Depression and anxiety in people with inflammatory bowel disease

A cross-sectional survey on the psychological impact of the COVID-19 pandemic on inflammatory bowel disease patients in Saudi Arabia

Background/Aims

The coronavirus (COVID-19) pandemic has caused significant disruption to patients with chronic illnesses. We explored the emotional state, perception, and concerns of Saudi patients with inflammatory bowel disease (IBD) during the crisis.

Materials and Methods

We conducted a cross-sectional survey from 30 March to 5 April, 2020 using a pre-designed questionnaire distributed through social media platforms to IBD patients. The five-part questionnaire included an assessment of psychological wellbeing using a previously validated Arabic version of the Hospital Anxiety and Depression Scale (HADS), which includes domains for anxiety (HADS-A) and depression (HADS-D). A logistic regression analysis was used to uncover possible associations between patient characteristics and anxiety and depression.

Results

The data from 1156 IBD patients were analyzed. Normal, borderline, and HADS-A scores consistent with a diagnosis of anxiety were reported by 423 (36.6%), 174 (15.1%), and 559 (48.4%) patients, respectively. However, 635 (69%) patients had normal scores and 273 (30.1%) had borderline HADS-D scores; no patients reported scores consistent with depression. Based on a multiple logistic regression analysis, patients educated till a high school diploma (OR = 2.57, 95% CI: 0.09-6.05, P = 0.03) and that had indeterminate colitis (OR = 2.23, 95% CI: 1.27-3.89, P = 0.005) were more likely to express anxiety.

Conclusions

Many patients expressed symptoms of anxiety, although not depression. Female patients, patients educated till a high school diploma, and those with indeterminate colitis were more likely to have anxiety. IBD patients require greater attention during a pandemic to avoid adverse disease-related outcomes.

COVID-19 and Inflammatory Bowel Disease: Patient Knowledge and Perceptions in a Single Center Survey

Background and objectives: Spreading of SARS-CoV-2 infection from China to countries with a higher prevalence of inflammatory bowel disease (IBD) has generated concern among gastroenterologists and patients. The aim of this survey is to evaluate knowledge about clinical importance of COVID-19, disease management, prevention measures, and anxiety level during pandemic among patients with IBD. Material and methods: From 15th March to 15th April 2020, a questionnaire survey was administered to 200 patients with IBD by email or phone application. The questionnaire consisted of five sections: (1) anthropometric, demographic and clinical characteristics, (2) knowledge about clinical importance of COVID-19, (3) IBD management, (4) prevention measures, (5) anxiety level during pandemic. Results: One hundred forty two questionnaires were completed. Ninety-seven patients (68.3%) were males with a mean age of 46 years (SD 13; range 17-76). Fifty-four individuals (38%) were affected by Crohn disease and 88 (62%) by Ulcerative Colitis. Most patients reported high knowledge about clinical importance of COVID-19 (80%), IBD management (72%), and prevention measures (97%). Sixty-two percent of them showed moderate-high level of anxiety. High education level was independently associated with high knowledge about clinical importance of COVID-19 (odds ratio [OR] 5, 95% confidence interval [CI] 1.49-16.6, p = 0.009) and older age (OR 1, 95%, CI 1.01-1.1, p = 0.01), while the receipt of e-format educational material with low knowledge about clinical importance of COVID-19 (OR 3, 95%, CI 1.08-9.3, p = 0.03). Displaying an active disease appeared to be independently associated with low knowledge of IBD management (OR 5.8, 95% CI 1.4-22.8, p = 0.01) and no variables other than an older age was independently associated with higher level of anxiety (OR 1.04, 95% CI 1.009-1.09, p = 0.01). Conclusions: High educational level and aging promote knowledge about clinical importance of COVID-19, while e-format educational material does not. Taken together with findings that an active disease status compromises knowledge of IBD management and the high level of anxiety related to increasing age, these data suggest the need of further supporting patient-oriented strategies in IBD during Covid-19 pandemic.

Immune dysregulation in depression: Evidence from genome-wide association

A strong body of evidence supports a role for immune dysregulation across many psychiatric disorders including depression, the leading cause of global disability. Recent progress in the search for genetic variants associated with depression provides the opportunity to strengthen our current understanding of etiological factors contributing to depression and generate novel hypotheses. Here, we provide an overview of the literature demonstrating a role for immune dysregulation in depression, followed by a detailed discussion of the immune-related genes identified by the most recent genome-wide meta-analysis of depression. These genes represent strong evidence-based targets for future basic and translational research which aims to understand the role of the immune system in depression pathology and identify novel points for therapeutic intervention.

Gastroenterologist-Lead Management of Iron Deficiency Anemia in Inflammatory Bowel Disease Is Effective, Safe, and May Increase Quality of Life

BACKGROUND

The effectiveness and safety of gastroenterologist (GI)-lead treatment of iron deficiency anemia (IDA) in inflammatory bowel disease (IBD) have not been well-studied.

METHODS

A retrospective chart review of patients with IBD, IDA, and evidence of treatment with iron at a tertiary IBD center was conducted.

RESULTS

In 351 patients, hemoglobin and quality of life scores increased significantly after treatment with iron. Twelve of 341 patients treated with intravenous iron had an adverse effect. Twenty-seven patients required a hematology referral.

CONCLUSION

GIs should consider treating patients with IBD and IDA with intravenous iron as it is safe and effective.

Low Rate of Drug Discontinuation, Frequent Need for Dose Adjustment, and No Association with Development of New Arthralgia in Patients Treated with Vedolizumab: Results from a Tertiary Referral IBD Center

BACKGROUND

Evaluating clinical data on the safety and efficacy of vedolizumab (VDZ) in 'real-world' setting is still desirable. Recent reports have raised concerns that arthralgia may be associated with VDZ.

AIMS

The aim of this study is to present clinical experience with VDZ from a tertiary IBD center.

METHODS

Retrospective chart reviews were performed of consecutive patients exposed to VDZ between 2015 and 2018. Clinical, biomarker, and endoscopic efficacy and safety data were evaluated.

RESULTS

A total of 130 IBD (75CD, 55UC) patients were included. Median duration of VDZ therapy was 65 weeks. Probability of drug discontinuation was 4.9% and 9.4% at 1 and 2 years. Dose intensification was more frequent in CD compared to UC (at 1 and 2 years: 64.8/87.9% vs. 26.5/35.7%, p < 0.001). Clinical remission rates at 3-, 6- and 12 months were 44.4%, 71.4% and 77.1% in UC, and 9.1%, 26.7% and 29.2% in CD patients, respectively. Prior use of multiple biologic agents was associated with diminished efficacy of VDZ in CD. Three new cases of arthralgia were encountered during follow-up.

CONCLUSION

Vedolizumab (VDZ) therapy displayed good drug sustainability and clinical efficacy in a population with severe disease phenotype and high rates of previous anti-TNF failure. Frequent dose intensification was required. The safety profile was good, and no association between newly onset arthralgia and VDZ therapy was observed.

Gaining resilience and reducing stress in the age of COVID-19

PURPOSE OF REVIEW

The world is experiencing the evolving situation associated with the outbreak of the Corona Virus Disease-2019 (COVID-19) virus, and there is more of need than ever for stress management and self-care. In this article, we will define the physiological, psychological and social aspects, stages, and components of stress reactions in the context of COVID-19, review the relevant literature on stress reactions, and offer some guidance on how to help patients mitigate the physiological and psychological impact of the pandemic through resilience-building techniques.

RECENT FINDINGS

There is continued evidence that the fight or flight response involves activation throughout the body at physiological, biochemical and immune levels. This response can be mitigated through increasing parasympathetic nervous system activation as well as cognitive and behavioral interventions.

SUMMARY

This article will review the stress, provide a theoretical layout to predict upcoming response, and offer clinicians some practical interventions to employ as the stress of the COVID-19 pandemic continues.

The Role of the Gut Microbiota in Dietary Interventions for Depression and Anxiety

There is emerging evidence that an unhealthy dietary pattern may increase the risk of developing depression or anxiety, whereas a healthy dietary pattern may decrease it. This nascent research suggests that dietary interventions could help prevent, or be an alternative or adjunct therapy for, depression and anxiety. The relation, however, is complex, affected by many confounding variables, and is also likely to be bidirectional, with dietary choices being affected by stress and depression. This complexity is reflected in the data, with sometimes conflicting results among studies. As the research evolves, all characteristics of the relation need to be considered to ensure that we obtain a full understanding, which can potentially be translated into clinical practice. A parallel and fast-growing body of research shows that the gut microbiota is linked with the brain in a bidirectional relation, commonly termed the microbiome-gut-brain axis. Preclinical evidence suggests that this axis plays a key role in the regulation of brain function and behavior. In this review we discuss possible reasons for the conflicting results in diet-mood research, and present examples of areas of the diet-mood relation in which the gut microbiota is likely to be involved, potentially explaining some of the conflicting results from diet and depression studies. We argue that because diet is one of the most significant factors that affects human gut microbiota structure and function, nutritional intervention studies need to consider the gut microbiota as an essential piece of the puzzle.

The Bidirectional Relationship of Depression and Inflammation: Double Trouble

Depression represents the number one cause of disability worldwide and is often fatal. Inflammatory processes have been implicated in the pathophysiology of depression. It is now well established that dysregulation of both the innate and adaptive immune systems occur in depressed patients and hinder favorable prognosis, including antidepressant responses. In this review, we describe how the immune system regulates mood and the potential causes of the dysregulated inflammatory responses in depressed patients. However, the proportion of never-treated major depressive disorder (MDD) patients who exhibit inflammation remains to be clarified, as the heterogeneity in inflammation findings may stem in part from examining MDD patients with varied interventions. Inflammation is likely a critical disease modifier, promoting susceptibility to depression. Controlling inflammation might provide an overall therapeutic benefit, regardless of whether it is secondary to early life trauma, a more acute stress response, microbiome alterations, a genetic diathesis, or a combination of these and other factors.

Liver hydrolysate prevents depressive-like behavior in an animal model of colitis: Involvement of hippocampal neurogenesis via the AMPK/BDNF pathway

Patients with inflammatory bowel disease (IBD) have higher rates of psychiatric pathology, including anxiety and depression. The dextran sulfate sodium (DSS)-treated mouse is a well-characterized animal model of colitis that exhibits IBD-like and depressive-like changes. A recent study found that phosphorylated (p-) adenosine monophosphate-activated protein kinase (AMPK) was associated with anti-inflammatory and antidepressant effects. Our previous research in an animal model of major depression suggests that liver hydrolysate (LH) has an antidepressant effect and combats physical fatigue by enhancement via the hippocampal or peripheral p-AMPK pathway. In this study, we examined whether or not LH has antidepressant and anti-inflammatory effects in mice with DSS-induced changes. We evaluated colon inflammation in DSS-treated mice and used the tail suspension and forced swimming tests to confirm whether or not LH prevents IBD-like symptoms and depressive-like behavior. Hippocampal expression of AMPK, brain-derived neurotrophic factor (BDNF), doublecortin, and neuronal nuclear antigen proteins was assessed by Western blotting. Hippocampal neurogenesis and morphometric changes in the microglia and astrocytes were examined by immunohistochemistry. DSS-treated mice showed IBD-like pathology and depressive-like behavior, a reduction in the hippocampal neuronal nuclear antigen level and neurogenesis, and increased hippocampal activation of microglia and astrocytes. These changes were reversed by LH. DSS-treated mice showed enhanced hippocampal expression of p-AMPK and BDNF after administration of LH. LH prevented depressive-like behavior by enhancing hippocampal neurogenesis through the AMPK/BDNF pathway and anti-neuroinflammation in the hippocampus. LH may be a therapeutic option for patients with IBD and depression.

Surgery, stomas, and anxiety and depression in inflammatory bowel disease: a retrospective cohort analysis of privately insured patients

AIM

Patients with inflammatory bowel disease (IBD) are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and the temporal association with abdominal surgery and stoma formation.

METHOD

We conducted a retrospective cohort study in adult patients with IBD using difference-in-difference methodology and a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.

RESULTS

We identified 10 481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41 924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (P < 0.001). Surgical patients had higher odds of anxiety [one surgery, adjusted OR 6.90 (95% CI 6.11-7.79), P < 0.001; two or more surgeries, 7.53 (5.99-9.46), P < 0.001] and depression [one surgery, 6.15 (5.57-6.80), P < 0.001; two or more surgeries, 6.88 (5.66-8.36), P < 0.001] than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from 'pre' to 'post' time periods [1.43 (1.18-1.73), P < 0.001]. Amongst surgical patients, stoma formation was independently associated with anxiety [1.40 (1.17-1.68), P < 0.001] and depression [1.23 (1.05-1.45), P = 0.01]. New ostomates experienced a greater increase in postoperative anxiety [1.24 (1.05-1.47), P = 0.01] and depression [1.19 (1.03-1.45), P = 0.01] than other surgical patients.

CONCLUSION

IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.

Depression, comorbidities and the TNF-α system

Depression has frequently been reported to be associated with other physical diseases and changes in the cytokine system. We aimed to investigate associations between a medical history of depression, its comorbidities and cytokine plasma levels in the Bavarian Nutrition Survey II (BVS II) study sample and in patients suffering from an acute depressive episode.

The BVS II is a representative study of the Bavarian population aged 13–80 years. The disease history of its 1050 participants was assessed through face-to-face interviews. A sub-sample of 568 subjects and 62 additional acutely depressed inpatients of the Max Planck Institute of Psychiatry participated in anthropometric measurements and blood sampling. Tumor necrosis factor-α (TNF-α) and soluble TNF receptor (sTNF-R) p55 and sTNF-R p75 plasma levels were measured using enzyme-linked immunosorbent assays.

A history of depression was associated with a higher incidence of high blood pressure, peptic ulcer, dyslipoproteinemia, osteoporosis, allergic skin rash, atopic eczema and thyroid disease.

Within the BVS II sample, participants with a history of depression differed from subjects who had never had depression with regard to sTNF-R p55 and sTNF-R p75 levels even when controlling for age, BMI and smoking status. Acutely depressed inpatients showed even higher levels of sTNF-R p55 and sTNF-R p75 than subjects in the normal population. TNF-α levels were also significantly elevated in acutely depressed patients.

These results confirm earlier studies regarding the comorbidities of depression and support the hypothesis that activation of the TNF-α system may contribute to the development of a depressive disorder.

Differential relationships of somatization, depression, and anxiety to severity of Crohn’s disease

Patients with Crohn’s disease, an inflammatory bowel disease, struggle with chronic somatic symptoms that could bring about emotional distress. This study assessed the relative role of somatization, and depressive and anxiety symptoms in disease activity among 619 Crohn’s patients (18–79 years; 58.3% women). Structural equation modeling revealed that somatization was the only unique predictor of disease activity beyond depression and anxiety. In addition, the effect of somatization on disease activity was stronger in men compared to women. Findings suggest that somatization represents a distinct domain of psychological distress that may play a role in the health of patients with Crohn’s disease.

Microbiota-gut-brain axis and its affect inflammatory bowel disease: Pathophysiological concepts and insights for clinicians

Despite the bi-directional interaction between gut microbiota and the brain not being fully understood, there is increasing evidence arising from animal and human studies that show how this intricate relationship may facilitate inflammatory bowel disease (IBD) pathogenesis, with consequent important implications on the possibility to improve the clinical outcomes of the diseases themselves, by acting on the different components of this system, mainly by modifying the microbiota. With the emergence of precision medicine, strategies in which patients with IBD might be categorized other than for standard gut symptom complexes could offer the opportunity to tailor therapies to individual patients. The aim of this narrative review is to elaborate on the concept of the gut-brain-microbiota axis and its clinical significance regarding IBD on the basis of recent scientific literature, and finally to focus on pharmacological therapies that could allow us to favorably modify the function of this complex system.

Predicting the development of psychological morbidity in inflammatory bowel disease: a systematic review

BACKGROUND

Psychological morbidity in inflammatory bowel disease is common with significant impact on quality of life and health outcomes, but factors which predict the development of psychological morbidity are unclear.

AIM

To undertake a systematic literature review of the predictors of psychological morbidity in patients with inflammatory bowel disease.

METHODS

Electronic searches for English-language articles were performed with keywords relating to psychological morbidity according to the Diagnostic and Statistical Manual of Mental Disorders IV and subsequent criteria, and inflammatory bowel disease; in MEDLINE, PsychInfo, Web of Science and EMBASE for studies published from January 1997 to 25 January 2019.

RESULTS

Of 660 studies identified, seven met the inclusion criteria. All measured depression, with three also measuring anxiety. Follow-up duration was variable (median of 18 months range 6-96 months). Risk factors identified for development of psychological morbidity included physical factors: aggressive disease (HR 5.77, 95% CI 1.89 to 17.7) and greater comorbidity burden (OR 4.31, 95% CI 2.83 to 6.57) and psychological risk factors: degree of gratitude (r=-0.43, p<0.01) and parenting stress (R-change=0.03, F(1,58)=35.6, p<0.05). Age-specific risk was identified with young people (13-17 years) at increased risk.

CONCLUSIONS

Identifiable risks for the development of psychological morbidity in inflammatory bowel disease include physical and psychological factors. Further research is required from large prospective studies to enable early interventions in those at risk and reduce the impact of psychological morbidity.

Classical Human Leukocyte Antigen Alleles and C4 Haplotypes Are Not Significantly Associated With Depression

BACKGROUND

The prevalence of depression is higher in individuals with autoimmune diseases, but the mechanisms underlying the observed comorbidities are unknown. Shared genetic etiology is a plausible explanation for the overlap, and in this study we tested whether genetic variation in the major histocompatibility complex (MHC), which is associated with risk for autoimmune diseases, is also associated with risk for depression.

METHODS

We fine-mapped the classical MHC (chr6: 29.6-33.1 Mb), imputing 216 human leukocyte antigen (HLA) alleles and 4 complement component 4 (C4) haplotypes in studies from the Psychiatric Genomics Consortium Major Depressive Disorder Working Group and the UK Biobank. The total sample size was 45,149 depression cases and 86,698 controls. We tested for association between depression status and imputed MHC variants, applying both a region-wide significance threshold (3.9 × 10-6) and a candidate threshold (1.6 × 10-4).

RESULTS

No HLA alleles or C4 haplotypes were associated with depression at the region-wide threshold. HLA-B*08:01 was associated with modest protection for depression at the candidate threshold for testing in HLA genes in the meta-analysis (odds ratio = 0.98, 95% confidence interval = 0.97-0.99).

CONCLUSIONS

We found no evidence that an increased risk for depression was conferred by HLA alleles, which play a major role in the genetic susceptibility to autoimmune diseases, or C4 haplotypes, which are strongly associated with schizophrenia. These results suggest that any HLA or C4 variants associated with depression either are rare or have very modest effect sizes.

Shame and emotion regulation in inflammatory bowel disease: Effects on psychosocial functioning

Although patients with inflammatory bowel disease seem to be prone to high levels of shame, the mechanisms behind the impact of chronic illness–related shame on patients’ functioning have not been explored yet. This study aims to address these gaps using a sample of 161 patients with inflammatory bowel disease who completed self-report measures on an online survey. The results from path analyses showed that chronic illness–related shame presented direct and indirect effects on psychological health ( R2 = .66) and social relationships ( R2 = .46). The indirect effects were mediated by experiential avoidance and uncommitted living. Possible explanations to these findings and clinical implications are discussed.

Perception of quality of life in people experiencing or having experienced a Clostridioides difficile infection: a US population survey

BACKGROUND

Although the incidence, severity and mortality of Clostridioides (Clostridium) difficile infection (CDI) have been increasing, patients' quality of life changes resulting from CDI have not been studied thoroughly. This study aimed at exploring the consequences of CDI on quality of life through patients' perspective.

METHODS

An observational, cross-sectional study involving 350 participants with a self-reported CDI diagnosis was conducted through an online self-administered survey. Participants were grouped into those who had active disease ("Current CDI") and those who had a history of CDI ("Past CDI").

RESULTS

One hundred fifteen participants (33%) reported Current CDI and 235 (67%) reported Past CDI. A large majority of participants admitted that their daily activities were impacted by the infection (93.9% and 64.7% of Current and Past CDI respondents respectively, p < 0.05). Physical and psychological consequences of CDI were experienced by 63.5% and 66.1% of participants with active CDI. Despite the infection being cleared, these consequences were still frequently experienced in Past CDI cohort with similar rates (reported by 73.2% of respondents for both, physical consequences p = 0.08; psychological consequences p = 0.21). After the infection, 56.6% of respondents noted that post-CDI symptoms remained; 40.9% believed they would never get rid of them.

CONCLUSIONS

While the societal burden of CDI is well described in the literature, our study is one of the first aimed at understanding the major burden of CDI on quality of life. Our results highlight the long-lasting nature of CDI and further reinforce the need for enhanced therapeutics in the prevention and treatment of this devastating infection.

Mechanisms of Psychiatric Comorbidities in Epilepsy

Psychiatric illnesses, including depression and anxiety, are highly comorbid with epilepsy (for review see Josephson and Jetté (Int Rev Psychiatry 29:409-424, 2017), Salpekar and Mula (Epilepsy Behav 98:293-297, 2019)). Psychiatric comorbidities negatively impact the quality of life of patients (Johnson et al., Epilepsia 45:544-550, 2004; Cramer et al., Epilepsy Behav 4:515-521, 2003) and present a significant challenge to treating patients with epilepsy (Hitiris et al., Epilepsy Res 75:192-196, 2007; Petrovski et al., Neurology 75:1015-1021, 2010; Fazel et al., Lancet 382:1646-1654, 2013) (for review see Kanner (Seizure 49:79-82, 2017)). It has long been acknowledged that there is an association between psychiatric illnesses and epilepsy. Hippocrates, in the fourth-fifth century B.C., considered epilepsy and melancholia to be closely related in which he writes that "melancholics ordinarily become epileptics, and epileptics, melancholics" (Lewis, J Ment Sci 80:1-42, 1934). The Babylonians also recognized the frequency of psychosis in patients with epilepsy (Reynolds and Kinnier Wilson, Epilepsia 49:1488-1490, 2008). Despite the fact that the relationship between psychiatric comorbidities and epilepsy has been recognized for thousands of years, psychiatric illnesses in people with epilepsy still commonly go undiagnosed and untreated (Hermann et al., Epilepsia 41(Suppl 2):S31-S41, 2000) and systematic research in this area is still lacking (Devinsky, Epilepsy Behav 4(Suppl 4):S2-S10, 2003). Thus, although it is clear that these are not new issues, there is a need for improvements in the screening and management of patients with psychiatric comorbidities in epilepsy (Lopez et al., Epilepsy Behav 98:302-305, 2019) and progress is needed to understand the underlying neurobiology contributing to these comorbid conditions. To that end, this chapter will raise awareness regarding the scope of the problem as it relates to comorbid psychiatric illnesses and epilepsy and review our current understanding of the potential mechanisms contributing to these comorbidities, focusing on both basic science and clinical research findings.

Effects of EGCG on depression-related behavior and serotonin concentration in a rat model of chronic unpredictable mild stress

The aim of this study is to examine the antidepressant-like effect of EGCG and get deeper insights into implications of modulating serotonin (5-HT) in the colon and brain.

Potential application of helminth therapy for resolution of neuroinflammation in neuropsychiatric disorders

Neuropsychiatric disorders (NPDs) are among the major debilitating disorders worldwide with multiple etiological factors. However, in recent years, psychoneuroimmunology uncovered the role of inflammatory condition and autoimmune disorders in the etiopathogenesis of different NPDs. Hence, resolution of inflammation is a new therapeutic target of NPDs. On the other hand, Helminth infections are among the most prevalent infectious diseases in underdeveloped countries, which usually caused chronic infections with minor clinical symptoms. Remarkably, helminths are among the master regulator of inflammatory reactions and epidemiological studies have shown an inverse association between prevalence of autoimmune disorders with these infections. As such, changes of intestinal microbiota are known to be associated with inflammatory conditions in various NPDs. Conversely, helminth colonization alters the intestinal microbiota composition that leads to suppression of intestinal inflammation. In animal models and human studies, helminths or their antigens have shown to be protected against severe autoimmune and allergic disorders, decline the intensity of inflammatory reactions and improved clinical symptoms of the patients. Therefore, "helminthic therapy" have been used for modulation of immune disturbances in different autoimmunity illnesses, such as Multiple Sclerosis (MS) and Inflammatory Bowel Disease (IBD). Here, it is proposed that "helminthic therapy" is able to ameliorate neuroinflammation of NPDs through immunomodulation of inflammatory reactions and alteration of microbiota composition. This review discusses the potential application of "helminthic therapy" for resolution of neuroinflammation in NPDs.

Tumor Necrosis Factor-α Variations in Patients With Major Depressive Disorder Before and After Antidepressant Treatment

Tumor necrosis factor-α (TNF-α) had been identified as a key pro-inflammatory cytokine in the pathophysiology of major depressive disorder (MDD) and the mechanism of antidepressant treatment. The primary aim of the present study was to examine the serum TNF-α levels in Chinese inpatients with MDD during the acute phase and to explore the changes in TNF-α levels after effective clinical treatment. Fifty-seven consecutive inpatients with MDD and 30 healthy controls were recruited. The serum TNF-α levels were detected using ELISA. Symptoms of depression were evaluated using the 24-item Hamilton Rating Scale for Depression (HAM-D-24). TNF-α levels and HAM-D-24 scores were assessed at baseline and after 2 and 12 weeks of follow-up. The serum TNF-α levels were higher in the MDD group than in the control group. After 2 and 12 weeks of antidepressant treatment, there were significant improvements in the patients' symptoms and significant decreases in the TNF-α levels. The baseline TNF-α levels significantly correlated with the decreased HAM-D-24 scores, particularly for the depressive symptoms of anxiety/somatization and weight loss. The present findings indicate that depression is accompanied by activation of TNF-α, which also has a predictive value for the antidepressant treatment response in patients with MDD.

Comment on: Incidence of Adverse Psychiatric Events During the Treatment of Inflammatory Bowel Disease With Biologic Therapies: A Systematic Review

In this article, we comment on work by Jain and colleagues. They found that there are very few instances of increased anxiety and depression in drug trials for IBD. We believe these rates are likely higher and discuss supporting literature.

PDTC Alleviates Depressive Symptoms and Colon Tissue Injury via Inhibiting NO Overproduction in CUMS Rats

Background

The accumulated evidence demonstrates that stress plays an important role in the pathogenesis of depression that is associated with intestinal dysfunctions. However, the mechanisms remain unresolved.

Methods

A total of 40 male Wistar rats were obtained and randomly divided into four equal-sized group: control, PDTC + chronic and unpredictable mild stress (CUMS), FLX + CUMS, and CUMS. Western blotting and qRT-PCR were used to examine the levels of nitric oxide (NO), nuclear factor kappa beta (NF-κB), inducible nitric oxide synthase (iNOS), and iNOS mRNA in spinal cord L1-2 and colon.

Key Results

Chronic and unpredictable mild stress increased the serum CORT level, decreased body weight and sucrose preference, and altered OFT performance, while increased levels of NO, iNOS mRNA, iNOS and NF-κB protein in colon and spinal cord were accompanied by histopathological changes in colon. Pretreatment with an NF-κB inhibitor, pyrrolidine dithiocarbamate (PDTC), reversed these effects. Fluoxetine failed to prevent NO increase in both spinal cord and colon, while the iNOS protein level, although not statistically significantly increased compared to control, was not decreased compared to CUMS. Also, fluoxetine failed to prevent histological changes.

Conclusion

In conclusion, the NF-κB/iNOS pathway may be involved in the mechanism of CUMS-induced depressive-like behavior and colon tissue injury.

Effect of Enterococcus faecalis 2001 on colitis and depressive-like behavior in dextran sulfate sodium-treated mice: involvement of the brain-gut axis

BACKGROUND

Patients with inflammatory bowel disease (IBD), including those with ulcerative colitis and Crohn's disease, have higher rates of psychiatric disorders, such as depression and anxiety; however, the mechanism of psychiatric disorder development remains unclear. Mice with IBD induced by dextran sulfate sodium (DSS) in drinking water exhibit depressive-like behavior. The presence of Lactobacillus in the gut microbiota is associated with major depressive disorder. Therefore, we examined whether Enterococcus faecalis 2001 (EF-2001), a biogenic lactic acid bacterium, prevents DSS-induced depressive-like behavior and changes in peripheral symptoms.

METHODS

We evaluated colon inflammation and used the tail suspension test to examine whether EF-2001 prevents IBD-like symptoms and depressive-like behavior in DSS-treated mice. The protein expression of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), X-linked inhibitor of apoptosis protein (XIAP), and cleaved caspase-3 in the rectum and hippocampus was assessed by western blotting. Hippocampal neurogenesis, altered nuclear factor-kappa B (NFκB) p65 morphometry, and the localization of activated NFκB p65 and XIAP were examined by immunohistochemistry.

RESULTS

Treatment with 1.5% DSS for 7 days induced IBD-like pathology and depressive-like behavior, increased TNF-α and IL-6 expression in the rectum and hippocampus, activated caspase-3 in the hippocampus, and decreased hippocampal neurogenesis. Interestingly, these changes were reversed by 20-day administration of EF-2001. Further, EF-2001 administration enhanced NFκB p65 expression in the microglial cells and XIAP expression in the hippocampus of DSS-treated mice.

CONCLUSION

EF-2001 prevented IBD-like pathology and depressive-like behavior via decreased rectal and hippocampal inflammatory cytokines and facilitated the NFκB p65/XIAP pathway in the hippocampus. Our findings suggest a close relationship between IBD and depression.

The influence of self-criticism on depression symptoms among ambulatory patients with inflammatory bowel disease

Considering that self-criticism is an important process in the development and maintenance of depression, and taking into account the stigma associated with inflammatory bowel disease (IBD), the present study aimed to analyse whether self-criticism exacerbates the relationships of depression symptoms with IBD symptomatology and chronic illness-related shame. The sample included 53 ambulatory IBD patients (66% females) with ages from 18 to 65. Moderation analyses were conducted using structural equation modelling. Self-criticism exacerbated the associations of depression with IBD symptoms (b = 0.01; standard error [SE] = 0.00; Z = 3.73; P < .001) and illness shame (b = 0.02; SE = 0.01; Z = 2.40; P = .016). For the same level of IBD symptomatology or chronic illness-related shame, those individuals who present more feelings of inadequacy towards the self, experience more symptoms of depression. This exacerbation effect is stronger when IBD symptomatology and chronic illness-related shame are more intense. A high self-critical IBD patient may view the illness and/or symptomatology as a flaw or error that should be self-corrected. Physicians and other health professionals should be attentive to these pathological mechanisms and should attempt to alleviate them. It may be beneficial to refer high self-critical patients to psychological care.

Chronic Unpredictable Mild Stress in Rats Induces Colonic Inflammation

Chronic psychological stress is associated with an increased risk for relapse of inflammatory bowel diseases (IBD) and impedes the treatment of this condition. However, the impact of stress on the risk of IBD onset remains unclear. The goal of the present study was to examine whether chronic unpredictable mild stress (CUMS) could initiate or aggravate the onset of colon inflammation in rats which, in turn, would be capable of triggering bowel disease. We found that CUMS exposure increased infiltration of CD-45 positive cells and MPO activity, as well as augmented the expression of the inflammatory cytokines, IFN-γ and IL-6 within the colon of these rats. In addition, CUMS treatment changed the composition and diversity of gut microbiota and enhanced intestinal epithelial permeability, indicating the presence of a defect in the intestinal barrier. This CUMS-induced disruption of mucosal barrier integrity was associated with a reduction in expression of the tight junction protein, occludin 1, and an inhibition in mucosal layer functioning via reductions in goblet cells. Results from bacterial cultures revealed an increased presence of bacterial invasion after CUMS treatment as compared with that observed in controls. Thus, our data indicate that CUMS treatment induces alterations of the fecal microbiome and intestinal barrier defects, which facilitates bacterial invasion into colonic mucosa and further exacerbates inflammatory reactions within the colon. Accordingly, chronic stress may predispose patients to gastrointestinal infection and increase the risk of inflammation-related gut diseases.

Sleep quality and associated factors in Iranian inflammatory bowel disease patients

Background:

Sleep is essential in maintaining health and quality of life. Inflammatory bowel disease (IBD) patients suffer from poor sleep quality. This study aimed to investigate the prevalence of sleep disturbances in Iranian IBD patients as well as the variables which can be attributed to the quality of sleep in IBD patients.

Materials and Methods:

Seventy-one patients filled in Pittsburg Sleep Quality Index (PSQI) questionnaire and a sociodemographic questionnaire. Disease activity was assessed by Crohn's Disease (CD) Activity Index and Ulcerative Colitis (UC) Activity Index. Regression analysis was used to identify the association between sociodemographic and disease characteristics with sleep quality.

Results:

We found that 32.4% of all patients, 23.1% of patients with “in remission to mild” disease, and 66.7% of patients with “moderate” disease, had poor sleep quality. CD patients were more likely to have poor sleep quality comparing UC ones in crude (odds ratio [OR] =2.14; 95% confidence interval [CI] 1.14–4.04) and adjusted (OR = 6.19; 95% CI 1.13, 34.07) models. Patients with good quality of sleep had lower systolic blood pressure and diastolic blood pressure (P = 0.09 and 0.035 respectively).

Conclusion:

Notable percentage of IBD patients suffer from poor sleep quality even in the remission phase. Treatment of sleep disturbances, especially in CD patients, is recommended in the IBD patient-care program.

[Disorders of the anxiety-depressive spectrum in inflammatory bowel diseases (psychosomatic correlations)]

AIM

To systemize anxiety-depressive disorders in patients with inflammatory bowel diseases (IBD) and to reveal clinically relevant psychosomatic correlations.

MATERIAL AND METHODS

Fifty inpatients with IBD, including 32 with ulcerative colitis and 19 with Crohn's disease, were examined using clinical and follow-up methods.

RESULTS AND CONCLUSION

Affective mental disorders (depressions of various structures of different genesis) were found in most (72%) of cases. Adaptation disorders in patients with personality pathology, depression in cyclothymia, bipolar disorder and schizophrenia were identified as well. Psychosomatic correlations depended on the stage of IBD and the genesis of affective disorders. Somatogenic asthenic disorders prevailed at the stage of IBD manifestation and depressions of different structure with different course (recurrent, bipolar, attack-like) at the further stages of IBD. The psychosomatic relations at the subsequent stages of IBD were characterized by psychosomatic balancing. There were tendencies of convergence and divergence of mental disorders with the current somatic disease. The most severe variants (chronic continuous course, resistance to therapy) were found in patients with comorbid endogenous mental disorders. This was primarily due to the lack of a rational attitude of patients to the somatic disease and, therefore, the low compliance that must be taken into account in the treatment.

Rising incidence of psychiatric disorders before diagnosis of immune-mediated inflammatory disease

AIMS

After the diagnosis of immune-mediated inflammatory diseases (IMID) such as inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA), the incidence of psychiatric comorbidity is increased relative to the general population. We aimed to determine whether the incidence of psychiatric disorders is increased in the 5 years before the diagnosis of IMID as compared with the general population.

METHODS

Using population-based administrative health data from the Canadian province of Manitoba, we identified all persons with incident IBD, MS and RA between 1989 and 2012, and cohorts from the general population matched 5 : 1 on year of birth, sex and region to each disease cohort. We identified members of these groups with at least 5 years of residency before and after the IMID diagnosis date. We applied validated algorithms for depression, anxiety disorders, bipolar disorder, schizophrenia, and any psychiatric disorder to determine the annual incidence of these conditions in the 5-year periods before and after the diagnosis year.

RESULTS

We identified 12 141 incident cases of IMID (3766 IBD, 2190 MS, 6350 RA) and 65 424 matched individuals. As early as 5 years before diagnosis, the incidence of depression [incidence rate ratio (IRR) 1.54; 95% CI 1.30-1.84) and anxiety disorders (IRR 1.30; 95% CI 1.12-1.51) were elevated in the IMID cohort as compared with the matched cohort. Similar results were obtained for each of the IBD, MS and RA cohorts. The incidence of bipolar disorder was elevated beginning 3 years before IMID diagnosis (IRR 1.63; 95% CI 1.10-2.40).

CONCLUSION

The incidence of psychiatric comorbidity is elevated in the IMID population as compared with a matched population as early as 5 years before diagnosis. Future studies should elucidate whether this reflects shared risk factors for psychiatric disorders and IMID, a shared final common inflammatory pathway or other aetiology.

Risk of Anxiety and Depression in Patients with Inflammatory Bowel Disease: A Nationwide, Population-Based Study

Background and Aims: Inflammatory bowel disease (IBD) may be associated with anxiety and depression. The aim of this study was to evaluate the incidence of anxiety and depression in patients with IBD compared to the general population. Methods: A nationwide population-based cohort study was conducted using claims data from the National Healthcare Insurance service in Korea. We compared the incidence of anxiety and depression between 15,569 IBD patients and 46,707 non-IBD controls, age and sex matched at a ratio of 1:3. Results: During a mean follow-up of six years, IBD patients experienced significantly more anxiety (12.2% vs. 8.7%; p < 0.001) and depression (8.0% vs. 4.7%; p < 0.001) compared to controls. The curves showing cumulative incidences of anxiety and depression showed a steep rise within one year following a diagnosis of IBD, leading to lines with a constant slope. The hazard ratio (HR) for new onset anxiety following a diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) was 1.63 and 1.60, respectively, compared to controls (p < 0.001). Compared to controls, the HR for developing depression after a diagnosis of CD and UC was 2.09 and 2.00, respectively (p < 0.001). The risks of anxiety and depression in patients with IBD were higher compared to controls, except in those with diabetes mellitus, hypertension, and dyslipidemia, or who required immunomodulators and biologics within one year of the IBD diagnosis. Conclusions: The risk of anxiety and depression increased after a diagnosis of IBD compared to the general population.

Attending to the Alliance in the Application of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: A Case Study

As conceptualizations of mood and anxiety disorders shift toward a dimensional approach, transdiagnostic treatments have gained recognition and support. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) is an evidence-based cognitive behavioral therapy that targets the core processes that underlie common and comorbid mental disorders. It is designed to help clients learn how to confront, experience, and respond to their emotions in adaptive ways through the modification of their emotion regulation strategies. The current case study describes the flexible application of the UP with a treatment-naïve 25-year-old female who presented to outpatient therapy with symptoms of anxiety and depression. Additions to the UP were made to address issues related to the therapeutic alliance and information discovered over the course of treatment. Outcome measures administered to the client reflect significant symptom improvement and add to a growing body of literature that supports the usefulness of transdiagnostic approaches to treating a range of disorders. Moreover, quantitative and qualitative data point to the necessity for clinicians to attend to the therapeutic alliance and consider cultural factors when delivering manualized treatment approaches to individuals from diverse backgrounds.

Harmonization of quality of care in an IBD center impacts disease outcomes: Importance of structure, process indicators and rapid access clinic

BACKGROUND AND AIMS

We aimed to evaluate the quality of care at a tertiary inflammatory bowel disease (IBD) center using quality of care indicators (QIs) including patient assessment strategy, monitoring, treatment decisions and outcomes.

METHODS

We retrospectively reviewed the quality of care pre- and post-referral and during follow-up at the at the McGill University Health Center (MUHC) IBD center. Consecutive patients were included presenting with an outpatient visit ('index visit') between July and December 2016. Disease characteristics, biochemistry, imaging and endoscopy data, changes in medications, and vaccination profiles were captured.

RESULTS

1357 patients were included. At referral, a large proportion of patients were objectively re-evaluated (ileocolonoscopy: 79%, cross-sectional imaging: 39.3%, biomarkers: 89.9%, 81.9%). Therapeutic strategy was changed in 53.6% with 22.5% of patients starting biologics. Tight objective patient monitoring was applied during follow-up (colonoscopy: 79%, cross-sectional imaging: 61.8% were available at index visit; C-reactive protein: 78%, Faecal calprotectin: 37.6%, therapeutic drug monitoring: 16.3% were performed additionally). Maximum therapeutic step was biologicals in 48.8% of the patients, while only 6.6% of all patients were steroid dependent. Implementation of a rapid access clinic improved healthcare delivery.

CONCLUSIONS

Our data support that tight monitoring was applied at the MUHC IBD center with a high emphasis on objective patient (re)evaluation, timely access and accelerated treatment strategy at referral and during follow-up.

Electroacupuncture and Moxibustion Improved Anxiety Behavior in DSS-Induced Colitis Mice

Background and Aims

Psychological disorders are prevalent in patients with inflammatory bowel disease, but the underlying mechanisms remain unknown. The aim of this study was to study whether electroacupuncture (EA) and moxibustion (MB) can improve anxiety behavior in DSS-induced colitis mice and to investigate whether this effect is related to hypothalamic-pituitary-adrenocortical (HPA) axis.

Methods

The colitis model was established by drinking 2.5% dextran sodium sulfate (DSS). DSS-induced colitis mice were treated by EA or MB. Disease activity index (DAI) was scored; intestinal morphological and pathological structure was observed; anxiety behavior was tested by the elevated plus maze and open field. The concentration of corticotropin-releasing hormone (CRH) and cortisol (CORT) in serum was measured by enzyme-linked immunosorbent assay (ELISA). The protein expression of CRH in the colon and hypothalamus was detected by Western blot (WB).

Results

Both EA and MB treatments can improvethe morphology of their distal colonic mucosal epithelia, as well as the disease activity index. Meanwhile, anxiety behavior in colitis mice was improved slightly after EA and MB treatment. In addition, the levels of CRH and CORT in the serum were slightly improved after EA and MB treatment. These effects are further supported by WB results. The expression of CRH in the colon and hypothalamus was increased significantly after treatment, compared with the model group.

Conclusion

EA and MB were able to regulate the concentration of CRH in serum and protein expression in the peripheral and central at different levels and promote the recovery of the HPA axis that may be the basis for EA and MB to improve colonic pathology and alleviate anxiety behavior in DSS-induced colitis.

Long-term course of inflammatory bowel disease after the Great East Japan Earthquake

BACKGROUND AND AIM

This study analyzed inflammatory bowel disease activity for 2 years after the Great East Japan Earthquake.

METHODS

We compared the relapse rates of patients with ulcerative colitis or Crohn's disease 1 and 2 years after the earthquake with rates immediately after the earthquake. To evaluate continuous disease courses, we also performed multivariate time-to-event analyses from the time of the earthquake to the onset of additional treatments.

RESULTS

Of 903 patients with ulcerative colitis or Crohn's disease in our previous study, we could evaluate 2-year courses in 677 patients (394 ulcerative colitis and 283 Crohn's disease). Compared with the relapse rates of ulcerative colitis and Crohn's disease immediately after the earthquake (15.8% and 7.0%, respectively), those in the corresponding periods in 2012 (2.5% and 1.1%, respectively) and 2013 (2.3% and 2.5%, respectively) significantly decreased. There were 226 patients who required additional treatments after the earthquake. Multivariate time-to-event analyses revealed that only patients who had experienced the death of family members or friends were likely to need additional treatments (hazard ratio = 1.77, 95% confidence interval = 1.25-2.47). No other factors had a significant influence.

CONCLUSIONS

The relapse rates 1 and 2 years after the earthquake significantly decreased. The factors that influenced long-term relapse were different from those that influenced short-term relapse.

Influences and Impact of Anxiety and Depression in the Setting of Inflammatory Bowel Disease

BACKGROUND

Individuals with inflammatory bowel disease (IBD) are at increased risk of developing anxiety or depression (A&D). Crohn's disease (CD) and ulcerative colitis (UC) with comorbid A&D are both more challenging to manage. IBD providers need to better understand the causes and impact of A&D in order to improve care for IBD patients. We sought to identify clinical factors that influence development of A&D and healthcare utilization in IBD.

METHODS

This is a retrospective analysis using an IBD natural history registry from a single tertiary care referral center. Presence of A&D was determined based upon responses to the Hospital Anxiety and Depression Scale. Demographic and clinical factors were abstracted to evaluate for significant associations.

RESULTS

Four hundred thirty-two IBD patients (132 UC, 256 CD, and 44 indeterminate colitis) were included in this study. One hundred ninety-two (44.4%) had anxiety or depression or both, and most were female (59.4%, P < 0.05). History of surgery (P < 0.05), female gender (P < 0.05), smoking (P < 0.05), and extra-intestinal manifestations (P < 0.01) were each independently predictive of A&D. Inflammatory bowel disease patients with A&D more often underwent imaging studies (53.6% vs 36.7%, P < 0.05), visited the ED (30.7% vs 20.8%, P < 0.05), or were hospitalized (31.7% vs 21.7%, P < 0.05). They were also more frequently prescribed corticosteroids (50.5% vs 36.7%, P < 0.01) and biologic medications (62.5% vs 51.3%, P < 0.05). Finally, they were more likely to have had at least 1 "no-show" (29.2% vs 16.7%, P < 0.01) and had a higher mean number of "no-shows" (0.69 +/- 0.1 vs 0.30 +/- 0.1, P < 0.01) over the study period.

DISCUSSION

Anxiety and depression are common in the setting of IBD and are strongly associated with surgical history, disease complications (including extra-intestinal manifestations), smoking, and female gender. Inflammatory bowel disease patients with A&D are also more likely to require therapy and to utilize healthcare resources. This study refines our understanding of A&D development and its impact in IBD and provides additional considerations for management in this setting.

Gut-brain actions underlying comorbid anxiety and depression associated with inflammatory bowel disease

IntroductionInflammatory bowel disease (IBD) is a chronic relapsing and remitting disorder characterised by inflammation of the gastrointestinal tract. There is a growing consensus that IBD is associated with anxiety- and depression-related symptoms. Psychological symptoms appear to be more prevalent during active disease states with no difference in prevalence between Crohn's disease and ulcerative colitis. Behavioural disturbances including anxiety- and depression-like symptoms have also been observed in animal models of IBD.

RESULTS

The likely mechanisms underlying the association are discussed with particular reference to communication between the gut and brain. The close bidirectional relationship known as the gut-brain axis includes neural, hormonal and immune communication links. Evidence is provided for a number of interacting factors including activation of the inflammatory response system in the brain, the hypothalamic-pituitary-adrenal axis, and brain areas implicated in altered behaviours, changes in blood brain barrier integrity, and an emerging role for gut microbiota and response to probiotics in IBD.DiscussionThe impact of psychological stress in models of IBD remains somewhat conflicted, however, it is weighted in favour of stress or early stressful life events as risk factors in the development of IBD, stress-induced exacerbation of inflammation and relapse.

CONCLUSION

It is recommended that patients with IBD be screened for psychological disturbance and treated accordingly as intervention can improve quality of life and may reduce relapse rates.

Cortical Inflammation is Increased in a DSS-Induced Colitis Mouse Model

While inflammatory bowel disease (IBD) might be a risk factor in the development of brain dysfunctions, the underlying mechanisms are largely unknown. Here, mice were treated with 5% dextran sodium sulfate (DSS) in drinking water and sacrificed on day 7. The serum level of IL-6 increased, accompanied by elevation of the IL-6 and TNF-α levels in cortical tissue. However, the endotoxin concentration in plasma and brain of mice with DSS-induced colitis showed a rising trend, but with no significant difference. We also found significant activation of microglial cells and reduction in occludin and claudin-5 expression in the brain tissue after DSS-induced colitis. These results suggested that DSS-induced colitis increases systemic inflammation which then results in cortical inflammation via up-regulation of serum cytokines. Here, we provide new information on the impact of colitis on the outcomes of cortical inflammation.

Comparison of comorbid depression between irritable bowel syndrome and inflammatory bowel disease: A meta-analysis of comparative studies

BACKGROUND

The prevalence of comorbid depression is high in chronic gastrointestinal disorders, including irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). For these two disorders in particular, the findings have not been consistent. This meta-analysis systematically compares the rates and severity of comorbid depression between IBS and IBD patients.

METHODS

A systematic literature search was conducted using PubMed, PsycINFO, Embase, Cochrane Library, Wan Fang, SinoMed, Chinese National Knowledge Infrastructure from their inception date to September 12, 2017 for comparative studies on IBS and IBD patients. Standardized mean differences (SMDs) and odds ratios (OR) of comorbid depression were calculated using random effect models. Data on comorbid anxiety in the included studies were also extracted and analyzed.

RESULTS

Altogether, 22 studies with 1,244 IBS and 1,048 IBD patients were included. While there was no significant group difference in the prevalence of depression (10 studies, OR = 1.18, 95%CI: 0.87-1.60, P = 0.29), the IBS group had more severe depression (pooled SMD = 0.18, 95%CI: 0.04-0.33, P = 0.01) and anxiety than the IBD group (pooled SMD = 0.31, 95%CI: 0.14-0.49, P = 0.0006). Sixteen (72.7%) studies were assessed as 'high quality' using the Newcastle-Ottawa Scale (NOS).

CONCLUSIONS

Although the prevalence of comorbid depression was similar between groups, IBS patients had more severe comorbid depressive and anxiety symptoms compared to IBD patients. Appropriate assessment and treatment of depressive and anxiety symptoms in these patient groups should be implemented.

Curcumin as a therapeutic agent for blocking NF-κB activation in ulcerative colitis

Ulcerative colitis (UC) is a chronic, relapsing, remitting, and inflammatory disorder that afflicts millions of people around the world. It carries a substantial economic burden, reducing the quality of life, ability to work, and increasing disability. Conventional medical treatment of UC includes the use of aminosalicylates, corticosteroids, and immunosuppressive drugs. However, these medicines are not always effective due to some serious side effects. Nuclear factor-kappa B (NF-κB) is a key factor in the inflammatory setting and strongly affects the course of mucosal inflammation in UC. This review aims to describe the complex role of NF-κB in UC and discuss existing pharmacological attempts by curcumin for blocking NF-κB activation to develop new therapeutic strategies in UC. Several studies have shown intriguing pharmacologic effects associated with curcumin, which inhibits NF-κB expression by regulating NF-κB/IkB pathway and down-regulation expression of pro-inflammatory cytokines, such as Interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor (TNF)-α. The efficacy of curcumin has been confirmed in several experimental models of UC. Furthermore, curcumin significantly induced clinical remission in active mild-to-moderate UC patients and reduced clinical relapse in quiescent UC patients. The inhibitory effects of curcumin on NF-κB and its unrivaled safety profile indicate that it remains effective for the treatment of UC. In addition, curcumin is a nontoxic, inexpensive, and easily available natural polyphenol. In conclusion, curcumin can be used as a potential and safe drug in the management of patients with remission and mild-to-moderate UC.

Non-pharmacological therapies for inflammatory bowel disease: Recommendations for self-care and physician guidance

We performed a scoping review on sought-after complementary therapies for patients with inflammatory bowel disease (IBD), specifically diet, physical activity and exercise (PA/E), and psychotherapy. We aim to update patients with IBD on therapies for self-care and provide physicians with guidance on how to direct their patients for the management of IBD. A search of MEDLINE, EMBASE, and PUBMED was completed in Sept 2016. Studies on diet, PA/E, or psychotherapy in patients with IBD were included. Medical Subject Heading terms and Boolean operators were used. The search was limited to full-text English articles describing an adult population. This review included 67 studies: Diet (n = 19); PA/E (n = 19); and psychotherapy (n = 29). We have made the following recommendations: (1) Diet: Consumption of diets rich in vegetables, fruit and soluble fiber may be beneficial in IBD. A trial of a low FODMAP diet can be considered in those patients with functional gastrointestinal symptoms. Restrictive diets are lacking in evidence and should be avoided; (2) PA/E: Regular low-moderate intensity activity, including cardiovascular and resistance exercise, has been shown to improve quality of life (QOL) and may improve inflammation; and (3) psychotherapy: Therapies such as cognitive-behavioural interventions, mindfulness, hypnosis, and stress management have been shown to improve QOL, but evidence is limited on their impact on anxiety, depression, and disease activity. Overall, these complementary therapies are promising and should be used to treat patients with IBD from a more holistic perspective.

Psychiatric comorbidities in patients with inflammatory bowel disease

BACKGROUND

Psychiatric comorbidities are associated with inflammatory bowel disease (IBD). We conducted an observational study to evaluate the prevalence of depression and anxiety in patients with IBD.

METHODS

Seventy consecutive consenting patients with IBD (62 ulcerative colitis [UC], 8 Crohn's disease [CD]; 40 males, mean age [SD] 36.2 [11.3] years) and 100 healthy volunteers (44 males, age 31.22 [SD] [10.5] years) as controls were enrolled. All participants were directed to take self-assessment tests, Patient Health Questionnaire -9 (PHQ-9) and Symptom Checklist Anxiety Scale (SCL-A20). Participants having a score ≥ 10 on PHQ-9, or ≥ 29 on SCL-A20 were administered the Hamilton Depression Rating Scale (HAM-D) or Hamilton Anxiety (HAM-A) scales, respectively. The severity of depression and anxiety was graded with HAM-D and HAM-A scales, respectively. The protocol was approved by the Institutional Ethics Committee.

RESULTS

The prevalence of depression (34.3% vs. 5%, p < 0.0001, OR 9.7) and anxiety (18.6% vs. 2%, p = 0.0002, OR 11.17) was higher in patients with IBD as compared to controls. The severity of depression was higher in patients compared to controls (mean rank 17 vs. 7, p = 0.04). The prevalence of depression was not different between UC and CD; all IBD patients with anxiety had UC. The mean duration of disease and history of corticosteroid treatment or surgery for IBD were not associated with the presence of depression or anxiety. Patients with severe CD (Crohn's disease activity index, CDAI > 450) had more severe depression. The severity of UC did not correlate with severity of anxiety or depression in UC.

CONCLUSIONS

Anxiety and depression are more prevalent in IBD patients as compared to healthy individuals.

Quality of Sleep and Coexistent Psychopathology Have Significant Impact on Fatigue Burden in Patients With Inflammatory Bowel Disease

BACKGROUND

Fatigue is common in inflammatory bowel disease (IBD) patients and is associated with factors such as psychopathology, sleep quality, and disease activity.

GOAL

To investigate the combined role of all the above factors in the burden of fatigue among IBD patients.

STUDY

We conducted an observational study of adult patients enrolled in an IBD clinical research registry at a tertiary care clinic. Fatigue burden was defined by Item 1 of the Short-form IBD Questionnaire (SIBDQ), which is scored on a 7-point Likert scale. Crohn's disease (CD) and ulcerative colitis (UC) disease activity were measured with the Harvey-Bradshaw Index or the UC Activity Index, respectively. Labs were obtained to assess anemia, vitamin deficiencies, and inflammatory markers. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Use of psychotropic medications and narcotics was used as proxy measure of psychopathology and pain.

RESULTS

Among 685 IBD patients enrolled in the registry, 631 (238 UC, 393 CD) had a complete SIBDQ. High fatigue burden was found in 57.5% of patients (64.4% CD, 46.2% UC). Fatigue burden was significantly associated with sleep disturbance (PSQI), SIBDQ, and disease activity. CD patients had more fatigue burden than UC patients. Multivariate regression showed that poor quality of life, sleep disturbance, and being on a psychotropic medication are significantly associated with fatigue burden for both UC and CD.

CONCLUSION

Because fatigue is common in IBD patients, these findings suggest that attention to quality of sleep and psychopathology is as important as medical disease management.

Association of Inflammatory Bowel Disease (IBD) with Depressive Symptoms in the United States Population and Independent Predictors of Depressive Symptoms in an IBD Population: A NHANES Study

Background/Aims

There is a paucity of population-based studies on the association between inflammatory bowel disease (IBD) and depression in the U.S. population. We sought to study this association using the National Health and Nutrition Examination Survey (NHANES) database.

Methods

We used NHANES data from 2009 to 2010. Our study included 190,269,933 U.S. adults without IBD and 2,325,226 with IBD. We sought to determine whether IBD is an independent risk factor for depressive symptoms (DS) in the U.S. population and studied the independent predictors of DS in IBD population.

Results

DS was present in 49% of the IBD population versus 23% of the non-IBD population (p<0.001). During the multivariate analysis, we found that IBD was independently associated with DS in the U.S. population (p=0.002). The independent predictors of DS in the IBD population were older age (p=0.048) and divorced/separated/widowed status (p=0.005). There was nonsignificant increase in suicidal risk in IBD population with DS versus that in non-IBD population with DS (27% vs 12%, respectively, p=0.080). Only 36% of IBD individuals with DS visited mental health professional or psychiatrist within the past year.

Conclusions

IBD is independently associated with DS in the U.S. population. Further research is warranted on risk stratification, screening and management of those with IBD who are at risk of depression.

Depression Is Associated With More Aggressive Inflammatory Bowel Disease

OBJECTIVES

Depression is prevalent in inflammatory bowel disease (IBD) patients. The impact of depression on IBD is not well-studied. It is unknown how providers should assess depression.

METHODS

We used data from the Sinai-Helmsley Alliance for Research Excellence cohort, to assess methods of diagnosing depression and effects of baseline depression on disease activity at follow-up. A patient health questionnaire (PHQ-8) score ≥5 was consistent with mild depression. Relapse was defined as a modified Harvey-Bradshaw Index ≥5 or Simple Clinical Colitis Activity Index >2. We performed binomial regression to calculate adjusted risk ratios (RRs).

RESULTS

We included 2,798 Crohn's disease (CD) patients with 22-month mean follow-up and 1,516 ulcerative colitis (UC) patients with 24-month mean follow-up. A total of 64% of CD patients and 45% of UC patients were in remission at baseline. By self-report, 20% of CD and 14% of UC patients were depressed. By PHQ-8, 38% of CD and 32% of UC patients were depressed (P<0.01). Adjusted for sex, remission, and disease activity, CD patients with baseline depression were at an increased risk for relapse (RR: 2.3; 95% confidence interval (CI): 1.9-2.8), surgery, or hospitalization (RR: 1.3 95% CI: 1.1-1.6) at follow-up. UC patients with baseline depression were also at increased risk for relapse (RR: 1.3; 95% CI: 0.9-1.7), surgery, or hospitalization (RR: 1.3; 95% CI: 1.1-1.5) at follow-up.

CONCLUSIONS

Baseline depression is associated with a higher risk for aggressive IBD at follow-up. A single question is not a sensitive method of assessing depression. Providers should consider administering the PHQ-8 to capture those at greater risk for aggressive disease.

Anorexia Nervosa Complicating Pediatric Crohn Disease-Case Report and Literature Review

Crohn disease and anorexia nervosa share common symptoms of weight loss and reduced oral intake. The prevalence of both disorders has increased over time. Symptoms of Crohn disease and anorexia nervosa can mimic each other leading to a delayed diagnosis and requiring complex, multidisciplinary management. Here we present a case of a 15 year old girl with Crohn disease who subsequently developed anorexia nervosa, and review the published literature on the occurrence of both diagnoses.