Depression: An Overlooked Villain in Autoimmune Hepatitis?
Authors: Maciej K. Janik, Ewa Wunsch, Joanna Raszeja‐Wyszomirska, Marcin Krawczyk, Piotr Milkiewicz
Journal: Hepatology (2019)

Potential conflict of interest: Nothing to report. To the Editor: We read with great interest the recent article by Wong et al. on the impact of autoimmune hepatitis (AIH) on health‐related quality of life.1 So far, this issue has been vastly neglected in patients with AIH. Our particular attention has been drawn to data on mood disturbance, particularly depression. This problem is of great importance in patients with AIH as depression is one of the key factors responsible for nonadherence to therapy, which increases the risk of relapse and disease progression. A considerable proportion of AIH patients are young adults, often on prolonged steroids that are shown to significantly affect mood.2 For their assessment of depression, Wong et al. used the Hospital Admission Depression Scale (HADS‐D) questionnaire, a screening modality adjusted for patients with chronic liver diseases. They found that 5.5% of their patients may suffer from clinically significant depression. We are aware of only two other studies dealing with this issue, both of which used another questionnaire, the Patient Health Questionnaire‐9 (PHQ‐9). Schramm et al.3 found features of moderate depression (PHQ‐9 scores >10) in 10.8% patients. In our own study, 29.3% of patients scored >10 points.4 Certainly, both HADS‐D and PHQ‐9 are merely screening tools, which only give a rough idea of the problem and do not allow for precise diagnosis. Three available studies on depression in AIH show a significant difference in incidence (Table 1), which suggests limited applicability of these commonly used screening tests. To date there are no rigorous studies that apply formal psychiatric assessment that allows physicians to estimate the real prevalence of depression in AIH. Table 1 - Comparing Studies Concerning HRQoL in AIH UK Germany Poland Total cohort (n) 990 103 140 Female (%) 80 71 77 Age (years; mean, range) 58 (17‐95) 50 (17‐82) 40 (18‐88) Cirrhosis (%) 33 27 55 Steroids (%) 56 54 64 Tools Quality of life EQ‐5D‐5L SF‐12 SF‐36 Anxiety HADS GAD‐7 STAI Fatigue FIS — MFIS Depression HADS PHQ‐9 PHQ‐9 Cognitive CFQ — MFIS Screening positive for depression (%) 5.5 10.8 29.3 Abbreviations: AIH, autoimmune hepatitis; CFQ, Cognitive Failure Questionnaire; EQ‐5D‐5L, European Quality‐of‐Life 5‐Dimension 5‐Level; FIS, Fatigue Impact Score; GAD‐7, Generalized Anxiety Disorder Screener; HADS, Hospital Admission Depression Scale; HRQoL, health‐related quality of life; MFIS, Modified Fatigue Impact Scale; PHQ‐9, Patient Health Questionnaire‐9; SF‐12, 12‐item Short Form Health Survey; SF‐36, Short‐Form Survey‐36; STAI, State‐Trait Anxiety Inventory. Patients with AIH are not routinely screened for depression, and it is only the clinical impression of the treating physician that results in him or her proceeding with more detailed psychiatric investigations. Similarly, clinical trials do not consider depressive symptoms as a possible cause of treatment failure. Until a comprehensive study aimed at assessing this problem in different countries is done, we will not be able to properly tackle this important issue.