Patient-reported Anxiety: A Possible Predictor of Pediatric Inflammatory Bowel Disease Health Care Use

Effects of a Written Expression-Based Positive Psychological Intervention on the Psychological Status of Patients With Inflammatory Bowel Disease: A Randomized Controlled Trial

This prospective parallel-group controlled trial explored the effects of a written expression-based positive psychological intervention on the psychological status of patients with inflammatory bowel disease. Primary outcomes were anxiety, depression, hope, optimism, and subjective well-being, assessed at 8 weeks. Secondary outcomes were coping mode, quality of life at 8 weeks, and patient feedback. Sixty-eight volunteer patients meeting inclusion criteria were recruited from a hospital in China and randomized into the intervention group (positive psychological intervention+care as usual = 33) and the control group (care as usual = 35). The intervention group showed significantly greater improvements in anxiety, depression, hope, and quality of life (p > .05). The intervention group scored the feasibility, simplicity, and applicability of the positive psychological intervention themes at more than 6.5 for all measures. The study concludes that written expression-based positive psychological interventions alleviate negative emotions in inflammatory bowel disease patients and enhance their positive psychological characteristics. This approach also promotes a positive coping mode in inflammatory bowel disease patients, and the intervention measures devised are convenient, feasible, and well-accepted by patients.

The Impact of Psychiatric Comorbidity on Health Care Utilization in Inflammatory Bowel Disease: A Population-based Study

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increase in psychiatric comorbidity (PC) compared with the general population. We aimed to determine the impact of PC on health care utilization in persons with IBD.

METHODS

We applied a validated administrative definition of IBD to identify all Manitobans with IBD from April 1, 2006, to March 31, 2016, and a matched cohort without IBD. A validated definition for PC in IBD population was applied to both cohorts; active PC status meant ≥2 visits for psychiatric diagnoses within a given year. We examined the association of active PC with physician visits, inpatient hospital days, proportion with inpatient hospitalization, and use of prescription IBD medications in the following year. We tested for the presence of a 2-way interaction between cohort and PC status.

RESULTS

Our study matched 8459 persons with IBD to 40,375 controls. On crude analysis, IBD subjects had ≥3.7 additional physician visits, had >1.5 extra hospital days, and used 2.1 more drug types annually than controls. Subjects with active PC had >10 more physician visits, had 3.1 more hospital days, and used >6.3 more drugs. There was a synergistic effect of IBD (vs no IBD) and PC (vs no PC) across psychiatric disorders of around 4%. This synergistic effect was greatest for anxiety (6% [2%, 9%]). After excluding psychiatry-related visits and psychiatry-related hospital stays, there remained an excess health care utilization in persons with IBD and PC.

CONCLUSION

Inflammatory bowel disease with PC increases health care utilization compared with matched controls and compared with persons with IBD without PC. Active PC further increases health care utilization.

Systematic Review: Anxiety in Children and Adolescents With Chronic Medical Conditions

OBJECTIVE

Youth with chronic medical conditions (CMCs) have been reported to be at increased risk for developing anxiety disorders. Importantly, suffering from anxiety may also have an impact on their disease-related outcomes. This study set out to systematically review the literature on anxiety and seven CMCs (asthma, congenital heart disease, diabetes, epilepsy, inflammatory bowel disease, juvenile idiopathic arthritis, and sickle cell disease) among youth.

METHOD

A systematic review was performed according to the PRISMA statement. Searches were conducted across PubMed, PsycNET, Embase, and reference lists of the included studies (1990-2018). Three independent reviewers screened titles and abstracts and conducted full-text assessment. Studies were included if they reported the prevalence of anxiety or the association of anxiety on disease-related outcomes in children and/or adolescents with the focal CMCs.

RESULTS

A total of 53 studies met the predetermined inclusion criteria. Across the CMCs, the prevalence of anxiety disorder was increased in youths with CMCs compared to the general population. Evidence for a relationship between anxiety and adverse disease-related outcomes was limited. For asthma, inflammatory bowel disease, and sickle cell disease, there was some evidence indicating that anxiety was associated with adverse outcomes; supported by two longitudinal studies, one in asthma and one in inflammatory bowel disease. For diabetes, results were inconsistent; with some studies indicating that anxiety was associated with worse and others with better treatment adherence.

CONCLUSION

The prevalence of anxiety disorders in youth with CMCs is higher than that in the general population. Anxiety may also be associated with adverse disease-related outcomes for youths, but it is not possible to draw definitive conclusions. Longitudinal studies making use of parent/youth composite anxiety measures and a combination of parent/youth reported and objective measures of disease-related outcomes are needed. Given the burden of disease of anxiety disorders, regardless of the impact on the disease outcomes, screening for and treatment of anxiety is recommended in youths with CMCs.

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.

Challenges in Transitional Care in Inflammatory Bowel Disease: A Review of the Current Literature in Transition Readiness and Outcomes

Transitional care for patients with IBD focuses on efforts to successfully transfer care from pediatric to adult providers while encouraging the assumption of health care responsibility. As 25% of patients will be diagnosed with IBD before the age of 18 years, many will undergo this process. Efforts to enhance this process have included transition clinics and other means to improve patient comfort with transition and develop the skill of health care self-management. Currently, most pediatric practitioners provide transition care with informal education and emphasize independence without formal programs. A variety of tools to assess transition readiness have been developed. Given the varied disease process, often varied and subjective outcomes, and lack of studies such as randomized controlled trials, further data are necessary to determine the best avenue to transition and assess outcomes. Critically relevant to providing adequate care to transitioning patients includes understanding the development of self-management skills and the developmental processes relevant to young adults with IBD. Transition represents an area for quality improvement, and although progress has been made in recognition and promotion of transition practices, future directions in research will allow improved understanding of the evidence-based practices and needs of these individuals to further enhance their care.

Systematic review with meta-analysis: anxiety and depression in children and adolescents with inflammatory bowel disease

BACKGROUND

The co-existence of psychological problems and paediatric inflammatory bowel disease (IBD) is receiving increasing attention. Most studies investigated anxiety and depression, with prevalence rates varying from 0% to 50%. A systematic review is necessary to provide clear insight into the prevalence of anxiety and depression in paediatric IBD.

AIM

To systematically evaluate available data on the prevalence of anxiety and depressive symptoms and disorders in paediatric IBD (aged 6-18 years).

METHODS

Comprehensive searches were performed in Embase, Medline Ovid, Web of Science, Cochrane, PubMed, PsychInfo Ovid, and Google scholar for studies published from 1994 to 2017. Pooled prevalence rates were calculated using inverse variance heterogeneity models. Meta-regression was used to study if disease type, disease activity and gender influence prevalence.

RESULTS

Twenty-eight studies (N = 8107, mean age: 14.3) were identified. Pooled prevalence estimates were 16.4% (95% confidence interval [CI] 6.8%-27.3%) for anxiety symptoms and 4.2% (95% CI 3.6%-4.8%) for anxiety disorders. Pooled prevalence estimates were 15.0% (95% CI 6.4%-24.8%) for depressive symptoms and 3.4% (95% CI 0%-9.3%) for depressive disorders. Meta-regression showed no influence of disease type or gender on these prevalence rates, but studies with a higher percentage of active disease had a higher rate of depressive symptoms.

CONCLUSIONS

The described pooled prevalence of anxiety and depressive symptoms is lower than in adult IBD. However, due to varying instruments/cut-offs for measuring symptoms and few studies investigating disorders, the results should be interpreted with caution. Cross-cultural use of the same instruments is needed to gain better insight into prevalence rates.

Effects of gut-derived endotoxin on anxiety-like and repetitive behaviors in male and female mice

BACKGROUND

Gut dysbiosis is observed in several neuropsychiatric disorders exhibiting increases in anxiety behavior, and recent work suggests links between gut inflammation and such disorders. One source of this inflammation may be lipopolysaccharide (LPS), a toxic component of gram-negative bacteria. Here, we (1) determine whether oral gavage of LPS, as a model of gut-derived endotoxemia, affects anxiety-like and/or repetitive behaviors; (2) test whether these changes depend on TLR4 signaling; and (3) test the extent to which gut-derived endotoxin and TLR4 antagonism affects males and females differently.

METHODS

In experiment 1, male wild-type (WT) and Tlr4-/- mice were tested for locomotor, anxiety-like, and repetitive behaviors in an automated open field test apparatus, 2 h after oral gavage of LPS or saline. In experiment 2, male and female WT mice received an oral gavage of LPS and an injection of one or two TLR4 antagonists that target different TLR4 signaling pathways ((+)-naloxone and LPS derived from R. sphaeroides (LPS-RS)). Univariate and multivariate analyses were used to identify effects of treatment, sex, and genotype and their interaction.

RESULTS

In experiment 1, oral gavage of LPS increased anxiety-like behavior in male WT mice but not in Tlr4-/- mice. In experiment 2, oral gavage of LPS increased anxiety-like and decreased repetitive behaviors in WT mice of both sexes. Neither antagonist directly blocked the effects of orally administered LPS. However, treatment with (+)-naloxone, which blocks the TRIF pathway of TLR4, had opposing behavioral effects in males and females (independent of LPS treatment). We also identified sex differences in the expression of interleukin-6, a pro-inflammatory cytokine, in the gut both in basal conditions and in response to LPS.

CONCLUSION

In spite of the ubiquitous nature of LPS in the gut lumen, this is the first study to demonstrate that intestinally derived LPS can initiate behavioral aspects of the sickness response. While an increased enteric load of LPS increases anxiety-like behavior in both sexes, it likely does so via sex-specific mechanisms. Similarly, TLR4 signaling may promote baseline expression of repetitive behavior differently in males and females. This study lays the groundwork for future interrogations into connections between gut-derived endotoxin and behavioral pathology in males and females.

Telemedicine for management of inflammatory bowel disease (myIBDcoach): a pragmatic, multicentre, randomised controlled trial

BACKGROUND

Tight and personalised control of inflammatory bowel disease in a traditional setting is challenging because of the disease complexity, high pressure on outpatient clinics, and rising incidence. We compared the effects of self-management with a telemedicine system, which was developed for all subtypes of inflammatory bowel disease, on health-care utilisation and patient-reported quality of care versus standard care.

METHODS

We did this pragmatic, randomised trial in two academic and two non-academic hospitals in the Netherlands. Outpatients aged 18-75 years with inflammatory bowel disease and without an ileoanal or ileorectal pouch anastomosis, who had internet access and Dutch proficiency, were randomly assigned (1:1) to care via a telemedicine system (myIBDcoach) that monitors and registers disease activity or standard care and followed up for 12 months. Randomisation was done with a computer-generated sequence and used the minimisation method. Participants, health-care providers, and staff who assessed outcome measures were not masked to treatment allocation. Primary outcomes were the number of outpatient visits and patient-reported quality of care (assessed by visual analogue scale score 0-10). Safety endpoints were the numbers of flares, corticosteroid courses, hospital admissions, emergency visits, and surgeries. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02173002.

FINDINGS

Between Sept 9, 2014, and May 18, 2015, 909 patients were randomly assigned to telemedicine (n=465) or standard care (n=444). At 12 months, the mean number of outpatient visits to the gastroenterologist or nurse was significantly lower in the telemedicine group (1·55 [SD 1·50]) than in the standard care group (2·34 [1·64]; difference -0·79 [95% CI -0·98 to -0·59]; p<0·0001), as was the mean number of hospital admissions (0·05 [0·28] vs 0·10 [0·43]; difference -0·05 [-0·10 to 0·00]; p=0·046). At 12 months, both groups reported high mean patient-reported quality of care scores (8·16 [1·37] in the telemedicine group vs 8·27 [1·28] in the standard care group; difference 0·10 [-0·13 to 0·32]; p=0·411). The mean numbers of flares, corticosteroid courses, emergency visits, and surgeries did not differ between groups.

INTERPRETATION

Telemedicine was safe and reduced outpatient visits and hospital admissions compared with standard care. This self-management tool might be useful for reorganising care of inflammatory bowel disease towards personalised and value-based health care.

FUNDING

Maastricht University Medical Centre and Ferring.

Patient Health Communication Mediating Effects Between Gastrointestinal Symptoms and Gastrointestinal Worry in Pediatric Inflammatory Bowel Disease

BACKGROUND

To investigate the effects of patient health communication regarding their inflammatory bowel disease (IBD) to their health care providers and significant others in their daily life as a mediator in the relationship between gastrointestinal symptoms and gastrointestinal worry in pediatric patients.

METHODS

The Pediatric Quality of Life Inventory Gastrointestinal Symptoms, Gastrointestinal Worry, and Communication Scales, and Pediatric Quality of Life Inventory 4.0 Generic Core Scales were completed in a 9-site study by 252 pediatric patients with IBD. Gastrointestinal Symptoms Scales measuring stomach pain, constipation, or diarrhea and patient communication were tested for bivariate and multivariate linear associations with Gastrointestinal Worry Scales specific to patient worry about stomach pain or bowel movements. Mediational analyses were conducted to test the hypothesized mediating effects of patient health communication as an intervening variable in the relationship between gastrointestinal symptoms and gastrointestinal worry.

RESULTS

The predictive effects of gastrointestinal symptoms on gastrointestinal worry were mediated in part by patient health communication with health care providers/significant others in their daily life. In predictive models using multiple regression analyses, the full conceptual model of demographic variables, gastrointestinal symptoms (stomach pain, constipation, or diarrhea), and patient communication significantly accounted for 46, 43, and 54 percent of the variance in gastrointestinal worry (all Ps < 0.001), respectively, reflecting large effect sizes.

CONCLUSIONS

Patient health communication explains in part the effects of gastrointestinal symptoms on gastrointestinal worry in pediatric patients with IBD. Supporting patient disease-specific communication to their health care providers and significant others may improve health-related quality of life for pediatric patients with IBD.