Depression and inflammatory bowel disease: findings from two nationally representative Canadian surveys

Suicidal Behavior Among Hospitalized Adults With Inflammatory Bowel Disease: A United States Nationwide Analysis

BACKGROUND

Suicidal behavior in inflammatory bowel disease (IBD) has been minimally explored. We aimed to determine United States (US) nationally representative prevalence estimates of suicidal ideation (SI) and suicide/self-inflicted injury (S/SII) among hospitalized adults with IBD and to examine trends in suicidal behavior over time.

METHODS

A retrospective cross-sectional study using National (Nationwide) Inpatient Sample data (2006-2011) identified adults with Crohn's disease (CD) or ulcerative colitis (UC), SI or S/SII, and multiple comorbid risk factors for suicidal behavior.

RESULTS

We identified 331,777 (estimated 1.64 million) IBD-related hospitalizations (64% CD, 36% UC) and 39,787,239 (estimated 196.08 million) hospitalizations among the general US population. Among IBD-related hospitalizations, 2502 discharges were associated with SI (prevalence 0.76%) and 1104 with S/SII (prevalence 0.33%). Both were significantly greater in CD versus UC (P < 0.001). Relative to the general US population, IBD patients were significantly less likely to demonstrate suicidal behavior: (SI:0.33% versus 0.59%, P < 0.001) (S/SII:0.75% versus 1.04%, P < 0.001). Multivariable logistic regression revealed that IBD was associated with decreased odds of SI (adjusted odds ratio [aOR] 0.62, 95%CI 0.60-0.65) and S/SII (aOR 0.43, 95%CI 0.40-0.45) relative to the general population, and suicidal behavior was lower in IBD compared to disease-related controls with rheumatoid arthritis and systemic lupus erythematosus. Similar increasing trends in suicidal behavior were observed in IBD and non-IBD populations (2006-2011).

CONCLUSION

In this large US database, SI or S/SII occurred in over 1% of the IBD population and was increased in CD versus UC.

Trends in prevalence, mortality, health care utilization and health care costs of Swiss IBD patients: a claims data based study of the years 2010, 2012 and 2014

Background

Real-life data on inflammatory bowel disease (IBD) prevalence and costs are scarce. The aims of this study were to provide an overview of the prevalence, mortality, health care utilization and costs of IBD patients in Switzerland in the years 2010, 2012, and 2014.

Methods

Based on claims data of the Helsana-Group, prevalence of IBD was assessed for 2010, 2012 and 2014. Mortality rates, costs (inpatient, outpatient, medication costs) and utilization (visits, hospitalizations) were compared between patients with and without IBD, and between IBD patients treated with and without biologics. Results were extrapolated to the Swiss general population using national census data. Multivariate linear regression was used to identify socio-demographic and regional factors influencing total costs.

Results

The overall extrapolated prevalence rates of IBD were 0.32% in 2010, 0.38% in 2012, and 0.41% in 2014. Mortality rate didn’t differ between the IBD and non-IBD population. Costs increased annually by 6% in IBD versus 2.4% in non-IBD subjects, which was solely due to increased outpatient costs. Almost one-fourth of IBD patients were hospitalized at least once a year. Costs were higher in IBD patients treated with biologics (OR = 3.98, CI: 3.72-4.27, p < 0.001) when compared to IBD patients without biologic therapies. Over 70% of the total costs in IBD patients treated with biologics were due to drug costs, compared with 28% in patients without use of biologic therapies, whereas inpatient costs didn’t differ.

Conclusions

The prevalence of IBD seems to be increasing in Switzerland. Outpatient costs increased substantially, while no decrease in inpatient costs was found. Treatment of IBD is more and more based on biologic therapies.

Electronic supplementary material

The online version of this article (10.1186/s12876-017-0681-y) contains supplementary material, which is available to authorized users.

Depressive Symptoms Predict Anti-tumor Necrosis Factor Therapy Noncompliance in Patients with Inflammatory Bowel Disease

BACKGROUND

Noncompliance in use of anti-tumor necrosis factor (anti-TNF) therapy in patients with moderate-to-severe inflammatory bowel disease (IBD) can be a factor in medication failure. Few studies have evaluated the contribution of depressive symptoms to medication noncompliance in anti-TNF therapies.

METHODS

A retrospective chart review was performed in a single-center tertiary care IBD center for patients with Crohn's disease and ulcerative colitis starting anti-TNF therapy over a 2-year period. Medication noncompliance was defined as interruption of medication (not filling anti-TNF prescription if injectable or not getting infliximab infusion for 30 days beyond needed date for continuation) due to patient-driven circumstances. Depressive symptoms were evaluated at baseline using the well-validated Patient Health Questionnaire-9 (PHQ-9), with PHQ-9 ≥ 10 indicative of at least moderate depressive symptoms. Statistical analysis was performed using Cox proportional hazards regression controlling for age, sex, psychiatric history, and disease.

RESULTS

A total of 246 patients (75 with ulcerative colitis, 171 with Crohn's disease) were started on anti-TNF therapy. Seventy-nine patients (32%) had a prior psychiatric diagnosis reported in the medical record. Thirty-three patients (13%) were noncompliant in follow-up. Sixty patients (24%) had at least moderate depressive symptoms at baseline (PHQ ≥ 10). Depressive symptoms at baseline were significantly associated with noncompliance in follow-up (hazards ratio 2.28, CI 1.1-4.6, p < 0.05).

CONCLUSION

Depressive symptoms at baseline were associated with medication noncompliance of anti-TNF therapies at follow-up when controlling for age, sex, disease type, and history of psychiatric disease.

Symptom clusters in adults with inflammatory bowel disease

Symptoms (pain, fatigue, sleep disturbance, depression, and anxiety) in inflammatory bowel disease (IBD) are associated with reduced quality of life. Understanding how IBD symptoms cluster and the clinical and demographic factors associated with symptom clusters will enable focused development of symptom management interventions. The study purposes were to (i) identify symptom cluster membership among adults with IBD and (ii) examine associations between demographic (age, gender, race/ethnicity, and education) and clinical factors (smoking status, time since diagnosis, medication type, IBD type, disease activity), and membership in specific symptom cluster groups. We conducted a retrospective study of data from the Crohn's and Colitis Foundation of America's (CCFA) Partners Cohort and used Patient Reported Outcome Measurement Information System (PROMIS) measures to measure pain interference, fatigue, sleep disturbance, anxiety, and depression. The sample included 5,296 participants with IBD (mean age 44, 72% female). In latent class analysis (LCA), four groups of participants were identified based on symptoms: "low symptom burden" (26% of sample), "high symptom burden" (38%), "physical symptoms" (22%), and "psychological symptoms" (14%). In multinomial regression, female gender, smoking, corticosteroids, Crohn's disease, and active disease state were associated with membership in the high symptom burden group. Additional research is needed to test interventions that may be effective at reducing symptom burden for individuals with IBD.

Prevalence and effectiveness of psychiatric treatments for patients with IBD: A systematic literature review

OBJECTIVES

Higher prevalence of psychiatric disorders, such as anxiety and depression, has been found in people with Crohn's disease and Ulcerative Colitis compared to the general population. Nowadays, international guidelines advocate psychotherapy and psycho-pharmacological treatments as playing an important role in IBD care. The main goal of this systematic literature review was summarize the evidence on the utilization and effectiveness of treatments for depression and anxiety in persons with IBD.

METHODS

A systematic literature review was conducted using three different electronic databases: MEDLINE, PsychINFO, and EMBASE to identify studies reporting the prevalence and efficacy of psycho-pharmacological and psychotherapeutic treatments for IBD. A quality appraisal was conducted using several scales as appropriate for each study design. A narrative synthesis was also performed.

RESULTS

Forty-three studies were included. Although a high rate of psychoactive drug use was found in people with IBD, a low proportion of IBD patients have access to psychiatric referral. 1/3 of the studies found that psychotherapy was effective for improving the quality of life, perception of stress, anxiety and depression as well as disease. Antidepressants proved effective in reducing disease activity, gastrointestinal symptoms, anxiety and depression.

CONCLUSION

Our results suggest that psychiatric treatment should be implemented in IBD care. However, further studies are needed to confirm the findings of our systematic review.

Intrinsic neural network dysfunction in quiescent Crohn's Disease

Psychological factors and comorbidities play an important role in inflammatory bowel diseases. Such comorbidity could be associated with a specific neural phenotype. Brain regions associated with emotion regulation and self-referential processing, including areas assigned to the “default mode network” (DMN), could be promising candidates in this regard. We investigated the functional integrity of multiple intrinsic neural networks in remitted patients with Crohn’s disease (CD) and sought to establish relationships between neural network connectivity and psychiatric symptoms. Fifteen CD patients in remission and 14 controls were investigated. We employed resting-state functional magnetic resonance imaging (fMRI) at 3 Tesla followed by a spatial Independent Component Analysis for fMRI data. Abnormal connectivity in CD patients was observed in DMN subsystems only (p < 0.05, cluster-corrected). Increased connectivity was found in the anterior cingulate and left superior medial frontal gyrus (aDMN) and the middle cingulate cortex (pDMN). Middle cingulate activity showed a significant association with anxiety scores in patients (p = 0.029). This study provides first evidence of selectively disrupted intrinsic neural network connectivity in CD and suggests abnormalities of self-referential neural networks. An increased sensitivity to self-related affective and somatic states in CD patients could account for these findings and explain a higher risk for anxiety symptoms.

The association between immune markers and recent suicide attempts in patients with serious mental illness: A pilot study

Previous studies have identified elevations in markers of gastrointestinal inflammation in schizophrenia and mood disorders but studies have not measured the association between these markers and recent suicide attempts. We assessed 210 patients receiving treatment for schizophrenia, bipolar disorder, or major depression. We employed the Columbia Suicide Severity Rating Scale to identify recent and lifetime suicide attempts (actual, aborted, and interrupted). Psychiatric participants and a control group of 72 individuals without a psychiatric disorder had a blood sample drawn from which were measured specific markers of gastrointestinal inflammation and also C-Reactive protein (CRP). A total of 20 (10%) of psychiatric participants had a suicide attempt in the previous one month and 95 (45%) an attempt during their lifetime but not in the previous one month. The recent attempters had significantly elevated levels of antibodies to yeast mannan from Saccharomyces cerevisiae (ASCA), the food antigen gliadin, and bacterial lipopolysaccharide (LPS) compared with the non-psychiatric group when adjusting for demographic and clinical variables. These markers were not elevated in individuals with a past, but not recent, suicide attempt history. Our study indicates that there is evidence of gastrointestinal inflammation in some individuals who have had a recent suicide attempt.

Protocol for a randomised, placebo-controlled pilot study for assessing feasibility and efficacy of faecal microbiota transplantation in a paediatric ulcerative colitis population: PediFETCh trial

INTRODUCTION

Ulcerative colitis (UC) is a chronic, relapsing condition characterised by colonic inflammation. Increasing prevalence in early-age diagnosis provides opportunities for additional complications in later life as a result of prolonged exposure to inflammatory and therapeutic insults, necessitating novel avenues for therapeutics which may result in fewer side effects. Faecal microbiota transplantation (FMT) has previously demonstrated potential therapeutic benefit in an adult randomised-controlled trial and several recurrent Clostridium difficile infection studies. This phase Ib pilot will be the first randomised, single-blinded, placebo-controlled trial to assess feasibility and patient outcomes in a paediatric inflammatory bowel disease (IBD) population.

METHODS AND ANALYSIS

Fifty patients will be randomised 1:1 to receive normal saline control or active sample. Enema administrations will be performed two times per week for 6 weeks, followed at a 6-month follow-up period. Feasibility outcomes will include measures of patient eligibility, recruitment, willingness to participate, samples collections, hospitalizations and drop-out rate. Improvements in disease symptoms will determine the efficacy of treatment. Clinical disease scores will be taken throughout the study period using the Paediatric Ulcerative Colitis Activity Index (PUCAI). Monitoring of inflammatory markers in blood and stool will be performed at regular intervals. Microbiome analysis will be conducted on stool samples collected throughout the trials period. Imaging and endoscopic surveillance will be conducted if clinically necessary.

ETHICS AND DISSEMINATION

Ethics was obtained from local hospital research ethics boards across all three sites. Health Canada and FDA approval was obtained for the use of an Investigatory New Drug product. Results from this trial will be presented in international conferences and published in peer-review journals.

TRIAL REGISTRATION NUMBER

Trial registration number: NCT02487238; preresults.

Chronic comorbidities associated with inflammatory bowel disease: prevalence and impact on healthcare costs in Switzerland

OBJECTIVE

Inflammatory bowel disease (IBD) was shown to be associated with a variety of chronic comorbidities. We aimed to evaluate the frequency of 21 chronic conditions and compared frequencies in IBD and non-IBD populations. Further, healthcare costs of those (additional) chronic conditions were calculated.

PATIENTS AND METHODS

A total of 4791 IBD patients, who were insured at Helsana Insurance Group in 2014, were compared with 1 114 638 individuals without IBD. Entropy balancing was performed to create balanced samples. Chronic conditions were identified by means of the updated Pharmacy-based Cost Group model. Multivariate log-transformed linear regression modeling was performed to estimate the effect of the morbidity status (non-IBD +none, +1, +2, and +3 or more chronic conditions) on the healthcare costs.

RESULTS

Overall, 78% of IBD patients had at least one comorbidity, with a median of three comorbidities. Largest differences between individuals with and without IBD were found for rheumatologic conditions, acid-related disorders, pain, bone diseases, migraines, cancer, and iron-deficiency anemia, whereas no significant differences between the two groups were found for diabetes, dementia, hyperlipidemia, glaucoma, gout, HIV, psychoses, and Parkinson's disease after adjustments for a variety of covariates. Each increase in the morbidity status led to increased healthcare costs; rheumatologic conditions, acid-related disorders, and pain as the most frequent comorbidities more than doubled total costs in IBD patients.

CONCLUSION

We found a considerably high prevalence of concomitant chronic diseases in IBD patients. This was associated with considerably higher healthcare costs, especially in the outpatient setting.

Patient-Reported Outcomes of Quality of Life, Functioning, and GI/Psychiatric Symptom Severity in Patients with Inflammatory Bowel Disease (IBD)

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at risk for psychiatric disorders that impact symptom experience and health-related quality of life (HRQOL). Therefore, comprehensive biopsychosocial assessments should be considered in ambulatory care settings. Patient-Reported Outcomes Measurement Information System (PROMIS) measures created by the National Institutes of Health have shown construct validity in a large IBD internet-based cohort, but their validity in ambulatory settings has not been examined. We sought to validate PROMIS patient-reported measures of HRQOL, functioning, and psychiatric symptom severity at a tertiary IBD clinic.

METHODS

Adult patients (n = 110) completed the PROMIS Global Health scale, PROMIS-29, SF-12, and WHODAS 2.0. Pearson's correlation coefficients (r) determined the relationships between scores to validate the PROMIS Global Health Physical and Mental metrics, compared with the SF-12 and WHODAS 2.0. We compared these measures by disease subtype of Crohn's disease or ulcerative colitis.

RESULTS

PROMIS measures were highly correlated (r range = 0.64-0.82) with standard measures of HRQOL and functioning. On the PROMIS Global Health measures, 20.9% had impaired physical health, and 13.7% had impaired mental health. Impairments were reported in pain interference (20% of patients), anxiety (18.2%), satisfaction with social role (15.5%), physical functioning (10.9%), fatigue (10%), depression (7.3%), and sleep disturbance (5.5%). Patients with Crohn's disease had worse scores than those with ulcerative colitis on measures of the global physical health (P = 0.027), physical functioning (P = 0.047), and pain interference (P = 0.0009).

CONCLUSIONS

PROMIS instruments provide valid assessment of HRQOL and functioning in ambulatory adults with IBD. Of note, patients with Crohn's disease demonstrated significantly worse impairments than those with ulcerative colitis.

Mind-Body Interventions for Pediatric Inflammatory Bowel Disease

Pediatric inflammatory bowel disease is an autoimmune disease that causes chronic inflammation of the gastrointestinal mucosa. There is emerging evidence that the brain–gut connection affects inflammatory bowel disease (IBD) patients more than previously thought. This is evidenced by comorbid mood disorders, irritable bowel symptoms concurrent with quiescent IBD, and the potential of psychosocial stressors to trigger IBD flares. Mind–body interventions such as psychotherapy, relaxation, mindfulness, biofeedback, yoga, and clinical hypnosis offer an adjunct to standard medical treatment for IBD. We will review the current evidence base for these mind–body interventions in the treatment of pediatric IBD, illustrate a case study, and offer suggestions for future research for this promising field.

Antidepressants in Inflammatory Bowel Disease: A Systematic Review

BACKGROUND

Antidepressants are commonly used to treat symptoms of anxiety and depression in inflammatory bowel disease (IBD). Recent studies suggest a link between IBD activity and an individual's emotional state which raises the possibility that antidepressants may potentially modify the disease course of IBD. This systematic review thus primarily aims to evaluate the efficacy of antidepressants on IBD activity, and secondarily, on anxiety and depression.

METHODS

MEDLINE, EMBASE, Cochrane (IBD Group), CINAHL, AMED, PsycINFO, and OpenGrey were searched from 1990 onward with no restrictions on study design. A quality appraisal was conducted using several scales as appropriate for each study design. A narrative synthesis was also conducted.

RESULTS

Fifteen eligible studies included in the review (1 randomized controlled trial, 2 cohorts, 1 case-control, 1 cross-sectional survey, 1 qualitative, 2 audits, 1 case series, and 6 case reports) examined a range of antidepressants. Twelve studies suggested that antidepressants have a positive impact on IBD course. Nine studies reported anxiety and depression as an outcome, of these 8 reported beneficial effects of antidepressants. Most of the studies were deemed to be at low risk of bias, apart from the case reports, which were at high risk of bias.

CONCLUSIONS

This research indicates that antidepressants may have a beneficial effect on IBD course. However, it is currently not possible to determine their efficacy for certain because of the lack of randomized trials. Further trials using objective measures of IBD activity, longer follow-up periods, and larger sample sizes are needed.

Etiology and Treatment of Pain and Psychosocial Issues in Patients With Inflammatory Bowel Diseases

There is increasing evidence that brain-gut interactions are altered during development of inflammatory bowel diseases (IBDs). Understanding the relationship between the neurobiology, psychological symptoms, and social ramifications of IBD can guide comprehensive care for the whole patient. The most common psychological conditions in patients with IBD are chronic abdominal pain, anxiety, and depression. We review the evidence-based data and rates of these conditions and their respective relationship to IBD and the diagnostic approaches to identify patients with these conditions. Different treatment options for pain and psychosocial conditions are discussed, and new models of team-based IBD care are introduced. Providing the health care provider with tools to diagnose and manage psychological conditions in patients with Crohn's disease or ulcerative colitis is necessary for their total care and should be part of quality-improvement initiatives.

Prevalence of Anxiety and Depression in Patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) patients are not routinely screened for depression and anxiety despite knowledge of an increased prevalence in people with chronic disease and negative effects on quality of life.

METHODS

Prevalence of anxiety and depression was assessed in IBD outpatients through retrospective chart review. The presence of anxiety and/or depression was determined using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 self-report questionnaires or by diagnosis through psychiatric interview. Patient demographics, disease characteristics, and medication information were also collected. Multivariable analysis was used to determine associations between patient factors and depression and anxiety.

RESULTS

327 patient charts were reviewed. Rates of depression and anxiety were found to be 25.8% and 21.2%, with 30.3% of patients suffering from depression and/or anxiety. Disease activity was found to be significantly associated with depression and/or anxiety (p = 0.01). Females were more likely to have anxiety (p = 0.01).

CONCLUSION

A significant proportion of IBD patients suffer from depression and/or anxiety. The rates of these mental illnesses would justify screening and referral for psychiatric treatment in clinics treating this population. Patients with active disease are particularly at risk for anxiety and depression.

Preventative Care in the Patient with Inflammatory Bowel Disease: What Is New?

Patients with inflammatory bowel disease (IBD) do not receive routine preventative care at the same rate as general medical patients. This patient population is at increased risk of vaccine preventable illness such as influenza and pneumococcal pneumonia. This review will discuss health maintenance needs and preventative care issues in patients with IBD.

Systematic review with meta-analysis: the effect of tobacco smoking on the natural history of ulcerative colitis

BACKGROUND

Tobacco smoking is associated with a reduced risk of developing ulcerative colitis (UC). A high proportion of UC patients perceive a benefit in disease outcomes secondary to smoking. However, the effects of smoking on the natural history of UC are uncertain.

AIM

To conduct a systematic review and meta-analysis of the effects of tobacco smoking on the natural history of UC.

METHODS

A search of MEDLINE, EMBASE and EMBASE classic was carried out (up to December 2015) to identify observational studies reporting data on smoking and rates of colectomy, flare of disease activity, proximal disease extension, and development of pouchitis following panproctocolectomy and ileal pouch-anal anastomosis in patients with UC. Dichotomous data were pooled to obtain odds ratios (ORs), with 95% confidence intervals (CIs).

RESULTS

The search identified 16 eligible studies: five (2615 patients) studying colectomy; four (620 patients) reporting on flare of disease activity; four (687 patients) examining proximal disease extension and three (355 patients) assessing development of pouchitis. Compared with nonsmokers, the odds of colectomy (OR = 0.89; 95% CI 0.62-1.26), flare of disease activity (OR = 1.26; 95% CI 0.65-2.44), proximal extension of disease (OR = 0.57; 95% CI 0.20-1.66) or the development of pouchitis (OR = 0.57; 95% CI 0.21-1.53) were not significantly lower in smokers.

CONCLUSIONS

Smoking may not improve the natural history of ulcerative colitis. Given the health benefits of smoking cessation and the lack of clear benefit in ulcerative colitis, smoking cessation advice should be incorporated into guidance on the management of ulcerative colitis.

Symptoms of Depression and Anxiety Are Independently Associated With Clinical Recurrence of Inflammatory Bowel Disease

BACKGROUND & AIMS

We examined the relationship between symptoms of depression and anxiety and clinical recurrence of inflammatory bowel disease (IBD) in a large patient cohort. We considered the progression of depression and anxiety over time.

METHODS

We collected clinical and treatment data on 2007 adult participants of the Swiss IBD study (56% with Crohn's disease [CD], 48% male) performed in Switzerland from 2006 through 2015. Depression and anxiety symptoms were quantified by using the Hospital Anxiety and Depression Scale. The relationship between depression and anxiety scores and clinical recurrence was analyzed by using survival-time techniques.

RESULTS

We found a significant association between symptoms of depression and clinical recurrence over time (for all patients with IBD, P = .000001; for subjects with CD, P = .0007; for subjects with ulcerative colitis, P = .005). There was also a significant relationship between symptoms of anxiety and clinical recurrence over time in all subjects with IBD (P = .0014) and in subjects with CD (P = .031) but not ulcerative colitis (P = .066).

CONCLUSIONS

In an analysis of a large cohort of subjects with IBD, we found a significant association between symptoms of depression or anxiety and clinical recurrence. Patients with IBD should therefore be screened for clinically relevant levels of depression and anxiety and referred to psychologists or psychiatrists for further evaluation and treatment.

Effectiveness of disease-specific cognitive-behavioural therapy on depression, anxiety, quality of life and the clinical course of disease in adolescents with inflammatory bowel disease: study protocol of a multicentre randomised controlled trial (HAPPY-IBD)

INTRODUCTION

Adolescents with inflammatory bowel disease (IBD) show a higher prevalence of depression and anxiety, compared to youth with other chronic diseases. The inflammation-depression hypothesis might explain this association, and implies that treating depression can decrease intestinal inflammation and improve disease course. The present multicentre randomised controlled trial aims to test the effectiveness of an IBD-specific cognitive-behavioural therapy (CBT) protocol in reducing symptoms of subclinical depression and anxiety, while improving quality of life and disease course in adolescents with IBD.

METHODS AND ANALYSIS

Adolescents with IBD (10-20 years) from 7 hospitals undergo screening (online questionnaires) for symptoms of depression and anxiety. Those with elevated scores of depression (Child Depression Inventory (CDI) ≥13 or Beck Depression Inventory (BDI) II ≥14) and/or anxiety (Screen for Child Anxiety Related Disorders: boys ≥26, girls ≥30) receive a psychiatric interview. Patients meeting criteria for depressive/anxiety disorders are referred for psychotherapy outside the trial. Patients with elevated (subclinical) symptoms are randomly assigned to medical care-as-usual (CAU; n=50) or CAU plus IBD-specific CBT (n=50).

MAIN OUTCOMES

(1) reduction in depressive and/or anxiety symptoms after 3 months and (2) sustained remission for 12 months.

SECONDARY OUTCOMES

quality of life, psychosocial functioning, treatment adherence. In addition, we will assess inflammatory cytokines in peripheral blood mononuclear cells and whole blood RNA expression profiles. For analysis, multilevel linear models and generalised estimating equations will be used.

ETHICS AND DISSEMINATION

The Medical Ethics Committee of the Erasmus MC approved this study. If we prove that this CBT improves emotional well-being as well as disease course, implementation is recommended.

TRIAL REGISTRATION NUMBER

NCT02265588.

Controversies Revisited: A Systematic Review of the Comorbidity of Depression and Anxiety with Inflammatory Bowel Diseases

BACKGROUND

Although mental health concerns are known to occur commonly for those with inflammatory bowel diseases (IBD), the nature of this comorbid relationship has not been systematically reviewed to date. A review in 2007 identified 5 controversies regarding anxiety/depression rates and various comparators between and within IBD. We aimed to systematically analyze and critique the current evidence regarding this comorbidity, providing an update to the 5 controversies.

METHODS

Ebscohost Medline, CINAHL, Embase, and PsychINFO were searched between 2005 and 2014 using systematic review methodology. Controlled quantitative studies examining either symptoms or diagnoses of anxiety and depression in IBD were included in the review, with study quality assessed using a scale developed a priori to evaluate observational research.

RESULTS

(1) IBD versus healthy controls (pooled mean proportions) (n = 13 studies): anxiety 19.1% versus 9.6%, depression 21.2% versus 13.4%; (2) IBD inactive versus IBD active disease (n = 26): anxiety 28.2% versus 66.4%, depression 19.9% versus 34.7%; (3) ulcerative colitis versus Crohn's disease (n = 28): anxiety 31% versus 37%, depression 22% versus 24.4%; (4) IBD versus other chronic medical conditions (n = 17): anxiety 41.9% versus 48.2%, depression 14.5% versus 28.4%; (5) onset of anxiety/depression before or after IBD onset (n = 2): adults more likely to develop anxiety/depression before IBD onset, but a substantial proportion develops depression after onset; an increased risk for children of developing anxiety/depression after IBD onset.

CONCLUSIONS

The high rates of anxiety and depression for those with IBD, particularly when disease is active, warrant a systemic approach to screening and treatment.

T helper 17 cells may drive neuroprogression in major depressive disorder: Proposal of an integrative model

The exact pathophysiology of major depressive disorder (MDD) remains elusive. The monoamine theory, which hypothesizes that MDD emerges as a result of dysfunctional serotonergic, dopaminergic and noradrenergic pathways, has guided the therapy of this illness for several decades. More recently, the involvement of activated immune, oxidative and nitrosative stress pathways and of decreased levels of neurotrophic factors has provided emerging insights regarding the pathophysiology of MDD, leading to integrated theories emphasizing the complex interplay of these mechanisms that could lead to neuroprogression. In this review, we propose an integrative model suggesting that T helper 17 (Th17) cells play a pivotal role in the pathophysiology of MDD through (i) microglial activation, (ii) interactions with oxidative and nitrosative stress, (iii) increases of autoantibody production and the propensity for autoimmunity, (iv) disruption of the blood-brain barrier, and (v) dysregulation of the gut mucosa and microbiota. The clinical and research implications of this model are discussed.

Toward a better understanding of the central consequences of intestinal inflammation

Inflammatory bowel diseases (IBDs), which include Crohn's disease and ulcerative colitis, are inflammatory diseases of the gastrointestinal tract. Quality of life for IBD patients is negatively affected by associated pain and gastrointestinal dysfunction, but also by serious behavioral symptoms that include depression, anxiety, fatigue, and cognitive dysfunction. Because these behavioral comorbidities are poorly understood, we have investigated them in a rat model of IBD caused by infusion of a hapten (trinitrobenzene sulfonic acid (TNBS)) into the lower colon. TNBS colitis has many similarities to Crohn's disease, and we have found that it is associated with changes in central nervous system function. TNBS-treated animals have lowered seizure thresholds, which resolve following remission, and hippocampal slices from such animals display increased excitability. There are significant changes in excitatory, AMPA receptor-mediated transmission, in part due to increased numbers of AMPA receptors lacking the GluR2 subunit. Long-term potentiation and depression are reduced in colitic animals, and the synaptic alterations are reversed if microglial activation and tumor necrosis factor α synthesis within the brain are blocked.

Behavioral despair associated with a mouse model of Crohn's disease: Role of nitric oxide pathway

Crohn's disease (CD) is associated with increased psychiatric co-morbidities. Nitric oxide (NO) is implicated in inflammation and tissue injury in CD, and it may also play a central role in pathogenesis of the accompanying behavioral despair. This study investigated the role of the NO pathway in behavioral despair associated with a mouse model of CD. Colitis was induced by intrarectal (i.r.) injection of 2,4,6-trinitrobenzenesulfonic acid (10mg TNBS in 50% ethanol). Forced swimming test (FST), pharmacological studies and tissues collection were performed 72 h following TNBS administration. To address a possible inflammatory origin for the behavioral despair following colitis induction, tumor necrosis factor-alpha (TNF-α) level was measured in both the hippocampal and colonic tissue samples. In parallel, hippocampal inducible nitric oxide synthase (iNOS) and nitrite level were evaluated. Pharmacological studies targeting the NO pathway were performed 30-60 min before behavioral test. Colitis was confirmed by increased colonic TNF-α level and microscopic score. Colitic mice demonstrated a significantly higher immobility time in the FST associated to a significant increase of hippocampal TNF-α, iNOS expression and nitrite content. Acute NOS inhibition using either Nω-nitro-l-arginine methyl ester (a non-specific NOS inhibitor) or aminoguanidine hydrochloride (a specific iNOS inhibitor) decreased the immobility time in colitic groups. Moreover, acute treatment with both NOS inhibitors decreased the TNF-α level and nitrite content in the hippocampal samples. This study suggests that the NO pathway may be involved in the behavioral effects in the mouse TNBS model of CD. These findings endow new insights into the gut-brain communication during the development of colonic inflammation, which may ultimately lead to improved therapeutic strategies to combat behavior changes associated with gastrointestinal disorders.

The effects of psychiatric treatment on depression, anxiety, quality of life, and sexual dysfunction in patients with inflammatory bowel disease

OBJECTIVE

Depression and anxiety are common disorders in inflammatory bowel disease (IBD). Our aim is to prospectively determine the effect of psychiatric treatment on scores for depression, anxiety, quality of life (QoL), and sexual dysfunction in an outpatient population diagnosed with IBD and also anxiety and/or depression disorder.

PATIENTS AND METHODS

Patients who scored higher than the cutoff point on the Hospital Anxiety Depression Scale were referred for further structured psychiatric evaluation and determination of the need for psychiatric drug treatment. Patients who underwent drug therapy completed Short Form-36 (SF-36) and the Arizona Sexual Experience Scale at baseline and after 6 months of follow-up.

RESULTS

Major depressive disorder and generalized anxiety disorder were the most common diagnoses. After 6 months, 47 patients had completely adhered to drug treatment (group A), whereas 20 were nonadherent (group B). In group A, all domains of SF-36, Arizona Sexual Experience Scale, depression/anxiety scores, and Crohn's disease activity index were statistically improved after treatment when compared with the baseline. In group B, the three domains of SF-36, platelet count, and mean corpuscular volume were worse between baseline and at 6 months.

CONCLUSION

In IBD patients having any psychiatric disorder, 6 months of antidepressant drug treatment is associated with an improvement in depression, anxiety, QoL, and sexual functioning scores, as well as an improvement in Crohn's disease activity index. On the other hand, insufficient psychiatric treatment seems to be related to a poor QoL.

The impact of a ten-week physical exercise program on health-related quality of life in patients with inflammatory bowel disease: a prospective randomized controlled trial

BACKGROUND

Improving health-related quality of life is a primary target of therapy for patients with inflammatory bowel disease. Physical activity has been demonstrated to improve health-related quality of life in several patient populations with chronic disease. There are very few studies investigating the effects of physical activity on health-related quality of life in inflammatory bowel disease. The primary purpose of this study is to investigate the effects of 10 weeks of moderate physical activity on health-related quality of life in patients with inflammatory bowel disease.

METHODS

Thirty patients with mild to moderate IBD (Crohn's Disease Activity Index (CDAI) <220 or Rachmilewitz Index (RI) <11) were randomized 1:1 to either supervised moderate-intensity running thrice a week for 10 weeks or a control group who were not prescribed any exercise. Health-related quality of life, symptoms, and inflammation were assessed at baseline and after 10 weeks.

RESULTS

Participants were 41 ± 14 years (73% female), had a body mass index of 22.8 ± 4.1 kg/m(2), and an average CDAI or RI of 66.8 ± 42.4 and 3.6 ± 3.1. No adverse events occurred during the 10-week training period. Health-related quality of life, reported as IBDQ total score, improved 19% in the intervention group and 8% in the control group. Scores for the IBDQ social sub-scale were significantly improved in the intervention group compared with controls (ΔIBDQsocial = 6.27 ± 5.46 vs. 1.87 ± 4.76, p = 0.023).

CONCLUSION

Patients suffering from moderately active IBD are capable of performing symptom-free regular endurance exercise. Our data support the assumption that PA is feasible in IBD patients. PA may furthermore improve quality of life through improvements in social well-being, and may, therefore, be a useful adjunct to IBD therapy.

Ulcerative Colitis Symptomatology and Depression: The Exacerbator Role of Maladaptive Psychological Processes

BACKGROUND

Several studies have indicated that depressive symptomatology plays a pertinent role in the clinical recurrences of ulcerative colitis (UC). Due to the self-perpetuating cycle between UC symptomatology and depressive mood, it is considered that more investment should be given to the study of factors that influence depressive symptomatology in UC patients.

AIMS

This study aimed therefore at analyzing the exacerbator effect of maladaptive psychological strategies, such as cognitive fusion and brooding, on the relationship between UC symptomatology and depressive symptoms.

METHODS

The sample of the current study included 84 Portuguese patients with UC that completed an Internet-based survey (comprising demographic and medical questions, and self-report measures of depression, cognitive fusion, and brooding).

RESULTS

Results showed that UC symptomatology explained 21% of depression severity's variance. In addition, a significant interaction between UC symptomatology and cognitive fusion was found and explained 50% of depressive symptoms' severity. A similar interaction was revealed between UC symptomatology and brooding, which accounted for 42% of depression's variance. These findings demonstrated that, for the same level of UC symptomatology, those participants who revealed more cognitive fusion or more brooding presented significant higher levels of depression.

CONCLUSIONS

The present study revealed cognitive fusion and brooding as moderators that exacerbate the impact of UC symptomatology on reported levels of depression. Psychological interventions that focus on the promotion of adaptive emotion regulation strategies to deal with adverse and stressful events should therefore be developed and implemented in UC patients' health care.

Childhood Maltreatment Is Associated with Ulcerative Colitis but Not Crohn's Disease: Findings from a Population-based Study

BACKGROUND

Previous research suggests a link between childhood adversities and inflammatory bowel disease (IBD); however, study limitations prevent generalization of findings. To address this, the current study uses a Canadian population-based sample to investigate the relationship between 3 childhood adversities and 2 types of IBD while controlling for a range of factors.

METHODS

Secondary data analysis of a subsample of the nationally representative 2012 Canadian Community Health Survey-Mental Health consisted of those with no missing data on any of the variables of interest (n = 21,852). The survey response rate was 68.9%. This study used logistic regression to estimate odds ratios of 3 types of childhood adversities (physical abuse, sexual abuse, and witnessing parental domestic violence) separately for ulcerative colitis and Crohn's disease, each compared with those without IBD. The final model controls for sociodemographics, health behaviors, and mental health. The exposure was assessed by retrospective self-report, and the outcome was by self-report of a health professional diagnosis.

RESULTS

In a fully adjusted model, those who are physically (odds ratio = 2.28; confidence interval, 1.39-3.75) or sexually abused (odds ratio = 2.64; confidence interval, 1.61-4.33) during childhood had significantly higher odds of ulcerative colitis than their non-maltreated peers. No relationship is found between witnessing parental domestic violence and ulcerative colitis. None of the early adversities are significantly related to Crohn's disease.

CONCLUSIONS

Childhood physical and sexual abuse are related to ulcerative colitis, but not Crohn's disease. Future research that can address epigenetic and neuroendocrine factors should investigate pathways through which early adversities may translate into one type of IBD but not another.

Patterns of Antibiotic Exposure and Clinical Disease Activity in Inflammatory Bowel Disease: A 4-year Prospective Study

BACKGROUND

Antimicrobial treatment is known to cause short- and long-term changes in the composition of normal human microbiota. The relationship between antibiotic use and overall clinical behavior in inflammatory bowel disease (IBD) has not been explored. We aim to prospectively characterize patterns of antibiotic use and clinical IBD activity in a large IBD cohort.

METHODS

Prospective observational study from a longitudinal IBD natural history registry between 2009 and 2012. Antibiotic prescriptions were identified and categorized using electronic medical record data. Cumulative rates over the 4-year study period were compared. Demographic, clinical, laboratory, health care utilization, and treatment data of the patients with IBD were collected and analyzed. Quality of life was measured by Short IBD Questionnaire data. Primary outcomes were markers of disease activity including Short IBD Questionnaire scores, C-reactive protein levels, health care utilization, and medication use.

RESULTS

Seven hundred eighteen patients followed over 4 years were included (47.6% male; mean age, 46.7 ± 15.2 yr), 59.9% had Crohn's disease, whereas 38.6% had ulcerative colitis. Most patients (66.3%) were exposed to antibiotics during the study period. Antibiotic-exposed patients were more likely to have Crohn's disease (63% versus 53.7%; P = 0.05), require narcotics (43.7% versus 14.9%; P < 0.0001), receive antidepressants (43.1% versus 18.6%; P < 0.001), prednisone (52.7% versus 31%; P < 0.0001), or biological therapy (52% versus 36.5%; P < 0.0001). Antibiotic-exposed patients had a lower mean Short IBD Questionnaire (50.2 ± 11.5 versus 56.4 ± 9.5; P < 0.0001), higher rates of C-reactive protein elevation (49.2% versus 31.8%; P < 0.0001), and higher health care utilization compared with nonantibiotic-exposed patients.

CONCLUSIONS

The majority of patients with IBD receive antibiotic treatment, and these individuals demonstrate a more severe clinical course.

Psychosocial Support of the Inflammatory Bowel Disease Patient

Inflammatory bowel disease (IBD) is a chronic, debilitating disease whose effects spread far beyond the gut. IBD does not generally result in excess mortality; health care providers should thus focus their efforts on improving health-related quality of life and minimizing associated morbidity. A bidirectional relationship exists between IBD and psychiatric conditions; chronic inflammation can produce neuromodulatory effects with resultant mood disorders, and the course of IBD is worse in patients with anxiety and depression. Screening for the early signs of depression or anxiety and initiating appropriate treatment can lead to improved functioning and positively impact disease course.

Robust Association Between Inflammatory Bowel Disease and Generalized Anxiety Disorder: Findings from a Nationally Representative Canadian Study

BACKGROUND

Although the link between inflammatory bowel diseases (IBD) and depression is well accepted, less is known about the relationship between IBD and anxiety disorders and factors associated with anxiety among those with IBD.

METHODS

Data were derived from the nationally representative 2012 Canadian Community Health Survey-Mental Health. The survey response rate was 68.9%. Two sets of analyses were undertaken. First, a series of logistic regression analyses were used to estimate the odd ratios of generalized anxiety disorder among those with IBD compared with those without (n = 22,522). The fully adjusted model controlled for sociodemographics, depression, substance abuse/dependence, pain, and adverse childhood experiences. Second, among those with IBD (n = 269), significant correlates of generalized anxiety disorder were identified using logistic regression. The presence of generalized anxiety disorder was determined using the WHO-CIDI lifetime criteria, and IBD was assessed by a self-reported health professional diagnosis.

RESULTS

Individuals with IBD had over twice the odds of anxiety compared with those without IBD, even when controlling for a range of potential explanatory factors (odds ratio = 2.18; 95% confidence interval, 1.50-3.16). Controlling for chronic pain and childhood adversities attenuate the relationship the most. Among those with IBD, a history of childhood sexual abuse, female gender, and chronic pain are the strongest correlates of anxiety. Those with Crohn's and ulcerative colitis were equally vulnerable to generalized anxiety disorder.

CONCLUSIONS

Our findings show that IBD is robustly related to generalized anxiety disorder. Health care professionals should be aware of the increased prevalence of generalized anxiety disorder among their patients with IBD, particularly women, those in chronic pain, and those with a history of childhood sexual abuse.

Primary Care of the Patient with Inflammatory Bowel Disease

Inflammatory bowel disease involves 2 major disorders, ulcerative colitis and Crohn disease, both of which are due to inflammatory dysregulation in the gastrointestinal tract. Although these disorders have many overlapping features in pathophysiology and management, our current understanding of inflammatory bowel disease has illuminated several distinguishing features of the 2 diseases. This article highlights similarities and differences most applicable to a primary care physician's practice. Also detailed are disease-related and treatment-related complications, and routine health maintenance practices for the patient with inflammatory bowel disease.

Prevalence of mental health disorders in inflammatory bowel disease: an Australian outpatient cohort

BACKGROUND

This study aimed to characterize prevalence of anxiety and depressive conditions and uptake of mental health services in an Australian inflammatory bowel disease (IBD) outpatient setting.

METHODS

Eighty-one IBD patients (39 males, mean age 35 years) attending a tertiary hospital IBD outpatient clinic participated in this study. Disease severity was evaluated according to the Manitoba Index. Diagnosis of an anxiety or depressive condition was based upon the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale.

RESULTS

Based on Hospital Anxiety and Depression Scale subscale scores >8 and meeting Mini-International Neuropsychiatric Interview criteria, 16 (19.8%) participants had at least one anxiety condition, while nine (11.1%) had a depressive disorder present. Active IBD status was associated with higher prevalence rates across all anxiety and depressive conditions. Generalized anxiety was the most common (12 participants, 14.8%) anxiety condition, and major depressive disorder (recurrent) was the most common depressive condition reported (five participants, 6.2%). Seventeen participants (21%) reported currently seeking help for mental health issues while 12.4% were identified has having at least one psychological condition but not seeking treatment.

CONCLUSION

We conclude that rates of anxiety and depression are high in this cohort, and that IBD-focused psychological services should be a key component of any holistic IBD service, especially for those identified as having active IBD.

Concerns and worries in people living with inflammatory bowel disease (IBD): A mixed methods study

OBJECTIVE

This mixed-methods study aimed to explore concerns and worries related to living with inflammatory bowel disease (IBD).

METHODS

Overall, 294 patients with a clinically established diagnosis of IBD were enrolled in this cross-sectional study. Concerns and worries were measured with one open-ended question. Measures of anxiety and depressive symptoms and disease activity were also administered. A thematic analysis was conducted and thematic map created. Spearman's rho was used to identify univariate correlations between predictors and the main themes. Binary logistic regression was used to test the predictors of the main themes.

RESULTS

Despite the majority of study participants being in IBD remission (74%, n=217), all but 11 reported significant IBD-related concerns. Twenty two percent reported symptoms of depression and 41% of anxiety. Four themes were identified: Quality of life (51%); Unpredictability (35%); Symptoms (34%) and Treatments (19%). Males and older people were less concerned about Quality of life (OR=.597, 95% CI: .363-.980 and OR=.980, 95% CI: .965-.995, respectively). Those in remission were less concerned about Symptoms (OR=.510, 95% CI: .281- .926) while those with longer disease duration worried more about the Symptoms (OR=1.035, 95% CI: 1.010-1.061). Males were less concerned about Treatments (OR=.422, 95% CI: .229-.777).

CONCLUSION

IBD patients report significant disease-related concerns even when in remission. Further exploration of what predicts patient concerns may help in shaping health-care delivery so that it better addresses patient needs.

Inflammatory bowel disease and anxiety: links, risks, and challenges faced

Inflammatory bowel disease (IBD) causes severe physical symptoms and is also associated with psychological comorbidities. Abnormal anxiety levels are found in up to 40% of patients with IBD. Anxiety symptoms are often related to flares of IBD but may persist in times of remission. Detection of anxiety disorder (AD) in patients with IBD can be challenging. Patients with anxiety may also exhibit symptoms in keeping with functional gastrointestinal disorders (FGID). Evidence for the effectiveness of pharmacological and psychological therapies for anxiety stems from patients without IBD. Studies in patients with IBD have either been small or shown negative results. In light of this, a combined approach involving IBD physicians to improve disease control and psychologists or psychiatrists to treat anxiety is advised. This review examines the evidence of anxiety issues in IBD with a focus on extent of the problem, risk factors for anxiety, and the effectiveness of interventions.

Treatment with immunosuppressive therapy may improve depressive symptoms in patients with inflammatory bowel disease

INTRODUCTION

Recent research suggests a relationship of inflammatory bowel disease (IBD) and depression. Our objective was to evaluate for improvement of depressive symptoms with treatment of IBD using immunosuppressive medications.

METHODS

A retrospective study of consecutive patients with IBD started on immunosuppressive agents [anti-tumor necrosis factor (anti-TNF) or immunomodulator therapy] was conducted. Patients were evaluated if disease activity indices using Harvey Bradshaw Index for Crohn's disease (CD) and Simple Clinical Colitis Disease Activity Index for ulcerative colitis (UC) and depressive indices using Patient Health Questionnaire-9 (PHQ-9) scores were obtained before and at least 30 days after initiation of therapy.

RESULTS

Sixteen patients with UC and 53 patients with CD (all with active disease symptoms) were evaluated over a 60 day median follow-up evaluation (range 30, 140 days). Twenty-two patients started on immunomodulator therapy, and 47 patients started on anti-TNF therapy. Crohn's disease patients had significantly decreased PHQ-9 scores at follow-up [median 9 (range 3, 14) to 4 (1, 8)], with significant decreases only in those started on anti-TNF therapy. Changes in PHQ-9 and CRP were correlated (ρ = 0.38, p < 0.05). In patients with UC, PHQ-9 scores [5 (3, 9) to 2 (0, 5)] were significantly decreased. Percentage at risk of moderate to severe depression (PHQ-9 scores ≥10) was lower after treatment [Crohn's disease 51-18 % (p < 0.05), ulcerative colitis 18-0 %].

CONCLUSION

Depressive scores decreased significantly in patients with IBD treated with immunosuppressive therapy and the number at risk for moderate to severe depression improved significantly.

The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Abdominal pain and the neurotrophic system in ulcerative colitis

BACKGROUND

We undertook a study to test the hypothesis that inflammation alters peripheral sensory mechanisms, thereby contributing to chronic abdominal pain in ulcerative colitis (UC).

METHODS

Patients with UC and healthy individuals rated abdominal pain using a visual analog scale and completed surveys describing anxiety or depression (Hospital Anxiety and Depression Score) and gastrointestinal symptoms (Rome III questionnaire). Patient age, sex, and severity of inflammation were determined. Rectal biopsies were processed using immunohistochemical techniques to assess nerve fiber density and real-time PCR to determine transcript expression of neurotrophins (nerve growth factor, glial cell-derived neurotrophic factor, artemin, neurturin), ion channels (transient receptor potential vanilloid type 1, transient receptor potential ankyrin 1) and inflammatory mediators (tumor necrosis factor-α, interleukin [IL]-1β, IL-6, IL-10, IL-17).

RESULTS

A total of 77 patients with UC (27 female, 50 male) and 21 controls (10 female, 11 male) were enrolled. Patients with UC with pain had significantly higher depression scores than controls and patients with UC without pain (P < 0.05). There was no correlation between any of the inflammatory markers and pain scores. Visual analog scale pain scores significantly correlated with younger age, higher depression scores, increased expression of neurturin and decreased expression of transient receptor potential ankyrin 1 in the mucosa. Mucosal nerve fiber density did not correlate with any measures of inflammation or pain. Only higher depression scores independently predicted pain in UC (r > 0.5).

CONCLUSIONS

We did not observe changes in mucosal innervation and did not see a significant relationship between nerve fiber density, inflammatory mediators, neurotrophic factors, or mucosal ion channel expression and pain. In contrast, the importance of depression as the only independent predictor of pain ratings mirrors functional disorders, where central processes significantly contribute to symptom development and/or perpetuation.

How can we improve models of care in inflammatory bowel disease? An international survey of IBD health professionals

BACKGROUND AND AIMS

Few studies have specifically examined models of care in IBD. This survey was designed to help gather information from health professionals working in IBD services on current care models, and their views on how to best reshape existing models for IBD care worldwide.

METHODS

An online mixed-methods survey was conducted with health professionals caring for IBD patients. Recruitment was conducted using the snowballing technique, where members of professional networks of the investigators were invited to participate. Results of the survey were summarised using descriptive statistics.

RESULTS

Of the 135 included respondents, 76 (56%) were female, with a median age of 44 (range: 23-69) years, 50% were GI physicians, 34% nurses, 8% psychologists, 4% dieticians, 2% surgeons, 1% psychiatrists, and 1% physiotherapists. Overall, 73 (54%) respondents considered their IBD service to apply the integrated model of care, and only 5% reported that they worked exclusively using the biomedical care (no recognition of psychosocial factors). The majority of respondents reported including mental health assessment in their standard IBD care (65%), 51% believed that an ideal IBD service should be managed in specialist led clinics, and 64% wanted the service to be publicly funded. Respondents pictured an ideal IBD service as easy-access fully multi-disciplinary, with a significant role for IBD nurses and routine psychological and nutritional assessment and care.

CONCLUSIONS

Health care professionals believe that an ideal IBD service should: be fully integrated, involve significant roles of nurses, psychologists and dieticians, run in specialist clinics, be easily accessible to patients and publicly funded.

Pain management in patients with inflammatory bowel disease: translational approaches from bench to bedside

Abdominal pain is a common symptom in patients with inflammatory bowel disease (IBD) that negatively affects quality of life and can lead to increased health-seeking behavior. Although abdominal pain has been traditionally attributed to inflammation, there is growing literature demonstrating the existence of functional abdominal pain in patients with IBD, of which there are a variety of potential causes. Thus, when approaching a patient with IBD who has abdominal pain, in addition to IBD-related complications (e.g., inflammation/stricture), it is important to screen for related contributors, including peripheral factors (visceral hypersensitivity, bacterial overgrowth, and bowel dysmotility) and centrally mediated neurobiological and psychosocial underpinnings. These central factors include psychological symptoms/diagnoses, sleep disturbance, and stress. Opioid-induced hyperalgesia (e.g., narcotic bowel syndrome) is also growing in recognition as a potential central source of abdominal pain. This review draws from clinical studies and animal models of colitis and abdominal pain to consider how knowledge of these potential etiologies can be used to individualize treatment of abdominal pain in patients with IBD, including consideration of potential novel treatment modalities for the future. Accurate assessment of the source(s) of pain in patients with IBD can help guide appropriate diagnostic workup and use of disease-modifying therapy.

Psychosocial complications of Crohn’s disease and cause of death

Patients who suffer from Crohn’s disease are prone not only to the complications of a relapsing, unpredictable disease, but also to feelings of stigmatization; depression; and increased risk of suicidal ideation, suicide, or drug and alcohol abuse. Cases performed at the Jackson County Medical Examiner’s Office from 2008 to 2010 were reviewed. Autopsy findings, investigator reports, toxicology results, medical records, and interviews with survivors were analyzed. Twelve cases of Crohn’s disease were recovered. In 10 of these cases, inflammatory bowel disease was not the cause of death. Instead, psychosocial consequences of the disease had significant implications in the deaths. The mean age of decedents was 45 years, with a female predominance. In eight cases, the decedents lived alone. Five patients had issues of acute or chronic drug or alcohol use. Five patients committed suicide. These cases underscore the role of psychosocial factors that can contribute significantly to the cause of death in patients with Crohn’s disease.

Pediatric inflammatory bowel disease and depression: treatment implications

PURPOSE OF REVIEW

Depression in pediatric inflammatory bowel disease is increasingly recognized to be a heterogeneous condition with diverse underlying predisposing and precipitating factors. Although there is a growing awareness regarding the benefits of integrating behavioral health into medical care, the way psychiatric treatments can best target different aspects of depression and related dysfunction has not been systematically explored.

RECENT FINDINGS

This review discusses neurobiological risk factors for depression in inflammatory bowel disease including inflammation, associated anti-inflammatory treatment with corticosteroids, pain, and sleep disturbance, as well as psychosocial factors including reactions to illness, illness perception, and disease and environmental stressors with an emphasis on how these factors can influence treatment decisions. Empirically supported psychosocial and psychopharmacological interventions are discussed within this context.

SUMMARY

Understanding the diverse pathways that can lead to depression in youths with inflammatory bowel disease can lead to the development of more targeted interventions and better integration of psychosocial care into the medical treatment of inflammatory bowel disease.

Parenting stress predicts depressive symptoms in adolescents with inflammatory bowel disease

OBJECTIVES

Adolescents with inflammatory bowel disease (IBD) are at an increased risk for depression and poor IBD management. Although depression and family factors have been associated in cross-sectional analyses, their casual association over time has not been studied. The primary objective of this study was to assess the temporal association between parenting stress and adolescent depressive symptoms in IBD.

METHODS

Along with a primary parent, adolescents [Mage(years)=15.5±1.4] with a confirmed diagnosis of Crohn's disease or ulcerative colitis and prescribed a treatment regimen of a 5-ASA medication and/or 6-MP/azathioprine were recruited from routine gastroenterology clinic visits at two pediatric medical centers. The current study was nested in a larger IBD self-management trial. Adolescents completed the Children's Depression Inventory. Parents completed a sociodemographic questionnaire and the Pediatric Inventory for Parents. Gastroenterologists provided disease severity assessments on the basis of the clinic appointment corresponding to the study visit or the most recent clinic appointment. Questionnaires were readministered ∼6 months after the initial visit.

RESULTS

Participants include 93 families at baseline and 65 at follow-up (69.8% retention; N=65). A cross-lagged panel analysis was used to detect causal directionality and change in adolescent depression and parenting stress over 6 months. Baseline parenting stress accounted for a significant amount of the variance in depressive symptoms at follow-up [R-change=0.03, F(1,58)=35.6, P<0.05].

CONCLUSION

Parenting stress impacts adolescent depressive symptoms in IBD. Identification of parenting stress and adolescent depression should occur early and possibly in the context of routine clinic visits.

The role of hypnotherapy for the treatment of inflammatory bowel diseases

Inflammatory bowel diseases (IBD) are chronic disorders of unknown aetiology which are characterized by episodes of exacerbations and remissions. There is evidence that perceived distress contributes to IBD symptom flares; anxiety and depression are frequently found in patients with the active disease. Because there is no cure, treatment has to focus on prevention of complications, induction/maintenance of remission and improvement of quality of life. Gut-directed hypnotherapy (GHT) has been used successfully in functional gastrointestinal disorders. Few experimental studies and case reports have been published for IBD; GHT increases the health-related quality of life and reduces symptoms. Additionally, GHT seems to have an immune-modulating effect and is able to augment clinical remission in patients with quiescent ulcerative colitis.

Predictors of abdominal pain in depressed pediatric inflammatory bowel disease patients

BACKGROUND

Pediatric patients with inflammatory bowel disease (IBD) have high rates of abdominal pain. The study aims were to (1) evaluate biological and psychological correlates of abdominal pain in depressed youth with IBD and (2) determine predictors of abdominal pain in Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

Seven hundred sixty-five patients aged 9 to 17 years with IBD seen over 3 years at 2 sites were screened for depression. Depressed youth completed comprehensive assessments for abdominal pain, psychological (depression and anxiety), and biological (IBD-related, through disease activity indices and laboratory values) realms.

RESULTS

Two hundred seventeen patients with IBD (161 CD, 56 UC) were depressed. One hundred sixty-three (120 CD, 43 UC) patients had complete abdominal pain index scores. In CD, abdominal pain was associated with depression (r = 0.33; P < 0.001), diarrhea (r = 0.34; P = 0.001), erythrocyte sedimentation rate (r = 0.22; P = 0.02), low albumin (r = 0.24; P = 0.01), weight loss (r = 0.33; P = 0.001), and abdominal tenderness (r = 0.38, P = 0.002). A multivariate model with these significant correlates represented 32% of the variance in pain. Only depression (P = 0.03), weight loss (P = 0.04), and abdominal tenderness (P = 0.01) predicted pain for patients with CD. In UC, pain was associated with depression (r = 0.46; P = 0.002) and nocturnal stools (r = 0.32; P = 0.046). In the multivariate model with these significant correlates, 23% of the variance was explained and only depression (P = 0.02) predicted pain.

CONCLUSIONS

The psychological state of pediatric patients with IBD may increase the sensitivity to abdominal pain. Thus, screening for and treating comorbid depression may prevent excessive medical testing and unnecessary escalation of IBD medications.