**Background:** Mental illness is common yet underdiagnosed in patients with chronic liver disease (CLD) and has been associated with worse outcomes including reduced quality of life, frailty, and increased mortality. However, the impact of routine outpatient mental health care on outcomes in cirrhosis has not been studied in a large cohort. US veterans represent a unique population with high burden of psychiatric and substance use comorbidities.
**Methods:** This retrospective cohort study used the VOCAL database of patients with cirrhosis across 128 Veterans Health Administration centers from January 1, 2008 to December 31, 2021. After exclusions, 115,409 patients with incident cirrhosis were included. Mental health diagnoses (depression, anxiety, PTSD, bipolar disorder, schizophrenia, AUD, SUD) were identified using ICD-9/10 codes in a time-updated fashion (every 30 days). Outpatient mental health visits were categorized using clinic stop codes. The primary outcome was all-cause mortality, ascertained via the Vital Status File. Inverse probability treatment weighting (IPTW) was used to balance covariates including age, sex, race, BMI, liver disease etiology, comorbidities, MELD-Na, and AUDIT-C score. Adjusted Cox regression models were performed for baseline mental health diagnosis, time-updated mental health diagnosis, and subgroup analyses evaluating regular outpatient care.
**Key Results:** Of 115,409 patients, 94,278 (81.7%) had any mental health diagnosis at baseline: 14,420 (12.5%) had non-AUD/SUD only, 25,272 (21.9%) had AUD/SUD only, and 54,586 (47.3%) had both. Median follow-up was 46.8 months (IQR: 21.1–80.7). Over the study period, there was a significant increase in mental health clinic visits per person-year (β=0.078, 95% CI: 0.065–0.092, p<0.001) but a decrease in AUD/SUD clinic utilization (β=−0.023, 95% CI: −0.030 to −0.016, p<0.001). In IPTW-adjusted Cox models, any baseline mental health diagnosis was associated with a 14% increased mortality hazard (HR=1.14; 95% CI: 1.12–1.15; p<0.001). With time-updated mental health comorbidity, the hazard increased to 54% (HR=1.54; 95% CI: 1.52–1.56; p<0.001). For non-AUD/SUD diagnoses, the time-updated model showed an 11% increased risk (HR=1.11; 95% CI: 1.10–1.13; p<0.001), while AUD/SUD diagnoses showed a 44% increased risk (HR=1.44; 95% CI: 1.42–1.46; p<0.001). Regular outpatient mental health visits were associated with reduced mortality: 3% for any mental health diagnosis (HR=0.97; 95% CI: 0.95–0.99; p<0.001), 9% for non-AUD/SUD (HR=0.91; 95% CI: 0.90–0.93; p<0.001), and 21% for AUD/SUD (HR=0.79; 95% CI: 0.77–0.82; p<0.001). In cause-specific mortality analysis, mental health comorbidities were associated with both liver-related (cause-specific HR=1.62; 95% CI: 1.59–1.65; p<0.001) and non-liver-related mortality (cause-specific HR=1.36; 95% CI: 1.33–1.40; p<0.001).
**Clinical Implications:** Mental illness is highly prevalent (81.7%) among veterans with cirrhosis and is associated with significantly increased all-cause mortality, particularly for AUD/SUD. Regular outpatient mental health care appears protective, with the greatest benefit in patients with AUD/SUD (21% risk reduction). These findings support integrated care models that combine hepatology with mental health and addiction services. The declining AUD/SUD clinic utilization despite rising incidence of these disorders represents a critical care gap. Limitations include potential healthy user bias, misclassification via ICD codes, a predominantly male veteran population limiting generalizability, and residual confounding. Future research should focus on integrated care program implementation and randomized trials.