Anxiety and Depression in Liver Disease: Pathways, Prevalence, and Implications for Care - a Review.

Anxiety and depressive symptoms and disorders are highly prevalent among individuals living with chronic liver disease, yet remain insufficiently recognised and addressed in hepatology care. Evidence supports a bidirectional relationship between liver and mental health: psychiatric conditions may contribute to behavioural and metabolic risk factors for liver disease, while chronic liver disease increases vulnerability to anxiety and depression through biological mechanisms, symptom burden, and stigma. These interactions adversely affect continuity of care, health-related behaviours, and disease progression, highlighting a persistent gap in integrated hepatology care. In this review, we synthesise evidence on prevalence, underlying mechanisms, and care models addressing anxiety and depressive symptoms and clinically defined disorders across major chronic liver disease aetiologies, including metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol-related liver disease (ALD), and chronic hepatitis B and C. We consider disease stages ranging from non-cirrhotic disease to compensated cirrhosis, adopting a liver-centred but clinically inclusive perspective. Across studies, outcomes are assessed using symptom-based scales and diagnostic criteria. Reported prevalence varies widely: in ALD, depressive symptoms range from 9.00% to 34.92%; in MASLD, anxiety from 6.90% to 56.11% and depression from 2.61% to 75.00%; in chronic HBV, anxiety from 6.00% to 39.56% and depression from 0.65% to 68.18%; and in HCV prior to direct-acting antiviral therapy, anxiety from 8.28% to 60.0% and depression from 8.99% to 55.06%, reflecting heterogeneity in populations and measurement methods. We highlight key implementation barriers and argue for integrating mental health as a core component of hepatology care. Adapting transplant assessment models to routine care, alongside policies addressing stigma, social determinants, and health-system incentives, may improve quality of life, slow disease progression, and reduce the burden of chronic liver disease.