well tolerated. Conclusions: In this placebo-controlled study, latanoprost was not more effective than placebo in the treatment of MD and did not improve speech discrimination in noise, hearing, and tinnitus or vertigo symptoms.

Endolymph volumes within the cochlea and vestibule differ between Meniere's disease (MD) and similar-age controls. Magnetic resonance imaging (MRI) has potential to diagnose endolymphatic hydrops (EH). In this study, we utilize archival human temporal bones (HTB) to establish objective reference values for endolymph volumes within the cochlea and vestibule in patients with MD and in age-similar controls, for correlation with future MRI studies. Nineteen HTBs were selected for 3-dimensional reconstruction and volume analysis, including 12 HTBs with MD and 7 age-similar control HTBs. HTBs were segmented and volumes of interest were measured allowing for calculation of the vestibular and cochlear endolymphatic ratios (vELR and cELR), representative of the degree of EH within the vestibule and cochlea. Endolymph volumes within the vestibule and cochlea were significantly higher in MD HTBs. There was no difference in volumes of the bony vestibule and cochlea. The vELR and cELR were significantly larger in MD. Control HTB measurements were utilized to establish the upper bound of normal for the vELR and cELR, which were determined to be 33.2% and 8.84%, respectively. Endolymph volumes and the corresponding vELR and cELR values were significantly higher in MD, indicative of EH. Through the ELR, this study provides objective anatomic reference values directly comparable to MRI studies of EH. A threshold for the vELR and cELR is proposed, above which a diagnosis of EH may be warranted.

We aimed to compare the efficacy of intratympanic and surgical interventions in the management of patients with refractory Meniere disease (MD). Embase, PubMed, Web of Science, Medline, Scopus, Google Scholar, and Cochrane Central Register of Control Trials up to April 2025. The PRISMA guideline and PICO statement were used. The hearing preservation and vertigo control rate were compared between intratympanic gentamicin (ITGI), intratympanic corticosteroids (ITSI), vestibular nerve section (VNS), and endolymphatic sac surgery (ELSS). Classification of vertigo control rate was based on the AAO-HNS (1995) guideline, and the hearing outcome was assessed by the differences in the mean SDS percentage and PTA threshold before and after interventions. In total, 16 studies including 853 participants met the inclusion criteria. VNS had significantly better outcomes of PTA and SDS than ITGI (change of PTA = MD: -16.9dB, P-value: 0.002; change of SDS = MD: 15.64%, P-value: 0.001). As for comparisons of ELSS or ITSI with ITGI, no significant differences were found (P > 0.05). VNS had numerically higher, but not statistically significant, vertigo control rate than ITGI (RR: 1.39, P-value: 0.57). ITGI demonstrated higher control rate than ELSS and ITSI, while only the difference between ITGI and ITSI was statistically significant (RR: 2.7, P-value: 001). VNS is the most effective option, which can be considered for patients who fail other treatments. ITGI was more effective than ELSS and ITSI in vertigo control, but it should be applied at low doses due to its ototoxic side effects.

Visualization of endolymphatic hydrops using MRI has become a cutting-edge method not only for diagnosing Meniere's disease but also for pathophysiological elucidation of the disease. Here, we review recent advances in imaging analysis of the inner ear in Meniere's disease, which could provide additional information over previous findings. In addition to identification of endolymphatic hydrops on MRI, high-intensity signals in the perilymph, which represent alterations in vascular permeability in the blood-perilymph barrier (BPB), might be a key to elucidating the pathophysiology of Meniere's disease. Moreover, high-intensity signals in the endolymphatic duct, which indicate disturbances of the lymph-capillary system, might provide new information for elucidating the pathogenesis of hearing loss and dizziness/vertigo not associated with endolymphatic hydrops. Presence of endolymphatic hydrops is not necessarily the cause of symptoms related to Meniere's disease. Alteration of the BLB might lead to additional disturbances in ears with Meniere's disease and induce clinical symptoms. Disturbances of the lymph-capillary system in endolymphatic duct might induce audio-vestibular symptoms in ears without endolymphatic hydrops. Further development of MRI evaluation of inner ear conditions is desirable not only for accurate diagnosis and elucidation of the pathophysiology of the diseases, but also for early medical intervention to prevent their progression.

3D-FLAIR sequence has an important contribution to the display of endolymphatic hydrops (EH) in Meniere disease (MD), but its clinical application is limited because of the long acquisition time. We investigated whether 3D-FLAIR combined with compressed sensing (CS) technology (3D-FLAIR-CS) can shorten the scan time while maintaining the image quality and diagnostic efficiency for EH. This prospective study included 50 patients with unilateral definite MD who underwent 3T MR imaging 4 hours after gadolinium injection using traditional 3D-FLAIR (10 minutes 35 seconds) and 3D-FLAIR-CS (5 minutes 25 seconds). Image quality was assessed using quantitative (the contrast-to-noise ratio [CNR], SNR, and signal intensity ratio [SIR]) and qualitative methods. The chi-square test compared the diagnostic efficacy of the sequences, paired t tests analyzed quantitative differences, and intra-/interobserver agreement was evaluated using the weighted kappa statistic. Among 50 patients (23 men, 27 women; 27 left ears, 23 right ears), no significant differences were found between the 2 sequences in image quality or diagnosing EH (P >.05). There were no statistically significant differences in CNR (affected side: P = .09; asymptomatic side: P = .07), SNR (affected side: P = .12; asymptomatic side: P = .10), and SIR (affected side: P = .13; asymptomatic side: P = .45) between traditional 3D-FLAIR and 3D-FLAIR-CS, and both sequences exhibited excellent intra- and interobserver agreement (kappa >0.80). Acquisition time for the 3D-FLAIR-CS sequence is reduced by a factor of about 2 compared to traditional 3D-FLAIR, while image quality and diagnostic efficacy in the assessment of EH are the same.

Quantitative study of vestibular endolymphatic hydrops in Meniere's disease based on Three-Dimensional real Inversion Recovery (3D-real IR) sequence.

Allergic rhinitis (AR) is increasingly recognized for its broader impacts on health, including possible links to various vestibular disorders. This study aims to investigate the association between prior AR and peripheral vestibular disorder (PVD) within Taiwan's National Health Insurance system. Utilizing the Longitudinal Health Insurance Database 2010, this case-control study analyzed data from patients diagnosed with PVD (n=78,503) and 235,509 propensity-score-matching controls. To evaluate the association between prior AR and PVD, we carried out multiple logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI). The Chi-squared test indicates a notable contrast in prior AR occurrence between individuals with PVD and those under control (32.2% vs. 22.8%, p<0.001). Furthermore, our findings reveal significant statistical differences in AR prevalence among patients with Meniere's disease (32.1% vs. 22.8%, p<0.001), benign paroxysmal positional vertigo (32.2% vs. 22.8%, p<0.001) as well as vestibular neuritis (32.6% vs.22.8, p <0.001) relative to controls. The adjusted OR for prior AR among sampled PVD patients was found to be 1.605 (95% CI=1.577~1.634). After making similar adjustments for MD, BPPV, and VN cases; we discovered that adjusted ORs of AR were respectively recorded as: 1.598 (95% CI=1.530~1.668), 1.597 (95% CI=1.534~1.662), and finally at 1.636 (95 % CI =1.552 ~1.725). The study suggests a significant link between prior AR and the occurrences of PVD. However, given the distinct pathophysiological mechanisms of these disorders and the high prevalence of AR in the general population, the findings should be interpreted with caution. These results are hypothesis-generating and underscore the need for prospective and mechanistic studies to clarify whether the observed associations reflect causal relationships or coincidental comorbidity.

Ménière's Disease (MD) is a complex vestibular disorder, and its pathological mechanism has not been fully elucidated so far. Compare the positive rates of anti-myelin-associated antibodies between patients with MD and the normal control group, and analyze the clinical characteristics of MD patients with positive anti-myelin-associated antibodies. Between April 2020 and July 2020, a total of 66 patients diagnosed with definite MD and 42 healthy controls were recruited at Shandong Provincial ENT Hospital. A comprehensive auditory-vestibular function assessment was conducted for the MD patients, which included Pure Tone Audiometry, Speech Discrimination Score (SDS), Auditory Brainstem Response, vestibular-evoked myogenic potential (VEMP), caloric testing, video head impulse test, and inner ear Gadolinium MRI, among other examinations. Additionally, indirect immunofluorescence testing was employed to detect anti-myelin-associated antibodies in all participants, followed by a correlation analysis between the detected results and the clinical manifestations. Furthermore, the vestibular end organ of a MD patient who had undergone labyrinthectomy was obtained through surgery for transmission electron microscopy (TEM) examination, in order to observe the ultrastructure of the vestibular nerve and determine the presence of any demyelinating lesions. When compared with the control group, the positivity rate of antibodies related to central nervous system (CNS) demyelinating diseases in patients with MD did not exhibit a statistically significant difference (p = 0.217). In contrast, the positivity rate of antibodies associated with peripheral nerve demyelinating diseases showed a highly significant statistical difference (p < 0.001), the positivity rates of anti-sulfatide antibodies and anti-GM1 antibodies in the MD group were significantly higher than those in the control group (p < 0.001). Patients with positive anti-GM1 antibodies were found to be older (p = 0.014), yet they demonstrated higher SDS (p = 0.023), a lower degree of semicircular canal paresis (p = 0.017), and a reduced abnormal rate of cervical VEMP (p = 0.049). Conversely, no significant correlation was observed between the expression of anti-sulfatide antibodies and the clinical symptoms or auditory-vestibular function levels of the patients. TEM of the vestibular nerve tissue obtained from MD patients revealed distinct demyelinating lesions. There is a phenomenon of demyelination of the vestibular nerve in patients with MD, and the positive rate of anti-myelin-associated antibodies in the peripheral blood of these patients is significantly higher than that in the control group. Among them, anti-GM1 antibodies may be correlated with auditory and vestibular functions, and they are expected to become a biological marker for MD.

High-salt intake exacerbates endolymphatic hydrops and alters aldosterone regulation in a Ménière's disease animal model.

To present an overview of differences in caloric test and video Head Impulse Test (vHIT) results between Menière's disease (MD) and vestibular migraine (VM) patients. Following PRISMA guidelines, comprehensive searches were conducted in PubMed, Embase, and Medline up to December 2024. Clinical studies comparing caloric and/or vHIT results in MD and VM patients were included. Exclusion criteria were non-English or non-Dutch papers, pediatric studies, and studies using non-standard caloric test protocols. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for analytical cross-sectional studies. Certainty of evidence was assessed according to the Oxford Centre for Evidence-Based Medicine. Meta-analyses of caloric test and vHIT results were performed. Twenty-one studies, including 8 prospective cohort studies, with 3096 study subjects (1561 MD; 1535 VM), were included. Fourteen studies were assessed as low risk of bias. Results showed that patients with MD were significantly more likely than those with VM to show a canal paresis on caloric testing (OR=7.00, 95% CI: 5.69-8.61, P<0.00001). This indicates that a reduced vestibular response on caloric testing strongly favors a diagnosis of MD over VM. Similarly, MD patients had higher odds of having an abnormal horizontal vHIT (OR=3.38, 95% CI: 2.39-4.78, P<0.00001), and were also more likely to demonstrate corrective (catch-up) saccades during vHIT (OR=3.52, 95% CI: 2.11-5.88, P<0.00001). These findings (level 3 evidence) suggest that in clinical practice, evidence of peripheral vestibular dysfunction-detected by either caloric testing or vHIT-can help distinguish MD from VM.

IntroductionThe advent and growth of social media platforms have dramatically altered the landscape of health information sharing, particularly for conditions like Meniere's disease. This study delves into the nature and impact of shared experiences and peer support concerning Meniere's disease on social media, underscoring the critical need for analyzing this content for its influence and accuracy. This study aims to analyze the portrayal of Meniere's disease across social media platforms, focusing on content accuracy and misinformation, to provide vestibular care professionals with insights for improving patient education and fostering more effective patient engagement.Materials and methodsEmploying a comprehensive qualitative approach, our study scrutinized 1108 social media posts about Meniere's disease from Facebook, Instagram, and TikTok-over 3months. Analysis included authorship identification, examination of the subject matter, tone assessment, and evaluation of post popularity and engagement metrics.Results and analysisA significant portion of the analyzed posts were predominantly image-driven, with a majority authored by patients or their family members. Instagram was the most utilized for Meniere's disease discussions, followed by Facebook and then TikTok. The content analysis revealed that personal experiences comprised 40% of the posts, followed by informational posts, and queries or advice-seeking posts. Sentiment analysis showcased a diverse range of emotions: 45% of posts displayed a positive tone, 35% were neutral, and 20% expressed negative sentiments.DiscussionThe findings from this study highlight a significant demand for accurate and authoritative educational resources on social media regarding Meniere's disease. They offer vestibular care providers, including otolaryngologists, audiologists, physical therapists, speech-language pathologists, and others valuable insights into improving patient-centered care by developing and implementing effective communication strategies. Emphasizing patient empowerment, these strategies should cater to a patient population that is increasingly turning to social media for health-related information. The study also points to the necessity of addressing misinformation and guiding patients towards reliable sources of medical information online.

Effects of intratympanic administration of glucocorticoids on the guinea pig inner ear.

Background and Aim: This study compared the American Academy of Otolaryngology- Head and Neck Surgery (AAO-HNS) criteria for Meniere’s Disease (MD) with vestibular staging methods that address inner ear progression, a consideration not found in the AAO- HNS criteria. Methods: A cross-sectional study recruited patients with MD, aged 18 to 60, from June 8, 2022, to March 20, 2023; however, we excluded patients with problems such as difficulty rolling their eyes, difficulty turning their head, conductive or mixed hearing loss, cental nerves system disorders, retrocochlear lesions, pregnancy, and receiving psychotropic drugs. Furthermore, patients with a history of labyrinthitis, vestibular migraine, stroke, benign positional vertigo, or bilateral vestibulopathy within the past 6 months were excluded. All patients were tested with audiometry, vestibular evoked myogenic potential, caloric test, and video head impulse test. Two neuro-otologists assessed and classified patients with MD according to the AAO-HNS (1990 and 2020) criteria. Results: Forty-two patients were enrolled. The correlation between vestibular staging and both AAO-HNS (1990 and 2020) criteria was medium (p=0.02 and p&lt;0.01, respectively). According to AAO-HNS 1995, 69% of definite MD cases were classified as stage C, whereas all probable MD cases and 30% of possible MD cases were categorized as stage B. Regarding AAO-HNS 2020, 70% of definite MD cases were classified as stage C, whereas 33.3% of probable MD cases were classified as stage B. Conclusion: Definite MD could predict pathology in the cochleo-sacculo-utricular and lateral canals (stage C), whereas probable MD could suggest that the lesion involved the cochleo-sacculo-utricular canal (stage B). Trial registration: This trial was registered at Thai Clinical Trials Registry on June 6, 2022 (TCTR20220606003).

Recent advancements in diagnosis and treatment of inner ear disorders, including benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuritis, have significantly improved patient care. In this review, new technologies such as video head impulse testing, dynamic posturography, virtual reality, and mechanical rotation chairs have enhanced diagnostic accuracy and facilitated improved and targeted treatment, which are addressed. Furthermore, rapid and consistent use of vestibular rehabilitation has proven effective in reducing vertiginous symptoms and improving overall balance performance significantly.

Degenerative changes in the neurovascular unit (NVU) in the human spiral ganglia (SG) in patients with Meniere's disease (MD) compared with normal patients underlie the clinical manifestations of MD. Endolymphatic hydrops (EH) is the pathologic correlate of MD, yet the etiology of MD is poorly understood. EH alone does not adequately explain the changes in permeability of the cochlear blood-labyrinthine barrier seen with delayed contrast MRI or fluctuations in symptoms. Hematoxylin and eosin sections of the cochlea were obtained from temporal bones of normal patients (n=5, age: 47 to 63y, 1 male/4 female) and patients diagnosed with MD (n=8, age 51 to 88, 4 male/4 female). The number of spiral ganglia neurons (SGNs) in each cochlea was estimated. SGNs and blood vessels in the cochlea from normal and MD patients (archival celloidin sections from the same patients) were reliably identified with antibodies against acetylated-3-tubulin and glucose transporter-1, respectively, and visualized by immunofluorescence and laser confocal microscopy. There was a significant decrease (50% loss) of SGNs among patients diagnosed with MD compared with age-matched controls (P<0.05) and contralateral unaffected cochlea (35% decrease). Immunofluorescence-stained sections showed a marked decrease of blood vessels and a corresponding loss of SGNs in MD cochlea compared with controls. The decrease of spiral ganglia neurons and associated blood vessels showed regional damage of the cochlea. These results suggest that the NVU interaction may be critical to preserve the SGNs in MD and establish a framework for understanding the etiology and treatment of MD beyond EH. Not applicable.

To report long-term outcomes for patients undergoing round window reinforcement (RWR) surgery as a second operation for hyperacusis symptoms in superior semicircular canal dehiscence (SSCD) syndrome. Retrospective case series of the RWR cases performed by the senior author at our tertiary center between 2013 and 2024. All patients underwent RWR surgery using the same technique, and the primary SSCD occlusion was also performed by the senior author. Three patients were included in this case series. The mean interval between primary SSCD occlusion surgery and RWR was 25 months. The mean length of follow-up post-RWR surgery was 50 months. All patients reported resolution of their hyperacusis symptoms in the operated ear at the time of the last follow-up. One patient developed a degree of manageable imbalance and difficulty with hearing with background noise, 1 patient developed hyperacusis on the contralateral side but remained asymptomatic on the side of the operated ear, and 1 patient remained asymptomatic of SSCD at 8 years post-RWR but developed symptoms suggestive of Meniere's disease, which was well controlled with diet and betahistine. Hearing outcomes were variable, with 2 out of 3 patients reporting a mild worsening of hearing loss post-RWR. Patients with hyperacusis symptoms demonstrated resolution of their symptoms after RWR in the operated ear. Careful patient selection is required, and patients need to be informed about the potential for postoperative hearing loss as part of informed decision-making.

Abstract Introduction Differentiation between Meniere’s disease (MD) and vestibular migraine (VM) represents one of the most challenging audiological scenarios. This study aims to evaluate the role of using vestibular-evoked myogenic potentials and magnetic resonance imaging in better assessment of these two entities. Methods A retrospective case-control study was conducted at our tertiary referral center on cases diagnosed with MD and VM during the period from January 2023 to December 2024. Inclusion criteria included sure diagnosis with either definite VM or definite MD. Patients with peripheral hearing loss due to other causes and other neurological diseases causing headaches, and those with cervical vertebral problems were excluded. All cases had basic audiological evaluation, assessment of vestibular-evoked myogenic potentials (VEMPs) both cervical (cVEMPs) and ocular (oVEMPs), and magnetic resonance imaging of the inner ear. Results A total of 26 affected ears with MD, 26 unaffected ears, 52 ears with VM, and 40 ears as a control group were evaluated. Regarding the cVEMP test, a statistically significant delay in p13 latency was found in the affected ears in the MD group, unaffected ears in the MD group, and the VM group compared to the control group at 500 Hz (p-value = 0.001). Regarding N23 latency, only affected MD had significantly prolonged latency compared to the control group at 500 Hz. Also, there was a delay in N23 latency in VM at this frequency compared to the control group. There was a significantly lower P13-N23 amplitude in the affected ears by MD in comparison to the control group. Radiological findings revealed a significantly larger distance between the posterior semicircular canal and posterior fossa in the VM group when compared to the control group. Receiver operating curve was done to detect the cutoff point between the VM and control groups regarding this distance and yielded a value of 1.99. Conclusion Abnormal c/oVEMP recordings, which appeared in MD patients more than in VM patients with positive frequency tuning, offer the possibility of using VEMP to differentiate MD from VM and for early detection and therapeutic monitoring of MD.

Abstract Introduction The vestibular neural network is connected to cortical and subcortical areas of the brain suggesting the possible interconnection between vestibular and cognitive functions. The study examines the impact of peripheral vestibular disorders like Benign Paroxysmal Positional Vertigo (BPPV), Meniere’s Disease (MD) and Acute Vestibular Neuropathy (AVN) on cognitive skills and its related aspects. The study also explored if there is any relationship between dizziness related to self-perceived handicap and cognitive skills among individuals with vestibular disorders. A cross-sectional study design was employed to assess cognitive skills using Montreal Cognitive Assessment (MoCA) and Digit span test (DST) in 34 individuals with peripheral vestibular dysfunction and 34 healthy controls. Dizziness Handicap Inventory (DHI) was administered to assess the self-perceived dizziness related handicap. The relationship between the self-reported dizziness related handicap through Dizziness Handicap inventory (DHI) and performance-based cognition tests was assessed. Results Mann Whitney U test indicated significantly poorer scores on various cognitive domains of MoCA test and DST in individuals with vestibular dysfunction than healthy individuals. Comparison of the cognitive skills across individuals with BPPV, MD and AVN revealed no significant difference among them. There was no correlation observed between self-perceived dizziness handicap and cognitive abilities in individuals with vestibular dysfunction. Conclusion The study revealed that cognitive dysfunction is affected in individuals with peripheral vestibular loss, specifically in domains like visuospatial skills, executive functioning, memory, attention and language. However, cognition need not always linked to perceptual handicap reported by these individuals.

The objective of this study was to evaluate anxiety, depression, dizziness disability, sleep, and quality of life in individuals diagnosed with Ménière's disease (MD) and vestibular migraine (VM). Additionally, the study sought to examine the impact of anxiety and depression levels, as well as dizziness disability, on sleep and quality of life. The present study included a total of 51 individuals, with 25 subjects in the MD group and 26 subjects in the VM group. The Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI), the Dizziness Handicap Inventory (DHI), the 36-Item Short Form Health Survey (SF-36) for quality of life, and the Pittsburgh Sleep Quality Index (PSQI) were administered face-to-face to all subjects. A statistically significant difference was not observed between the two groups in terms of BDI, BAI, DHI total, and subcategories (Emotional, Physical, and Functional; p > .05). Among the subdimensions of SF-36, only Vitality and Mental Health scores were found to be statistically significantly higher in the MD group compared to the VM group (p = .039 and p = .030, respectively). Conversely, the PSQI score exhibited a statistically significant difference, with higher values observed in the VM group compared to the MD group (p = .023). VM and MD significantly impact psychological and physiological outcomes, including anxiety, depression, dizziness, quality of life, and sleep. Psychiatric comorbidities and reduced quality of life profoundly affect daily life. Therefore, a multidisciplinary approach, including psychiatric support, is essential for effective management.