The importance of fatigue cognitions 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.
References (62)
- et al.
Report of the first International Liver Transplantation Society expert panel consensus conference on liver transplantation and hepatitis C
Liver Transpl
(2003) - et al.
The role of illness severity and illness representations in adjusting to multiple sclerosis
J Psychosom Res
(2003) - et al.
Fatigue and social impairment in multiple sclerosis: the role of patients' cognitive and behavioral responses to their symptoms
J Psychosom Res
(2006) - et al.
The central role of cognitive processes in the perpetuation of chronic fatigue syndrome
J Psychosom Res
(2010) - et al.
Understanding multiple sclerosis fatigue: a synthesis of biological and psychological factors
J Psychosom Res
(2006) - et al.
A comparison of depression screening instruments in hepatitis C and the impact of depression on somatic symptoms
Psychosomatics
(2011) - et al.
Depression, fatigue, and functional disability in patients with chronic hepatitis C
J Psychosom Res
(2000) - et al.
Biopsychosocial predictors of fatigue in chronic hepatitis C
J Psychosom Res
(2005) - et al.
Validation of the Insomnia Severity Index as an outcome measure for insomnia research
Sleep Med
(2001) - et al.
The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the Beck depression and anxiety inventories
Behav Res Ther
(1995)
The brief illness perception questionnaire
J Psychosom Res
Liver biopsy
Gastroenterol Clin Biol
Non-invasive evaluation of liver fibrosis using transient elastography
J Hepatol
Determinants of chronic fatigue in disease-free breast cancer patients: a cross-sectional study
Ann Oncol
Anxiety disorders: why they persist and how to treat them
Behav Res Ther
A cognitive model of insomnia
Behav Res Ther
Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors
Sleep Med
The psychology of fatigue in patients with multiple sclerosis: a review
J Psychosom Res
Cognitive behavior therapy for functional somatic complaints. The example of chronic fatigue syndrome
Psychosomatics
Diagnosed with hepatitis C: a descriptive exploratory study
Int J Nurs Stud
Chronic insomnia
Lancet
The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies
Sleep Med Rev
Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial
Lancet
A pilot randomised controlled trial of an Internet-based cognitive behavioural therapy self-management programme (MS Invigor8) for multiple sclerosis fatigue
Behav Res Ther
World Health Organization hepatitis C fact sheet 2011
Management of chronic hepatitis C: consensus guidelines
Can J Gastroenterol
Neurobehavioral correlates of chronic hepatitis C infection
J Psychopathol Behav Assess
Review of patient-reported outcome measures in chronic hepatitis C
Health Qual Life Outcomes
Fatigue does not correlate with the degree of hepatitis or the presence of autoimmune disorders in chronic hepatitis C infection
Eur J Gastroenterol Hepatol
Fatigue in patients with chronic hepatitis C
J Viral Hepat
Fatigue, depression and chronic hepatitis C infection
Psychol Med
Cited by (19)
Hepatitis C virus infection, and neurological and psychiatric disorders – A review
2017, Journal of Advanced ResearchCitation Excerpt :The study provides important evidence to support the hypothesis that HCV itself is responsible for a major component of HRQL impairments. Fatigue is one of the most commonly reported symptoms of infection with hepatitis C, and can be persistent and debilitating [6,19,25–29]. It has been assessed using various qualitative and quantitative methodologies in the literature, with a reported prevalence ranging from 20% to 80% in different cohorts.
Hepatitis C infection: A multi-faceted systemic disease with clinical, patient reported and economic consequences
2016, Journal of HepatologyCitation Excerpt :PROs are defined as measurements of a patient’s state of health as perceived by the patient and are reported directly from the patient without any modification [74]. Therefore, through the use of PRO instruments, clinical investigators have been able to establish that patients with HCV infection experience tremendous impairment in their health related quality of life (HRQOL) and well-being, especially in the domains of physical functioning, mental health, and work productivity as a result of the virus itself [64–73,75–80]. Additionally, multivariate analyses have determined that disease severity (presence of advanced liver disease), and psychiatric co-morbidities, especially depression, are important drivers of PRO impairment [67,75,76,78].
Predictive value of P300 event-related potential component in early cognitive impairment in patients with uncomplicated newly diagnosed hepatitis C virus
2022, Egyptian Journal of Neurology, Psychiatry and Neurosurgery
- ☆
This study was conducted at the University Health Network, University of Toronto, Toronto, Canada.