Elsevier

Journal of Hepatology

Volume 46, Issue 6, June 2007, Pages 1099-1103
Journal of Hepatology

Depression in patients with primary biliary cirrhosis and primary sclerosing cholangitis

https://doi.org/10.1016/j.jhep.2007.01.036Get rights and content

Background/Aims

Former studies reported a high prevalence of depression in patients with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). These studies hypothesized that the presence of depression could explain the fatigue experienced by these patients.

Methods

Our aim was to study the prevalence of depression in a Dutch population with PBC and PSC. In addition, to investigating the effects of using an additional diagnostic structured psychiatric interview, after screening with the Beck Depression Inventory (BDI), a self-report severity scale instrument used in former studies. Patients with PBC and PSC (n = 92) completed the BDI. Patients with scores of 10 or higher (n = 39) were interviewed using a structured psychiatric interview. Patients with scores lower than 10 were at random (30/53, 57%) also interviewed using a structured psychiatric interview.

Results

Of the 92 patients that were included 42% had depressive symptoms according to the BDI. However, of these patients only 3.7% had a depressive syndrome according to the DSM-IV criteria as assessed with the structured psychiatric interview.

Conclusions

The prevalence of a depressive disorder in patients with PBC and PSC is not higher than in the general population. Fatigue in patients with PBC and PSC cannot be explained by depression.

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

References (25)

  • K.B. Wells et al.

    Psychiatric disorder in a sample of the general population with and without chronic medical conditions

    Am J Psychiatry

    (1988)
  • U. Broome et al.

    Natural history and prognostic factors in 305 Swedish patients with primary sclerosing cholangitis

    Gut

    (1996)
  • Cited by (67)

    • Assessing screening instruments and thresholds to detect risk of depression in diabetes patients, a brief report

      2019, Primary Care Diabetes
      Citation Excerpt :

      However, the PPV and Youden Index were modest in all instruments with the proposed thresholds, meaning that the three instruments could lead to a relatively large number of false positive cases when applied in clinical practice. This is similar to a previous study on screening of depression in patients with primary biliary cirrhosis and sclerosing cholangitis [17]. Therefore, the instruments could well be used as a first selection step of possible cases, but a second, more comprehensive diagnostic examination (e.g. a constructive interview) is required to identify diabetes in need of treatment for depression.

    • Preventative care in cholestatic liver disease: Pearls for the specialist and subspecialist

      2019, Liver Research
      Citation Excerpt :

      PBC shares generally similar symptoms with PSC, including pruritus and fatigue. Fatigue is the most common symptom, affecting approximately 78% of patients with PBC and is associated with autonomic neuropathy, hypothyroidism, and overall decreased survival.23–26 Pruritus is a more specific symptom in PBC (and CLDs in general), affecting approximately 30–70% of patients.

    • Symptoms of PBC – Pathophysiology and management

      2018, Best Practice and Research: Clinical Gastroenterology
      Citation Excerpt :

      Fatigued PBC patients have been shown to experience delayed sleep timing associated with impaired sleep quality and day time somnolence [21]. Considerable limitations to lifestyle experienced by the fatigued PBC patient contribute to depressive symptoms in contrast to an overt depressive illness contributing to fatigue in PBC [22]. Animal studies by the Swain group, in mouse models of inflammatory liver injury, proposed a possible immune mediated inflammatory pathway via entry of inflammatory cells into the central nervous system (CNS) and eventually leading to central neural changes and resultant behavioural alterations.

    View all citing articles on Scopus

    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.

    View full text