Liver Illness and Psychiatric Patients

Depression and NAFLD risk: A meta-analysis and Mendelian randomization study

BACKGROUND

Both depression and nonalcoholic fatty liver disease (NAFLD) have a high global prevalence. Growing evidence suggests an association between depression and NAFLD, while the association remains unclear. Thus, in this study, we aimed to explore the effect of depression on the risk of developing NAFLD.

METHODS

The meta-analysis examined the association between depression and the risk of NAFLD by including observational studies. Relevant studies were searched in PubMed, Embase, the Cochrane Library, and Web of Science. Then a two-sample Mendelian randomization (MR) analysis was performed to explore causal association using genetic instruments identified from a genome-wide association study.

RESULTS

Six eligible studies were included in the meta-analysis, involving 289,22 depression cases among 167,554 participants. Meta-analysis showed a significant association between depression and a higher risk of developing NAFLD (OR = 1.14, 95 % CI: [1.05, 1.24], P = 0.002). However, we found no convincing evidence supporting a causal role of genetically predicted depression with NAFLD risk (OR = 0.861, 95 % CI: [0.598, 1.238], P = 0.420).

LIMITATIONS

The insufficient number of included studies, the use of summary-level data, and restrictions on population sources are the major limiting factors.

CONCLUSIONS

Meta-analysis and MR analysis demonstrated inconsistent results on the relationship between depression and a high risk of developing NAFLD. Specifically, meta-analysis confirmed that depression increases the risk of developing NAFLD, while MR analysis did not support a causal association between genetically determined depression and the risk of NAFLD.

Characteristics of Comorbid Physical Disease in Patients With Severe Mental Illness in South Korea: A Nationwide Population-Based Study (2014-2019)

OBJECTIVE

The purpose of this study was to identify the associations of chronic physical disease between patients with severe mental illness (SMI) and the general population of South Korea.

METHODS

This study was conducted with National Health Insurance Corporation data from 2014 to 2019. A total of 848,058 people were diagnosed with SMI in this period, and the same number of controls were established by matching by sex and age. A descriptive analysis was conducted on the sociodemographic characteristics of patients with SMI. Conditional logistic regression analysis was performed to identify the associations between comorbid physical disease in patients with SMI and those of the general population. SAS Enterprise Guide 7.1 (SAS Inc, Cary, NC, USA) were used to perform all statistical tests.

RESULTS

The analysis revealed significant differences in medical insurance, income level, and Charlson Comorbidity Index weighted by chronic physical disease, between patients with SMI and the general population. Conditional logistic regression analysis between the two groups also revealed significant differences in eight chronic physical diseases except hypertensive disease.

CONCLUSION

This study confirmed the vulnerability of patients with SMI to chronic physical diseases and we were able to identify chronic physical disease that were highly related to patients with SMI.

Contributing roles of mitochondrial dysfunction and hepatocyte apoptosis in liver diseases through oxidative stress, post-translational modifications, inflammation, and intestinal barrier dysfunction

This review provides an update on recent findings from basic, translational, and clinical studies on the molecular mechanisms of mitochondrial dysfunction and apoptosis of hepatocytes in multiple liver diseases, including but not limited to alcohol-associated liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and drug-induced liver injury (DILI). While the ethanol-inducible cytochrome P450-2E1 (CYP2E1) is mainly responsible for oxidizing binge alcohol via the microsomal ethanol oxidizing system, it is also responsible for metabolizing many xenobiotics, including pollutants, chemicals, drugs, and specific diets abundant in n-6 fatty acids, into toxic metabolites in many organs, including the liver, causing pathological insults through organelles such as mitochondria and endoplasmic reticula. Oxidative imbalances (oxidative stress) in mitochondria promote the covalent modifications of lipids, proteins, and nucleic acids through enzymatic and non-enzymatic mechanisms. Excessive changes stimulate various post-translational modifications (PTMs) of mitochondrial proteins, transcription factors, and histones. Increased PTMs of mitochondrial proteins inactivate many enzymes involved in the reduction of oxidative species, fatty acid metabolism, and mitophagy pathways, leading to mitochondrial dysfunction, energy depletion, and apoptosis. Unique from other organelles, mitochondria control many signaling cascades involved in bioenergetics (fat metabolism), inflammation, and apoptosis/necrosis of hepatocytes. When mitochondrial homeostasis is shifted, these pathways become altered or shut down, likely contributing to the death of hepatocytes with activation of inflammation and hepatic stellate cells, causing liver fibrosis and cirrhosis. This review will encapsulate how mitochondrial dysfunction contributes to hepatocyte apoptosis in several types of liver diseases in order to provide recommendations for targeted therapeutics.

The development of the Metabolic-associated Fatty Liver Disease during pharmacotherapy of mental disorders - a review

Introduction: Metabolic-associated Fatty Liver Disease (MAFLD) is a term for Non-alcoholic Fatty Liver Disease (NAFLD) that highlights its association with components of the Metabolic Syndrome (MetS). MAFLD is becoming a clinically significant problem due to its increasing role in the pathogenesis of cryptogenic cirrhosis of the liver.

Material and methods: The resulting work is a review of the most important information on the risk of MAFLD development in the context of the use of particular groups of psychotropic drugs. The study presents the epidemiology, with particular emphasis on the population of psychiatric patients, pathophysiology and scientific reports analyzing the effect of the psychotropic medications on MAFLD development.

Results: The drugs that can have the greatest impact on the development of MAFLD are atypical antipsychotics, especially olanzapine, and mood stabilizers (MS) - valproic acid (VPA). Their effect is indirect, mainly through dysregulation of organism’s carbohydrate and lipid metabolism.

Conclusions: The population of psychiatric patients is particularly vulnerable to the development of MAFLD. At the root of this disorder lies the specificity of mental disorders, improper dietary habits, low level of physical activity and tendency to addictions. Also, the negative impact of the psychotropic drugs on the systemic metabolism indirectly contributes to the development of MAFLD. In order to prevent fatty liver disease, it is necessary to monitor metabolic and liver parameters regularly, and patients should be screened by ultrasound examination of the liver. There are also important preventive actions from the medical professionals, including education of patients and sensitizing to healthy lifestyle.

Effects of Chronic Diseases on All-Cause Mortality in People with Mental Illness: A Retrospective Cohort Study Using the Korean National Health Insurance Service-Health Screening

The aim of this study was to compare mortality and the prevalence of chronic diseases between people with mental illness and the general population, and to explore which chronic diseases increase the risk of all-cause mortality, especially in people with mental illness. This study assessed data from the 2002-2019 Korean National Health Insurance Service-Health Screening sample cohort. Results revealed that all-cause mortality was higher in people with mental illness compared to people without mental illness (11.40% vs. 10.28%, p = 0.0022). Several chronic diseases have a higher prevalence and risk of all-cause mortality in individuals with mental illness than the general population. Among people with the same chronic disease, those with mental disorders had a higher risk of all-cause mortality. Cancer (aHR 2.55, 95% CI 2.488-2.614), liver cirrhosis (aHR 2.198, 95% CI 2.086-2.316), and arrhythmia (aHR 1.427, 95% CI 1.383-1.472) were the top three chronic diseases that increased the risk of all-cause mortality in people with mental illness compared to people without mental illness. Our results suggest the need for more attention to chronic diseases for people with mental illness in clinical practice by explaining the effect of chronic disease on all-cause mortality in people with mental illness.

Outcomes of Hospitalized Acute Alcoholic Hepatitis (AH) in Patients With Bipolar 1 Disorder (B1D)

Introduction: Alcoholic hepatitis (AH) is a common cause of hospital admissions and is associated with a high mortality rate. AH occurs frequently in patients with heavy alcohol use. Alcohol use disorder (AUD) commonly presents with comorbid psychiatric disorders such as bipolar disorder. Bipolar disorder patients are also known to be at an increased risk for chronic liver diseases. Bipolar 1 disorder (B1D) is often considered the most severe presentation among different types of bipolar disorder. This study assesses the clinical outcomes of patients admitted for AH with concomitant B1D.

Methods: Adult patients with AH were identified within the 2014 National Inpatient Sample (NIS) database. International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes were used to select for all of the diagnoses for this study. AH patients were subdivided into those with and without B1D. The outcomes of interest were sepsis, hepatic encephalopathy, acute respiratory failure, acute kidney injury, ischemic stroke, hepatic failure, coagulopathy, and inpatient mortality. A multivariate logistic regression analysis was performed to explore whether B1D is an independent predictor for the outcomes.

Results: Among 4,453 patients with AH identified, 166 patients also had B1D. AH patients with comorbid B1D were seen to be younger (42.9 years old vs. 46.2 years old, p < 0.05) and more commonly female (55.4% vs. 36.5%, p < 0.05). The B1D subgroup of AH patients were found to less likely develop acute hepatic failure (adjusted odds ratio (aOR) 0.13, 95% confidence interval (CI): 0.02-0.97, p < 0.05). The adjusted odds ratios for the remaining outcomes were not statistically significant.

Conclusions: Our study indicates that B1D may be an independent protective factor against acute hepatic failure in patients hospitalized with AH. This finding can be explained by frequent laboratory monitoring and psychiatric assessments performed by psychiatrists treating B1D patients, as well as the impact B1D has on cortisol release induced by hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis.

Jiang Zhi Granule protects immunological barrier of intestinal mucosa in rats with non-alcoholic steatohepatitis

CONTEXT

Jiang Zhi Granule (JZG) is known to improve hepatic function, reduce liver fat deposition and inflammation in non-alcoholic fatty liver disease (NAFLD).

OBJECTIVE

To determine the protective mechanism of JZG on immunological barrier of intestinal mucosa in rats with diet-induced non-alcoholic steatohepatitis (NASH).

MATERIALS AND METHODS

A Sprague-Dawley (SD) model of NASH was established using a high-fat diet and 1% dextran sulphate sodium (DSS) through drinking water. The rats were randomized into four groups and treated for four weeks, respectively, including normal control (NC), model control (MC), positive control (PC) and JZG. Mesenteric lymph nodes (MLNs) cells were isolated and cultured to assess a potential disruption of the enteric immune barrier. Also, investigation of intestinal mucosal dendritic cell-toll-like-receptor-myeloid differentiation primary response 88 (DC-TLR-MyD88) signalling pathway in vitro was examined.

RESULTS

The lethal concentration 50 (LD50) of JZG was greater than 5 g/kg, while its inhibitory concentration 50 (IC50) was 1359 μg/mL in HepG2. In JZG group, the plasma levels of alanine transaminase (ALT), aspartate transaminase (AST), malondialdehyde (MDA), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG) and serum endotoxin were significantly (p < 0.01) reduced. In contrast, plasma concentrations of high-density lipoprotein cholesterol (HDL-C) and superoxide dismutase (SOD) were increased. Furthermore, proinflammatory factor, interferon-γ (IFN-γ)+ from CD4+ T cells in DSS-induced NASH rats increased significantly (p < 0.01) compared to NC group. Importantly, JZG treatment substantially decreased (p < 0.01) the relative expressions of TLR-44 and MyD88.

CONCLUSIONS

JZG treatment may protect immunological barrier of intestinal mucosa in NASH individual.

Undiagnosed disease in decedents with and without schizophrenia: an autopsy-based case-control study

BACKGROUND

Individuals with schizophrenia (SCZ) suffer from higher morbidity and mortality than the general population. Some of this is due to concurrent somatic disease.

AIMS

To identify and compare the somatic comorbidities antemortem (AM) and postmortem (PM) in autopsied decedents with SCZ and with no mental illness (NMI), using the Charlson Comorbidity Index (CCI).

MATERIALS

A total of 106 autopsied decedents with SCZ and 156 decedents with NMI were included. AM diagnoses were sampled from Danish national health registers. PM diagnoses were included from forensic autopsies. Negative binomial regression models were used to test associations between age, sex, SCZ diagnosis, manner of death and the CCI score both AM and PM.

RESULTS

The CCI score increased significantly from AM to PM for both decedents with SCZ and NMI (SCZ, AM 0.669 vs PM 1.208, p = 0.008) (NMI, AM 0.519 vs PM 1.218, p = 0.000). Regression analysis showed that age was significantly associated with the CCI score both AM and PM (AM, OR 1.044 [1.029-1.060] p ≤ 0.001) (PM, OR 1.028 [1.015-1.041], p ≤ 0.001). A diagnosis of SCZ was correlated with the CCI score AM but not PM (AM, OR 1.880 [1.207-2.928], p = 0.005) (PM, OR 1.170 [0.828-1.654], p = 0.374).

CONCLUSION

The autopsies revealed undiagnosed diseases in both decedents with SCZ and NMI. The diseases were primarily of cardiovascular, pulmonary and gastrointestinal origin and may have contributed to premature mortality. Age was the only covariate significantly associated with the CCI score both AM and PM; the SCZ diagnosis was positively correlated to the CCI score before death.

Liver disease prevalence and severity in people with serious mental illness: a cross-sectional analysis using non-invasive diagnostic tools

BACKGROUND/PURPOSE OF THE STUDY

Little is known about all-cause liver disease in people with serious mental illness (SMI), despite heightened risk factors. We, therefore, prospectively assessed liver disease by etiology and severity in a cross-sectional cohort of people with SMI at a tertiary health service.

METHODS

We recruited 255 people with SMI between August 2019 and March 2020. Liver disease data were derived from structured interview, medical records, biochemical and BBV serological analyses, and vibration-controlled transient elastography (VCTE). Steatosis was determined using a threshold of ≥ 248 db/m via the controlled attenuation parameter (CAP) on VCTE. Liver disease prevalence was assessed descriptively, and predictors of metabolic-dysfunction associated fatty liver disease (MAFLD) analyzed using linear regression and multivariable analysis. Best fit modeling of non-invasive screening tests for MAFLD was also assessed.

RESULTS

Valid VCTE was obtained for 252 (98.9%) participants. Median age was 40 years (IQR 31-49) with male predominance (65.9%). Hepatitis C Virus (HCV) seroprevalence was 14.7% (37/252), with four new viremic cases identified. Hepatic steatosis was diagnosed in 61.5% (155/252) of participants, with MAFLD criteria met in 59.9% (151/252) of cases. Clozapine and paliperidone were associated with hepatic steatosis (CAP + 23.3 db/m, p 0.013 and CAP + 25.5, p 0.037, respectively). Advanced liver disease, defined by LSM ≥ 8.2 kPa, was identified in 26 individuals (10.3%). MAFLD compared to no MAFLD was associated with more advanced liver disease (5.3 kPa, 4.3-6.5 versus 4.9 kPa, 3.9-5.6, p < 0.001).

CONCLUSION

Liver disease is common in people with SMI and should be screened for as part of standard physical health assessment.

A Gut Feeling: Acute Liver Failure - An Unusual Manifestation of Malignant Catatonia

We present a rare case in which malignant catatonia led to acute liver failure (ALF). A 19-year-old male was admitted for psychosis and developed ALF with a peak aspartate aminotransferase and alanine aminotransferase of 5,728 U/L and 7,735 U/L, respectively, and a peak international normalized ratio of 7.1. Liver biopsy showed significant confluent necrosis involving >70% of the liver tissue. He was listed for a liver transplant but was ultimately taken off of because of significant improvement with treatment by N-acetylcysteine infusion. Through our research, we found that symptoms of hepatitis can be seen with psychotic disorders, but ALF is rare.

Utility of the READMIT Index to Identify Community Hospital 30-Day Psychiatric Readmissions

This case-controlled study determined the utility of the READMIT index to identify the risk for 30-day readmission of patients discharged from an urban community hospital psychiatric inpatient unit. Data was collected from 118 matched patient pairs from 2017 to 2018. Findings demonstrated the READMIT index did not effectively discriminate those patients who were likely to readmit within 30 days. However, the following factors were associated with likelihood of 30-day readmission: the inability to care for self, number of lifetime readmissions, the comorbidity of liver disease, as well as a history of substance abuse.

Liver elastometry and alcohol withdrawal: Median-term follow-up in a psychiatric unit

The measurement of liver stiffness (LS) shows promise as a follow-up tool after alcohol withdrawal, but it has mainly been studied in the early phase or in patients with severe liver disease. A 6-month ancillary study of a specific psychiatric cohort of alcoholic patients without known liver disease followed after withdrawal was conducted (Clinical Trial NCT01491347). Clinical and biological data and LS values were collected every 2 months. A total of 129 patients were included in the study; 93 had an LS assessment within the first 7 days, and 37 had all four LS measurements. Only seven (7.5%) patients had an initial LS > 12.1 kPa, the threshold used to define severe fibrosis. Abstinence was not associated with changes in LS at the various median-term follow-up periods. However, LS of abstinent subjects decreased significantly relative to that of non-abstinent subjects between M0 and M2. CAP™ values were not associated with abstinence. The systematic median-term follow-up of withdrawn patients does not appear to be contributory. However, LS could help to detect relapse in the first 2 months after withdrawal for subjects treated in a psychiatric hospital for dependence. It thus could serve as a motivation tool. Prospective studies with various and higher baseline LS values are warranted for simultaneous longitudinal assessment, including for very short- and long-term LS after withdrawal.

Non-alcoholic fatty liver disease (NAFLD) as a neglected metabolic companion of psychiatric disorders: common pathways and future approaches

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic steatosis in over 5% of the parenchyma in the absence of excessive alcohol consumption. It is more prevalent in patients with diverse mental disorders, being part of the comorbidity driving loss of life expectancy and quality of life, yet remains a neglected entity. NAFLD can progress to non-alcoholic steatohepatitis (NASH) and increases the risk for cirrhosis and hepatic carcinoma. Both NAFLD and mental disorders share pathophysiological pathways, and also present a complex, bidirectional relationship with the metabolic syndrome (MetS) and related cardiometabolic diseases.

MAIN TEXT

This review compares the demographic data on NAFLD and NASH among the global population and the psychiatric population, finding differences that suggest a higher incidence of this disease among the latter. It also analyzes the link between NAFLD and psychiatric disorders, looking into common pathophysiological pathways, such as metabolic, genetic, and lifestyle factors. Finally, possible treatments, tailored approaches, and future research directions are suggested.

CONCLUSION

NAFLD is part of a complex system of mental and non-communicable somatic disorders with a common pathogenesis, based on shared lifestyle and environmental risks, mediated by dysregulation of inflammation, oxidative stress pathways, and mitochondrial function. The recognition of the prevalent comorbidity between NAFLD and mental disorders is required to inform clinical practice and develop novel interventions to prevent and treat these complex and interacting disorders.

Prevalence of comorbidities and correlates of hospital readmission rate in patients with acute mania: A one-year retrospective data from a tertiary care

OBJECTIVE

To assess the prevalence of medical comorbidities in acute manic patients over a period of 1 year, and to evaluate correlates of the readmission rate.

DESIGN/METHODS

A retrospective observational study was conducted on 158 acute manic patients from 2016 to 2017.

RESULTS

The most common physical comorbidity was obesity (36.1%) followed by cardiovascular disorders (15.2%) and liver dysfunctions (9.3%). Male gender was associated with higher readmission rate (Beta = -0.260), while taking anticholinergic drugs (Beta = -0.338) and having a family history of psychiatric disorders (Beta = -0.222) were associated with lower readmission rate.

PRACTICAL IMPLICATIONS

The study results may help physicians and other clinicians understand the burden of illness recurrence in bipolar disorder type I patients and adopt effective strategies to prevent relapse, taking into account all comorbidities.

Acute liver failure: A review for emergency physicians

INTRODUCTION

Acute liver failure (ALF) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of ALF.

DISCUSSION

While ALF remains a rare clinical presentation, surveillance data suggest an overall incidence between 1 and 6 cases per million people every year, accounting for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the U.S. The definition of ALF includes neurologic dysfunction, an international normalized ratio ≥ 1.5, no prior evidence of liver disease, and a disease course of ≤26 weeks, and can be further divided into hyperacute, acute, and subacute presentations. There are many underlying etiologies, including acetaminophen toxicity, drug induced liver injury, and hepatitis. Emergency physicians will be faced with several complications, including encephalopathy, coagulopathy, infectious processes, renal injury, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the transplant team for appropriate patients improves patient outcomes. This review provides several guiding principles for management of acute complications. Using a pathophysiological-guided approach to the management of ALF associated complications is essential to optimizing patient care.

CONCLUSIONS

ALF remains a rare clinical presentation, but has significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with a transplantation center is imperative, as is identifying the underlying etiology and initiating symptomatic care.

Analysis of psychotropic drug-related deaths in south Osaka

Objective

The aim of this study was to investigate the occurrence of deaths due to psychotropic drugs in south Osaka during a 10-year period and discuss societal factors from a medical viewpoint.

Methods

Psychotropic drug-related deaths were retrospectively investigated based on the forensic postmortem data of 1,746 decedents in 2005-2014, and we excluded cases in which stimulant drugs were detected. Of these, 133 cases (7.6%) were found to be psychotropic drug-related deaths and were analyzed.

Results

Psychotropic drug-related deaths occurred in 78 males (59%; age range, 14-95 years) and 55 females (41%; 20-84 years). The direct cause of death was acute drug intoxication in many cases, and of these, acute combined drug intoxication due to the use of multiple drugs accounted for 76% of the deaths. Most of these victims were found to have gastrointestinal and cardiovascular diseases. Cases of psychotropic drug-related deaths had especially poor medical conditions. In addition, tests were positive for blood alcohol in 23% of the cases.

Conclusion

The descriptive results revealed several factors that may be related to psychotropic drug-related deaths. To prevent drug abuse, several factors were deemed to be important, including improvements in the medical state of an individual, the avoidance of social isolation, and from a medical standpoint, the management of prescription drugs by medical personnel.