Coeliac disease and risk of mood disorders--a general population-based cohort study

Psychological, Psychiatric, and Organic Brain Manifestations of Celiac Disease

INTRODUCTION

Celiac disease is an autoimmune condition that affects approximately 1% of the population worldwide. Although its main impact often concerns the small intestine, resulting in villous atrophy and nutrient malabsorption, it can also cause systemic manifestations, particularly when undiagnosed or left untreated.

METHOD

Attention is directed to the possible psychological, psychiatric, and organic brain manifestations of celiac disease. Specific topics related to the influence and risk of such manifestations with respect to celiac disease are defined and discussed. Overall, eighteen main topics are considered, sifted from over 500 references.

RESULTS

The most often studied topics were found to be the effect on quality of life, organic brain dysfunction and ataxia, epilepsy, Down syndrome, generalized psychological disorders, eating dysfunction, depression, and schizophrenia. For most every topic, although many studies report a connection to celiac disease, there are often one or more contrary studies and opinions. A bibliographic analysis of the cited articles was also done. There has been a sharp increase in interest in this research since 1990. Recently published articles tend to receive more referencing, up to as many as 15 citations per year, suggesting an increasing impact of the topics. The number of manuscript pages per article has also tended to increase, up to as many as 12 pages. The impact factor of the publishing journal has remained level over the years.

CONCLUSION

This compendium may be useful in developing a consensus regarding psychological, psychiatric, and organic brain manifestations that can occur in celiac disease and for determining the best direction for ongoing research focus.

Monitoring coeliac disease in 2024, time to change practice?

PURPOSE OF REVIEW

Persistent villous atrophy is associated with morbidity in coeliac disease and most commonly due to ongoing gluten ingestion. Current methods for assessing gluten exposure and persisting villous atrophy include dietary questionnaires and repeat duodenal biopsy, which have limited accuracy or are invasive. This review discusses adjunctive and/or novel tests that could be used to overcome these challenges.

RECENT FINDINGS

Small bowel capsule endoscopy is well tolerated and helps to evaluate for persisting villous atrophy and importantly, complications associated with coeliac disease. Testing for urinary and/or stool gluten immunogenic peptides may help identify recent gluten exposure, but further studies are still warranted to evaluate the accuracy and applicability of this approach. Measuring spikes in circulating Interleukin-2 following gluten challenge has shown promise for coeliac disease diagnosis, and thus may serve as a useful confirmatory test in those with persisting symptoms but provides no information on mucosal inflammation. No specific gut microbial signature has been identified in coeliac disease; however, studies have shown a reduced microbial diversity in active disease, which with future refinement may prove clinically useful.

SUMMARY

There is no evidence to support alternative methods for assessing persisting villous atrophy in coeliac disease over performing an up-to-date duodenal biopsy. Monitoring for adherence to a gluten-free diet remains clinically challenging and should be a priority for future research.

Epidemiological, Endoscopic, Clinical, and Pathological Features of Patients with Celiac Diseases in Southern Littoral of Caspian Sea

Background: Celiac disease is an autoimmune disorder resulting from gluten consumption in genetically predisposed individuals. The present study investigated the epidemiological, endoscopic, and clinicopathological features of patients with celiac disease in the southern littoral of the Caspian Sea. Methods: 140 patients with celiac disease were interviewed and examined regarding demographic characteristics, clinical symptoms, and serologic, endoscopic, and pathological findings. Results: 44 (31.4%) of the patients were male and 68.6% were female. The mean age of the patients at diagnosis was 27.13±13.4 years (ranging from 2 to 60 years). The most common gastrointestinal (GI) symptoms were bloating (47.8%), abdominal pain (47.1%) and diarrhea (30.7%), respectively. Also, 17 (12.1%) patients did not complain of any GI symptoms.18 (12.8%) patients had aphthous stomatitis, 10.7% had dermatitis herpetiformis, 3.6% suffered from itching without a rash, two (1.4%) mentioned psoriasis and one (0.7%) had lichen planus. 19 (19.7%) of the female patients complained of menstrual bleeding disorders, 4% mentioned infertility, and 2% experienced primary amenorrhea. The most common comorbid condition was hypothyroidism in 16 (11.4%) patients. The most common endoscopic finding was duodenal scalloping (37.25%). In addition, 7.8% of the patients had a normal endoscopic appearance. 43 (30.7%) patients were classified as Marsh IIIC, 25.7% Marsh IIIB, 17.8% Marsh IIIA, 12.8% Marsh II and 12.8% were classified as Marsh I. Conclusion: Since celiac disease can present with non-GI manifestations and the majority of our patients had Marsh III classification, it seems that celiac disease must be considered as a routine screening test in GI clinics, and also, it should be kept in mind as a differential diagnosis in other specialty fields.

The Prevalence of Anxiety and Depressive Symptoms Among Patients With Celiac Disease in Jordan

Background Celiac disease is an immune-mediated intestinal disorder with a global prevalence of 1% that results from gluten sensitivity in a genetically susceptible person. It presents with gastrointestinal symptoms, consequences of malabsorption, and/or extraintestinal manifestations that include neuropsychiatric symptoms. Aim The aim of this study was to measure the frequency of anxiety and depressive symptoms in Jordanian patients with celiac disease. Methods This was a cross-sectional study. A questionnaire was sent electronically to celiac disease patients who were members of the Friends of Celiac Disease Patients Association through WhatsApp using Google Forms (Google, Mountain View, California). The questionnaire contained demographic and disease-related questions, in addition to questions that assessed anxiety and depressive symptoms using validated Arabic versions of the Generalized Anxiety Disorder-7 score and Patient Health Questionnaire-9, respectively. Results A total of 133 patients answered the questionnaires. Of the respondents, 82.7% were females, and the mean age was 33.9 +/- 11.22 years; 31.6% of patients were non-compliant with a gluten-free diet, and 56.4% were symptomatic at the time of the questionnaire. The prevalence of anxiety and depressive symptoms were 85% and 82.7%, respectively. There was no correlation between any of the variables and the presence of anxiety or depressive symptoms. Conclusion A significant proportion of celiac disease patients in Jordan have evidence of anxiety and depressive symptoms. Given this high prevalence and the possible impact on the quality of life, physicians need to screen patients for the presence of psychiatric comorbidities and refer those who have symptoms for further evaluation.

Celiac disease and risk of neuropsychiatric disorders: A nationwide cohort study

INTRODUCTION

Previous studies have indicated that patients with celiac disease (CD) may have an increased risk of developing neuropsychiatric disorders. However, large-scale epidemiologic studies on the topic are still scarce. We aimed to examine the association between CD and development of neuropsychiatric disorders during an 18-year follow-up period.

METHODS

We conducted a prospective cohort study. All Danish patients with an incident diagnosis of CD (ICD-10 K90.0) from 2000 to 2018 were identified in nationwide registries and compared with birthdate- and sex-matched controls (variable 1:10 ratio) for the development of a neuropsychiatric disease. Individual neuropsychiatric diseases were also examined. The absolute risk was calculated by the cumulative incidence, and the relative risk was estimated in Cox regression models.

RESULTS

We identified a cohort of 6329 patients with CD diagnosed from 2000 to 2018 and 63,287 matches at risk for developing incident neuropsychiatric disorders. The cumulative incidence of development of any neuropsychiatric disorder was 3.9%, 14.9%, 24.8%, 35.9% after 1, 5, 10, and 15 years of follow-up, respectively, in patients with CD compared with 1.8%, 9.3%, 18.3%, and 27.0% in controls. Gray's test for equality p < 0.001. The relative risk was HR = 1.58 (95% confidence interval: 1.49-1.68) in CD patients compared with matches. For the individual outcomes, CD was associated with an increased relative risk of developing anxiety, depression, eating disorders, epilepsy, migraine, and stress. We also found indications of an increased relative risk of ADHD, alcoholism, bipolar disorders, and drug abuse, although the associations were less clear. No associations were found between CD and dementia, Parkinson's disease, and schizophrenia.

CONCLUSIONS

In this nationwide study including more than 6000 patients with CD, we found an increased risk of development of a neuropsychiatric disorder compared with age- and sex-matched controls. The causes and the clinical relevance of these associations remain to be elucidated.

Anxiety and Associated Factors during the COVID-19 Pandemic Confinement in the Moroccan Adult Celiac Disease Population

Introduction

The widespread lockdown due to the COVID-19 pandemic was insured by Moroccan authorities in early 2020 to preserve the health of citizens. The lockdown and the pandemic imposed psychological effects on the population including anxiety. Celiac disease (CeD), a chronic disease among the most common inflammatory intestinal disorders, has been linked to adult emotional disturbances. Hence, CeD patients may suffer from anxiety or increase this condition due to the concomitant situation. The objective of this study was to assess COVID-19-related anxiety in a sample of adults with CeD in comparison with a matched healthy group.

Method

CeD patients (103) and matched healthy group (101) were investigated using a web-based COVID-19 and related lockdown anxiety survey. Anxiety was assessed with the State and Trait Anxiety Inventory (STAI test: Y1 for state anxiety and Y2 for trait anxiety).

Results

State anxiety was present among 65.3% of CeD and 41.6% of the comparison group, and the difference was statistically significant. CeD women suffered more from state anxiety than their compeers in the comparison group (t = 3.23; p = 0.002), and a significant correlation between good compliance to GFD and less state anxiety was found among CeD patients (r = 0.31; p = 0.002). 61.8% of CeD participants thought they were at higher risk of contamination by COVID-19, and they were mostly women (χ2 = 7.66, p < 0.006) and had significantly higher state anxiety mean scores than their compatriots who did not express these thoughts (t = 2.93; p = 0.004). Additionally, 41.5% of CeD participants had anxiety as a trait against 26.7% in the comparison group and the difference between the two groups was statistically significant.

Conclusion

Results of this survey allow a better understanding of the health-related pandemic effects on Moroccan CeD patients. It demonstrates that COVID-19 and related lockdowns had a serious impact on the psychological balance of these patients by increasing their anxiety. The survey results underlined the need to improve the psychological care of CeD patients notably by considering remote medical visits during this ongoing pandemic to provide mental health support.

Cerebellar Symptoms in Gluten Sensitivity: a Systematic Review of the Effect of a Gluten-Free Diet on Brain Imaging

Cerebellar manifestations have been described in patients with gluten sensitivity (GS)-related disorders. A better understanding of the neurological manifestations of GS requires the use of neuroimaging techniques. We performed a systematic review on neuroimaging findings in GS patients with cerebellar symptoms. We also included a specific search on neuroimaging findings in GS patients with cerebellar manifestations on a gluten-free diet (GFD). PubMed, Embase, and Bireme were systematically searched to identify studies assessing neuroimaging features of adults with cerebellar manifestations and GS with or without enteropathy on a GFD. Ten studies with a total of 222 adult-GS patients were included. Magnetic resonance imaging was used in 100% of the studies. Cerebellar atrophy was evaluated in 7 studies and observed in 63% of the patients. White matter abnormalities were described in 2 studies. Single-photon emission computed tomography was used in 2 studies, and decreased cerebellar perfusion was detected in 92% of the included patients. No study employed nuclear medicine after the start of GFD. Magnetic resonance spectroscopy (MRS) was performed in 2 studies before and after GFD. An increase in the Naa/Cr ratio in cerebellar vermis was seen in 98% of the cases on a strict GFD. Cerebellar atrophy was found to be a prevalent condition in GS patients. MRS demonstrated to be useful in the follow-up of GS patients with cerebellar manifestations on a GFD. Prospective studies using nuclear medicine imaging are needed to study brain changes in GS patients on a GFD.

Long-Term Effect of Gluten-Free Diets on Nutritional Status, Body Composition, and Associated Factors in Adult Saudi Females with Celiac Disease

This cross-sectional study examines the influence of long-term gluten-free diet (GFD) consumption on nutritional status, body composition, and associated factors in adult Saudi females with celiac diseases (CD). Fifty-one patients who have been diagnosed with CD and have been on GFD for more than 1 year were included in this study where data regarding their dietary pattern, as well as a complete analysis of their anthropometric parameters, vitamins B12 and D levels, and complete blood count (CBC), were collected. Data have shown that all included patients showed a reduced intake in all micro and macro-nutrients, as well as vitamin D, folate, calcium, and iron. However, the vast majority of all measured hematological parameters and blood indices were within the expected reference range. In addition, 51%, 43.1%, and 60.8% of the patients showed low waist/hip ratio (WHR), decreased level of total body fat (BF), and decreased level of visceral fat (VF), respectively, whereas 33.3% were slim. The poor educational level and some psychosocial factors were associated with the poor nutritional status of the patients. In conclusion, the GFD-dependent intake by female patients with CD adversely affects their nutritional intake and anthropometric indices and leads to a deficiency in major nutrients, vitamins, and ions.

An Investigation Into What Factors Influence Patterns of Clinical Presentation in Adult-Onset Celiac Disease

Introduction

Anxiety and depression are common in patients with celiac disease (CD), and many psychosocial explanations have been considered. However, as the gut-brain axis is becoming increasingly understood, biological mechanisms have been proposed, including vitamin or mineral deficiencies and gut inflammation.

Aim

To investigate associations between anxiety/depression and symptom severity, vitamin status, and gut inflammation in untreated adult patients presenting with a serologic indication of celiac disease.

Methods

The Hospital Anxiety and Depression Scale (HADS), Celiac Symptom Index (CSI), and Perceived Stress Scale (PSS) questionnaires were administered to 17 patients over a 14-month period. Duodenal biopsies were obtained to determine histological Marsh scores. Iron, B12, folate, vitamin D, and thyroid function tests were reviewed.

Results

HADS-Anxiety (HADS-A) scores correlated with symptom severity (rs = 0.62, P = 0.008), but not with any hematological investigations or degree of intestinal inflammation. No patients scored highly for depression. Iron deficiency was the most common deficiency observed (n = 6). Greater symptomatology was associated with female sex (females versus males: average CSI scores, 32.1 versus 23.6; t17 = 2.1, P < 0.05), younger age at presentation (rs = -0.55, P = 0.02), and lower Marsh score (Marsh 0 versus Marsh 3C: mean scores, 36 versus 24.5; t5 = 6.2, P = 0.009).

Conclusions

The anxiety experienced by patients with CD at presentation is likely a reactive form due to gastrointestinal symptoms rather than a biological process specific to CD. Older patients tend to present less symptomatically, highlighting the need for screening of at-risk individuals. The degree of villous atrophy does not correlate well with clinical presentation. Highly symptomatic patients should be screened for anxiety at presentation.

Celiac disease poses significant risk in developing depression, anxiety, headache, epilepsy, panic disorder, dysthymia: A meta-analysis

Celiac disease (CD) primarily affects the small intestine. Previous studies have identified higher incidences of neuropsychiatric diseases among CD patients compared to non-CD controls. Genome-wide association studies have identified >60 non-human leukocyte antigen (HLA) genes associated with CD, where estimated 15% genes have role in neurological health. We carried out a systematic review and meta-analysis to estimate the potential risk conferred by CD in developing neuropsychiatric diseases. Literature search was performed till June 2019. Incidences of neuropsychiatric diseases were compared among CD and non-CD controls. Funnel plots and Egger's tests were used to evaluate publication bias and estimate study effects. Qualities of the included studies were estimated using Newcastle-Ottawa Scale. Quality of evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Odds of developing neuropsychiatric diseases among CD were evaluated by computing meta-odds ratio (Manten-Haenszel method) and Z test p-value using random and fixed effect models based on the degree of study heterogeneity. Thirteen non-randomized case-control studies were found eligible. Subjects suffering from CD were found to have significantly more risk to develop depression (p<1.00E-05; OR=1.60 [1.37-1.86]), anxiety (p=0.05; OR=1.41 [1.00-1.97]), headache (p<0.1.00E-05; OR=3.27 [2.46-4.34]), epilepsy (p<1.00E-04; OR=11.90 [3.78-37.43]), panic disorder (p<1.00E-04; OR=4.64 [2.22-9.70]), and dysthymia (p=2.00E-03; OR=5.27 [1.83-15.22]). CD is a major predisposing factor in developing array of common neuropsychiatric diseases. Shared biological processes and molecular networks could play a crucial role in disease co-occurrence. Detailed molecular evidences are needed to establish the cause-effect relationship between these diseases.

Psychiatric Disorders in Patients With a Diagnosis of Celiac Disease During Childhood From 1973 to 2016

BACKGROUND & AIMS

Few studies have explored the link between childhood celiac disease and long-term psychiatric comorbidities. We performed a population-based cohort study of associations between childhood celiac disease and psychiatric disorders and investigated whether risk persists into adulthood.

METHODS

We performed a nationwide study in Sweden using data from the Epidemiology Strengthened by histoPathology Reports in Sweden cohort. In this cohort, 19,186 children with a diagnosis of biopsy-verified celiac disease from 1973 through 2016 were identified from Sweden's 28 pathology departments. Each patient was matched with as many as 5 reference children (controls, n = 94,249). Data on psychiatric disorders were obtained from the patient register. We used Cox proportional modeling to estimate hazard ratios (HRs).

RESULTS

During a median follow-up period of 12.3 years, 3174 children (16.5%) with celiac disease received a new diagnosis of a psychiatric disorder, compared with 13,286 controls (14.1%). Corresponding incidence rates were 12.2 per 1000 person-years (95% CI, 11.8-12.7) vs 10.3 per 1000 person-years (95% Cl, 10.2-10.5). Childhood celiac disease was associated with a 19% increase in risk of any psychiatric disorder (95% CI, 1.14-1.23); the increase in risk was observed in all childhood age groups. The highest HRs were seen in the first year after celiac diagnosis (HR, 1.70; 95% CI, 1.41-2.05). The risk increase persisted into adulthood (age, >18 y: HR, 1.11; 95% CI, 1.04-1.17). We found increased risks of mood disorders (HR, 1.20; 95% CI, 1.12-1.28), anxiety disorders (HR, 1.12; 95% CI, 1.06-1.19), eating disorders (HR, 1.34; 95% CI, 1.18-1.51), attention deficit hyperactivity disorder (HR, 1.29; 95% CI, 1.20-1.39), and autism spectrum disorder (HR, 1.47; 95% CI, 1.32-1.64). We found no statistically significant risk increase for psychotic disorders, psychoactive substance misuse, behavioral disorders, personality disorders, suicide attempt, or suicide. Celiac disease also was linked to an increased use of psychiatric drugs (HR, 1.34; 95% CI, 1.24-1.43). A conditional logistic regression found that psychiatric disorders also were more common before a diagnosis of celiac disease (odds ratio, 1.56; 95% CI, 1.39-1.76).

CONCLUSIONS

Childhood celiac disease is associated with an increased risk of subsequent psychiatric disorders, which persists into adulthood. Mental health surveillance should be integral in the care of celiac disease.

Epidemiology and risk of psychiatric disorders among patients with celiac disease: A population-based national study

BACKGROUND AND AIM

Celiac disease (CD) is a chronic disorder resulting from an immune reaction to gluten in genetically predisposed individuals. Although several studies have linked CD to psychiatric diseases, there are limited data on this topic. Using a large database, we sought to describe the epidemiology of several psychiatric disorders in CD.

METHODS

We queried a multicenter database (Explorys Inc), an aggregate of electronic health record data from 26 major integrated healthcare systems from 2016 to 2020 consisting of 360 hospitals in the USA. A cohort of patients with a Systematized Nomenclature Of Medicine - Clinical Terms diagnosis of CD was identified. Multivariate analysis was performed using Statistical Package for Social Sciences version 25.

RESULTS

Of the 37 465 810 patients in the database between 2016 and 2020, there were 112 340 (0.30%) individuals with CD. When compared with patients with no history of CD, patients with CD were more likely to have a history of anxiety (odds ratio [OR]: 1.385; 95% confidence interval [CI]: 1.364-1.407), depression (OR: 1.918; 95% CI: 1.888-1.947), bipolar (OR: 1.321; 95% CI: 1.289-1.354), attention-deficit hyperactivity disorder (OR: 1.753; 95% CI: 1.714-1.792), eating disorder (OR: 15.84; 95% CI: 15.533-16.154), and childhood autistic disorder (OR: 4.858; 95% CI: 3.626-6.508). Patients with CD and psychiatric conditions were more likely to be smokers, with history of alcohol and substance abuse as well as a history of personality disorder.

CONCLUSIONS

In this large database, patients with CD are at increased risk of having multiple psychiatric diseases including anxiety, depression, bipolar, attention-deficit hyperactivity disorder, eating disorder, and childhood autism. Individual care and referral to psychiatry when appropriate are warranted while taking care of this group of patients.

The impact of celiac disease and duration of gluten free diet on anterior and posterior ocular structures: Ocular imaging based study

PURPOSE

To evaluate the eyes of adult celiac disease (CD) patients and investigate the association between these ocular parameters with celiac specific antibodies and duration of gluten free diet (GFD).

METHODS

This cross-sectional study included 72 eyes of 36 CD patients (18-51 years of age) and 70 eyes of 35 age- and sex-matched healthy controls. In addition to a complete ophthalmologic examination, all patients were scanned by a Scheimpflug camera, specular microscopy and spectral domain optical coherence tomography.

RESULTS

Endothelial cell density (ECD), anterior chamber angle (ACA) degrees, anterior chamber depth (ACD), anterior chamber volume (ACV) and central macular thickness (CMT) values were lower in CD patients as compared with control group (p values = 0.038, 0.024, 0.002, 0.038 and 0.046 respectively). ECD and CMT were lower in celiac patients whom endomysial antibodies (EMA) IgA were positive (p = 0.001, p = 0.042 respectively). Tissue transglutaminase IgA antibody (anti tTG IgA) was weakly positively correlated (p > 0.05) with ACD, and positively (r = 0.319; p < 0.05) correlated with ACV. As the duration of compliance to the diet increased in the celiac group the mean and inferior retinal nerve fiber layer (RNFL) thickness decreased (p = 0.035, p = 0.008 respectively). Mean, inferior and temporal RNFL thicknesses were lower in celiac patients whose duration of GFD was longer than 5 years (p < 0.05).

CONCLUSIONS

Decreases in ECD, ACA degree, ACD, ACV and CMT can occur in CD patients. In adult celiac patients; ECD, CMT might be effected in the presence of positive EMA, and ACD, ACV might be effected in the presence of higher anti tTG IgA titer. Adult celiac patients who had longer duration of GFD may have thinner RNFL. RNFL may be thinner in celiac patients who comply with GFD for more than 5 years.

Major Depressive Disorder and Food Hypersensitivity: A Case Report

INTRODUCTION

Major depressive disorder (MDD) is a common chronic mental health condition and not all patients respond to pharmacotherapy. Increasing evidence suggests that dietary choices play a role in the pathogenesis of mental illness and serve as modifiable factors with utility in the treatment of these disorders. Although many mechanisms are being explored, one area of study is the role of food hypersensitivity reactions in mental health conditions.

CASE PRESENTATION

This article reports on a 34-year-old female patient with MDD whose symptoms improved in response to a dietary intervention involving the elimination of common food allergens. Reintroduction of the foods on several occasions was associated with a worsening of mood symptoms. Serum IgG testing reported results consistent with the reintroduction challenge.

DISCUSSION AND CONCLUSIONS

Hypothesized mechanisms underlying the potential relationship between food hypersensitivity and MDD are presented. Further research in this area is warranted.

Psychiatric Manifestations of Coeliac Disease, a Systematic Review and Meta-Analysis

Background: Coeliac disease (CD) is increasingly prevalent and is associated with both gastrointestinal (GI) and extra-intestinal manifestations. Psychiatric disorders are amongst extra-intestinal manifestations proposed. The relationship between CD and such psychiatric disorders is not well recognised or understood. Aim: The aim of this systematic review and meta-analysis was to provide a greater understanding of the existing evidence and theories surrounding psychiatric manifestations of CD. Methodology: An online literature search using PubMed was conducted, the prevalence data for both CD and psychiatric disorders was extracted from eligible articles. Meta analyses on odds ratios were also performed. Results: A total of 37 articles were included in this review. A significant increase in risk was detected for autistic spectrum disorder (OR 1.53, 95% CI 1.24–1.88, p < 0.0001), attention deficit hyperactivity disorder (OR 1.39, 95% CI 1.18–1.63, p < 0.0001), depression (OR 2.17, 95% CI 2.17–11.15, p < 0.0001), anxiety (OR 6.03, 95% CI 2.22–16.35, p < 0.0001), and eating disorders (OR 1.62, 95% CI 1.37–1.91, p < 0.00001) amongst the CD population compared to healthy controls. No significant differences were found for bipolar disorder (OR 2.35, 95% CI 2.29–19.21, p = 0.43) or schizophrenia (OR 0.46, 95% CI 0.02–10.18, p = 0.62). Conclusion: CD is associated with an increased risk of depression, anxiety, eating disorders as well as ASD and ADHD. More research is required to investigate specific biological explanations as well as any effect of gluten free diet.

Celiac Disease Autoimmunity and Emotional and Behavioral Problems in Childhood

BACKGROUND AND OBJECTIVES

Celiac disease (CeD) is associated with psychopathology in children. It is unknown whether this association is present in children with celiac disease autoimmunity (CDA) identified by screening. We examined the associations between subclinical CDA and emotional and behavioral problems in children without previous CeD diagnosis.

METHODS

In a population-based cohort study of 3715 children (median age: 6 years), blood titers of tissue transglutaminase autoantibodies were analyzed. CDA was defined as a measurement of tissue transglutaminase autoantibodies ≥7 U/mL (n = 51). Children with previous CeD diagnosis or children on a gluten-free diet, were excluded. The Child Behavior Checklist (CBCL) was filled in by parents and was used to assess behavioral and emotional problems of children at a median age of 5.9 years. Multiple linear regression models were applied to evaluate the cross-sectional associations between CDA and CBCL scores. Sensitivity analyses were done in a subgroup of children who were seropositive carrying the HLA antigen risk alleles for CeD.

RESULTS

In basic models, CDA was not associated with emotional and behavioral problems on the CBCL scales. After adjustment for confounders, CDA was significantly associated with anxiety problems (β = .29; 95% confidence interval 0.02 to 0.55; P = .02). After exclusion of children who did not carry the HLA-DQ2 and/or HLA-DQ8 risk alleles (n = 4), CDA was additionally associated with oppositional defiant problems (β = .35; 95% confidence interval 0.02 to 0.69). Associations were not explained by gastrointestinal complaints.

CONCLUSIONS

Our results reveal that CDA, especially combined with the HLA-DQ2 and HLA-DQ8 risk alleles, is associated with anxiety problems and oppositional defiant problems. Further research should be used to establish whether behavioral problems are a reflection of subclinical CeD.

Epidemiology of Celiac Disease

Celiac disease is a common, chronic inflammatory disorder of the small intestine triggered by exposure to gluten in individuals with certain genetic types. This disorder affects people of any age or gender. Although often thought to be European in origin, it is now global in extent. Presentations are variable, from asymptomatic patients to severe malnutrition. Initial detection usually relies on celiac-specific serology, and confirmation often requires intestinal biopsy. There have been substantial increases in prevalence and incidence over the last 2 decades for reasons that are almost certainly environmental but for which there is no clarity as to cause.

Cohort profile: ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden)

The ESPRESSO study constitutes a novel approach to examine the etiology and prognosis of gastrointestinal disease in which histopathology plays a prominent role. Between 2015 and 2017, all pathology departments (n=28) in Sweden were contacted and asked to procure histopathology record data from the gastrointestinal tract (pharynx to anus), liver, gallbladder, and pancreas. For each individual, local histopathology IT personnel retrieved data on personal identity number, date of histopathology, topography (where the biopsy is taken), morphology (biopsy appearance), and where available free text. In total, between 1965 and 2017, histopathology record data were available in 2.1 million unique individuals, but the number of data entries was 6.1 million because more than one biopsy was performed in many of the study participants. Index individuals with histopathology data were matched with up to five controls from the general population. We also identified all first-degree relatives (parents, children, full siblings), and the index individual's first spouse. The total study population consisted of 13.0 million individuals. Data from all the study participants have been linked to Swedish National Healthcare Registers allowing research not only on such aspects as fetal and perinatal conditions and the risk of future gastrointestinal disease but also on the risk of comorbidity and complications (including cancer and death). Furthermore, the ESPRESSO database allows researchers and practitioners to identify diagnoses and disease phenotypes not currently indexed in national registers (including disease precursors). The ESPRESSO database increases the sensitivity and specificity of already-recorded diseases in the national health registers. This paper is an overview of the ESPRESSO database.

Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study

BACKGROUND

Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown.

AIM

To examine the relationship between anxiety, depression and mucosal healing in coeliac disease.

METHODS

Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression.

RESULTS

During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27).

CONCLUSION

Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.

Cognitive Impairment and Celiac Disease: Is Transcranial Magnetic Stimulation a Trait d'Union between Gut and Brain?

Celiac disease is a systemic disorder with multifactorial pathogenesis and multifaceted symptomatology. In response to gluten exposure, a significant part of the general population produces antibodies that have been hypothesized to be deleterious to the brain. Among the well-known neurological manifestations, adult celiac patients often complain cognitive symptoms, ranging from the so-called "brain fog" till an overt dementia. Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation technique that can contribute to the assessment and monitoring of celiac patients, even in those without a clear neurological involvement. The studies here reviewed seem to converge on an impaired central motor conductivity and a "hyperexcitable celiac brain" to TMS, which partially reverts back after a long-term gluten restriction. Notably, a clear hyperexcitability is a stably reported feature of both degenerative and vascular dementia. Therefore, given its potential neuroprotective effect, the gluten-free diet should be introduced as early as possible, although the overall response of neurological symptoms (and cognition in particular) is still controversial. Identifying new and possibly modifiable risk factors may be of crucial importance for patients, clinicians, and researchers.

Cognitive Impairment and Celiac Disease: Is Transcranial Magnetic Stimulation a Trait d'Union between Gut and Brain?

Celiac disease is a systemic disorder with multifactorial pathogenesis and multifaceted symptomatology. In response to gluten exposure, a significant part of the general population produces antibodies that have been hypothesized to be deleterious to the brain. Among the well-known neurological manifestations, adult celiac patients often complain cognitive symptoms, ranging from the so-called "brain fog" till an overt dementia. Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation technique that can contribute to the assessment and monitoring of celiac patients, even in those without a clear neurological involvement. The studies here reviewed seem to converge on an impaired central motor conductivity and a "hyperexcitable celiac brain" to TMS, which partially reverts back after a long-term gluten restriction. Notably, a clear hyperexcitability is a stably reported feature of both degenerative and vascular dementia. Therefore, given its potential neuroprotective effect, the gluten-free diet should be introduced as early as possible, although the overall response of neurological symptoms (and cognition in particular) is still controversial. Identifying new and possibly modifiable risk factors may be of crucial importance for patients, clinicians, and researchers.

Psychiatric Comorbidity in Children and Adults with Gluten-Related Disorders: A Narrative Review

Gluten-related disorders are characterized by both intestinal and extraintestinal manifestations. Previous studies have suggested an association between gluten-related disorder and psychiatric comorbidities. The objective of our current review is to provide a comprehensive review of this association in children and adults. A systematic literature search using MEDLINE, Embase and PsycINFO from inception to 2018 using terms of ‘celiac disease’ or ‘gluten-sensitivity-related disorders’ combined with terms of ‘mental disorders’ was conducted. A total of 47 articles were included in our review, of which 28 studies were conducted in adults, 11 studies in children and eight studies included both children and adults. The majority of studies were conducted in celiac disease, two studies in non-celiac gluten sensitivity and none in wheat allergy. Enough evidence is currently available supporting the association of celiac disease with depression and, to a lesser extent, with eating disorders. Further investigation is warranted to evaluate the association suggested with other psychiatric disorders. In conclusion, routine surveillance of potential psychiatric manifestations in children and adults with gluten-related disorders should be carried out by the attending physician.

The Effect of Depressive Symptoms on the Association between Gluten-Free Diet Adherence and Symptoms in Celiac Disease: Analysis of a Patient Powered Research Network

BACKGROUND

The prevalence of depression in celiac disease (CD) is high, and patients are often burdened socially and financially by a gluten-free diet. However, the relationship between depression, somatic symptoms and dietary adherence in CD is complex and poorly understood. We used a patient powered research network (iCureCeliac^®) to explore the effect that depression has on patients' symptomatic response to a gluten-free diet (GFD).

METHODS

We identified patients with biopsy-diagnosed celiac disease who answered questions pertaining to symptoms (Celiac Symptom Index (CSI)), GFD adherence (Celiac Dietary Adherence Test (CDAT)), and a 5-point, scaled question regarding depressive symptoms relating to patients' celiac disease. We then measured the correlation between symptoms and adherence (CSI vs. CDAT) in patients with depression versus those without depression. We also tested for interaction of depression with regard to the association with symptoms using a multiple linear regression model.

RESULTS

Among 519 patients, 86% were female and the mean age was 40.9 years. 46% of patients indicated that they felt "somewhat," "quite a bit," or "very much" depressed because of their disorder. There was a moderate correlation between worsened celiac symptoms and poorer GFD adherence (r = 0.6, p < 0.0001). In those with a positive depression screen, there was a moderate correlation between worsening symptoms and worsening dietary adherence (r = 0.5, p < 0.0001) whereas in those without depression, the correlation was stronger (r = 0.64, p < 0.0001). We performed a linear regression analysis, which suggests that the relationship between CSI and CDAT is modified by depression.

CONCLUSIONS

In patients with depressive symptoms related to their disorder, correlation between adherence and symptoms was weaker than those without depressive symptoms. This finding was confirmed with a linear regression analysis, showing that depressive symptoms may modify the effect of a GFD on celiac symptoms. Depressive symptoms may therefore mask the relationship between inadvertent gluten exposure and symptoms. Additional longitudinal and prospective studies are needed to further explore this potentially important finding.

Psychotropic medication use among patients with celiac disease

BACKGROUND

Celiac disease is a multi-system disorder with manifestations that may result in psychiatric disorders. We assessed the prevalence of medication use to treat psychiatric disorders in celiac disease patients.

METHODS

We conducted a cross-sectional study of patients undergoing esophagogastroduodenoscopy over 9-years at a celiac disease referral center. We compared the prevalence of psychotropic medication use among celiac disease patients (n = 1293) to a control group (n = 1401) with abdominal pain or reflux.

RESULTS

Among all patients the mean age was 48.4 years, most were female (69.5%), and 22.7% used any psychotropic medication. There was no difference between overall psychotropic medication use among celiac disease patients and controls (23.9% vs 21.8%, OR 1.16; 95% CI 0.96-1.39, p = 0.12). However, those with celiac disease were more likely to use antidepressants on univariate (16.4% vs 13.4%, p = 0.03) and multivariate analysis (OR 1.28; 95% CI 1.03-1.59; p = 0.03). Use of psychotropic medications was not associated with disease duration or mode of presentation of celiac disease.

CONCLUSIONS

Celiac disease patients use psychotropic medications at similar rates as those with other gastrointestinal diseases, though subgroup analysis suggests they may use more antidepressants. Future studies should investigate whether celiac disease is associated with mood disorders that are not treated with medications.

Gender-Based Differences in a Population-Based Cohort with Celiac Disease: More Alike than Unalike

BACKGROUND

There is a gap in research focused on gender-based differences in non-referral populations with celiac disease.

AIMS

The aim of this study was to estimate those differences in a unique population-based cohort of patients with celiac disease with respect to (1) presenting symptoms, (2) associated autoimmune disorders, and (3) survival.

METHODS

Clinical data were systematically abstracted from the electronic medical record of a population-based incident cohort of patients with celiac disease. Logistic regression was used to assess the strength of the association of presenting symptoms and gender. Survival differences between genders were evaluated with Cox regression.

RESULTS

We included 282 patients (females 65%, median age 39 years) diagnosed between 1990 and 2015. The female to male ratio was 1.85:1. Men and women presented similarly. Women were more likely to present with constipation (OR 2.33; 95% CI 1.06-5.12; p = 0.035). Anemia and abdominal distention or bloating were more frequently seen in women, but not on a statistically significant level. Overall autoimmune diseases were equally prevalent (31.6%) in males (30.2%) and females (32.2%) (p = 0.74). Hypothyroidism predominated in women. Age-adjusted survival was lower among men than women (HR 3.00; 95% CI 1.26-7.21, p = 0.014), but not more so than in the general population. Cancer was the most common cause of death, and there were two possible celiac disease-related deaths.

CONCLUSIONS

This study showed that men and women are more alike than unalike when it comes to celiac disease presentation and prevalence of concurrent autoimmune disease.

Coeliac disease and psychiatric comorbidity: epidemiology, pathophysiological mechanisms, quality-of-life, and gluten-free diet effects

Coeliac Disease (CD) is an autoimmune disease in which an environmental factor, gluten, triggers a pathological reaction. It results in intra- and entra-intestinal manifestations of disease, including, most frequently, diarrhoea, weight loss, and anaemia. CD occurs in ∼1% of the western population, being one of the most common autoimmune lifelong disorders, and may present with a variety of psychiatric comorbidities. Psychiatric comorbidity in CD often complicates the diagnosis, reduces the quality-of-life, and worsens the prognosis of affected patients. This review summarizes the epidemiological studies that underline this connection, and focuses on the potential mechanisms related to this comorbility, such as nutritional deficiencies, immune responses, interference in brain processes, and dysfunctions in the gut-brain axis. Factors that play a central role on patients' quality of life, psychological well-being and adherence are presented. Finally, evidence of regression in psychiatric symptoms following the introduction of a gluten-free diet is underlined as well.

Depression and insomnia among individuals with celiac disease or on a gluten-free diet in the USA: results from a national survey

BACKGROUND

There is uncertainty regarding the prevalence of psychiatric illnesses in patients with celiac disease (CD) and people who avoid gluten (PWAG) without a diagnosis of CD.

PARTICIPANTS AND METHODS

We obtained data from 22 274 participants from the 2009-2014 National Health and Nutrition Examination Survey to compare the prevalence of depression, insomnia, quality-of-life variables, and psychotropic medication use in CD participants and PWAGs to controls. We used multivariable logistic regression to assess for independent associations between CD/PWAG status and the outcomes of these variables.

RESULTS

Depression was present in 8.2% of controls compared with 3.9% of participants with CD (P=0.18) and 2.9% of PWAGs (P=0.002). After adjustment for age, sex, race, income, and access to healthcare, PWAGs maintained lower odds of depression compared with controls (odds ratio=0.25; 95% confidence interval: 0.12-0.51; P=0.0001). The prevalence estimates of sleep difficulty among controls (27.3%) compared to participants with CD or PWAGs were 37.7% (P=0.15) and 34.1% (P=0.11). Those with diagnosed CD had increased odds of sleep difficulty (odds ratio=2.41; 95% confidence interval 1.04-5.60), but this was no longer significant after multivariable adjustment (P=0.17).

CONCLUSION

Among a nationally representative US sample, participants with CD overall showed no increased odds of depression or sleep difficulty. PWAGs showed lower odds of depression compared with controls. Future research should investigate the relationship between a diagnosis of CD and the development of psychiatric conditions.

Gluten related illnesses and severe mental disorders: a comprehensive review

The putative role of gluten in the pathophysiology of severe mental illnesses remains uncertain and there is doubt about the possible benefit of gluten-free diets for individuals affected by psychosis and mood disorders. The objective of this review was to summarize the findings linking gluten related conditions to pathophysiological substrates implicated in schizophrenia and mood disorders and review the evidences of potential benefits of glute-free diets in these populations. A literature search was conducted within PubMed and Scielo databases including references from inception until March 1st 2017. The strategy search was to use the key words "gluten", "celiac disease", "wheat", "bipolar disorder", "mood disorders", "psychosis", "schizophrenia", "depression". In the review about the potential efficacy of gluten-free diets in severe mental illnesses, we included only studies with original data, including cross sectional and longitudinal studies and clinical trials. Book chapters, review articles and meta-analysis and republished data were excluded. Although the current available evidences suggest that people with celiac disease or gluten allergy could have a slightly higher risk of schizophrenia and mood disorders compared to the general population, the literature review reveals significant inaccuracies in the data. There is insufficient evidence to recommend gluten-free diets for populations with psychosis and mood disorders.

Celiac Disease Is Associated with Childhood Psychiatric Disorders: A Population-Based Study

OBJECTIVES

To determine the risk of future childhood psychiatric disorders in celiac disease, assess the association between previous psychiatric disorders and celiac disease in children, and investigate the risk of childhood psychiatric disorders in siblings of celiac disease probands.

STUDY DESIGN

This was a nationwide registry-based matched cohort study in Sweden with 10 903 children (aged <18 years) with celiac disease and 12 710 of their siblings. We assessed the risk of childhood psychiatric disorders (any psychiatric disorder, psychotic disorder, mood disorder, anxiety disorder, eating disorder, psychoactive substance misuse, behavioral disorder, attention-deficit hyperactivity disorder [ADHD], autism spectrum disorder [ASD], and intellectual disability). HRs of future psychiatric disorders in children with celiac disease and their siblings was estimated by Cox regression. The association between previous diagnosis of a psychiatric disorder and current celiac disease was assessed using logistic regression.

RESULTS

Compared with the general population, children with celiac disease had a 1.4-fold greater risk of future psychiatric disorders. Childhood celiac disease was identified as a risk factor for mood disorders, anxiety disorders, eating disorders, behavioral disorders, ADHD, ASD, and intellectual disability. In addition, a previous diagnosis of a mood, eating, or behavioral disorder was more common before the diagnosis of celiac disease. In contrast, siblings of celiac disease probands were at no increased risk of any of the investigated psychiatric disorders.

CONCLUSIONS

Children with celiac disease are at increased risk for most psychiatric disorders, apparently owing to the biological and/or psychological effects of celiac disease.

Anxiety and depression in caregivers of individuals with celiac disease - A population-based study

BACKGROUND & AIMS

Partner burden is common in celiac disease (CD), but it is unclear if parents of children with CD have increased burden, and if this may translate into depression and anxiety meriting healthcare.

METHODS

Nationwide population-based study of 41,753 parents and spouses ("caregivers") to 29,096 celiac patients and 215,752 caregivers to 144,522 matched controls. Caregivers were identified from the Swedish Total Population Register, and linked to data on psychiatric disease in the National Patient Registry. Hazard ratios (HRs) for depression, anxiety, and (as a reference outcome measure) bipolar disorder were examined in a lifetime fashion but also in temporal relationship to date of CD diagnosis using Cox regression. A priori, we focused on parents of individuals diagnosed ≤19 years of age (children at the age of disease onset) and spouses of individuals diagnosed in adulthood, as such parents and spouses ("high-risk caregivers") were most likely to live together with the patient at time of disease onset.

RESULTS

On Cox analysis, depression was 11% more common in high-risk caregivers (HR=1.11: 95%CI=1.03-1.19) than in control caregivers while anxiety was 7% more common (HR=1.07: 95%CI=0.98-1.16). Combining anxiety and depression into a composite outcome measure, there was an 8% statistically significant risk increase (95%CI=1.02-1.14). The highest excess risks for both depression and anxiety were seen just before and 4-8 years after the CD diagnosis. In contrast, bipolar disorder was not more common in caregivers to CD patients.

CONCLUSION

Caregivers to patients with CD may be at increased risk of severe burden.

Celiac disease and Down syndrome mortality: a nationwide cohort study

Background

Individuals with Down syndrome (DS) have increased mortality and are also at increased risk of celiac disease (CD). It is unknown if CD influences mortality in DS. In this study we examined the risk of death in individuals with DS according to celiac status.

Methods

In this nationwide population-based cohort study, we first identified individuals with CD (diagnosed 1969–2008) through small intestinal biopsy report data showing villous atrophy (Marsh stage III) from Sweden’s 28 pathology departments. Celiac individuals were then matched with up to five reference individuals from the general population. In these cohorts we identified individuals with DS using International Classification of Disease codes (ICD) registered in the Swedish Patient Register (includes inpatients and hospital-based outpatients), the Medical Birth Register, and the Register of Congenital Malformations. Of 29,096 individuals with CD, 201 (0.7%) had DS compared to 124 of the 144,522 reference individuals (0.09%). Data on mortality were obtained from the Swedish Cause of Death Registry. Hazard ratios (HRs) for death were calculated using Cox regression.

Results

During follow-up, there were seven deaths among individuals with DS and CD (7/201, 3.5%) as compared with 14 deaths among DS individuals without a record of CD (14/124, 11.3%). Adjusting for potential confounders, CD did not influence the risk of death in DS (HR = 1.36; 95%CI = 0.33–5.59). Cardiovascular death occurred in two individuals with CD and three individuals without CD, while death from malignancy occurred in one individual with CD and two individuals without CD.

Conclusion

While both DS and CD have been linked to increased risk of death, this study found no excess mortality in DS patients with a concurrent diagnosis of CD, however confidence intervals were wide.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0801-4) contains supplementary material, which is available to authorized users.

Is Toxoplasma gondii a Trigger of Bipolar Disorder?

Toxoplasma gondii, a ubiquitous intracellular parasite, has a strong tropism for the brain tissue, where it forms intracellular cysts within the neurons and glial cells, establishing a chronic infection. Although latent toxoplasmosis is generally assumed to be asymptomatic in immunocompetent individuals, it is now clear that it can induce behavioral manipulations in mice and infected humans. Moreover, a strong relation has emerged in recent years between toxoplasmosis and psychiatric disorders. The link between T. gondii and schizophrenia has been the most widely documented; however, a significant association with bipolar disorder (BD) and suicidal/aggressive behaviors has also been detected. T. gondii may play a role in the etiopathogenesis of psychiatric disorders affecting neurotransmitters, especially dopamine, that are implicated in the emergence of psychosis and behavioral Toxoplasma-induced abnormalities, and inducing brain inflammation by the direct stimulation of inflammatory cytokines in the central nervous system. Besides this, there is increasing evidence for a prominent role of immune dysregulation in psychosis and BD. The aim of this review is to describe recent evidence suggesting a link between Toxoplasma gondii and BD, focusing on the interaction between immune responses and this infectious agent in the etiopathogenesis of psychiatric symptoms.

Diagnosis and Updates in Celiac Disease

Celiac disease is an autoimmune disorder induced by gluten in genetically susceptible individuals. It can result in intraintestinal and extraintestinal manifestations of disease including diarrhea, weight loss, anemia, osteoporosis, or lymphoma. Diagnosis of celiac disease is made through initial serologic testing and then confirmed by histopathologic examination of duodenal biopsies. Generally celiac disease is a benign disorder with a good prognosis in those who adhere to a gluten-free diet. However, in refractory disease, complications may develop that warrant additional testing with more advanced radiologic and endoscopic methods. This article reviews the current strategy to diagnose celiac disease and the newer modalities to assess for associated complications.

The progression of coeliac disease: its neurological and psychiatric implications

The aim of the paper is to show the various neurological and psychiatric symptoms in coeliac disease (CD). CD is a T cell-mediated, tissue-specific autoimmune disease which affects genetically susceptible individuals after dietary exposure to proline- and glutamine-rich proteins contained in certain cereal grains. Genetics, environmental factors and different immune systems, together with the presence of auto-antigens, are taken into account when identifying the pathogenesis of CD. CD pathogenesis is related to immune dysregulation, which involves the gastrointestinal system, and the extra-intestinal systems such as the nervous system, whose neurological symptoms are evidenced in CD patients. A gluten-free diet (GFD) could avoid cerebellar ataxia, epilepsy, neuropathies, migraine and mild cognitive impairment. Furthermore, untreated CD patients have more symptoms and psychiatric co-morbidities than those treated with a GFD. Common psychiatric symptoms in untreated CD adult patients include depression, apathy, anxiety, and irritability and schizophrenia is also common in untreated CD. Several studies show improvement in psychiatric symptoms after the start of a GFD. The present review discusses the state of the art regarding neurological and psychiatric complications in CD and highlights the evidence supporting a role for GFD in reducing neurological and psychiatric complications.

Development of a Risk Score for Extraintestinal Manifestations of Coeliac Disease

The aim of this study was to identify indicators of coeliac disease (CD) in an Australian cohort, beyond the known gastrointestinal symptoms. Individuals were recruited from the general population and at the 2014 Gluten Free Expo in Sydney and in Melbourne, Australia. Data on their current health status including medical history, diagnosis for CD, and family history were collected. Multivariable logistic regression was used to identify independent predictors of CD. A weighted risk score system was then generated for the independent predictors, and a risk score was calculated for each individual. A total of 301 individuals were included in the study. We found an association between CD and having a family history of CD (odds ratio [OR] 7.6, 95%confidence interval [CI] 3.7-15.6), an autoimmune disorder (OR 2.1, 95%CI 1.1-4.1), anemia (OR 5.8, 95%CI 2.8-11.9), lactose intolerance (OR 4.5, 95%CI 1.2-17.7), and depression (OR 4.8, 95%CI 1.9-11.6). Risk score analysis found individuals in the medium (OR 4.8, 95%CI 2.5 to 9.3) and high-risk (OR 36.6, 95%CI 16.4 to 81.6) groups were significantly more likely to report having CD compared with those in the low-risk group. This study identifies a set of factors more commonly observed in individuals with CD, beyond the traditional gastrointestinal complaints. These include a family history of CD, the presence of another autoimmune disorder, anemia, lactose intolerance, and depression. A risk score was developed (Coeliac Risk COMPARE) which scores individuals based on the presence or absence of these additional symptoms and provides an additional screening tool when assessing whether the patient requires follow-up testing for CD.

Bread and Other Edible Agents of Mental Disease

Perhaps because gastroenterology, immunology, toxicology, and the nutrition and agricultural sciences are outside of their competence and responsibility, psychologists and psychiatrists typically fail to appreciate the impact that food can have on their patients' condition. Here we attempt to help correct this situation by reviewing, in non-technical, plain English, how cereal grains-the world's most abundant food source-can affect human behavior and mental health. We present the implications for the psychological sciences of the findings that, in all of us, bread (1) makes the gut more permeable and can thus encourage the migration of food particles to sites where they are not expected, prompting the immune system to attack both these particles and brain-relevant substances that resemble them, and (2) releases opioid-like compounds, capable of causing mental derangement if they make it to the brain. A grain-free diet, although difficult to maintain (especially for those that need it the most), could improve the mental health of many and be a complete cure for others.

The role of IgG hypersensitivity in the pathogenesis and therapy of depressive disorders

Depressive episodes are associated not only with changes in neurotransmission in the central nervous system, but also may lead to structural changes in the brain through neuroendocrine, inflammatory, and immunological mechanisms. The aim of this article is to present a new hypothesis connecting the inflammatory theory of depression with IgG food hypersensitivity and leaky gut syndrome. This new potential pathway that may mediate the pathogenesis of depression implies the existence of subsequent developmental stages. Overproduction of zonulin triggered, for example, by gliadin through activation of the epidermal growth factor receptor and protease-activated receptor causes loosening of the tight junction barrier and an increase in permeability of the gut wall ('leaky gut'). This results in a process allowing larger molecules that would normally stay in the gut to cross into the bloodstream and in the induction of IgG-dependent food sensitivity. This condition causes an increased immune response and consequently induces the release of proinflammatory cytokines, which in turn may lead to the development of depressive symptoms. It seems advisable to assess the intestinal permeability using as a marker, for example, zonulin and specific IgG concentrations against selected nutritional components in patients with depression. In the case of increased IgG concentrations, the implementation of an elimination-rotation diet may prove to be an effective method of reducing inflammation. This new paradigm in the pathogenesis of depressive disorders linking leaky gut, IgG-dependent food sensitivity, inflammation, and depression is promising, but still needs further studies to confirm this theory.

The Burden of Depressive and Bipolar Disorders in Celiac Disease

Introduction:

Aims: to measure the association between Celiac Disease (CD) and affective disorders, particularly Bipolar Disorder (BD), since it has not been studied yet, and to measure how much the quality of life (QoL) of a person with CD is affected by comorbidity with these disorders.

Methods:

Design: Case-control study. Cases: 60 consecutive patients with CD. Controls: 240 subjects without CD, randomly selected after sex- and age-matching from a database of an epidemiological study. Psychiatric diagnoses according to DSM-IV carried out by physicians using structured interview tools (ANTAS-SCID). QoL was measured by means of SF-12.

Results:

The lifetime prevalence of Major Depressive Disorder (MDD) was higher in CD than in controls (30.0% vs 8.3%, P<0.0001) as well as Panic Disorder (PD) (18.3% vs 5.4%, P<0.001) and BD (4.3% vs 0.4%, P<0.005). Patients with CD show a lower mean score than controls on SF12 (35.8±5.7 vs. 38.2±6.4; p=0.010), but those without comorbidity with MDD, PD and BD do not. The attributable burden of CD in worsening QoL - when comorbid with these disorders - was found comparable to that of serious chronic diseases like Wilson’s Disease, and lower than Multiple Sclerosis only.

Conclusion:

MDD, PD and BD are strictly associated with CD. The comorbidity with these disorders is the key determinant of impaired quality of life in CD. Thus a preventive action on mood and anxiety disorders in patients suffering from CD is required. Moreover a screening for CD in people with affective disorders and showing key symptoms or family history of CD is recommended.

Effects of Gluten-Free Diet on Quality of Life and Depression in Children With Celiac Disease

OBJECTIVES

The aim of this study was to investigate the level of depression and quality of life in children with celiac disease (CD). In addition, it aimed to examine the relations of depression level and life quality with adherence to a gluten-free diet (GFD).

METHODS

Twenty-five children with CD and 25 healthy controls were included. The Depression Scale for Children and the General Purpose Health-Related Quality of Life Scale for Children were performed on patients before and after receiving recommendations to follow a GFD.

RESULTS

No significant differences were found in the depression scores between the patients and the control subjects (P > 0.05). In contrast, total scores and scores of the emotional well-being subscale of the measure of Quality of Life Scale for Children were significantly lower in patients with CD compared with the control group (P < 0.05). No significant improvements were observed in depression or life quality scores of the total subsample of celiac patients, all of whom received a recommendation to follow a GFD (P > 0.05). Significant decrease was observed in the depression scores, however, of celiac patients who were able to actually adhere to the GFD compared with nonadherent patients.

CONCLUSIONS

CD negatively affected quality of life in children. Adherence to GFD was associated with reduction in depression symptoms. Improving the adherence of celiac patients to a GFD may have a favorable effect on their depression symptoms.

Psychological morbidity of celiac disease: A review of the literature

BACKGROUND

Celiac disease has been linked to decreased quality of life and certain mood disorders. The effect of the gluten free diet on these psychological aspects of the disease is still unclear.

OBJECTIVES

The objective of this article is to review the literature on psychological morbidity of celiac disease.

METHODS

We performed a PubMed search for the time period from 1900 until June 1, 2014, to identify papers on psychological aspects of celiac disease looking specifically at quality of life, anxiety, depression and fatigue.

RESULTS

Anxiety, depression and fatigue are common complaints in patients with untreated celiac disease and contribute to lower quality of life. While aspects of these conditions may improve within a few months after starting a gluten-free diet, some patients continue to suffer from significant psychological morbidity. Psychological symptoms may affect the quality of life and the dietary adherence.

CONCLUSION

Health care professionals need to be aware of the ongoing psychological burden of celiac disease in order to support patients with this disease.

Increased use of hypnotics in individuals with celiac disease: a nationwide case-control study

Background

Although poor sleep is common in numerous gastrointestinal diseases, data are scarce on the risk of poor sleep in celiac disease. The objective of this study was to estimate the risk of repeated use of hypnotics among individuals with celiac disease as a proxy measure for poor sleep.

Methods

This is a nationwide case–control study including 2933 individuals with celiac disease and 14,571 matched controls from the general Swedish population. Poor sleep was defined as ≥2 prescriptions of hypnotics using prospective data from the National Prescribed Drug Register (data capture: July 2005-January 2008). We estimated odds ratios and hazard ratios for poor sleep before and after celiac disease diagnosis respectively.

Results

In this study, poor sleep was seen in 129/2933 individuals (4.4%) with celiac disease, as compared with 487/14,571 controls (3.3%) (odds ratio = 1.33; 95% CI = 1.08-1.62). Data restricted to sleep complaints starting ≥1 year before celiac disease diagnosis revealed largely unchanged risk estimates (odds ratio = 1.23; 95% CI = 0.88-1.71) as compared with the overall risk (odds ratio 1.33). The risk of poor sleep in celiac disease was essentially not influenced by adjustment for concomitant psychiatric comorbidity (n = 1744, adjusted odds ratio =1.26; 95% CI = 1.02-1.54) or restless legs syndrome (n = 108, adjusted odds ratio = 1.33; 95% CI = 1.08-1.63). Poor sleep was also more common after celiac disease diagnosis as compared with matched controls (hazard ratio = 1.36; 95% CI = 1.30-1.41).

Conclusions

In conclusion, individuals with celiac disease suffer an increased risk of poor sleep, both before and after diagnosis. Although we cannot rule out that surveillance bias has contributed to our findings, our results are consistent with previous data suggesting that sleep complaints may be a manifestation of celiac disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0236-z) contains supplementary material, which is available to authorized users.

Celiac and non-celiac gluten sensitivity: a review on the association with schizophrenia and mood disorders

An association between many psychiatric and gluten-related disorders has been known for some time. In the case of schizophrenia and mood disorders, the major psychiatric disorders, there is much evidence, not without contradictions, of a possible association between schizophrenia and celiac disease. The association between mood disorders and gluten-related disorders, especially celiac disease, has only been studied for depression, often coupled with anxiety, and very recently for bipolar disorder. Since non-celiac gluten sensitivity is now known to be different from celiac disease, many studies have shown that gluten sensitivity is also associated with major psychiatric disorders. Here we review the literature on the association between schizophrenia/mood disorders and celiac disease/gluten sensitivity, pointing out the differences between these associations.

Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology

A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.

Randomised clinical trial: gluten may cause depression in subjects with non-coeliac gluten sensitivity - an exploratory clinical study

BACKGROUND

Current evidence suggests that many patients with self-reported non-coeliac gluten sensitivity (NCGS) retain gastrointestinal symptoms on a gluten-free diet (GFD) but continue to restrict gluten as they report 'feeling better'.

AIM

To investigate the notion that a major effect of gluten in those with NCGS is on mental state and not necessarily on gastrointestinal symptoms.

METHODS

Twenty-two subjects (24-62 years, five male) with irritable bowel syndrome who had coeliac disease excluded but were symptomatically controlled on a GFD, undertook a double-blind cross-over study. Participants randomly received one of three dietary challenges for 3 days, followed by a minimum 3-day washout before crossing over to the next diet. Challenge gluten-free food was supplemented with gluten (16 g/day), whey (16 g/day) or not supplemented (placebo). End-points included mental state as assessed by the Spielberger State Trait Personality Inventory (STPI), cortisol secretion and gastrointestinal symptoms.

RESULTS

Gluten ingestion was associated with higher overall STPI state depression scores compared to placebo [M = 2.03, 95% CI (0.55-3.51), P = 0.010] but not whey [M = 1.48, 95% CI (-0.14 to 3.10), P = 0.07]. No differences were found for other STPI state indices or for any STPI trait measures. No difference in cortisol secretion was identified between challenges. Gastrointestinal symptoms were induced similarly across all dietary challenges.

CONCLUSIONS

Short-term exposure to gluten specifically induced current feelings of depression with no effect on other indices or on emotional disposition. Gluten-specific induction of gastrointestinal symptoms was not identified. Such findings might explain why patients with non-coeliac gluten sensitivity feel better on a gluten-free diet despite the continuation of gastrointestinal symptoms.