7% of the patient population with significantly elevated ALT values had similar levels of symptoms to the remainder of the population. One area of controversy in PBC is the role played by depression in the causation of fatigue. Whereas reports Veliparib purchase of depression are common in the clinical records of patients, detailed psychiatric evaluation has failed to demonstrate major depressive illness.12, 22 This issue is of real importance to patients both in terms of management and perceptions of their illness (both their own and those of others). In the UK population depression, assessed in terms of percentage of patients meeting criteria for “caseness”

using the HADS-D, a measure optimized for use in a chronic disease population, was rare as an isolated feature in both fatigued and nonfatigued patients (3% with severe fatigued and <1% with mild or

none). Depression was often seen in the context of a symptom complex, which included symptoms of autonomic dysfunction and daytime somnolence (two associations described previously and confirmed in this national patient cohort). Indeed, depressive symptoms were seen 10 times more often in fatigued patients with additional symptoms of autonomic dysfunction and/or sleep disturbance (30% of patients) than they were in isolation (3%). One interpretation would be that depression per se is not a cause of fatigue in PBC but may be a secondary, exacerbating feature in patients with MAPK Inhibitor Library manufacturer a high cumulative burden of other symptoms. The presence of depression in this setting may contribute to the overall clinical expression of disease and impaired life quality, and is an important potential target for therapy. Such treatment should be prescribed with the realization that it may only improve the secondary depression and not the underlying IKBKE fatigue or other symptoms. The importance of the complex of depressive symptoms, autonomic symptoms, and sleep disturbance with fatigue is indicated by the fact that 75% of patients with no fatigue or mild fatigue did not

have any of these additional underpinning symptoms. Only 11% of severely fatigued patients lacked additional symptoms. In contrast, 19% of severely fatigued patients had all three of these symptoms, a combination which was not seen in any patient with mild or no fatigue. In a cross-sectional study of this type it is difficult to draw conclusions about the hierarchy of symptoms linked to fatigue. A structured approach to management addressing each of these additional symptoms would be of interest, and would represent a potential approach to the treatment of fatigue. If any of these associated symptoms are causal in PBC, substantial gains in terms of fatigue reduction might be expected. Even if these symptoms are consequential upon fatigue in PBC they will exert a significant effect on life quality in their own right and QOL gains might be expected.