Depression and anxiety management in cirrhosis

Abstract

Depressive and anxiety symptoms are more prevalent in patients with cirrhosis compared to the general population. Between 2009 and 2019, the prevalence of depression in cirrhosis increased by 80%, while the prevalence of generalized anxiety disorder increased by over 400%. When present, anxiety and depression are linked to lower health-related quality of life, more severe symptoms (eg, fatigue), and poorer response to medical treatment. Screening instruments for depression and anxiety have shown acceptable validity in patients with cirrhosis. However, the diagnosis of depression and anxiety disorder remains challenging in this population and should follow the established criteria for general populations. Treatment interventions are numerous and include patient education and support around liver disease, pharmacological agents, and psychotherapy. Antidepressants are the treatment of choice for patients with depressive or anxiety disorder and cirrhosis. However, consideration must be given to dose adjustment and choice of agent due to changes in their metabolism in patients with liver disease. Psychotherapy may be used as a stand-alone therapy or concomitantly with pharmacotherapy. The high prevalence and complexity of depressive and anxiety symptoms in patients with cirrhosis support the integrated care approach in which patients are cared for by multidisciplinary teams.

FIGURE 1

Clinical overlap between HE and major depression. Abbreviations: DSM V, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; ICD, International Classification of Diseases 11th Revision.

FIGURE 2

Suggested stepwise approach in the management of depressive and anxiety symptoms in patients with cirrhosis. Abbreviations: CSSRS, Columbia suicide severity risk scale; FDA, Food and Drug Administration; GAD, generalized anxiety disorder; PHQ, Patient Health Questionnaire; SBIRT, screening, brief intervention, and treatment.