Management of Stress in Inflammatory Bowel Disease: A Therapeutic Option?

James R Goodhand; Mahmood Wahed; David S Rampton

Expert Rev Gastroenterol Hepatol. 2009;3(6):661-79.

Abstract and Introduction

Abstract

There is increasing evidence that psychological stress and associated mood disorders are linked with, and can adversely affect the course of, inflammatory bowel disease (IBD). Unfortunately, owing to methodological difficulties inherent in undertaking appropriately targeted and blinded trials, there are limited high-quality data regarding the effects on IBD of interventions aimed to ameliorate stress and mood disorders. Nevertheless, patients want psychological intervention as well as conventional medical strategies. Emerging trial evidence supports the suggestion that psychologically orientated therapy may ameliorate IBD-associated mood disorders, but there are no strong data as of yet to indicate that stress management has a beneficial effect on the activity or course of IBD. As yet, which, when and how interventions targeted at psychological stress and mood disturbances should be offered to individual patients with IBD is not clear.

Introduction

Chronic psychological stress is associated with adverse effects on health.^[1–3] The inflammatory bowel diseases (IBDs) – Crohn's disease (CD) and ulcerative colitis (UC) – were classified as psychosomatic disorders, with early studies reporting a close association between IBD and psychiatric diagnoses. Recent well-designed studies have confirmed the anecdotal suggestion that psychological stress can trigger relapse in IBD. Here, we outline these topics and review the evidence assessing psychotherapy and related modalities as therapeutic options in patients with IBD.

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Abstract and Introduction
Stress
Psychoneuroimmunology of IBD
Stress in IBD
Role of Psychological Treatments in IBD
Scope of the Review of Therapeutic Options
Psychotherapy
Antidepressants
Hypnotherapy
Exercise
What & to Whom
Expert Commentary & Five-year View
Conclusion
References
Sidebar

Table 1. Longitudinal studies assessing the association between adverse life events, stress and depression with disease activity in inflammatory bowel disease.
Study (year)	Psychological factor	Psychometric tool	Diagnosis of relapse	Patients sample (n)	Findings	Ref.
Riley et al. (1990)	Life events	PLES HADS	Endoscopy^*	92 UC	No association over 3 months	^[67]
North et al. (1991)	Life events	SRRS BDI	Symptom scores	32 IBD (24 UC; 8 CD)	No association over 2 years	^[51]
Duffy et al. (1991)	Life events	SRE	Modified DAI	124 IBD (53 UC; 77 CD)	Positive association over 6 months	^[60]
Bitton et al. (2003)	Life events	PERILES PSS, SCL-90R	Endoscopy	60 UC	Positive association over 1 month	^[58]
Vidal et al. (2006)	Life events	SRRS	CDAI/HBI (CD)* TWI/SCCAI (UC)	163 IBD (76 UC:79 CD)	No association over 11 months	^[66]
Levenstein et al. (2000)	Perceived stress	PSQ – R PSQ – G	Endoscopy*	62 UC	Positive association over 2 years	^[61]
Bitton et al. (2008)	Perceived stress and coping	HS, PSS, CISS, SCL-90R	CDAI	87 CD	Positive association over 1 year	^[57]
Bernstein et al. (2009)	Perceived stress	PSS	MIBDI Steroid requirement	451 IBD (176 UC; 275 CD)	Positive association over 1 year	^[68]
Mardini et al. (2004)	Depression	BDI, BAI BHS, RLC	CDAI*	18 CD	Positive association 8–12 weeks later	^[62]
Mittermaier et al. (2004)	Depression	BDI, STAI, IBDQ, PSQ, IBDQ	CDAI (CD) CAI (UC)	60 IBD (13 UC; 47 CD)	Positive association over 18 months	^[64]
Persoons et al. (2005)	Depression	PHQ-9, TAS-20, SSL-I	CDAI*	100 CD	Less likely to respond to infliximab	^[65]
Deter et al. (2008)	Depression	BDI, STAI, HRQoL, CQ	Endoscopy* CDAI	87 CD	Positive association over 4 years	^[59]
Mickoka-Walus et al. (2008)	Depression	HADS, SCL-90R, SF-12	CDAI (CD)* SCCAI (UC)	59 IBD (27 UC; 32 CD)	No association over 1 year	^[63]

*Studies showing a positive association with disease activity at inclusion and relapse.
BAI: Beck's Anxiety Inventory; BDI: Beck's Depression Inventory; BHS: Beck Hopelessness Scale; CAI: Colitis Activity Index; CD: Crohn's disease; CDAI: Crohns Disease Activity Index; CISS: Coping Inventory for Stressful Situations; CQ: Coping behavior; HADS: Hospital Anxiety and Depression Scale; HBI: Harvey Bradshaw Index; HRQoL: Health-related quality of life; HS: Hassles Scale; IBD: Inflammatory bowel disease; IBDQ: Inflammatory Bowel Disease Questionnaire; MIBDI: Manitoba Inflammatory Bowel Disease Index; PERILES: Psychiatric Epidemiology Research Interview Life Events Scale; PHQ-9: Patient Health Questionnaire 9 items; PLES: Paykel Life Events Scale; PSQ: Perceived Stress Questionnaire; PSS: Perceived Stress Scale; R&G: Recent and general; RLC: Multiple Holmes Recent Life Changes; SCCAI: Simple Clinical Colitis Activity Index; SCL-90R: Symptom Checklist – 90R; SF-12: Short Form – 12; SRE: Schedule of Recent Experiences; SRRS: Social Readjustment Rating Scale; SSL-I: Social Support List – Interactions; STAI: Spielberger State-Trait Anxiety Inventory; TAS-20: Toronto Alexithymia Scale – 20 items; TWI: Truelove and Witts index; UC: Ulcerative colitis.

Table 2. An approach to selecting the appropriate psychological treatment.
Stage of adjustment	Intervention
Uncertainty about illness	Education Peer counseling
Residual uncertainty	Supportive counselling
Distress	Reassess disease activity Relaxation and exercise Hypnosis Cognitive–behavioral psychotherapy Antidepressants
Suffering	Psychiatric review

Interventions are selected according to the stage of adjustment and degree of psychological distress associated with inflammatory bowel disease.
Adapted from.^[131]

Table 3. Summary of longitudinal studies examining the effect of psychoanalytic and psychodynamic psychotherapy on inflammatory bowel disease activity and associated mood disorders.
Study (year)	Type of intervention	Patient sample (follow-up period)	Baseline		Effect of intervention (assessment method)			Ref.
Study (year)	Type of intervention	Patient sample (follow-up period)	IBD activity	Mood status	IBD	Mood	QoL	Ref.
O'Connor et al. (1964)	Individual (Up to 104 sessions) 1. Psychoanalysis	UC 57 intervention 57 controls (8 years)	Mixed active/inactive	Intervention: 56 psychiatric disorder Controls: 20 psychiatric disorder	Possibly improved (Symptoms, proctoscopy)	Improved (WB,RT, TAT)	Not assessed	^[87]
Jantschek et al. (1998) Deter et al. (2007) Deter et al. (2008)	Individual (26 sessions over 1 year) 1. Short-term psychodynamic 2. Autogenic training	CD* 72 Intervention 36 Controls (2 years)	Mixed active/inactive		No effect overall (CDAI); reduced in-hospital days in subgroups	No effect (BDI, STAI, PSKB)	No effect (QL)	^[59,88,90]
Maunder et al. (2001)	Group (20 sessions over 20 weeks) 1. Supportive expressive therapy	IBD 21 CD 9 UC (20 weeks)	Mixed active/inactive	33% depressed 70% anxious	No effect (Symptoms)	No effect (HADS)	No effect (IBDQ)	^[91]

*Denotes randomized, controlled trials.
BDI: Beck's depression inventory; CD: Crohn's disease; CDAI: Crohn's Disease Activity Index; HADS: Hospital Anxiety and Depression Scale; IBD: Inflammatory bowel disease; IBDQ: Inflammatory Bowel Disease Questionnaire; PSKB: Psychic and socio-communicative status (Psychischer und sozial-kummunikativer befund); QL: Quality of Life Questionnaire; QoL: Quality of life; RT: Rorschach Test; STAI: State Trait Anxiety Inventory; TAT: Thematic Apperception Test; UC: Ulcerative colitis; WB: Wechsler Bellevue.

Table 4. Longitudinal studies evaluating the effect of cognitive–behavioral psychotherapeutic techniques in inflammatory bowel dsease.
Study (year)	Type of intervention	Patient sample (follow-up period)	Baseline		Effect of intervention (assessment method)			Ref.
Study (year)	Type of intervention	Patient sample (follow-up period)	IBD activity	Mood status	IBD	Mood	QoL
Milne et al. (1986)	Group (6 sessions) 1. Personal planning skills 2. Communication skills 3. Autogenic training	IBD* 40 intervention 40 controls (1 year)	Mixed active/inactive		Improved (CDAI)		Improved (IBD stress)	^[92]
Schwarz et al. (1991)	Individual (12 sessions) 1. Progressive muscle relaxation 2. Thermal biofeedback 3. Cognitive coping strategies 4. Education relating to symptomatology	IBD* 11 intervention 10 controls (3 months)	Not clear	Excluded major depression, bipolar disorder, schizophrenia	No effect (symptom score)	No effect (BDI, STAI)	Improved (IBD stress)	^[93]
Mussell et al. (2003)	Group (15 sessions) 1. Psycho-education in IBD 2. Psycho-education in cognition and emotion 3. Adaptive coping strategies 4. Progressive muscle relaxation	IBD 14 CD 14 UC (9 months)	Mixed active/inactive	Excluded psychiatric disorders	No effect (CDAI, CAI)	Improved in women (CES-D, SCL-90 R)		^[94]
Garcia-Vega et al. (2004)	Individual (8 sessions) 1. Stress-management group • progressive muscle relaxation • stress management 2. Self-directed stress-management group • personal planning skills • autogenic training	CD* 30 intervention 15 controls (12 months)	All inactive	Not assessed	Equivocal (HBI measured at baseline but not at follow-up)	Not assessed	Not assessed	^[95]
Elsenbruch et al. (2005) Langhorst et al. (2007)	Group (60-h training) 1. Stress-management training 2. Moderate exercise 3. Mediterranean diet 4. Behavioral techniques 5. Self care strategies	UC 15 Iitervention 15 controls (10 weeks)	Mixed active/inactive	Excluded psychiatric disorders	Improved IBDQ bowel symptoms at 10 weeks but not at 1 year (no change in CAI)	No effect (PSS)	Improved (SF-36, IBDQ)	^[96,97]
Diaz Sibaja et al. (2007)	Group (10 sessions) 1. Illness information 2. Coping model 3. Problem sovling strategies 4. Social skill training 5. Distraction 6. Cognitive restructuring techniques	IBD 34 CD 23 UC (12 months)	All Inactive	18% depressed 35% anxious	Not assessed	Improved (HADS, BDI, SCL-90)		^[98]
Szigethy et al. (2007, 2009)	Individual (9–11 sessions) 1. Education CBT, IBD, depression, problem solving 2. Relaxation skills 3. Cognitive therapy 4. Coping skill 5. Personnel planning	IBD^† (adolescents) 15 CD:7 UC Intervention 14 CD:5UC Controls (12–14 weeks)	Mixed active/inactive	All mild/moderate subsyndromal depression	No effect PCDAI CSK	Improved (CDI and CDI-P, K-SADS, CGAS, PCSC)		^[100,101]

*Denotes randomized controlled studies.
BDI: Beck's Depression Inventory; CAI: Colitis Activity Index; CBT: Cognitive behavioral therapy; CD: Crohn's disease; CDAI: Crohns Disease Activity Index; CDI: Children's Depression Inventory; CDI-P: Children's Depression Inventory, Child and Parent; CES-D: Center of Epidemiological Studies – Depression Scale; CGAS: Children's Global Assessment Scale; CSK: Clinical Score of Kozarek; HADS: Hospital Anxiety and Depression Scale; HBI: Harvey Bradshaw Index; IBD: Inflammatory bowel disease; IBD Stress: Inflammatory Bowel Disease Stress Index; IBDQ: Inflammatory Bowel Disease Questionnaire; K-SADS: Schedule for Affective Disorders and Schizophrenia for School Age Children – Present and Lifetime; PCDAI: Pediatric Crohn's Disease Activity Index; PCSC: Perceived Control Scale for Children; PSS: Perceived Stress Scale; QoL: Quality of Life; SCL-90: Symptom Check List 90; SCL-90 R: Symptom Check List 90 Revised; SF-36: Short Form – 36 questions; STAI: State Trait Anxiety Inventory; UC: Ulcerative colitis.

Table 5. Longitudinal studies evaluating the effect of education techniques in inflammatory bowel disease.
Study (year)	Type of intervention	Patient sample (follow-up period)	Baseline		Effect of intervention (assessment method)			Ref.
Study (year)	Type of intervention	Patient sample (follow-up period)	IBD activity	Mood status	IBD	Mood	QoL	Ref.
Larsson et al. (2003)	Group (8 sessions × 2–3 h)	26 CD 23 UC 6 months	Mixed active/inactive		No change (symptom score)	No effect (HADS)	No effect (IBDQ, SF-36)	^[104]
Kennedy et al. (2004)	Individual (1 session)	92 CD:177 UC* intervention 139 CD:226 UC control (1 year)	Mixed active/inactive		Improved self-reported relapse, reduced hospital outpatient attendances	No effect (HADS)	No effect (IBDQ)	^[105]
Waters et al. (2005)	Group (4 sessions × 3 h)	31 CD:14 UC* intervention 26 CD:18 UC control (8 weeks)	Mixed active/inactive	Not measured	No details (CDAI, Seo AI)		No effect (IBDQ)	^[106]
Bregenzer et al. (2005)	Group (4 sessions × 2 h)	40 CD:33 UC* intervention 49 CD:23 UC control (10 months)	Mixed active/inactive	Depression scale: normal range	No effect (CDAI, CAI)	No effect (GDS)	No effect (GLQI)	^[107]

*Denotes randomized controlled studies.
CAI: Colitis Activity Index; CD: Crohn's disease; CDAI: Crohn's Disease Activity Index; GDS: General Depression Scale; GLQI: Gastrointestinal Life Quality Index; HADS: Hospital Anxiety and Depression Scale; IBDQ: Inflammatory Bowel Disease Questionnaire; QoL: Quality of life; Seo AI: Seo Activity Index; SF-36: Short Form – 36 questionnaire; UC: Ulcerative colitis.

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