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.
Mental health disorders can affect how providers care for patients. In the past, for example, in both VA and non-VA studies, patients were often excluded from interferon-based HCV treatments due to MHDs.22,35,43-45 These exclusions included psychiatric issues (35%), alcohol abuse (31%), drug abuse (9%), or > 1 of these reasons (26%).46 Depression also has been associated with decreased care seeking by patients. Patients with cirrhosis and depression often do not seek medical care due to perceived stigma.47 Nearly one-fifth of patients with HCV in one study reported that they did not share information about their disease with others to avoid being stigmatized.48 Other studies have noted similar difficulty with patients’ seeking HCV treatment, advances in medications notwithstanding.49-52
Depression among patients with cirrhosis has been associated with reduced QOL, worsened cognitive function, increased mortality, and frailty.18,53,54 Psychiatric symptoms have been associated with disability and pain among patients with cirrhosis and with weight gain among patients with NAFLD.5,55 Mental health symptoms also predicted lower work productivity in patients with HCV.8 Histologic changes in the liver have been described among patients with psychiatric disorders, although the mechanism is not well understood.15,16
Although not a focus of this review, it is well established that MHDs are associated with increased substance use. Since there is a well-established connection between alcohol and adverse liver-related outcomes regardless of etiology of liver disease, mental health is thus indirectly linked to poor liver outcomes through this mechanism.37,38,56-67
Integrated Care in Liver Disease
Although there are no set guidelines on how to approach patients with liver disease and MHD/SUD comorbidities, integrated care approaches that include attention to both CLD and psychiatric needs seem promising. Integrated care models have been recommended by several authors specifically for patients with HCV and co-occurring MHDs and SUDs.4,33,42,43,45,68-72 Various integrated care models for CLD and psychiatric comorbidities have been studied and are detailed in Table 2.
In addition to these studies, there are various other integrated care models used for disease management in cirrhosis outside of MHDs/SUDs (eg, pharmacy integration into liver care to minimize adverse effects and drug-drug interactions) that have shown benefit but are beyond the scope of this review.
The most well described models of integrated care in CLD have been used for patients with HCV as noted in prior reviews.22,34,49,73 These studies included liver care integrated with substance abuse clinics/specialists, mental health professionals, and/or case managers. Outcomes that have been assessed include adherence, HCV treatment completion, HCV treatment eligibility/initiation, and reduction in alcohol use.31,46, 74-77 A large randomized controlled trial (RCT) comparing integrated care with usual care found that integrated care, including collaborative consultation with mental health providers and case managers, was associated with increased antiviral treatment and sustained virologic response (SVR).50,78 One study of integrated care in the era of direct-acting antiviral treatment for HCV found that twice as many veterans initiated treatment with integrated care (with case management and a mental health provider) as opposed to usual care. In this integrated care model, mental health providers provided ongoing brief psychological interventions designed to address the specific risk factors identified at screening, facilitated treatment, and served as a regular contact.79 Overall, integrating mental health care and HCV care has resulted in increased adherence, increased treatment eligibility/initiation, treatment completion, higher rates of SVR, and reduction in alcohol use.31,46,74-77
In addition to positive medical outcomes with integrated care models, patients and providers generally have favorable impressions of the clinics using an integrated care approach. For example, multiple qualitative studies of the Hepatitis C Community Clinic in New Zealand have described that patients and providers have positive feelings about integrated care models for HCV.80-82 Another study evaluating integrated care at 4 hepatitis clinics in British Columbia, Canada found that clients overall valued the clinic and viewed it favorably; however, they identified several areas for continued improvement, including communication and time spent with clients, follow-up and access to care, as well as education on coping and managing their disease.83
Beyond HCV, other patients with CLD could benefit from integrated care approaches. Given the association of psychiatric symptoms with weight outcomes among patients with NAFLD, integrating behavioral support has been recommended.55 Multidisciplinary care has been trialed in patients with NAFLD. One model included behavioral therapy with psychological counseling, motivation for lifestyle changes, and support by a trained expert cognitive behavioral psychologist. Although this study did not include a control group, the patients in the study experienced an 8% weight reduction, reduction in aminotransferases, and decreased hepatic steatosis by ultrasound.84
Integrated care also has been advocated for patients with alcohol-related liver disease. One study recommended creating a personalized framework to support self-management for this population.85 Another study assessed patients with alcohol-related cirrhosis and hepatic encephalopathy and recommended integrating individual coping strategies and support into liver care for this group of patients.86
A United Kingdom study of multidisciplinary care that included a team of gastroenterologists, psychiatrists, and a psychiatric liaison nurse, found improved accessibility to care and patient/family satisfaction using this model. Outpatient appointments were offered to 84% of patients after collaborative care was introduced as opposed to 12% previously. Patients and family members reported that this approach decreased the stigma of mental health care, allowing patients to be more open to intervention and education in this setting.87 A systematic review of patients with alcohol-related CLD found that among 5 RCTs with 1,945 cumulative patients, integrated care was associated with increased short-term abstinence but not sustained abstinence.88 Thus integrated care has been used most in patients with HCV-related CLD, but growing evidence supports its use for patients with other etiologies of CLD, including NAFLD and alcohol.
