In the current issue of Clinical and Molecular Hepatology, Jang et al. [5] reported that patients with liver cirrhosis newly diagnosed had higher suicide rates. The suicide rate was 2.59 times higher in the first 2 years after diagnosis and 3.72 times higher in patients aged between 18 and 49 years compared to the rates in the matched cohort group [5]. These suicide risks were similar between alcohol-related vs. non-alcohol-related, and compensated vs. decompensated groups. Previous studies on the association of liver cirrhosis and depression were based on a limited number of cases [6-9], self-reported liver disease, and suicidal ideation [10]. They classified depression using either the Beck depression inventory or the Hamilton depression rating scale [8,9], which was far from the physician’s diagnosis [3]. The operational diagnosis of liver cirrhosis used in the current study may be clinically inaccurate. However, this study is unique in that it was based on a nationwide claims database. Moreover, the present study evaluated the association between liver cirrhosis and unambiguous objective cause of death, namely suicide. The suicide incidence rate in younger patients with liver cirrhosis was distinctively higher than that of the general population. According to the Korean Statistical Information Service, the number of self-harm cases that led to suicide was 26.9 per 100,000 persons, and it accounted for 4.7% of the total deaths in South Korea in 2019 [11]. The frequency of suicidal cases tends to increase in higher age groups; 67.8 per 100,000 persons in their 80s, 46.2 per 100,000 persons in their 70s, and 33 per 100,000 persons in their 60s [12]. The underlying mechanism for the association between the psychological substrate and liver cirrhosis remains unclear. Free triiodothyronine levels lower than 3.5 mol/L among chronic hepatitis B patients have been associated with clinical depression (odds ratio [OR], 7.85; 95% confidence interval [CI], 1.839–33.547) and clinical insomnia (OR, 3.91; 95% CI, 1.417–10.789), respectively [13]. Blood serotonin level was decreased in liver cirrhosis patients with depressive disorder [14,15]. Disarrangement of melatonin homeostasis was presumed to be related to daytime sleepiness and fatigue [16]. Nevertheless, further studies on the possible mechanisms are required.

These results support the need for patient-centered interventions to improve the quality of life for patients with liver cirrhosis. Paradoxically, the group with anxiety/depression showed longer overall survival than the non-disorder group among patients with hepatocellular carcinoma [17]. Patients should be educated on how to take care of themselves during unpredictable decompensating events. They also need to be briefed on their treatment goals and how they can prepare for their future [18]. Nonhospice palliative care for end-stage liver disease is frequently misconstrued as end-oflife care by both patients and healthcare providers [4]. However, it is not far from clinical practice. Verna et al. [4] suggested using screening tools to integrate palliative care intervention in the earlier stages of liver cirrhosis. Such tools included 1) Child-Pugh class C, 2) more than one liver-related admission within the last 6 months, 3) ongoing alcohol use in the context of known alcohol-associated liver disease, 4) unsuitability for liver transplantation, and 5) the World Health Organization/Eastern Cooperative Oncology Group performance score of 3 or 4 [4]. An ongoing multicenter randomized controlled trial aims to assess and compare the effectiveness of palliative care led by a specialist (non-hepatologist) and a trained hepatologist [18]. The change in patients’ quality of life in the first 3 months is the primary outcome. The results of this trial will provide scientific evidence supporting the need for integration of palliative care in routine hepatology care. Furthermore, evidence-based profit margins for palliative care services should be implemented in the healthcare system.