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.
This review found that MHDs are common among patients with CLD and that there is an association between the worsening of liver disease outcomes for patients with comorbid mental health and substance use diagnoses as well as an association of poor MHD/SUD outcomes among patients with CLD (eg, increased suicide attempts among those with comorbid CLD and depression). These data synthesis support screening for MHDs in patients with CLD and providing integrated or multidisciplinary care where possible. Integrated care provides both mental health and CLD care in a combined setting. Integrated care models have been associated with improved health outcomes in patients with CLD and psychiatric comorbidities, including increased adherence, increased HCV treatment eligibility; initiation, and completion; higher rates of HCV treatment cure; reduction in alcohol use; and increased weight loss among patients with NAFLD.
Integrated care is becoming the standard of care for patients with CLD in many countries with national medical care systems. Scotland, for example, initiated an HCV action plan that included mental health and social care. It reported a reduced incidence of HCV infection among patients with a history of IDU, increased treatment initiation, and increased HCV testing with this approach.89 Multidisciplinary care is a class 1 level B recommendation for HCV care in Canada, meaning that it is the highest class of evidence and is supported by at least 1 randomized or multiple nonrandomized studies.90 Similarly, the US Department of Health and Human Services has developed a “National Viral Hepatitis Action Plan” with more than 20 participating federal agencies. The plan highlights the importance of integrating public health and clinical services to successfully improve viral hepatitis care, prevention, and treatment across the US.
The content of the integrated care interventions has been variable. Models with the highest success of liver disease outcomes in this study seem to have screened patients for MHDs and/or SUDs and then used trained professionals to address these issues while also focusing on liver care. An approach that includes evidence-based treatments or intervention for MHDs/SUDs is likely preferable to nonspecific support or information giving. However, it is notable that even minimal interventions (eg, providing informational materials) have been associated with improved outcomes in CLD. The actual implementation of integrated care for MHDs/SUDs into liver care likely has to be tailored to the context and available resources.
One study proposed several models of integrated care that can be adapted to the available resources of a given clinical practice setting. These included fully integrated models where services are colocated, collaborative practice models in which there is a strong relationship between providers in hepatology and mental health and SUD clinics, and then hybrid models that integrate/colocate when possible and collaborate when colocation isn’t available. Although the fully integrated care model likely is the most ideal, any multidisciplinary approach has the potential to decrease barriers and increase access to treatment.91
Another study used modeling to develop an integrated care framework for vulnerable veterans with HCV that incorporated both implementation factors (eg, research evidence, clinical experience, facilitation, and leadership) based on the Promoting Action on Research Implementation in Health Services framework and patients’ factors from the Andersen Behavioral Model (eg, geography and finances) to form a hybrid framework for this population.92
Limitations
There are several notable limitations of this review. Although the review focused on depression, anxiety, and SUDs, given the high prevalence of these disorders, other MHDs are also common among patients with CLD and were not addressed. For example, veterans with HCV also commonly had posttraumatic stress disorder, bipolar disorder, and schizophrenia.10 Further investigation should focus on these disorders and their impacts. Additionally, the authors did not specifically search for alcohol-related care in the search terms. This review also did not address nonpsychiatric types of integrated care, which could be the focus of future reviews. Despite these limitations, this review provides support for the use of integrated care in the context of CLD and co-occurring MHDs and SUDs.
Conclusion
Several studies support integrated care for patients with liver disease and co-occurring psychiatric disorders. There are multiple integrated care models in place, although they have largely been used in patients with HCV. More studies are needed to assess the role of integrated mental health care in other populations of patients with CLD. There is an abundance of research supporting the role of integrated care in improving health outcomes across many chronic diseases, including implementation of mental health into primary care in large health care systems like the VA health care system.93 Health care systems should work toward alignment of resources to meet these needs in specialty care settings, such as liver disease care in order optimize both liver disease and MHD/SUD outcomes for these patients.
