Brain, gut both crucial in psychotherapy for chronic digestive disorders

Last Updated: 2018-02-08

By Megan Brooks

NEW YORK (Reuters Health) - For patients with irritable bowel syndrome (IBS), Crohn's disease and other chronic digestive diseases, attention to the brain is as important as the gut, researchers say in a February 3 online article in Gastroenterology.

Chronic digestive diseases can't be "disentangled" from their psychosocial context, and it's important to incorporate brain-gut psychotherapies into routine gastrointestinal (GI) care, note Dr. Laurie Keefer and colleagues.

Brain-gut psychotherapies, including cognitive-behavior therapy (CBT) and gut-directed hypnotherapy (HYP), target abdominal pain, visceral hypersensitivity and GI motility and/or facilitate improved coping, resilience and self-regulation skills, the authors point out.

These therapies are best delivered by mental health professionals specializing in psychogastroenterology, but gastroenterologists also have an important role to play, they note.

Gastroenterologists "should increase their own comfort level talking about the psychological factors influencing digestive health so as to reduce stigma and ensure patients follow through with the help they need," Dr. Keefer, director of psychobehavioral research at the Icahn School of Medicine at Mount Sinai in New York City, told Reuters Health by email.

"There are newer ways to receive psychogastroenterology support in clinical GI practice that include minimal therapist contact approaches, telehealth, web-based therapies and digital therapeutics that might bridge the gap for patients seeking out such services," she added.

In their report, Dr. Keefer and colleagues encourage gastroenterologists to routinely assess health-related quality of life, anxieties related to GI symptoms, early life adversity, and functional impairment related to digestive complaints.

"Without a gastroenterologist's strong, compelling recommendation for these effective therapies and his/her knowledge about how to successfully facilitate referrals for such treatments, many patients do not receive care at all, or do so too late in the process when self-management has failed and refractory psychopathology and/or inflammatory disease have developed," write Dr. Keefer and colleagues.

They also suggest that each gastroenterologist:

- Master patient-friendly language on the following topics: (a) the brain-gut pathway and how this pathway can become dysregulated by any number of factors; (b) the psychosocial risk, perpetuating and maintaining factors of GI diseases; and (c) why the gastroenterologist is referring a patient to a mental health provider.

- Know the structure and core features of the most effective brain-gut psychotherapies.

- Establish a direct referral and ongoing communication pathway with 1-2 qualified mental health providers and assure patients that s/he will remain part of their care team.

- Familiarize themselves with one or two neuromodulators that can be used to augment behavioral therapies when necessary.

While inflammatory bowel disease (IBD) is associated with mood disorders, it's unclear whether the interaction is bi-directional, with mood disorders contributing to progression of IBD and IBD affecting mental health, note the authors of a related paper online January 21 in Gastroenterology.

To investigate, Dr. David Gracie from Leeds Gastroenterology Institute in the UK and colleagues conducted a longitudinal prospective study of 405 adults with Crohn's disease (CD) or ulcerative colitis (UC). They determined IBD activity, and anxiety and depression status, at baseline and after the follow-up period lasting at least two years.

The researchers report that CD or UC disease activity at baseline was associated with nearly a six-fold increase in risk for a later abnormal anxiety score (hazard ratio, 5.77). In patients with inactive IBD at baseline, abnormal anxiety scores at baseline were associated with the subsequent need for glucocorticosteroid therapy or IBD flare (HR, 2.08) and escalation of therapy (HR, 1.82).

This study provides evidence for "bi-directional effects of IBD activity and psychological disorders. Patients with IBD should be monitored for psychologic well-being," the authors conclude.

"No single study has sought to address the potential bi-directional relationship between psychological co-morbidity/mood and disease activity in IBD in a single cohort of patients," Dr. Gracie told Reuters Health by email. "This study demonstrates that new psychological co-morbidity is more likely to develop in patients with active, rather than quiescent, IBD and that a new-onset disease activity is more likely to develop in patients with pre-existing psychological co-morbidity than in those who do not suffer from mood disorders."

"These findings," added Dr. Gracie, "suggest that a better awareness of psychological co-morbidity in patients with IBD, and more research efforts into management of psychological co-morbidity/mood disorders in IBD may improve disease outcomes, particularly as the evidence base for traditional therapeutic interventions for mood disorders is scant in IBD."

SOURCES: http://bit.ly/2EbiieF and http://bit.ly/2EOgUM0

Gastroenterology 2018.