Controversies Revisited: A Systematic Review of the Comorbidity of Depression and Anxiety with Inflammatory Bowel Diseases

Correlation Analysis Between Disease Activity and Anxiety, Depression, Sleep Disturbance, and Quality of Life in Patients with Inflammatory Bowel Disease

Objective

To explore the correlation between disease activity and anxiety, depression, sleep quality, and quality of life in patients with inflammatory bowel disease (IBD).

Methods

The disease activity of IBD patients was evaluated by 66 gastroenterologists from 42 hospitals in 22 provinces in China from September 2021 to May 2022. Anxiety, depression, sleep quality and quality of life of IBD patients were investigated and statistically analyzed by different scales, including Generalized Anxiety Disorder 7-item Scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), and Inflammatory Bowel Disease Quality-of-Life Questionnaire (IBD-Q).

Results

A total of 2478 IBD patients were included, of which 1532 (61.8%) were in active stage and 946 (38.2%) were in remission. The proportions of active IBD with anxiety, depression, sleep disturbance, and poor quality of life were 29.5%, 29.7%, 71.1%, and 50.1%, respectively, while the proportions of remission IBD with anxiety, depression, sleep disturbance, and poor quality of life were 19.1%, 24.4%, 69.3%, and 17.4%, respectively. IBD patients who also had anxiety, depression, sleep disturbances and poor quality of life had 80 cases (8.46%) in remission and 114 cases (7.44%) in active stage, with 54 cases (9.18%) in mild activity, 51 cases (6.95%) in moderate activity and 9 cases (4.49%) in severe activity. IBD patients with different disease activity levels differed in GAD-7 scores, PHQ-9 scores, PSQI scores, and IBD-Q scores (all P<0.001). In IBD patients, anxiety, depression, and sleep disturbance, which interact with each other, can further aggravate their disease activity (all P<0.001).

Conclusion

Anxiety, depression, sleep disturbances, and quality of life are strongly correlated with disease activity in IBD patients, and IBD patients with psychological disturbances are most often in the active stage and have a poor quality of life.

Anxiety and depression in patients with inactive inflammatory bowel disease: The role of fatigue and health-related quality of life

Inflammatory bowel diseases (IBD) are chronic conditions characterized by a remitting-relapsing course. Patients with IBD have an impaired quality of life and are more often affected by anxiety and depression. This study aimed to evaluate the prevalence and severity of anxiety and depression in patients with inactive IBD, and to identify factors associated with them. A total of 132 consecutive patients diagnosed with IBD for over 3 months that were in corticosteroid-free remission at the time of assessment were enrolled in this observational, cross-sectional study. Anxiety, depression, fatigue, and health-related quality of life (HR-QoL) were evaluated using the following self-administered questionnaires: HADS, Functional Assessment of Chronic Illness Therapy-Fatigue, and IBDQ 32. Symptoms of anxiety and depression were considered for HADS-A > 7 points and HADS-D > 7 points, respectively. Out of the 132 patients included, 76 (57.6%) were men. The median patient age was 38 years (interquartile range 30-47). Eighty-three patients (62.9%) were diagnosed with Crohn disease, and 49 (37.1%) with ulcerative colitis. Most of the patients were treated with biologics (85.6%). Anxiety was identified in 34.1% of patients, and two thirds of them (68.9%) had mild symptoms. A lower proportion of patients were presenting symptoms of depression (18.2%), the vast majority (91.7%) having mild forms. In the multivariate analysis, anxiety was significantly associated with fatigue [odds ratio (OR) 4.39, 95% confidence interval (CI): 1.22-15.79, P = .02] and lower HR-QoL (OR 2.46, 95% CI: 1.70-3.91, P < .001), while depression was associated with exposure to multiple biologics (OR 3.33, 95% CI: 1.01-10.97, P = .04) and fatigue (OR 9.70, 95% CI: 1.67-56.27, P = .01). In conclusion, anxiety and depression are highly prevalent in patients with IBD even during the periods of remission. Both anxiety and depression are associated with fatigue. In addition, lower HR-QoL is associated with anxiety and exposure to multiple biologics with depression.

Identification of the informational and supportive needs of patients diagnosed with inflammatory bowel disease: a scoping review

Background

Inflammatory Bowel Disease (IBD) affects the quality of life. Patient education and support needs are crucial components of comprehensive chronic illness care. The main purposes of this review were to (i) explore the informational and supportive needs of these patients to improve the quality of life in the existing literature and (ii) identify the gaps related to the needs of the patients in articles.

Methods

The scoping review is based on the Daudt methodological framework, a modified version of Arksey and O'Malley. Electronic databases were extensively searched from January 01, 2000 to April 30, 2022. Four electronic databases (PubMed/Medline, CINAHL, APA PsycInfo, Psychology and Behavioral Sciences Collection, APA PsycArticles, and ProQuest) were searched using controlled vocabulary, and specific keywords. The searched terms were matched to each database. We manually searched two key journals, namely the Journal of Inflammatory Bowel Disease and the Journal of Crohn's and Colitis.

Results

In the review, 75 studies on the assessment of the information and support needs of patients with IBD were reviewed. In this regard, 62 and 53 studies were regarding information needs and support needs, respectively. Most of the information needs of patients with IBD reported in the studies were related to diet needs, and educational needs were the most essential support needs.

Conclusions

Health policymakers and managers can develop care and educational programs related to this disease in health centers according to the needs of the patients. Health professionals, especially gastroenterologists, are the primary referral sources for information on patients. Therefore, gastroenterologists can take the lead in planning and educating the patients and sharing their decisions.

Systematic review registration

OSF, https://doi.org/10.17605/OSF.IO/3MWGJ.

The bidirectional risk of inflammatory bowel disease and anxiety or depression: A systematic review and meta-analysis

OBJECTIVE

Inflammatory bowel disease (IBD) is associated with anxiety and depression, but the magnitude and directionality of risk remains uncertain. This study quantifies the risk of anxiety or depression following a diagnosis of IBD, and the risk of IBD in individuals with anxiety or depression, using population representative data.

METHOD

We performed a systematic literature search using MEDLINE and Embase and included unselected cohort studies reporting risk of anxiety or depression in patients with IBD or risk of IBD in patients with anxiety or depression. We undertook Random Effect Model meta-analysis to calculate pooled Hazard Ratios (HR) for the risk of anxiety and depression in IBD and subgroup meta-analysis to calculate risk by IBD subtype and in pediatric-onset IBD.

RESULTS

Nine studies were included; seven of which examined incidence of anxiety or depression among a total of >150,000 IBD patients. Meta-analysis showed an increased risk of both anxiety (HR: 1.48, 95% CI: 1.29-1.70) and depression (HR: 1.55, 95% CI: 1.35-1.78) following IBD diagnosis. Two studies investigating >400,000 individuals with depression showed a 2-fold increased risk of IBD.

CONCLUSIONS

The bidirectional association between IBD and anxiety and depression is clinically relevant and could indicate shared or mutually dependent disease mechanisms.

Exploring neural activity in inflammatory bowel diseases using functional connectivity and DKI-fMRI fusion

Although MRI has made considerable progress in Inflammatory bowel disease (IBD), most studies have concentrated on data information from a single modality, and a better understanding of the interplay between brain function and structure, as well as appropriate clinical aids to diagnosis, is required. We calculated functional connectivity through fMRI time series using resting-state functional magnetic resonance imaging (rs-fMRI) and diffusion kurtosis imaging (DKI) data from 27 IBD patients and 29 healthy controls. Through the DKI data of each subject, its unique structure map is obtained, and the relevant indicators are projected onto the structure map corresponding to each subject by using the graph Fourier transform in the grasp signal processing (GSP) technology. After the features are optimized, a classical support vector machine is used to classify the features. IBD patients have altered functional connectivity in the default mode network (DMN) and subcortical network (SCN). At the same time, compared with the traditional brain network analysis, in the test of some indicators, the average classification accuracy produced by the framework method is 12.73% higher than that of the traditional analysis method. This paper found that the brain network structure of IBD patients in DMN and SCN has changed. Simultaneously, the application of GSP technology to fuse functional information and structural information is superior to the traditional framework in classification, providing a new perspective for subsequent clinical auxiliary diagnosis.

Mental Illnesses in Inflammatory Bowel Diseases: mens sana in corpore sano

Background and aims: Inflammatory bowel diseases (IBD) are chronic disorders associated with a reduced quality of life, and patients often also suffer from psychiatric comorbidities. Overall, both mood and cognitive disorders are prevalent in chronic organic diseases, especially in the case of a strong immune component, such as rheumatoid arthritis, multiple sclerosis, and cancer. Divergent data regarding the true incidence and prevalence of mental disorders in patients with IBD are available. We aimed to review the current evidence on the topic and the burden of mental illness in IBD patients, the role of the brain-gut axis in their co-existence, and its implication in an integrated clinical management. Methods: PubMed was searched to identify relevant studies investigating the gut-brain interactions and the incidence and prevalence of psychiatric disorders, especially of depression, anxiety, and cognitive dysfunction in the IBD population. Results: Among IBD patients, there is a high prevalence of psychiatric comorbidities, especially of anxiety and depression. Approximately 20-30% of IBD patients are affected by mood disorders and/or present with anxiety symptoms. Furthermore, it has been observed that the prevalence of mental illnesses increases in patients with active intestinal disease. Psychiatric comorbidities continue to be under-diagnosed in IBD patients and remain an unresolved issue in the management of these patients. Conclusions: Psychiatric illnesses co-occurring in IBD patients deserve acknowledgment from IBD specialists. These comorbidities highly impact the management of IBD patients and should be studied as an adjunctive therapeutic target.

The effectiveness of mindfulness-based interventions in inflammatory bowel disease: A Systematic Review & Meta-Analysis

BACKGROUND

Mental health has been identified as contributing to the pathogenesis of Inflammatory Bowel Disease (IBD). Resultingly, psychotherapeutic interventions, such as Mindfulness-Based Interventions (MBI), have been increasingly investigated for improving IBD outcomes.

OBJECTIVES

To systematically review the current state of evidence of MBI's for individuals living with IBD.

METHODS

We performed a systematic review searching Medline, PsychINFO, CINAHL, Embase, Cochrane and Scopus, to identify controlled clinical trials, investigating MBI's for various IBD biopsychosocial outcomes. Data was pooled using the inverse-variance random effects model, with restricted maximum likelihood estimation, providing the standardized mean difference (SMD) between control and experimental groups, at both short and long-term follow up.

RESULTS

We identified 8 studies with 575 participants. Meta-analytic results found that MBI's were more efficacious than control groups in the short-term improvement of stress (SMD = -0.38, 95% CI [-0.65, -0.10], p = 0.007), mindfulness (SMD = 0.59, 95% CI [0.36, 0.83], p = 0.00001), C-Reactive Protein (CRP) (SMD = -0.25, 95% CI [-0.49, -0.01], p = 0.04) and health-related quality of life (HRQoL) (SMD = 0.45, 95% CI [0.24, 0.66], p = 0.0001) (including all emotional, bowel, social and systemic subscales). This was maintained in the long-term for stress (SMD = -0.44, 95% CI [-0.88, -0.01], p < 0.05) and mindfulness (SMD = 0.52, 95% CI [0.14, 0.90], p = 0.008), but not for HRQoL, with no long-term data available for CRP.

CONCLUSIONS

Given that MBI's appear to be effective in improving several IBD outcomes, they may be a useful adjuvant therapy in wholistic IBD care, with further trials warranted.

Change of monocytes/macrophages in ulcerative colitis patients with symptoms of anxiety and depression

BACKGROUND AND AIMS

Monocytes/macrophages play important roles in inflammatory bowel disease and depression, but few studies had focused on the change of monocytes/macrophages in ulcerative colitis (UC) patients with psychiatric disorders.

METHODS

UC patients were divided into two groups based on the Hospital Anxiety and Depression Scale (HADS). Demographic and clinical data were captured. Peripheral blood samples and intestinal biopsies were collected for the analysis of monocyte immunophenotype, phagocytic function, and CD4 + T cell differentiation. Transmission electron microscopy was used to observe the ultrastructure of intestinal macrophages.

RESULTS

A total of 139 UC patients were included. 37.41% and 32.37% of UC patients had symptoms of anxiety and depression. In patients with symptoms of anxiety/depression, mayo score, platelet count, erythrocyte sedimentation rate, and endoscopic score, histological scores were significantly higher than those in UC patients without. In patients with symptoms of anxiety/depression, the percentages of CD14 + + CD16 + monocytes and CD14 + CD16++ monocytes were higher, and the phagocytosis was decreased. Patients with symptoms of anxiety/depression had more CD68 + cells and higher M1/M2 ratios in the intestine mucosal layer compared to those without.

CONCLUSIONS

Monocytes and intestinal macrophages from UC patients with anxiety/depression tended to polarize to pro-inflammatory subtypes, and their function was also impaired.

Multimodal Brain MRI of Deep Gray Matter Changes Associated With Inflammatory Bowel Disease

BACKGROUND

Behavioral symptoms, including mood disorders, substantially impact the quality of life of patients with inflammatory bowel disease (IBD), even when clinical remission is achieved. Here, we used multimodal magnetic resonance imaging (MRI) to determine if IBD is associated with changes in the structure and function of deep gray matter brain regions that regulate and integrate emotional, cognitive, and stress responses.

METHODS

Thirty-five patients with ulcerative colitis (UC) or Crohn's disease (CD) and 32 healthy controls underwent 3 Tesla MRIs to assess volume, neural activity, functional connection strength (connectivity), inflammation, and neurodegeneration of key deep gray matter brain regions (thalamus, caudate, pallidum, putamen, amygdala, hippocampus, and hypothalamus) involved in emotional, cognitive and stress processing. Associations with sex, presence of pain, disease activity, and C-reactive protein (CRP) concentration were examined.

RESULTS

Significantly increased activity and functional connectivity were observed in cognitive and emotional processing brain regions, including parts of the limbic system, basal ganglia, and hypothalamus of IBD patients compared with healthy controls. Inflammatory bowel disease patients exhibited significantly increased volumes of the amygdala and hypothalamus, as well as evidence of neurodegeneration in the putamen and pallidum. Hippocampal neural activity was increased in IBD patients with active disease. The volume of the thalamus was positively correlated with CRP concentration and was increased in females experiencing pain.

CONCLUSIONS

Patients with IBD exhibit functional and structural changes in the limbic and striatal systems. These changes may be targets for assessing or predicting the response to therapeutic interventions aimed at improving comorbid emotional and cognitive symptoms.

The impact of restrictions on psychological outcomes in patients with inflammatory bowel disease on biological treatment during the coronavirus pandemic in Norway

PURPOSE

The coronavirus (COVID-19) pandemic restrictions have led to changes in the follow-up routine of patients in outpatient clinics at hospitals in Norway. The purpose of this study was to assess possible associations between psychological health and concerns regarding COVID-19 societal and hospital restrictions in patients with inflammatory bowel disease on biological therapy.

METHODS

Patients with IBD (≥ 18 years) undergoing biological treatment (TNF-alpha inhibitor, ustekinumab, vedolizumab) for IBD were recruited from an IBD outpatient clinic in Norway. Data were collected through self-report, including questions covering concerns regarding their disease, medical therapy, and follow-up during the pandemic, Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 questionnaire (GAD-7). Multiple logistic regression with backward conditional selection was fitted to examine associations between patients' depression and anxiety levels and their concerns about COVID-19 restrictions, controlled for sociodemographic and disease-related factors.

RESULTS

Five-hundred and six patients were included in this study. General condition, self-isolation, employment status, fear of visiting the hospital, and changes to patients' appointments made by the hospital were independently associated with higher levels of depression. Female gender, experiencing symptoms of COVID-19, self-isolation, experiencing an increased risk of COVID-19 because of IBD, being afraid to visit the hospital because of COVID-19 restrictions, and having their appointment cancelled due to COVID-19 were independently associated with higher anxiety levels.

CONCLUSION

Concerns about physical health and societal and hospital restrictions were associated with anxiety and depression in patients with IBD undergoing biological treatment. The findings will help facilitate healthcare services for patients with IBD in outpatient clinics and develop guidelines for follow-up.

Depression and anxiety are associated with poor outcomes in patients with inflammatory bowel disease: A nationwide population-based cohort study in South Korea

BACKGROUND

Prevalence of depression and anxiety are known to be increased in patients with inflammatory bowel disease (IBD), but it is unclear whether such elevations adversely affect IBD outcomes.

OBJECTIVE

We aimed to investigate the association between depression or anxiety and clinical outcomes of IBD.

METHOD

Using claims data from the South Korean National Health Insurance Service (NHIS), patients with IBD were identified by codes of the International Classification of Disease, 10th Revision (ICD-10) and the Rare/Intractable Disease (RID) registration program for years 2010 to 2017. ICD-10 codes were also used to identify depression and anxiety in this population. Primary study endpoints were IBD-related outcomes, including emergency room (ER) visits, hospitalizations, and surgeries during the follow-up period.

RESULTS

Our cohort included 32,867 patients with IBD, of whom 3794 (11.5%) experienced depression and anxiety during the 6-year median follow-up period. In multivariate analysis, comorbid depression and anxiety were associated with increased risks of ER visits (hazard ratio [HR] = 1.34, 95% confidence interval [CI]: 1.19-1.51) and hospitalizations (HR = 1.24, 95% CI: 1.12-1.37), whereas surgical risk was not different for IBD patients with and without depression and anxiety. There was no differential effect of depression and anxiety on outcomes in IBD patients, but depression was more closely associated with outcomes in CD patients and anxiety in UC patients.

CONCLUSION

In patients with IBD, comorbid depression and anxiety are associated with increased risks of ER visits and hospitalizations, but not surgery. These associations are more pronounced for depression in CD patients and for anxiety in UC patients.

Ingestion of Lacticaseibacillus rhamnosus Fmb14 prevents depression-like behavior and brain neural activity via the microbiota-gut-brain axis in colitis mice

Large preclinical evidence suggested that colitis was one of the risk factors for depression and probiotics were effective therapeutic agents to prevent the disease. The effect of Lacticaseibacillus rhamnosus Fmb14 on colitis-related depression-like behavior and its possible mechanisms were investigated. One week of DSS exposure led to the following changes in male C57BL/6N mice: a reduction in the movement distance from 2218 to 1299 cm, time in central areas from 23.6 s to 11.5 s, and time in the bright box from 217 s to 103 s, which were restored to 1816 cm, 18.4 s, and 181 s, respectively, with preadministration of Fmb14 for 8 weeks. All improvements provided by Fmb14 indicated a remarkable protective effect on depression-like behavior. Fmb14 first worked to repair intestinal barrier damage and the inflammatory response in the colon through ZO1 and Ocln enhancement and IL-1β, NF-κB and IL-6 reduction, respectively. Second, dysbiosis of the gut microbiota was modulated by Fmb14, including reduction of Akkermansia (18.9% to 5.4%), Mucispirillum (0.6% to 0.1%) and Bifidobacterium (0.32% to 0.03%). Fmb14 supplementation ameliorates the brain inflammatory response via IL-18 and NF-κB reduction and improves the blood-brain barrier via increased levels of ZO1 and Ocln. Moreover, brain activity was facilitated by an increase in BDNF and dopamine and the downregulation of GABA in the Fmb14 group. As a consequence of the modulatory effect on the dysfunction of neurotransmitters and neuroinflammation, Fmb14 prevents neurodegeneration by inhibiting neuronal apoptosis and Nissl edema. In addition, the correlation analysis further demonstrated the preventative effect of Fmb14 on depression-like behavior through the microbiota-gut-brain axis. Together, these findings demonstrated the important role of Fmb14 in biological signal transduction over the microbiota-gut-brain axis to improve mood disorders.

Reducing Health Anxiety in Patients With Inflammatory Bowel Disease Using Video Testimonials: Pilot Assessment of a Video Intervention

BACKGROUND

Health anxiety has many damaging effects on patients with chronic illness. Physicians are often unable to alleviate concerns related to living with a disease that has an impact on daily life, and unregulated websites can overrepresent extreme anxiety-inducing outcomes. Educational clinician video interventions have shown some success as an acute anxiolytic in health settings. However, little research has evaluated if peer-based video interventions would be a feasible alternative or improvement.

OBJECTIVE

This pilot study assesses the efficacy of anxiety reduction for patients with Crohn disease (CD) and those with ulcerative colitis (UC) by showing patient testimonial videos during hospital visits. It investigates the degree to which patient testimonials can affect state anxiety, and whether patients are comfortable enough with the technology to share their stories.

METHODS

Patients with CD (n=51) and those with UC (n=49) were shown testimonial videos of patients with CD during their physician consultations at Kitasato University Kitasato Institute Hospital in Japan. The video testimonials were collected from Dipex Japan, the Japan branch of an international organization specializing in understanding patient experiences. Patients completed a Visual Analogue Scale for Anxiety before and after viewing the videos, a Hospital Anxiety and Depression Scale (HADS) survey before the videos, and satisfaction surveys. Patients receiving infusion therapy participated in the study while receiving treatment to minimize hospital workflow disruption.

RESULTS

Anxiety reduction, on the Visual Analog Scale for Anxiety, was significant in the entire cohort both when viewed as an ordinal variable (P=.003, t₉₈=1086.5) and as a continuous variable (P=.01, t₉₄=-2.54, 90% CI -3.47 to -0.72). Eighty percent (n=15) of patients with high HADS Anxiety (HADS-A) scores and 71% (n=24) of patients with high starting state anxiety experienced reduced anxiety after watching testimonials. Patients with high state anxiety but low HADS-A scores experienced anxiety reduction (69%, n=16). Forty-two percent (n=100) of patients responded that they would share their stories for future users. When patients with UC received testimonials from patients with CD, 71% (n=49) of patients reported that they were relevant despite differences in condition.

CONCLUSIONS

Our pilot results suggest that patient testimonial videos can reduce illness-related state anxiety for patients with CD and those with UC, especially in those with higher baseline state anxiety. The success of this study in reducing anxiety and achieving patient involvement suggests that video interventions for reducing anxiety might be a low-cost intervention that could scale to any number of hospitals, suggesting that technology can help scale up efforts to record and share patient testimonials. Future work can establish whether patient testimonials can be helpful in other contexts, such as before major surgeries or when a family member receives a difficult diagnosis.

Probiotics as a Tool for Regulating Molecular Mechanisms in Depression: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Depression is one of the main mental disorders. Pharmacological treatment of depression is often associated with delayed effects or insufficient efficacy. Consequently, there is a need to discover new therapeutic methods to cope with depression faster and more effectively. Several lines of evidence indicate that the use of probiotic therapy reduces depressive symptoms. Nonetheless, the exact mechanisms linking the gut microbiota and the central nervous system, as well as the potential mechanisms of action for probiotics, are still not entirely clarified. The aim of this review was to systematically summarize the available knowledge according to PRISMA guidelines on the molecular mechanisms linking probiotics and healthy populations with subclinical depression or anxiety symptoms, as well as depressed patients with or without comorbid somatic illnesses. The standardized mean difference (SMD) with 95% confidence intervals (CI) was calculated. Twenty records were included. It has been found that probiotic administration is linked to a significant increase in BDNF levels during probiotic treatment compared to the placebo (SMD = 0.37, 95% CI [0.07, 0.68], p = 0.02) when considering the resolution of depressive symptoms in depressed patients with or without comorbid somatic illnesses. CRP levels were significantly lower (SMD = -0.47, 95% CI [0.75, -0.19], p = 0.001), and nitric oxide levels were significantly higher (SMD = 0.97, 95% CI [0.58, 1.36], p < 0.0001) in probiotic-treated patients compared to the placebo, however, only among depressed patients with somatic co-morbidities. There were no significant differences in IL-1β, IL-6, IL-10, TNF-α, and cortisol levels after probiotic administration between the intervention and control groups (all p > 0.05). Firm conclusions on the effectiveness of probiotics and their possible association with inflammatory markers in the healthy population (only with subclinical depressive or anxiety symptoms) cannot be drawn. The advent of clinical trials examining the long-term administration of probiotics could evaluate the long-term effectiveness of probiotics in treating depression and preventing its recurrence.

Corylin ameliorates chronic ulcerative colitis via regulating the gut-brain axis and promoting 5-hydroxytryptophan production in the colon

BACKGROUND

Chronic ulcerative colitis (UC) is a lifelong disease, patients with chronic UC have a high prevalence of common mental disorders. The increasing interest in the role of gut-brain axis is seen in inflammatory bowel diseases.

PURPOSE

Corylin is a representative flavonoid compound isolated from the Psoraleae Fructus. This study aimed to identify the effects and mechanism of corylin on the inflammation interactions and 5-HT synthesis between the gut and brain in chronic UC.

METHODS

Dextran sulfate sodium (DSS) induced chronic UC mouse model was established to assess the therapeutic effect of corylin on chronic UC symptoms. The expression of inflammatory cytokines was detected in the colon and brain. The expression of tight junction (TJ) proteins of intestinal mucosal barrier and blood-brain barrier (BBB) and the ionized calcium-binding adaptor molecule 1 (Iba1) in the hippocampus were determined by western blotting and immunofluorescence staining. In addition, several tryptophan (Trp) metabolites and related neurotransmitters in faeces, colon, serum, and brain were detected by UPLC-MS/MS. The interaction between corylin and 5-hydroxytryptophan decarboxylase (5-HTPDC) was performed by molecular docking and surface plasmon resonance (SPR). Finally, the changes of gut microbiota composition were analyzed by 16S rRNA sequencing.

RESULTS

Corylin significantly alleviated colitis symptoms and inhibited inflammatory response in the colon and brain of DSS-induced chronic UC mice. The TJ proteins of intestinal mucosal barrier and BBB were improved and the expression of Iba1 in the hippocampus was normalized after corylin treatment. In addition, corylin treatment increased the expression of neurotransmitters in the brain, especially 5-hydroxytryptamine (5-HT) and 5-hydroxytryptophan (5-HTP), but the expression of 5-HT in the colon was inhibited. Further study firstly proved that corylin could bind to the 5-HTDPC, and then inhibit the expression of 5-HTDPC and VB₆, resulting in the 5-HT reduction and 5-HTP accumulation in the colon. Moreover, the intake of corylin transformed the diversity and composition of intestinal microbiota, Bacteroides, Escherichia-Shigella, and Turicibacter were decreased but Dubosiella, Enterorhabdus, and Candidatus_Stoquefichus were increased.

CONCLUSION

Corylin administration ameliorated DSS-induced colitis and inhibited intestinal inflammation and neuroinflammation via regulating the inflammation interactions across gut-brain axis and increasing 5-HTP generation in the colon.

Surfactin Mitigates Dextran Sodium Sulfate-Induced Colitis and Behavioral Disorders in Mice by Mediating Gut-Brain-Axis Balance

Ulcerative colitis (UC) is associated with brain neurotransmitter disorders and intestinal dysbiosis. Bacillus amyloliquefaciens fmb50 produces the lipopeptide surfactin, which has a wide range of biological activities. However, the effects of surfactin on DSS-induced colitis have not been reported. In the present study, oral surfactin significantly ameliorated colitis in a mouse model and reduced depression-like behavior, such as slowed walking speed, shortened movement distance in the open field test, and weakened exploration ability in the light-dark shuttle test. Surfactin noticeably improved gut microbial dysbiosis, intestinal barrier dysfunction in the colon, and blood-brain barrier dysfunction in the brain. Furthermore, the colon levels of occludin were upregulated by 68.51%, and the brain levels of occludin and ZO-1 were upregulated by 77.81% and 36.42%, respectively. Surfactin supplementation also inhibited inflammatory responses by inactivating the tumor necrosis factor-α (TNF-α), nuclear factor kappa-B (NF-κB), and NLRP3 signaling pathways in the colon and brain. Thus, we believe that surfactin improved the behavioral disorders by upregulating the levels of 5-hydroxytryptamine (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), norepinephrine (NE), and brain-derived neurotrophic factor (BDNF), suppressing the inflammatory responses, and improving the blood-brain barrier dysfunction. Surfactin also reduced the abundances of gut microbes that are related to colitis, especially targeting facultative anaerobes of the phylum Proteobacteria, and it increased the abundance of beneficial bacteria such as Lactobacillus and unidentified Prevotella. Combined with its nontoxic nature observed in this long-term study in mice, oral surfactin might be a promising intervention strategy for preventing colitis by acting on the microbiota-gut-brain axis.

National Prevalence of Psychological Distress and Use of Mental Health Care in Inflammatory Bowel Disease

BACKGROUND

Individuals with inflammatory bowel disease (IBD) have elevated symptoms of anxiety and depression. The burden of such symptoms, accompanied by functional impairment in IBD, is not well documented, nor is utilization of mental health care in this population.

METHODS

Adults ≥18 years were identified in the cross-sectional 2015-2016 National Health Interview Survey. Responses from the Kessler Index were used to estimate the national prevalence of psychological distress with impairment and mental health-care use in IBD. Factors associated with psychological distress with impairment in IBD were analyzed using logistic regression.

RESULTS

The prevalence of psychological distress with impairment was significantly higher in IBD than non-IBD adults (7.69% vs. 3.50%, respectively; P < .01). Among those with IBD and psychological distress with impairment, only a third (36.29%) had seen or talked to a mental health provider in the preceding 12 months. About half of these found the cost of mental health care unaffordable. On multivariable analysis, factors associated with psychological distress in IBD included increasing emergency room visits and trouble finding a health provider.

CONCLUSIONS

A significant number of adults with IBD in the United States have psychological distress accompanied by functional impairment. However, mental health care is underutilized in this population. Many of these individuals find the cost of mental health care unaffordable, struggle to find a health provider, and experience repeated emergency room visits. Ongoing efforts to improve mental health care in IBD should address issues of access and cost. Additionally, these efforts should seek to understand other barriers to mental health-care use.

A Phenomenological Investigation of Trauma in 18 Adults Living With Inflammatory Bowel Disease

While trauma is recognized as being common in Inflammatory Bowel Disease (IBD) cohorts, limited research has explored how trauma impacts the lived experience of IBD. The aim of this study was to develop an understanding of how trauma impacts the experience of living with IBD and its subsequent management. An interpretative phenomenological analysis with thematic analysis was conducted. Eighteen adults with IBD participated in this qualitative research study. Key themes identified included: (1) Trauma was associated with the journey of IBD; (2) the impact of IBD and trauma, and (3) coping strategies. Pre-existing non-IBD trauma was prevalent, with several participants reporting links between traumatic events and their IBD diagnosis. Experiences of IBD trauma were described by participants across all stages of their illness journey. The study can assist healthcare professionals to better understand the experience of living with IBD and trauma and the factors that can contribute to traumatic responses.

The relationship of major depressive disorder with Crohn's disease activity

INTRODUCTION

Crohn's disease (CD) has been related to an increased prevalence of psychiatric disorders and suicide risk (SR). However, the nature of their relationship still deserves clarification. The aim of this study is to assess the prevalence of major depressive disorder (MDD) in patients with CD, and to investigate the relationship between MDD and CD outcomes.

METHODS

A cross-sectional study involving CD patients was performed. CD activity was evaluated by the Harvey-Bradshaw index and CD phenotype by the Montreal classification. The presence of MDD was assessed by the Patient Health Questionnaire score-9 (PHQ-9). Sociodemographic data and other characteristics were retrieved from electronic medical records.

RESULTS

283 patients with CD were included. The prevalence of MDD was 41.7%. Females had a risk of MDD 5.3 times greater than males. CD disease duration was inversely correlated with MDD severity. Individuals with active CD were more likely to have MDD (OR = 796.0; 95% CI 133.7‒4738.8) than individuals with CD remission. MDD was more prevalent in inflammatory behavior (45.5%) and there were no statistical differences regarding the disease location. 19.8% of the sample scored positive for SR.

CONCLUSION

The present results support data showing an increased prevalence of MDD in individuals with CD. Additionally, it indicates that MDD in CD might be related to the activity of CD. Prospective studies are warranted to confirm these results and to address whether MDD leads to CD activity, CD activity leads to MDD or both ways are existent.

The gut-microbiota-brain axis in a Spanish population in the aftermath of the COVID-19 pandemic: microbiota composition linked to anxiety, trauma, and depression profiles

The prevalence of anxiety and depression soared following the COVID-19 pandemic. To effectively treat these conditions, a comprehensive understanding of all etiological factors is needed. This study investigated fecal microbial features associated with mental health outcomes (symptoms of anxiety, depression, or posttraumatic stress disorder (PTSD)) in a Spanish cohort in the aftermath of the COVID-19 pandemic. Microbial communities from stool samples were profiled in 198 individuals who completed validated, self-report questionnaires. 16S ribosomal RNA gene V3-4 amplicon sequencing was performed. Microbial diversity and community structure were analyzed, together with relative taxonomic abundance. In our cohort of N=198, 17.17% reported depressive symptoms, 37.37% state anxiety symptoms, 40.90% trait anxiety symptoms, and 8.08% PTSD symptoms, with high levels of comorbidity. Individuals with trait anxiety had lower Simpson's diversity. Fusicatenibacter saccharivorans was reduced in individuals with comorbid PTSD + depression + state and trait anxiety symptoms, whilst an expansion of Proteobacteria and depletion of Synergistetes phyla were noted in individuals with depressive symptoms. The relative abundance of Anaerostipes was positively correlated with childhood trauma, and higher levels of Turicibacter sanguinis and lower levels of Lentisphaerae were found in individuals who experienced life-threatening traumas. COVID-19 infection and vaccination influenced the overall microbial composition and were associated with distinct relative taxonomic abundance profiles. These findings will help lay the foundation for future studies to identify microbial role players in symptoms of anxiety, depression, and PTSD and provide future therapeutic targets to improve mental health outcomes.

The Interplay of Biopsychosocial Factors and Quality of Life in Inflammatory Bowel Diseases: A Network Analysis

GOAL

The aim of this study was to investigate the network of biopsychosocial factors and quality of life (QoL) in persons with inflammatory bowel diseases (IBDs) and explore the influence of psychological factors on the course of the disease.

BACKGROUND

QoL of persons with IBD depends on disease activity but also on numerous interacting psychosocial factors. The influence of psychosocial factors on the disease course in controversially discussed.

MATERIALS AND METHODS

In 2 independent IBD samples (sample 1: n=209, anonymous internet survey; sample 2: n=84, outpatients with active disease), we measured QoL, anxiety, depression, illness identity, self-esteem, loneliness, childhood trauma, and visceral sensitivity with questionnaires. In addition, fatigue, hemoglobin levels, and response to therapy were assessed in sample 2. We estimated multiple regularized partial correlation networks and conducted accuracy and stability tests of the networks.

RESULTS

In both samples, QoL had the strongest relationships with visceral sensitivity and the illness identity engulfment. Depression was the most central factor in the networks. Baseline depression scores, visceral sensitivity, and engulfment were associated with response to therapy in sample 2.

CONCLUSIONS

This first network study to assess the interplay between biopsychosocial factors and QoL in IBD reveals a comparable network structure in 2 samples. Results partly replicate findings from previous studies with regard to the importance of depression and yield information on the central role of the newly introduced concepts of illness identity and visceral sensitivity. Preliminary findings point to an influence of these parameters on the disease course, which indicates their role as a possible target in individualized therapy.

Patients' experiences with virtual group gut-directed hypnotherapy: A qualitative study

Background

Hypnotherapy is a useful treatment for a variety of gastrointestinal conditions. While there is strong evidence for delivering other treatments virtually and in groups, there is no research thus far on delivering hypnotherapy in this format. Given the growth of both psychogastroenterology and telehealth, these methods should be explored as they have great potential for increasing access and cost-effectiveness of intervention.

Aims

This qualitative study was developed to help understand patients experiences in virtual, group-based, gut-directed hypnotherapy (GDH) in two different institutions.

Methods

Authors developed a qualitative interview with the assistance of two patient partners and then recruited patients from New York University and Dartmouth Health to participate. Interviews were completed one-on-one with patients who started and then completed GDH (≥5 visits) and who did not complete GDH (≤3 visits). Data were coded and then analyzed using thematic analysis.

Results

Twenty-one patients from NYU and Dartmouth participated in qualitative interviews. Broadly, patients reported coming to GDH because they believed in the importance of the mind-body connection or were desperate for treatment. Regardless of why patients came to GDH, they generally reported positive outcomes for GI symptoms and for other physical and mental health conditions. Most patients appreciated the group and virtual formats, though some concerns about inflexible schedules and lack of anonymity were voiced. Despite these concerns, there was broad support for virtual, group-based GDH and general excitement for behavioral health programming.

Conclusion

Virtual, group-based GDH is an acceptable treatment for patients from rural and urban settings. Given the possible improvements in access and cost-effectiveness that this treatment modality can provide, GI practices may want to consider it in lieu of or in addition to the traditional one-on-one treatment format. Barriers and facilitators and recommendations for practice are discussed.

Medical and social determinants of health as predictors of adverse outcomes in patients with inflammatory bowel disease

There is a growing recognition that social determinants of health (SDOH) influence outcomes in patients with chronic diseases. This study aimed to investigate the influence of SDOH on outcomes in patients with inflammatory bowel disease (IBD). We conducted a retrospective cohort study of adult patients with IBD from 1996 to 2019. Patients were identified using ICD-10 codes for ulcerative colitis and Crohn's disease, and chart review was performed to validate the diagnosis and extract clinical information. SDOH factors including food security, financial resources, and transportation were self-reported by the patient. Random forest models were trained and tested in R to predict either IBD-related hospitalization or surgery. A total of 175 patients were studied, and the majority reported no financial resource, food security, or transportation concerns. For the model using clinical predictors, the sensitivity was 0.68 and specificity was 0.77 with an area under the receiver operating characteristic curve (AUROC) of 0.77. The model's performance did not significantly improve with the addition of SDOH information (AUROC of 0.78); however, model performance did vary by phenotype (AUROC of 0.86 for patients with Crohn's disease and AUROC of 0.68 for patients with ulcerative colitis). Further research is needed to understand the role of SDOH factors and IBD-related outcomes.

A survey on the impact of IBD in sexual health: Into intimacy

Patients with Inflammatory Bowel Disease (IBD) are at increased risk of psychological and physical burden, including sexual dysfunction (SD). This study aimed to assess the prevalence of SD and to identify its predictive factors, in IBD patients. This unicentric cross-sectional case-control survey (ratio 2:1) included patients followed at the day hospital IBD consultation, in the Gastroenterology department of a tertiary referral center, for 2 years. Participants received anonymous questionnaires, concerning basic characteristics and sexual function, and a questionnaire on anxiety and depression, body image, fatigue, and IBD-specific health-related quality of life (QoL). We analyzed data from 120 IBD patients and 60 healthy controls. Forty-two female (56.8%) and 6 male (14.6%) IBD patients, and 6 women (15%) and 2 males (10%) of the control group presented SD. SD was significantly higher in IBD patients with age between 18 and 30 and 51 and 60 than in healthy controls (P < .05) Regarding multivariate analysis, age was a predictive factor for SD in males (P = .014), and anxiety and depression (P = .002) and fatigue (P = .043) in females. SD is a predictor of lower QoL among IBD patients, considering the last 15 (P < .001) and 60 days (P = .001), regarding univariate analysis. SD (P = .007), body image distortion (P < .001), and fatigue (P = .004) were predictors of low QoL (last 15 days, multivariate analysis). SD was more prevalent in IBD patients than in the control group and impacted negatively the QoL of patients. Age was a predictive factor for SD in men while anxiety and depression, and fatigue were predictive of SD in women.

Treat-to-target and sequencing therapies in Crohn's disease

Crohn's disease (CD) is a chronic immune-mediated inflammatory condition which can negatively impact a patient's quality of life. The traditional management strategy for CD has focused on symptomatic control, however, this approach fails to prevent organ damage and to change the progressive course of this disease. Thus, the field has moved towards a treat-to-target strategy that includes identifying individualized objective targets, choosing a therapy based on individual factors that include disease severity and risk, closely monitoring disease activity at predefined time points, and optimizing therapies as needed. Due to the increasing number of therapies approved for CD, this review explores the various factors which should be considered in the sequencing of treatment options together with using the treat-to-target framework to control disease activity early in its course and provide holistic patient care.

Moxibustion alleviates depression-like behavior in rats with Crohn's disease by inhibiting the kynurenine pathway metabolism in the gut-brain axis

Background

Moxibustion is a potential therapy for inflammatory bowel disease-related depression, but its specific mechanism of action is unclear. This study aimed to investigate the molecular mechanism by which moxibustion alleviates depressive behavior in rats with Crohn's disease (CD).

Methods

The CD rat model was established with 2,4,6-trinitrobenzenesulfonic acid. Treatment with moxibustion was applied to Tianshu (ST25, bilateral), Qihai (CV6), and Baihui (GV20) acupoints, and the effect of moxibustion was compared with that of the combination of moxibustion plus indoleamine-2,3-dioxygenase 1 (IDO1) inhibitor, 1-methyltryptophan (1-MT). The effects of moxibustion and moxibustion plus 1-MT combination on colonic inflammation and depressive behavior (assessed by forced swimming test, sucrose preference test, and open field test) were investigated. The changes in IDO1, TNF-α, and IL-1β in rat colon and hippocampus were assessed by Western blot (WB). Gas chromatography-mass spectrometry, immunofluorescence staining, and WB were applied to detect kynurenine pathway (KP) metabolites, hippocampal neuronal activity, and microglia activation, respectively.

Results

Both moxibustion and moxibustion plus 1-MT combination significantly alleviated intestinal inflammation and depressive behavior, downregulated the levels of IDO1 in the colon and hippocampus, and inhibited inflammation-inducing factors IL-1β and TNF-α, as well as the kynurenine/tryptophan (KYN/TRP) ratio of KP metabolites, and upregulated the kynurenic acid (KYNA)/KYN ratio and the KYNA/quinolinic acid (QUIN) ratio in the hippocampus in rats with CD; Hippocampal ionized calcium-binding adaptor molecule-1 (Iba-1), c-fos protein expression, activated microglia, and neuronal activation was also significantly reduced by moxibustion and moxibustion plus 1-MT. The addition of 1-MT did not significantly increase the therapeutic effect of moxibustion.

Conclusion

Moxibustion can improve depressive behavior in rats with CD, which may be related to its regulation of KP metabolism in the gut-brain axis and inhibition of hippocampal microglia activation and neuronal activation.

Psychiatric Disorders in Adult and Paediatric Patients With Inflammatory Bowel Diseases - A Systematic Review and Meta-Analysis

BACKGROUND

Inflammatory bowel diseases [IBD], which are associated with a high disease burden, are also reported to be accompanied by a high prevalence of psychiatric disorders. However, the literature on IBD and psychiatric disorders has not been reviewed.

METHODS

This systematic review followed the PRISMA guidelines, and its protocol was registered at PROSPERO [ID: CRD42020214359]. PubMed, Embase and PsycINFO were consulted for the literature search. Studies reporting on diagnosed psychiatric disorders in IBD were included. Pooled prevalence rates were calculated using random effects meta-analyses. Study quality was assessed using the Newcastle-Ottawa Scale [NOS].

RESULTS

Sixty-nine studies were identified with an average cohort size of 60 114 patients. Pooled prevalence rates were: mood disorders, 10% (95% confidence interval [CI] = 7%; 15%); anxiety disorders, 12% [95% CI = 8%; 18%]; substance misuse, 3% [95% CI = 1%; 7%]; psychotic disorders, 2% [95% CI = 1%; 4%]; behavioural disorders, 1% [95% CI = 0%; 3%]; personality disorders, 3% [95% CI = 1%; 10%]; developmental disorders, 1% [95% CI = 0%; 3%]; and behavioural and emotional disorders with onset usually during childhood, 1% [95% CI = 1%; 3%]. All analyses had high statistical heterogeneity [I2 > 99%]. Seven studies reported an increased risk of suicide in IBD patients compared to controls.

CONCLUSION

The prevalence of psychiatric comorbidities was high [11-82%] in patients with IBD and was higher than in the background population. Addressing mental health problems in patients with IBD can improve their adherence to treatment and the somatic disease course and, consequently, reduce morbidity and mortality.

Principles for Assessing Quality of Life in Patients With Crohn's Disease

ABSTRACT

Crohn's disease (CD) is a lifelong inflammatory bowel disease that can severely impact quality of life. Many questionnaires exist to assess quality of life for patients with CD, but some of these questionnaires were developed without qualitative data from patients or include only limited symptoms. Patient-Reported Impact of Symptoms in CD provides an innovative and patient-centered framework for assessing quality of life in patients with CD, soliciting qualitative data from patient interviews, and using this to guide a cross-sectional study. Their findings should inform how clinicians guide conversations with their patients regarding quality of life.

Management of Sexual Dysfunction in Gastrointestinal Disorders

Patients with gastrointestinal (GI) disorders are at increased risk of sexual dysfunction (SD) due to a combination of biomedical, psychological, social, and interpersonal factors. While most patients desire information on the impact of their GI disorder on sexual function, few providers initiate this conversation. GI providers should routinely assess their patients for SD, validate these concerns, and provide brief education and a referral for evaluation and/or treatment. Treatment of sexual concerns is often multidisciplinary and may involve a sexual medicine physician, pelvic floor physical therapists, and sex therapists.

Emerging drugs for the treatment of inflammatory bowel disease

INTRODUCTION

Anti-tumor necrosis factor (TNF)-α have been the mainstay therapy for Crohn's (CD) and ulcerative colitis (UC) for decades. With growing need for highly effective therapy, various therapeutic targets have been introduced including anti-integrins, anti-interleukin (IL) 12/23, selective anti-IL23, Janus Kinase (JAK) inhibitors, sphingosine-1-phosphate (S1P) receptor modulators, and mRNA-124 splicing agent.

AREAS COVERED

The current state of available IBD therapies and those in development are reviewed, with recommendations made on positioning in clinical practice.

EXPERT OPINION

Selecting and sequencing IBD therapies remains a clinical challenge. Disease phenotype, severity of symptoms, patient comorbidities, and prior drug exposure should be considered when considering therapy options. Anti-TNF remains a time-tested option that is effective in both UC and CD. The perception that newer biologics have slower onset of action is probably overestimated and providers should reconsider need for concurrent corticosteroid. JAK-inhibitors provide rapid symptom improvement in patients with moderate-severe UC. Due to safety concerns, it is recommended as a second-line therapy for UC. The goal for IBD treatment should be personalized, have rapid onset of action, induce durable clinical and endoscopic remission, and have excellent safety.

Use of Benzodiazepines and Z-Drugs in Inflammatory Bowel Disease

INTRODUCTION

We estimated the incidence and prevalence of benzodiazepine and Z-drug (separately and jointly as BZD) use in the inflammatory bowel disease (IBD) population compared with matched controls without IBD and examined the association of mood/anxiety disorders (M/ADs) with the use of BZD from 1997 to 2017.

METHODS

Using administrative data from Manitoba, Canada, we identified 5,741 persons with incident IBD who were matched in a 1:5 ratio to controls on sex, birth year, and region. Validated case definitions were used to identify M/AD. Dispensations of BZD were identified. Multivariable generalized linear models were used to assess the association between IBD, M/AD, and BZD use.

RESULTS

In 2016, the incident age/sex-standardized benzodiazepine use rates per 1,000 were 28.06 (95% confidence interval [CI] 26.41-29.81) in the IBD cohort and 16.83 (95% CI 16.28-17.39) in controls (adjusted rate ratio = 1.69 [95% CI 1.56-1.79]). Benzodiazepine incidence rates were higher for women with IBD than men, but the RR between cases and controls were similar for men and women. The incident age/sex-standardized Z-drug use rate per 1,000 was 21.07 (95% CI 19.69-22.41) in the IBD cohort. This was 1.87-fold higher than in controls (95% CI 1.73-2.01). In 2017, approximately 20% of persons with IBD used benzodiazepines and 20% used Z-drugs. There was a subadditive effect of both benzodiazepine and Z-drug uses between IBD and M/AD after adjusting for covariates.

DISCUSSION

The use of BZD is more common in people with IBD than in population controls. Strategies to reduce the use of BZDs in persons with IBD and to offer alternative management strategies for M/ADs, sleep disorders, and other symptomatic concerns are needed.

Depression and anxiety in inflammatory bowel disease: epidemiology, mechanisms and treatment

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic, relapsing immune-mediated disease with a varying and sometimes severe disease course. IBD is often diagnosed in early adulthood and can lead to a substantial decline in quality of life. It has been suggested that patients with IBD are at increased risk of depression and anxiety, but it is still unclear to what extent these diseases co-occur and in what sequence they arise. This Review summarizes the literature on the degree of co-occurrence of IBD with depression and anxiety and the temporal relationship between these diseases. We also discuss the effect of psychological stress on the onset and course of IBD. In addition, we outline the possible mechanisms underlying the co-occurrence of IBD and depression and anxiety, which include changes in brain signalling and morphology, increases in peripheral and intracerebral pro-inflammatory cytokines, impairment of the nitric oxide pathway, changes in vagal nerve signalling, gut dysbiosis and genetics. Finally, we examine the possible effects of treatment of depression and anxiety on the risk and course of IBD, the influence of psychological interventions on IBD, and the effects of IBD treatment on psychiatric comorbidity.

Rooibos (Aspalathus linearis) alters secretome trace amine profile of probiotic and commensal microbes in vitro

ETHNOPHARMACOLOGY RELEVANCE

Aspalathus linearis (Burm.f.) R. Dahlgren (rooibos) tea is anecdotally renowned for its calming effect in the context of gastrointestinal discomfort, but little scientific support is available to elucidate potential mechanisms of action. Enhancement of dietary polyphenol content to improve gut health via prebiotic-like modulation of the gut microbiota has gained significant research interest. Given the known high polyphenol content of rooibos, rooibos tea may potentially exert a prebiotic effect in the gut to facilitate an improvement in chronic inflammatory gastrointestinal conditions.

AIM OF THE STUDY

This study aimed to determine the prebiotic or health-modulating potential of rooibos tea in terms of its effect on gut microbial growth and secretome trace amine composition, as well as to determine how differential rooibos processing alters this activity.

METHODS

Three rooibos preparations (green and fermented leave aqueous extracts, as well as a green leaf ethanol extract) were compared in terms of their phenolic composition (qTOF-LC/MS). Moreover, the effect of rooibos exposure on growth and secretome trace amine levels of probiotic and commensal microbes were assessed (LC/MS). In addition, given the known female bias prevalent for many gastrointestinal disorders, experiments were conducted in the absence and presence of estradiol.

RESULTS

Polyphenolic composition of rooibos was drastically reduced by fermentation. Aqueous extracts of both green and fermented rooibos improved microbial growth, although fermented rooibos had the most pronounced effect (p < 0.01). In terms of secretome trace amine profile, both aqueous extracts of rooibos seemed to facilitate increased putrescine secretion (p < 0.0001) and decreased tryptamine production (p < 0.0001). Estradiol seemed to suppress trace amine secretion by bacteria (Lactobacillus plantarum, Lactobacillus reuteri and Enterococcus mundtii) but increased it in yeast (Saccharomyces boulardii).

CONCLUSION

Rooibos altered gut probiotic and commensal microbial growth and secretome trace amine profiles in vitro, suggesting it has potential to modulate gut microbial composition and functionality as a prebiotic. Current data suggest that these effects are highly dependent on raw material processing. Finally, rooibos may be able to prevent estradiol-associated alterations in trace amine profile, which may have important implications for patient management in female-predominant gastrointestinal disorders.

The Effectiveness of Patient Training in Inflammatory Bowel Disease Knowledge via Instagram: Randomized Controlled Trial

Background

Patients’ knowledge was found to be a key contributor to the success of therapy. Many efforts have been made to educate patients in their disease. However, research found that many patients still lack knowledge regarding their disease. Integrating patient education into social media platforms can bring materials closer to recipients.

Objective

The aim of this study is to test the effectiveness of patient education via Instagram.

Methods

A randomized controlled trial was conducted to test the effectiveness of patient education via Instagram among patients with inflammatory bowel disease. Participants were recruited online from the open Instagram page of a patient organization. The intervention group was educated via Instagram for 5 weeks by the research team; the control group did not receive any educational intervention. The knowledge about their disease was measured pre- and postintervention using the Inflammatory Bowel Disease Knowledge questionnaire. Data were analyzed by comparing mean knowledge scores and by regression analysis. The trial was purely web based.

Results

In total, 49 participants filled out both questionnaires. The intervention group included 25 participants, and the control group included 24 participants. The preintervention knowledge level of the intervention group was reflected as a score of 18.67 out of 24 points; this improved by 3 points to 21.67 postintervention. The postintervention difference between the control and intervention groups was 3.59 points and was statistically significant (t_32.88=–4.56, 95% CI 1.98-5.19; P<.001). Results of the regression analysis, accounting for preintervention knowledge and group heterogeneity, indicated an increase of 3.33 points that was explained by the intervention (P<.001).

Conclusions

Patient education via Instagram is an effective way to increase disease-related knowledge. Future studies are needed to assess the effects in other conditions and to compare different means of patient education.

Trial Registration

German Clinical Trials Register DRKS00022935; https://tinyurl.com/bed4bzvh

Psychological stress in inflammatory bowel disease: Psychoneuroimmunological insights into bidirectional gut–brain communications

Inflammatory bowel disease (IBD), mainly including ulcerative colitis (UC) and Crohn’s disease (CD), is an autoimmune gastrointestinal disease characterized by chronic inflammation and frequent recurrence. Accumulating evidence has confirmed that chronic psychological stress is considered to trigger IBD deterioration and relapse. Moreover, studies have demonstrated that patients with IBD have a higher risk of developing symptoms of anxiety and depression than healthy individuals. However, the underlying mechanism of the link between psychological stress and IBD remains poorly understood. This review used a psychoneuroimmunology perspective to assess possible neuro-visceral integration, immune modulation, and crucial intestinal microbiome changes in IBD. Furthermore, the bidirectionality of the brain–gut axis was emphasized in the context, indicating that IBD pathophysiology increases the inflammatory response in the central nervous system and further contributes to anxiety- and depression-like behavioral comorbidities. This information will help accurately characterize the link between psychological stress and IBD disease activity. Additionally, the clinical application of functional brain imaging, microbiota-targeted treatment, psychotherapy and antidepressants should be considered during the treatment and diagnosis of IBD with behavioral comorbidities. This review elucidates the significance of more high-quality research combined with large clinical sample sizes and multiple diagnostic methods and psychotherapy, which may help to achieve personalized therapeutic strategies for IBD patients based on stress relief.

A randomized controlled trial of a multicomponent online stress reduction intervention in inflammatory bowel disease

BACKGROUND

Psychological stress negatively impacts inflammatory bowel disease (IBD) outcomes. Patients have prioritized access to online interventions; yet, the data on these have been limited by mixed in-person/online interventions, low adherence, and non-randomized controlled trial (RCT) design.

OBJECTIVES

We assessed the efficacy of and adherence to a 12-week online multicomponent stress reduction intervention in IBD.

DESIGN

This is a RCT.

METHODS

Adult participants on stable IBD medical therapy with elevated stress levels from four centers were randomized to intervention or control groups. Intervention participants received a 12-week online program including a weekly yoga, breathwork and meditation video (target 2-3 times/week), a weekly cognitive behavioral therapy/positive psychology informed video activity, and weekly 10-min check-ins by a study team member. Control participants received weekly motivational messages by email. All patients received standard of care IBD therapy. The primary outcome was Cohen's Perceived Stress Scale (PSS). Secondary outcomes evaluated mental health, resilience, health-related quality of life (HRQoL), symptom indices, acceptability, adherence, and inflammatory biomarkers. Analysis of covariance was used to determine between-group differences.

RESULTS

Of 150 screened patients, 101 were randomized to the intervention (n = 49) and control (n = 52) groups (mean age: 42.5 ± 14.1 years; M:F 1:3, 48% with ulcerative colitis and 52% with Crohn's disease). The between-group PSS improved by 22.4% (95% confidence interval, 10.5-34.3, p < 0.001). Significant improvements were seen in mental health, resilience, and HRQoL measures, with a median satisfaction score of 89/100 at the end of the 12 weeks. In the 44/49 patients who completed the intervention, 91% achieved program adherence targets.

CONCLUSION

This 12-week online intervention improved perceived stress, mental health, and HRQoL, but did not impact IBD symptom indices or inflammatory biomarkers. The program was readily adopted and adhered to by participants with high retention rates. After iterative refinement based on participant feedback, future studies will evaluate the impact of a longer/more intense intervention on disease course.

REGISTRATION

ClinicalTrials.gov Identifier NCT03831750.

PLAIN LANGUAGE SUMMARY

An online stress reduction intervention in inflammatory bowel disease patients improves stress, mental health, and quality of life People with inflammatory bowel disease (IBD) have high levels of stress, anxiety, and depression. Although IBD patients have expressed the need for online mental wellness interventions, the existing data to support these interventions in IBD are limited. In this trial, 101 IBD patients had the chance to participate in a 12-week online stress reduction intervention. In those patients randomly selected to participate in the online intervention, each week they received the following: a 20- to 30-min yoga, breathwork, and meditation video that they were asked to do 2-3 times a week, a 10- to 20-min mental wellness activity they were asked to do once during the week, and a 10-min telephone check-in with a study team member. Participants who were not selected to use the online intervention received a weekly motivational message by email. In all, 90 of the 101 participants (89%) completed the study with the mean age of participants being 43 years and the majority being females (75%). Ninety-one percent of participants who completed the intervention met the program target of doing the yoga, breathwork, and meditation video at least 2 times per week. Significant improvements were seen in perceived stress (by 22.4%), depression (by 29.5%), anxiety (by 23.7%), resilience (by 10.6%), and quality of life (by 8.9%). No changes were seen in IBD severity or in blood markers of inflammation. In conclusion, this study demonstrates evidence that a 12-week online stress reduction intervention had low dropout rates, high adherence and beneficial effects on stress, mental health, and quality of life measures. Continued feedback will be sought from study participants and our IBD patient partners to refine the intervention and assess the impact in future studies of patients with active IBD, as well as the impact of a longer/more intense intervention.

Inflammatory Bowel Disease: Role of Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) is an accepted therapy for the treatment of refractory forms of epilepsy and depression. The brain–gut axis is increasingly being studied as a possible etiological factor of chronic inflammatory diseases, including inflammatory bowel diseases (IBD). A significant percentage of IBD patients lose response to treatments or experience side effects. In this perspective, VNS has shown the first efficacy data. The aim of this narrative review is to underline the biological plausibility of the use of VNS in patients affected by IBD, collect all clinical data in the literature, and hypothesize a target IBD population on which to focus the next clinical study.

Exploring Patient Perspectives on a 12-Week Online, Stress Reduction Intervention in Inflammatory Bowel Disease

Background

Online stress reduction interventions may be useful adjuncts to standard medical therapies for inflammatory bowel disease (IBD). As part of the evaluation of a 12-week randomized control trial (RCT) of an online multicomponent stress reduction program, our aim for the current study was to use qualitative methods to more deeply explore the patient experience with the online programming.

Methods

Upon completion of the 12-week RCT, all intervention participants were invited to participate in semistructured interviews. A qualitative descriptive approach was used. Interviews were analyzed through a theoretical thematic analysis process, whereby transcripts were coded, and codes then grouped into larger categories and themes.

Results

A total of 56 interviews were analyzed with the emergence of 3 main themes: (1) IBD as a source of stress and uncertainty, (2) understanding the positive impacts of the stress reduction program, and (3) suggested strategies to enhance program desirability. IBD was described as causing uncertainty, significant disruptions to daily activities, and stress, which in turn worsened symptoms. The online program was associated with a perceived reduction in IBD symptom burden, an increased ability to manage daily and disease-associated stressors, and a more positive mindset. Variation in program content and fostering connections with others in the IBD community were identified as potential strategies to enhance future programming.

Conclusions

This qualitative companion study highlights the power of the patient voice to deepen our understanding of the impact of IBD, and the potential benefit of an online stress reduction program including suggestions for iterative refinement.

Impact of adalimumab on disease burden in moderate-to-severe ulcerative colitis patients: The one-year, real-world UCanADA study

BACKGROUND

A gap remains in documenting the impact of anti-tumor necrosis factor therapy on disease burden in ulcerative colitis (UC) patients treated in a real-world setting. The use of patient-reported outcomes (PROs) has been discussed as a primary endpoint in the context of the FDA PRO Guidance, for labelling purposes. Specifically, the efficacy and safety of adalimumab have been demonstrated in pivotal trials; however, data are needed to understand how clinical results translate into improvements in key aspects of the daily lives of UC patients, such as symptoms, health-related quality of life (HRQoL), and disability.

AIM

To assess real-world effectiveness of adalimumab on PRO measures in patients with moderate-to-severe UC.

METHODS

UCanADA was a single arm, prospective, 1-year multicenter Canadian post-marketing observational study in which multiple PRO questionnaires were completed—with psychologic distress/depression symptoms as the primary endpoint—by patients with moderate-to-severe UC. Assessments were performed during patients’ routine care visit schedule, which was at the initiation of adalimumab (baseline), after induction (approximately 8 wk), and 52 wk after baseline. Additional optional assessments between weeks 8 and 52 were collected at least once but no more than two times during this period. Serious safety events and per-protocol adverse events were collected.

RESULTS

From 23 Canadian centres, 100 patients were enrolled and 48 completed the study. Measured with the Patient Health Questionnaire–9 items at week 52, 61.5% (40/65) [95% confidence interval (CI): 49.7%-73.4%] of the patients improved in psychologic distress/depression symptoms, which was slightly higher in completers [65.9% (29/44); 95%CI: 51.9%-79.9%)]. At week 52, clinical response and clinical remission were achieved respectively by 65.7% (44/73) and 47.8% (32/73) of the patients. The odds of improving depressive symptoms for those achieving a clinical remission at week 52 was 7.94 higher compared with those not achieving a clinical remission (CI: 1.42, 44.41; P = 0.018). Significant changes from baseline to weeks 8 and 52 were observed in disability, HRQoL, and fatigue. Meaningful improvement was reported in work impairment.

CONCLUSION

At week 52, over 60% of the UCanADA patients had depressive symptoms significantly reduced, as well as HRQoL, fatigue symptoms, and work impairment improved. No new safety signals were detected.

Peer support for carers and patients with inflammatory bowel disease: a systematic review

BACKGROUND

The support provided by people with the same condition, including inflammatory bowel diseases (IBD), has the potential to improve a range of psychosocial outcomes by allowing people with the disease to receive emotional support as well as to learn coping strategies from more experienced peers. The aim of this systematic review was to summarise the evidence on peer support interventions and their effectiveness on people with IBD.

METHODS

Bibliographic databases, conference proceedings, grey literature, and clinical trial registers were searched from inception to November 2021. Comparative and single-arm studies that evaluated interventions that were solely or contained in part peer support, for people with IBD and/or their carers of any age and in any setting were included. Effectiveness was evaluated using outcomes relating to physical and psychosocial function, disease control and healthcare utilisation. Data for each outcome were tabulated and presented in a narrative synthesis. Study design specific tools were used to assess risk of bias. Study selection and risk of bias assessment were undertaken by two reviewers independently.

RESULTS

Fourteen completed studies and five ongoing studies met the inclusion criteria. Substantial heterogeneity was observed in the studies in relation to the intervention type and peer support was usually part of a wider intervention. All but one study analysed the total effect of the intervention, so it was not possible to fully isolate the effect of the peer support alone. The appropriateness of outcomes and outcome measurement tools for the assessment of effects was a further key issue. As such, overall, no significant evidence of beneficial effects of peer support interventions on quality of life and other psychosocial outcomes was found.

CONCLUSIONS

New randomised controlled trials designed to isolate the effects of peer support are needed to evaluate the (net) effects of peer support only. Agreement on the outcomes to be targeted, and the choice of reliable and validated measurement tools for standalone peer support interventions would provide a focus for further intervention design and evaluation.

SYSTEMATIC REVIEW REGISTRATION

The protocol was accepted in the international prospective register of systematic reviews (PROSPERO CRD42020168817).

People Living with Inflammatory Bowel Disease Want Multidisciplinary Healthcare: A Qualitative Content Analysis

This study reports on the preferences of people with inflammatory bowel disease (IBD) for their healthcare. Overall, 477 people with IBD responded to an open-ended survey question within a larger study. We qualitatively content-analysed these responses with open coding using NVivo. Respondents expressed a desire for (1) better communication, (2) multidisciplinary care, (3) better treatment, services and specialist care, (4) whole person care, (5) health promotion, (6) proactive healthcare, (7) fewer administrative issues and (8) improved hospital experience. Patients with IBD want patient-centred, multidisciplinary care. Healthcare professionals should facilitate patients' access to proactive care.

Exploring the Relationship Between Self-Isolation and Distress Among People with Gastrointestinal Disorders During the COVID-19 Pandemic

This study aimed to explore the association between perceived isolation and symptoms of distress in people with GI disorders at the time of the pandemic; and to examine factors which moderate this relationship. This online cross-sectional survey was advertised in May-September 2020 via patient organisations and associated social media. Overall, 831 people (82% female, mean age 49 years) from 27 countries participated. A significant relationship between social isolation and psychological distress was noted (r = .525, p < .001). GI symptoms moderated the association between isolation and distress (B = .047, t = 2.47, p = .015). Interventions targeting these factors may help to reduce distress in people with GI disorders at the time of major stressors such as the COVID-19 pandemic.

Risk of dementia in patients with inflammatory bowel disease: a Danish population-based study

BACKGROUND

Inflammatory bowel disease (IBD) may be associated with increased dementia risk, but the literature is conflicting.

AIM

To investigate dementia risk in patients with IBD.

METHODS

We conducted a nationwide population-based cohort study in Denmark (1977-2018) including all patients with incident IBD matched with up to 10 general population comparators without IBD by sex, year of birth and region of residence. We calculated cumulative incidence proportions (CIPs) of dementia treating death as a competing risk, and adjusted hazard ratios (HRs) comparing IBD patients with matched comparisons. In a nested case-control analysis, we investigated the impact of IBD severity, steroid use, colorectal and small bowel surgery, and healthcare system contacts on dementia risk.

RESULTS

Of 88,985 patients with IBD (69.6% with ulcerative colitis [UC], 30.4% with Crohn's disease [CD]) and 884,108 comparisons, 2076 patients (78.1% with UC) and 23,011 comparisons (76.6% UC comparisons) developed dementia. The 40-year CIP of all-cause dementia was 7.2% for UC patients and 5.8% for CD patients. UC patients had a slightly increased HR of all-cause dementia (HR = 1.07 [95% confidence interval (CI): 1.01;1.12]) and Alzheimer's disease (HR = 1.10 [95% CI: 1.01-1.19]). CD patients had an increased HR of all-cause dementia (HR = 1.15 [95% CI: 1.05-1.27]) and frontotemporal dementia (HR = 2.70 [95% CI: 1.44-5.05]). Dementia in IBD patients was associated with frequent healthcare system contacts.

CONCLUSIONS

UC and CD are associated with slightly increased all-cause dementia risk, particularly frontotemporal dementia in CD patients. Frequent healthcare system contacts by patients with IBD and detection bias may play a role in the association.

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.

Extending the Common Sense Model to Explore the Impact of the Fear of COVID-19 on Quality of Life in an International Inflammatory Bowel Disease Cohort

The aim of this cross-sectional study was to use an extended common sense model (CSM) to evaluate the impact of fear of COVID-19 on quality of life (QoL) in an international inflammatory bowel disease cohort. An online study involving 319 adults (75% female, mean (SD) 14.06 (15.57) years of symptoms) completed the Gastrointestinal Symptom Rating Scale, Brief Illness Perceptions Questionnaire, Fear of Contracting COVID-19 Scale, Brief-COPE, Depression, Anxiety and Stress Scale, and the EUROHIS-QOL. The extended CSM had an excellent fit (χ2 (9) = 17.06, p = .05, χ2/N = 1.90, RMSEA = 0.05, SRMR = 0.04, CFI = .99, TLI = .97, GFI = 0.99), indicating the influence of gastrointestinal symptoms on QoL was mediated by illness perceptions, fear of COVID-19, adaptive and maladaptive coping, and psychological distress. Interventions targeting the fear of COVID-19 in the context of an individual's perceptions will likely enhance QoL during the pandemic.

The association between inflammatory bowel disease and mental ill health: a retrospective cohort study using data from UK primary care

BACKGROUND

Patients with active inflammatory bowel disease (IBD) and mental illnesses experience worse IBD outcomes.

AIM

To describe the incidence of mental illnesses, including deliberate self-harm, in IBD patients.

METHODS

A population-based retrospective cohort study using IQVIA medical research data of a primary care database covering the whole UK, between January 1995 and January 2021. IBD patients of all ages were matched 4:1 by demographics and primary care practice to unexposed controls. Following exclusion of patients with mental ill health at study entry, adjusted hazard ratios (HR) of developing depression, anxiety, deliberate self-harm, severe mental illness and insomnia were calculated using a Cox proportional hazards model.

RESULTS

We included 48,799 incident IBD patients: 28,352 with ulcerative colitis and 20,447 with Crohn's disease. Incidence rate ratios of mental illness were higher in IBD patients than controls (all p < 0.001): deliberate self-harm 1.31 (95% CI 1.16-1.47), anxiety 1.17 (1.11-1.24), depression 1.36 (1.31-1.42) and insomnia 1.62 (1.54-1.69). Patients with Crohn's disease were more likely to develop deliberate self-harm HR 1.51 (95% CI 1.28-1.78), anxiety 1.38 (1.16-1.65), depression 1.36 (1.26-1.47) and insomnia 1.74 (1.62-1.86). Patients with IBD are at increased risk of deliberate self-harm (HR 1.20 [1.07-1.35]). The incidence rate ratios of mental illnesses were particularly high during the first year following IBD diagnosis: anxiety 1.28 (1.13-1.46), depression 1.62 (1.48-1.77) and insomnia 1.99 (1.78-2.21).

CONCLUSION

Deliberate self-harm, depression, anxiety and insomnia were more frequent among patients with IBD. IBD is independently associated with an increased risk of deliberate self-harm.

Prior episode of colitis impairs contextual fear memory

Accumulating evidence has shown that intestinal inflammations in inflammatory bowel disease (IBD) also drive pathological responses in organs outside the intestine, including the brain. Previous studies using the dextran sodium sulfate (DSS)-induced colitis model have shown that colonic inflammation contributes to the development of anxiety- and depression-related behaviors; however, little is known about whether memory function is affected. Here, we subjected male and female C57BL/6J mice to DSS-induced colitis for 6 days, followed by Pavlovian conditioned fear (CF) tests 15 days after the start of inflammation, when local colonic inflammation has receded. The contextual and cued CF tests were used to assess associative fear memory. We found that DSS-induced colitis led to significant impairment in contextual fear memory in both male and female mice; on the other hand, auditory cued fear memories were comparable between control and DSS-treated mice. There were marked signs of astrogliosis in the hippocampal regions 17 days (D17) after colitis induction. Furthermore, molecular characterization of hippocampi showed marked but transient increases in the expression of inflammatory genes Nfkb, Trem2 (microglial marker), GFAP (astrocyte marker), Il1b, and S100a8 in DSS-treated mice. While the expression of Nfkb, Trem2, and GFAP showed a peak on day 10, the S100a8 expression was high on days 10 and 17 and subsided on day 42. Interestingly, expression of Bdnf remained elevated in the times assessed (D10, 17, 42). Together, these results demonstrated that DSS-induced colitis could induce prolonged neuroinflammation and impaired contextual fear memory.

Quality of Life in Patients With Inflammatory Bowel Disease: Importance of Psychological Symptoms

Background

Depressive, anxiety, and stress symptoms are prevalent in patients with inflammatory bowel disease (IBD) and may negatively influence the disease course and quality of life. The study aimed to assess the relationship between psychological factors and patients’ quality of life (QoL).

Materials and methods

A cross-sectional study with the use of a structured questionnaire among 38 patients with Crohn’s disease and 30 with ulcerative colitis was conducted. The inflammatory bowel disease questionnaire (IBDQ-32) was used to evaluate the patients’ quality of life, and the Depression, Anxiety, Stress Scale (DASS21) was used to evaluate these psychological factors. Pearson descriptive statistics and multiple regression analyses were performed.

Results

According to the findings of the multiple regression analysis, depressive, anxiety, and stress symptoms were negatively associated with quality of life. Participants with higher scores of anxiety had inferior QoL in intestinal symptoms (p=0.013) and in systemic symptoms (p=0.013), with higher scores of depression had inferior QoL in emotional function (p<0.001), and higher scores of stress had inferior QoL in the domain of social support (p=0.002). Psychological symptoms of emotional disorders appear to be associated with lower quality of life in IBD patients.

Conclusion

This study examined levels of depression, anxiety, and stress in Greek patients with IBD, which were associated with lower levels of their quality of life. Interventions to improve QoL in patients with IBD should consider the effect of psychological symptoms.