The importance of fatigue cognitions in chronic hepatitis C infection

https://doi.org/10.1016/j.jpsychores.2014.11.011Get rights and content

Highlights

  • Fatigue is an unresolved clinical issue in chronic hepatitis C (HCV) infection.

  • We evaluated sleep, depression, and fatigue cognitions in association with HCV fatigue.

  • The main predictors of fatigue were fatigue-specific cognitions.

  • Fatigue cognitions could be new treatment targets in HCV related fatigue.

Abstract

Chronic Hepatitis C virus (HCV) infection is a source of significant public health burden worldwide. Fatigue is a cardinal patient reported consequence of the disease. HCV infection associated fatigue leads to significant impairment in the quality of life and day-to-day functioning. Despite its clinical significance, the factors that contribute to adverse impact of fatigue in HCV infection are largely unknown.

Objectives

This study evaluated the contributions of insomnia, depression symptoms, and fatigue-specific cognitions to fatigue-related functional impairment.

Methods

Fatigue, insomnia, depression symptoms, as well as fatigue cognitions were assessed in participants (36% females; age > 18 years, N = 115) with chronic HCV infection at a tertiary hepatitis clinic.

Results

Sixty percent of participants reported clinically significant fatigue (Fatigue Severity Index FSS  4). Comorbidities and fatigue perceptions accounted for 61% of the variation of fatigue. Fatigue perceptions were the main predictors of adverse fatigue outcomes (B = .114, 95% CI = .054–.154). Patients with clinically significant fatigue were four-times more likely than less fatigued patients to believe that the main cause of their fatigue was the infection.

Conclusion

Patients' beliefs about their fatigue were the main predictors of adverse fatigue outcomes. These results suggest that fatigue associated with chronic hepatitis C infection can be conceptualized using a cognitive behavioral approach. This was the first study to evaluate the role of both comorbid mood/sleep and cognitive predictors of fatigue in a single model. Integrating the findings into existing treatment strategies could improve patient reported outcomes in chronic hepatitis C infection.

Introduction

Hepatitis C virus (HCV) causes chronic, insidious liver infection in 130–170 million individuals around the world [1]. The screening of transfusion blood has resulted in a significant decline in the rate of new infections in North America and Europe, but chronic HCV infection has been, and is predicted to remain, the leading cause of liver transplantation on these continents [2]. Although anti-viral treatment is available, its impact is restricted because: (1) the majority of individuals with chronic HCV infection are not aware of their infection, therefore do not seek anti-viral treatment; (2) patients with mild liver disease may not be offered treatment; (3) treatment adherence may be limited as a result of psychiatric comorbidities; and (4) not all patients show sustained treatment response to the currently available antiviral agents [3]. Therefore, a significant proportion of those infected live with a slowly progressing liver disease for years or decades. For these individuals, symptoms that impact quality of life and every day functioning are of the key disease-related concerns.

Fatigue is among the leading patient-reported symptoms in chronic HCV infection [4], [5]. In qualitative studies, patients described fatigue as the most concerning symptom of their illness and in quantitative reports fatigue was the second most common patient-reported outcome measure of the infection [5]. In the presence of persistent fatigue, increased effort is required to maintain important social roles and activities. Therefore, fatigue has an impact both on subjective well-being and on everyday functioning. Previous research has failed to detect a relationship between disease markers (e.g. virus load and liver disease severity) and fatigue in chronic hepatitis C infection [6], [7], [8]. This evidence suggests that factors other than the disease per se give rise to the “lived experience” of fatigue in the context of chronic HCV infection. Despite fatigue being ubiquitous and a significant concern for patients with chronic HCV infection, the secondary factors that may contribute to chronic fatigue in this condition are largely unexplored. In order to advance the study of fatigue in chronic HCV infection, one should rely on evidence-based fatigue models that can be systematically tested and adapted to hepatitis C -related fatigue.

Theoretical models of fatigue in the medically ill posit that disease-related (primary) biological factors give rise to physiological fatigue that is maintained and amplified by secondary factors associated with the disease, including depression and sleep problems [9]. A parallel line of research, conceived in the cognitive–behavioral tradition, has shown that patients' beliefs about their illness and fatigue predict chronic fatigue independently of the characteristics (e.g. severity, course and activity) of the underlying disease [10], [11], [12], [13], [14], [15], [16], [17]. The importance of fatigue cognitions is also supported by the fact that change of fatigue-specific beliefs mediates the therapeutic effect of cognitive behavioral therapy for fatigue in multiple sclerosis and chronic fatigue syndrome [14], [15], [18].

The studies on fatigue-specific cognitions and behaviors have been largely related to cancer, multiple sclerosis and chronic fatigue syndrome hitherto. Although the above theories have not been tested in patients with HCV infection, the association of depression with fatigue has been established in patients with HCV treated at tertiary liver clinics [8], [19], [20], [21]. However, the relative contribution of depression to fatigue even in this selected patient population is unclear, since the studies conducted thus far have not included other, theoretically important “secondary” factors (e.g. sleep problems and fatigue-cognitions) concurrently in the assessments and in the statistical models. With respect to sleep, limited evidence indicates that 60–70% of patients with chronic HCV infection report sleep problems, but the prevalence of specific sleep disorders and the contribution of compromised sleep to fatigue in HCV are unknown. Hepatitis C related fatigue has not been studied from the cognitive behavioral perspective. Qualitative studies have been a rich source of information vis-à-vis patients' subjective perception of the illness. However, a quantitative evaluation of these illness cognitions in relation to fatigue has been very limited [22].

Given that: (1) a large number of individuals with HCV infection do not require/receive antiviral treatment; and (3) mood, sleep, and non-adaptive cognitions are amenable to therapeutic interventions, evaluating the possible contribution of these factors to HCV-related fatigue is imperative.

The objective of the current study was to evaluate the “secondary fatigue” and cognitive models in chronic HCV infection. Specifically, we set out to evaluate the contribution of depression, insomnia, as well as fatigue perceptions to clinically significant (functionally disabling) fatigue in patients with chronic HCV infection. Our hypothesis was that depression symptoms, clinical insomnia, and fatigue-perceptions predict the functional impact of fatigue above and beyond the severity of the liver disease and the presence other medical comorbidities.

Section snippets

Participants

A consecutive sample of English speaking participants (N = 132, age > 18 years) diagnosed with chronic hepatitis C infection was recruited at the Toronto General Hospital Liver Clinic, Toronto, Canada. All participants were anti-HCV positive as verified by ELISA II or III, and confirmed by RIBA II or III, or by PCR for HCV RNA. Only individuals who had not received antiviral treatment within 6 weeks of enrolment were recruited; this period was determined based on the pharmacological properties of the

Demographics

Table 1 summarizes the sample characteristics. Briefly, the participants were 23–82 years old (M = 55.82, SD = 9.85). Almost two-thirds of the sample (63.85%) was male. Participants were diagnosed with the chronic HCV infection less than one year to 35 years prior to the data collection (M = 12.64, SD = 8.95). Participants had the full range of liver disease severity (fibrosis stages F0 to F4). Almost half of the sample reported a history of anti-HCV treatment (49.6%). Participants reported a history of

Discussion

We evaluated for the first time the unique contributions of depression, insomnia, and fatigue-specific cognitions on fatigue-induced functional impairment in patients with chronic hepatitis C infection. The study revealed that fatigue-specific cognitions (i.e. concern about fatigue and personal control beliefs) were the main predictors of fatigue-induced functional impairment. Insomnia and depression accounted for close to one quarter of the variation of fatigue (after controlling for the liver

Author declaration of conflict of interest

The authors of the manuscript entitled “The Importance of Fatigue Cognitions in Chronic Hepatitis C Infection” wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

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    This study was conducted at the University Health Network, University of Toronto, Toronto, Canada.

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