Untreated coeliac disease and attempted suicide

Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study

BACKGROUND

Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown.

AIM

To examine the relationship between anxiety, depression and mucosal healing in coeliac disease.

METHODS

Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression.

RESULTS

During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27).

CONCLUSION

Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.

Long-term mortality in people with celiac disease diagnosed in childhood compared with adulthood: a population-based cohort study

INTRODUCTION

To explore whether the excess mortality in celiac disease is related directly to the disease and duration of gluten exposure before diagnosis we have examined the long-term mortality experience of people with celiac disease diagnosed as children and as adults.

METHODS

Two hundred eighty-five children and 340 adults diagnosed with celiac disease were followed until death, loss to follow-up, or December 31, 2004. We calculated standardized mortality ratios (SMRs).

RESULTS

All-cause mortality more than 5 yr after diagnosis was increased threefold in children (SMR 3.32, 95% CI 2.05-5.07) compared with only a 38% increase in adults (SMR 1.38, 95% CI 1.16-1.63). This excess mortality in children was primarily because of an increased risk of death from accidents, suicide, and violence (seven deaths, SMR 3.22, 95% CI 1.29-6.63), cancer (five deaths, SMR 3.72, 95% CI 1.21-8.67), and cerebrovascular disease (two deaths, SMR 10.03, 95% CI 1.21-36.00).

CONCLUSIONS

Children diagnosed with celiac disease had a threefold increased risk of long-term mortality. This is in marked contrast to the experience of adult celiac disease where the long-term increase of mortality was modest. The increased mortality in children from external causes may reflect behavioral change associated with coping with a chronic disease and its treatment.

Affective disorders and quality of life in adult coeliac disease patients on a gluten-free diet

BACKGROUND

Psychiatric symptoms, common in untreated coeliac disease patients, may improve after gluten withdrawal.

AIMS

To estimate the incidence of psychiatric disorders in coeliac disease patients on gluten withdrawal and to evaluate: (1) the psychological weight of a chronic disease that involves a restrictive diet and a limited life style; (2) the acceptance of the disease; (3) the effects of both disease and diet on behaviour and quality of life.

PATIENTS AND METHODS

Three groups of 100 patients (coeliac disease patients, diabetic patients and healthy controls, respectively) were assessed by means of a professional semi-structured diagnostic interview based on DSM-IV criteria. This interview, together with specific psychiatric questionnaires, ruled out axis I or II psychopathological disturbances.

RESULTS

The modified Self-rating Depression Scale and State and Trait Anxiety Inventory Y2 scores were significantly higher in both coeliac and diabetic patients than in healthy controls. The duration of gluten restriction was related to significantly higher modified Self-rating Depression Scale scores in patients with a more recent diagnosis. Quality of life was poorer in both coeliac and diabetic patients than in healthy controls and significantly correlated with anxiety. The Illness Behaviour Questionnaire showed a high psychological and somatic perception of illness in both coeliac and diabetic patients. Its subscale scores correlated significantly with anxiety and depression symptoms.

CONCLUSIONS

In coeliac disease, affective disorders should be ascribed to difficulties in adjusting to the chronic nature of the disease rather than directly to the disease itself, thus giving an indication for preventive liaison psychiatric interventions.

Depression in adult untreated celiac subjects: diagnosis by the pediatrician

Untreated celiac disease can lead to serious behavioral disorders. We describe three adult patients with undiagnosed or untreated celiac disease without particular intestinal signs, causing persistent depressive symptoms in three of the parents of our pediatric patients. In two of the three cases, the pediatrician suspected the diagnosis when taking the family history of the children. In fact, a diagnosis of celiac disease was made during childhood, when they had intestinal symptoms, but the gluten-free diet was spontaneously interrupted during the teenage period because of the disappearance of the typical intestinal signs. In the third case the mother was tested for antiendomysium antibodies (EmA), as she had a diagnosed celiac child. In all three patients, the depressive symptoms improved quickly with a gluten-free diet. In conclusion, celiac disease should be taken into consideration in the presence of behavioral and depressive disorders, particularly if they are not responsive to the usual antidepressive therapy.