A Behavioral Health Program for Alcohol Use Disorder, Substance Abuse, and Depression in Chronic Liver Disease

Abstract

Alcohol use disorder, substance abuse, and depression are illnesses that deteriorate the quality of life (QOL) of patients with chronic liver disease (CLD). Screening and behavioral health programs integrated into routine practice can mitigate the deleterious effects of such illnesses but have not been adopted in hepatology practices. We implemented a behavioral health program based on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model and assessed its acceptability and effectiveness in improving QOL. This was a quality improvement study. Patients with CLD and a scheduled outpatient visit in the hepatology clinic were screened while waiting for their appointment. All patients who screened positive for any of the three illnesses were offered a brief intervention (BI) at the point of care and at 3 months by a trained social worker. The BI used the principles of motivational interviewing and cognitive behavioral therapy. Severity of illness was assessed at baseline, 3 months, and 6 months. Participants completed an acceptability survey at 6 months. We screened 303 patients; 61.7% were positive for any of the three illnesses assessed. Among the positive patients, depression was most common (48.4%), alcohol and substance abuse were each 26%. For the 95 patients who underwent BI, QOL improved from baseline to 3 and 6 months ( P < 0.001) and patients with depression improved the most. Depression was the only independent predictor of change in QOL over time. Of the enrolled patients, 82% agreed BIs improved their overall care and 87% indicated a desire to continue with the behavioral program. Conclusion: An outpatient behavioral health program based on the SBIRT model is acceptable to patients with CLD and may help improve QOL over time.

The Impact of Social Workers in Cirrhosis Care: a Systematic Review

“…Three were conducted in the USA, one in Denmark, and two in Canada. Studies included in the review were published between 1990 and 2021—two studies were conducted over two decades ago [ 25 , 26 ], and three were published in the past 3 years [ 27 ••, 28 , 29 ••]. Sample sizes ranged from 33 to 286.…”

“…No specific tool was used to assess sobriety at follow-up No specific tools were used to measure study endpoints No specific tool was used to measure alcohol consumption The Chronic Liver Disease Questionnaire (CLDQ) [ 27 ••] was used to assess quality of life. Illness severity was assessed using validated questionnaires for alcohol use disorder (Alcohol Use Disorders Identification Test [AUDIT]) [ 28 ], substance use disorder (Drug Abuse Screen Test [DAST-10]) [ 29 ••], or depression (Patient Health Questionnaire-9 [PHQ-9]) [ 30 ] The Brief COPE questionnaire with 14 coping-related subscales [ 35 ], Hamilton Depression Rating Scale [HAM-D] [ 36 ], and Hamilton Anxiety Rating Scale [HAM-A] [ 37 ] were used to assess study endpoints Alcohol use post-transplant was assessed through patient self-report and biomarker testing The role of social workers in supporting patients (type of intervention) The motivational intervention included at least 3 separate discussions of the relationship of patient’s disease to continued drinking, namely: the patient’s health and drinking history was reviewed by the lead of the unit; 1 h later the trainee clinician reinforce the message; 2 days later the principal nurse or the gastroenterology fellow reviewed the patient and the need for therapy and support; a social worker discussed the available programs and facilities that may benefit the patient*; and lastly a group session with a psychiatric nurse *This component was needed for the intervention to be considered delivered The specific interventions used by health workers were not described. All patients were assessed by all members of a multidisciplinary team (including a social worker) to determine their eligibility for liver transplant.…”

“…In 2019, Verma et al [ 29 ••] implemented a brief motivational intervention for 95 outpatients with chronic liver disease who screened positive for alcohol use disorder, substance use disorder, and/or depression while awaiting their hepatology clinic appointments. Patients who screened positive were offered a brief motivational intervention delivered by trained social workers at the point of care and at 3 months.…”

Multimodal multidisciplinary management of alcohol use disorder in liver transplant candidates and recipients

“…In the emergency department and primary care settings the practice of screening, brief intervention, and referral to treatment (SBIRT) identified and reduced drinking in select patients-SBIRT may not be sufficient in patients with heavy alcohol use (11). Nonetheless SBIRT has been trialed in a liver clinic and has been shown to effectively identify AUD and comorbid depression with 82% of enrolled patients finding their quality of life improved and 87% wishing to continue with the behavioral program (12). Brief sessions taking as little as 5 minutes that incorporate motivational interviewing (MI) can be particularly effective in mobilizing patients to seek specialized treatment (1).…”

Integrating Patient‐Reported Outcomes Within Routine Hepatology Care: A Prompt to Action

“…As an example, a tailored behavioral health intervention using these PROs improved QoL and depression and reduced the intensity of alcohol use in an outpatient hepatology practice. (11) A pilot study within a hepatology practice demonstrated the acceptability of PRO integration. PROs were assessed using PROMIS-29 (Patient Reported Outcomes Measurement Information System), available through the National Institutes of Health assessment center.…”