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These results in our study agree with a previous larger study with 245 patients comparing the same anxiety/depression dimension of the EQ-5D-3L questionnaire with the HADS subscales (Thayabaranathan et al., 2022)

The mechanisms likely involve immune modulation (microglia in ALS can adopt a neurodegenerative phenotype that might be restrained by microbial signals) and metabolic support (providing nutrients like nicotinamide or SCFAs to neurons and glia) [214, 218]