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Cited by 77Liver Disease and TransplantationMental Health Treatment and AccessAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Depression and anxiety are common among patients with cirrhosis

Open access
Hernaez, Ruben, Kramer, Jennifer R., Khan, Aisha, Phillips, Jessica, McCallister, Katharine, Chaffin, Kassie, Hernandez, Adriana Portela, Fullington, Hannah +7 more·2022·Clinical Gastroenterology and Hepatology
DOI 10.1016/j.cgh.2020.08.045PMC PMC8210475
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Abstract

BACKGROUND & AIMS: Depression and anxiety can have negative effects on patients and are important to treat. There have been few studies of their prevalence among patients with cirrhosis. We aimed to characterize the prevalence and risk factors for depression and anxiety in a large multi-center cohort of patients with cirrhosis. METHODS: We conducted a telephone-based survey of patients with cirrhosis at 3 health systems in the United States (a tertiary-care referral center, a safety net system, and a Veterans hospital) from April through December 2018. Of 2871 patients approached, 1021 (35.6%) completed the survey. Depression and anxiety were assessed using the PHQ-9 (range 0–25) and STAI (range 20–80) instruments, with clinically significant values defined as PHQ-9 ≥15 and STAI ≥40. We performed multivariate logistic regression analysis to identify factors associated with significant depression and anxiety. RESULTS: The median PHQ-9 score was 7 (25th percentile–75th percentile, 3–12) and the median STAI score was 33 (25th percentile–75th percentile, 23–47); 15.6% of patients had moderately severe to severe depression and 42.6% of patients had high anxiety. In multivariable analyses, self-reported poor health (odds ratio [OR], 4.08; 95% CI, 1.79–9.28), being widowed (OR, 2.08; 95% CI, 1.07–4.05), fear of hepatocellular carcinoma (OR, 1.89; 95% CI, 1.04–3.42), higher household income (OR, 0.30; 95% CI, 0.10–0.95), and Hispanic ethnicity (OR, 0.57; 95% CI, 0.33–0.97) were associated with moderately severe to severe depression. Male sex (OR, 0.71; 95% CI, 0.51–0.98), self-reported poor health (OR, 2.73; 95% CI, 1.73–4.32), and fear of hepatocellular carcinoma (OR, 2.24; 95% CI, 1.33–3.78) were associated with high anxiety. CONCLUSIONS: Nearly 1 in 6 patients with cirrhosis have moderately severe to severe depression and nearly half have moderate–severe anxiety. Patients with cirrhosis should be evaluated for both of these disorders.

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Crossref · 10.1016/j.cgh.2020.08.045

Cites

35 of 35 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 21 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    15.6% of patients with cirrhosis in the cohort had moderately severe to severe depression (PHQ-9 ≥15).

    “15.6% of patients had moderately severe to severe depression”
    • Also stated in: § Prevalence of Depression and Anxiety · plain
      “moderately severe (PHQ-9 score 15–19) and severe (PHQ-9 score ≥20) depression present in 11.3% and 4.3% of the population, respectively”
    • Also stated in: § Discussion · plain
      “over 15% having depression”
    Quote in the paperSubstantial claim
  • Findingown data

    Fear of hepatocellular carcinoma was associated with high anxiety (OR 2.24; 95% CI 1.33-3.78).

    “Male sex (OR, 0.71; 95% CI, 0.51–0.98), self-reported poor health (OR, 2.73; 95% CI, 1.73–4.32), and fear of hepatocellular carcinoma (OR, 2.24; 95% CI, 1.33–3.78) were associated with high anxiety.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Higher household income was associated with moderately severe to severe depression (OR 0.30; 95% CI 0.10-0.95).

    “In multivariable analyses, self-reported poor health (odds ratio [OR], 4.08; 95% CI, 1.79–9.28), being widowed (OR, 2.08; 95% CI, 1.07–4.05), fear of hepatocellular carcinoma (OR, 1.89; 95% CI, 1.04–3.42), higher household income (OR, 0.30; 95% CI, 0.10–0.95), and Hispanic ethnicity (OR, 0.57; 95% CI, 0.33–0.97) were associated with moderately severe to severe depression.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Male sex was associated with high anxiety (OR 0.71; 95% CI 0.51-0.98).

    “Male sex (OR, 0.71; 95% CI, 0.51–0.98), self-reported poor health (OR, 2.73; 95% CI, 1.73–4.32), and fear of hepatocellular carcinoma (OR, 2.24; 95% CI, 1.33–3.78) were associated with high anxiety.”
    Quote in the paperNot a substantial claim
  • Findingown data

    42.6% of patients with cirrhosis in the cohort had moderate-severe anxiety (STAI ≥40).

    “42.6% of patients had high anxiety”
    • Also stated in: § Prevalence of Depression and Anxiety · plain
      “moderate–severe anxiety being present in 42.6% of the cohort”
    • Also stated in: § Discussion · plain
      “over 40% having anxiety”
    Quote in the paperSubstantial claim
  • May combine two claims. 19
  • Classified as probably not a substantial claim. 15

  • May combine two claims.

    Findingown data

    Age, liver disease etiology, and severity of liver dysfunction were not risk factors for either depression or anxiety in multivariable analyses.

    “Age, liver disease etiology, and severity of liver dysfunction were not risk factors for either depression or anxiety in multivariable analyses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Fear of having and dying from HCC most of the time was reported in 16.2% and 14.3% of the cohort, with the highest proportions among Parkland patients.

    “fear of having and dying from HCC most of the time was reported in 16.2% and 14.3% of the cohort, with the highest proportions among Parkland patients for both”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The prevalence of moderately severe to severe depression was 14.1% among Child-Turcotte-Pugh class A patients and 19.9% among patients with Child-Turcotte-Pugh class B or C cirrhosis.

    “The prevalence of moderately severe to severe depression was 14.1% among Child-Turcotte-Pugh class A patients and 19.9% among patients with Child-Turcotte-Pugh class B or C cirrhosis”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Overall, 55.0% of the cohort had neither depression nor anxiety, 29.4% had anxiety alone, 2.5% had depression alone, and 13.1% had both depression and anxiety.

    “Overall, half (55.0%) of the cohort had neither depression nor anxiety, 29.4% had anxiety alone, 2.5% had depression alone, and 13.1% had both depression and anxiety.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Over one-fourth (28.0%) of patients from Parkland reported fear of HCC most of the time, compared with 16.1% at UTSW and 15.7% at MEDVAMC.

    “Over one-fourth (28.0%) of patients from Parkland reported fear of HCC most of the time, compared with 16.1% and 15.7% of those at UTSW and MEDVAMC, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Our results may not be generalizable to all patients and settings, particularly those outside the United States.

    “our results may not be generalizable to all patients and settings, particularly those outside the United States, although we examined patients across 3 major types of US health systems.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The survey was limited by nonresponse bias, although the response rate is similar to those of similar mailed efforts.

    “our survey was limited by nonresponse bias, although our response rate is similar to those of similar mailed efforts.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [36] Younossi, 2013, Knowledge about infection is the only predictor of treatment in patients with chronic hepatitis C, J Viral Hepat source

      Not checked in the free run.

    • cites [37] Singal, 2019, Mailed outreach invitations significantly improve HCC surveillance rates in patients with cirrhosis: a randomized clinical trial, Hepatology source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    All cases with cirrhosis were confirmed with chart-validation by 2 transplant hepatologists and disagreements were resolved by consensus.

    “All cases with cirrhosis were confirmed with chart-validation by 2 transplant hepatologists (R.H., A.G.S.) and disagreements were resolved by consensus.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    The present study only assessed these symptoms at a single time point, so we could not determine if these mental health symptoms would persist or change over time.

    “the present study only assessed these symptoms at a single time point, so we could not determine if these mental health symptoms would persist or change over time.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Models were adjusted for study site and clinically meaningful factors that could act as confounders (eg, age, sex, language).

    “Models were adjusted for study site and clinically meaningful factors that could act as confounders (eg, age, sex, language).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    Survey respondents had similar clinical characteristics compared with survey nonrespondents, although respondents had a higher proportion of women and Hispanics.

    “As previously published,20 survey respondents had similar clinical characteristics compared with survey nonrespondents, although respondents had a higher proportion of women and Hispanics (Supplementary Table 1).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Singal, 2020, Patient-reported barriers are associated with HCC surveillance receipt in a multi-center cohort of patients with cirrhosis, Clin Gastroenterol Hepatol

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    PHQ-9 is accurate for grading depression severity and sensitive to changes over time, including in patients with cirrhosis.

    “which is accurate for grading depression severity and sensitive to changes over time, including in patients with cirrhosis.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [21] Kroenke, 2001, The PHQ-9: validity of a brief depression severity measure, J Gen Intern Med source

      Not checked in the free run.

    • cites [22] Reyes-Gibby, 2012, Depressive symptoms and health-related quality of life in breast cancer survivors, J Womens Health (Larchmt) source

      Not checked in the free run.

    • cites [23] Lee, 2013, Association of chronic liver disease with depression: a population-based study, Psychosomatics source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Depression and anxiety may contribute to behaviors leading to chronic liver disease rather than cirrhosis causing depression and anxiety.

    “this finding suggests that depression and anxiety may contribute to behaviors leading to chronic liver disease (eg, substance abuse, unhealthy eating habits, and lack of physical exercise) rather than cirrhosis causing depression and anxiety”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Moderately severe to severe depression and anxiety were both common among patients with cirrhosis.

    “moderately severe to severe depression and anxiety were both common among patients with cirrhosis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The associations with HCC-related concerns and poor overall health status may not be causal.

    “the associations with HCC-related concerns and poor overall health status may not be causal.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    We excluded patients with Child-Turcotte-Pugh class C cirrhosis, who may have increased depression and anxiety, given the increased risk of liver-related mortality.

    “we excluded those with Child-Turcotte-Pugh class C cirrhosis, who may have increased depression and anxiety, given the increased risk of liver-related mortality.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    HCC is a common cause of death in patients with cirrhosis, and prior studies have suggested patients express fear of developing or dying from HCC.

    “HCC is a common cause of death in patients with cirrhosis, and prior studies have similarly suggested patients express fear of developing or dying from HCC.31,32”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [31] Singal, 2011, Patient involvement in healthcare is associated with higher rates of surveillance for hepatocellular carcinoma, J Clin Gastroenterol source

      Not checked in the free run.

    • cites [32] Farvardin, 2017, Patient-reported barriers are associated with lower hepatocellular carcinoma surveillance rates in patients with cirrhosis, Hepatology source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Ascites and hepatic encephalopathy were ascertained using ICD-9 and ICD-10 codes and medications using a validated algorithm.

    “Ascites and hepatic encephalopathy were ascertained using ICD-9 and ICD-10 codes and medications using a validated algorithm and classified as none, mild or controlled, and severe or uncontrolled.28”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Kaplan, 2015, Development and performance of an algorithm to estimate the Child-Turcotte-Pugh score from a National Electronic Healthcare Database, Clin Gastroenterol Hepatol source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Unmeasured differences, such as social withdrawal, may also lead to differential prevalence estimates in non-respondents.

    “unmeasured differences, such as social withdrawal, may also lead to differential prevalence estimates in non-respondents.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    STAI has been used in breast, colon, and lung cancer screening programs and in patients with cirrhosis.

    “which has been used in breast, colon, and lung cancer screening programs24–26 and in patients with cirrhosis.27”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [24] Laing, 2014, Psychological distress after a positive fecal occult blood test result among members of an integrated healthcare delivery system, Cancer Epidemiol Biomarkers Prev source

      Not checked in the free run.

    • cites [25] Tosteson, 2014, Consequences of false-positive screening mammograms, JAMA Intern Med source

      Not checked in the free run.

    • cites [26] Byrne, 2008, Anxiety, fear of cancer, and perceived risk of cancer following lung cancer screening, Med Decis Mak source

      Not checked in the free run.

    • cites [27] Nardelli, 2013, Depression, anxiety and alexithymia symptoms are major determinants of health related quality of life (HRQoL) in cirrhotic patients, Metab Brain Dis source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    We found similar proportions of depression and anxiety despite most patients in our cohort having compensated cirrhosis.

    “Interestingly, we found similar proportions of depression and anxiety despite most patients in our cohort having compensated cirrhosis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    It is possible that our results may underestimate the prevalence of depression and overestimate anxiety based on associations seen in multivariable analysis.

    “It is possible that our results may underestimate the prevalence of depression and overestimate anxiety based on associations seen in multivariable analysis.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    In this large, diverse cohort of 1021 patients with cirrhosis, moderately severe to severe depression and anxiety were both common.

    “In this large, diverse cohort of 1021 patients with cirrhosis, we found moderately severe to severe depression and anxiety were both common, with over 15% having depression and over 40% having anxiety.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Of 2875 patients with cirrhosis who met inclusion criteria, 1021 (35.5%) completed the baseline survey.

    “Of 2875 patients with cirrhosis who met inclusion criteria, 1021 (35.5%) completed the baseline survey: 629 at Parkland, 155 at UTSW, and 237 at MEDVAMC (Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Site-level differences in the prevalence of depression and anxiety were no longer significant in multivariable models, suggesting that these differences were explained by patient-level differences.

    “However, these differences were no longer significant in multivariable models, suggesting that these differences were explained by patient-level differences.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Prior studies have reported depression and anxiety in 15% to >50% of patients with Child-Turcotte-Pugh class B or C and liver cancer.

    “Prior studies have reported depression and anxiety in 15% to >50% of patients with Child-Turcotte-Pugh class B or C and liver cancer.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [27] Nardelli, 2013, Depression, anxiety and alexithymia symptoms are major determinants of health related quality of life (HRQoL) in cirrhotic patients, Metab Brain Dis source

      Not checked in the free run.

    • cites [29] Buganza-Torio, 2019, Depression in cirrhosis - a prospective evaluation of the prevalence, predictors and development of a screening nomogram, Aliment Pharmacol Ther source

      Not checked in the free run.

    • cites [30] Bianchi, 2005, Psychological status and depression in patients with liver cirrhosis, Dig Liver Dis source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    We did not capture granular information on alcohol use via validated measures such as Alcohol Use Disorders Identification Test-Concise in all patients, nor other substance abuse behaviors.

    “we did not capture granular information on alcohol use via validated measures such as Alcohol Use Disorders Identification Test-Concise in all patients, nor other substance abuse behaviors.”
    Quote in the paperNot a substantial claim
27 of 27

  • The paper relies on this without support.

    Depression and anxiety have negative effects on patients and are important to treat.

    “Depression and anxiety can have negative effects on patients and are important to treat.”

  • The paper relies on this without support.

    There have been few studies of the prevalence of depression and anxiety among patients with cirrhosis.

    “There have been few studies of their prevalence among patients with cirrhosis.”

  • The paper relies on this without support.

    The burden of depression and anxiety in a broad cirrhosis patient population, particularly across different health care settings, is lacking.

    “the burden of these mental health disorders in a broad cirrhosis patient population, particularly across different health care settings, is lacking.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • In a baseline survey of 1021 patients with compensated cirrhosis across 3 US institutions, self-reported poor health, being widowed, fear of HCC, higher household income, and Hispanic ethnicity were associated with moderately severe to severe depression.

    “In a baseline survey of 1021 patients with compensated cirrhosis across 3 US institutions, we showed that self-reported poor health, being widowed, fear of HCC, higher household income, and Hispanic ethnicity were associated with moderately severe to severe depression.”

    From Management of depression/anxiety in patients with chronic liver disease (2024) · cites this paper as [1]

    The Results (Correlates of Depression and Anxiety) identify all five factors as associated with moderately severe to severe depression, and the Results (Patient Population) report 1021 baseline-survey respondents across three US institutions. However, the Discussion says most—not all—patients had compensated cirrhosis, so describing the entire cohort that way overstates the source. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Depression and anxiety are more common among individuals with liver disease and cirrhosis compared to the general population.

    “Depression and anxiety are more common among individuals with liver disease and cirrhosis compared to the general population.1,6”

    From Management of depression/anxiety in patients with chronic liver disease (2024) · cites this paper as [1]

    The Discussion reports that depression and anxiety were common in a cohort of patients with cirrhosis. It does not compare their prevalence with the general population, and the study cohort does not establish prevalence across liver disease more broadly. Page numbers were not provided in our copy. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Approximately 1 in 6 patients with cirrhosis have moderately severe to severe depression.

    “Approximately 1 in 6 patients with cirrhosis have moderately severe to severe depression, and half have moderate severe anxiety.1”

    From Management of depression/anxiety in patients with chronic liver disease (2024) · cites this paper as [1]

  • Approximately half of patients with cirrhosis have moderate severe anxiety.

    “Approximately 1 in 6 patients with cirrhosis have moderately severe to severe depression, and half have moderate severe anxiety.1”

    From Management of depression/anxiety in patients with chronic liver disease (2024) · cites this paper as [1]

  • In the same survey, male sex, self-reported poor health, and fear of HCC were associated with high anxiety.

    “Further, male sex, self-reported poor health, and fear of HCC were associated with high anxiety.1”

    From Management of depression/anxiety in patients with chronic liver disease (2024) · cites this paper as [1]

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Authors
Hernaez, R., Kramer, J. R., Khan, A., Phillips, J., McCallister, K., Chaffin, K., Hernandez, A. P., Fullington, H., Ortiz, C., Blackwell, J.-M., Loewen, A., Liu, Y., Tiro, J. A., Lee, S. C., & Singal, A. G.
Affiliations
  • Michael E. DeBakey VA Medical Center (US)
  • The University of Texas Southwestern Medical Center (US)
ORCID
Venue
Clinical Gastroenterology and Hepatology
Publisher
Elsevier BV
Published
2022-01
Volume
20
Issue
1
Pages
194-203.e1
ISSN
1542-3565 (ISSN-L)
DOI
10.1016/j.cgh.2020.08.045
PMC
PMC8210475
OpenAlex
W3063389502
Semantic Scholar
6fac15df371c79964cf79883713798957e7d8511
Cited by
77
References
35
Citations by year
2026: 15 · 2025: 22 · 2024: 16 · 2023: 11 · 2022: 7 · 2021: 5 · 2020: 1
FWCI
3.53
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Gastroenterology and Hepatology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • Digital Commons-TMC (Texas Medical Center) (submittedVersion)
Funders
  • Cancer Prevention and Research Institute of Texas
  • National Institute of Diabetes and Digestive and Kidney Diseases
  • National Cancer Institute
  • Center for Innovations in Quality, Effectiveness and Safety
Topics
  • Health Sciences › Medicine › Hepatology › Liver Disease and Transplantation
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
liver cirrhosis, depression, anxiety, prevalence, risk factors, marital status, Hispanic origin, household income, sex differences, PHQ-9, State-Trait Anxiety Inventory, mental health
MeSH terms
Anxiety, Anxiety Disorders, Cross-Sectional Studies, Depression, Humans, Liver Cirrhosis, Male, Surveys and Questionnaires, United States, Prevalence

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