|Year : 2020 | Volume
| Issue : 1 | Page : 28-32
Depression and anxiety in patients with chronic liver disease and their relationship with quality of life
Arka Banerjee1, Amlan Kusum Jana2, Samir Kumar Praharaj3, Debabrata Mukherjee4, Suddhendu Chakraborty5
1 Department of Gastroenterology, Institute of Post Graduate Medical Education and Research, School of Digestive and Liver Diseases, Kolkata, India
2 Department of Psychiatry, KPC Medical College and Hospital, Kolkata, India
3 Department of Psychiatry, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Department of General Medicine, Calcutta National Medical College and Hospital, Kolkata, India
5 Department of Psychiatry, Bongaon J R Dhar Subdivisional Hospital, Bangaon, West Bengal, India
|Date of Submission||27-Jul-2019|
|Date of Decision||25-Sep-2019|
|Date of Acceptance||01-Oct-2019|
|Date of Web Publication||30-May-2020|
Dr. Amlan Kusum Jana
75/5E, S. N. Roy Road, Kolkata - 700 038, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Chronic liver disease (CLD) is a long-standing and debilitating condition where comorbid psychiatric conditions add on to the morbidity. The current study aims to observe how comorbid clinical anxiety and depression affects the overall picture. Aims: To observe how depression and anxiety influences the overall outcome of CLD patients. Settings and Design: It was a hospital-based cross-sectional study. Materials and Methods: Seventy-five consecutive CLD patients were assessed for depression and anxiety through the Hospital Anxiety and Depression Scale and for quality of life (QOL) through the abbreviated version of WHOQOL scale. Statistical Analysis: The data were analyzed using the Statistical Package for the Social Sciences 16.0 for Windows. Patients were grouped as with or without anxiety and depression. The groups were compared using Mann–Whitney U-test and Fisher's exact test for continuous and categorical variables, respectively. Results: Both anxious (P = 0.005) and depressed (P < 0.001) patients were significantly older than their nonanxious and nondepressed counterparts. Significantly higher proportion of patients with depression were married (P = 0.002) and employed (P = 0.014) than those without. Both the patients with anxiety and those with depression had significantly poorer QOL in all measurable domains than those without anxiety or depression. Conclusion: When clinically significant anxiety and depression are present as comorbidities in CLD patients, they significantly worsen the QOL in them.
Keywords: Anxiety, chronic liver disease, depression, quality of life
|How to cite this article:|
Banerjee A, Jana AK, Praharaj SK, Mukherjee D, Chakraborty S. Depression and anxiety in patients with chronic liver disease and their relationship with quality of life. Ann Indian Psychiatry 2020;4:28-32
|How to cite this URL:|
Banerjee A, Jana AK, Praharaj SK, Mukherjee D, Chakraborty S. Depression and anxiety in patients with chronic liver disease and their relationship with quality of life. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Jul 25];4:28-32. Available from: https://www.anip.co.in/text.asp?2020/4/1/28/285501
| Introduction|| |
Chronic illnesses such as polyarthritis, peptic ulcer, and inflammation have long been known to cause psychological morbidities such as depression. Chronic liver disease (CLD) is a condition with significant morbidity and mortality. In its due course, this debilitating condition takes a huge toll on one's physical as well as psychological well-being. Consequently, quality of life (QOL) in these patients is often impaired. Anxiety and depression have been implicated as the direct causes behind this drop in QOL in previous studies., Symptoms such as fatigue, pruritus, and abdominal discomfort from ascites have been shown to impair QOL in chronic hepatitis, cholestasis, and cirrhosis. A broad biopsychological perspective has been provided by previous researchers  to provide a better understanding of the etiopathogenesis of CLD. At this juncture, it seems that depression and anxieties are so important in determining the overall morbidity of CLD that their assessment should be an integral part of overall evaluation of these patients. Further, there have been many instances where the disease entity appears contrary to its common association to alcohol consumption. The whole clinical identity of nonalcoholic fatty liver disease (NAFLD) and its more severe variant nonalcoholic steatohepatitis (NASH) and their association with psychiatric morbidities such as anxiety depression and mood disorders have been studied. A few studies also considered NAFLD to be a part of metabolic syndrome, an entity long known to be associated with psychiatric comorbidities., Lifestyle modification and alleviation from depressive illness shows obesity to be a vulnerable factor as well. Studies showed obesity to be associated with NAFLD in about 74% of cases. Some studies found cognitive dysfunction (e.g., memory impairment and attention deficit) to be significantly more frequent in the obese NAFLD population compared to the general population. These cognitive dysfunctions are well known to be associated with core psychiatric disorders such as depression. Studies point out that NASH alone can be a prominent risk factor for major depressive disorder. However, along with CLD, possible comorbidities need to be ruled out such as hypertension, smoking, and preexisting lung disease. Incidence of suicidal attempts with CLD is also not uncommon and has been studied. Like depressive illness, anxiety also seems to coexist with CLD in as high as 45% of cases. Even in the aspect of treatment, it has been suggested that, in conditions such as liver cirrhosis, control of psychological illness is an important factor for successful treatment of gastrointestinal symptoms. CLD, like other chronic disease entities is known to impair activities of daily living which in turn can lead to low mood. There are studies that explore dietary consumption and substance abuse with the incidence of CLD. Although alcohol is widely known to precipitate alcoholic liver disease, moderate wine consumption has been found to reduce the histopathological severity of NAFLD. Other than anxiety and depression, psychosis is also found to be strongly associated with CLD and autoimmune liver disease. The cause is both natural and iatrogenic. Further studies have shown that the etiopathogenesis of CLD actually alters cerebral blood flow that results in cognitive dysfunction. Alteration of serum proteins and their resultant effect leading to the appearance of psychotic symptoms is another proposed factor. The presence of anti-P ribosomal antibodies is another studied factor for the appearance of psychosis in CLD. The coexistence of psychiatric morbidity with CLD is a strong challenge to the clinicians as a few psychotropic drugs owing to their pathways of metabolism are known to cause hepatotoxicity  and need to be avoided. Hence, exclusion of psychiatric morbidity is essential and so is the correlation to plan the treatment plan and achieve a good QOL for the patient. With this background, the current study was conducted to observe the relations of anxiety and depression with various parameters of CLD patients including their QOL. Because there has not been any study published from India on these patients looking for the role of anxiety and depression, the current study is expected to provide a new perspective on the effect of psychiatric comorbidity on the overall picture of CLD.
| Materials and Methods|| |
The study was conducted in the department of medicine in a tertiary hospital in India. Ethical clearance was obtained from the institutional ethics committee before conducting the study. Assessments of cases were made on a cross-sectional basis. The sample consisted of 75 consecutive CLD patients of both sexes aged between 20 and 50 years, admitted in the hospital, who were diagnosed by history, clinical examination, and relevant investigations. Written informed consent was obtained from all the participants. Patients with diabetes mellitus or those on any drug which could cause impaired glucose tolerance were excluded.
Sociodemographic and clinical data were gathered using a pro forma specially designed for the study covering all the relevant parameters described in literature. They included age, sex, years of education, occupation, residence, family type (nuclear/extended), medical and psychiatric history, current and past intake of psychoactive substance, history of jaundice, and gastrointestinal (GI) bleeding among others. Among the parameters noted in relation to liver function or pathology were prothrombin time, international normalized ratio, liver enzyme levels, bilirubin, alkaline phosphatase, HBsAg, anti-HCV, antinuclear antibody, ceruloplasmin in (if Wilson's disease was suspected) ascitic fluid study findings, ultrasonography of hepatobiliary system, and upper GI endoscopy finding. Child–Pugh score and class were calculated to classify patients according to severity.
Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). This relatively old scale, with validity demonstrated even in recurrent anxiety, consists of 14 items, seven each to assess depression and anxiety. Each item has a maximum score of 3. Scores of 11 or more on either depression or anxiety denote significant psychological morbidity.
QOL was assessed through the abbreviated version of the WHO Quality of life (WHOQOL) scale. It is a 26-item questionnaire which is scored on a Likert scale from 1 to 5 and generates scores on the following broad domains: physical health, psychological health, social relationships, and environment.
All the assessments were done by a qualified psychiatrist (AB). A thorough mental status examination was done by him in all the patients, and any patient with overt psychosis with a chance of making incorrect assessments in self-rated questionnaires was also excluded. All the scales were administered on the patients during their stay in hospital as inpatient.
The collected data were statistically analyzed using Statistical Package for the Social Sciences 16.0 for Windows (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Based on the HADS subscale score (11 or <11), patients were grouped as with or without anxiety and depression. Data normality was examined using Shapiro–Wilk test statistic and histogram analysis. The groups were compared using Mann–Whitney U-test and Fisher's exact test for continuous and categorical variables, respectively. The effect sizes were reported as r (calculated from Z value of Mann–Whitney U-test) and Cramer's V. The level of significance was set at P < 0.05 (two-tailed).
| Results|| |
Of 75 patients, 28 (37.33%) had clinically significant anxiety and 53 (70.67%) had depression. Comparison of clinical parameters between groups (divided on the basis of whether or not having anxiety or depression) showed that the patients with anxiety (P = 0.005) and depression (P < 0.001) were significantly older than their nonanxious and nondepressed counterparts. Both the patients with anxiety and those with depression were having longer duration of illness compared to those without, but the difference reached statistical significance (P = 0.026) for patients with depression. Postprandial plasma glucose level was significantly higher (P = 0.01) and serum sodium level significantly lower (P = 0.049) in patients with depression than those without [Table 1].
In sociodemographic profile, the groups were comparable for most of the measures. Differences were noticed in marital and employment status. Significantly higher proportion of patients with depression were married (P = 0.002) and employed (P = 0.014) as compared to their nondepressed counterparts [Table 2].
When the QOL scores were compared, for all the subscales of WHOQOL-BREF, both the patients with anxiety and those with depression had significantly lower scores than those without anxiety or depression [Table 3].
| Discussion|| |
The first finding of the current study was a high prevalence of anxiety (37.33%) and depression (70.67%) in the study population. This is higher than those reported in previous studies, e.g., 19.6% for anxiety and 24.5% for depression  and 10.7% for both anxiety and depression. Because the study was conducted in a tertiary referral hospital, the patients seeking service would mostly having more severe symptoms and longer duration of illness compared to other patients living in community. Many of the patients included in the study might have had clinical depression or anxiety for a long time, but had remained undetected. This is commonly seen in these parts of the world as patients are reluctant to seek professional consultation for psychiatric illness due to the stigma attached with the conditions. An interesting finding in the study was higher incidence of depression in married people compared to their unmarried counterparts. This goes against common findings in general prevalence of depression.
The analysis was done in a different way from the previous studies. Rather than comparing anxiety and depression scores between patients and healthy controls, in the current study, comparisons were done between CLD patients with and without clinical depression and anxiety. Chronic physical illnesses are known to impair QOL in individuals. In patients with cirrhosis, QOL has been shown to be associated with severity of illness and the restrictions in general lifestyle. The current study aimed to observe whether the presence of clinical depression or anxiety significantly worsens it even further. It was seen that both anxiety and depression when present in a clinically significant severity produced statistically significant impairment in all the domains of QOL. This finding lends support to the argument that focusing treatment on psychiatric conditions is probably necessary for holistic improvement of CLD patients.
Significantly longer duration of illness in depressed patients seems to be self-evident, but the surprising finding was their marital and employment status. Contrary to the traditional wisdom, being married and remaining employed did not protect them from depression. Probably, the burden of long-standing physical illness had overridden the beneficial effects of employment and marriage in them.
Many of the parameters associated with the severity of CLD, especially conditions such as cirrhosis, e.g., albumin and bilirubin, failed to make any impact on anxiety or depression. A somewhat similar finding was reported in an earlier study  where serum bilirubin, albumin, and prothrombin time did not correlate with health-related QOL score.
A cross-sectional design and a moderate sample size were two important limitations of the study. Besides, the sample was drawn from a tertiary referral hospital and therefore might not have represented the general population. A further analysis of the subgroups of sample based on etiological diagnosis of CLD, showing their relations with anxiety, depression, and QOL, could have produced interesting findings. A more detailed correlation could have been established between the histopathological entity of CLD and the psychiatric morbidity, which encourages future studies in this area. The incidences of deliberate self harm or suicide were not included in this study and invites scope for further research into this area. Association of psychosis with autoimmune and CLD is not shown in this study. Another limitation of this study is use of a single-scale HADS, which is a screener and this enables an assessment period of only a week before the evaluation, which is, at times, not enough to substantially state the anxiety and depression to be not merely due to an event of chronic medical illness. However, we aim to repeat similar studies in future with a scope for repeat evaluation after 2 weeks and 6 weeks with a larger sample, which may substantiate our clinical finding further. Another way by which this shortcoming could have been overcome was to include a brief psychiatric and psychological interviewing beyond that required for initial rapport establishment, which could have further strengthened our findings. However, we are but sure that future scopes will enable us to discuss entities of chronic medical illness such as CLD further along with its psychiatric comorbidities.
| Conclusion|| |
Syndromal depression is known to worsen the clinical course and outcome of myocardial infarction. Its effect on liver ailments is not much known. In the current study, it has been shown that both syndromal anxiety and depression can have adverse impact on the overall outcome of chronic liver disease. The current study shows worsening in the quality of life but not in other biological parameters. Further studies in this field should come up with more interesting findings.
This study was approved by Institutional Ethics Committee with reference number CNMC/ETH1C/100/P obtained on 7th January 2010.
Declaration of Patient Consent
Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Patten SB, Williams JV, Lavorato DH, Modgill G, Jetté N, Eliasziw M. Major depression as a risk factor for chronic disease incidence: Longitudinal analyses in a general population cohort. Gen Hosp Psychiatry 2008;30:407-13.
Wong GL, Law FM, Wong VW, Hui AY, Chan FK, Sung JJ, et al.
Health-related quality of life in Chinese patients with primary biliary cirrhosis. J Gastroenterol Hepatol 2008;23:592-8.
Gutteling JJ, Duivenvoorden HJ, Busschbach JJ, de Man RA, Darlington AS. Psychological determinants of health-related quality of life in patients with chronic liver disease. Psychosomatics 2010;51:157-65.
Häuser W, Holtmann G, Grandt D. Determinants of health-related quality of life in patients with chronic liver diseases. Clin Gastroenterol Hepatol 2004;2:157-63.
Haag S, Senf W, Häuser W, Tagay S, Grandt D, Heuft G, et al.
Impairment of health-related quality of life in functional dyspepsia and chronic liver disease: The influence of depression and anxiety. Aliment Pharmacol Ther 2008;27:561-71.
Kim CH, Younossi ZM. Nonalcoholic fatty liver disease: A manifestation of the metabolic syndrome. Cleve Clin J Med 2008;75:721-8.
Marchesini G, Brizi M, Bianchi G, Tomassetti S, Bugianesi E, Lenzi M, et al.
Nonalcoholic fatty liver disease: A feature of the metabolic syndrome. Diabetes 2001;50:1844-50.
Stewart KE, Haller DL, Sargeant C, Levenson JL, Puri P, Sanyal AJ. Readiness for behaviour change in non-alcoholic fatty liver disease: Implications for multidisciplinary care models. Liver Int 2015;35:936-43.
Sass DA, Chang P, Chopra KB. Nonalcoholic fatty liver disease: A clinical review. Dig Dis Sci 2005;50:171-80.
Elwing JE, Lustman PJ, Wang HL, Clouse RE. Depression, anxiety, and nonalcoholic steatohepatitis. Psychosom Med 2006;68:563-9.
Weinstein AA, Kallman Price J, Stepanova M, Poms LW, Fang Y, Moon J, et al.
Depression in patients with nonalcoholic fatty liver disease and chronic viral hepatitis B and C. Psychosomatics 2011;52:127-32.
Le Strat Y, Le Foll B, Dubertret C. Major depression and suicide attempts in patients with liver disease in the United States. Liver Int 2015;35:1910-6.
Youssef NA, Abdelmalek MF, Binks M, Guy CD, Omenetti A, Smith AD, et al.
Associations of depression, anxiety and antidepressants with histological severity of nonalcoholic fatty liver disease. Liver Int 2013;33:1062-70.
Fritz E, Hammer J. Gastrointestinal symptoms in patients with liver cirrhosis are linked to impaired quality of life and psychological distress. Eur J Gastroenterol Hepatol 2009;21:370-5.
Elliott C, Frith J, Day CP, Jones DE, Newton JL. Functional impairment in alcoholic liver disease and non-alcoholic fatty liver disease is significant and persists over 3 years of follow-up. Dig Dis Sci 2013;58:2383-91.
Dunn W, Xu R, Schwimmer JB. Modest wine drinking and decreased prevalence of suspected nonalcoholic fatty liver disease. Hepatology 2008;47:1947-54.
O'Carroll RE, Hayes PC, Ebmeier KP, Dougall N, Murray C, Best JJ, et al.
Regional cerebral blood flow and cognitive function in patients with chronic liver disease. Lancet 1991;337:1250-3.
Fessel WJ. Disturbed serum proteins in chronic psychosis. Serological, medical and psychiatric correlations. Arch Gen Psychiatry 1961;4:154-9.
Shoenfeld Y. To smell autoimmunity: Anti-P-ribosomal autoantibodies, depression, and the olfactory system. J Autoimmun 2007;28:165-9.
Selim K, Kaplowitz N. Hepatotoxicity of psychotropic drugs. Hepatology 1999;29:1347-51.
Manns MP, Strassburg CP. Autoimmune hepatitis: Clinical challenges. Gastroenterology 2001;120:1502-17.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.
Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale. An updated literature review. J Psychosom Res 2002;52:69-77.
Köllner V, Einsle F, Schade I, Maulhardt T, Gulielmos V, Joraschky P. The influence of anxiety, depression and post traumatic stress disorder on quality of life after thoracic organ transplantation. Z Psychosom Med Psychother 2003;49:262-74.
Development of the world health organization WHOQOL-BREF quality of life assessment. The WHOQOL group. Psychol Med 1998;28:551-8.
DeKlyen M, Brooks-Gunn J, McLanahan S, Knab J. The mental health of married, cohabiting, and non-coresident parents with infants. Am J Public Health 2006;96:1836-41.
Polis S, Fernandez R. Impact of physical and psychological factors on health-related quality of life in adult patients with liver cirrhosis: A systematic review protocol. JBI Database System Rev Implement Rep 2015;13:39-51.
[Table 1], [Table 2], [Table 3]