Psychotherapy May Help Sleep Apnea, Obesity, and NAFLD

Portrait of beautiful young woman writing on clipboard while listening to obese woman during therapy session on mental issues
Nonalcoholic fatty liver disease often has several systemic comorbities, including obstructive sleep apnea. Researchers explored a psychological link between them.

Psychotherapy directed at obesity reduction is an effective adjunct therapy for individuals with obstructive sleep apnea (OSA) and non-alcoholic fatty liver disease (NAFLD), according to findings from a Serbian-based study published in The Journal of Gastrointestinal and Liver Diseases.  

Seventy-one enrollees who met the study criteria were selected. Of these, 34 agreed to psychotherapy while 37 refused. The participants who refused psychotherapy continued to receive treatment for their disease without the psychotherapy component. Physicians diagnosed patients with NAFLD using ultrasonography which determined fatty liver content and degree of liver fibrosis. Polysomnography measured oxygen desaturation and apnea-hypopnea indices to determine OSA severity, and obesity diagnosis depended on body mass index (BMI). The investigators repeated these tests at the end of the study.

The researchers obtained body weight and height measurements to calculate BMI. They also collected blood samples at the beginning and end of the study to obtain fasting blood glucose levels and a lipid profile. The lipid profile included total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride, aminotransferase and gamma-glutamyl transpeptidase levels.

All patients answered the 25-item Obesity Questionnaire. Participants were offered to fill in the Hamilton depression rating questionnaire before and after psychotherapy, and underwent the Rosenberg Self-Esteem test. Psychotherapy lasted for one year with 34 patients attending sessions once per week. Two patients stopped therapy after 6 weeks.

Compared with individuals in the control group, self-esteem increased significantly in the intervention group following 1 year of psychotherapy (P =.005).  Comparatively, BMI (P <.01), LDL (P =.02), triglycerides (P =.03), aspartate aminotransferase (P <.01), alanine aminotransferase (P <.01), gamma-glutamyl transpeptidase (P <.01), and level of fatty liver in the moderate steatosis group only (P >.01) decreased significantly.

Compared with the control group, the number of severe cases of OSA decreased in the intervention group following psychotherapy. While depression decreased and total cholesterol and HDL levels improved, these changes were not statistically significant between groups. No degree of change in liver fibrosis occurred following psychotherapy.

Statistical analysis correlated the improvement in self-esteem directly with the change in BMI (P =.03), which further motivated individuals receiving psychotherapy to continue to seek treatment for obesity.

Study limitations included possible selection bias due to use of purposeful sampling as well as the uneven gender distribution affecting external generalizability. Lastly, patient reluctance to undergo the percutaneous liver biopsy procedure due to its risky invasiveness in addition to psychotherapy or bariatric surgery due to lack of insurance coverage unless their BMI exceeded 40 kg/m2 also limited study results.

“Further investigation should be directed towards the evaluation of different psychotherapeutic methods in NAFLD treatment, with the particular stress on obesity,” the investigators said. “It is advisable to use psychotherapy in combination with other clinical methods of treatment.”


Filipovic BF, Latas M, Kiurski S, et al. The role of psychotherapy in the treatment of patients with nonalcoholic fatty liver disease and obstructive sleep apnea. J Gastrointestin Liver Dis. 2021;30(4):477-484. doi:10.15403/jgld-3758