Systematic Review With Meta-analysis

Anxiety and Depression in Children and Adolescents With Inflammatory Bowel Disease

L. Stapersma; G. van den Brink; E. M. Szigethy; J. C. Escher; E. M. W. J. Utens


Aliment Pharmacol Ther. 2018;48(5):496-506. 

In This Article

Abstract and Introduction


Background: The co-existence of psychological problems and paediatric inflammatory bowel disease (IBD) is receiving increasing attention. Most studies investigated anxiety and depression, with prevalence rates varying from 0% to 50%. A systematic review is necessary to provide clear insight into the prevalence of anxiety and depression in paediatric IBD.

Aim: To systematically evaluate available data on the prevalence of anxiety and depressive symptoms and disorders in paediatric IBD (aged 6–18 years).

Methods: Comprehensive searches were performed in Embase, Medline Ovid, Web of Science, Cochrane, PubMed, PsychInfo Ovid, and Google scholar for studies published from 1994 to 2017. Pooled prevalence rates were calculated using inverse variance heterogeneity models. Meta-regression was used to study if disease type, disease activity and gender influence prevalence.

Results: Twenty-eight studies (N = 8107, mean age: 14.3) were identified. Pooled prevalence estimates were 16.4% (95% confidence interval [CI] 6.8%–27.3%) for anxiety symptoms and 4.2% (95% CI 3.6%–4.8%) for anxiety disorders. Pooled prevalence estimates were 15.0% (95% CI 6.4%–24.8%) for depressive symptoms and 3.4% (95% CI 0%–9.3%) for depressive disorders. Meta-regression showed no influence of disease type or gender on these prevalence rates, but studies with a higher percentage of active disease had a higher rate of depressive symptoms.

Conclusions: The described pooled prevalence of anxiety and depressive symptoms is lower than in adult IBD. However, due to varying instruments/cut-offs for measuring symptoms and few studies investigating disorders, the results should be interpreted with caution. Cross-cultural use of the same instruments is needed to gain better insight into prevalence rates.


Inflammatory bowel disease (IBD; Crohn's disease [CD] and ulcerative colitis [UC]) is a chronic relapsing inflammatory disorder of the intestine, with increasing incidence and prevalence worldwide.[1] Patients may have abdominal pain, (bloody) diarrhoea, often accompanied by systemic symptoms such as lack of appetite, weight loss and fatigue. IBD has an unpredictable and fluctuating disease course, with relapses and periods of clinical remission. In up to 25% percent of patients, IBD manifests during late childhood and adolescence.[2] Adolescence is already challenging, due to significant psychological, physical and social changes. Having IBD during adolescence can pose a real threat to a healthy psychosocial development. Studies indicate that paediatric IBD patients are at risk for several psychosocial and psychological problems.[3,4] Most studies focussed on anxiety and/or depressive symptoms, and reported greatly varying prevalence rates, from 2%[5]–50%[6] for anxiety symptoms and 0%[7]–33%[8] for depressive symptoms. Only a few studies investigated prevalence of anxiety and depressive disorders, which ranged respectively from 3%[9]–7%[10] and 1%[11]–17%.[10]

In mental health care, a distinction is made between anxiety/depressive symptoms and anxiety/depressive disorders for several reasons. First, patients with a clinical disorder have severe symptoms that cause significant impairment in their daily life. Patients with elevated symptoms (who do not meet all criteria of a clinical disorder) do suffer from these milder symptoms, but do not experience such a significant impairment in their daily life. Second, disorders comprise a combination of symptoms, and are diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in a psychiatric interview. On the other hand, symptoms are often measured using a questionnaire.

The bidirectional relationship between IBD and psychological problems has been previously described and can be explained in terms of the "brain-gut"-axis. This axis describes that the presence of intestinal inflammation might negatively influence mood and vice versa: anxiety and/or depression may increase intestinal inflammation and may trigger a relapse of IBD.[12–15] While many individual studies looked at the prevalence of anxiety and/or depressive symptoms and disorders in paediatric IBD patients, no comprehensive systematic review or meta-analysis has been conducted.

Unfortunately, the few published reviews on psychological outcomes in paediatric IBD either differed in scope (eg did not focus specifically on prevalence rates of anxiety and/or depression) or had several shortcomings. Some reviews only included older studies published in the previous decade,[4,16] whereas others only included studies with a control group[4] or included a small portion of the available paediatric studies.[17] A review by Brooks et al discussed the impact of psychological morbidity in paediatric IBD (including anxiety and depression, but not their prevalence rates).[18] Greenley et al studied psychosocial adjustment (including anxiety and depression) of adolescents with IBD, but only included studies published before 2007, which used a comparison group or normative data (thus excluding cross-sectional or cohort studies without a comparison group). The authors reported that adolescents with IBD had higher rates of depressive disorders than those with other chronic conditions. However, their prevalence rates of anxiety and depressive symptoms, and anxiety disorders were not significantly different from healthy adolescents or those with other chronic diseases.[4] A third, nearly a decade old review by Ross et al, included studies till 2009, investigating psychosocial functioning and quality of life. They found an increased incidence of anxiety and depressive disorders, varying from 25% to 73%, in adolescents with IBD.[16] A fourth systematic review included studies published between 2005 and 2014, but studied comorbidity of anxiety and depression in both paediatric and adult IBD, and included only a limited number of the available paediatric studies.[17] Considering the previous reviews, there is a clear need to perform a systematic review with meta-analysis to provide prevalence rates on anxiety and depression in paediatric IBD, including all available studies.

The current systematic review and meta-analysis aims to systematically assess the prevalence rates of anxiety and depressive symptoms and disorders specifically in paediatric IBD, using all studies published between 1994 and 2017 (aim 1). In addition, we aimed to investigate whether disease type, disease activity or gender influences these prevalence rates (aim 2). It is important to gain more clear insight into the overall prevalence and risk factors of anxiety and depression in paediatric IBD, to increase awareness, facilitate early detection of anxiety and depression, and, if necessary, early psychological treatment.