Depression and Anxiety Can Shorten Time to IBD Flare

Ricki Lewis, PhD

February 18, 2016

Depression and anxiety can precede and shorten the time to recurrence of inflammatory bowel disease (IBD) in some patients, according to a Kaplan-Meier analysis published online January 25 in Clinical Gastroenterology and Hepatology.

"It thus seems prudent to recommend that screening for common mental disorders and referring for psychological/psychiatric treatment should be included in standard IBD care," Antonina Mikocka-Walus, PhD, from the Department of Health Sciences, University of York, United Kingdom, and colleagues write.

Although IBD has long been associated with depression and anxiety, "the relationship of depression and anxiety with disease activity in IBD has been controversial, with no causal link established to date," the study authors report.

In a recent survey of the literature, Dr Mikocka-Walus and colleagues found that 7 of 12 prospective studies positively associated depression and anxiety with IBD flare-ups, while 5 did not. They attribute the inconsistency between the studies to differences in study designs, such as observation period, sample size and selection, and methods of assessing anxiety, depression, and IBD severity.

The investigators therefore conducted a prospective study using the Swiss IBD Cohort to paint a temporal portrait of the associations between the two psychiatric conditions and IBD. Patients participated between 2006 and 2015 and were diagnosed with IBD at least 4 months before the study began.

Clinical exams to assess IBD at enrollment and annually thereafter used the Crohn's Disease Activity Index and the Modified Truelove and Witts Severity Index. Patients took the 14-question Hospital Anxiety and Depression Scale, with a score of 7 being the cutoff for anxiety/depression symptoms.

Of the 2007 patients included in the study, 56% had Crohn disease (CD), and the remainder had ulcerative colitis (UC) or indeterminate colitis. Median age at baseline was 40.5 years, 48.3% were males, and median disease duration was 7.2 years.

At baseline, 20.2% of the participants exceeded the cutoff for the depression score, and 37.5% had an anxiety score above cutoff. The prevalence of depression was about equal between the sexes (200 [20.6%] males vs 205 [19.8%] females; P = .635), but females were more likely to experience anxiety (448 [43.2%] female vs 304 [31.3%] male; P < .001).

At baseline there was no significant association among Crohn's Disease Activity Index score, anxiety, or depression (P = .221 and P = .266, respectively) or between the Modified Truelove and Witts Severity Index score and anxiety or depression (P = .167 and P = .288, respectively).

However, in participants experiencing depression or anxiety, clinical recurrence of IBD occurred sooner than among participants without depression or anxiety. Sex was not a factor.

The Kaplan-Meier curves revealed a stronger association between depression and clinical recurrence of IBD over time (all IBD, P = .000001; CD, P = .0007; UC, P = .005) than between anxiety and recurrence. Although the association between anxiety and IBD recurrence over time was observable in the whole sample (P = .0014), as well as in only the participants with CD (P = .031), this was not so for participants with UC (P = .066).

Depression and anxiety also tracked with specific manifestations of IBD. Depression alone had a statistically significant association with fistula, surgery, and steroid use in patients with CD and with flares in patients with UC and with CD. Anxiety alone was associated with flares in CD and UC and steroid use in UC. Anxiety and depression were both associated with use of biologics in CD.

The association between anxiety and IBD recurrence was weaker than that for depression. The researchers speculate that apathy in patients with depression may cause noncompliance with IBD treatment, whereas anxiety may be more episodic, such as when a person cannot find a bathroom.

The study authors acknowledge that limitations of the study include self-assessment of anxiety and depression and the length of time between follow-ups.

"Previous studies have only examined this issue using a cross-sectional design, meaning that causality cannot be established, so the findings are therefore novel and important, and provide support for the existence of brain-gut interactions, which may affect the natural history of IBD," write David J. Gracie, MD, from the Leeds Gastroenterology Institute, St. James’s University Hospital, United Kingdom, and Alexander C. Ford, MD, from the Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, United Kingdom, in a letter to the editor published online February 9 in Clinical Gastroenterology and Hepatology.

However, they add that the study by Dr Mikocka-Walus and colleagues could not distinguish a pathological connection between depression and anxiety and IBD flares from an increased likelihood of reporting worsening gastrointestinal symptoms among individuals with impaired mood.

Dr Gracie and Dr Ford agree with the study authors in recommending inclusion of psychological/psychiatric screening in standard IBD care. "Whatever the reason for this association, it has important implications for future management strategies in IBD. It suggests that a paradigm shift away from therapies focused solely on reducing the inflammatory burden is needed in a subset of patients," they write.

This study was supported by the Swiss National Science Foundation. The authors and correspondents have disclosed no relevant financial relationships.

Clin Gastroenterol Hepatol. Published online January 25, 2016. Article abstract. Published online February 9, 2016. Letter

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