Integrating Care for Patients With Chronic Liver Disease and Mental Health and Substance Use Disorders
Mental health disorders are common among patients with chronic liver disease, and current literature supports the use of better screening and providing integrated or multidisciplinary care where possible.
Dr. Rogal is an Assistant Professor and Dr. Patel is a Resident at University of Pittsburgh in Pennsylvania. Dr. Akpan is a Gastroenterologist at Baylor Scott & White Health, Texas. Ms. Maguire is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. Dr. Chartier is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System. Correspondence: Dr. Patel (patelkr2@upmc.edu)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Chronic liver disease (CLD) encompasses a spectrum of common diseases associated with high morbidity and mortality. In 2010, cirrhosis, or advanced-stage CLD, was the eighth leading cause of death in the U.S., accounting for about 49,500 deaths.1 The leading causes of CLD are hepatitis C virus (HCV), which affects about 3.6 million people in the US; nonalcoholic fatty liver disease (NAFLD), which has been increasing in prevalence in up to 75% of CLD cases; and alcohol misuse.2,3 Substance use disorders (SUDs) are a common cause of CLD. About one-third of cirrhosis cases can be attributed to alcohol use, and there is a strong association between IV drug use and HCV. Individual studies point to the high prevalence of mental health disorders (MHDs) among patients with CLD.4-19 It is clear that mental health disorders and SUDs impact outcomes for patients with CLD such that addressing these co-occurring disorders is critical to caring for this population.
An integrated or multidisciplinary approach to medical care attempts to coordinate the delivery of health and social care to patients with complex disease and comorbidities.20 Integrated care models have been shown to positively impact outcomes in many chronic diseases. For example, in patients with heart failure, multidisciplinary interventions such as home visits, remote physiologic monitoring, telehealth, telephone follow-up, or a hospital/clinic team-based intervention have been shown to reduce both hospital admissions and all-cause mortality.21 Similarly, there have been studies in patients with CLD exploring integrated care models. Although individual studies have assessed outcomes associated with various MHDs/SUDs among patients with different etiologies of liver disease, this review assesses the role of integrated care models for patients with CLD and MHDs/SUDs across etiologies.
Methods
A search of the PubMed database was conducted in November 2016 with the following keywords: “liver disease” and “mental health,” “liver disease” and “depression,” “liver disease” and “integrated care,” “substance use” and “liver disease,” “integrated care” and “hepatitis,” “integrated care” and “cirrhosis,” “integrated care” and “advanced liver disease,” and “integrated care” and “alcoholic liver disease” or “nonalcoholic fatty liver disease.” Articles covered a range of study types, including qualitative and quantitative analyses as well as other systematic reviews on focused topics within the area of interest. The authors reviewed the abstracts for eligibility criteria, which included topics focused on the study of mental health or substance use aspects and/or integrated mental health/substance use care for liver diseases (across etiologies and stages), published from January 2004 to November 2016, written in English, and focused on an adult population. Five members of the research team reviewed abstracts and eliminated any that did not meet the eligibility criteria.
A total of 636 records were screened and 378 were excluded based on abstract relevance to the stated topics as well as eligibility criteria. Following this review, full articles (N = 263) were reviewed by at least 2 members of the research team. For both levels of review, articles were removed for the criteria above and additional exclusion criteria: editorial style articles, duplicates, transplant focus, or primarily focused on health-related quality of life (QOL) not specific to MHDs. Although many articles fit more than one exclusion criteria, an article was removed once it met one exclusion criteria. After individual assessment by members of the research team, 71 articles were kept in the review. The team identified 14additional articles that contributed to the topic but were not located through the original database search. The final analysis included 85 articlesthat fell into 3 key areas: (1) prevalence of comorbid MHD/SUD in liver disease; (2) associations between MHD/SUD and disease progression/management; and (3) the use of integrated care models in patients with CLD.
Results
In general, depression and anxiety were common among patients with CLD regardless of etiology.5 Across VA and non-VA studies, depressive disorders were found in one-third to two-thirds of patients with CLD and anxiety disorders in about one-third of patients with CLD. 5,7,8,10,15,16, 22-25Results of the studies that assess the prevalence of MHDs in patients with CLD are shown in Table 1.
MHDs and SUDs in Patients With CLD
Mental health symptoms have been associated with the severity of liver disease in some but not all studies.17,18,26 Mental health disorders also may have more dire consequences in this population. In a national survey of adults, 1.6% of patients with depression were found to have liver disease. Among this group with depression, suicide attempts were 3-fold higher among patients with CLD vs patients without CLD.19
Substance use disorders (including alcohol) are common among patients with CLD. This has been best studied in the context of patients with HCV.22, 27-32 For example among patients with HCV, the prevalence of injection drug use (IDU) was 48% to 65%, and the prevalence of marijuana use was 29%.33-36 In a report of 174,302 veterans with HCV receiving VA care, the following SUDs were reported as diagnosis in this patient population: alcohol, 55%; cannabis, 26%; stimulants, 35%; opioids, 22%; sedatives or anxiolytics, 5%; and other drug use, 39%.10
Both Non-VA and VA studies have found overlap between HCV and alcohol-related liver disease with a number of patients with HCV using alcohol and a number of patients with alcohol-related liver disease having a past history of IDU and HCV.37,38 Across VA and non-VA studies, patients with HIV/HCV co-infection have been found to have particularly high rates of MHDs and SUDs. One VA retrospective cohort study of 18,349 HIV-infected patients noted 37% were seropositive for HCV as well.39-41 These patients with HIV/HCV infection when compared with patients with only HIV infection were more likely to have a diagnosis of mental health illness (76.1% vs 63.1%), depression (56.6% vs 45.6%), alcohol abuse (64.2% vs 30.1%), substance abuse (68.0% vs 25.7%), and hard drug use (62.9% vs 20.6%).42 Patients with CLD and ongoing alcohol use have been found to have increased mental health symptoms compared with patients without ongoing alcohol use.17 Thus MHDs and SUDs are common and often coexist among patients with CLD.
