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

Antidepressant treatment in inflammatory bowel disease: a systematic review and meta-analysis

Around 25% of patients with inflammatory bowel disease (IBD) have depressive symptoms, yet antidepressants have been poorly studied in IBD. We systematically searched IBD studies testing antidepressants in four databases. Outcomes were depressive symptoms, anxiety, IBD disease activity, quality of life (QoL) and adverse events. For randomized controlled trials (RCTs), we performed random-effects meta-analysis of the standardized mean difference (SMD) in posttreatment scores between antidepressant and placebo groups. Risk of bias was assessed using the Cochrane Common Mental Disorders Depression Anxiety and Neurosis Group tool (clinical trials) and Newcastle-Ottawa scale (cohort studies). We included 11 studies ( n  = 327): three placebo-controlled RCTs, two nonrandomized trials, and six other study types. In the pooled analysis, antidepressants improved depressive symptoms [SMD = -0.71 (95% confidence interval (CI) -1.32 to -0.10), P  = 0.02, I2  = 51%] and QoL [SMD = 0.88 (95% CI 0.30-1.45), P  = 0.003, I2  = 44%] more than placebo. Serotonin and noradrenaline reuptake inhibitors (SNRIs) alone improved depressive symptoms [SMD = -0.95 (95% CI -1.45 to -0.45, P  < 0.001, I2  = 11%], anxiety [SMD = -0.92 (95% CI 1.72 to -0.13), P  = 0.023, I2  = 65%] and QoL [SMD = 1.14 (95% CI 0.66-1.62), P  < 0.001, I2  = 0%]. The three RCTs were of good quality. In conclusion, based on three small but good-quality studies, antidepressants improve depressive symptoms and QoL compared to placebo in IBD. SNRI antidepressants may also improve anxiety. A fully powered study of antidepressants in IBD is needed.

Antidepressant fluoxetine alleviates colitis by reshaping intestinal microenvironment

BACKGROUND

The impact of antidepressants on Inflammatory bowel diseases (IBD) has been extensively studied. However, the biological effects and molecular mechanisms of antidepressants in alleviating colitis remain unclear.

METHODS

We systematically assessed how antidepressants (fluoxetine, fluvoxamine and venlafaxine) affected IBD and chose fluoxetine, the most effective one, for mechanism studies. We treated the C56BL/6 mice of the IBD model with fluoxetine and their controls. We initially assessed the severity of intestinal inflammation in mice by body weight loss, disease Activity Index scores and the length of the colon. The H&E staining and immunohistochemical staining of MUC2 of colon sections were performed to observe the pathological changes. RT-qPCR and western blot were conducted to assess the expression level of the barrier and inflammation-associated genes. Then, single-cell RNA sequencing was performed on mouse intestinal mucosa. Seurat was used to visualize the data. Uniform Manifold Approximation and Projection (UMAP) was used to perform the dimensionality reduction. Cell Chat package was used to perform cell-cell communication analysis. Monocle was used to conduct developmental pseudotime analysis. Last, RT-qPCR, western blot and immunofluorescence staining were conducted to test the phenomenon discovered by single-cell RNA sequencing in vitro.

RESULTS

We found that fluoxetine treatment significantly alleviated colon inflammation. Notably, single-cell RNA sequencing analysis revealed that fluoxetine affected the distribution of different cell clusters, cell-cell communication and KEGG pathway enrichment. Under the treatment of fluoxetine, enterocytes, Goblet cells and stem cells became the dominating cells. The pseudotime analysis showed that there was a trend for M1 macrophages to differentiate into M2 macrophages. Lastly, we tested this phenomenon in vitro, which exhibited anti-inflammatory effects on enterocytes.

CONCLUSIONS

Fluoxetine exhibited anti-inflammatory effects on intestinal mucosa via remodeling of the intestinal cells and macrophages, which reveals that fluoxetine is a promising therapeutic drug for the treatment of IBD and psychiatric comorbidities.

Burden of Anxiety, Depression and Perceived Stress in Patients with Inflammatory Bowel Disease: A Cohort Study from North India

BACKGROUND

Patients with Inflammatory bowel disease (IBD) are susceptible to psychiatric co-morbidities. We aimed to ascertain the burden of anxiety, depression, and perceived stress in patients with IBD from north India.

METHODS

Consenting adult patients with an established diagnosis of IBD were enrolled. The enrolled patients filled the Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS) questionnaires. The patient and disease characteristics were analyzed to determine the correlations and predictors of psychiatric comorbidities.

RESULTS

A total of 318 patients (255 UC, 63 CD; mean age 40.13 ± 12.06 years, 168 [52.8%] males; mean partial Mayo score 2.10 ± 2.35; and mean HBI 2.77 ± 2.13) were enrolled. The prevalence of anxiety, depression and moderate to high perceived stress was 14%, 12%, and 41%, respectively. Females had higher mean perceived stress, anxiety and depression scores compared to males. The partial Mayo score (PMS) correlated poorly with anxiety (ρ = 0.083, p = 0.187), depression (ρ = 0.123, p = 0.49) and perceived stress (ρ = 0.169; p = 0.007). The Harvey Bradshaw index (HBI) correlated fairly with anxiety (ρ = 0.336, p = 0.007) and poorly with depression (ρ = 0.287, p = 0.022) and perceived stress (ρ = 0.20; p = 0.117). Younger age (OR 0.93, 95% CI 0.90-0.97; p = 0.001) and hand-grip strength (OR 4.63, 95% CI 1.88-11.42; p = 0.001) predicted anxiety in patients with UC while rural area of residence (OR 4.75, 95% CI 1.03-21.98; p = 0.046) and HBI (OR 1.60, 95% CI 1.12-2.29; p = 0.009) were significant predictors of anxiety in patients with CD.

CONCLUSION

Psychiatric comorbidities are common in patients with IBD, with higher prevalence in females. Young adults with UC and sarcopenia; and individuals with active CD living in rural areas are at an increased risk of anxiety.

Moderating the Relationship Between Ulcerative Colitis and Crohn's Disease and Symptoms of PTSD: The Role of Remission

GOALS

This study examined whether inflammatory bowel disease (IBD) patients endorse clinically significant symptoms of post-traumatic stress disorder (PTSD), and tested whether remission status and remission expectations effectively moderate the relationship between endorsements of PTSD symptoms and aspects of IBD.

BACKGROUND STUDY

The enduring somatic threat model speaks to the presentation of symptoms of trauma that result from ongoing somatic concerns rather than discrete external events. Literature shows patients living with acute conditions experience symptoms of PTSD; however, few studies extend this to the IBD population. In addition, literature suggests remission may serve as a protective factor for the impact of IBD; as such, aspects of remission may serve as moderators in the relationship between aspects of IBD and PTSD symptoms.

RESULTS

Among a sample of adults with IBD, results showed that 32.8% of participants met the established cutoff for PTSD symptoms warranting further diagnostic evaluation. The findings further showed several aspects of remission moderated the relationship between multiple distinct IBD related concerns and PTSD symptoms.

CONCLUSIONS

Given the results of this study, it would be beneficial for providers to maintain awareness of the potential impact of PTSD symptoms, including the ways in which these symptoms may influence patient engagement/presentation. Ultimately, these results inform efforts to continue appropriate referral to mental health professionals for follow up.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Mental Health and Inflammatory Bowel Disease

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn's disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.

IBD-related mental health disorders: where do we go from here?

Inflammatory bowel disease is a complex and debilitating disease which is known to cause mental burden for patients. Even though few studies look at mental health disease in this cohort of patients, there is growing evidence of a correlation between disease activity and prevalence of mental health conditions such as anxiety, depression and post-traumatic stress disorder. In this literature review, the relationship between inflammatory bowel disease and mental health disorders is explored, with an emphasis on recognition, screening and therapeutic options and special considerations for these complex comorbidities. The relationship between medical and psychological disease is not often considered and less well understood and there is a need for further research in these fields. Patients would have much to gain both medically and psychologically from a multidisciplinary approach to this chronic disease association.

Gut microbiota decreased inflammation induced by chronic unpredictable mild stress through affecting NLRP3 inflammasome

Dysbiosis of the gut microbiota is associated with the development of depression, but the underlying mechanism remains unclear. The aim of this study was to determine the relationship between microbiota and NLRP3 inflammasome induced by chronic unpredictable mild stress (CUMS). Fecal transplantation (FMT) experiment was conducted to elucidate the potential mechanism. Levels of NLRP3 inflammasome, microbiota, inflammatory factors and tight junction proteins were measured. CUMS stimulation significantly increased the levels of NLRP3, Caspase-1 and ASC in brain and colon(p<0.05), decreased the levels of tight junction proteins Occludin and ZO-1 (p<0.05). Interestingly, increased NLRP3 inflammasome and inflammatory cytokines and decreased tight junction proteins were found in antibiotic-treated (Abx) rats received CUMS rat fecal microbiota transplantation. Furthermore, fecal microbiota transplantation altered the microbiota in Abx rats, which partially overlapped with that of the donor rats. Importantly, probiotic administration amended the alteration of microbiota induced by CUMS treatment, then reduced the levels of NLRP3 inflammasome and inflammatory factors. In conclusion, these findings suggested that depression-like behaviors induced by CUMS stimulation were related to altered gut microbiota, broke the intestinal barrier, promoted the expression of NLRP3 inflammasome and elevated inflammation. Therefore, improving the composition of microbiota via probiotic can attenuate inflammation by amending the microbiota and suppressing the activation of NLRP3 inflammasome, which is considered as a novel therapeutic strategy for depression.

Anxiety and depression in patients with inactive inflammatory bowel disease: The role of fatigue and health-related quality of life

Inflammatory bowel diseases (IBD) are chronic conditions characterized by a remitting-relapsing course. Patients with IBD have an impaired quality of life and are more often affected by anxiety and depression. This study aimed to evaluate the prevalence and severity of anxiety and depression in patients with inactive IBD, and to identify factors associated with them. A total of 132 consecutive patients diagnosed with IBD for over 3 months that were in corticosteroid-free remission at the time of assessment were enrolled in this observational, cross-sectional study. Anxiety, depression, fatigue, and health-related quality of life (HR-QoL) were evaluated using the following self-administered questionnaires: HADS, Functional Assessment of Chronic Illness Therapy-Fatigue, and IBDQ 32. Symptoms of anxiety and depression were considered for HADS-A > 7 points and HADS-D > 7 points, respectively. Out of the 132 patients included, 76 (57.6%) were men. The median patient age was 38 years (interquartile range 30-47). Eighty-three patients (62.9%) were diagnosed with Crohn disease, and 49 (37.1%) with ulcerative colitis. Most of the patients were treated with biologics (85.6%). Anxiety was identified in 34.1% of patients, and two thirds of them (68.9%) had mild symptoms. A lower proportion of patients were presenting symptoms of depression (18.2%), the vast majority (91.7%) having mild forms. In the multivariate analysis, anxiety was significantly associated with fatigue [odds ratio (OR) 4.39, 95% confidence interval (CI): 1.22-15.79, P = .02] and lower HR-QoL (OR 2.46, 95% CI: 1.70-3.91, P < .001), while depression was associated with exposure to multiple biologics (OR 3.33, 95% CI: 1.01-10.97, P = .04) and fatigue (OR 9.70, 95% CI: 1.67-56.27, P = .01). In conclusion, anxiety and depression are highly prevalent in patients with IBD even during the periods of remission. Both anxiety and depression are associated with fatigue. In addition, lower HR-QoL is associated with anxiety and exposure to multiple biologics with depression.

Management of Sexual Dysfunction in Gastrointestinal Disorders

Patients with gastrointestinal (GI) disorders are at increased risk of sexual dysfunction (SD) due to a combination of biomedical, psychological, social, and interpersonal factors. While most patients desire information on the impact of their GI disorder on sexual function, few providers initiate this conversation. GI providers should routinely assess their patients for SD, validate these concerns, and provide brief education and a referral for evaluation and/or treatment. Treatment of sexual concerns is often multidisciplinary and may involve a sexual medicine physician, pelvic floor physical therapists, and sex therapists.

Developmental defects and behavioral changes in a diet-induced inflammation model of zebrafish

Soybean meal evokes diet-induced intestinal inflammation in certain fishes. Although the molecular aspects of soybean-induced intestinal inflammation in zebrafish are known, the impact of the inflammatory diet on fish behavior remain largely underexplored. We fed zebrafish larvae with three diets - control, soybean meal and soybean meal with β-glucan to gain deeper insight into the behavioral changes associated with the soybean meal-induced inflammation model. We assessed the effect of the diets on the locomotor behavior, morphological development, oxygen consumption and larval transcriptome. Our study revealed that dietary soybean meal can reduce the locomotor activity, induce developmental defects and increase the oxygen demand in zebrafish larvae. Transcriptomic analysis pointed to the suppression of genes linked to visual perception, organ development, phototransduction pathway and activation of genes linked to the steroid biosynthesis pathway. On the contrary, β-glucan, an anti-inflammatory feed additive, counteracted the behavioral and phenotypic changes linked to dietary soybean. Although we did not identify any differentially expressed genes from the soybean meal alone fed group vs soybean meal + β-glucan-fed group comparison, the unique genes from the comparisons of the two groups with the control likely indicate reduction in inflammatory cytokine signaling, inhibition of proteolysis and induction of epigenetic modifications by the dietary glucan. Furthermore, we found that feeding an inflammatory diet at the larval stage can lead to long-lasting developmental defects. In conclusion, our study reveals the extra-intestinal manifestations associated with soybean meal-induced inflammation model.

Selective serotonin reuptake inhibitors and inflammatory bowel disease; Beneficial or malpractice

IBD, a chronic inflammatory disease, has been manifested as a growing health problem. No Crohn’s and Colitis councils have officially ratified anti-depressants as a routine regimen for IBD patients. However, some physicians empirically prescribe them to rectify functional bowel consequences such as pain and alleviate psychiatric comorbidities. On the other side, SSRIs’ prescription is accompanied by adverse effects such as sleep disturbances. Prolonged intermittent hypoxia throughout sleep disturbance such as sleep apnea provokes periodic reductions in the partial oxygen pressure gradient in the gut lumen. It promotes gut microbiota to dysbiosis, which induces intestinal inflammation. This phenomenon and evidence representing the higher amount of serotonin associated with Crohn’s disease challenged our previous knowledge. Can SSRIs worsen the IBD course? Evidence answered the question with the claim on anti-inflammatory properties (central and peripheral) of SSRIs and illuminated the other substantial elements (compared to serotonin elevation) responsible for IBD pathogenesis. However, later clinical evidence was not all in favor of the benefits of SSRIs. Hence, in this review, the molecular mechanisms and clinical evidence are scrutinized and integrated to clarify the interfering molecular mechanism justifying both supporting and disproving clinical evidence. Biphasic dose-dependent serotonin behavior accompanying SSRI shifting function when used up for the long-term can be assumed as the parameters leading to IBD patients’ adverse outcomes. Despite more research being needed to elucidate the effect of SSRI consumption in IBD patients, periodic prescriptions of SSRIs at monthly intervals can be recommended.

The Impact of Disease Activity on SD and ED in Patients With Inflammatory Bowel Disease

BACKGROUND

Increased disease activity may be a risk factor for sexual dysfunction (SD) in patients with inflammatory bowel disease (IBD). This study investigated associations between objective measures of disease activity and sexual function.

METHODS

Adults with IBD undergoing ileocolonoscopy were prospectively recruited. Demographic, sexual function (Female Sexual Function Index and International Index of Erectile Function), disease activity (endoscopic, biomarker, and symptoms), psychological symptoms, and quality-of-life data were collected. Rates of SD and erectile dysfunction (ED) were compared between patients with active and inactive inflammation and symptoms using the Fisher's exact test. Logistic regression examined associations between SD and ED, and disease characteristics and psychological symptoms.

RESULTS

A total of 159 participants were included, 97 had Crohn's disease and 85 were women. SD was reported in 36 of 59 and 13 of 59 sexually active women and men, respectively and ED in 22 of 59 sexually active men. Rates of SD and ED were similar between individuals with active and inactive IBD based on endoscopic indices (P > .05) and biomarkers (P > .05). Women with active IBD symptoms experienced significantly higher rates of SD (P < .05), but men did not (P > .05). Multivariable logistic regression identified that symptoms of severe depression (odds ratio, 5.77; 95% confidence interval, 1.59-20.94) were associated with SD in women, and severe anxiety (odds ratio, 15.62; 95% confidence interval, 1.74-140.23) was associated with ED in men.

CONCLUSIONS

Objective measures of disease activity are not associated with SD or ED in patients with IBD. Clinicians should consider concomitant psychological symptoms contributing to the sexual health of patients with IBD.

Viphyllin™, a standardized extract from black pepper seeds, mitigates intestinal inflammation, oxidative stress, and anxiety-like behavior in DSS-induced colitis mice

Inflammatory bowel diseases (IBD) are the common health concern in populations across the world. Clinical evidence suggests that IBD, characterized by intestinal inflammation, is associated with neuronal manifestations to a greater extent. In this study, we have investigated the protective effects of Viphyllin™, a standardized black pepper (Piper nigrum) seed extract containing 30% β-caryophyllene against dextran sodium sulfate (DSS)-induced colitis in mice. Oral pretreatment of Viphyllin at the 50 mg and 100 mg/kg doses significantly reversed the clinical symptoms of colitis in mice. Viphyllin markedly inhibited NLRP3 inflammasome activation and improved barrier function in colon tissue. Viphyllin further mitigated the DSS-induced anxiety-like behavior in mice. Interestingly, Viphyllin improved brain antioxidant status and promoted neuronal cell survival in colitis model mice. In conclusion, our findings strongly support the health claims of Viphyllin as a functional ingredient to deal with IBD and related neuronal symptoms. PRACTICAL APPLICATIONS: Prevalence of inflammatory bowel diseases is not uncommon in the modern lifestyle. Gut health is associated with neurological disorders that contribute substantially to the deterioration of quality of life and socioeconomic development. In this research work, the protective action of a black pepper seed extract standardized to 30% β-caryophyllene (Viphyllin) is evaluated against Dextran sodium sulfate-induced experimental colitis model. Here we have demonstrated the beneficial role of Viphyllin in mitigating intestinal inflammation as a function of NLRP3 inflammasome inhibition. Further, the extract improves intestinal barrier function. In an important aspect of the study, we have provided the data on the effect of Viphyllin on neurological symptoms and brain health in colitis model mice.

Estimation of the bidirectional relationship between schizophrenia and inflammatory bowel disease using the mendelian randomization approach

It has been reported that schizophrenia (SCZ) and inflammatory bowel disease (IBD) are related. However, whether there is a bidirectional interaction between them remains unclear. The aim of this study was to conduct a bidirectional Mendelian randomization (MR) analysis to elucidate the causal relationship between SCZ and IBD and its subtypes, including Crohn's disease (CD) and ulcerative colitis (UC). Single-nucleotide polymorphisms (SNPs) extracted from the summary data of genome-wide association studies were used as genetic instruments. MR was performed using the inverse-variance-weighted method. The MR-Egger and weighted median methods were used for sensitivity analyses. Analysis using 70 SNPs as genetic instruments showed that SCZ was associated with an increased risk of IBD (OR = 1.14, 95% CI: 1.09-1.20, P = 9.21 × 10^-8), CD (OR = 1.16, 95% CI: 1.07-1.25, P = 1.42 × 10^-4), and UC (OR = 1.14, 95% CI: 1.07-1.21, P = 2.72 × 10^-5). The results of the sensitivity analyses were robust and no evidence of pleiotropy was observed. Bidirectional MR analyses showed no causal effects of IBD, CD, or UC on SCZ. This study suggests that SCZ has causal effects on IBD and its subtypes, whereas IBD has no effect on SCZ. Brain-gut axis interactions may help clarify the causal relationship between SCZ and IBD. However, further studies are needed to elucidate the biological mechanisms behind the brain-gut interactions.

Venlafaxine as an Adjuvant Therapy for Inflammatory Bowel Disease Patients With Anxious and Depressive Symptoms: A Randomized Controlled Trial

BACKGROUND AND AIMS

The effect of antidepressant therapy on Inflammatory Bowel Disease (IBD) remains controversial. This trial aimed to assess whether adding venlafaxine to standard therapy for IBD improved the quality of life (QoL), mental health, and disease activity of patients with IBD with anxious and depressive symptoms.

METHODS

A prospective, randomized, double-blind, and placebo-controlled clinical trial was conducted. Participants diagnosed with IBD with symptoms of anxiety or depression were randomly assigned to receive either venlafaxine 150 mg daily or equivalent placebo and followed for 6 months. Inflammatory Bowel Disease Questionnaire (IBDQ), Mayo score, Crohn's disease activity index (CDAI), Hospital Anxiety and Depression Scale (HADS), and blood examination were completed before the enrollment, during, and after the follow-up. Mixed linear models and univariate analyses were used to compare groups.

RESULTS

Forty-five patients with IBD were included, of whom 25 were randomized to receive venlafaxine. The mean age was 40.00 (SD = 13.12) years old and 25 (55.6%) were male. Venlafaxine showed a significant improvement on QoL (p < 0.001) and disease course (p = 0.035), a greater reduction in HADS (anxiety: p < 0.001, depression: p < 0.001), Mayo scores (p < 0.001), and CDAI (p = 0.006) after 6 months. Venlafaxine had no effect on IL-10 expression, endoscopic scores, relapse rate, and use rate of biologics and corticosteroids, but did reduce serum level of erythrocyte estimation rate (ESR; p = 0.003), C-reactive protein (CRP; p < 0.001) and tumor necrosis factor-α (TNF-α; p = 0.009).

CONCLUSIONS

Venlafaxine has a significantly beneficial effect on QoL, IBD activity, and mental health in patients with IBD with comorbid anxious or depressive symptoms. (Chinese Clinical Trial Registry, ID: ChiCTR1900021496).

The impact of disease activity on psychological symptoms and quality of life in patients with inflammatory bowel disease-results from the Stress, Anxiety and Depression with Disease Activity (SADD) Study

BACKGROUND

Disease activity may be a risk factor for psychological illness in patients with inflammatory bowel disease (IBD).

AIM

To correlate objective measures of disease activity with psychological symptoms.

METHODS

Adult patients with IBD undergoing ileocolonoscopy were prospectively recruited. Demographic, psychological symptoms (depression, anxiety, stress), disease activity (symptoms, biomarkers, endoscopy), and quality of life (QoL) data were collected. One-way ANOVA and multivariable analyses examined the associations between disease activity and symptoms of psychological illness, and identified other predictors of mental illness and reduced QoL.

RESULTS

A total of 172 patients were included, 107 with Crohn's disease (CD) and 65 with ulcerative colitis (UC). There was no significant association between objective disease activity (endoscopic scores, faecal calprotectin or C-reactive protein) and depression, anxiety or stress scores (P > 0.05 for all comparisons). Gastrointestinal symptoms were significantly associated with symptoms of depression, anxiety and stress in patients with CD and UC (P < 0.05). On multivariable analysis, only gastrointestinal symptoms were associated with severe symptoms of depression (OR 20.78 [6.71-92.37], P < 0.001) and anxiety (OR 4.26 [1.70-12.25], P = 0.004). Anti-TNF and corticosteroid use, the presence of severe depressive, moderate-severe stress and gastrointestinal symptoms, and endoscopically active IBD were associated with a reduced QoL (P < 0.05). Longer duration of IBD predicted an improved QoL (P < 0.05).

CONCLUSIONS

Objective measures of disease activity are not associated with symptoms of psychological illness in patients with IBD. Clinicians should consider underlying mental illness in patients with IBD with active gastrointestinal symptoms.

High Levels of Psychological Resilience Are Associated With Decreased Anxiety in Inflammatory Bowel Disease

BACKGROUND

Anxiety and depression are comorbid disorders with IBD and are associated with poor outcomes. Resilience is an innate but modifiable trait that may improve the symptoms of psychological disorders. Increasing resilience may decrease the severity of these comorbid disorders, which may improve IBD outcomes. The aim of this study was to describe the association between resilience, anxiety, and depression in IBD patients.

METHODS

We performed a cross-sectional study of IBD patients. Patients completed a questionnaire consisting of the Connor-Davidson Resilience Scale (CD-RISC), a measure of resilience, the Generalized Anxiety Disorder 7 (GAD-7), and the Patient Health Questionnaire-9. Primary outcome was severity of anxiety and depression in patients with high resilience. Multivariable linear regression analysis evaluated the association between severity of anxiety and depression and level of resilience.

RESULTS

A sample of 288 patients was analyzed. Bivariable linear regression analysis showed a negative association between resilience and anxiety (Pearson rho = -0.47; P < .0001) and between resilience and depression (Pearson rho = -0.53; P < .0001). Multivariable linear regression indicated that high resilience is independently associated with lower anxiety and that for every 1-unit increase in CD-RISC, the GAD-7 score decreased by 0.04 units (P = .0003). Unlike anxiety, the association between resilience and depression did not remain statistically significant on multivariable analysis.

CONCLUSIONS

High resilience is independently associated with lower anxiety in IBD patients, and we report a quantifiable decrease in anxiety score severity for every point of increase in resilience score. These findings suggest that IBD patients with higher resilience may have better coping mechanisms that buffer against the development of anxiety.

Psychological Predictors of Sexual Quality of Life Among Iranian Women With Vaginismus: A Cross-Sectional Study

Background

Vaginismus is an involuntary contraction of muscles around the vaginal and one of the most common sexual disorders among women. It is often associated with psychological problems, leading to poor sexual quality of life (SQOL). This study aimed to determine SQOL predictors in women with vaginismus.

Methods

In this cross-sectional study, convenience sampling was used to enroll 236 individuals with vaginismus among all women visiting sexual health clinics of Tehran, Iran in 2018. The data were collected using the Sexual Quality of Life-Female (SQOL-F) Questionnaire, Hospital Anxiety and Depression Scale (HADS), and Rosenberg Self-Esteem Scale. The data were analyzed using the General Linear Model (GLM).

Results

The mean (SD) SQOL score of the participants was 56.82 (20.18). There was a significant direct correlation between the participants' self-esteem and their SQOL (r = 0.54, p < 0.001). However, the participants' SQOL had significant inverse correlations with the variables of anxiety (r = - 0.48, p < 0.001) and depression (r = -0.47, p < 0.001). Based on the GLM results, the variables of anxiety, depression, self-esteem, and duration of disorder predicted SQOL, and explained 42.3% of the variance of SQOL in the participants.

Conclusion

The results indicated that psychological factors such as anxiety, depression, and self-esteem are predictors of SQOL in women with vaginismus.

Sexual Dysfunction in Patients With Chronic Gastrointestinal and Liver Diseases: A neglected Issue

INTRODUCTION

Normal sexual activity is an important determinant of quality of life. Unfortunately, several chronic health disorders are associated with an impaired sexual function.

OBJECTIVE

To provide coverage of the current literature on prevalence and pathophysiology of sexual dysfunction in patients with gastrointestinal and liver disorders METHODS: A Comprehensive review of the literature on the prevalence of sexual dysfunction in chronic gastrointestinal and liver disorders, assessing the underlying mechanism (s) was performed.

RESULTS

Many gastrointestinal disorders, either functional or organic, are associated with some degree of sexual dysfunction. The main pathogenic mechanisms are: (i) the disease itself causing fatigue, anxiety or depression with a potential alteration of self-esteem; (ii) worry of transmitting a potential infectious agent through sexual activity; (iii) alteration of the endocrine mechanisms which are necessary for normal sexual functioning; (iv) chronic pro- inflammatory conditions which may cause endothelial dysfunction and abnormal vascular responses; (v) iatrogenic.

CONCLUSION

Based on this review, a thorough evaluation of sexual function through validated questionnaires and/or psychological interviews with patients with chronic gastrointestinal disorders should be part of the clinical assessment in order to timely diagnose and possibly treat sexual dysfunction in this clinical setting. L Romano, L Granata, F Fusco, et al. Sexual Dysfunction in Patients With Chronic Gastrointestinal and Liver Diseases: A neglected Issue. Sex Med Rev 2021;XX:XXX-XXX.

Association between antidepressant medication use and steroid dependency in patients with ulcerative colitis: a population-based study

Background

Animal studies indicate a potential protective role of antidepressant medication (ADM) in models of colitis but the effect of their use in humans with ulcerative colitis (UC) remains unclear.

Objective

To study the relationship between ADM use and corticosteroid dependency in UC.

Design

Using the Clinical Practice Research Datalink we identified patients diagnosed with UC between 2005 and 2016. We grouped patients according to serotonin selective reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) exposure in the 3 years following diagnosis: ‘continuous users’, ‘intermittent users’ and ‘non-users’. We used logistic regression to estimate the adjusted risk of corticosteroid dependency between ADM exposure groups.

Results

We identified 6373 patients with UC. Five thousand two hundred and thirty (82%) use no ADMs, 627 (10%) were intermittent SSRI users and 282 (4%) were continuous SSRI users, 246 (4%) were intermittent TCA users and 63 (1%) were continuous TCA users.

Corticosteroid dependency was more frequent in continuous SSRI and TCA users compared with non-users (19% vs 24% vs 14%, respectively, χ² p=0.002). Intermittent SSRI and TCA users had similar risks of developing corticosteroid dependency to non-users (SSRI: OR 1.19, 95% CI 0.95 to 1.50, TCA: OR 1.14, 95% CI 0.78 to 1.66). Continuous users of both SSRIs and TCAs had significantly higher risks of corticosteroid dependency compared with non-users (SSRI: OR 1.62, 95% CI 1.15 to 2.27, TCA: OR 2.02, 95% CI 1.07 to 3.81).

Conclusions

Continuous ADM exposure has no protective effect in routine clinical practice in UC and identifies a population of patients requiring more intensive medical therapy. ADM use is a flag for potentially worse clinical outcomes in UC.

Sexual Dysfunction in Inflammatory Bowel Disease: What the Specialist Should Know and Ask

Inflammatory bowel disease (IBD) is a chronic condition that globally affects the health of people who suffer from it, deteriorating their quality of life (QoL). An aspect rarely explored by healthcare providers is the influence of the disease on the sexual functioning of individuals. This discretion is mainly due to an unconscious resistance when asking our patients about their sexual functioning because of a lack of knowledge and skills to tackle this topic or disinterest on the part of professionals, and fear or shame on the part of patients. Sexual function is a constant concern in IBD patients that has been reflected in several studies, especially if we consider that the prevalence of sexual dysfunction (SD) in IBD is higher than that reported in the general population. The etiology of SD in patients with IBD remains unclear but is likely to be multifactorial, where biological, psychosocial, and disease-specific factors are involved. Currently, there are no formal recommendations in the IBD clinical guidelines on how to manage SD in these patients. The use of validated clinical scales could improve the detection of SD and allow the treatment of the underlying causes in order to improve the QoL of patients with IBD. This review aims to illustrate the different aspects involved in SD in IBD patients and the importance of the participation of a multidisciplinary team in the early detection and treatment of SD at different stages of the disease.

Relation of Repetitive Thinking Styles with Anxiety and Depression in Patients with Inflammatory Bowel Disease

In this study, we aimed to evaluate the relationship between the repetitive thinking styles and anxiety and depression in patients with inflammatory bowel disease (IBD). One hundred IBD outpatients (39 active and 61 remission) attending the gastroenterology clinic and 100 healthy controls were included.The rumination and worry scores of IBD patients, particularly in their active period, were significantly higher than controls. Additionally, the correlation of rumination and worry with anxiety and depression was statistically significant. Our results suggest that psychological interventions targeting repetitive thinking would alleviate depression and anxiety as well as GI symptoms in people with IBD which should be confirmed by further studies.

Buspirone alleviates anxiety, depression, and colitis; and modulates gut microbiota in mice

Gut microbiota regulate the neurodevelopmental processes and brain functions through the regulation of the microbiota–gut interaction and gut–brain communication. Buspirone, an agonist for serotonin 5-HT1A receptors, is used for the treatment of anxiety/depression. Therefore, to understand the gut microbiota-mediated mechanism of buspirone on anxiety/depression, we examined its effect on the immobilization stress (IS) or Escherichia coli K1 (EC)-induced anxiety/depression in mice. Oral or intraperitoneal administration of buspirone significantly suppressed stressor-induced anxiety/depression-like behaviors in the elevated plus maze, light/dark transition, tail suspension, and forced swimming tasks. Their treatments also reduced TNF-α expression and NF-κB⁺/Iba1⁺ cell population in the hippocampus and myeloperoxidase activity and NF-κB⁺/CD11c⁺ cell population in the colon. Buspirone treatments partially restored IS- or EC-induced gut microbiota perturbation such as β-diversity to those of normal control mice: they reduced the IS- or EC-induced gut Proteobacteria population. In particular, the anxiolytic activity of buspirone was positively correlated with the populations of Bacteroides and PAC001066_g in EC- or IS-exposed mice, while the populations of Lachnospiraceae, KE159660_g, LLKB_g, Helicobacter, and PAC001228_g were negatively correlated. The anti-depressant effect of buspirone was positively correlated with the Roseburia population. The fecal microbiota transplantations from buspirone-treated mice with IS-induced anxiety/depression or normal control mice suppressed IS-induced anxiety/depression-like behaviors and reduced hippocampal NF-κB⁺/Iba1⁺ and colonic NF-κB⁺/CD11c⁺ cell populations in the transplanted mice. Furthermore, they modified IS-induced perturbation of gut microbiota composition, particularly Proteobacteria, in the transplanted mice. In conclusion, buspirone alleviates IS as well as EC-induced anxiety/depression and colitis. It also suppresses associated neuroinflammation and modulates gut microbiota. Future studies can help to explain the relationship, if any, in the central and peripheral effects of buspirone.

Effect of escitalopram on an acetic acid-induced ulcerative colitis model

Ulcerative colitis (UC) is a chronic and recurrent gastrointestinal (GI) disorder with an unknown aetiology and pathogenesis. Regarding the effectiveness of antidepressants on UC in animal models of depression and the known anti-inflammatory effects of escitalopram this study was conducted to evaluate the beneficial effects of escitalopram on an acetic acid-induced UC model without depression. UC model was induced by intra rectal (i.r.) administration of 4% acetic acid in rats after 24 hours of fasting. Animals were treated with three doses of escitalopram (5, 10 and 20 mg/kg). Prednisolone (4 mg/kg) was used as a reference drug in UC. Histological and oxidative stress markers were measured in all groups. Results showed significant increase in superoxide dismutase (SOD) activity and glutathione (GSH) levels, as well as significant decrease in myeloperoxidase (MPO) activity, malondialdehyde (MDA) levels, macroscopic factors (ulcer surface area, ulcer severity and weight-to-colon ratio) and microscopic and histological parameters (severity and extent of inflammation, cryptic destruction and severity of tissue involvement) in escitalopram treated rats (10, 20 mg/kg) compared to the UC group. In conclusion, the results of our study are in support of beneficial anti-inflammatory and antioxidant effects of escitalopram in UC.

The Brain-Gut Axis: Psychological Functioning and Inflammatory Bowel Diseases

The brain-gut axis represents a complex bi-directional system comprising multiple interconnections between the neuroendocrine pathways, the autonomous nervous system and the gastrointestinal tract. Inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, is a chronic, relapsing-remitting inflammatory disorder of the gastrointestinal tract with a multifactorial etiology. Depression and anxiety are prevalent among patients with chronic disorders characterized by a strong immune component, such as diabetes mellitus, cancer, multiple sclerosis, rheumatoid arthritis and IBD. Although psychological problems are an important aspect of morbidity and of impaired quality of life in patients with IBD, depression and anxiety continue to be under-diagnosed. There is lack of evidence regarding the exact mechanisms by which depression, anxiety and cognitive dysfunction may occur in these patients, and whether psychological disorders are the result of disease activity or determinants of the IBD occurrence. In this comprehensive review, we summarize the role of the brain-gut axis in the psychological functioning of patients with IBD, and discuss current preclinical and clinical data on the topic and therapeutic strategies potentially useful for the clinical management of these patients. Personalized pathways of psychological supports are needed to improve the quality of life in patients with IBD.

Depression and Anxiety Disorders in Patients With Inflammatory Bowel Disease

Mental health is a significant yet overlooked aspect of inflammatory bowel disease (IBD) patient care, with challenges in determining optimal treatments and psychological health resources. The most common psychological conditions in patients with IBD are anxiety and depression. The increased prevalence of these mental disorders appeals to mental screening of each person diagnosed with IBD at initial consultation. There are simple and clinically viable methods available to screen for mental problems. Psychological methods may be as or even more significant as a therapeutic modality. Herein we discuss the three major areas of psychological co-morbidity in IBD: (1) the prevalence and risk factors associated with anxiety and depression disorders for patients with IBD; (2) diagnosis of psychological disorders for patients with IBD; (3) treatment with patients with IBD and mental disorders. The gastroenterologists are encouraged to screen and treat these patients with IBD and mental disorders, which may improve outcomes.

The New Proactive Approach and Precision Medicine in Crohn's Disease

The proactive approach to Crohn's disease (CD) management advocates moving toward algorithmic tight-control scenarios that are designed for each CD phenotype to guide remission induction, maintenance therapy, active monitoring, and multidisciplinary care to manage the complexities of each inflammatory bowel disease (IBD) patient. This requires accurate initial clinical, laboratory, radiological, endoscopic, and/or tissue diagnosis for proper phenotypic stratification of each CD patient. A substantial proportion of patients in symptomatic remission have been reported to demonstrate evidence of active disease, with elevated fecal calprotectin(FC) and C-reactive protein (CRP) levels as a hallmark for mucosal inflammation. Active mucosal inflammation, and elevated CRP and fecal calprotectin (FC) have been shown to be good predictors of clinical relapse, disease progression, and complications in IBD patients. The next frontier of treatment is personalized medicine or precision medicine to help solve the problem of IBD heterogeneity and variable responses to treatment. Personalized medicine has the potential to increase the efficacy and/or reduce potential adverse effects of treatment for each CD phenotype. However, there is currently an unmet need for better elucidation of the inflammatory biopathways and genetic signatures of each IBD phenotype, so personalized medicine can specifically target the underlying cause of the disease and provide maximal efficacy to each patient.

Surgery, stomas, and anxiety and depression in inflammatory bowel disease: a retrospective cohort analysis of privately insured patients

AIM

Patients with inflammatory bowel disease (IBD) are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and the temporal association with abdominal surgery and stoma formation.

METHOD

We conducted a retrospective cohort study in adult patients with IBD using difference-in-difference methodology and a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.

RESULTS

We identified 10 481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41 924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (P < 0.001). Surgical patients had higher odds of anxiety [one surgery, adjusted OR 6.90 (95% CI 6.11-7.79), P < 0.001; two or more surgeries, 7.53 (5.99-9.46), P < 0.001] and depression [one surgery, 6.15 (5.57-6.80), P < 0.001; two or more surgeries, 6.88 (5.66-8.36), P < 0.001] than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from 'pre' to 'post' time periods [1.43 (1.18-1.73), P < 0.001]. Amongst surgical patients, stoma formation was independently associated with anxiety [1.40 (1.17-1.68), P < 0.001] and depression [1.23 (1.05-1.45), P = 0.01]. New ostomates experienced a greater increase in postoperative anxiety [1.24 (1.05-1.47), P = 0.01] and depression [1.19 (1.03-1.45), P = 0.01] than other surgical patients.

CONCLUSION

IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.

Evaluation of depression, anxiety and quality of life in hepatitis C patients who treated with direct acting antiviral agents

BACKGROUND/AIMS

Hepatitis C virus (HCV) infection is known to impair the quality of life (QoL). Increased levels of anxiety and depression have been found in HCV infection with a prevalence of 28% and 33%, respectively. Our aim was to investigate depression, anxiety, and QoL of chronic hepatitis C (CHC) patients before and after treatment with a direct-acting antiviral agent (DAAA).

MATERIALS AND METHODS

In this study, enrolled CHC patients who had undergone DAAA treatment in our out-patient clinic. We administered the Hospital Anxiety and Depression (HAD) questionnaire to measure the severity of the anxiety and depression symptoms and the Short Form-36 (SF-36) questionnaire to measure the QoL at the beginning and at the end of the treatment.

RESULTS

Pretreatment anxiety and depression scores showed a statistically significant difference from the post treatment scores (p=0.000 and p=0.029 respectively). When we compared the SF-36 subitems before and after the treatment, a statistical significance was found in physical functioning (p=0.026), physical role limitation (p=0.009), bodily pain (p=0.011), general health (p=0.017), social functioning (p=0.006), and emotional role limitation (p=0.007). Also, an improvement was seen in the vitality (p=0.488) and mental health (p=0.714), which was not statistically significant.

CONCLUSION

Depression got minimally worse in the male group despite an improvement in CHC. Anxiety scores were improved with treatment in the cirrhotic and non-cirrhotic groups significantly. A decrease in anticipatory anxiety may be related to the high treatment success with DAAA. Nearly all the subitems of the QoL scores were improved after treatment and these were more common in the female group. Elimination of HCV may itself decrease the number of patients who need psychiatric treatment.

Men With Inflammatory Bowel Disease: Sexual Function, Fertility, Medication Safety, and Prostate Cancer

Half of patients with inflammatory bowel disease (IBD) are men, yet less attention has been focused on their sexual issues despite higher rates of sexual dysfunction and infertility than the general population. Depression and IBD disease activity are the most consistently reported risk factor for sexual dysfunction among men with IBD. Methotrexate and sulfasalazine have been rarely associated with impotence. Sulfasalazine reversibly reduces male fertility. No other medications used in IBD significantly affect fertility in humans. There is no increase in adverse fetal outcomes among offspring of fathers with IBD. Patients with IBD seem to be at a higher risk for prostate cancer; therefore, screening as recommended for high-risk patients should be considered.

Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

PURPOSE OF REVIEW

This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies.

RECENT FINDINGS

Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.

Chronic Unpredictable Mild Stress in Rats Induces Colonic Inflammation

Chronic psychological stress is associated with an increased risk for relapse of inflammatory bowel diseases (IBD) and impedes the treatment of this condition. However, the impact of stress on the risk of IBD onset remains unclear. The goal of the present study was to examine whether chronic unpredictable mild stress (CUMS) could initiate or aggravate the onset of colon inflammation in rats which, in turn, would be capable of triggering bowel disease. We found that CUMS exposure increased infiltration of CD-45 positive cells and MPO activity, as well as augmented the expression of the inflammatory cytokines, IFN-γ and IL-6 within the colon of these rats. In addition, CUMS treatment changed the composition and diversity of gut microbiota and enhanced intestinal epithelial permeability, indicating the presence of a defect in the intestinal barrier. This CUMS-induced disruption of mucosal barrier integrity was associated with a reduction in expression of the tight junction protein, occludin 1, and an inhibition in mucosal layer functioning via reductions in goblet cells. Results from bacterial cultures revealed an increased presence of bacterial invasion after CUMS treatment as compared with that observed in controls. Thus, our data indicate that CUMS treatment induces alterations of the fecal microbiome and intestinal barrier defects, which facilitates bacterial invasion into colonic mucosa and further exacerbates inflammatory reactions within the colon. Accordingly, chronic stress may predispose patients to gastrointestinal infection and increase the risk of inflammation-related gut diseases.

The Influence of Antidepressants on the Disease Course Among Patients With Crohn's Disease and Ulcerative Colitis-A Danish Nationwide Register-Based Cohort Study

BACKGROUND

Psychiatric comorbidity might modify the disease course adversely in patients with inflammatory bowel disease (IBD). Treatment options include antidepressants, which, apart from improving mood, have anti-inflammatory properties that might modify the disease course. This nationwide study aimed to examine the influence of antidepressants on the disease course among patients with ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

Patients registered with an incident diagnosis of CD or UC in the Danish National Patient Register (2000-2017) were included. Information on antidepressant use and proxy measures of disease activity (health care and drug utilization) was extracted from national population registers. Poisson regression was performed to estimate disease activity rates by antidepressant use adjusted for confounders. Furthermore, the analyses were performed stratified by IBD subtype and type of antidepressants.

RESULTS

A total of 42,890 patients were included (UC: 69.5%; CD: 30.5%). When adjusted for confounders, a lower incidence rate of disease activity was found among antidepressant users compared with nonusers in both CD (incidence rate ratio [IRR], 0.75; 95% confidence interval [CI], 0.68-0.82) and UC (IRR, 0.90; 95% CI, 0.84-0.95) patients. Further, markedly lower rates of disease activity were found among CD (IRR, 0.51; 95% CI, 0.43-0.62) and UC (IRR, 0.67; 95% CI, 0.59-0.75) patients with no use of antidepressants before IBD onset.

CONCLUSIONS

In this nationwide study, antidepressant use was found to be beneficial on the disease course among patients with UC and CD, particularly in patients with no use of antidepressants before IBD onset. Randomized controlled trials are warranted to investigate the potential of antidepressants being an adjunct treatment to conventional IBD therapy.

The influence of disease type and activity to sexual life and health quality in inflammatory bowel disease

BACKGROUND/AIMS

Inflammatory bowel disease (IBD) has a major impact on patients' quality of life (QoL), mood, and sexual life. The purpose of the present study was to show the effect of disease type and activity on sexual life and QoL in patients with IBD.

MATERIALS AND METHODS

A total of 122 patients with IBD and 42 sex- and age-matched control cases were included in the study. Demographic characteristics were recorded. The disease activity of patients with IBD was assessed by the Harvey-Bradshaw Index in Crohn's disease (CD) and the Mayo Clinical Ulcerative Colitis Activity Index in ulcerative colitis (UC). All participants were subjected to complete three questionnaires: Short Form 36 (SF-36), Hospital Anxiety and Depression Scales (HAD-A and HAD-D), and Arizona Sexual Experience Scale (ASEX).

RESULTS

There was no difference in terms of demographic characteristics between the three groups, except cigarette exposure in CD. The disease activity of patients with UC and CD was not different (p>0.05). The mean HAD-A score was significantly higher in the CD group, whereas the mean HAD-D score was higher in the IBD group than in the control group (p<0.05). Anxiety was seen more frequently in women. SF-36 scale scores were found to be lower in the UC and CD groups than in the control group (p<0.05). The mean ASEX scores of women with UC (19.59±7.59) and CD (19.38±6.27) were both significantly higher than those of the control group (15±4.76). Although the mean ASEX scores of men were not different, some ASEX subscores of the IBD groups were worse than those of the control.

CONCLUSION

Inflammatory bowel disease is a chronic disease that has multiple complications affecting patients' psychosocial life. Patients have more anxiety, depression, and sexual dysfunction when their disease is active. Patients should be screened for psychological diseases and sexual dysfunction, and necessary treatments should be given.

Sleep and Inflammatory Bowel Disease: An Important Bi-Directional Relationship

Sleep deprivation and lack of sleep are a significant public health concern. Several studies have suggested an intricate relationship between sleep, inflammation, and the immune system. Poor sleep has been described well in subjects with inflammatory bowel disease (IBD) and has been linked to disease activity and shown as a predictor for subclinical inflammation and a risk factor for relapse and poorer outcomes. This review describes the relationship between poor sleep, inflammation, and the immune system. Furthermore, the relationship between sleep and IBD are reviewed. The causes of poor sleep in inflammatory bowel disease patient is discussed. Potential therapeutic interventions for the management of common sleep disturbances are provided.

Optimizing the multidimensional aspects of the patient-physician relationship in the management of inflammatory bowel disease

The patient-physician relationship has a pivotal impact on the inflammatory bowel disease (IBD) outcomes. However, there are many challenges in the patient-physician relationship; lag time in diagnosis which results in frustration and an anchoring bias against the treating gastroenterologist, the widespread availability of medical information on the internet has resulted in patients having their own ideas of treatment, which may be incongruent from the treating physicians’ goals resulting in patient physician discordance. Because IBD is an incurable disease, the goal of treatment is to sustain remission. To achieve this, patients may have to go through several lines of treatment. The period of receiving stepping up, top down or even accelerated stepping up medications may result in a lot of frustration and anxiety for the patient and may compromise the patient-physician relationship. IBD patients are also prone to psychological distress that further compromises the patient-physician relationship. Despite numerous published data regarding the medical and surgical treatment options available for IBD, there is a lack of data regarding methods to improve the therapeutic patient-physician relationship. In this review article, we aim to encapsulate the challenges faced in the patient-physician relationship and ways to overcome in for an improved outcome in IBD.

Development of a Sexual Dysfunction Scale for Women With Inflammatory Bowel Disease

Background

Women with inflammatory bowel disease (IBD) may have decreased sexual function. To understand how common this condition is in our female patients, we developed a new IBD-specific Female Sexual Dysfunction Scale (the IBD-FSDS).

Methods

We performed a prospective cross-sectional study of 454 female IBD patients ≥18 years of age attending 1 of 3 IBD clinics in the United States or Denmark. We gathered information on sexual function via a de novo 23-item scale. General sexual functioning was measured with the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R). Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Medical history and sociodemographic data were collected via chart review. Exploratory factor analyses (EFAs) of the English language version of IBD-FSDS assessed unidimensionality, factor structure, reliability, criterion validity, and construct validity.

Results

EFAs suggested retaining 15-items creating a unidimensional scale with strong internal consistency reliability (α = 0.93). Validity of the English language IBD-FSDS was measured using Spearman's coefficient, demonstrating significant criterion validity with the FSDS-R (P < 0.05) and the FSFI (P < 0.05) and significant construct validity with the composite for cases of active IBD (P < 0.05) and PHQ-9 (P < 0.05). Sexual dysfunction in women with IBD was significantly associated with depression (P = 0.042), active IBD (P = 0.002), and no history of surgery (P = 0.044).

Conclusions

We have developed and validated an IBD-specific scale to assess the psychosexual impact of IBD in women. This novel screening questionnaire may help health care providers recognize factors contributing to impaired sexual function in their female patients.

The Effect of Antidepressants on the Course of Inflammatory Bowel Disease

BACKGROUND AND AIMS

Mood may have an important role in the natural history of inflammatory bowel disease (IBD). However, the impact of antidepressant use on prognosis is unknown. We aimed to address this in a longitudinal study in a referral population.

METHODS

We collected demographic data, clinical disease activity and mood using validated questionnaires, and antidepressant use at baseline. Longitudinal disease activity was defined by disease flare or need for glucocorticosteroids, escalation of medical therapy, hospitalisation, or intestinal resection. We compared rates of these over a minimum period of 2 years according to antidepressant use at baseline.

RESULTS

In total, 331 patients provided complete data, of whom 54 (15.8%) were taking an antidepressant at study entry. Older age, female gender, and abnormal mood scores were associated with antidepressant use. During longitudinal follow-up, there was a trend towards lower rates of any of the four endpoints of IBD activity of interest in patients with abnormal anxiety scores at baseline and who were receiving an antidepressant (42.3% versus 64.6%, P = 0.05). Based on univariate Cox regression analysis, there was a trend towards lower rates of escalation of medical therapy among patients receiving antidepressants at baseline (hazard ratio (HR) = 0.59; 95% confidence interval (CI) 0.35-1.00, P = 0.05). None of the differences observed persisted after multivariate Cox regression.

CONCLUSIONS

Antidepressants may have some beneficial effects on the natural history of IBD, but larger studies with longer follow-up are required. Whether these effects are limited to patients with abnormal mood remains uncertain.

Depression Is Associated With More Aggressive Inflammatory Bowel Disease

OBJECTIVES

Depression is prevalent in inflammatory bowel disease (IBD) patients. The impact of depression on IBD is not well-studied. It is unknown how providers should assess depression.

METHODS

We used data from the Sinai-Helmsley Alliance for Research Excellence cohort, to assess methods of diagnosing depression and effects of baseline depression on disease activity at follow-up. A patient health questionnaire (PHQ-8) score ≥5 was consistent with mild depression. Relapse was defined as a modified Harvey-Bradshaw Index ≥5 or Simple Clinical Colitis Activity Index >2. We performed binomial regression to calculate adjusted risk ratios (RRs).

RESULTS

We included 2,798 Crohn's disease (CD) patients with 22-month mean follow-up and 1,516 ulcerative colitis (UC) patients with 24-month mean follow-up. A total of 64% of CD patients and 45% of UC patients were in remission at baseline. By self-report, 20% of CD and 14% of UC patients were depressed. By PHQ-8, 38% of CD and 32% of UC patients were depressed (P<0.01). Adjusted for sex, remission, and disease activity, CD patients with baseline depression were at an increased risk for relapse (RR: 2.3; 95% confidence interval (CI): 1.9-2.8), surgery, or hospitalization (RR: 1.3 95% CI: 1.1-1.6) at follow-up. UC patients with baseline depression were also at increased risk for relapse (RR: 1.3; 95% CI: 0.9-1.7), surgery, or hospitalization (RR: 1.3; 95% CI: 1.1-1.5) at follow-up.

CONCLUSIONS

Baseline depression is associated with a higher risk for aggressive IBD at follow-up. A single question is not a sensitive method of assessing depression. Providers should consider administering the PHQ-8 to capture those at greater risk for aggressive disease.

High Demand for Psychotherapy in Patients with Inflammatory Bowel Disease

BACKGROUND

The relative contribution of psychological factors to the onset and course of inflammatory bowel diseases (IBD) is a matter of constant debate since its beginning, as is the clinical need and the efficacy of psychotherapeutic interventions. However, the perspective of patients with IBD has largely been ignored in this debate.

METHODS

Psychometric tests including the Short-Form IBD Questionnaire (SIBDQ), the ADAP test measuring demand for psychotherapy, and the Fear-of-Progression Questionnaire Short Form as well as disease-related questions were positioned on the internet between December 2014 and January 2016. The study was advertised through DCCV (German branch of the European Federation of Crohn's and Ulcerative Colitis Associations).

RESULTS

n = 631 patients responded, and complete data from n = 578 (356 Crohn's disease, 219 ulcerative colitis, 3 unclear) were available for analysis. n = 296 had previous experiences with psychotherapy, whereas n = 282 had not. This distribution clearly determined the factor "demand for psychotherapy" (chi-square = 23.7, P < 0.001). When all available data were entered into a (stepwise-forward) regression model, psychotherapy demand was dependent on previous experience (P < 0.001), fear of progression (P < 0.001), quality of life (P = 0.001), smoking (P = 0.003), and previous surgery (P = 0.005) with the total model explaining 29.7% of the variance. The total explained variance of this model was higher in ulcerative colitis (37.6%) than in Crohn's disease alone (25.4%).

CONCLUSIONS

The demand for psychotherapy as additional therapy in IBD depends on previous experience with psychotherapy, fear for disease progression but also other disease or social characteristics and quality of life.

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.

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.

Considering the Bidirectional Pathways Between Depression and IBD: Recommendations for Comprehensive IBD Care

Because of disease chronicity and required shifts in coping and self-management skills over time, it is not surprising that patients with inflammatory bowel disease (IBD) are at increased risk for mental health issues, including depression. Modern conceptualizations of chronic care recognize that the relationship between depression and disease is bidirectional, with (1) poor health leading to poor self-management just as often as poor self-management leads to poor health and (2) inflammation driving depression and depression driving inflammation. Depression in the setting of IBD has been undertreated in this population in the past and, if it remains as such, will continue to pose a significant risk to the current health care system. In this article, we explore these bidirectional relationships and make recommendations for the assessment and treatment of depression in the context of IBD.

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.