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Psychosomatics 41:472-480, December 2000
© 2000 The Academy of Psychosomatic Medicine

Depression in Korean Immigrants With Hepatitis B and Related Liver Diseases

Elisabeth J.S. Kunkel, M.D., Jin Sung Kim, M.D., Hie-Won Hann, M.D., Olu Oyesanmi, M.D., Lynette A. Menefee, Ph.D., Howard L. Field, M.D., Philip L. Lartey, M.D., and Ronald E. Myers, Ph.D.

Received August 17, 1999; revised November 3, 1999; accepted May 31, 2000. From Department of Internal Medicine, Jefferson Medical College, Philadelphia, Pennsylvania. Address correspondence to Dr. Kunkel, Director Consultation-Liaison Psychiatry, Department of Psychiatry and Human Behavior, 1020 Sansom Street, Thompson Bldg. Suite 1652, Philadelphia, PA 19107.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors evaluated 50 Korean immigrants who had chronic viral hepatitis or who were healthy carriers for the hepatitis B virus in terms of the relationships between their depression scores, psychosocial stressors, social support, and biological markers of dysfunction. All participants completed a questionnaire, describing their worries and concerns, and the short form of the Beck Depression Inventory (BDI-sf). Hepatic transaminases, albumin levels, and prothrombin times were measured during routine clinic follow-up visits and were abstracted from the medical record. Values recorded within 3 months before and within 3 months after the psychiatric interview were correlated with BDI scores. BDI-sf total scores were significantly associated with transaminase elevations (P<0.001) both before and after BDI-sf administration. BDI scores were not associated with other measures of liver dysfunction or other medical causes of depression. Patients with higher BDI-sf total scores had more psychosocial stressors (P=0.008) and lower Global Assessment of Functioning (GAF) scores (P=0.000).

Key Words: Depression • Hepatitis B • liver-related diseases

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Asian immigrants, one of the fastest growing segments of the U.S. population, have a high carrier rate of hepatitis B virus (HBV) (5%–20%) compared with other U.S. citizens (0.1%–0.2%). As a result, Asian immigrants are at an increased risk for chronic hepatitis B and hepatocellular carcinoma (HCC).1 It takes 20–40 years to develop HCC after initial hepatitis B infection,2 but the relative risk of HCC is a hundred times greater for HBV carriers (compared with noncarriers) worldwide.1,3 In most of Asia, China, and Africa, HCC is the second most common malignancy.2 In the United States, where the incidence of HCC has been increasing, blacks are affected twice as often as whites.4 In contrast to the U.S. pattern of transmission through infected needles and blood, HBV in Asia is most commonly transmitted vertically, from mother to infant. Horizontal transmission within families also occurs in children under 10 years of age.5

Various psychiatric symptoms accompany the physical disability associated with hepatitis. The "posthepatitis syndrome," described by Caravati6 in 1944, included fatigue, emotional instability, right upper quadrant discomfort, and malnutrition. In later 20th century publications, descriptions of psychiatric morbidity in patients with chronic liver disease are confused by population heterogeneity, with no distinctions between hepatitis A, B, and C. Serologic markers for hepatitis A (HAV) and B viruses were not available until the 1970s. Markers for hepatitis C virus (HCV) were not available until 1989.7,8

In 1984, Lok et al. were one of the first groups to study a virally homogeneous population. Using their own questionnaire, they measured the psychosocial impact of being an HBV carrier in 40 British patients.9 Thirty-six patients (90%) reported that their physical and psychological health, including their work, sexual, social, and family attitudes, were negatively affected. Twenty-four patients (60%) were asymptomatic from their HBV exposure. Ten years later, Davis et al.10,11 used the Sickness Impact Profile (SIP) to evaluate the impact of chronic hepatitis C and the effect of treatment with interferon-{alpha}-2b in 160 patients in the United States. After 24 weeks of interferon-{alpha} (IFN-{alpha}) treatment, 106 patients (66%) showed significant improvements in work, sleep/rest, and recreation/pastimes scores. In the 54 untreated control patients with chronic hepatitis C, mean SIP scores were unchanged or slightly worsened over time.

Foster et al.12 reported a significant reduction in subscores that measured mental and general health perceptions using the MOS 36-Item Short-Form Health Survey (SF-36) in British patients who had contracted HBV infection. These patients showed no significant reduction in the SF- 36 scores for modalities that affected physical performance. British health care workers who had accidental exposure to blood products were mostly concerned with the way colleagues, family, and friends might react once these acquaintances found out they had HBV infection.13 Singh et al.14 prospectively compared total mood disturbances, anxiety, and depression in 82 liver transplantation candidates in the United States with end-stage liver disease due to HCV or due to other liver diseases. Patients with HCV showed higher scores in total mood disturbances, anxiety, and depression.

Although reports of "asthenic" reactions, anxiety, and/ or emotional problems have been reported in patients with viral hepatitis,15 descriptions of the psychological problems in patients with HCC are extremely unusual. One of the major psychooncology textbooks discusses HCC only in relation to alcohol.16 In our experience, patients with HCC are desperate and overwhelmed by the cancer's rapidly progressing, downward course.

The purpose of our study is to screen Asian immigrant outpatients with chronic liver disease secondary to hepatitis B for depression and to attempt to determine whether depression [as measured by the Beck Depression Inventory- Short Form (BDI-sf)] is related to liver dysfunction in these patients. Depression is known to precede the development of certain malignancies (e.g., pancreatic cancer) and can be associated with a poorer prognosis in several chronic diseases.17,18 First, we felt it would be important to identify the prevalence of depression in Asian immigrants exposed to hepatitis B. Second, we questioned whether depression could be a marker for deterioration in liver function tests. Third, we postulated that a family history of liver disease or deaths in the family due to liver disease would be associated with higher degrees of depression. To our knowledge, no such study had ever been done with an Asian immigrant population.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
The Asian outpatient liver clinic is located at a major metropolitan teaching hospital and treats approximately 2,000 patients with HBV infection—20 of whom have HCC. The clinic was established as an outgrowth of community screening programs that were offered to the growing Asian immigrant populations in the eastern United States. The clinic provides ongoing screening, follow-up, and treatment for patients with liver disease. From September to December 1998, we consecutively approached 50 Korean immigrants who were attending the outpatient liver clinic. To ensure a degree of homogeneity in the Asian population, we selected only Korean immigrants for the study.19 All patients had liver problems associated with HBV. All patients were advised to discontinue any complementary or alternative medications upon entry into the clinic. Patients were approached sequentially at outpatient clinic visits. Fifty patients agreed to participate in this pilot study. Exclusion criteria included hepatic encephalopathy, inability to complete the study questionnaire and/or the BDI-sf, severe medical conditions such as cardiopulmonary diseases that might affect quality of life, and patients with non-B hepatitis. We did not exclude any patients, and all patients agreed to participate in the study.

Measures
Interviews were conducted in Korean by a consultation-liaison psychiatrist (JSK). The psychiatrist completed a study questionnaire that elucidated the patients' concerns and knowledge about liver disease. Concerns about infectivity, disease progression, sexual dysfunction, and social withdrawal were identified from the patients' interview responses. A history of Axis IV DSM-IV psychosocial stressors was elicited from all patients.

We chose the three most common psychosocial stressors in our study for the purpose of data analyses. We gave one point for each stressor identified; patients received scores of 0 to 3, accordingly. During the interview, overall functioning of patients in our study was elicited using the DSM-IV Axis V Global Assessment of Functioning (GAF) Scale (0– 100).

All patients completed the BDI-sf, which has been tested in medical outpatients. The BDI-sf20 is a 13-item, abbreviated version of the 21-item, self-report BDI screening test for depression.21 The BDI-sf is suitable for use in medical outpatient clinics where brief, yet quantifiable, screening tests are required. The BDI-sf is scored as an index of severity of depressed mood. Individual items assessed on the BDI-sf include mood, pessimism, sense of failure, lack of satisfaction, guilty feelings, self-hate, self- punitive wishes, social withdrawal, indecisiveness, body image, work inhibition, fatigability, and loss of appetite. Each of the 13 items is scored from 0 to 3.

The BDI-sf has been found to correlate highly with the standard 21-item BDI (r=0.96, P<0.001) and relates the clinical depth-of-depression (r=0.61).22 The estimated degree of depression according to the 21-item BDI for categorized groups is 0–4 (none or minimal), 5–7 (mild), 8–15 (moderate), and 16+ (severe). As there are no specific cutoffs for depression on the BDI-sf, we used the cutoff scores of the 21-item BDI to analyze the 13-item BDI-sf. We assumed that using the 21-item presumably higher BDI cutoff scores would provide a conservative estimate of depression in this population. We asked patients to select the best option that seemed to fit them at the time of the BDI- sf administration. We gave patients a copy of the BDI-sf that we had translated into Korean.

Medical records were audited for demographic factors, past medical history, years since immigration, years followed in the outpatient liver clinic, alcohol use, medications, and laboratory values. We recorded biochemical parameters for liver dysfunction as part of the ongoing medical surveillance. Measures of hepatic dysfunction included serum glutamic-pyruvic aminotransferase (SGPT or ALT) (normal, 0–50 IU/L), serum glutamic-oxaloacetic aminotransferase (SGOT or AST) (normal, 0–45 IU/L), serum albumin (normal, 3.5–5.5 g/dl), and prothrombin times (PT) (normal, 10–12 seconds). The same laboratory processed all laboratory specimens.

Laboratory measures were performed at two different times. Time 1 (t1) included biochemical measures found in the patients' medical records within 3 months before the study interview. The interviewer was blind to the t1 values of the patients. Time 2 (t2) included the first laboratory specimen that was drawn within 3 months after the study interview. The t2 values were not available to the patient, the hepatologist, or the study psychiatrist. As part of the liver clinic's typical routine, patients were informed by their hepatologist (HWH) that their liver enzymes measured at t1 were "normal" or "abnormal" on the follow-up visit, which occurred before completion of the psychiatric interview and the BDI-sf.

Data Analysis
We calculated frequency distributions for categorical variables. In order to examine the association between variables, we calculated Pearson product-moment correlations between BDI-sf scores and transaminases, albumin values, and PT values, respectively. Simple linear regression was used to examine whether depression symptomatology was associated with biological markers for liver disease at t2. We determined statistical significance at P values<0.01. We performed a multiple regression analysis using BDI-sf scores as the dependent variable and liver function test (LFT) results, medications causing depression, and medical conditions causing depression as independent variables. All the variables were entered in one step.

Two patients, who had very high transaminase measurements, were eliminated from the original data; we considered them outliers. Of the 48 patients whose data were included for final data analysis, t2 transaminase measurements could not be obtained for 6 patients (i.e., 48 patients were analyzed at t1 and 42 patients were analyzed at t2). Only 41 patients had their PT measured before the interview, and 11 had PT measurements after the interview. Out of the 50 patients, 48 had albumin measurements before the interview, and 36 patients had postinterview measurements. "Before" values were not grouped with "after" values. All 50 patients were included in analyzing the study questionnaire data.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Subjects
The study participants were 37 men and 13 women, ranging from 24 to 69 years of age. The time period from diagnosis of liver disease to study interview (1998) ranged from 8 months to 18 years. Of those participating, there were 10 healthy carriers; 16 patients with chronic hepatitis B; 20 patients with hepatic cirrhosis; and 4 with HCC. The 4 patients who had HCC, diagnosed from 5 to 18 years before the study, had been originally diagnosed with liver disease secondary to HBV. The time from immigration to the United States to the study interview ranged from 1 to 31 years before the study period. No patients reported using complementary medications. Eleven patients had medical conditions or disorders that may have contributed to their depression (e.g., diabetes, hypertension, and hypothyroidism). Nine patients were on medications that have been reported to cause depression (e.g., propranolol) or lethargy/drowsiness (e.g., spironolactone). On average, BDI-sf scores were lower than the total study population for these groups; we did not exclude these patients from the analysis (see BDI-sf findings).

Interview Findings
All 50 patients were quite candid during the psychiatric interview. Patients reported that the most fearful and anxious period postdiagnosis lasted about 1 year. Some patients stated that their primary physicians had told them that "good treatment methods have not yet been found, and effective drugs are still absent." They were told to "rest, take vitamin C, wait for spontaneous remission, and [were] wished well." These statements led to feelings of hopelessness, helplessness, and depression. During the period of initial diagnosis, while awaiting laboratory results from their primary physician, patients complained about the "delay" of a referral to a hepatologist. Patients with families worried about those who would be left behind in the event that they died. Many participants reported feeling jealous that the unaffected partner would survive and then go on to have new partners. They described changing or reviewing life insurance policies periodically, for fear of sudden death. Thirty-nine patients (78%) were concerned about infecting other people.

Forty-seven of the 50 patients decreased their sexual activity—3 did not have a sexual partner. The most common reason given for restricting sexual activity was that patients indicated that too much sexual activity might worsen their disease state. They restricted their sexual activity in order to increase or conserve their "energy." Other less common causes of reduced sexual activity were erectile dysfunction, feeling inferior to the healthy sexual partner, and fear of transmitting the disease. Seventeen patients (34%) withdrew socially; however, only 12 patients (24%) experienced rejection by other people because of their liver disease.

As a structured clinical interview was not used, we were unable to determine whether the presence of an Axis I disorder might account for higher BDI-sf scores. According to the psychiatrist's interview findings, current history of alcohol abuse was present in 4 patients (8%), and only 1 patient indicated a history of alcohol abuse. No significant correlation between alcohol abuse and depression scores (P=0.77) was found. The treating hepatologist reviewed all patients' charts, including those of the 4 patients above, and found no evidence of alcohol dependence or abuse. Even in patients who did drink socially, liver disease was unrelated to alcohol use.

DSM-IV Axis IV stressors included occupational (38%), economic (24%), primary support (22%), educational (4%), and social (2%) stressors. Patients with more stressors had higher BDI-sf scores (P=0.008). DSM-IV Axis V GAF scores (rated during interview) ranged from 50 to 90 (average=83.5). Although 35 patients (70%) had GAF scores>85, 15 patients (30%) had GAF scores<80. Interviewed patients with lower GAF scores had higher BDI-sf scores (P=0.001).

No significant correlation was found between BDI-sf depression scores and age, gender, family history of liver disease, or death(s) in the family because of liver disease. Thirty-four patients (68%) indicated a positive family history of liver disease. Of these 34 patients, 19 patients (56%) reported family death(s) because of liver disease.

BDI-sf Findings
For all 50 patients, the average total BDI-sf score was 5.4. Twenty-seven patients (54%) reported none or minimal depression (BDI-sf =0–4); 8 patients (16%) reported mild depression (BDI-sf=5–7); 12 patients (24%) reported moderate depression (BDI-sf=8–15); and 3 patients (6%) reported severe depression (BDI-sf>=16). In other words, 23 patients (46%) endorsed depressive symptomatology, according to the BDI-sf (scores>5), indicating mild to severe depression. Table 1 shows the frequency of all 13 individual items on the BDI-sf with scores>=1. Mean BDI- sf scores in each liver disease group were as follows: healthy carriers (4.7), chronic hepatitis (7.1), cirrhosis (4.6), and HCC (9.0). There was no relationship between length of time since diagnosis of liver disease and BDI-sf scores, nor between number of years attending the liver clinic and BDI-sf scores.


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TABLE 1. Frequency of individual items with scores >= 1 on the BDI-sf* (n=50)



Patients who were not taking medications that are known to cause depression or lethargy had a mean BDI-sf of 6. As IFN-{alpha} frequently causes neuropsychiatric side effects, especially depression,23,24 we considered whether treatment with IFN-{alpha} might contribute to the BDI-sf scores. Nine patients had received IFN-{alpha} before the study, but none had received IFN-{alpha} within the year that preceded the administration of the BDI-sf. Scores on the BDI-sf for 5 patients taking propranolol, a medication known to cause depression, ranged from 2 to 10 (mean=5.4). Four patients were taking spironolactone, which can cause lethargy. BDI-sf scores for these participants ranged from 1 to 10 (mean=4.5).

Fatigue is a common symptom in hepatitis. For the group as a whole, increased levels of fatigue (an individual item in the BDI-sf) were associated with increased total BDI-sf depression scores (r=0.584, P<0.000). Of those who reported job difficulties, fatigue was a major contributing factor in 32 of the 35 patients (91%). Other reasons for job difficulties were physical pain and feelings of isolation.

Table 2 shows the mean±standard deviation (SD) and range for SGPT and SGOT at t1 and at t2. For SGPT and SGOT, respectively, values at t1 were highly correlated with values at t2 (SGOT: r=0.694, P<0.001; SGPT: r=0.673, P<0.001). Transaminase means were compared in the patients according to the following types of diseases: for SGOT at t1 [HCC (56.0), cirrhosis (40.4), chronic hepatitis (42.8), healthy carriers (22.6)]; for SGOT at t2 [HCC (62.0), cirrhosis (41.8), chronic hepatitis (33.8), healthy carriers (23.1)]; for SGPT at t1 [HCC (54.8), cirrhosis (36.2), chronic hepatitis (58.6), healthy carriers (30.0)]; and for SGPT at t2 [HCC (47.7), cirrhosis (39.9), chronic hepatitis (48.2), healthy carriers (29.3)].


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TABLE 2. Frequency of liver transaminases (n=48 at t1; n=42 at t2)



We compared albumin values and prothrombin times (PT) at t1 and t2, respectively (see Table 3 and Table 4). Sixty-six percent (27/41) of the patients had elevated PT values at t1, and 82% (9/11) had elevated PT values at t2. Elevated PT values at t1 were not significantly correlated with elevated BDI-sf scores (P=0.360). Albumin was decreased in 17% (8/48) of the group at t1, and 19% (7/36) of the group at t2. Decreased albumin at t1 was not significantly correlated with increased BDI-sf scores (P=0.919). We reviewed the laboratory finding of all 14 patients who had normal transaminase values to make sure we were identifying all patients with active liver disease. Normal transaminases can represent active liver disease in some patients.25 Only 3 of these 14 patients were thought to have active liver disease despite normal transaminases. BDI-sf values for these individuals were 1, 3, and 4, suggesting low levels of depressive symptomatology. Of these 3 patients, only 1 patient had normal albumin values (at t1 and t2) and a PT of 14.1 at t1; the other 2 patients had low albumin values at t1 and t2 and elevated PT values at t1.


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TABLE 3. Frequency of albumin levels (n=48 at t1; n=36 at t2)




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TABLE 4. Frequency of PT values (n=41 at t1; n=11 at t2)



Correlations were significant at the P<0.01 level between higher BDI-sf scores and higher SGPT and SGOT values measured both at t1 and at t2 (see Table 5). We performed a multiple regression analysis to determine whether BDI-sf scores were independently associated with SGOT and SGPT at t2. In our model, depression accounted for 21% of the variance of SGPT values at t2 [F (1,46)=10.6; P=0.002] and 16% of the variance of SGOT values at t2 [F (1,40)=7.4; P=0.010]. Higher scores on the BDI-sf were associated with higher SGOT and SGPT values. We did not include other disease-related variables (e.g., time since liver disease was diagnosed and number of times patients were told they had abnormal SGOT and SGPT) in the model, because they were not significantly correlated with the outcome variables (SGOT, SGPT). We performed a second multiple regression analysis to determine the relative contribution of LFT results, medications causing depression, and medical conditions causing depression on BDI-sf scores. Only elevated LFTs accounted for 22.5% of the variance in BDI-sf scores; the other variables were not significant. An ANOVA of this regression analysis was highly significant [F (3,46)=4.455; P=0.008].


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TABLE 5. Correlation between the BDI-sf scores and liver transaminases (n=48 at t1; n=42 at t2)



Interestingly, 12 patients (average BDI-sf score of 3.8) incorrectly perceived their diagnosis: 6 chronic hepatitis patients perceived they were healthy carriers; 1 chronic hepatitis patient perceived he was healthy; 1 patient with cirrhosis indicated he had chronic hepatitis; and 4 patients with cirrhosis indicated they were healthy carriers.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Higher BDI-sf scores were associated with elevated transaminases, more psychosocial stressors, and lower GAF scores. There are a number of possible explanations for why higher BDI-sf scores might be associated with these variables. First, patients were aware of their t1 LFT results. Patients who had abnormal LFTs at t1 may have been more distressed and, therefore, more likely to endorse symptoms of depression on the BDI-sf. We questioned whether medications or medical conditions could have caused secondary depression, but we did not find this in our results. In fact, in a multiple regression analysis that considered abnormal LFT results, medical causes of depression, and medications causing depression, abnormal LFT results accounted for 22.5% of the variance in BDI-sf scores; the other variables were not significant.

Fatigue, a symptom endorsed by 64% of patients on the BDI-sf, may have been caused by chronic liver disease and may have falsely elevated total BDI-sf scores. Despite our concern that somatic features of liver disease elevated depression scores, psychosocial symptoms of depression also were endorsed at high frequencies. Psychosocial symptoms are less likely to be attributed to the liver disease but were present at increased frequencies in this study. Participants reported sadness (40%), failure (26%), suicide (22%), guilt (22%), and pessimism (18%). It is unclear why the 3 patients with active liver disease, but normal transaminases, were not particularly depressed. Two of the 3 patients perceived themselves to be "healthy carriers," perhaps because they were aware that their transaminase values were normal. This misperception may have lowered their distress as reflected by the lower BDI-sf scores.

Forty-six percent of our patients had mild to severe depression as measured by the BDI-sf. Surprisingly, 22% of patients reported suicidal ideation on the BDI-sf. This high prevalence of psychiatric distress has not been reported previously in Asian populations. Although higher depression scores were significantly correlated with transaminases at t1 and t2, patients were aware of their transaminase abnormalities before being interviewed (i.e., at t1), and their awareness probably confounded the BDI-sf scores. Future research in this area should investigate whether the elevation of transaminases is associated with higher subsequent depression scores in patients who are unaware of their transaminase values. The high correlation between t1 and t2 values (P<0.001) makes the patients' knowledge of their t1 transaminase levels a problem in evaluating the association of t2 values with depression scores, even though patients were not aware of their t2 values at the time they completed the BDI-sf.

In the Korean culture, higher alcohol consumption is generally more accepted than in the United States. Although we did not identify any evidence of current alcohol abuse or dependence in our sample, 11 patients reported histories of intermittent heavy alcohol use in the past. Future work should include a standardized alcohol inventory (e.g., CAGE, Addiction Severity Index) and should consider cross-cultural factors in determining the presence of alcohol abuse or dependence.26,27

Sixty-four percent of patients reported fatigue on the BDI-sf. Fatigue led to fear of death, fear of loss of job, and restrictions in sexual activity and was strongly correlated with higher BDI-sf scores. This finding suggests that measurements of psychological distress in patients with hepatitis probably are influenced by fatigue. Of course, in addition to being related to hepatitis, fatigue might be an indicator of depression. It may be more socially acceptable to report fatigue than to report psychological distress in this Asian immigrant population, and somatic complaints may be indicative of mood disorders.28 In Asian societies the mind and body are viewed as one entity, and there is a tendency to voice only physical, socially acceptable complaints, rather than to report emotional distress.19 Our observations suggest that Asian patients with hepatitis who complain of fatigue on medical history should probably be further screened for the presence of depression. Future work should include a separate scale of fatigue and/or other somatic complaints.

In our study, no patients were taking IFN-{alpha} at the time of the BDI-sf administration. Given that patients on IFN- {alpha} experience fatigue early on during interferon treatment and depression later during interferon treatment,29 future studies should control for use of IFN-{alpha} in assessing psychosocial measures and fatigue. On average, patients taking propranolol or spironolactone had lower average BDI- sf scores than patients not taking medications that cause depression or lethargy. Furthermore, the use of medications with psychiatric side effects did not account for the increase in BDI-sf scores in the multiple regression analysis.

In our study, 34 patients (68%) had multiple family members with hepatitis, cirrhosis, and/or HCC. Although we expected that prior experience with death and liver disease in a patients' family would be associated with more depression and anxiety about the future, univariate analyses of depression scores did not differentiate between participants with a positive family history of liver disease and those with a negative family history. However, when a family member died, infected patients wanted their transaminases rechecked, and if the levels were increased, they described feeling depressed and had thoughts that death was imminent. Patients reported feelings of resentment and annoyance with their dead grandparents who had infected them, and the patients were concerned that their disease could progress to cancer if they lived long enough. They expressed regret over not adhering to earlier immunization recommendations, follow-up treatment, drug recommendations, and in some, having continued to consume alcohol even after diagnosis.

Not surprisingly, those patients, who were experiencing more psychosocial stressors, were more vulnerable to depression. In the literature, some HBV carriers have been described as modern day "lepers."30 Although acquired immunodeficiency syndrome (AIDS) among Korean immigrants is very rare, 2 patients in our study reported that they were treated like AIDS patients. One patient reported that at his place of work, he was actually recommended for leave of absence until the disease could be "controlled." Fear of social ostracism in the Korean community is realistic. Once a patient is diagnosed, household members and friends tend to avoid any form of contact because of the misconception that the disease is contagious. In relation to these concerns, 34% of patients in our study avoided social relationships. Our findings are consistent with another study that reported that Chinese parents who had children who were diagnosed as hepatitis B carriers hid the disease to protect their children from being shunned by the society.31 In our study, patients felt guilty about potentially infecting their children or spouse. Male patients worried more about their illness increasing the financial burden and household responsibilities on their wives than the risk of disease transmission.

Misconception about diagnosis was also a major issue reported in our study; some chronic hepatitis patients with normal transaminases indicated they were healthy. It would be useful to know if having a misconception about one's diagnosis relates to compliance with medical treatment, rates of psychiatric distress, social withdrawal, and/or health-related perceptions. Supportive educational counseling may be helpful in correcting these misconceptions and in reducing worry and anxiety.32

During the clinical interview, patients reported less anxiety and depression as time passed following their initial diagnosis of hepatitis; most of them had adapted to their disease. Family ties, religion and good relationships with their physician appeared to be important during this stage. However, depression and anxiety increased again with deteriorating liver function. Many patients hardly worked because of fear of disease progression; they often associated any right upper quadrant pain with liver disease. Adequate information from health personnel about common symptoms and available treatment modalities could help improve the outlook among our study population.

Our pilot study is limited by its small sample size, the use of one interviewer, the lack of a structured psychiatric interview, the confounding influence of patients' prior knowledge of t1 LFT results on their subsequent BDI-sf scores, and incomplete data on biological markers at t1 and t2. Data in the medical records was incomplete, and records were not always specific regarding the exact drugs patients were taking (i.e., some records listed "antihypertensive medication"). However, our study does provide some descriptive information about this understudied population. Although all patients had problems related to HBV, the sample was heterogeneous in terms of including a range of patients from healthy carriers to those with chronic hepatitis, cirrhosis, and/or hepatocellular cancer. This study needs to be replicated in other non-Korean and nonimmigrant populations to improve its generalizability. In order to better delineate the relationship between depression and biological markers, it would be useful to follow carriers prospectively, using BDI-sf scores, transaminases, and/or other biological markers of liver disease. Future investigations should use standard pre- and postintervals for measurement of the biological markers, and to ensure that all patients were tested for all markers at both time points. In our descriptive study, t2 occurred within 1 to 90 days after completion of the BDI-sf. No control group was used because we did not conduct an intervention.

In summary, Korean immigrants with chronic liver disease were screened for depression. To our knowledge, this is the first study to report a relationship between BDI- sf scores in patients with chronic liver disease and biological parameters of liver dysfunction. Subsequent exploration may reveal whether depressed patients experience worse liver dysfunction over time and whether worsening liver dysfunction might relate to behavior and/or biological factors. Researchers should explore the relationship of BDI-sf depression scores with subsequent transaminase elevations. As t2 transaminase elevations were highly correlated with t1 values, and as patients were aware if their t1 transaminase values were abnormal, this may have confounded our correlation of BDI-sf scores with t2 transaminase values. Keeping the patients blind to their t1 LFT results would prevent their knowledge of abnormal LFT results from influencing their subsequent BDI-sf scores. Our observations need to be substantiated in larger groups of Korean and non-Korean patients with different degrees of liver impairment.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Zane NWS, Taekeuchi DT, Young KNJ (eds): Hepatitis B, in Confronting Critical Issues of Asian and Pacific Islander Americans. Thousand Oaks, CA, SAGE Publications, 1994, pp 148–173
  2. Beasley RP, Lin CC, Hwang LY, et al: Hepatocellular carcinoma and hepatitis B virus: a prospective study of 22,707 men in Taiwan. Lancet 1981; 2:1129–1132
  3. DiBisceglie AM, Rustgi VK, Hoofnagle JH: NIH conference, Hepatocellular carcinoma. Ann Intern Med 1988; 108:390–401
  4. El-Serag HB, Mason AC: Rising incidence of hepatocellular carcinoma in the United States. N Engl J Med 1999; 340:745–750[Abstract/Free Full Text]
  5. Zakim D, Boyer TD (eds); Hepatic Oncogenesis, in Hepatology: A Textbook of Liver Disease, 3rd Edition, Vol 2. Philadelphia, PA, Saunders, 1996, pp 1490–1452
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