IBD may be more aggressive in depressed patients

Last Updated: 2017-12-14

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Patients with inflammatory bowel disease (IBD) tend to be depressed and have diminished quality of life, and IBD patients with depression tend to develop more-aggressive disease sooner than non-depressed patients, new research suggests.

"In clinic, patients who are depressed or have other mental health problems seem to have IBD that is harder to control," lead author Dr. Bharati Kochar of the University of North Carolina at Chapel Hill School of Medicine told Reuters Health.

"For patients with IBD, depression can affect disease outcomes over time, and simply asking whether a patient is depressed or not is not a sensitive method of assessing IBD patients for depression," she said in an email.

Instead, the authors recommend that clinicians treating IBD patients should periodically assess them for depression using a validated tool such as the patient health questionnaire (PHQ-8).

As reported in the American Journal of Gastroenterology, online November 14, Dr. Kochar and colleagues used data from the Sinai-Helmsley Alliance for Research Excellence cohort to assess methods of diagnosing depression and the effects of baseline depression on disease activity over time.

They included 2,798 patients with Crohn's disease (CD) with an average follow-up of 22 months, and 1,516 patients with ulcerative colitis (UC) with an average follow-up of 24 months. At baseline, 64% of CD patients and 45% of UC patients were in remission.

A PHQ-8 score of 5 or above indicated mild depression. A modified Harvey-Bradshaw Index of 5 or above, or a Simple Clinical Colitis Activity Index above 2, indicated relapse.

Overall, 20% of patients with CD and 14% of those with UC reported that they were depressed. According to PHQ-8 results, 38% of CD patients and 32% of those with UC were depressed.

After adjustments for sex, remission, and disease activity, CD patients who were depressed at baseline had significantly elevated relative risks for relapse (RR, 2.3), hospitalization (RR, 1.3), and IBD-related surgery (RR, 1.3) at follow-up. UC patients with baseline depression had significantly elevated risks for hospitalization (RR, 1.3) and IBD-related surgery (RR, 1.8) at follow-up; depressed UC patients' excess risk for relapse did not quite reach statistical significance (RR, 1.3; 95% CI, 0.9-1.8).

"I admit that I used to simply ask IBD patients whether they were depressed or not as a screening tool for depression, and I was surprised to learn that it may not be a sensitive way of assessing for depression in this population with chronic disease," Dr. Kochar said.

"This is a large multicenter study with data collected by a trained study coordinator, which is a major strength of this study. However, all patients . . . were treated at a tertiary care IBD center, which may limit the generalizability of the results," she noted.

Several experts who were not involved in the study shared their comments with Reuters Health by email.

According to Dr. Sunanda V. Kane of Mayo Clinic in Rochester, Minnesota, "Depression is a very important part of the assessment. Even if you don't feel comfortable treating it, you should be assessing for it and referring patients for care."

"This is a real phenomenon and needs to be taken seriously," she said. "I have long been a proponent of addressing psychological issues with IBD patients. Food and eating are central to our social nature, and the unpredictability of the need for a washroom or a surgery can be devastating."

Dr. Megan E. Riehl of the University of Michigan in Ann Arbor, advised, "Be prepared to screen and discuss depressive symptoms with IBD patients at each visit and have resources in place to make referrals to mental health specialists to aid with managing emotional symptoms. . . . Patients can begin to expect that this is a dialogue they will have on a routine basis with their provider, which can aid in de-stigmatizing mental health aspects of the patient experience."

"Patients are likely to feel more validated in their symptom experience when they report mood symptoms on a validated screening measure, have a provider who talks with them about those symptoms, and be offered resources to address their mood symptoms," she added.

Dr. Judith Scheman of Cleveland Clinic, in Ohio, noted, "This study adds to the increasing literature demonstrating the value of the bio-psycho-social model of medical care. Evidence is increasing in numerous fields in medicine, including IBD, that psychosocial variables are the best predictors of treatment outcome and, as such, need to be addressed along with the biological factors."

"There is a direct association between depression and anxiety on inflammation and immune response. Addressing these psychosocial factors via medication and non-medication approaches can help mediate the course of the illness," Dr. Scheman said.

SOURCE: http://go.nature.com/2jx3FWK

Am J Gastroenterol 2017.