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Background: Social support, which is a crucial external resource for cancer patients, was demonstrated to be a positive predictor of learned helplessness (LH). But it is far from clear whether and how social support decreases the LH in cancer patients. The purpose of present study is to detect the association between social support and LH and the role of individual resilience and self-efficacy in mediating this relationship. Methods: The convenience sampling method was utilized. From August 2022 to February 2024, a total of 537 lung cancer patients (M age = 60.25 years, SDage = 9.85 years) from five tertiary hospitals in one municipalities (Chongqing), and two provinces (Sichuan and Yunnan) were recruited, among which 389 were males and 148 were females. LH, social support, individual resilience, and self-efficacy were assessed by using standard scales. A structural equation model was constructed employing AMOS 23.0 to examine the interrelationships among social support, individual resilience, self-efficacy, and LH of lung cancer patients. Results: A total of 537 lung cancer patients were finally included. Social support, individual resilience, and self-efficacy were positively related to LH (r = -0.299 to -0.451, p < 0.01). The mediation model revealed that the direct effect of social support on LH was significant (ß = -0.407, p < 0.001). Besides, social support could also affect LH through three pathways: (1) the mediating effect of individual resilience (ß = -0.075, p < 0.001); (2) the mediating effect of self-efficacy (ß = -0.060, p < 0.05); (3) the chain mediating effect of individual resilience and self-efficacy (ß = -0.011, p < 0.05). Conclusion: The results indicate that social support alleviates lung cancer patients' LH, and that individual resilience and self-efficacy mediate the correlation between social support and LH. Besides providing adequate social support, intervention strategies built on individual resilience and self-efficacy should be applied to reduce LH in lung cancer patients.

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(1) Background: Currently, numerous qualitative research studies on food and its influence on health are being conducted. In qualitative research, data are obtained by analyzing participants' responses. However, silence during conversation has been little studied. The aim of this study was to interpret the silences in the narratives of elderly people living alone about the potential risks of not keeping a healthy diet. (2) Methods: This is a descriptive and interpretative observational study under the qualitative research paradigm following a phenomenological and ethnographic perspective. The study was developed in two phases with people over 65 years old. In the first phase, from June 2021 to January 2022, 90 interviews, 12 life history analyses, 58 food diaries and 51 free listings (cultural domain technique) were conducted. In the second phase, from March to June 2022, 3 participatory workshops and 24 pile sorts (cultural domain technique) were conducted, as well as 3 focus groups. Only data from participants over 65 years old living alone are analyzed in this paper. The ATLAS-ti (Version 22) qualitative analysis software was used for coding and data analysis. (3) Results: The results show that elderly people living alone would sometimes remain silent during the various conversations conducted within the research. This silence reflects their desire to downplay the risks to their health from not eating well due to their unwanted loneliness. The people participating in our research had chronic health problems, financial insecurity and emotional problems. (4) Conclusions: We concluded that elderly people living alone are unable to maintain a healthy diet because they downplay their risk of malnutrition. This mindset is caused by their loneliness and bolstered by a situation of learned helplessness and social injustice.

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In the last decade, activity-dependent strategies for labelling multiple immediate early gene (IEG) ensembles in mice have generated unprecedented insight into the mechanisms of memory encoding, storage, and retrieval. However, few strategies exist for brain-wide mapping of multiple ensembles, including their overlapping population, and none incorporate capabilities for downstream network analysis. Here, we introduce a scalable workflow to analyze traditionally coronally-sectioned datasets produced by activity-dependent tagging systems. Intrinsic to this pipeline is simple multi-ensemble atlas registration and statistical testing in R (SMARTR), an R package which wraps mapping capabilities with functions for statistical analysis and network visualization. We demonstrate the versatility of SMARTR by mapping the ensembles underlying the acquisition and expression of learned helplessness (LH), a robust stress model. Applying network analysis, we find that exposure to inescapable shock (IS), compared to context training (CT), results in decreased centrality of regions engaged in spatial and contextual processing and higher influence of regions involved in somatosensory and affective processing. During LH expression, the substantia nigra emerges as a highly influential region which shows a functional reversal following IS, indicating a possible regulatory function of motor activity during helplessness. We also report that IS results in a robust decrease in reactivation activity across a number of cortical, hippocampal, and amygdalar regions, indicating suppression of ensemble reactivation may be a neurobiological signature of LH. These results highlight the emergent insights uniquely garnered by applying our analysis approach to multiple ensemble datasets and demonstrate the strength of our workflow as a hypothesis-generating toolkit.

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Fetal hypoxia and maternal stress frequently culminate in neuropsychiatric afflictions in life. To replicate this condition, we employed a model of prenatal severe hypoxia (PSH) during days 14-16 of rat gestation. Subsequently, both control and PSH rats at 3 months old were subjected to episodes of inescapable stress to induce learned helplessness (LH). The results of the open field test revealed an inclination towards depressive-like behavior in PSH rats. Following LH episodes, control (but not PSH) rats displayed significant anxiety. LH induced an increase in glucocorticoid receptor (GR) levels in extrahypothalamic brain structures, with enhanced nuclear translocation in the hippocampus (HPC) observed both in control and PSH rats. However, only control rats showed an increase in GR nuclear translocation in the amygdala (AMG). The decreased GR levels in the HPC of PSH rats correlated with elevated levels of hypothalamic corticotropin-releasing hormone (CRH) compared with the controls. However, LH resulted in a reduction of the CRH levels in PSH rats, aligning them with those of control rats, without affecting the latter. This study presents evidence that PSH leads to depressive-like behavior in rats, associated with alterations in the glucocorticoid system. Notably, these impairments also contribute to increased resistance to severe stressors.

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TMP269, a class IIA histone deacetylase inhibitor with selectivity, that has a protective effect on the central nervous system, yet its specific mechanism of action remains ambiguous. Although major depressive disorder (MDD) is highly prevalent, its pathophysiology is poorly understood. Recent evidence suggests that histone deacetylase 5 plays a key role in the pathological process of depression and the fact that preclinical studies have shown HDAC5 to be a potential antidepressant target, the search for natural drugs or small molecule compounds that can target HDAC5 may be a potential therapeutic strategy for the treatment of depression. In addition, we examined the role of the Brain-derived neurotrophic factor (BDNF), an important neurotrophic factor for neuronal survival and growth, as a potential downstream target of HDAC5. We found downward revision of HDAC5 levels in the hippocampus ameliorated depressive-like behavior in LH (Learned helplessness) mice. Furthermore, injection of HDAC5 overexpressing adenoviral vectors in the hippocampal dentate gyrus of wild-type mice produced a somewhat depressive-like phenotype. Pharmacological, immunofluorescence and biochemical experiments showed that TMP269 could produce antidepressant effects by inhibiting mouse hippocampal HDAC5 and thus modulating its downstream BDNF. Over all, TMP269 mitigated LH-induced depressive-like behaviors and abnormalities in synapse formation and neurogenesis within the hippocampus. These findings suggest potential beneficial effects of TMP269 on depression.

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Purpose: This study aims to translate and validate the Learned Helplessness Scale (LHS) for use in the educational context and specifically among Chinese law school students. Understanding learned helplessness in the context of Chinese law students can provide unique insights into the interaction of legal education, psychological health, and cultural influences, thereby contributing to a more nuanced understanding of learned helplessness. Methods: A total of 711 Chinese college students from two law schools participated in this study. The Learned Helplessness Scale (LHS) was translated into Chinese using forward and backward translation. Exploratory and confirmatory factor analysis, and construct validity were conducted to assess the dimensionality of the Chinese version of the LHS (Chinese LHS). Results: The exploratory factor analysis indicated that the Chinese LHS has a four-factor structure consisting of 14 items, which accounted for 50% of the total variance. The subsequent confirmatory factor analysis further supported this four-factor structure. The internal consistency of the Chinese LHS was found to be medium to high, with Cronbach's α values ranging from 0.63 to 0.87 for the subfactors, and 0.79 for the total scale. In addition, concurrent validity is also confirmed. Conclusion: The 14-item version of the Chinese LHS is a psychometric sound instrument for assessing learned helplessness among Chinese law school students.

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The interactions between infants and caregivers are critical to infant development and caregiver well-being. Traditional developmental research has primarily emphasized the infant's development when studying infant-caregiver interactions, but a less commonly assessed feature of those interactions is the effect of the infant's crying on the caregiver's behavior. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method (Moher et al., Public Library of Science Medicine, 6(7), e1000097, 2009), we conducted a systematic review of the literature evaluating the effects of crying on caregiver behavior. We searched for peer-reviewed articles in the Scopus and Web of Science Core Collection databases that included research studies in which researchers observed and manipulated infant crying and simultaneously measured features of caregiver behavior (actual or analogue). We used this body of literature to evaluate the existing evidence of the effects of crying on caregiver behavior, address the limitations and current gaps in our understanding of those interactions, and identify areas for future behavioral research.

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Objective: : Environmental deprivation, a type of childhood maltreatment, has been reported to constrain the cognitive developmental processes such as associative learning and implicit learning, which may lead to functional and morphological changes in the ventral pallidum (VP) and pessimism, a well-known cognitive feature of major depression. We examined whether neonatal isolation (NI) could influence the incidence of learned helplessness (LH) in a rat model mimicking the pessimism, and the number of vesicular glutamate transporter 2 (VGLUT2)-expressing VP cells and Penk-expressing VP cells. Methods: : The number of escape failures from foot-shocks in the LH test was measured to examine stress-induced depression-like behavior in rats. The number of VGLUT2-expressing VP cells and Penk-expressing VP cells was measured by immunohistochemistry. Results: : In NI rats compared with Sham rats, the incidence of LH in adulthood was increased and VGLUT2-expressing VP cells but not Penk-expressing VP cells in adulthood were decreased. VGLUT2-expressing VP cells were decreased only in the LH group of NI rats and significantly correlated with the escape latency in the LH test. Conclusion: : These findings suggest that the aberrant VP neuronal activity due to environmental deprivation early in life leads to pessimistic associative and implicit learning. Modulating VP neuronal activity could be a novel therapeutic and preventive strategy for the patients with this specific pathophysiology.

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Purpose: Learned helplessness (LH) is the psychological state in which an individual experiences multiple failures and setbacks and experiences a sense of loss when facing the current situation. It is a significant burden for lung cancer patients that can impair quality of life and lead to physical, social, and psychological difficulties. Thus, this study aimed to determine the level of LH among patients with lung cancer and identify factors associated with LH. Patients and Methods: From August 2022 to March 2023, 237 patients with lung cancer from Chongqing University Cancer Hospital were selected for this study. A general information questionnaire, the LH scale, the Brief Illness Perception questionnaire, the Strategies Used by People to Promote Health questionnaire, the Medical Coping Modes questionnaire, and the Self-esteem scale were used for the investigation. Multiple linear regression was employed to identify influencing factors for LH in patients with lung cancer. Results: The total LH score of patients with lung cancer was 52.19±11.20. Multiple linear regression analysis showed that illness perception (ß=0.249, P=0.001), self-efficacy (ß=-0.194, P=0.017), and resignation coping mode (ß=0.267, P<0.001) were the main influencing factors of LH (P<0.05), which explained 42.0% of the total variance. Conclusion: The score of LH in patients with lung cancer was at a moderate level in this study. Illness perception, self-efficacy, and resignation coping mode have been found to impact LH among patients with lung cancer. Healthcare professionals should implement effective interventions, such as promoting self-efficacy, encouraging positive coping, and reducing illness perception, to alleviate LH.

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Introduction: To explore the predictive effect of effort-reward imbalance on students' learning engagement and to elucidate the underlying mechanism, 796 students were selected for a survey. Methods: The participants were required to complete four scales: the Effort-reward Imbalance Scale, the Learning Engagement Scale, the Learned Helplessness Questionnaire, and the Perceived Social Support Scale. Results: (1) Students' effort-reward imbalance significantly and negatively predicts their learning engagement; (2) Learned helplessness serves as a mediator in the relationship between students' effort-reward imbalance and learning engagement; (3) Social support plays a moderating role in the association between effort-reward imbalance and learned helplessness. High levels of social support can buffer the impact of an effort-reward imbalance on learned helplessness, and the protective effect of social support is more obvious when the effort-reward imbalance is low. Discussion: The present study revealed how an effort-reward imbalance affects learning engagement among students through the dimensions of learned helplessness and perceived social support. The constructed model not only further clarifies the mechanism underlying the relationship between effort-reward imbalance and learning engagement but also holds significant implications for guiding students' education.

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BACKGROUND: Although findings from both animal and clinical research indicate that the blood-brain barrier (BBB) contributes to the pathogenesis of various psychiatric disorders (including depression), the underlying mechanisms are unknown. We investigated the levels of the tight-junction proteins claudin-5 and aquaporin-4 (AQP-4) in astrocytes of learned helplessness (LH) rats (an animal model of depression) and non-LH rats (a model of resilience). METHODS: We administered inescapable mild electric shock to rats and then identified the LH and non-LH rats by a post-shock test. The expressions of claudin-5 and AQP-4 in several brain regions of the LH and non-LH rats were then evaluated by a western blot analysis. RESULTS: The levels of both claudin-5 and AQP-4 in the CA-1 and CA-3 hippocampal areas of the LH group were significantly lower than those of the control group, whereas those of the non-LH rats were not significantly different from those of the control and LH rats. CONCLUSIONS: These results suggest that LH rats but not non-LH rats experienced down-regulations of claudin-5 and AQP-4 in the CA-1 and CA-3. It is possible that a region-specific modulation of claudin-5 and AQP-4 is involved in the mechanisms of vulnerability but not resilience in depression.

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@#The phenomenon of depression has been a major concern recently, both nationally and globally. Depression is a disorder that involves changes in thoughts, emotions, feelings, and behaviours that make a person’s daily life difficult, and if left untreated, can adversely affect individuals and society. Depression among adolescents certainly deserves attention as this group is considered as an asset that will drive the country in the future. In terms of methodology, PubMed, Science direct, and Google Scholar search engines were used which focused on psychological theories related to adolescent depression. In addition, the search also focuses on Cognitive Approach or more precisely, about Cognitive Behaviour Theory (CBT). Over the past few decades, Cognitive Behaviour Theory (CBT) has been proven to be the most dominant theory in psychological studies including depression in adolescents. As a result, it is found that, under the CBT group, Learned Helplessness Theory and Beck’s Cognitive Behaviour Theory were the two most widely discussed on the concept of depression to date. Therefore, this article will discuss the background and the concept of these theories in describing depression. However, Beck’s CBT has been selected as the most appropriate theory in discussing depression in adolescents because this theory is able to explain this issue further and in detail, in addition to having an extensive amount of research showing the effectiveness of Beck’s CBT in helping adolescents with depression compared to Learned Helplessness Theory.

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Beta-hydroxybutyrate (BHB), an endogenous NLRP3 inflammasome inhibitor, has been shown to be associated with the pathophysiology of depression in rodents. However its active mechanism has not been revealed. Herein, we probed both the pathways and brain regions involved in BHB's antidepressant-like effects in a learned helplessness (LH) rat model of depression. A single bilateral infusion of BHB into the cerebral ventricles induced the antidepressant-like effects on the LH rats. The antidepressant-like effects of BHB were blocked by the TrkB inhibitor ANA-12 and the AMPA receptor antagonist NBQX, indicating that the antidepressant-like effects of BHB involve BDNF-TrkB signaling and AMPA receptor activation. Further, infusions of BHB into the prelimbic and infralimbic portions of medial prefrontal cortex, the dentate gyrus of hippocampus, and the basolateral region of amygdala produced the antidepressant-like effects on LH rats. However, infusions of BHB into the central region of amygdala, the CA3 region of hippocampus, and the shell and core regions of nucleus accumbens had no effect. Finally, a single bilateral infusion of BHB into the cerebral ventricles of naive rats strengthened learning ability on repeated active avoidance test where saline-infused animals failed to increase avoidance responses.

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BACKGROUND: BTRX-246040, a nociceptin/orphanin FQ peptide receptor antagonist, is being developed for the treatment of depressive patients. However, the underlying mechanism of this potential antidepressant is still largely unclear. Here, we studied the antidepressant-related actions of BTRX-246040 in the ventrolateral periaqueductal gray (vlPAG). METHODS: The tail suspension test, forced swim test, female urine sniffing test, sucrose preference test, and learned helplessness (LH) combined with pharmacological approaches were employed to examine the antidepressant-like effects and drug effects on LH-induced depressive-like behavior in C57BL/6J mice. Electrophysiological recordings in vlPAG neurons were used to study synaptic activity. RESULTS: Intraperitoneal administration of BTRX-246040 produced antidepressant-like behavioral effects in a dose-dependent manner. Systemic BTRX-246040 (10 mg/kg) resulted in an increased frequency and amplitude of miniature excitatory postsynaptic currents (EPSCs) in the vlPAG. Moreover, slice perfusion of BTRX-246040 directly elevated the frequency and amplitude of miniature EPSCs and enhanced the evoked EPSCs in the vlPAG, which were blocked by pretreatment with the nociceptin/orphanin FQ peptide receptor agonist Ro 64-6198. In addition, intra-vlPAG application of BTRX-246040 produced antidepressant-like behavioral effects in a dose-dependent manner. Moreover, intra-vlPAG pretreatment with 6-cyano-7-nitroquinoxaline-2,3-dione reversed both systemic and local BTRX-246040-mediated antidepressant-like behavioral effects. Furthermore, both systemic and local BTRX-246040 decreased the LH phenotype and reduced LH-induced depressive-like behavior. CONCLUSIONS: The results suggested that BTRX-246040 may act through the vlPAG to exert antidepressant-relevant actions. The present study provides new insight into a vlPAG-dependent mechanism underlying the antidepressant-like actions of BTRX-246040.

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Introduction: Pavlovian bias is an innate motivational tendency to approach rewards and remain passive in the face of punishment. The relative reliance on Pavlovian valuation has been found to increase when the perceived control over environmental reinforcers is compromised, leading to behavior resembling learned helplessness (LH). Methods: Sixty healthy young adults underwent a Go-NoGo reinforcement learning task and received anodal high-definition transcranial direct current stimulation (HD-tDCS) over the medial prefrontal/dorsal anterior cingulate cortex in our randomized, double-blind, sham- controlled study. Furthermore, we evaluated changes in cue-locked mid-frontal theta power derived from simultaneous electroencephalography (EEG). We hypothesized that active stimulation would reduce Pavlovian bias during manipulation of outcome controllability, and the effect would be accompanied by stronger mid-frontal theta activity, representing arbitration between choice strategies in favor of instrumental relative to Pavlovian valuation. Results: We found a progressive decrease in Pavlovian bias during and after loss of control over feedback. Active HD-tDCS counteracted this effect while not affecting the mid-frontal theta signal. Discussion: The results were at odds with our hypotheses but also with previous findings reporting LH-like patterns during and after loss of control without brain stimulation. The discrepancy may be related to different protocols for the controllability manipulation. We argue that the subjective evaluation of task controllability is crucial in mediating the balance between Pavlovian and instrumental valuation during reinforcement learning and that the medial prefrontal/dorsal anterior cingulate cortex is a key region in this respect. These findings have implications for understanding the behavioral and neural underpinnings of LH in humans.

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"Learned helplessness" refers to debilitating outcomes, such as passivity and increased fear, that follow an uncontrollable adverse event, but do not when that event is controllable. The original explanation argued that when events are uncontrollable the animal learns that outcomes are independent of its behavior, and that this is the active ingredient in producing the effects. Controllable adverse events, in contrast, fail to produce these outcomes because they lack the active uncontrollability element. Recent work on the neural basis of helplessness, however, takes the opposite view. Prolonged exposure to aversive stimulation per se produces the debilitation by potent activation of serotonergic neurons in the brainstem dorsal raphe nucleus. Debilitation is prevented with an instrumental controlling response, which activates prefrontal circuitry detecting control and subsequently blunting the dorsal raphe nucleus response. Furthermore, learning control alters the prefrontal response to future adverse events, thereby preventing debilitation and producing long-term resiliency. The general implications of these neuroscience findings may apply to psychological therapy and prevention, in particular by suggesting the importance of cognitions and control, rather than habits of control.

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BACKGROUND: Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy-based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring. OBJECTIVE: In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm. METHODS: We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged. RESULTS: We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users. CONCLUSIONS: These games may help improve the effectiveness and engagement levels of computerized interventions for depression.

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BACKGROUND: Increasing evidence suggests the role of gut microbiota in resilience versus vulnerability after stress. However, the role of gut microbiota and microbiome-derived metabolites in resilience versus susceptibility in rodents exposed to stress remains unclear. METHODS: Adult male rats were exposed to inescapable electric stress under the learned helplessness (LH) paradigm. The composition of gut microbiota and metabolites in the brain and blood from control (no stress) rats, LH resilient rats, and LH susceptible rats were examined. RESULTS: At the genus level, the relative abundances of Asaccharobacter, Eisenbergiella, and Klebsiella in LH susceptible rats were significantly higher than that of LH resilient rats. At the species level, the relative abundances of several microbiome were significantly altered between LH susceptible rats and LH resilient rats. Furthermore, there were several metabolites in the brain and blood altered between LH susceptible rats and LH resilient rats. A network analysis showed correlations between the abundance of several microbiome and metabolites in the brain (or blood). LIMITATIONS: Detailed roles of microbiome and metabolites are unclear. CONCLUSIONS: These findings suggest that abnormal compositions of the gut microbiota and metabolites might contribute to susceptibility versus resilience in rats subjected to inescapable electric foot shock.

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BACKGROUND: Learned helplessness may be the underlying cause of poor mental health status among college students during the COVID-19 lockdown, and self-compassion as a positive psychological quality may influence the link between learned helplessness and mental health. METHODS: A sample of 869 Chinese college students (443 male and 426 female), with a mean age of 20.03 (SD = 1.68), completed the Learned Helplessness Scale (LHS), Self-Compassion Scale (SCS), and DASS-21. The moderating effect of self-compassion on the relationship between learned helplessness and anxiety, depression, and stress were calculated. RESULTS: The interaction term between learned helplessness and self-compassion has a significant coefficient on anxiety, depression, and stress, pointing out self-compassion as a moderator of the association between learned helplessness and adverse mental health. LIMITATIONS: In the absence of longitudinal data or experimental manipulations, cross-sectional methods cannot verify causal conclusions among the study variables. The analysing results are based only on self-reported data. DISCUSSION: The present study contributes to a deeper understanding of how learned helplessness and self-compassion during COVID-19 contribute to adverse mental health. The findings suggest that adverse mental health during lockdown is significantly associated with learned helplessness and that self-compassion can buffer this effect, contributing to future psychotherapy and clinical research. Future studies should examine the relationship through a longitudinal design to sort out whether self-compassion is a protective factor against learned helplessness or a moderator of the effects of learned helplessness on mental health.

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Background: Learned helplessness (LH) is a common psychological phenomenon among chronic disease patients. However, LH remains underrecognized in the context of maintenance haemodialysis (MHD) patients. This qualitative study is the first study of this topic to be conducted in a Chinese cultural context, and its purpose is to explore the LH experiences of MHD patients and to highlight their interpretations of LH. Methods: We employed a qualitative research design. A purposive sampling method was used to recruit participants. The sample size was determined by data saturation. Data were obtained from MHD patients in a blood purification centre located in Hunan Province, China. Data were collected from June to September 2022. The researchers conducted in-depth, semistructured interviews with participants after obtaining informed consent. Texts were transcribed verbatim from the audio recordings of these interviews. Data processing and analysis were based on Giorgi's phenomenological approach. Results: Twenty-two respondents completed the interviews (aged 29-75 years, including ten females and twelve males). Four themes emerged from the interviews: (1) triggers of helplessness (hope is gone; witnessing renal friends' helplessness; out of control; nothing works); (2) being tied down (limitation; perceived loss; social isolation; giving in); (3) I am just a loser (self-image disorder; low self-concept; negative attitudes; guilt; abandonment); (4) alive day is the day (fatalism; my duty; downwards comparison). Conclusion: The study reveals that multiple stressors drive MHD patients' LH. These salient phenomena demonstrate the importance of recognizing MHD patients' LH. We suggest that support services should be developed alongside a framework that addresses MHD patients' LH from the beginning of treatment.