Low Health Literacy in Patients with Steatotic Liver Disease and Depressive Symptoms

Background and Objectives: Health literacy (HL) affects the course of chronic diseases, yet little is known about HL in steatotic liver disease (SLD), and the role of mental comorbidities has not been examined. This study assessed HL in patients with SLD and sought to identify factors linked to lower HL. Materials and Methods: This bicentric cross-sectional study comprised 234 patients with SLD: 209 recruited prospectively in Homburg, Germany (2024–2025), and 25 patients with metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis from an existing cohort in Mainz. HL was measured with the German version of the nine-scale Health Literacy Questionnaire (HLQ). SLD was defined by a controlled attenuation parameter ≥ 275 dB/m, and advanced chronic liver disease (ACLD) by liver stiffness ≥ 15 kPa (Baveno VII/VIII) or known cirrhosis. Depressive symptoms were assessed with the Patient Health Questionnaire-9 (PHQ-9 ≥ 10; Homburg) or the Hamilton Depression Rating Scale (HDRS-17 ≥ 8; Mainz). Results: Sixty-eight patients (29%) had depressive symptoms (Homburg 25.8%, Mainz 56.0%). The groups were comparable with respect to age, sex, schooling, liver stiffness and BMI. In univariable analyses, patients with depressive symptoms had lower scores on scales 2, 3, 6 and 7. After adjustment for sex, age, BMI, schooling, and ACLD, associations remained significant for scale 2 (“Having sufficient information to manage my health”; β = −0.14, p = 0.04), scale 3 (“Actively managing my health”; β = −0.15, p = 0.02), scale 6 (“Ability to actively engage with healthcare providers”; β = −0.21, p = 0.003) and scale 7 (“Navigating the healthcare system”; β = −0.16, p = 0.02). The association with scale 6 was consistent across all sensitivity analyses, including an analysis restricted to the Homburg cohort. ACLD was not independently associated with any HLQ scale, whereas higher BMI was associated with lower scores in five of nine domains. Conclusions: More than one in four patients with SLD has depressive symptoms, which are associated with lower self-reported HL, especially regarding engagement with healthcare providers and navigation of the healthcare system. Screening for depression could help to identify patients who require additional support.