Impact of depressive mood on relapse in patients with inflammatory bowel disease: a prospective 18-month follow-up study

Depression and inflammatory bowel disease: findings from two nationally representative Canadian surveys

Most studies of depression and inflammatory bowel disease (IBD) have been drawn from clinical populations or from samples selected from the membership of Crohn's and ulcerative colitis community organizations. This study determined the prevalence and correlates of depression in people with IBD or a similar bowel disorder from 2 nationally representative Canadian surveys. In the Canadian Community Health Survey, conducted in 2000 through 2001, there were 3076 respondents who reported that they had "a bowel disorder such as Crohn's disease or colitis" that had lasted >or=6 months and had been diagnosed by a health professional. The National Population Health Survey, conducted from 1996 through 1997, had 1438 respondents who reported that they had such a condition. Within each subsample, bivariate analyses were conducted to compare the depressed and nondepressed individuals. Logistic regression analyses also were conducted using the Canadian Community Health Survey 1.1 data set. The 12-month period prevalence of depression among individuals with IBD and similar bowel disorders was comparable in the 2 data sets (16.3% and 14.7%). Depression rates were higher among female respondents, those without partners, younger respondents, those who reported greater pain, and those who had functional limitations. Seventeen percent of depressed respondents had considered suicide in the past 12 months; an additional 30% had considered suicide at an earlier time. Only 40% of depressed individuals were using antidepressants. Individuals with IBD and similar bowel disorders experience rates of depression that are triple those of the general population. It is important for clinicians to assess depression and suicidal ideation among their patients with active IBD symptoms, particularly among those reporting moderate to severe pain.

Autonomic response to standardized stress predicts subsequent disease activity in ulcerative colitis

OBJECTIVES

Prospective studies of the role of psychological stress in ulcerative colitis are inconsistent or show a modest relationship. We tested the hypothesis that individual differences in autonomic function are associated with differences in the disease course of ulcerative colitis.

METHODS

The spectral power of heart rate variability, an indirect marker of autonomic function, was measured during a standardized stress protocol in 93 ulcerative colitis patients. Patients were categorized as typical or atypical by an increase or decrease, respectively, in the high frequency band of heart rate variability from a period of acute stress to recovery 5 min later. Disease activity was measured at baseline (time 1) and a second time point (time 2) 7-37 months later.

RESULTS

An atypical pattern of heart rate variability at time 1, present in 29% of patients, was associated with lower mean disease activity at time 2 (atypical, 0.56+/-0.93; typical, 2.27+/-2.56, P=0.001). The contribution of heart rate variability pattern to explaining time 2 disease activity was independent of the contributions of other factors that differed between groups, including time 1 disease activity and lifetime corticosteroid use.

DISCUSSION

An atypical pattern of autonomic reactivity may be a marker of individual differences in stress regulation that has prognostic significance in ulcerative colitis.

Effects of mind-body therapy on quality of life and neuroendocrine and cellular immune functions in patients with ulcerative colitis

BACKGROUND

The aim of this study was to investigate the effects of mind-body therapy on neuroendocrine and cellular immune measures, health-related quality of life and disease activity in patients with ulcerative colitis (UC) in remission.

METHODS

Thirty UC patients in remission or with low disease activity were randomly assigned to an intervention group (n = 15) or a usual-care waiting control group (n = 15). Intervention consisted of a structured 60-hour training program over 10 weeks which included stress management training, moderate exercise, Mediterranean diet, behavioral techniques and self-care strategies. Quality of life, perceived stress and disease activity were assessed with standardized questionnaires (IBDQ, SF-36, PSS, CAI). In addition, the distribution of circulating lymphocytes and lymphocyte subsets as well as the beta-adrenergic modulation of TNF-alpha production in vitro were analyzed. Urine catecholamines and plasma cortisol, prolactin and growth hormone were measured pre- and postinterventionally, and were compared with a healthy control group (n = 10).

RESULTS

In response to therapy, patients in the intervention group showed significantly greater improvement in the SF-36 scale Mental Health and the Psychological Health Sum score compared with changes observed in the usual-care waiting control group. Patients in the intervention group showed significantly greater improvement on the IBDQ scale Bowel Symptoms compared with the control group. However, no significant group differences in circulating lymphocyte subsets or endocrine parameters were observed in response to therapy. In addition, no significant effects of intervention on either the basal levels of TNF-alpha or the suppressive action of the beta-adrenergic agonist isoproterenol on TNF-alpha production were observed.

CONCLUSION

Mind-body therapy may improve quality of life in patients with UC in remission, while no effects of therapy on clinical or physiological parameters were found, which may at least in part be related to selective patient recruitment.

Clinical depression and regulation of the inflammatory response during acute stress

OBJECTIVE

This study examined whether clinical depression is associated with a differential inflammatory response to an acute bout of psychological stress.

METHODS

A total of 72 women participated in the study; half met diagnostic criteria for clinical depression; the others had no history of psychiatric illness. The groups were matched with respect to age and ethnicity. All subjects were exposed to a 17-minute mock-job interview; blood was drawn to assess secretion and regulation of inflammatory molecules.

RESULTS

The stressor was associated with feelings of shame and anxiety, a mobilization of monocytes, neutrophils, and C-reactive protein into the circulation, and greater endotoxin-stimulated production of interleukin-6 and tumor necrosis factor-alpha by white blood cells in vitro. Depressed subjects began the session with greater sensitivity to the antiinflammatory properties of glucocorticoids than control subjects. Following exposure to the stressor protocol, however, sensitivity decreased among depressed subjects and increased among controls. This was manifest by disparities in interleukin-6 and tumor necrosis factor-alpha production in the presence of dexamethasone.

CONCLUSIONS

These findings suggest that under acutely challenging conditions, depression is associated with greater resistance to molecules that normally terminate the inflammatory cascade. An impaired capacity to regulate inflammation could underlie some of the excess morbidity and mortality that has been associated with depression.

The impact of major depressive disorder on the short- and long-term outcome of Crohn's disease treatment with infliximab

BACKGROUND

Major depressive disorder is the most common psychiatric diagnosis in Crohn's disease. In other chronic diseases, evidence suggests that depression influences the course of the disease. Strong evidence of such a mediating role of major depressive disorder in Crohn's disease has never been found.

AIM

To assess the relationship between major depressive disorder and outcome of treatment of luminal Crohn's disease with infliximab.

METHODS

In this prospective study, 100 consecutive unselected patients underwent assessment of psychosocial, demographical disease-related biological and clinical parameters at baseline and at 4 weeks after infliximab. Major depressive disorder was diagnosed using the Patient Health Questionnaire. Subsequently, the patients were followed up clinically until the next flare or during 9 months.

RESULTS

The Crohn's disease responded in 75% of the patients, and remission was achieved in 60%. The presence of major depressive disorder at baseline predicted a lower remission rate (OR = 0.166, 95% CI = 0.049-0.567, P = 0.004). At follow-up, 88% of the patients needed retreatment. At univariate regression analysis, major depressive disorder significantly decreased time to retreatment (P = 0.001). Multivariate Cox regression confirmed major depressive disorder as an independent determinant of active disease both at baseline and at re-evaluation (hazard ratio = 2.271, 95% CI: 1.36-3.79, P = 0.002).

CONCLUSION

Major depressive disorder is a risk factor for failure to achieve remission with infliximab and for earlier retreatment in patients with active luminal Crohn's disease. Assessment and management of major depressive disorder should be part of the clinical approach to patients with Crohn's disease.

Disruption of the blood-brain barrier during TNBS colitis

Well-documented central nervous system changes during colitis suggest possible alterations of blood-brain barrier (BBB) permeability, yet the integrity of the BBB has not been fully evaluated in experimental colitis. Our aim was to investigate whether trinitrobenzene sulphonic acid (TNBS) colitis was associated with an increase in the permeability of the BBB. Sprague-Dawley rats were given an intracolonic injection of saline or TNBS and studied 1, 2, 3, 7 and 21 days after treatment. The extravasation of endogenous immunoglobulin G, a large molecule, was not altered at any time after TNBS treatment. In contrast, significant increases in the BBB leakage of sodium fluorescein, a much smaller molecule, were observed 1 and 2 days after the induction of colitis, in and around the circumventricular organs; the organum vasculosum of the lamina terminalis, subfornical organ and median eminence of the hypothalamus. TNBS-treated rats also exhibited sodium fluorescein leakage in focal areas in the brain parenchyma. The expression of endothelial barrier antigen, a protein associated with the BBB, was reduced about 60% 48 h after the induction of colitis. This returned to control values by 3 weeks, when colitis had largely subsided. In conclusion, experimental colitis transiently increased permeability of the brain to small molecules through a mild disruption of the BBB.

Is irritable bowel syndrome a low-grade inflammatory bowel disease?

Irritable Bowel Syndrome (IBS) is multifactorial in its etiology and heterogeneous in its clinical presentation and pathogenesis. It is recognized that inflammation plays an important role in symptom generation, at least in a subset of patients with IBS. Previous gastroenteritis has been identified as the most important risk factor for IBS, and several studies reported that a substantial proportion of patients with gastrointestinal infection develops IBS symptoms,which can persist for several years. Recent studies have demonstrated that a proportion of IBS patients without any history of enteritis has signs of immune activation in the gut. There is clinical overlap between IBS and inflammatory bowel disease (IBD), with IBS-like symptoms frequently reported in patients before the diagnosis of IBD, and a higher than expected percentage reports of IBS symptoms in patients in remission from established IBD. Thus,these conditions may coexist with a higher than expected frequency, or may exist on a continuum, with IBS and IBD at different ends of the same spectrum. This article examines these relation-ships using immune activation and inflammation as a common pathogenic process to IBD and a subset of IBS patients.

Evidence that stress contributes to inflammatory bowel disease: evaluation, synthesis, and future directions

BACKGROUND

There is a long but inconsistent history of observations suggesting that psychologic stress contributes to the course of ulcerative colitis (UC) and Crohn's disease (CD). This study evaluated the strength of evidence for a causal link between stress, depression, and inflammatory bowel disease course.

METHODS

Literature review and unstructured qualitative analysis of all reported prospective studies of stress or depression and disease outcomes and randomized controlled studies (RCTs) of stress reduction interventions.

RESULTS

Although results remain inconsistent, prospective studies support a role for psychologic stress in the course of UC and for depressive symptoms in the course of CD. RCTs do not support the benefit of stress reduction for unselected patients with CD. UC has not been studied with adequately designed RCTs. Animal models suggest mechanisms whereby stress can exacerbate preexisting inflammatory disease, especially through increased epithelial permeability.

CONCLUSIONS

A synthesis of the literature is presented suggesting approaches to reconcile apparently contradictory findings. Recommendations for further research emphasize refinements to avoid type II error and to identify subgroups of patients who are most likely to experience stress-related effects on illness or to benefit from stress reduction intervention.

Is irritable bowel syndrome a low-grade inflammatory bowel disease?

Irritable Bowel Syndrome (IBS) is multifactorial in its etiology and heterogeneous in its clinical presentation and pathogenesis. It is recognized that inflammation plays an important role in symptom generation, at least in a subset of patients with IBS. Previous gastroenteritis has been identified as the most important risk factor for IBS, and several studies reported that a substantial proportion of patients with gastrointestinal infection develops IBS symptoms,which can persist for several years. Recent studies have demonstrated that a proportion of IBS patients without any history of enteritis has signs of immune activation in the gut. There is clinical overlap between IBS and inflammatory bowel disease (IBD), with IBS-like symptoms frequently reported in patients before the diagnosis of IBD, and a higher than expected percentage reports of IBS symptoms in patients in remission from established IBD. Thus,these conditions may coexist with a higher than expected frequency, or may exist on a continuum, with IBS and IBD at different ends of the same spectrum. This article examines these relation-ships using immune activation and inflammation as a common pathogenic process to IBD and a subset of IBS patients.

Embracing complexity: what determines quality of life in inflammatory bowel disease?

A subset of patients with inflammatory bowel disease have markedly impaired quality of life. In this issue, Mussell et al. report that patients' self-rated health status and disease-related concerns were determined at least as strongly by their habitual use of depressive coping patterns as by their disease activity. Although past disease severity may have confounded these results, the finding that quality of life is better for patients armed with a positive approach to problem-handling suggests that psychologically oriented interventions could have far-reaching benefits for selected patients. Since evidence is accumulating that stress and distress can worsen tissue inflammation and clinical course in animal models and in clinical populations with inflammatory bowel disease, we may dare to hope that interventions aimed at improving patients' stress tolerance, depressive symptoms, and coping capacities might not only improve perceived quality of life but could potentially decrease bowel inflammation and reduce some patients' need for toxic medications or surgery. Designing, applying, and evaluating such interventions should be a major item on the agenda of psychosomatic medicine in gastroenterology, and biological reductionism should be replaced by the biopsychosocial model.

Assessing the demand for psychological care in chronic diseases: development and validation of a questionnaire based on the example of inflammatory bowel disease

BACKGROUND

This study was designed to develop and validate the ADAPT (Assessment of the Demand for Additional Psychological Treatment), a questionnaire assessing the demand for disease-oriented counseling (DOC), integrated psychosomatic care (IPC), and psychotherapy (PT) in chronically ill patients on the example of inflammatory bowel diseases (IBDs).

METHODS

After its development, the ADAPT was distributed to 39 IBD patients along with the Hospital Anxiety and Depression scale (HAD), the Rating Form of IBD Patient Concerns (RFIPC), and a questionnaire on social support (SOZU-K22). For construct validity, 19 hypotheses were made on how DOC, IPC, and PT should correlate with HAD, RFIPC, SOZU-K22, and disease-related variables. To analyze interindividual responsiveness, patients were classified according to their bio-psycho-social state, and DOC, IPC, and PT scores were compared between these classes. The test-retest method with a 4-week time lapse was used to analyze reliability and intraindividual responsiveness. DOC, IPC, and PT scores between baseline and follow-up were compared separately for patients classified as "stable" or "changed" according to changes in HAD and disease activity.

RESULTS

Observed correlations were largely in agreement with the 19 hypotheses. DOC, IPC, and PT achieved significantly different scores between different patients. After 4 weeks, DOC, IPC, and PT revealed stable scores in patients with "stable" HAD and revealed significantly different scores in patients with "changed" HAD. Changed disease activity was not associated with significant changes of the ADAPT.

CONCLUSIONS

The ADAPT is the first questionnaire to assess subjective demand for additional psychological care in chronically ill patients. The first application of the ADAPT to 39 IBD patients suggests its validity, reliability, and responsiveness.