Cognitive-behavioral therapy for depression in adolescents with inflammatory bowel disease: a pilot study

Feasibility, Acceptability, and Preliminary Efficacy of Acceptance Commitment Therapy for Adults Living With Inflammatory Bowel Disease and Distress

BACKGROUND

The bidirectional relationship between inflammatory bowel disease (IBD) flare-ups and depression/anxiety symptoms has prompted investigations into psychotherapy to improve health-related quality of life (HRQoL) by targeting depression and anxiety. Acceptance commitment therapy (ACT) is effective in improving symptoms of depression and anxiety in people with chronic diseases, yet minimal research has examined ACT's effectiveness for IBD. This study examines the feasibility, acceptability, and preliminary efficacy of the ACTforIBD program, an online program codesigned with consumers to deliver ACT to those with IBD.

METHODS

Adults with IBD and symptoms of mild-moderate distress were randomized to ACTforIBD or an active control (psychoeducation) condition. Participants completed 8 weekly, 1-hour sessions, 4 of which were therapist facilitated. Feasibility was based on recruitment and retention and acceptability was derived from postprogram satisfaction measures. Preliminary efficacy was determined by group differences in rate of change in study outcomes from baseline to postprogram.

RESULTS

Of 62 participants (89% women, 11% men; mean age  33 years), 55 completed the program (ACTforIBD: n = 26 [83.9%]; active control: n = 29 [93.5%]). Adherence and acceptability were high in the ACTforIBD group, with 80% of participants completing all self-directed modules and 78% of participants expressing satisfaction with the program. Significant and marginally significant group × time interactions were found for anxiety symptoms (b = -1.89; 95% confidence interval, -3.38 to -0.42) and psychological HRQoL (b = -0.04; 95% confidence interval, -0.07 to 0.01), showing decreased anxiety and increased psychological HRQoL in the intervention group.

CONCLUSIONS

ACTforIBD is feasible, acceptable, and improved anxiety symptoms, and psychological HRQoL. This highlights the need for a full-scale randomized controlled trial to further examine the program's efficacy.

The impact of integrating behavioral health services into pediatric subspecialty care: A systematic review

Pediatric gastroenterology patients are at risk for co-occurring behavioral health concerns, such as depression and anxiety, compared with youth without medical conditions. The objective of this systematic review was to assess the scientific literature supporting the hypothesis that integrating behavioral health services into gastroenterology clinics could improve patient psychosocial well-being. We searched MEDLINE, EMBASE, The Cochrane Library, Web of Science, PsycINFO, and CINAHL databases and gray literature to identify studies reporting the impact of behavioral health integration on the psychosocial well-being of pediatric gastroenterology patients. Two independent coders evaluated each study for inclusion and extracted data regarding patient demographics, study design, behavioral health integration approaches, and psychosocial outcomes. Results were synthesized using narrative review procedures. Eighteen studies met the inclusion criteria. Most reported outcomes from research grant-funded randomized controlled trials or open trials investigating behavioral health interventions based on Cognitive-Behavioral Therapy, primarily with youth with irritable bowel disease or functional gastrointestinal disorders. Within the highest-quality, comparable studies, nearly 80% reported at least one statistically significant treatment effect on patient psychosocial well-being. Many studies used rigorous methods that minimize bias, but did not provide models for sustainable, programmatic behavioral health integration outside the bounds of a research study. The studies included in this review suggest that behavioral integration could have the potential to positively impact gastroenterology patients' psychosocial functioning. However, more research is needed to investigate the appropriate intensity of behavioral health services and evaluate models for integrating behavioral healthcare in pediatric gastroenterology settings beyond the research-funded clinical trial context.

Efficacy of psychological therapies in people with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

There is increasing evidence for an influence of the gut-brain axis on the natural history of inflammatory bowel disease (IBD). Psychological therapies could, therefore, have beneficial effects in individuals with IBD, but data are conflicting. We aimed to update our previous systematic review and meta-analysis to assess whether the inclusion of more randomised controlled trials (RCTs) showed any beneficial effects and whether these effects varied by treatment modality.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials from Jan 1, 2016, to April 30, 2023, for RCTs published in any language recruiting individuals aged 16 years or older with IBD that compared psychological therapy with a control intervention or treatment as usual. We pooled dichotomous data to obtain relative risks (RR) with 95% CIs of inducing remission in people with active disease or of relapse in people with quiescent disease at final follow-up. We pooled continuous data to estimate standardised mean differences (SMD) with 95% CIs in disease activity indices, anxiety scores, depression scores, stress scores, and quality-of-life scores at completion of therapy and at final follow-up. We pooled all data using a random-effects model. Trials were analysed separately according to whether they recruited people with clinically active IBD or predominantly individuals whose disease was quiescent. We conducted subgroup analyses by mode of therapy and according to whether trials recruited selected groups of people with IBD. We used the Cochrane risk of bias tool to assess bias at the study level and assessed funnel plots using the Egger test. We assessed heterogeneity using the I2 statistic.

FINDINGS

The updated literature search identified a total of 469 new records, 11 of which met eligibility criteria. 14 studies were included from our previous meta-analysis published in 2017. In total, 25 RCTs were eligible for this meta-analysis, all of which were at high risk of bias. Only four RCTs recruited patients with active IBD; there were insufficient data for meta-analysis of remission, disease activity indices, depression scores, and stress scores. In patients with active IBD, psychological therapy had no benefit compared with control for anxiety scores at completion of therapy (two RCTs; 79 people; SMD -1·04, 95% CI -2·46 to 0·39), but did have significant benefit for quality-of-life scores at completion of therapy (four RCTs; 309 people; 0·68, 0·09 to 1·26), although heterogeneity between studies was high (I2=82%). In individuals with quiescent IBD, RR of relapse of disease activity was not reduced with psychological therapy (ten RCTs; 861 people; RR 0·83, 95% CI 0·62 to 1·12), with moderate heterogeneity (I2=60%), and the funnel plot suggested evidence of publication bias or other small study effects (Egger test p=0·046). For people with quiescent IBD at completion of therapy, there was no difference in disease activity indices between psychological therapy and control (13 RCTs; 1015 people; SMD -0·01, 95% CI -0·13 to 0·12; I2=0%). Anxiety scores (13 RCTs; 1088 people; -0·23, -0·36 to -0·09; 18%), depression scores (15 RCTs; 1189 people; -0·26, -0·38 to -0·15; 2%), and stress scores (11 RCTs; 813 people; -0·22, -0·42 to -0·03; 47%) were significantly lower, and quality-of-life scores (16 RCTs; 1080 people; 0·31, 0·16 to 0·46; 30%) were significantly higher, with psychological therapy versus control at treatment completion. Statistically significant benefits persisted up to final follow-up for depression scores (12 RCTs; 856 people; -0·16, -0·30 to -0·03; 0%). Effects were strongest in RCTs of third-wave therapies and in RCTs that recruited people with impaired psychological health, fatigue, or reduced quality of life at baseline.

INTERPRETATION

Psychological therapies have beneficial, short-term effects on anxiety, depression, stress, and quality-of-life scores, but not on disease activity. Further RCTs in selected groups are needed to establish the place for such therapies in IBD care.

FUNDING

None.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Mental Health and Inflammatory Bowel Disease

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn's disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.

IBD-related mental health disorders: where do we go from here?

Inflammatory bowel disease is a complex and debilitating disease which is known to cause mental burden for patients. Even though few studies look at mental health disease in this cohort of patients, there is growing evidence of a correlation between disease activity and prevalence of mental health conditions such as anxiety, depression and post-traumatic stress disorder. In this literature review, the relationship between inflammatory bowel disease and mental health disorders is explored, with an emphasis on recognition, screening and therapeutic options and special considerations for these complex comorbidities. The relationship between medical and psychological disease is not often considered and less well understood and there is a need for further research in these fields. Patients would have much to gain both medically and psychologically from a multidisciplinary approach to this chronic disease association.

Diagnosis and Psychotherapeutic Needs by Early Maladaptive Schemas in Patients With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is chronic and incurable. Imperious diarrhea, rectal bleeding, fatigue, and weight loss, the main manifestations, cause a decrease in the quality of the patient's personal and professional life. The objectives of this study were to identify a possible relationship between early maladaptive schemas and disease activity status using logistic regression, to identify the prevalence of early maladaptive schemes in patients and to propose a psychotherapeutic intervention plan. The following were found in a sample of 46 patients aged 16-76 years. An increase in the domain overvigilance and inhibition score had a significant effect (Wald = 6.583, p = 0.010), with an increase of 1.137 CI95% [1.031, 1.254] of the risk of the disease being diagnosed as active. High and very high scores were observed for the emotional deprivation scheme (nearly three-quarters) and dependence/incompetence, vulnerability to harm and illness and subjugation schemas (over 80%). The results show that the proposed model could predict and reconfirm the diagnosis; patients have specific psychotherapeutic needs. The therapeutic goal would be to offer care, empathy and protection, to strengthen self-confidence, to make patients realize that they have the ability to cope, to provide permission, encourage the patient to experiment, and guide the patient to express their anger healthily. The therapy scheme's intervention could lead to increased long-term disease management capacity and, consequently, reduce costs directly and indirectly caused by this condition.

Promoting psycho-social wellbeing for engaging inflammatory bowel disease patients in their care: an Italian consensus statement

BACKGROUND

Inflammatory bowel diseases (IBD) are remitting and relapsing diseases that mainly interest the gastrointestinal tract. IBD is associated with a condition of psycho-social discomfort that deeply compromises the quality of life and the competence of patient to be fully engaged in their self-management. As a consequence, effective care of IBD patients should include not only medical but also psychological support in order to improve patients' wellbeing. Although this, to date there is no standardized approach to promote psychological wellbeing of IBD patients in order to improve the perception of the quality of the care. To fill this gap, a consensus conference has been organized in order to define the psychosocial needs of IBD patients and to promote their engagement in daily clinical practice. This paper describes the process implemented and illustrates the recommendations deriving from it, which focus on the importance of a multidisciplinary approach in IBD management.

RESULTS

The consensus conference has been organized in three phases: (1) literature review about life experiences, engagement, and psychosocial needs of IBD patients; (2) workshops with IBD experts and patients' representatives; (3) drafting of statements and voting. Seventy-three participants were involved in the consensus conference, and sixteen statements have been voted and approved during the consensus process.

CONCLUSIONS

The main conclusion is the necessity of the early detection of - and, in case of need, intervention on- psycho-social needs of patients in order to achieve patient involvement in IBD care.

Burden of comorbid anxiety and depression in patients with inflammatory bowel disease: a systematic literature review

INTRODUCTION

Patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, often have comorbid anxiety and depression that affects their quality of life (QoL) and management of their IBD.

AREAS COVERED

A systematic literature review (SLR) was conducted to identify articles and conference abstracts on comorbid anxiety and depression in IBD patients using MEDLINE® and Embase® (January 2003 - June 2018). The impact of these psychological comorbidities on QoL and economic burden was examined. Non-pharmacologic interventions and disease-specific unmet clinical needs associated with these comorbidities were also evaluated.

EXPERT OPINION

There is evidence that individual and group-based cognitive behavioral therapy can reduce rates of anxiety and depression in adults and adolescents with IBD. Patients with IBD and anxiety or depression had an increased risk of hospitalization, emergency department visits, readmission, and used outpatient services more often than people without these conditions. Several disease-specific unmet clinical needs for IBD patients were identified. These included lack of reimbursement for mental-health care, inconsistent screening for psychological comorbidities and patients not consulting mental-health professionals when needed. IBD patients may benefit from integrated medical and psychological treatment, and should be considered for behavioral treatment.Plain Language Summary.

BACKGROUND

People with IBD may have mental-health conditions, such as anxiety and depression. These conditions can affect people's quality of life and how they manage their IBD.

WHAT DID THIS REVIEW LOOK AT?

We found 79 publications on anxiety or depression in people with IBD, published between January 2003 and June 2018. In people with IBD and anxiety or depression, researchers looked at: the impact on health-related quality of life and healthcare utilization, including access to and reimbursement for mental-health services how effective interventions that do not involve the use of medicines were (known as non-pharmacologic therapy).

WHAT WERE THE MAIN FINDINGS FROM THIS REVIEW?

People with IBD and anxiety or depression were more likely to be admitted to hospital and visit emergency departments than people without these conditions. Access to mental-health care varied and some people with IBD were not screened for depression.Individual and group-based talking therapy (known as cognitive behavioral therapy) reduced rates of anxiety and depression in some people with IBD.

WHAT WERE THE MAIN CONCLUSIONS FROM THIS REVIEW?

We found evidence that people with IBD and anxiety or depression may benefit from certain non-pharmacologic interventions. However, many people with IBD and anxiety or depression did not have access to mental-health services. Healthcare professionals should address gaps in patient care to improve outcomes in people with IBD and anxiety or depression.See Additional file 1 for an infographic plain language summary.

Review: How has cognitive behaviour therapy been adapted for adolescents with comorbid depression and chronic illness? A scoping review

BACKGROUND

Depression becomes increasingly common in adolescence. Around 10%-20% of adolescents have a chronic illness, and they are more likely to experience depression. There is emerging evidence for cognitive behaviour therapy (CBT) interventions to treat depression in adolescents with chronic illnesses, yet no review has been undertaken of how these CBT interventions are delivered in practice.

METHODS

We conducted a scoping review to summarise how CBT has been delivered in adolescents with chronic illness and depression. We included studies that evaluated CBT aimed at treating depression/depressive symptoms in adolescents with chronic illness. Searches were carried out across Embase and PsycNET.

RESULTS

Twelve studies met our inclusion criteria. These included diabetes (n = 3), inflammatory bowel disease (n = 3), polycystic ovary syndrome (n = 2), chronic headache (n = 1), chronic pain (n = 1), chronic fatigue syndrome (n = 1) and Fanconi anaemia (n = 1). Adaptations made to the delivery of CBT included cognitive restructuring of illness-related thoughts, behavioural activation balancing illness-related and enjoyable activities, psychoeducation of the comorbidity and link between the chronic illness and depression, relationship building, skill building and parental or familial involvement. CBT was typically delivered by trained professionals with expertise in working with adolescents, who worked under supervision.

CONCLUSIONS

CBT for depression is commonly adapted for this population, and the nature of cognitions and behaviours targeted in CBT may typically depend on how the chronic illness presents. There is relatively little evidence to date, and a need for more research into the efficacy and effectiveness of treatments for adolescent depression in this vulnerable population specifically.

Psychological Treatments for Depression in Adolescents: More Than Three Decades Later

Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well-CBT and IPT-has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.

Systematic Review: Psychosocial Correlates of Pain in Pediatric Inflammatory Bowel Disease

BACKGROUND

Pain is a common symptom in pediatric inflammatory bowel disease (IBD) and is associated with poor health outcomes, yet additional knowledge about the psychosocial correlates of pain is needed to optimize clinical care. The purpose of this study is to systematically review the psychosocial factors associated with pain and pain impact in youth diagnosed with IBD within a developmentally informed framework.

METHODS

Manual and electronic searches yielded 2641 references. Two authors conducted screening (98% agreement), and data extraction was performed in duplicate. Average study quality was rated using the National Institutes of Health Quality Assessment Tool.

RESULTS

Ten studies (N = 763 patients; N = 563 Crohn disease, N = 200 ulcerative/ indeterminate colitis) met the inclusion criteria. Findings showed consistent evidence that higher levels of child depression symptoms and child pain catastrophizing were associated with significantly greater pain and pain impact (magnitude of association ranged from small to large across studies). Greater pain and pain impact were also associated with higher levels of child anxiety symptoms, child pain threat, child pain worry, and parent pain catastrophizing. Within the included studies, female sex and disease severity were both significantly associated with pain and pain impact. Study quality was moderate on average.

CONCLUSIONS

There is evidence that child psychosocial factors are associated with pain and pain impact in pediatric IBD; more studies are needed to examine parent- and family-level psychosocial factors. Youth with IBD should be routinely screened for pain severity, pain impact, and psychosocial risk factors such as anxiety/depression.

Stressful life events, depression, and the moderating role of psychophysiological reactivity in patients with pediatric inflammatory bowel disease

OBJECTIVE

The development of depressive symptoms in youth with IBD is a concerning disease complication, as higher levels of depressive symptoms have been associated with poorer quality of life and lower medication adherence. Previous research has examined the association between disease activity and depression, but few studies have examined individual differences in experience of stressful life events in relation to depressive symptoms. The purpose of the current study is to examine the relation between stressful life events and depression within pediatric IBD and to determine whether individual differences in stress response moderates this association.

METHODS

56 youth ages 8-17 years old diagnosed with IBD completed questionnaires about their depressive symptoms and history of stressful life events. We assessed skin conductance reactivity (SCR) to a stressful task as an index of psychophysiological reactivity.

RESULTS

Stressful life events (r = 0.36, p = .007) were positively related to depressive symptoms. Youth who demonstrated a greater maximum SC level during the IBD-specific stress trial compared to baseline (n = 32) reported greater depressive symptoms. For these same participants, the relationship between stressful life events and depressive symptoms depended on SCR F(3, 28) = 4.23, p = .01, such that at moderate and high levels of SCR, a positive relationship between stressful life events and depressive symptoms was observed.

CONCLUSIONS

The relationship between stressful life events and depressive symptoms in youth with IBD may depend on individual differences in processing stress, such that risk may increase with greater psychophysiological reactivity.

Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses

BACKGROUND

Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2).

DATA SOURCES

For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted.

REVIEW METHODS

The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project.

RESULTS

Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research.

LIMITATIONS

Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis.

CONCLUSIONS

There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Depression Screening in Pediatric Inflammatory Bowel Disease Clinics: Recommendations and a Toolkit for Implementation

OBJECTIVE

Rates of youth depression are increasing, and approximately 75% of adolescents with depression go unrecognized. Research in pediatric IBD documents increased depression risk, with rates up to 25%, as well as worse adherence and treatment outcomes associated with depressive symptoms. Evidence-based psychological interventions improve the physical and emotional health of these patients, highlighting the importance of detection and treatment. Psychosocial screening has been shown to increase the accurate identification of psychosocial problems and facilitate timely psychosocial intervention. The objective of this article is to establish clinical guidelines for depression screening in youth diagnosed with IBD and to provide resources for implementation.

METHODS

The psychosocial screening task force group constituted of psychologists and social workers in the ImproveCareNow (ICN) learning health system reviewed research and clinical guidelines in other fields, and consulted with physicians, nurses, other psychosocial professionals, patients with IBD, and parents of children with IBD in ICN.

RESULTS/CONCLUSIONS

It is recommended that adolescents with IBD ages 12 and older be screened for depression annually. Additional practical recommendations for implementation, triage, and treatment within the pediatric gastroenterology clinic are also provided.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Effect of Cognitive Behavioral Therapy on Clinical Disease Course in Adolescents and Young Adults With Inflammatory Bowel Disease and Subclinical Anxiety and/or Depression: Results of a Randomized Trial

BACKGROUND

Anxiety and depressive symptoms are prevalent in patients with inflammatory bowel disease (IBD) and may negatively influence disease course. Disease activity could be affected positively by treatment of psychological symptoms. We investigated the effect of cognitive behavioral therapy (CBT) on clinical disease course in 10-25-year-old IBD patients experiencing subclinical anxiety and/or depression.

METHODS

In this multicenter parallel group randomized controlled trial, IBD patients were randomized to disease-specific CBT in addition to standard medical care (CBT + care us usual [CAU]) or CAU only. The primary outcome was time to first relapse in the first 12 months. Secondary outcomes were clinical disease activity, fecal calprotectin, and C-reactive protein (CRP). Survival analyses and linear mixed models were performed to compare groups.

RESULTS

Seventy patients were randomized (CBT+CAU = 37, CAU = 33), with a mean age of 18.3 years (±50% < 18 y, 31.4% male, 51.4% Crohn's disease, 93% in remission). Time to first relapse did not differ between patients in the CBT+CAU group vs the CAU group (n = 65, P = 0.915). Furthermore, clinical disease activity, fecal calprotectin, and CRP did not significantly change over time between/within both groups. Exploratory analyses in 10-18-year-old patients showed a 9% increase per month of fecal calprotectin and a 7% increase per month of serum CRP in the CAU group, which was not seen in the CAU+CBT group.

CONCLUSIONS

CBT did not influence time to relapse in young IBD patients with subclinical anxiety and/or depression. However, exploratory analyses may suggest a beneficial effect of CBT on inflammatory markers in children.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Depression Predicts Prolonged Length of Hospital Stay in Pediatric Inflammatory Bowel Disease

OBJECTIVE

Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures.

METHODS

Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders.

RESULTS

For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53).

CONCLUSIONS

Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.

Complementary and Alternative Medicine Use in Children With Inflammatory Bowel Disease

Complementary and alternative medicine (CAM) consists of products and practices that are not considered to be a part of conventional medicine. This article reviews pediatric studies on CAM in inflammatory bowel disease (IBD) along with relevant adult studies. Prevalence of CAM use ranges from 22% to 84% in children with IBD all over the world. CAM use in IBD includes diet changes, supplements, herbals, botanicals, and mind-body therapies. Common reasons for using CAM include severe disease and concern for adverse effects of conventional medicines. Despite widespread use, there are limited studies on efficacy and safety of CAM in children. Small studies suggest a favorable evidence for use of probiotics, fish oil, marijuana, and mind-body therapy in IBD. Adverse effects of CAM are reported but are rare. The article provides current state of knowledge on the topic and provides guidance to physicians to address CAM use in pediatric patients with IBD.

Best Practice Update: Incorporating Psychogastroenterology Into Management of Digestive Disorders

Chronic digestive diseases, including irritable bowel syndrome, gastroesophageal reflux disease, and inflammatory bowel diseases, cannot be disentangled from their psychological context-the substantial burden of these diseases is co-determined by symptom and disease severity and the ability of patients to cope with their symptoms without significant interruption to daily life. The growing field of psychogastroenterology focuses on the application of scientifically based psychological principles and techniques to the alleviation of digestive symptoms. In this Clinical Practice Update, we describe the structure and efficacy of 2 major classes of psychotherapy-cognitive behavior therapy and gut-directed hypnotherapy. We focus on the impact of these brain-gut psychotherapies on gastrointestinal symptoms, as well as their ability to facilitate improved coping, resilience, and self-regulation. The importance of the gastroenterologist in the promotion of integrated psychological care cannot be overstated, and recommendations are provided on how to address psychological issues and make an effective referral for brain-gut psychotherapy in routine practice.

Mind-Body Interventions for Pediatric Inflammatory Bowel Disease

Pediatric inflammatory bowel disease is an autoimmune disease that causes chronic inflammation of the gastrointestinal mucosa. There is emerging evidence that the brain–gut connection affects inflammatory bowel disease (IBD) patients more than previously thought. This is evidenced by comorbid mood disorders, irritable bowel symptoms concurrent with quiescent IBD, and the potential of psychosocial stressors to trigger IBD flares. Mind–body interventions such as psychotherapy, relaxation, mindfulness, biofeedback, yoga, and clinical hypnosis offer an adjunct to standard medical treatment for IBD. We will review the current evidence base for these mind–body interventions in the treatment of pediatric IBD, illustrate a case study, and offer suggestions for future research for this promising field.

Effect of psychological therapy on disease activity, psychological comorbidity, and quality of life in inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease is associated with psychological comorbidity and impaired quality of life. Psychological comorbidity could affect the natural history of inflammatory bowel disease. Psychological therapies might therefore have beneficial effects on disease activity, mood, and quality of life in patients with inflammatory bowel disease. We did a systematic review and meta-analysis examining these issues.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials for articles published between 1947 and Sept 22, 2016. Randomised controlled trials (RCTs) recruiting patients with inflammatory bowel disease aged at least 16 years that compared psychological therapy with a control intervention or usual treatment were eligible. We pooled dichotomous data to obtain relative risks of induction of remission in active disease or prevention of relapse of quiescent disease, with 95% CIs. We pooled continuous data to estimate standardised mean differences in disease activity indices, anxiety, depression, perceived stress, and quality-of-life scores in patients dichotomised into those with clinically active or quiescent disease, with 95% CIs. We extracted data from published reports and contacted the original investigators of studies for which the required data were not available. We pooled all data using a random-effects model.

FINDINGS

The search identified 1824 studies, with 14 RCTs of 1196 patients eligible for inclusion. The relative risk of relapse of quiescent inflammatory bowel disease with psychological therapy versus control was 0·98 (95% CI 0·77-1·24; p=0·87; I²=50%; six trials; 518 patients). We observed a significant difference in depression scores (standardised mean difference -0·17 [-0·33 to -0·01]; p=0·04; I²=0%; seven trials; 605 patients) and quality of life (0·30 [0·07-0·52]; p=0·01; I²=42%; nine trials; 578 patients) with psychological therapy versus control at the end of therapy for patients with quiescent disease. However, these beneficial effects were lost at final point of follow-up (depression scores -0·11 [-0·27 to 0·05], p=0·17, I²=0%, eight trials, 593 patients; quality of life 0·15 [-0·05 to 0·34], p=0·14, I²=22%, ten trials, 577 patients). When we assessed the effect of individual physiological therapies on quality of life, only cognitive behavioural therapy had any significant beneficial effect (0·37 [0·02-0·72]). We noted no effect on disease activity indices or other psychological wellbeing scores when compared with control in patients with quiescent disease. Dichotomous data for induction of remission and continuous data for change in clinical disease activity indices, depression, anxiety, and perceived stress scores were only reported in one RCT of patients with active disease. Quality of life was assessed in two RCTs of patients with active disease, but was not significantly different between intervention and control groups (0·27 [-0·05 to 0·59]).

INTERPRETATION

Psychological therapies, and cognitive behavioural therapy in particular, might have small short-term beneficial effects on depression scores and quality of life in patients with inflammatory bowel disease. Further RCTs of these interventions in patients with coexistent psychological distress are required.

FUNDING

None.

Effect of Psychotherapy on Health Care Utilization in Children With Inflammatory Bowel Disease and Depression

OBJECTIVES

Pediatric patients with inflammatory bowel disease (IBD) are at an increased risk of developing depression compared with community controls. Depression often negatively influences illness behaviors such as resource utilization. We sought to investigate the effects of treating depression on utilization of medical resources in depressed pediatric patients with IBD by comparing rates of health care utilization 1 year before and after psychotherapy.

METHOD

Two hundred seventeen subjects ages 9 to 17 years with IBD and depression received 3 months of psychotherapy for depression as part of a multicenter randomized controlled trial. Of these 217 subjects, 70 had utilization data available 1 year prior and 1 year after receiving 3 months of psychotherapy. Primary outcomes included frequency of hospitalizations, inpatient hospital days, outpatient gastrointestinal visits, and number of emergency room visits, radiological examinations, and endoscopies. Within subject analyses were completed comparing health care utilization 12 months before psychotherapy compared with the 12 months after the conclusion of psychotherapy.

RESULTS

Fifty-one and 19 patients had CD and UC, respectively. A total of 55.7% of patients had major depression and 44.3% had minor depression. Overall, all study measures of health care utilization were significantly reduced after psychotherapy (P < 0.01)-including gastrointestinal-related (mean values) hospitalization frequency, inpatient days, outpatient visit, emergency room visits, radiological examinations, and endoscopies.

CONCLUSIONS

Psychotherapy for comorbid depression in pediatric patients with IBD is associated with decreased GI-related health care utilization. The present study highlights the importance of screening for depression in a pediatric population with IBD, and that psychotherapy may be a reasonable adjunctive treatment for pediatric patients with IBD and comorbid depression.

Effectiveness of disease-specific cognitive-behavioural therapy on depression, anxiety, quality of life and the clinical course of disease in adolescents with inflammatory bowel disease: study protocol of a multicentre randomised controlled trial (HAPPY-IBD)

Introduction

Adolescents with inflammatory bowel disease (IBD) show a higher prevalence of depression and anxiety, compared to youth with other chronic diseases. The inflammation-depression hypothesis might explain this association, and implies that treating depression can decrease intestinal inflammation and improve disease course. The present multicentre randomised controlled trial aims to test the effectiveness of an IBD-specific cognitive–behavioural therapy (CBT) protocol in reducing symptoms of subclinical depression and anxiety, while improving quality of life and disease course in adolescents with IBD.

Methods and analysis

Adolescents with IBD (10–20 years) from 7 hospitals undergo screening (online questionnaires) for symptoms of depression and anxiety. Those with elevated scores of depression (Child Depression Inventory (CDI) ≥13 or Beck Depression Inventory (BDI) II ≥14) and/or anxiety (Screen for Child Anxiety Related Disorders: boys ≥26, girls ≥30) receive a psychiatric interview. Patients meeting criteria for depressive/anxiety disorders are referred for psychotherapy outside the trial. Patients with elevated (subclinical) symptoms are randomly assigned to medical care-as-usual (CAU; n=50) or CAU plus IBD-specific CBT (n=50). Main outcomes: (1) reduction in depressive and/or anxiety symptoms after 3 months and (2) sustained remission for 12 months. Secondary outcomes: quality of life, psychosocial functioning, treatment adherence. In addition, we will assess inflammatory cytokines in peripheral blood mononuclear cells and whole blood RNA expression profiles. For analysis, multilevel linear models and generalised estimating equations will be used.

Ethics and dissemination

The Medical Ethics Committee of the Erasmus MC approved this study. If we prove that this CBT improves emotional well-being as well as disease course, implementation is recommended.

Trial registration number

NCT02265588.

Mediated moderation of the relation between maternal and adolescent depressive symptoms: role of adolescent physical health

BACKGROUND

To examine the mediating effect of family functioning on the relation between maternal and adolescent depressive symptoms and determine whether the magnitude of the mediating effect is different for adolescents with and without chronic physical health conditions.

METHODS

Data come from the National Longitudinal Survey of Children and Youth. A representative survey of 11,813 adolescents and their mothers was included. Maternal and adolescent depressive symptoms were measured using the 12-item Center for Epidemiological Studies Depression Scale. Family functioning was measured using the McMaster Family Assessment Device. Multilevel multiple-group path analysis was used to examine potential mediating and moderating effects.

RESULTS

Family functioning measured when adolescents were 14-15 years mediated the relation between maternal depressive symptoms (measured at 10-13 years) and adolescent depressive symptoms (measured at 16-19 years) for both adolescents with [αβ = 0.02 (0.02, 0.03)] and without chronic health conditions [αβ = 0.01 (0.00, 0.01)]. These findings provided evidence to suggest mediated moderation, Δαβ = 0.02 (0.01, 0.03), that is, the mediating effect of family functioning was significantly larger for adolescents with chronic health conditions.

CONCLUSIONS

The mediating effect of family functioning in the relation between maternal and adolescent depressive symptoms is larger for adolescents with chronic health conditions. Within the framework of family-centered care, maternal depressive symptoms and family functioning are suitable targets for preventive intervention for adolescents with chronic health conditions.

Psychosocial Support of the Inflammatory Bowel Disease Patient

Inflammatory bowel disease (IBD) is a chronic, debilitating disease whose effects spread far beyond the gut. IBD does not generally result in excess mortality; health care providers should thus focus their efforts on improving health-related quality of life and minimizing associated morbidity. A bidirectional relationship exists between IBD and psychiatric conditions; chronic inflammation can produce neuromodulatory effects with resultant mood disorders, and the course of IBD is worse in patients with anxiety and depression. Screening for the early signs of depression or anxiety and initiating appropriate treatment can lead to improved functioning and positively impact disease course.

Symptom management in inflammatory bowel disease

Patients with inflammatory bowel disease can present with a wide variety of symptoms. Most are related to disease activity and should be managed with appropriate medical therapy for inflammatory bowel disease. However, some patients may develop symptoms due to the side effects of the medications, or due to immunosuppression. In these cases, the offending medications should be discontinued until resolution of the symptoms and a few may be able to restart therapy. Symptoms can also occur as an extraintestinal manifestation of the disease or due to concomitant autoimmune-mediated disorders. Regardless of the etiology, symptoms should be addressed promptly with immediate evaluation and appropriate therapy, as a delay may lead to permanent sequela.

Effect of 2 psychotherapies on depression and disease activity in pediatric Crohn's disease

BACKGROUND

Crohn's disease (CD) is associated with depression. It is unclear if psychosocial interventions offer benefit for depressive symptoms during active CD. In this secondary analysis of a larger study of treating depression in pediatric inflammatory bowel disease, we assessed whether cognitive behavioral therapy (CBT) would differentiate from supportive nondirective therapy in treating depression and disease activity in youth with CD. We also explored whether somatic depressive symptoms showed a different pattern of response in the overall sample and the subset with active inflammatory bowel disease.

METHODS

Youth with depression and CD (n = 161) were randomized to 3 months of CBT (teaching coping skills) or supportive nondirective therapy (supportive listening). Depressive severity was measured using the Children's Depression Rating Scale-Revised (CDRS-R) with the somatic depressive subtype consisting of those CDRS-R items, which significantly correlated with CD activity. Disease activity was measured by the Pediatric Crohn's disease Activity Index. Given the potential confound of higher dose steroids, subanalyses excluded subjects on >20 mg/d prednisone equivalent (n = 34).

RESULTS

Total CDRS-R scores in the overall sample significantly decreased over time after both treatments (P < 0.0001). Treatment with CBT was associated with a significantly greater improvement in the Pediatric Crohn's disease Activity Index (P = 0.05) and somatic depressive subtype (P = 0.03) in those with active inflammatory bowel disease (n = 95) compared with supportive nondirective therapy. After excluding those on steroids (n = 34), there was a significant improvement in total CDRS-R (P = 0.03) and in Pediatric Crohn's disease Activity Index (P = 0.03) after CBT.

CONCLUSIONS

Psychotherapy may be a useful adjunct to treat depression in the context of CD-related inflammation in youth who are not concurrently on higher dose steroids.

Psychological interventions for mental health disorders in children with chronic physical illness: a systematic review

BACKGROUND

Children with chronic physical illness are significantly more likely to develop common psychiatric symptoms than otherwise healthy children. These children therefore warrant effective integrated healthcare yet it is not established whether the known, effective, psychological treatments for symptoms of common childhood mental health disorders work in children with chronic physical illness.

METHODS

EMBASE, MEDLINE, PsycINFO and CINAHL databases were searched with predefined terms relating to evidence-based psychological interventions for psychiatric symptoms in children with chronic physical illness. We included all studies (randomised and non-randomised designs) investigating interventions aimed primarily at treating common psychiatric symptoms in children with a chronic physical illness in the review. Two reviewers independently assessed the relevance of abstracts identified, extracted data and undertook quality analysis.

RESULTS

Ten studies (209 children, including 70 in control groups) met the criteria for inclusion in the review. All studies demonstrated some positive outcomes of cognitive behavioural therapy for the treatment of psychiatric symptoms in children with chronic physical illness. Only two randomised controlled trials, both investigating interventions for symptoms of depression, were found.

CONCLUSIONS

There is preliminary evidence that cognitive behavioural therapy has positive effects in the treatment of symptoms of depression and anxiety in children with chronic physical illness. However, the current evidence base is weak and fully powered randomised controlled trials are needed to establish the efficacy of psychological treatments in this vulnerable population.

Randomized efficacy trial of two psychotherapies for depression in youth with inflammatory bowel disease

OBJECTIVE

Pediatric inflammatory bowel disease (IBD) is associated with high rates of depression. This study compared the efficacy of cognitive behavioral therapy (CBT) to supportive nondirective therapy (SNDT) in treating youth with comorbid IBD and depression.

METHOD

Youth (51% female and 49% male; age 9-17 years, mean age 14.3 years) with depression and Crohn's disease (n = 161) or ulcerative colitis (n = 56) were randomly assigned to a 3-month course of CBT or SNDT. The primary outcome was comparative reduction in depressive symptom severity; secondary outcomes were depression remission, increase in depression response, and improved health-related adjustment and IBD activity.

RESULTS

A total of 178 participants (82%) completed the 3-month intervention. Both psychotherapies resulted in significant reductions in total Children's Depression Rating Scale Revised score (37.3% for CBT and 31.9% for SNDT), but the difference between the 2 treatments was not significant (p = .16). There were large pre-post effect sizes for each treatment (d = 1.31 for CBT and d = 1.30 for SNDT). More than 65% of youth had a complete remission of depression at 3 months, with no difference between CBT and SNDT (67.8% and 63.2%, respectively). Compared to SNDT, CBT was associated with a greater reduction in IBD activity (p = .04) but no greater improvement on the Clinical Global Assessment Scale (p = .06) and health-related quality of life (IMPACT-III scale) (p = .07).

CONCLUSION

This is the first randomized controlled study to suggest improvements in depression severity, global functioning, quality of life, and disease activity in a physically ill pediatric cohort treated with psychotherapy. Clinical trial registration information-Reducing Depressive Symptoms in Physically Ill Youth; http://clinical trials.gov; NCT00534911.

Development of a self-efficacy scale for adolescents and young adults with inflammatory bowel disease

BACKGROUND

Pediatric inflammatory bowel disease (IBD) self-management fits well within a social-cognitive framework. At the heart of social-cognitive theory is self-efficacy, a set of beliefs about one's ability to perform certain tasks. Self-efficacy is a strong predictor of health outcomes in chronic diseases and could serve as an intermediary outcome measure of self-management for pediatric IBD. The aim of this preliminary study was to develop items for the design of a self-efficacy scale specifically for adolescents and young adults with IBD.

METHODS

Survey development is an iterative process. As defined by the US Food and Drug Administration guidelines for developing a patient-reported outcome measurement, the first step of this process is to obtain patient input. Using qualitative research methods, adolescents and young adults were recruited from an outpatient pediatric gastroenterology clinic to participate in a semistructured interview. Transcriptions of the recorded interviews were reviewed for themes related to self-efficacy around disease management. A consensus panel of gastroenterologists and health psychologists reviewed the initially constructed items. Those specific items were then reviewed and adjusted by a panel of participants for content and understandability using cognitive interview methods. The resulting 13-item scale is presented here.

RESULTS

Nineteen patients and 5 parents participated in the study. The study sample was 42% girls, 79% whites, 74% had Crohn disease, and 79% had not required surgery. Median age was 15 years (range 10-22 years). Theme analysis and expert review yielded 13 items across 4 theoretical domains: managing medical care, managing daily life with IBD, managing emotions, and managing the future with IBD.

CONCLUSIONS

A 13-item disease-specific scale has been developed based on patient input to assess self-efficacy around self-management in adolescents with IBD. Efforts to validate this newly designed scale are presently under way.

Predictors of depression in youth with Crohn disease

OBJECTIVE

The aim of the study was to determine whether infliximab use and other potential predictors are associated with decreased prevalence and severity of depression in pediatric patients with Crohn disease (CD).

METHODS

A total of 550 (n = 550) youth ages 9 to 17 years with biopsy-confirmed CD were consecutively recruited as part of a multicenter randomized controlled trial. Out of the 550, 499 patients met study criteria and were included in the analysis. At recruitment, each subject and a parent completed the Children's Depression Inventory (CDI). A child or parent CDI score ≥  12 was used to denote clinically significant depressive symptoms (CSDS). Child and parent CDI scores were summed to form total CDI (CDIT). Infliximab use, demographic information, steroid use, laboratory values, and Pediatric Crohn's Disease Activity Index (PCDAI) were collected as the potential predictors of depression. Univariate regression models were constructed to determine the relations among predictors, CSDS, and CDIT. Stepwise multivariate regression models were constructed to predict the relation between infliximab use and depression while controlling for other predictors of depression.

RESULTS

Infliximab use was not associated with a decreased proportion of CSDS and CDIT after adjusting for multiple comparisons. CSDS and CDIT were positively associated with PCDAI, erythrocyte sedimentation rate, and steroid dose (P < 0.01) and negatively associated with socioeconomic status (SES) (P < 0.001). In multivariate models, PCDAI and SES were the strongest predictors of depression.

CONCLUSIONS

Disease activity and SES are significant predictors of depression in youth with Crohn disease.

Identifying mechanisms of change: utilizing single-participant methodology to better understand behavior therapy for child depression

This study examined therapeutic mechanisms of action at the single-participant level in a behavior therapy (BT) for youth depression. By controlling for non-specific early responses, identifying potential mechanisms of action a priori, taking frequent measures of hypothesized mechanisms and dependent variables, rigorously evaluating internal validity, and using a variety of analytic methods, a unique model for analysis of potential mediators was created. Eleven children (M age = 9.84) meeting criteria on the Children's Depression Rating Scale-Revised (M = 55.36) and Children's Depression Inventory (M = 23.45) received non-directive therapy (NDT), followed by BT for those still displaying significant symptoms. Four participants (36%) had a clinically significant response to NDT. For the remaining seven, statistically significant changes in depressive symptoms and family interactions during the BT interval were found at the group level. At the single-participant level, evidence suggesting that outcome was at least partially mediated by changes in treatment targets was obtained for four of seven (57%). As the field further embraces efforts to learn not only whether treatments work but also how they work, the single-participant approach to evaluating mediators provides a useful framework for evaluating theories of therapeutic change.

Managing inflammatory bowel disease in adolescent patients

Increasing numbers of adolescents are being diagnosed with Crohn's disease or ulcerative colitis, the two main subtypes of inflammatory bowel disease. These young people face many short- and long-term challenges; one or more medical therapies may be required indefinitely; their disease may have great impact, in terms of their schooling and social activities. However, the management of adolescents with one of these incurable conditions needs to encompass more than just medical therapies. Growth, pubertal development, schooling, transition, adherence, and psychological well-being are all important aspects. A multidisciplinary team setting, catering to these components of care, is required to ensure optimal outcomes in adolescents with inflammatory bowel disease.

Integrating illness concerns into cognitive behavioral therapy for children and adolescents with inflammatory bowel disease and co-occurring anxiety

PURPOSE

To examine the feasibility and preliminary benefits of an integrative cognitive behavioral therapy (CBT) with adolescents with inflammatory bowel disease and anxiety.

DESIGN AND METHODS

Nine adolescents participated in a CBT program at their gastroenterologist's office. Structured diagnostic interviews, self-report measures of anxiety and pain, and physician-rated disease severity were collected pretreatment and post-treatment.

RESULTS

Postintervention, 88% of adolescents were treatment responders, and 50% no longer met criteria for their principal anxiety disorder. Decreases were demonstrated in anxiety, pain, and disease severity.

PRACTICE IMPLICATIONS

Anxiety screening and a mental health referral to professionals familiar with medical management issues is important.

Psychosocial issues in pediatric inflammatory bowel disease: report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Pediatric inflammatory bowel disease (IBD) can affect many areas of psychosocial functioning, and comprehensive medical care includes consideration of psychosocial issues as well as disease factors. The purpose of this clinical report is to review research on psychosocial functioning in pediatric IBD and to provide recommendations for care providers in the areas of psychopathology, health-related quality of life, and social, family, and school functioning. Youth with IBD are at increased risk for difficulty in all areas reviewed, and many psychosocial factors are associated with disease activity, which highlights the importance of monitoring psychosocial functioning as part of clinical care. Several interventions have empirical support or show promise for addressing psychosocial difficulty, and recommendations for monitoring and treating these issues are provided.

Psychological factors and stress in inflammatory bowel disease

The role of psychological distress and personality as predisposing factors for the development of inflammatory bowel disease (IBD) remains controversial. Attempts to investigate the role of psychological factors in IBD exhibited rather conflicting results. Among the studies concerning the effects of stress or depression on the course of IBD, the majority suggest that stress worsened IBD, the rest giving either negative or inconclusive results. However, application of strategies, including avoidance of coping and training patients in problem solving or emotion-oriented, could influence the course of IBD. Large controlled clinical trials are needed in order to clarify the impact of psychological interventions on the quality of life and the course of disease.

Using the Children's Depression Inventory in youth with inflammatory bowel disease: support for a physical illness-related factor

The objective of the present investigation was to evaluate the factor structure of the Children's Depression Inventory (CDI) in adolescents with inflammatory bowel disease (IBD) to better understand the CDI's psychometric properties in a medically complicated population. An exploratory factor analysis was performed on CDI data collected from a clinical sample of 191 youth with IBD, aged 11 to 17 years. Exploratory factor analysis with quartimax rotation yielded 3 factors: mood, behavioral/motivational, and somatic complaints. Only the somatic factor (ie, fatigue, sleep, decreased appetite, and worry about aches and pain) showed a significant positive correlation with IBD severity. The CDI holds promise as a brief measure for the assessment of depressive features psychometrically independent of IBD severity and common steroid treatments as well as of nongastrointestinal specific somatic complaints in a sample of adolescents with IBD. Continued work in this area of research appears promising in honing the assessment of depressive and somatic symptoms in youths with IBD.

Psychological issues in inflammatory bowel disease: an overview

Inflammatory bowel disease (IBD) including Crohn's disease (CD) and ulcerative colitis (UC) is a chronic and disabling disease with unknown etiology. There have been some controversies regarding the role of psychological factors in the course of IBD. The purpose of this paper is to review that role. First the evidence on role of stress is reviewed focusing on perceived stress and patients' beliefs about it in triggering or exacerbating the course of IBD. The possible mechanisms by which stress could be translated into IBD symptoms, including changes in motor, sensory and secretory gastrointestinal function, increase intestinal permeability, and changes in the immune system are, then reviewed. The role of patients' concerns about psychological distress and their adjustment to disease, poor coping strategies, and some personality traits that are commonly associated with these diseases are introduced. The prevalence rate, the timing of onset, and the impact of anxiety and depression on health-related quality of life are then reviewed. Finally issues about illness behavior and the necessity of integrating psychological interventions with conventional treatment protocols are explained.

Anxiety, Depression, and Somatic Distress: Developing a Transdiagnostic Internalizing Toolbox for Pediatric Practice

Anxiety, depression, and somatic complaints are a common set of comorbid problems in children and adolescents. This "internalizing cluster" is highly prevalent, impairing during youth and into adulthood, and has substantial impacts on health-care systems. Fortunately, these problem areas may share several etiological factors and, thus, respond to similar interventions. In this paper, we present (a) the rationale for focusing on this cluster, (b) clinical theory on transdiagnostic processes uniting these problems, (c) description of core treatment techniques for this group, with a description of clinical outcomes for two sample cases, and (d) implications of this approach for new transdiagnostic treatment development and everyday clinical practice.

Parents' Readiness to Change Affects BMI Reduction Outcomes in Adolescents with Polycystic Ovary Syndrome

Evidence supports the importance of parental involvement for youth's ability to manage weight. This study utilized the stages of change (SOC) model to assess readiness to change weight control behaviors as well as the predictive value of SOC in determining BMI outcomes in forty adolescent-parent dyads (mean adolescent age = 15 ± 1.84 (13-20), BMI = 37 ± 8.60; 70% white) participating in a weight management intervention for adolescent females with polycystic ovary syndrome (PCOS). Adolescents and parents completed a questionnaire assessing their SOC for the following four weight control domains: increasing dietary portion control, increasing fruit and vegetable consumption, decreasing dietary fat, and increasing usual physical activity. Linear regression analyses indicated that adolescent change in total SOC from baseline to treatment completion was not predictive of adolescent change in BMI from baseline to treatment completion. However, parent change in total SOC from baseline to treatment completion was predictive of adolescent change in BMI, (t(24) = 2.15, p = 0.043). Findings support future research which carefully assesses adolescent and parent SOC and potentially develops interventions targeting adolescent and parental readiness to adopt healthy lifestyle goals.

Coping with chronic illness in childhood and adolescence

Chronic illnesses and medical conditions present millions of children and adolescents with significant stress that is associated with risk for emotional and behavioral problems and interferes with adherence to treatment regimens. We review research on the role of child and adolescent coping with stress as an important feature of the process of adaptation to illness. Recent findings support a control-based model of coping that includes primary control or active coping (efforts to act on the source of stress or one's emotions), secondary control or accommodative coping (efforts to adapt to the source of stress), and disengagement or passive coping (efforts to avoid or deny the stressor). Evidence suggests the efficacy of secondary control coping in successful adaptation to chronic illness in children and adolescents, disengagement coping is associated with poorer adjustment, and findings for primary control coping are mixed. Avenues for future research are highlighted.

Targeting reasoning biases in delusions: a pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions

Delusions are often resistant to change, persisting despite successful antipsychotic treatment or Cognitive Behavioural Therapy. This study aimed to target reasoning processes, particularly the 'Jumping to Conclusions' (JTC) bias and belief flexibility, which are thought to play a part in maintaining delusional conviction. 13 participants with a diagnosis of psychosis and high levels of conviction in their delusions completed a one-off computerised training package, lasting approximately 1.5 h. Outcomes were assessed at baseline, pre-intervention (two weeks later), post-intervention (immediately after completing the training) and at 1 month follow-up. The package was well received by participants. There were improvements in JTC, belief flexibility and delusional conviction between pre- and post-intervention measures. Controlled studies powered to detect changes in key outcomes are warranted in order to evaluate the efficacy of the programme.

Disease activity, behavioral dysfunction, and health-related quality of life in adolescents with inflammatory bowel disease

BACKGROUND

Approximately 20%-25% of all inflammatory bowel disease (IBD) cases have an onset in childhood or adolescence. Beyond disease severity, little is known regarding determinants of health-related quality of life (HRQOL) in this population. This study aimed to identify behavioral correlates of HRQOL and examine behavioral/emotional dysfunction (e.g., internalizing/externalizing symptoms) as the mechanism through which disease severity impacts HRQOL.

METHODS

In all, 62 adolescents (mean = 15.47 years, standard deviation [SD] = 1.42) with IBD (79% Crohn's disease) and their parents were recruited from one of two pediatric IBD specialty clinics located in the Midwest or Northeast region of the United States. Participants completed a demographic questionnaire, the Youth Self-Report version of the Child Behavior Checklist, and the IMPACT-III. Disease severity was calculated for Crohn's disease and ulcerative colitis using standardized measures.

RESULTS

Greater disease severity, externalizing symptoms, and internalizing symptoms were all independently associated with lower HRQOL. Furthermore, internalizing symptoms partially mediated the relationship between disease activity and HRQOL, reducing the effect of disease severity on HRQOL from 22% to 9% in the mediation model. A Sobel test examining the significance of the indirect effect of disease severity on HRQOL via behavioral dysfunction was marginally nonsignificant (P =.053).

CONCLUSIONS

Nondisease-specific variables (e.g., behavioral dysfunction) play an important role in impacting HRQOL. Behavioral dysfunction serves as the mechanism through which disease severity partially impacts HRQOL. Continued research to identify other predictors of HRQOL in pediatric IBD will greatly enhance our future ability to design interventions to improve HRQOL and maximize health outcomes.

Cognitive-behavioral therapy for children with comorbid physical illness

In addition to the usual developmental challenges, children and adolescents with chronic physical illness face psychosocial challenges that affect their quality of life. This review describes different aspects of coping with chronic physical illness in childhood and the empirical evidence examining the usefulness of cognitive-behavioral therapy (CBT) for the treatment of children and adolescents with chronic physical illnesses and related psychological comorbidities. Four diseases (diabetes, inflammatory bowel disease, cancer, and sickle cell disease) were chosen as model illnesses to demonstrate key CBT findings in more detail. Future research recommendations in this challenging population are also addressed.

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life-limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions.

Coping skills for reducing pain and somatic symptoms in adolescents with IBD

BACKGROUND

The current study involved the development and evaluation of a skills-based, psychological intervention for adolescent females with inflammatory bowel disease (IBD) and their parents. Psychological interventions were used to improve coping with pain and other somatic physical symptoms, as well as improve parental responses to children and adolescents who experience such symptomatology.

METHODS

Thirteen and 11 adolescent females and one of their parents made up the treatment and wait-list control groups, respectively, for a total of 24 parent-child dyads. Adolescents and parents attended a 1-day intervention that taught disease-related coping skills, pain management, relaxation techniques, communication, and limit setting (parents only). The treatment day was followed by 6 weeks of Web-based skill review including homework assignments and weekly group chat sessions.

RESULTS

Following treatment, significant improvements were found in adolescents' somatic symptoms and adaptive coping strategies. Further, parents reported reductions in irrational thoughts and improved behavioral reactions related to their daughter's physical symptoms. Implications of these findings, as well as limitations and future directions, are discussed.

CONCLUSION

Overall, preliminary support suggests that programmatic psychosocial interventions for reducing physical symptoms and improving coping may be beneficial for adolescents with IBD and their families.

Skills-Based Group Intervention for Adolescent Girls With Inflammatory Bowel Disease

In this study we describe the responses of six adolescent girls with inflammatory bowel disease and their parents to a 10-session, manualized intervention program focusing on decreasing pain and functional disability in adolescents with a chronic illness, and increasing coping and sense of competency for their parents. Measures of adolescent physical symptoms and parenting sense of competence and coping were collected at pretreatment, post-treatment, and 6-month follow-up. Improvements were observed post-treatment and at 6 month follow-up on measures of adolescents’ pain and functional disability, as well as parents’ sense of competency and use of adaptive coping strategies.The potential effectiveness of this type of program and implications for its use are discussed.