Chronic liver disease (CLD) is a progressive disorder characterized by persistent hepatic inflammation, hepatocellular injury, fibrosis, and gradual deterioration of liver function lasting for more than six months. It includes a broad spectrum of liver disorders such as chronic hepatitis B, hepatitis C, alcohol-related liver disease, autoimmune hepatitis, metabolic dysfunction-associated steatotic liver disease (MASLD), and inherited metabolic disorders. Progressive fibrosis ultimately leads to cirrhosis, portal hypertension, hepatic failure, and hepatocellular carcinoma, contributing substantially to morbidity and mortality worldwide [1,2]. CLD has emerged as a major public health problem in India owing to the increasing prevalence of viral hepatitis, alcohol consumption, obesity, diabetes mellitus, and metabolic syndrome, resulting in a significant healthcare burden [3]. The clinical manifestations of chronic liver disease extend beyond hepatic dysfunction and include profound physical, psychological, and social consequences. Patients frequently experience fatigue, weakness, sleep disturbances, pruritus, abdominal discomfort, muscle cramps, cognitive dysfunction, and reduced work capacity, all of which adversely affect their health-related quality of life (HRQoL). Although advances in medical management have improved survival, enhancing patients' quality of life has become an equally important therapeutic objective [4]. Several studies have demonstrated that deterioration in HRQoL occurs even during the compensated stages of liver disease and progressively worsens with increasing disease severity [4,5]. Fatigue is one of the most common and disabling symptoms experienced by patients with chronic liver disease. Unlike normal tiredness, fatigue associated with CLD is persistent, poorly relieved by rest, and significantly interferes with daily activities, occupational performance, and interpersonal relationships. The underlying mechanisms are multifactorial and include chronic inflammation, altered neurotransmission, autonomic dysfunction, sarcopenia, sleep disorders, and psychological distress. Persistent fatigue has consistently been identified as one of the strongest predictors of poor quality of life among patients with chronic liver disease [6,7]. Psychological morbidity is increasingly recognized as an important determinant of disease outcomes in CLD. Anxiety and depression are common because patients face uncertainty regarding disease progression, financial burden, repeated hospitalizations, lifestyle modifications, fear of complications, and possible liver transplantation. These psychiatric comorbidities negatively influence treatment adherence, self-care behaviour, social functioning, and overall quality of life. Therefore, assessment of mental health has become an essential component of comprehensive management of chronic liver disease [6,8]. Resilience, defined as an individual's ability to adapt positively to adversity and recover from stressful life events, has recently gained attention in chronic disease research. Patients with greater resilience demonstrate better psychological adjustment, improved coping strategies, enhanced treatment adherence, and superior quality of life despite chronic illness. Conversely, low resilience has been associated with increased fatigue, anxiety, depression, and poorer health outcomes. Despite its clinical importance, resilience has received relatively little attention among patients with chronic liver disease, particularly in the Indian population [8]. Several Indian investigators have highlighted the importance of assessing quality of life in patients with chronic liver disease. Ray et al. evaluated the Bengali version of the Chronic Liver Disease Questionnaire (CLDQ) and demonstrated significant impairment in physical, emotional, and social domains among Indian patients with CLD [9]. Benjamin et al. subsequently translated and validated the Hindi version of the CLDQ in 494 patients, confirming its excellent reliability and validity for assessment of health-related quality of life in Indian patients [5]. Similarly, Jyoti et al. reported that a substantial proportion of hospitalized CLD patients had poor to moderate quality of life, emphasizing the need for psychosocial interventions as part of routine clinical care [10]. Although previous studies have independently examined quality of life, fatigue, anxiety, or depression in chronic liver disease, only a limited number of studies have comprehensively evaluated all these domains together with resilience, especially in the Indian setting. Simultaneous assessment of these interrelated psychosocial factors may facilitate early identification of vulnerable patients and guide multidisciplinary interventions aimed at improving overall well-being and treatment outcomes. Therefore, the present study, "Evaluation of Quality of Life, Fatigue, Resilience, Anxiety, and Depression among Patients with Chronic Liver Disease," was undertaken to comprehensively assess these important patient-reported outcomes among patients attending a tertiary care hospital. The findings are expected to contribute to a better understanding of the psychosocial burden of chronic liver disease and support the development of holistic management strategies.

Study Design and Setting This hospital-based, cross-sectional observational study was conducted in the Department of Psychiatry, Venkateshwara Institute of Medical Sciences (VIMS), Gajraula, Uttar Pradesh, India, over a period of 12 months. Study Population The study included adult patients diagnosed with chronic liver disease (CLD) who were referred from the Department of General Medicine/Gastroenterology or attended the Psychiatry outpatient and inpatient services for psychological assessment during the study period. Sample Size A total of 130 patients with chronic liver disease were enrolled in the study using consecutive sampling after fulfilling the eligibility criteria and providing written informed consent. Inclusion Criteria • Patients aged 18 years or older. • Diagnosed with chronic liver disease of at least 6 months' duration, irrespective of etiology. • Able to understand and respond to study questionnaires. • Willing to participate and provide written informed consent. Exclusion Criteria • Patients with hepatic encephalopathy (Grade II or above) or severe cognitive impairment. • Patients with severe psychiatric disorders such as schizophrenia, bipolar affective disorder, or other psychotic illnesses diagnosed before the onset of liver disease. • Patients with major neurological disorders affecting cognition. • Patients with severe comorbid medical illnesses such as advanced malignancy or end-stage renal disease. • Patients unwilling to participate in the study. Data Collection After obtaining approval from the Institutional Ethics Committee and written informed consent from each participant, demographic and clinical details were recorded using a structured proforma. Information collected included age, sex, educational status, occupation, marital status, socioeconomic status, duration and etiology of chronic liver disease, associated comorbidities, alcohol use, and relevant laboratory and clinical findings. Study Instruments The following validated instruments were administered by trained psychiatrists: • Chronic Liver Disease Questionnaire (CLDQ): Used to assess disease-specific health-related quality of life across six domains: abdominal symptoms, fatigue, systemic symptoms, activity, emotional function, and worry. • Fatigue Severity Scale (FSS): A 9-item instrument used to evaluate the severity and impact of fatigue on daily functioning. Higher scores indicate greater fatigue. • Connor–Davidson Resilience Scale (CD-RISC-25): Used to assess psychological resilience. Higher scores represent greater resilience. • Hospital Anxiety and Depression Scale (HADS): A 14-item questionnaire comprising two subscales: anxiety (HADS-A) and depression (HADS-D), each containing seven items. Scores of 8–10 indicate borderline abnormality, while scores ≥11 suggest clinically significant anxiety or depression. Ethical Considerations The study protocol was reviewed and approved by the Institutional Ethics Committee of Venkateshwara Institute of Medical Sciences (VIMS), Gajraula, Uttar Pradesh, India. Written informed consent was obtained from all participants before enrolment. Confidentiality and anonymity of participant information were maintained throughout the study in accordance with the ethical principles of the Declaration of Helsinki. Statistical Analysis Data were entered into Microsoft Excel and analysed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as mean ± SD, and categorical variables as frequency and percentage. Group comparisons were performed using the Student's t-test/Mann–Whitney U test and Chi-square/Fisher's exact test, as appropriate. Correlations were assessed using Pearson's or Spearman's correlation coefficients, and multivariable linear regression was used to identify predictors of quality of life. A p-value <0.05 was considered statistically significant. Observation and Results A total of 130 patients diagnosed with chronic liver disease were enrolled in the study.Among the 130 patients with chronic liver disease, the majority were middle-aged males, with alcohol-related liver disease being the predominant etiology. The study demonstrated significantly impaired quality of life accompanied by high fatigue levels, reduced resilience, and a high prevalence of anxiety and depression. Quality of life was significantly associated with all psychological parameters, showing negative correlations with fatigue, anxiety, and depression and a positive correlation with resilience (p < 0.001 for all), highlighting the need for routine psychological assessment as part of comprehensive chronic liver disease management

Table 1. Socio-demographic Characteristics of Study Participants (n = 130) Variable Frequency (n) Percentage (%) Age (years) 18–30 15 11.5 31–40 24 18.5 41–50 39 30.0 51–60 34 26.2 >60 18 13.8 Gender Male 88 67.7 Female 42 32.3 Most patients (30.0%) belonged to the 41–50 years age group. The mean age was 49.2 ± 11.8 years. Males constituted 67.7% of the study population. Table 2. Clinical Characteristics of Patients (n = 130) Variable Frequency (n) Percentage (%) Etiology of CLD Alcohol-related liver disease 46 35.4 MASLD/NAFLD 34 26.2 Hepatitis B 22 16.9 Hepatitis C 15 11.5 Autoimmune/Others 13 10.0 Duration of Disease <2 years 38 29.2 2–5 years 56 43.1 >5 years 36 27.7 Alcohol-related liver disease was the commonest etiology (35.4%), followed by MASLD (26.2%). Nearly half (43.1%) of the patients had disease duration between 2 and 5 years. Table 3. Quality of Life, Fatigue, Resilience, Anxiety and Depression Scores (n = 130) Variable Mean ± SD Chronic Liver Disease Questionnaire (CLDQ) Score 4.15 ± 0.96 Fatigue Severity Scale (FSS) Score 5.28 ± 1.18 Connor–Davidson Resilience Scale (CD-RISC) Score 56.84 ± 11.72 HADS-Anxiety Score 9.94 ± 3.46 HADS-Depression Score 10.58 ± 3.92 Patients with chronic liver disease exhibited reduced quality of life, high fatigue scores, moderately reduced resilience, and clinically significant anxiety and depression. Table 4. Distribution of Patients According to Anxiety and Depression Severity (HADS) (n = 130) Category Anxiety n (%) Depression n (%) Normal (0–7) 36 (27.7) 32 (24.6) Borderline (8–10) 40 (30.8) 39 (30.0) Abnormal (≥11) 54 (41.5) 59 (45.4) Clinically significant anxiety was observed in 41.5% of patients, while 45.4% had clinically significant depression. Approximately one-third had borderline anxiety or depression. Table 5. Correlation of Quality of Life with Fatigue, Resilience, Anxiety and Depression (n = 130) Variable Pearson Correlation (r) p-value Fatigue Severity -0.69 <0.001* Resilience 0.61 <0.001* Anxiety -0.64 <0.001* Depression -0.72 <0.001* Quality of life showed a strong negative correlation with fatigue, anxiety, and depression, whereas it demonstrated a significant positive correlation with resilience. Depression exhibited the strongest association with poor quality of life (r = −0.72, p < 0.001).

The present study evaluated quality of life (QoL), fatigue, resilience, anxiety, and depression among 130 patients with chronic liver disease (CLD) attending a tertiary care hospital. The findings demonstrated significantly impaired quality of life, high fatigue levels, reduced resilience, and a high prevalence of anxiety and depressive symptoms, indicating that CLD adversely affects both physical and psychological well-being. In the present study, the majority of patients belonged to the 41–50-year age group, with males constituting 67.7% of the study population. This predominance of middle-aged men is consistent with the findings of Benjamin et al. who validated the Hindi version of the Chronic Liver Disease Questionnaire (CLDQ) in Indian patients and reported that CLD predominantly affected middle-aged males because of the higher prevalence of alcohol-related liver disease and chronic viral hepatitis in this demographic [5]. Similar observations were reported by Ray et al., who found a male predominance among patients with chronic liver disease attending a tertiary care centre in Eastern India [9]. Alcohol-related liver disease was the most common etiology (35.4%) in our study, followed by metabolic dysfunction-associated steatotic liver disease (MASLD). These findings are in agreement with Sarin et al., who reported that alcohol-related liver disease and metabolic liver disease have emerged as the leading causes of chronic liver disease and cirrhosis in India because of increasing alcohol consumption, obesity, diabetes mellitus, and metabolic syndrome [11]. Likewise, Sharma et al. observed that alcohol-related liver disease accounted for approximately one-third of CLD admissions in North India [12]. The mean CLDQ score observed in the present study indicated markedly impaired health-related quality of life. Chronic liver disease affects physical functioning, emotional well-being, daily activities, and social participation, thereby reducing overall quality of life. Similar findings were reported by Younossi et al., who demonstrated that patients with CLD experience significantly lower quality-of-life scores than healthy individuals, irrespective of disease etiology [4]. In India, Ghoshal and Das also emphasized that health-related quality of life declines progressively with worsening liver disease severity and should be considered an essential outcome measure during clinical management [6]. Fatigue was one of the most prominent symptoms identified in the present study, with a high mean Fatigue Severity Scale score. Fatigue in chronic liver disease is multifactorial and results from chronic inflammation, altered neurotransmission, sleep disturbances, autonomic dysfunction, and muscle wasting. Similar observations were reported by Jones et al., who identified fatigue as one of the most disabling symptoms in chronic liver disease and a major determinant of reduced quality of life [13]. Newton further reported that fatigue persists even in compensated liver disease and often remains despite improvement in biochemical parameters [14]. Our study demonstrated a high prevalence of clinically significant anxiety (41.5%) and depression (45.4%). Chronic illness, uncertainty regarding prognosis, financial burden, repeated hospitalizations, and fear of complications contribute substantially to psychological distress among CLD patients. Similar findings were reported by Nardelli et al., who found that anxiety and depression were highly prevalent among patients with liver cirrhosis and were associated with poorer treatment adherence and increased healthcare utilization [15]. Likewise, Dwight et al. reported significantly higher levels of depression and anxiety among patients with chronic hepatitis and cirrhosis compared with healthy controls [16]. An important finding of the present study was the relatively lower resilience scores among patients with chronic liver disease. Resilience plays a crucial role in helping patients adapt to chronic illness and maintain psychological well-being. Patients with greater resilience generally demonstrate better coping skills, improved adherence to treatment, and superior quality of life. Similar findings were reported by Bai et al., who showed that resilience was positively associated with psychological well-being and quality of life among patients with chronic diseases, including chronic liver disorders [17]. Correlation analysis in the present study revealed that quality of life was negatively associated with fatigue, anxiety, and depression, whereas resilience showed a positive correlation with quality of life. Depression demonstrated the strongest negative association with quality of life. These findings agree with those of Rajpurohit et al., who reported that psychological factors such as depression, anxiety, perceived stress, and social support were among the strongest predictors of impaired quality of life in patients with liver cirrhosis [18]. Similarly, Younossi et al. concluded that psychosocial factors independently influence health-related quality of life, irrespective of the severity of liver dysfunction [2]. Overall, the findings of the present study emphasize that chronic liver disease is not merely a hepatic disorder but a condition with profound psychosocial consequences. Routine assessment of quality of life, fatigue, resilience, anxiety, and depression should therefore be incorporated into standard hepatology practice. Early psychiatric intervention, counselling, psychosocial rehabilitation, and multidisciplinary care may significantly improve overall patient outcomes and quality of life.

The present study concludes that patients with chronic liver disease experience significant impairment in health-related quality of life, accompanied by high levels of fatigue, reduced resilience, and a considerable prevalence of anxiety and depression. Fatigue and depression were found to be the strongest factors associated with poorer quality of life, whereas greater resilience was associated with better psychological well-being and improved quality of life. These findings emphasize that chronic liver disease affects not only physical health but also emotional and psychosocial functioning, underscoring the need for a holistic approach to patient care. Routine screening for fatigue, anxiety, depression, and resilience should be integrated into the standard management of patients with chronic liver disease to facilitate early identification of psychological distress and timely intervention. A multidisciplinary approach involving hepatologists, psychiatrists, psychologists, and counsellors can enhance coping abilities, improve treatment adherence, and ultimately promote better health-related quality of life and overall clinical outcomes in this patient population. Funding: Nil. Conflict of Interest: None declared. Informed Consent: Written informed consent was obtained from all participants.

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