is on a topic that's rarely discussed in the context of chronic liver disease, behavioral health services. The Public Health SIG Planning Committee chose to focus on this topic for exactly that reason, and because it's an unmet, but critical need for chronic liver disease. Our goal over the next one and a half hours is to convince you of this need and highlight potential strategies to address this pressing need. My name is Maya Balakrishnan, I'm faculty at Baylor College of Medicine in Houston, Texas, and I'm co-leading this session with my colleague, Manisha Verma, who's based at Einstein in Philadelphia. We have four speakers who will discuss specific aspects of behavioral health related to chronic liver disease, and I'll introduce them with more detail in a few minutes. But first, I'd like to spend a few slides discussing behavioral health and laying the groundwork for how it relates to chronic liver disease. First, I'll define behavioral health, and then I'll describe how it intersects with chronic liver disease. Lastly, I'll introduce specific applications of behavioral health to chronic liver disease, which our speakers will delve into with much greater detail during each of their presentations. So, what is behavioral health? Well, the concept of behavioral health originated over 40 years ago, and its meaning has really changed over time. Currently, people tend to equate behavioral health with mental health and substance abuse and addictions. While it's true that behavioral health does encompass those two aspects, the definition of behavioral health can be thought of much more broadly to include risky health behaviors, for example, unhealthy dietary patterns, physical inactivity, and smoking. It also encompasses the management of stress-related physical symptoms, social isolation, and life stressors and crises. From a practical point of view, behavioral health services span mental health care, substance use, and addiction management, as well as support and interventions for health behavior change, for example, in dietary habits, smoking, and weight loss interventions. Behavioral health care has relevance through the disease spectrum, from disease prevention to treatment, from disease prevention to interventions and treatment, to post-recovery support. The link between behavioral health and chronic disease has been recognized for a very long time. In fact, 20 years ago, in 2001, the Institute of Medicine declared behavioral health care and primary care inseparable. This was based on recognized bi-directional relationships between behaviors and chronic disease, and it prompted a large body of work investigating how one impacts the other and how behavioral health and chronic disease care could be integrated. And there's numerous examples of how the two are linked, and a great deal of research that's been dedicated in looking at how the two can be delivered together in medical settings. One of the most cited examples in general medicine is the link between depression and type 2 diabetes, which I'll just review because conceptually, I think we can learn from this link and apply it to chronic liver disease. So it's well recognized that people with depression are more likely to engage in risky behavioral patterns in diet and physical activity, putting them at risk for type 2 diabetes and its complications. Well, the reverse is true as well. Type 2 diabetes-related distress, distress that comes about because of the experience of the disease and its symptoms can lead to or exacerbate depression. It can exacerbate risky behavioral patterns. It can even promote medical non-adherence and thus exacerbate the risky behavioral patterns leading to worsening type 2 diabetes and its complications. Behavioral healthcare is important to break this vicious cycle, with points of intervention being the management of depression through mental healthcare, through lifestyle counseling, and behavioral healthcare can also offer counseling and teaching strategies to help patients cope with their disease, with its physical symptoms and with the psychological experience of the disease. Now, behavioral health is far less studied in the context of chronic liver disease, but we can model the link between behavioral health and chronic liver disease in a similar manner. The most common chronic liver diseases are alcohol-related liver disease and NAFLD. Both are the consequences of risky health behaviors in diet, physical activity, and alcohol drinking. There are certain behavioral determinants that influence individual-level behaviors, that is, mental health disorders, addictions, certain cognitive factors, and social stressors. These influence how and to what extent people engage in these risky behaviors that put them at risk for alcohol-related liver disease and NAFLD, and also influence their likelihood of progressing to end-stage liver disease and the need for liver transplant. But conversely, chronic liver disease, as is well-recognized, itself is associated with illness-related distress. Chronic liver disease, cirrhosis, end-stage liver disease are all related with the development of illness-related distress, increased risk of depression, anxiety, which can exacerbate behavioral determinants of risky behaviors, can exacerbate risky behaviors directly, promote medical non-adherence, and again, exacerbate this progression to chronic liver disease, end-stage liver disease, and the need for transplant. So again, breaking the cycle potentially means engaging with behavioral healthcare. And that's the focus of today's session, to discuss how behavioral health is related to the care of chronic liver disease. And over the next four talks, our speakers will identify potential behavioral targets in the context of alcohol-related liver disease and NAFLDs, and also in the transplant patient population. They'll identify potential behavioral health targets and interventions in these patient populations. So first we'll hear from Jessica, from Dr. Mellinger, an assistant professor of medicine at the University of Michigan, who'll tackle alcohol-related liver disease and review behavioral health targets and strategies for intervention. Second, we'll hear from Dr. Sanyal, professor of medicine at Virginia Commonwealth University, who'll describe behavioral health complications of NAFLD and potential strategies for care. Third, we'll hear from Manisha Verma, associate professor of medicine at Einstein Healthcare Network, who'll review models of behavioral health and chronic liver disease integrated care. And last but not least, we'll hear from Dr. Winder, associate professor of psychiatry at the University of Michigan, who'll discuss mental health interventions in the liver transplant setting. So on behalf of the Public Health Planning Committee, thanks for joining us during this session, and we look forward to hearing your thoughts, reactions, and questions. Hello and welcome to the Public Health Special Interest Group session on behavioral health and liver disease. My name is Dr. Jessica Millinger, and I'm an assistant professor at the University of Michigan in gastroenterology and hepatology, where my clinical and research practice specializes in alcohol-related liver disease and the development of novel behavioral interventions to treat patients with ALD. I'll be speaking to you today about the role of behavioral health in alcohol use disorder and substance use disorder in liver disease. I have no relevant disclosures. So we just heard a little bit about what behavioral health is broadly, but just to recap, behavioral health is an overall, an umbrella term that defines a lot of and covers a lot of different behaviors that includes preventive health behavior, behavior that patients undergo when they are ill or believe themselves to be ill and are trying to find their way back to health, and then sick role behavior, where someone who is ill is trying to get well. It encompasses those behaviors as well. And a very good definition of kind of what we mean by behavioral health and what that encompasses is this that you see on your left. And it talks about the personal attributes like beliefs, expectations, motives, values, perceptions, other cognitive elements, as well as personality characteristics that include certain emotional states in addition to overt behavior patterns, actions, and habits that relate to health maintenance, health restoration, and health improvement. So you can see that it's very broad. And what that means for us as clinicians and researchers is that there are a lot of different points at which we can potentially intervene in the behaviors of our patients or the beliefs and factors influencing a behavior that we might see that could in fact improve their health. With respect to substance use disorder, it's also very important to understand that there is definitely a neurobiology behind this behavior. And understanding the neurobiological basis of addiction is really critical. And this is because for many substance use disorders, including alcohol use disorder, but especially for opioid use disorder, medications really form a backbone of treatment. So medication substitution therapy for opioid use disorders are really a critical component of treatment for those patients in addition to therapy, counseling, group therapies, and some of the other behavioral health treatments that we'll talk about. Here you can see that there's really a cycle of binge and intoxication that produces withdrawal and negative affect, and then leads back into preoccupation and anticipation, which kind of continues that addiction cycle. And many of these drivers of addiction stem from certain neuroadaptations that have developed as a consequence of these different cycles. And what we see are these different parts of the cycle. So when we think about withdrawal and negative affect, that's very much influences the stress and reward pathways, and then the response to and the craving for drug, alcohol, that leads back into this binge and intoxication cycle. So when we think about behavioral health, we're also thinking about this kind of neurocircuitry and understanding that this is a part of what many of our patients with alcohol use disorder, other substance use disorders are dealing with is also critical, because that means we can also think about and add to our armamentarium the kinds of medications that might help prevent or tamp down some of these parts of this cycle. In particular, relapse prevention medications for alcohol use disorder, for example, can be very key to help maintain durable behavior change as people try to unlearn some of the learned behaviors that accrue as a consequence of this cycle. So some other ways in addition to the biological model that I just showed you to think about behavior change and substance use disorder are to think about different behavior models and models of behavior change. And there are many. One that has gained a lot of ground lately is the social ecological model of behavior change. What this model talks about is the varying levels at which behavior change can be influenced. And for many of us, this is quite intuitive. When you start here at the innermost circle with the individual, this is often what we're seeing and often what gets focused on in interventions and research. So this is the individual attitudes, the beliefs, maybe the demographics. When we talk about race or gender or age as factors in alcohol use or substance use disorder treatment, we're really in this part of the circle here, this individual level. When we move out into the interpersonal realm, this is our relationship. So both at home, work, school, that can influence behavior change. So if you have a supportive environment where people are supportive of your alcohol cessation, your substance use cessation, that's gonna help you more than say, being surrounded by relationships where people are actively using, encouraging you to use, et cetera. On an organizational level, one example of this might be your church or your religious beliefs, for example, or even your work environment. So many patients start drinking because of work, continue drinking because it's kind of socially expected in their organization. At the community level, this could be any number of things from community organizations that help promote abstinence, a community in which you have access to substance use treatment facilities, substance use treatment providers, mental health providers, the cultural or community attitudes that you live within that surround you about alcohol use and substance use, the proximity of a liquor store, for example, and how many of those are in proximity to where you live in your neighborhood can all be critical. And then finally, the outermost circle here is really the alcohol and drug policies. This could be things like insurance coverage for behavioral health, out-of-pocket spending, alcohol and drug policies that produce more or less alcohol and drug use. These are all important features to think about as we think about behavior change. So how might having alcohol-related liver disease or liver disease, for example, impact that behavior change? There are a lot of different theories to potentially explain different behavior changes. The health belief model is one of those among many and is by no means the only one out there. But just to show you an example, this type of a conceptual model kind of helps us understand these features of behavioral health that might be influencing whether or not our patients ultimately get to the action here on the right that we want, which is reducing or stopping, let's say, alcohol use. So in this case, if we're thinking about ALD as a classic example, having certain psychological characteristics, like for example, depression, anxiety, as we talked about having a peer group that induces a lot of pressure, that can also produce people, produce a movement towards or away from a behavior change. Gender, age, race, all of those demographic variables can also sometimes influence it. And ALD itself may influence it. If people are diagnosed, this may strengthen the desire, strengthen that motivation to move through towards action. But it also involves individuals understanding how susceptible they are to liver disease, to worsening liver disease, to relapse, how severe they feel their problem is. If they haven't experienced decompensation from liver disease, for example, do they really take it seriously? Do they really believe it's a problem or not? And then whether or not they can perceive benefits to alcohol cessation in this case as the behavior change, and also whether or not they can see what barriers might be there and how they might overcome them. There are a lot of potential influences on substance use cessation as we talked about, including your motivation for change, the perceived positive and negative consequences of alcohol or substance use, different social and environmental factors, families and relationships, and then your own beliefs about alcohol use, relapse and alcohol use treatment are just some of the features that again, in that umbrella of behavioral health could be potential things that we can work on in clinic or in our work outside of clinic with respect to changing those behaviors. But crucially, it's important to understand that AUD and other substance use disorders are often run together. So these are really disorders that are rarely kind of on their own. And this large scale survey showed very clearly that for individuals with an alcohol use disorder reported in the past year or in their lifetime had substantially higher risk, odds ratios, pardon me, of another drug use disorder. So six fold higher if you had a severe AUD in your lifetime, a four fold higher nicotine use disorder and double the likelihood of a mood disorder. So these are really common. So substance use disorders and mood disorders are very common and it's important that we think about this when we're thinking about behavioral health and behavior change, because understanding that and getting our patients adequate treatment for many of those underlying and comorbid psychosocial issues can be really critical in improving their longterm outcomes. It also means that again, when we treat behaviors, we wanna think about what kinds of, what is triggering that behavior, for example. So again, to take kind of the classic example of alcohol use disorder in an ALD patient, many patients are induced to use alcohol or other substances because they have a physical symptom like pain or sleep disturbance. These are very common symptoms. They can be very debilitating, especially if you have encephalopathy, which often induces a sleep-wake reversal, but it isn't always due to HE, hypotic encephalopathy, and many of my patients have sleep disturbance. In fact, almost two thirds of cirrhosis patients will have sleep disturbances. This is a potential major relapse risk for patients who have alcohol use and other substance use disorders. So assessing sleep quality, insomnia, assessing pain as well, also a frequent symptom in our ALD or liver disease and alcohol use disorder patients, and it can be very complex and challenging to treat. So we wanna kind of think upstream as well and when we're thinking about how we can intervene. So when you're thinking about behavioral health, one of the most well-known models is the trans-theoretical model of behavior change that begins with the stage of pre-contemplation where people are not really contemplating a behavior change. And at this stage, they're often really underestimating the pros of change, overestimating the negative features and aren't aware maybe of their mistakes and misconceptions in their thinking. Contemplation tends to start their thinking about it. That pro-con might be starting to flip a little bit. They get, they're ambivalent about change, and this is really, this ambivalence is really where motivational interviewing can help. It's the key intervention for patients who are ambivalent about change. Preparation begins, they're starting to take small steps, maybe getting their social network involved, telling friends and family. And so here we can really encourage and support them as their physicians and then begin to help them prepare for that. In action, they are changing their behavior. They have changed it, and now they really need from us ways to strengthen that commitment. You know, examples of relapse prevention planning, how to avoid people in places that might tempt them, strengthening that. And then in maintenance, again, maintaining aware of stressful situations, really activating those relapse prevention plans and encouraging healthy behaviors as well to substitute for substance use disorder. So liver disease can be a definite motivating feature for behavior change, and this is a great study that shows this. This was done in the primary care clinic and it used audit screening and a liver checkup where patients were given a score on a green, yellow, or red in terms of how severe their liver disease might be based upon a proprietary algorithm. And what they found is that at a year later, individuals who received the audit screen and liver-specific feedback, those who had higher grades of liver disease in the yellow and red column, two-thirds of those people were more likely to have significantly reduced their audit score, indicating a significant reduction in harmful independent drinking patterns compared to those who hadn't. And so a really powerful example of how liver-specific feedback can actually improve motivation for patients to change. So what if you need some help though, and your patient doesn't wanna change, they don't want to stop alcohol use, or they have a lot of comorbidities from a psychiatric and a substance use standpoint that means you really think they wanna get in, you really want them to get some specialty alcohol use treatment or substance use treatment. This is really important, and this is often where our work in clinic can be the most beneficial, getting our patients into some type of professional substance use treatment. And that's because access rates are quite low. So for patients who have ALD, alcohol-related liver disease, alcohol use disorder treatment rates are very low, both amongst the privately insured in the graph on your left, which showed only 10% of patients at one year after their diagnosis had achieved a clinic visit with a mental health or substance use professional, and also in the VA system, which Veterans Administration System, where patients at six months after, about 14% of them had achieved any type of alcohol use disorder treatment. But in both studies, when patients with cirrhosis did achieve alcohol use treatment, we found decreased rates of decompensation, and in the VA study, a decreased rate of mortality. So really critical to get connected, but really difficult often to get them connected. And in this case, it's often because mental health access, substance use treatment access is just such a challenge, often because of insurance coverage issues, logistical issues, so can't get time off, difficulty finding coverage or finding childcare, et cetera, but also attitudinal, so maybe not feeling like one needs treatment, kind of not appreciating that there's a relapse risk here that alcohol treatment or substance use treatment can really help with. Often concerns about privacy or stigma are a part of that as well. And this is where we can really kind of help by assessing some of those attitudes and then working to change them in our work with our patients. ALD patients can often be different though, so when you are dealing with ALD patients, it is critical to understand this. They often have the decision to stop drinking thrust upon them by a medical event, so their medical health really becomes their priority and not their psychiatric health and not their substance use disorders, and they often don't perceive a need for specialty mental health substance abuse treatment as a consequence with that. They get very preoccupied with the medical treatment and don't think they have an addiction problem, and so that can make it a challenge to help people connect with behavioral health treatment, with that mental health and substance use treatment. And this again is where we as their medical professionals, their liver disease physicians can be helpful in talking to them about some of these misconceptions and really securing in them the idea that the treatment of your substance use disorder is the treatment for your liver disease. It's critical, it's not separate, it's not an add-on, it's not something we're making people do just to make them do it, it's actually really critical to the health of your liver and your overall life. So ways that you can help get your patient connected to treatment, there are two websites. The first of which I'll tell you about is the SAMHSA Treatment Locator, and this is a website, I have the website here. If you go to this website, you can put in a zip code and it will pop up for you in that area, substance use and mental health treatment providers who are part of their database. So I did this for my town, Ann Arbor, and you can see that when you put in the zip code, it shows you a location device, and a location you can click on any of these and get information about any of these different treatment facilities. There are also features that you can use to select if you want, for example, a buprenorphine prescriber for opioid use disorder, you can select for those. So really powerful website, important to know this because what you can do is just pop it into your computer at the bedside with your patient and print out a list and give it to them and then they can make those phone calls. Similarly, the NIAAA, the NIH's alcohol research arm has developed a really excellent website that takes you through information about what alcohol treatment looks like, how you can find quality alcohol treatment and behavioral health treatment, what to look for, where to find it. It also links into that treatment locator from SAMHSA that I just showed you. So this is also a really good website to bookmark and to let your patients know about and kind of have them move through this website. They can learn a lot about alcohol treatment, what it means and what they need to do. The motivational interviewing is really critical and it's a very important part of what we should all be doing with our patients for behavioral health, for alcohol use and substance use disorder treatment. And what motivational interviewing is, is it is a set of, really kind of a spirit and also a set of techniques and a method that helps you approach your patients in a way that ensures partnership, that respects their opinions, their beliefs and kind of meets them where they are so that we can collaborate with patients where they are at any given moment and then help them work towards change. It is available. You can get a motivational network interviewing training and I would suggest everybody do this and get trained in this and continue to keep up that training because this is a skill that you will use not just for alcohol use disorder, substance use disorder. It is a skill that you can use to help your ambivalent patients lose weight if they have non-alcoholic fatty liver, that you can help your patients who are ambivalent about taking their medications become more adherent. So a really critical and fundamental skillset for anybody dealing with patients who are affected by behavioral health concerns, which is all of us. And it's often because, when we think about motivational interviewing, our way of thinking and our way of talking may actually be making the problem worse. Sometimes by telling people what to do, by being overly prescriptive, by not meeting people where they are, we wind up actually pushing people into more resistance. So what can we do when we're practicing our motivational interviewing? Not get ahead of where our patients are, really listen and invite them to talk to us about their doubts and concerns and why they're not ready to, and convey optimism, that's really important. Focus on strengths and successes, no matter how small, and remember that change is not linear and can happen at any time. I would also suggest familiarizing yourself with the 12 steps. 12 step facilitation is a specific type of treatment, of behavioral treatment for alcohol use disorder. But even just having a familiarity with the big book, which is the main text of the 12 step program. Consider attending an open AA meeting or a 12 step meeting in your area to get a sense for how these meetings work, and know where to find meetings. So the aa.org, any of the 12 step groups that you might come across, Narcotics Anonymous, Overeaders Anonymous, any of the 12 step groups often have virtual intergroups that can be helpful. And finally, policy changes can also be very powerful. So for those of you who are interested in policy and maybe wanting to help move us in a better policy direction, to help reduce substance use, this is data from the UK where they showed that when they introduced a duty escalator, so where the cost of beer, cider, wine, spirits, and alcohol went up, because taxes went up during that timeframe, we actually saw a reduction in the number of liters of alcohol that were purchased and consumed. And similarly, when they phased in and looked at different types of financial changes to alcohol cessation, what they found was that when you phased in a duty increase plus setting a minimum unit price, this actually changed the consumption the most. So you had the biggest reductions in the lowest socioeconomic group as well. Finally, in this paper, we found that restrictive alcohol policies actually associated with lower ALD and related mortality in comparing different states who had different policies. Interestingly, the tax-related policies often didn't have the biggest impact, but the non-tax-related alcohol policies actually did. So some key evidence here that suggests that at the state and national level, what we do with respect to alcohol policy may also really make a difference. So finally, in conclusion, behavioral health really covers a broad array of health behaviors, beliefs, emotional states that influence alcohol use and substance use. Having comorbid alcohol use and substance use disorders and psychiatric illness is very common in our liver disease patients. And if we can familiarize ourself and practice motivational interviewing, we can be more helpful at getting our patients to connect with AUD or substance use treatment and also maybe even stop substance use altogether. Policy efforts at the local, state, and national level can also be effective at reducing negative outcomes. So we should be exploring this as a group and as a hepatology community as another key way that we could potentially reduce the negative impacts. Thanks so much. Good evening, ladies and gentlemen. It's a pleasure for me to talk to you today about the role of behavioral health in obesity-related liver disease. Here are my disclosures. I think a good place to start this conversation is to define mental health. Mental health is defined by the WHO as a state of well-being in which the individual realizes his or her own abilities, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. Now, this has come under some criticism, but regardless, I think it still captures the overall sense of what we mean by mental health. Now, breaking it down analytically, we need to make a distinction between the absence or a presence of a mental health disorder. But this is distinct from the ability of a person to function within society. And so we really think about mental health along two axes. One, the absence or presence of a mental disorder, and the other is the degree of functioning going from low levels of mental health to high levels of mental health. This, of course, creates four quadrants as you see on the slide, where at the top left, in the absence of a mental disorder and high level of mental health is an idealized situation, but any given person can reside in any of these quadrants, but over time may move from one quadrant to the other. So in reality then, mental health is a dynamic state of internal equilibrium that governs behavior and a harmonious relationship between body and mind. And there are several underlying constructs such as emotional well-being, psychological well-being, and social well-being. Now, in the setting of obesity-related liver disease, which is principally what we call non-alcoholic fatty liver disease, there is a growing body of literature connecting the biology of the disease to mental health and behavior. Now, let me start in the center of this cartoon where mental health conditions such as depression, anxiety, social isolation, food addictions, et cetera, determine our eating behavior, compliance with lifestyle and drugs, all of which are critically important both for the development of the disease and response to intervention. Now, based on these factors, one not only develops obesity, but also obesity-related outcomes such as fatty liver disease. And both the systemic and the liver disease through a variety of mechanisms such as cytokines, autonomic efferents, metabolites, microparticles circulating nucleic acids, et cetera, microbial products, feedback on the brain and modulate its neurocircuitry. And the brain then, based on its genetic background, life experiences such as post-traumatic stress disorder, et cetera, further get modified to produce the kind of behavioral disorders that then lead to how the behaviors changes. So there is solid biology to support the importance of behavioral health in this setting. So now let's take a look from the trenches and look at the spectrum of mental health disorders within a fatty liver disease population. Unfortunately, the data are somewhat limited, but they do provide some highlights. First, that in some population-based studies, there is a linkage between depression and NASH and lifetime major depression is greater in NASH versus controls. And these patients also had some degree of cognitive decline. So taking a deeper dive into depression within the U.S. NHANES dataset, when we look at patients with and without NAFLD, there is a significant linkage in a higher risk of depression as measured through a variety of ways in the NAFLD population. So after adjustments for age and race, gender, education level, marital status, economic status, smoking status, et cetera, the odds ratio varies from 1.84 to 1.87. Furthermore, patients with NAFLD are more prone to cognitive decline. And here are a number of studies using different modalities, but they all consistently show that patients with NAFLD have impaired cognitive experiences and experience decline in cognitive function over time. Now, the other important implication of these baseline background of mental health comorbidities is how they impact behavior as it relates to NAFLD. We looked at this some years ago and looked at a population of patients with NAFLD covering the full spectrum of histology. And we used tools which gave us population T-scores around 50, and we looked at a variety of traits. And what we found here is that 50% of these patients were on psychoactive medications, 31% were taking drugs from one class, and 18% from more than one class. There was also a fairly high rate of opioid use within an analgesic use within this population. And there were a high and high scores for cognitive complaints, depression, and anxiety. And similarly, there were in a substantial proportion of patients, we also saw problems with neuroticism, et cetera. Now, one of the big changes that are important in this area is whether the mental health status of a person affects their ability to engage in lifestyle intervention. And one of the modules that we looked at was called the University of Rhode Island Stages of Change, which captures the person's ability to change into pre-contemplation, contemplation, action, and maintenance. And patients scored high in the pre-contemplation phase, indicating that many of these patients, even though they were coming to a NASH clinic and people were being told about their obesity and underlying disease, actually had not seriously started contemplating why that they should change their lifestyle. And so they really had not quite made up their mind that this is even an issue. So this is particularly important because it provides at least one explanation of why many patients are unable to effectively engage in lifestyle intervention. Similarly, this is supported when we looked at self-reported perceptions of health. We found that patients scored high on their general perception of health, diet, and exercise, while simultaneously reporting low adherence and coping skills compared to the general population, indicating, again, that they are not mentally in a position where they can effectively engage and sustain lifestyle changes. So these are important background information because until we address these, our likelihood of success with lifestyle intervention is going to be low. So when we look at the impact of psychosocial characteristics on routine weight counseling, we once again found that many of these actually had a significant impact on the ability to lose weight, as measured over a period of six months following standard of care weight counseling provided in a general hepatology NASH clinic. Now, this is, of course, not generalizable truth. In a second set of studies in our group over here, we looked at patients who are being evaluated for transplant and peri-transplant. And unfortunately over here, we've found that office-based routine weight loss counseling done by a hepatologist did not really, was not very effective. And so there are variety of additional reasons. So the problem is clearly much more complex. One issue is some people have food addictions and have underlying eating disorders. I'll highlight one called the binge eating disorder. It's the most common eating disorder present in three to 5% of the general population. In our fatty liver disease population, up to 15% have this. And this is linked to impulse control. So it follows a cycle where initially there are unmet needs which trigger sensations, which then can be precipitated also by external events, such as emotional activity, et cetera. And that lead to eating comfort foods and forbidden foods very fast, secretively, mindlessly, till the food is gone, followed by a period of feeling tired, angry, and ashamed. Very similar to alcohol. Food addiction is yet another addiction. And without appropriate assessment, we really won't know who has it. We know these binge eating disorders are linked to diseases such as diabetes, as shown in this study. Since diabetes is tightly linked to fatty liver disease, I would suspect there is a tight linkage with presence of fatty liver disease as well. So once again, unless you know somebody has an eating disorder, you will not be able to, again, address the root causes of why people live and eat the things that they do and why they cannot engage in effective lifestyle change. Now, another aspect of mental health relates to the quality of life. And let's look at this in the setting of NAFLD. So this is a study that was done at University of Newcastle and also here in Virginia. And what we did do is look at health-related quality of life and patient-reported outcome measures in NASH-related cirrhosis. And what we found here is that there's a tight linkage between in this population, between the overall health-related quality of life and other important aspects of mental health, like the ability to have a good night's sleep, sensation of fatigue, chronic pain, depression, and anxiety. Similarly, psychological contributors are very important as the patient progresses towards more advanced disease. So this is a study from Jennifer Lye's group showing that resilience as a mental health construct is linked to frailty. And people who are resilient, when they become frail, still do better than people who are not resilient. And so resilience and liver frailty worsening are interlinked. And it is an underlying and underpinning factor that drives worsening of frailty in the context of cirrhosis. Now, many of the measures of health-related quality of life that are out there have not been fully validated based on the best practices as defined by the FDA. But this is currently being worked on. And as part of the Litmus Initiative, we are working closely with the group from Litmus with the group from Litmus in developing the NASH-CHECK instrument. And its initial validation, which was done both in Virginia and in Europe, it was reported in last year, where we took patients with NASH cirrhosis and did a targeted literature review, and then essentially were able to generate some insights to provide a overall outline of what the spectrum of health-related quality of life and its linkage to behavior, what it looked like. And this is really feeding, and was one of the things that was the basis of the NASH-CHECK instrument that is currently under development for this purpose. Now, NASH-CHECK will not only look at cirrhotics, but will also look at increased cirrhotic stages of fatty liver disease. So there has been now an evolution of ideas where we have gone from a two-dimensional construct to a three-dimensional construct, where you not only have the absence versus presence of mental disorder, a low level of mental health functioning versus high level of mental health functioning, but then there is a third dimension, which goes from early-stage fatty liver disease to cirrhosis where you actually get further changes in how our mental health changes based on the direct biological effects of cirrhosis in terms of fatigue, ability to carry on day-to-day activities, but also the development of encephalopathy and other well-established complications of cirrhosis. So this becomes now a multi-dimensional construct, which includes eating behavior, quality of life, mental health disorders, such as anxiety, depression, et cetera, addictions, another area that we didn't have time to talk about today, but clearly is extremely important, beyond even food addictions, where narcotic addictions may be a particular problem in this population because patients with fatty liver disease clear opioids at a lower rate than normal individuals. So for any given opioid dose may actually experience higher levels of opioid levels, along with cognitive decline as part of their fatty liver disease, but also decline related to cirrhosis. So each of these has to be considered as we think more holistically in terms of the overall profile of mental health disorders and behavioral disorders in the setting of fatty liver disease. So how do we use this information to improve the life of our patients? So this is work in progress, but it is really important to remember that fatty liver disease is part of a multi-system disorder, where our patients not only have fatty liver disease, but frequently have comorbidities involving the arteries, such as hypertension, peripheral vascular disease, coronary artery disease, cardiac disease, such as heart failure with preserved ejection fraction, type 2 diabetes, and chronic kidney disease. So at the root cause is diet-induced obesity, which as we have gone through is linked to a number of behavioral abnormalities. And so if we address this root cause, we are likely to see benefit across multiple end-organ diseases in this setting. So where this field is moving towards is more emphasis on trying to understand the root causes from a behavioral perspective as to why patients are unable to engage in effective lifestyle change and to move them to a point where they can indeed make those changes. Because weight loss not only improves the liver disease, it can actually improve all of the other end-organ diseases, particularly when I'm talking about weight loss, I'm talking about losing adipose tissue mass without necessarily losing muscle mass. So one thing that is seeing a lot of interest now is the role of motivational interviews. Remember, people are not motivated, they are in pre-contemplation phase. So motivational interview and cognitive behavioral therapy to improve obesity has been looked at certainly in the context of obesity. You can see the pooled odds ratio of the different studies favoring the intervention. And so this needs to be studied in more detail, specifically in the context of NASH. Mindfulness is another very important area that is emerging and allows one to retrain one's eating habits through mindful eating, being aware of physical sensations, thoughts, feelings related to eating, acceptance and non-judgment of sensations, thoughts, feelings, and body, and awareness and step-by-step change of daily patterns and eating habits. So in summary, mental health plays a critical role in the behavioral underpinning of obesity and its complications, including NAFLD. There are a variety of neurocognitive disorders that are linked to NAFLD, such as eating disorders, depression, addictions, and cognitive decline. Mental health can impact NAFLD in a multifaceted way through these. NIH should support focused trials on low-cost behavioral approaches for sustained improvement in metabolic health. There is also an urgent need for third-party payers to support mental health assessment in patients with features of metabolic syndrome to enhance the benefits of lifestyle modification. I thank you for your attention. Thank you to all who have joined this virtual session focused on behavioral health care for liver disease population. The title of my presentation during this session is on models of integrating behavioral health within the chronic liver disease care. Disclosures, I am being supported by the Patient-Centered Outcomes Research Institute Research Award related to palliative care for patients with end-stage liver disease. Nothing else to disclose. So the objectives of my presentation are to describe the key elements of a behavioral health model based on the SBIRT approach, which is screening, brief intervention, and referral to treatment, and a distinct multidisciplinary program. I'm gonna discuss the effects of these models on improving the quality of life of CLD patients and reducing the severity of alcohol, substance use, and depression. So as we all know, the behavioral health models have been in kind of place for a long time, and integrating behavioral health into routine clinical practice has shown improvements in health outcomes, quality of care, reduced costs, kind of the triple aim for our healthcare reform for chronic diseases. The American Hospital Association recommends having behavioral health services to be integrated throughout the healthcare delivery system, starting from inpatient to outpatient care. However, evidence to support models of integrated behavioral health within chronic liver disease care is quite limited, and we need to work on improving evidence and create some models of care for our special population, who is high needs. So a legacy of separate and parallel systems has been going on for a while, where medical care is distinct from behavioral healthcare, and there's a forced choice for patients between two kinds of problems, and clinicians, clinics, treatments, and even insurance kind of dictate where they can go for behavioral healthcare services. However, we see that integrated behavioral health leads to a better match of clinical services to the realities that patients and their clinicians face daily. So an integrated program of behavioral health for liver disease population not only benefits the patients, but also the clinicians, since the multidisciplinary approach brings together two specialties, which can deal with the patients suffering from alcohol liver disease, in particular, in addition to other chronic liver disease patients who have several other behavioral health needs, as we heard in our previous presentations. So what SBIRT approach is, it is kind of a proactive public health model based on an evidence-based practice to identify, reduce, and prevent dependence on alcohol and substance use. It involves universal screening, brief interventions, and referral to treatment for advanced cases. The screening large number of individuals presents an opportunity to engage those who are in need of treatment and really identify them at the point of care. So what we have done in our liver practices, we brought this SBIRT approach, which has been validated in diverse settings, and pilot tested in a program. So this slide really shows that SBIRT funding, which was from SAMHSA, the Substance Abuse Mental Health Services Association. They funded a pragmatic approach to test SBIRT in diverse settings, such as emergency department, primary healthcare, inpatient, outpatient settings. So the feasibility is proven. We just need to bring that model into our own little practices. This SBIRT approach has really helped improve identification and also improve treatment outcomes. So what we did in our hepatology practice is shown in this little diagram where we conducted universal screening through a set of questions for alcohol, substance use, and depression, which were validated self-reported questions at the time of check-in. If it's a negative screening, then we just thank the patients for completing these questions. And if it is positive screening, then the assessment by a trained social worker was kind of leaked in. So the screened social worker would speak to the patients and conduct evaluation for alcohol using the audit questionnaire, which is Alcohol Use Disorder Identification Test for substance abuse. That person would use DAS-10, which is a Drug Abuse Screen Test. And for depression, we used PHQ-9 to evaluate the severity of the disease. Based on the cutoff scores, we did brief intervention or referral to treatment. So brief interventions were offered by the same trained social worker at baseline, and then follow-up sessions were done at three months. And from baseline, if there was a need for referral, then she would refer those patients to behavioral health specialists internally or outside, depending on the insurance career, or to psychiatry for depression particularly. As a part of the brief interventions, it was mainly based on the concept of motivational interviewing. Motivational interviewing lasted about 15 to 20 minutes, and these brief interventions are evidence-based practices designed to motivate individuals at risk of substance use and related health problems to change their behavior by really helping them understand how their substance use puts them at risk and to reduce or give up those risky behaviors. So the six frames elements really informed the concept of brief intervention, which is feedback on the behavior, responsibility to change, advice to change, menu of alternatives, empathic counseling, damp confrontation, and self-efficacy through encouraging optimism. So we approached 303 patients at the time of routine check-in at a single outpatient hepatology clinic over a course of 16 months. About 187 patients screened positive for any of the things which we identified, which is alcohol, substance use, or depression. It was really amazing to see that actually 48% screened positive for depression, alcohol 26%, substance use 25.6%, and then those patients were further followed up as part of this training model. So 95 patients completely went, underwent intervention at baseline and at three months, mean age 53 years, 56% per male, 58% had an educational level of high school or less, 64% were with a primary diagnosis of Hep C, and 94% reported liver disease as their primary concern. So as an outcome measure, we used the chronic liver disease questionnaire, which was a liver disease specific instrument to assess health-related quality of life. And we found that there was improvement in the overall score from baseline to three months and even till six months. So the overall CLDQ score ranged, increased from 4.17 to 4.93, which is 0.47 points, 0.74 points at three months and 1.1 point at six months, which is clinically significant and statistically significant. Individuals' domain scores also improved both at six months and at three months. However, they did not reach clinical significance or statistical significance. So the overall CLDQ scores, as I mentioned, improved, and the quality of life was considered to be improved in that population by just not only the scores, but also individual interactions demonstrated their acceptance and positive attitude towards the intervention. Here we see, we also tested patients with depression and actually compared them to the patients who were non-depressed. And we found that overall CLDQ scores for depressed patients were about 10.8%. Increased from 3.7 to 5.0 over six months, and while those who were non-depressed patients started at 5.2 and ended at 5.9. So of course, the non-depressed had a higher baseline, so we didn't see much improvement. There was less in numbers, but it is very important finding we learned that patients with depression benefited the most from this kind of intervention. We also assessed the change in problem severity scores, which includes AUDIT, DAST, and PHQ-9, and found that patients were becoming abstinent over time, and particularly there was improvement in depression, both clinically and statistically. It is possible that improvement in depression contributed to improvement in the quality of life or the CLDQ scores. We also assessed patient acceptability at the end of six months using just brief patient's feedback surveys, and 82% of the participants agreed that this behavioral intervention improved their overall care within hepatology. 87% indicated a desire to continue with the behavioral program. 70% agreed that behavioral health service at the point of care in hepatology office overcame barriers of making an additional appointment to seek behavioral health care separately. Making separate appointments was considered to be a huge barrier among patients as we learned while speaking with them. So we concluded that SBIR-based behavioral health program or an intervention can be integrated in hepatology practice, and it can contribute to improved quality of life and reduce problem severity over time. These two are becoming key quality indicators in time to come as the whole healthcare system is moving towards value-based healthcare. Universal screening at the point of care helps identify the population which may benefit from behavioral health interventions, and patients with depression can benefit the most. However, some of the limitations I want to recognize is that this is a single arm study, which we did at a single outpatient clinic. There was no control group, so we cannot really compare an assessment of the efficacy of any treatment. Not all positives were enrolled because some patients had to leave early, some patients did not want to go through the intervention, so the results may not be completely generalizable. Some confounding variables, such as timing of brief intervention or expertise of social worker provider interactions can definitely have a substantial effect on response to this behavioral health program. However, we couldn't control for that. But just to kind of say that the trained social workers can become an important component of behavioral health interventions in hepatology practices moving forward. So what I feel the future directions is we still need to conduct a multi-center randomized control trial to further demonstrate feasibility and confirm the efficacy and effectiveness. The sustainability of such a program must be based on allowing reimbursements to social workers or behavioral staff within hepatology clinics, and adding this to the paper performance measures for our hepatology practice. There is a need to identify the dose of behavioral health service needed, like how many sessions are the bare minimum to improve upon your quality of life scores or your depression scores. So all this kind of research questions still remain unanswered. Another kind of collaborative model, which I wanted to include, was a multidisciplinary collaborative model in inpatient settings from UK, where they have a consultant psychiatrist specializing in substance abuse and psychiatric liaison nurse. They were both holding weekly meetings to discuss all inpatients and also conducted twice monthly liver clinics with the hepatology and GI providers for post-hospital follow-ups. They haven't done any quantitative assessment, but their qualitative data really shows that the outcome of this kind of multidisciplinary collaborative approach is very beneficial to patients in improving patient-centered care and bringing the concept of what the patient really wants and what their needs are to the center of the care management plans. Their evaluation comprised of screening, assessment of dependence severity, pharmacotherapy for detoxification, acute response for those undergoing alcohol withdrawal, brief interventions and patient and family education. So I really want to thank you all for attending this session and with some key takeaway messages saying that integrated behavioral health models can improve quality of life of chronic liver disease patients. Universal screening at the time of check-in is feasible within routine practice. Of course, it involves a buy-in from your division administrator, department administrator and clinical staff. It can help identify the specific population which needs the intervention and the individual needs of patients can be linked to the clinical management plans. There exists high depression among CLD patients and these patients can benefit the most with any sort of behavioral health program we can build in within our routine hepatology primary care. So thank you so much and I hope you enjoy the rest of the session where you'll hear more about the intoxication and the medications which can be used as a part of our behavioral health program. Thank you. Hello, I'm Scott Winder from the University of Michigan. I'll be speaking on psychological treatments for listed and delisted liver transplant candidates. I have no financial disclosures or conflicts of interest. We'll start today with some definitions and clinical scenarios. Then we'll talk about some key philosophies and models of care. We will then dive deeper into some of the specific psychotherapy paradigms and their efficacy in liver patients. We'll finish with some ideas about what is to be done to better take care of liver transplant patients psychotherapeutically. What are we referring to by psychological or behavioral treatments? Psychotherapies, there are many types, are talking therapies shown in numerous studies to help people with a wide array of mental illnesses and emotional difficulties. Their goal is to reduce symptoms and suffering and increase a person's wellbeing and daily function. Psychotherapies contain many theories and methods ranging from short-term to long-term encounters and skills-based work to insight building. I've listed some prominent therapies in this slide. They take place in serial sessions, which may be one-on-one with a therapist or in a group setting. Their efficacy is predicated on unique kinds of therapeutic alliance and trust. The therapeutic alliance we build with patients in transplant is unique. It must be rapidly established in order to address challenges within the sometimes urgent and always uncertain liver disease and transplant timetables. We must balance our advocacy role with our obligations as stewards of precious donor organs. This tension is both uncomfortable and essential. Helpful elements of a therapeutic alliance include compassion. We quickly and authentically connect with and care about patients, whether they are anxious or calm, drinking or sober, honest or deceptive, euthymic or depressed. Patients and families need to understand what we do with the confidential information that we elicit from them. Patients should understand our clinical roles in their care and on the selection committee. We should be clear about our expectations during the interview and during future care encounters. Patients and families should easily grasp the long-term nature of our alliance, which often extends years into the future. There are many reasons why a transplant team may consider psychological or behavioral treatment for a listed or delisted candidate. Depression, anxiety, abuse and trauma, addiction, medical non-adherence, personality challenges, interfering with team interactions in medical care, suicidal ideation, or marked ambivalence about transplant. This does not mean that appropriate psych treatment is readily available or that it will solve or improve these challenges, but teams could rightfully consider psychotherapy as a way patients might practically address these problems. Let's be more specific with some common clinical scenarios. An alcohol-related liver disease patient at transplant evaluation with a MELD of 14 has marked deficits in alcohol insight. Are we content continuing the evaluation after noting these deficits or closing his evaluation? Or do we believe that there are measures that can be taken to optimize him as a candidate? Let's look at another. A patient with a history of major depressive disorder and liver disease. It doesn't have to be alcohol-related liver disease, though we would expect more mood problems in the ALD population, which have been shown to affect post-transplant survival. This patient develops abrupt worsening of depression. Is there an intervention by which we could and should treat depression ahead of transplant? Another, soon after transplant evaluation, a previously adherent patient suddenly stops attending clinic and reliably returning phone calls. Is there an intervention to optimize communication and understand this person on a deeper level, thus avoiding evaluation closure? One more, a listed ALD patient relapses to alcohol use. The team is aware of the risk factor that pre-transplant drinking represents for post-transplant drinking, as well as all the other additional risks incurred, including increased mortality. The team considers delisting the patient versus placing them on hold, and above all, seeks to connect patient with adequate treatment to improve their disease trajectory. What models do we have or should we have to address such important and common scenarios? First, let's say something important, unfortunate, and obvious. Hepatology and psychiatry are frequently disparate and disconnected specialties within the health system. This means that even though behavior is a main driver of liver pathophysiology, I'm thinking of overdoses, NASH, hepatitis C, and ALD, behavioral specialists are often distant when sick liver patients in need may be most ready for their services. This means that psychiatric and liver care is often characterized by low interprofessional collaboration, poor care access and quality, inadequate expertise for the breadth of pathology, incomplete ownership of the patient, and discontinuity. There are many words we can use to describe the bridges that must be built and maintained to remedy this problem. Such collaborative bridges may take several forms depending on the resources, priorities, and will for change of any particular clinic or health system. This range of possibilities builds from completely unaffiliated clinicians to co-located and cross-trained clinicians treating the same patients at the same time. We'll return to this slide a little bit later in the talk and talk more about each of these types of collaboration. Psychological and behavioral treatments are more likely to be successfully implemented in medical clinics, which flatten traditional hierarchies, promote lateral and multidisciplinary leadership, respect all roles and expertise, and maintain an open and curious culture. Even the most collaborative liver clinics with embedded psychiatric specialists will still not be able to provide all levels of psychological and behavioral treatments for all listed and delisted patients. Ensuring that liver patients have access to the full array of available psychiatric treatments will require deliberate collaboration and outreach to multidisciplinary colleagues in the health system and surrounding local areas. Let's now turn to a general discussion of psychotherapy paradigms and their efficacy. Is psychological treatment within medical populations even worthwhile? This is a slice of the literature examining integrated psychological services in various medical populations. In general medicine, integrated addiction care improved abstinence and mortality rates compared to standard care. In liver transplant, an embedded alcohol addiction unit reduced post-transplant relapse and mortality. In hepatitis C patients, embedded substance use care favorably impacted abstinence rates and addiction severity as measured by a standardized scale. And in ALD, interprofessional liver psychiatry care reduced patients' MELD scores and hospital utilization rates. More studies are needed, and these data suggest that integrated care is feasible, effective, worthy of inflammation, and further study. So what psychotherapies work in liver patients? While there are many psychotherapies, few have been tested in liver disease and transplant patients. Let's briefly discuss each. A quick note, much of the psychological literature in liver patients focuses on substance use. Motivational interviewing is a widely used and evidence-based method which strengthens a person's motivation to change. It uncovers and mobilizes a person's own inherent reasons for change, whether patients are presently highly motivated or not. An MI intervention in hospitalized GI patients did not improve alcohol sobriety over standard treatment. Cognitive behavioral therapy, CBT, analyzes the antecedents of certain patterns of thought and behavior, as well as their consequences. It seeks to expand a person's ability to cope constructively and engage in activities which promote enjoyment and self-efficacy. It has been shown to be feasible and effective in ALD and hepatitis C by decreasing drinking and improving liver function. MET uses motivational psychology principles, stages of change perspective, and personalized feedback to build a patient's motivation and develop concrete plans for change. Listed patients who received MET attended more treatment sessions and drank less than treatment as usual. 12-step programs are a ubiquitous therapeutic approach which began in the 1960s with Alcoholics Anonymous. Several other versions have formed since. These communities use common spaces in person and online, group activities, peer mentorship, and fellowship to support sobriety. Alcohol relapses post-liver transplant are lower in patients involved in 12-step groups and relapse rates decrease as patient involvement increases. Relapse prevention therapy uses CBT principles in the service of two main goals. Number one, preventing relapses while maintaining a person's goal of alcohol abstinence versus harm reduction. Number two, acquiring skills to manage relapses and limit their unfavorable effects on one's health and life. This modality is not tested in liver patients. Couples and family therapy is a therapeutic approach directed at relationship and family factors which precipitate and maintain a person's drinking. It has not been studied in liver patients. Contingency management is a treatment paradigm based on learning and behavioral conditioning. Monetary and non-monetary rewards are used to incentivize desired behaviors like alcohol or drug abstinence. Turns out, liver transplant is itself a form of this treatment in that transplant is the incentive which motivates the desired behaviors of abstinence and therapy adherence. Finally, social behavior and network therapy work to alter and enhance a patient's social networks during group or individual sessions in the service of changing drinking. This therapy modality has been integrated successfully into liver transplant, but its efficacy is not known. So, practically speaking, what are we to do with all this information? How are we going to better connect listed or delisted liver patients with psychological treatment? Let's return to these general categories of liver-psych collaboration and explore how a hospital or clinic might integrate psychological treatment into liver care. More often than not, liver and psychiatric specialists are completely unaffiliated, meaning they have no personal or professional relationships and lack any shared understanding of how liver and psych pathologies intersect and overlap. There is rarely any coordination of workflows and patient care. An example would be a hepatology clinic which urges patients to attend 12-step recovery meetings or seek out some kind of addiction therapy somewhere on their own. We could call the next level of integration and interprofessionalism informal affiliation. This is also quite common. In this scenario, there is a consistent pattern of referrals accompanied by some awareness of and confidence in the services that patients receive. Some clinicians may provide written or verbal correspondence about patient treatment progress, but the providers do not know or commonly interact with their colleagues from other disciplines. An example would be a liver clinic which commonly refers to a select group of mental health agencies in the surrounding area and has some confidence and past success with the services offered. Next is clinician-to-clinician peer consultation. This might take the form of regular in-person or virtual multidisciplinary meetings where clinicians from various organizations attend to receive education, treatment recommendations, and establish new relationships and partnerships. An example is an academic medical center's liver and psych specialists who jointly host a monthly seminar which is broadcast to the region and places clinicians of different disciplines, training backgrounds, and affiliations in the same room to discuss complex medical and behavioral cases and receive expert recommendations. A well-known example in the field is Project ECHO and how it successfully and widely disseminated specialty liver care peer-to-peer. Next is institutional integration. Liver and psych services are proximal and coordinated within a single health system. Many liver and psych clinicians know each other and regularly consult on each other's patients. They understand something of their colleagues' discipline and scopes of practice. They can adjust their treatment to some of the nuances of the other discipline. They enjoy a shared mission and culture within a single institution. Clinical information flows rather easily interprofessionally through the electronic medical record and intermittent in-person staff encounters. An example would be coordinated workflows whereby liver patients receive inpatient psych consultation and rapid referrals to ambulatory psychotherapy. Lastly, co-location. In this model, liver and psych clinicians evaluate and treat the same patients in the same clinic at the same time. These clinicians build and maintain strong personal relationships among themselves, characterized by respect and appreciation for all roles and training. They frequently train and educate each other interprofessionally and thus establish shared goals and knowledge about the pathophysiology they encounter and treat. An example would be an alcohol-related liver disease clinic staffed by hepatology, psychology, psychiatry, social work, and nursing. Such clinics exist and are growing in number. Since substance use disorders commonly affect all phases of transplant care, we identified a need to bring psychiatric services to ALD patients upstream from transplant, as well as to delisted candidates in hopes of getting them back in qualifying shape for transplant. Early outcomes suggest that our services are benefiting patients by improving their liver function and reducing hospitalizations. Time doesn't permit a full description of how co-located clinics function, but a quick look at our patient education materials can reveal how seamlessly integrated hepatology and psychiatric services really can be. Not only do our patients receive three hours of evaluation by the team, they receive an open-ended, comprehensive, multidisciplinary treatment plan. As these pages of the patient education booklet we authored show, patients are guided through information about their liver health, which connects seamlessly to practical information about alcohol, cycles of habit, human emotion, and decision-making and coping skills. Our co-located services are still being expanded and refined, but we are convinced that this is a model by which psychological treatments can be successfully implemented in hepatology and transplant, given, as we've said, so much of liver health and successful transplantation is predicated on psychological and behavioral factors. Thank you.

behavioral health services

chronic liver disease

mental health

depression

anxiety

risky behaviors

motivational interviewing

12-step programs

substance abuse

social stressors

food addictions