Depression in patients with primary biliary cirrhosis and primary sclerosing cholangitis☆
Introduction
Large community studies utilizing structured psychiatric interviews have reported an annual prevalence of major depression in the general population of 3–5% [1], [2]. Compared to the general population, the prevalence of depression in patients with a chronic illness is increased [3], [4]. One study reported that patients with one or more chronic sicknesses had a 41% increase in the relative risk of having any recent psychiatric illness [5]. Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are chronic cholestatic liver diseases of which PBC has a relatively favourable prognosis for most patients [6], [7], [8]. Earlier studies in a population with PBC and PSC found a high prevalence of depression, ranging from 20% to 45% [9], [10], [11], [12]. In those studies, depression was associated with fatigue and it is suggested that depression may explain fatigue in PBC and other forms of liver cirrhosis.
However, those studies did not perform a structured psychiatric interview to confirm the diagnosis of depression but only used one or two severity scales to determine the diagnosis depressive disorder. Most studies used the Hamilton Rating Scale for Depression (HRSD), the Centre for Epidemiologic Studies Depression Rating Scale (CES-D) and the Beck Depression Inventory (BDI) for the screening of depression [13], [14], [15]. A certain cut-off score was used for these scales; when patients’ scores were higher than the cut-off score those patients were assumed to have a depressive disorder. However, these three scales were designed to measure the severity of the depressive disorder and not to determine the diagnosis of a depressive disorder.
In the present study we determined the prevalence of depression in a population of outpatients with PBC and PSC from the liver unit of the Erasmus Medical Centre, a university hospital. We used the BDI as a severity scale, and the depression part of a structured psychiatric interview the Schedule for Affective Disorders and Schizophrenia (SADS), to verify whether our group of patients with a BDI score ⩾10 did or did not have a depressive disorder according to the DSM IV criteria [16], [17]. We also analyzed the presence of depressive symptoms in those patients with a BDI score <10 compared to those with a BDI score ⩾10. We assumed that patients with a score higher than the cut-off point on the severity scale will have some symptoms of a depressive disorder, but will not necessarily meet all the DSM-IV criteria for the diagnosis of a depressive disorder.
Section snippets
Subjects
The Medical Ethics Board of the hospital approved the study protocol, and the study was performed in accordance with the standards laid down in the Declaration of Helsinki.
Consecutive patients with a diagnosis of PBC or PSC, who were scheduled to visit the outpatient clinic of the Department of Gastroenterology, were considered for participation in the study. Inclusion criteria for this study were a diagnosis of PBC or PSC and age >18 years; all patients gave written informed consent. Exclusion
Results
During a 1 year period 100 consecutive patients were asked to participate. A total of 92 patients were included and all provided written informed consent. Eight patients (5 with PBC) did not participate: one patient had advanced gastric carcinoma, two patients had inadequate understanding of the Dutch language, three patients refused participation, one patient did not fill out the BDI, and one patient missed the appointment. Table 2 presents the baseline characteristics of these 92 patients.
Discussion
In the present study we found a much lower prevalence of depressive disorder according to the DSM-IV criteria compared with three earlier studies in a similar population [10], [11], [12]. This difference in prevalence might be explained by the different methodological procedures used. The former studies used only the BDI, CES-D and the HRSD to screen for depression; however, these questionnaires were developed only to determine the severity of a depression, and not to diagnose the presence of a
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The authors who have taken part in this study declared that they have no relationship with the manufacturers of the drugs involved either in the past or present and did not receive funding from the manufacturers to carry out their research. They did not receive funding from any source to carry out this study.