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One in 5 With Cirrhosis Suffers Anxiety-1 in 12 Also Has Depression
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AASLD, The Liver Meeting, November 12-15, 2021
Mark Mascolini
A 3-clinic study in Canada's Alberta province diagnosed anxiety in 17% of 304 adults with cirrhosis [1]. Certain test-measured clinical outcomes were significantly worse in people with than without anxiety. The 8% who also had depression had significantly worse clinical outcomes, including frailty and lower health-related quality of life (HrQoL), than people diagnosed only with anxiety or only with depression.
Much mood disorder research in people with cirrhosis focuses on depression, noted researchers from the University of Alberta and colleagues from other centers. In contrast, anxiety remains under-diagnosed and undertreated in people with cirrhosis, and scant research assesses the impact of anxiety on clinical outcomes in this population. For these reasons, and because of spiking anxiety with the COVID pandemic, the researchers conducted this study.
The Alberta team used the Hospital Anxiety and Depression Scale (HADS) to screen for anxiety, and they diagnosed anxiety at the same visit with the Mini International Neuropsychiatric Interview (MINI). To determine HrQoL, they used the chronic liver disease questionnaire (CLDQ) and the EQ-VAS score, a vertical visual analog scale with which a person makes a global health assessment on a scale from 100 (best) to 0 (worst).
From people 18 to 80 years old, the investigators recruited 405 individuals diagnosed with cirrhosis from 3 tertiary care clinics in Alberta, which lies in western Canada. After excluding people taking antidepressants, disoriented people, or those with missing MINI or HADS data, the researchers ended up with 304 study participants. Follow-up continued for 6 months to track deaths or unplanned hospital admissions.
Of these 304 people, 52 (17%)-almost 1 in 5-had MINI-diagnosed anxiety. Twenty-five people-about 1 in 12 (8%)-had depression and anxiety. Compared with people free from anxiety, those with anxiety had lower (worse) HrQoL determined by the CLDQ (3.61 vs 4.96, P < 0.001) and EQ-VAS (51.8 vs 65.2, P < 0.001), while they had higher (worse) frailty by the Clinical Frailty Scale (3.65 vs 3.15, P = 0.004). A higher proportion of people with than without anxiety got admitted to the hospital or died within 6 months, but that difference fell short of statistical significance (42% vs 31%, P = 0.14). The researchers did not report demographic or socioeconomic data for the whole group or in people with versus without anxiety.
Compared with people with either anxiety or depression, those with both anxiety and depression had worse HrQoL by the CLDQ (3.01 vs 3.95) and EQ-VAS (48.6 vs 54.7), but frailty did not differ between these two groups. A nonsignificantly higher proportion of people with anxiety and depression versus those with either anxiety or depression got admitted to the hospital or died within 6 months, but that difference lacked statistical significance (46% vs 36.4%, P = 0.26).
The authors used multivariable backwards stepwise logistic regression to identify four independent predictors of anxiety in this population, current smoking and three components of the HADS: "I feel restless as I have to be on the move," "Worrying thoughts go through my mind," and "I get sudden feelings of panic." They combined these 4 items in a nomogram-a graphical calculating device that predicts the probability of anxiety on a scale from 0.05 to 0.95. The investigators stressed that this cirrhosis-specific nomogram requires validation.
When a person with cirrhosis screens positive for anxiety, the researchers advised colleagues to confirm the diagnosis with a diagnostic tool and then to treat that person appropriately. They referred colleagues interested in learning more about anxiety and cirrhosis to the Website https://cirrhosiscare.ca/symptom-management-provider/anxiety/). This useful site features discussions of assessing people for anxiety, considering potential causes, and approaches to mild, moderate, and severe anxiety.
Because their study tied anxiety of lower HrQoL and higher frailty levels, the researchers argued that "diagnosing and treating anxiety is clinically relevant and may improve HrQoL."
Reference
1. Patel K, Dang TN, Farhat K, et al. Anxiety in cirrhosis: a prospective study on prevalence and development of a practical screening nomogram. AASLD, The Liver Meeting, November 12-15, 2021. Parallel session 2: Health Services and Public Health.
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