Mental Health and Liver Disease
Mental Health and Liver Disease
Noha Abdel Gawad, MD, Staff Psychiatrist at University Health Network, Centre for Mental Health, Assistant Professor of Psychiatry at University of Toronto, Diplomate of the American Board of Psychiatry and Neurology (ABPN), ABPN Consultation Liaison Psychiatry subspecialty certification, Royal College of Physicians & Surgeons of Canada certification.
The liver has several different functions, all of which can affect brain health. For example, the liver is essential in metabolizing drugs, alcohol, and toxins and cleanses the body (and therefore brain) of toxic substances.
The liver also stores energy, in the form of glycogen, which is broken down into glucose (sugar) for energy. The brain requires 20% of the body’s glucose supply to function. Additionally, the liver produces and regulates different vitamins, minerals, and blood products that are essential in the healthy functioning of the brain and nervous system.
With this in mind, it’s important to be in the know of the five mental health factors that are related to liver health:
Depression and anxiety are two mental health indicators that significantly impact a person’s quality of life. We know that depressive disorders are at least three times more common in people with liver disease than those without.
Specifically, up to 17% of the liver disease population suffer from depression1, versus 5% of the general population2. In liver disease, factors such as low energy, fatigue, changes in employment status and functionality, and changes in recreational activities may contribute to depression.
The two primary signs of depression are sustained low mood (i.e., all day, every day) for two weeks or more, and the inability to enjoy pleasurable activities. Other important symptoms to watch for include low motivation, sense of hopelessness or helplessness, social withdrawal, death wishes, and suicidal thoughts. The symptoms of fatigue, appetite changes, sleep changes, and trouble concentrating tend to overlap both with liver disease and depression. Depression can be diagnosed by your family doctor or by a mental health professional. It is treated with either therapy or antidepressant medications, or a combination of both.
Treating depression improves social connection with friends and family, allowing a person to benefit mentally and physically from their support network. Treating depression also improves mood and motivation and in turn adherence to treatment recommendations and healthy lifestyle behaviours. This contributes to maintaining a healthier liver.
The term ‘trauma’ refers to any experienced or observed life-threatening event. This includes complicated hospitalizations, surgeries, or ICU admissions. Most people resume normal functioning after trauma; about 6% develop post-traumatic stress disorder (PTSD). This number jumps to 19%3 in those living with Hepatitis C HCV and 34% in people with alcohol-related liver disease (specifically alcoholic hepatitis) 4.
The opposite can also be true, where people with PTSD are three times more likely to be infected with the hepatitis C virus that those without PTSD. This may be because those with PTSD are more likely to engage in behaviours that can lead to hepatitis C (such as sharing drug needles and having unprotected sex), which puts them at higher risk of being infected by the hepatitis C virus.
Much can be said about the effects of trauma on our health. Trauma increases anxiety levels and keeps the body and brain constantly in a fight or flight mode. This raises the levels of stress hormones which negatively impacts organs including the brain and liver. Untreated PTSD causes a person to feel irritable and easily angered, to behave impulsively, to feel disconnected from others, and to have an overall lower mood with poor sleep and concentration.
This can be very disruptive to daily life and leaves people feeling alienated from loved ones and wondering what is wrong with them. Traumatic experiences sometimes create barriers to seeking medical attention or asking for help. Recognizing trauma symptoms for what they are promotes access to the appropriate mental health resources.
Adequate management of PTSD symptoms, through psychotherapy and/or medications, reduces its negative impact on mental and physical health and improves overall wellbeing.
The term cognition refers to one’s memory, attention, concentration, and ability to plan and execute tasks. Cognitive health is directly affected by liver health. The accumulation of toxins, in liver disease, can be associated with chemical disturbances in the brain which lead to forgetfulness, trouble concentrating, confusion, and behavioural disturbance, and is typically known as hepatic encephalopathy (HE).
HE can be mistaken for dementia, depression, psychosis, or attention deficit hyperactivity disorder (ADHD). In general, cognitive health is maintained through a balanced diet, moderate exercise, adequate sleep, and refraining from drugs and alcohol. In liver disease, these methods, in addition to taking the required medication as prescribed, are essential in preventing episodes of HE and maintaining good liver and brain health.
Recent data show that no amount of alcohol is safe for the brain6. Excessive alcohol use can damage any organ system, including the liver and the brain.
Common mental health consequences of chronic alcohol use include addiction, insomnia, anxiety, depression, and dementia. Remaining below the recommended limits and abstaining, if needed, protects the brain, liver, and remaining organs from the toxic effects of alcohol.
Healthy sleep promotes good mental health and poor sleep puts people at risk for anxiety, lower mood, and concentration difficulties (all of which might already be problematic in liver disease). In liver disease, a reversed sleep-wake cycle might signal the start of HE and decline in liver function. Healthy sleep hygiene habits include maintaining a regular sleep pattern with minimal interruptions, minimizing the use of substances that affect sleep (Eg. Alcohol, benzodiazepines), minimizing the use of screens at bedtime, and avoiding being awake in bed for longer than 20 minutes. Following these simple hacks helps promote healthy quantity and quality of sleep and helps maintain healthy bodily rhythms.
In summary, our bodily systems are all interconnected, and the relationship between our mental and physical health is closely related. The liver is no exception to this. Maintaining good mental health through healthy lifestyle behaviours and adequately managing any psychiatric symptoms can go a long way in maintaining liver health and quality of life.
1 (Le Strat Y, Le FollB, DubertretC. Major depression and suicide attempts in patients with liver disease in the United States. Liver Int. 2015 Jul;35(7):1910-6. doi: 10.1111/liv.12612. Epub2014 Jun 23. PMID: 24905236.)
3 Yovtcheva SP, Rifai MA, Moles JK, Van der Linden BJ. Psychiatric comorbidity among hepatitis C-positive patients. Psychosomatics. 2001 Sep-Oct;42(5):411-5. doi: 10.1176/appi.psy.42.5.411. PMID: 11739908.
4 Samala N, Lourens SG, Shah VH, Kamath PS, Sanyal AJ, Crabb DW, Tang Q, Radaeva S, Liangpunsakul S, Chalasani N. Posttraumatic Stress Disorder in Patients with Heavy Alcohol Consumption and Alcoholic Hepatitis. Alcohol Clin Exp Res. 2018 Oct;42(10):1933-1938. doi: 10.1111/acer.13862. Epub 2018 Aug 26. PMID: 30080255; PMCID: PMC6167141.)
5 Jiang T, Farkas DK, Ahern TP, Lash TL, Sørensen HT, Gradus JL. Posttraumatic Stress Disorder and Incident Infections: A Nationwide Cohort Study. Epidemiology. 2019;30(6):911-917. doi:10.1097/EDE.0000000000001071