Should We Incorporate Psychological Care Into the Management of IBD?
Should We Incorporate Psychological Care Into the Management of IBD?
Clinical attention to the psychological factors associated with inflammatory bowel diseases (IBD) might have consequences that affect not only the psychological wellbeing and quality of life of patients with IBD, but also the activity of the disease itself. IBD has a negative effect on all aspects of quality of life, but it impairs emotional behavior the most—for example, the development of depressive mood or anxiety during and after phases of active disease.
The frequency of psychological disturbances in patients with Crohn's disease seems to be slightly higher (up to 50%) than in patients with other chronic diseases. Studies suggest that children and adolescents with IBD are at high risk for developing a psychiatric disorder. Changes in the activity of disease over time significantly affect levels of psychological distress, and are closely related to increases and decreases in anxiety and depression. The degree of psychological disturbance seems to correlate with disease severity, and psychological factors are considered by clinicians to have a moderate influence on the course of the disease.
Mawdsley et al. reviewed advances in the understanding of the role of psychological distress in the pathogenesis of IBD. Psychosocial factors can contribute to dysregulation of the interactions between the central nervous system, gut, and functioning of the immune system via the hypothalamic–pituitary–lymphocyte axis and can, therefore, affect disease activity during times of distress. Furthermore, the neuroimmunoendocrine and behavioral effects of stress might alter bowel flora and responses to dietary antigens. These alterations could, in turn, increase both the virulence of gut pathogens and the permeability of the intestinal mucosa, thereby enhancing exposure of the immune system to bacterial products and other luminal antigens. Psychological distress also stimulates mast-cell degranulation and histamine release, and upregulates the responsiveness of local and circulating immune effector cells.
Prospective clinical studies suggest that patients with Crohn's disease who have depressive mood and associated anxiety are at a higher risk of further disease activity (i.e. exacerbation of disease), compared with patients without these symptoms. In patients with ulcerative colitis, psychological distress has been found to be associated with both objective (rectal mucosal inflammation) and subjective (reported symptoms) measures of disease. In a prospective, long-term, follow-up study, Levenstein et al. found that high, long-term stress triples the 8-month risk of exacerbation. Shorter duration of sleep, briefer remission period, histological activity (i.e. inflammation in the gut), and the use of nonsteroidal anti-inflammatory drugs, antibiotics, or oral contraceptives also increased the medium-term and long-term risk of exacerbation of disease. Adjustment for these variables, however, did not eliminate the association of exacerbation of disease with psychological distress. Furthermore, exacerbation of symptoms need not take the form of an inflammatory relapse. It has been shown that the symptoms of at least one functional gastrointestinal disorder occur in 81.9% of IBD patients in remission. In addition, mood disorders (such as depression and anxiety) have been shown to occur in 27.3% of patients with ulcerative colitis and 31.3% of patients with Crohn's disease. As both functional gastrointestinal disorders and mood disorders are associated with impaired quality of life and increased use of health-care resources, the recognition and treatment of these disorders could improve the daily lives of patients with IBD, and increase the cost-effectiveness of treatments.
The ADAPT (Assessment of the Demand for Additional Psychological Treatment) questionnaire was developed to assess the subjective demand for additional psychological care in chronically ill patients. This questionnaire, which used IBD as the model disease, was designed to identify and quantify patient demand for disease-oriented counseling, integrated psychosomatic care, and psychotherapy. The preliminary results of a study that questioned more than 300 patients with IBD at a tertiary center have shown that a third of patients with IBD strongly desire additional psychological support. This finding illustrates that many patients with IBD need more than medical help. These patients should be identified and counseled by their treating physician. Furthermore, if necessary, patients should be referred to adequately trained colleagues for psychological care.
Interventions that target the improvement of psychological distress, such as psychotherapy or stress management, have rarely been studied in randomized, controlled trials. The few randomized, controlled trials that have been conducted in patients with IBD have shown that psychotherapy and stress management have a positive effect on the psychological dimensions of the illness, including enhancing psychological wellbeing, improving disease-coping strategies, and reducing symptoms of psychological distress such as tiredness, abdominal pain, and abdominal distension. Apart from one study that contained inhomogeneity in randomization, no study has shown that psychotherapy influences the clinical course of IBD (i.e. the number of relapses, length of symptom-free periods, overall disease severity). In addition, all studies on this topic have included patients without psychological disorders or distress; this could be the reason why psychotherapy in patients with IBD without psychological disturbance shows little or no benefit with regard to the number of relapses observed.
Psychotherapeutic interventions are indicated for psychological disorders such as depression, anxiety, reduced quality-of-life attributable to psychological distress, and inadequate coping skills for dealing with illness. In clinical practice it is important, therefore, to identify patients with IBD who have severe psychological problems and who require additional psychological support. Psychological care should be incorporated into the management of IBD patients if indicated. The choice of psychotherapeutic method will depend on the level and type of psychological disturbance, and decisions regarding this are best made by specialists.
In conclusion, experience gained from the treatment of patients with IBD shows that clinical attention to psychiatric comorbidity, quality of patient coping skills for dealing with illness, and patient–physician relationships are essential components of a comprehensive and successful management approach to this chronic illness. Psychological distress, depression, and anxiety represent risk factors for recurrence of IBD. As strategies aimed at improving psychological support might have a favorable impact on psychological distress, gastroenterologists should be trained to integrate psychological factors into clinical practice. Psychosomatic care should be provided in IBD centers in order to identify patients with a higher risk for chronic disease activity. Further controlled studies are needed to evaluate the influence of psychotherapy interventions on the clinical course of IBD, especially in those patients at a high risk of developing psychological problems.
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Clinical attention to the psychological factors associated with inflammatory bowel diseases (IBD) might have consequences that affect not only the psychological wellbeing and quality of life of patients with IBD, but also the activity of the disease itself. IBD has a negative effect on all aspects of quality of life, but it impairs emotional behavior the most—for example, the development of depressive mood or anxiety during and after phases of active disease.
The frequency of psychological disturbances in patients with Crohn's disease seems to be slightly higher (up to 50%) than in patients with other chronic diseases. Studies suggest that children and adolescents with IBD are at high risk for developing a psychiatric disorder. Changes in the activity of disease over time significantly affect levels of psychological distress, and are closely related to increases and decreases in anxiety and depression. The degree of psychological disturbance seems to correlate with disease severity, and psychological factors are considered by clinicians to have a moderate influence on the course of the disease.
Mawdsley et al. reviewed advances in the understanding of the role of psychological distress in the pathogenesis of IBD. Psychosocial factors can contribute to dysregulation of the interactions between the central nervous system, gut, and functioning of the immune system via the hypothalamic–pituitary–lymphocyte axis and can, therefore, affect disease activity during times of distress. Furthermore, the neuroimmunoendocrine and behavioral effects of stress might alter bowel flora and responses to dietary antigens. These alterations could, in turn, increase both the virulence of gut pathogens and the permeability of the intestinal mucosa, thereby enhancing exposure of the immune system to bacterial products and other luminal antigens. Psychological distress also stimulates mast-cell degranulation and histamine release, and upregulates the responsiveness of local and circulating immune effector cells.
Prospective clinical studies suggest that patients with Crohn's disease who have depressive mood and associated anxiety are at a higher risk of further disease activity (i.e. exacerbation of disease), compared with patients without these symptoms. In patients with ulcerative colitis, psychological distress has been found to be associated with both objective (rectal mucosal inflammation) and subjective (reported symptoms) measures of disease. In a prospective, long-term, follow-up study, Levenstein et al. found that high, long-term stress triples the 8-month risk of exacerbation. Shorter duration of sleep, briefer remission period, histological activity (i.e. inflammation in the gut), and the use of nonsteroidal anti-inflammatory drugs, antibiotics, or oral contraceptives also increased the medium-term and long-term risk of exacerbation of disease. Adjustment for these variables, however, did not eliminate the association of exacerbation of disease with psychological distress. Furthermore, exacerbation of symptoms need not take the form of an inflammatory relapse. It has been shown that the symptoms of at least one functional gastrointestinal disorder occur in 81.9% of IBD patients in remission. In addition, mood disorders (such as depression and anxiety) have been shown to occur in 27.3% of patients with ulcerative colitis and 31.3% of patients with Crohn's disease. As both functional gastrointestinal disorders and mood disorders are associated with impaired quality of life and increased use of health-care resources, the recognition and treatment of these disorders could improve the daily lives of patients with IBD, and increase the cost-effectiveness of treatments.
The ADAPT (Assessment of the Demand for Additional Psychological Treatment) questionnaire was developed to assess the subjective demand for additional psychological care in chronically ill patients. This questionnaire, which used IBD as the model disease, was designed to identify and quantify patient demand for disease-oriented counseling, integrated psychosomatic care, and psychotherapy. The preliminary results of a study that questioned more than 300 patients with IBD at a tertiary center have shown that a third of patients with IBD strongly desire additional psychological support. This finding illustrates that many patients with IBD need more than medical help. These patients should be identified and counseled by their treating physician. Furthermore, if necessary, patients should be referred to adequately trained colleagues for psychological care.
Interventions that target the improvement of psychological distress, such as psychotherapy or stress management, have rarely been studied in randomized, controlled trials. The few randomized, controlled trials that have been conducted in patients with IBD have shown that psychotherapy and stress management have a positive effect on the psychological dimensions of the illness, including enhancing psychological wellbeing, improving disease-coping strategies, and reducing symptoms of psychological distress such as tiredness, abdominal pain, and abdominal distension. Apart from one study that contained inhomogeneity in randomization, no study has shown that psychotherapy influences the clinical course of IBD (i.e. the number of relapses, length of symptom-free periods, overall disease severity). In addition, all studies on this topic have included patients without psychological disorders or distress; this could be the reason why psychotherapy in patients with IBD without psychological disturbance shows little or no benefit with regard to the number of relapses observed.
Psychotherapeutic interventions are indicated for psychological disorders such as depression, anxiety, reduced quality-of-life attributable to psychological distress, and inadequate coping skills for dealing with illness. In clinical practice it is important, therefore, to identify patients with IBD who have severe psychological problems and who require additional psychological support. Psychological care should be incorporated into the management of IBD patients if indicated. The choice of psychotherapeutic method will depend on the level and type of psychological disturbance, and decisions regarding this are best made by specialists.
In conclusion, experience gained from the treatment of patients with IBD shows that clinical attention to psychiatric comorbidity, quality of patient coping skills for dealing with illness, and patient–physician relationships are essential components of a comprehensive and successful management approach to this chronic illness. Psychological distress, depression, and anxiety represent risk factors for recurrence of IBD. As strategies aimed at improving psychological support might have a favorable impact on psychological distress, gastroenterologists should be trained to integrate psychological factors into clinical practice. Psychosomatic care should be provided in IBD centers in order to identify patients with a higher risk for chronic disease activity. Further controlled studies are needed to evaluate the influence of psychotherapy interventions on the clinical course of IBD, especially in those patients at a high risk of developing psychological problems.
CLICK HERE for subscription information about this journal.
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