- Anxiety is common and often underdiagnosed
- Validated tools should be used to differentiate anxiety from somatic symptoms
- In mild to moderate anxiety, lifestyle modification and psychotherapy may be sufficient
- Urgent assessment and treatment are needed in patients presenting with suicidality or function loss
- There is limited research on the use of pharmacological therapy for anxiety in cirrhosis; consider appropriate dose adjustments
Anxiety is common and may be pre-morbid, or occur secondary to physiological and psychological changes associated with cirrhosis. Overlapping somatic symptoms (fatigue, insomnia, impaired concentration, irritability) can complicate the diagnosis of anxiety.
Questionnaires are helpful to screen for “at risk” individuals but the diagnosis of anxiety requires a clinical interview
There are a range of screening tools that can be used. The GAD-7 (Generalized Anxiety Disorder) is advantageous because it emphasizes non-somatic symptoms, but other tools such as the HAM-A (Hamilton Anxiety Rating) Scale and Beck Anxiety Inventory can also be used.
Consider non-pharmacological management in all patients with mild anxiety.
These therapeutic techniques can be learned using online resources (apps) or text resources in situations where access to a therapist is difficult.
If non-pharmacological therapy alone fails, consider adding pharmacological therapy, especially in cases of moderate to severe anxiety. There is limited evidence to guide the use of specific medications in cirrhosis.
Once initiated, treatment should be re-assessed at 2 weeks using validated questionnaires (e.g. GAD-7) to evaluate response.
- If there is improvement at two weeks, consider increasing the dose to further target symptoms
- If there is no improvement or significant side effects at follow-up, the likelihood of symptom remission is low. An alternate medication trial should be considered
- A full trial of an antidepressant (used for anxiety) occurs when the maximum allowable dose is used for 8 weeks.
This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Nicholas Mitchell, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon, Sarah Tymchuk
Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages.
- Self-test for anxiety (GAD-7): https://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=abn2339
- Exercise Therapy: https://cirrhosiscare.ca/healthy-living-provider/exercise-therapy-hcp/
- Nutrition Therapy: https://cirrhosiscare.ca/healthy-living-provider/nutrition-therapy-hcp/
- Alberta Health Services Self-Help tips: https://www.albertahealthservices.ca/news/page13125.aspx
- Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
- Medication prescribing in liver dysfunction. Ment Health Clin [Internet]. 2014;4(3):131-7, doi: https://doi.org/10.9740/mhc.n197913
- Mullish BH, Kabir MS, Thursz MR, Dhar A. Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation. Aliment Pharmacol Ther. 2014 Oct;40(8):880-92. doi: 10.1111/apt.12925. Epub 2014 Sep 1. PMID: 25175904.
- Telles-Correia D, Barbosa A, Cortez-Pinto H, Campos C, Rocha NB, Machado S. Psychotropic drugs and liver disease: A critical review of pharmacokinetics and liver toxicity. World J Gastrointest Pharmacol Ther. 2017 Feb 6;8(1):26-38. doi: 10.4292/wjgpt.v8.i1.26. PMID: 28217372; PMCID: PMC5292604.
- Wilcock A, Charlesworth S, Prentice W, Selby P, McKenna M, Cripps S, Considine A, Orr A, Wright M, Mihalyo M, Oxberry S. Prescribing in Chronic Severe Hepatic Impairment. J Pain Symptom Manage. 2019 Sep;58(3):515-537. doi: 10.1016/j.jpainsymman.2019.04.034. Epub 2019 May 9. PMID: 31077785.