Laboratorio Sperimentale di Ricerche Endocrinologiche Istituto Auxologico Italiano, IRCCS Milano, Italy Enrico Molinari Laboratorio Sperimentale di Ricerche Psicologiche Istituto Auxologico Italiano, IRCCS Piancavallo (VB), Italy
We have read with great interest the paper by Sandberg et al. (1) concerning the quality of life of adults with childhood-onset GH deficiency (GHD).
We agree that unbiased control/comparison groups (frequently unmatched for socioeconomic status), frequent inconsistent diagnostic criteria, and the use of nonstandardized tests have frequently distorted the results of several psychological studies appearing in literature.
In addition to these confusing factors, the heterogeneity between patients with childhood- and adult-onset GHD (due to the different ages at which deficiency sets in) may have also greatly contributed to reduce the value of conclusions drawn from all studies analyzing mixed populations. In fact, it is clearly evident that patients with childhood-onset GHD who have grown up with all the problems associated with GHD (and have progressively adapted to them) are different from those who acquired GHD in adulthood and who previously experienced a normal quality of life (2).
In our experience (3), the GH-induced achievement of full genetic growth potential also seems important in influencing the quality of life in adults with childhood-onset GHD, in disagreement with Sandberg et al. (1), who demonstrated that the relationships between adult height and psychosocial adjustment are actually rather small (between 23% of the variance in outcome scores) in normal statured adults with GHD (mean final height: -1.5 SD).
This statement is based on the data we obtained in a homogeneous group of short-statured adults (final height SD score lower than -2.5) with childhood-onset GHD (3, 4) who had been incompletely and discontinuously treated (due to the frequent lack of pituitary GH) during childhood, thus not achieving their full genetic growth potential (i.e. a satisfactory final height).
Short-statured adults with GHD tended to underestimate their body size by an average of 30%, with peaks of 47% for the head area; furthermore, they showed a low level of self-esteem, a closed attitude towards social relationships, a pessimistic attitude with a tendency towards depression, and a strong sense of detachment from the outside world.
After 6 months GH treatment, these patients presented an overall improvement in intellectual tasks, accompanied by a lower level of stress during their performance and a clear improvement in emotional control during specific and aspecific stress.
We are aware that the positive effects of GH treatment on the psychological well-being of these patients might be attributed, at least in part, to a series of aspecific variables, in particular the return to the circuit of care, the subjects high degree of motivation, and their hope of finding an improvement. However, the finding that 6 months after stopping GH therapy, the psychological characteristics of patients reverted to those recorded before treatment supports the GH dependence of the effects observed during therapy.
Although the finding of normal psychological outcomes can actually be relevant to the controversy regarding the risks and benefits of GH therapy in adults with GHD, as stated by Sandberg et al. (1) in their conclusions, we believe that the decision to treat (or not) these patients should take into account all the negative metabolic effects due to the chronic GH lack (such as abnormal body composition, reduced physical capacity, altered lipid metabolism, etc.). Nevertheless, long-term controlled studies evaluating the influences of GH substitution on the increased risk of mortality for cardiovascular diseases and early bone fractures of adults with GHD are mandatory to give reliable and convincing answers to the controversy regarding the opportunity of maintaining these patients on GH therapy lifelong.
Footnotes
Address correspondence to: Alessandro Sartorio, M.D., Research Center for Growth Disorders, Italian Institute for Auxology, Via Ariosto 13, 20145 Milan, Italy.
Received May 26, 1998.
References
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