Gut-directed hypnotherapy significantly augments clinical remission in quiescent ulcerative colitis

Role of stress and early-life stress in the pathogeny of inflammatory bowel disease

Numerous preclinical and clinical studies have shown that stress is one of the main environmental factor playing a significant role in the pathogeny and life-course of bowel diseases. However, stressful events that occur early in life, even during the fetal life, leave different traces within the central nervous system, in area involved in stress response and autonomic network but also in emotion, cognition and memory regulation. Early-life stress can disrupt the prefrontal-amygdala circuit thus favoring an imbalance of the autonomic nervous system and the hypothalamic-pituitary adrenal axis, resulting in anxiety-like behaviors. The down regulation of vagus nerve and cholinergic anti-inflammatory pathway favors pro-inflammatory conditions. Recent data suggest that emotional abuse at early life are aggravating risk factors in inflammatory bowel disease. This review aims to unravel the mechanisms that explain the consequences of early life events and stress in the pathophysiology of inflammatory bowel disease and their mental co-morbidities. A review of therapeutic potential will also be covered.

Navigating through 65 years of insights: lessons learned on functional abdominal pain in children

In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.

Can Hypnotherapy Be Considered a Valuable Component in the Management of Inflammatory Bowel Disease? Insights from a Comprehensive Review

Despite advancements in medication,managing inflammatory bowel disease (IBD) remains challenging, necessitatingalternative control methods. Gut-directed hypnotherapy, known for alleviating irritable bowel syndrome (IBS), is debated as an IBD management method. Anextensive search across PubMed, Cochrane Library, and Clinicaltrials.govuncovered five randomized trials and two case series involving IBD patients undergoing hypnotherapy. A small trial reported statistically significant remission at one year (p = .04), but larger trials, including one with 63 patients, showed no significant gastrointestinal improvements. The first case series noted post-intervention reduction in the mediators of inflammation in rectal mucosal, without long-term monitoring. The second case series observed the absence of flare episodes in 12 of 13 ulcerative colitis patients during follow-up, possibly influenced by the simultaneous use of two drugs alongside hypnotherapy. Psychological outcomes, demonstrated no significant differences between hypnotherapy and control groups. While current literature doesn't decisively support hypnotherapy for managing IBD symptoms, it underscores the importance of further research, including randomized clinical trials, to thoroughly assess its effectiveness in this context.

Clinical Education: Psychosocial Assessment and Treatment Planning for Patients with Inflammatory Bowel Disease

Psychosocial factors play an important role in the disease course and illness experience of patients with inflammatory bowel disease (IBD). Consultation with a health psychologist is an important component of care for many IBD patients and provides an opportunity to identify areas of psychosocial concern, recognize coping deficits and strengths, and facilitate treatment recommendations. Psychosocial assessment in IBD requires a nuanced approach that goes beyond general mental health screening and considers the disease-specific concerns that impact patients. In this paper, we outline strategies for an IBD-focused psychological evaluation, including specific guidance for assessing disease-specific concerns of anxiety, depression, post-traumatic stress, sleep, pain, body image disturbance, food-related quality of life, and psychological resilience.

Unmet needs of drugs for irritable bowel syndrome and inflammatory bowel diseases: interest of vagus nerve stimulation and hypnosis

The gut and the brain communicate bidirectionally through the autonomic nervous system. The vagus nerve is a key component of this gut-brain axis, and has numerous properties such as anti-inflammatory, antinociceptive, anti-depressive effects. A perturbation of this gut-brain communication is involved in the pathogeny of functional digestive disorders, such as irritable bowel syndrome, and inflammatory bowel diseases. Stress plays a role in the pathogeny of these diseases, which are biopsychosocial models. There are presently unmet needs of pharmacological treatments of these chronic debilitating diseases. Treatments are not devoid of side effects, cost-effective, do not cure the diseases, can lose effects over time, thus explaining the poor satisfaction of patients, their lack of compliance, and their interest for non-drug therapies. The gut-brain axis can be targeted for therapeutic purposes in irritable bowel syndrome and inflammatory bowel disease through non-drug therapies, such as hypnosis and vagus nerve stimulation, opening up possibilities for responding to patient expectations.

The Interaction between Stress and Inflammatory Bowel Disease in Pediatric and Adult Patients

Background: Inflammatory bowel diseases (IBDs) have seen an exponential increase in incidence, particularly among pediatric patients. Psychological stress is a significant risk factor influencing the disease course. This review assesses the interaction between stress and disease progression, focusing on articles that quantified inflammatory markers in IBD patients exposed to varying degrees of psychological stress. Methods: A systematic narrative literature review was conducted, focusing on the interaction between IBD and stress among adult and pediatric patients, as well as animal subjects. The research involved searching PubMed, Scopus, Medline, and Cochrane Library databases from 2000 to December 2023. Results: The interplay between the intestinal immunity response, the nervous system, and psychological disorders, known as the gut-brain axis, plays a major role in IBD pathophysiology. Various types of stressors alter gut mucosal integrity through different pathways, increasing gut mucosa permeability and promoting bacterial translocation. A denser microbial load in the gut wall emphasizes cytokine production, worsening the disease course. The risk of developing depression and anxiety is higher in IBD patients compared with the general population, and stress is a significant trigger for inducing acute flares of the disease. Conclusions: Further large studies should be conducted to assess the relationship between stressors, psychological disorders, and their impact on the course of IBD. Clinicians involved in the medical care of IBD patients should aim to implement stress reduction practices in addition to pharmacological therapies.

Short-term Psychodynamic Psychotherapy in Addition to Standard Medical Therapy Increases Clinical Remission in Adolescents and Young Adults with Inflammatory Bowel Disease: a Randomised Controlled Trial

BACKGROUND

Inflammatory bowel diseases [IBD] are chronic and pervasive conditions of the gastrointestinal tract with a rising incidence in paediatric and young adult populations. Evidence suggests that psychological disorders might be associated with relapse of disease activity. This study aims to evaluate the efficacy of short-term psychodynamic psychotherapy [STPP] in addition to standard medical therapy [SMT] in maintaining clinical remission in adolescents and young adults [AYA] with quiescent IBD, compared with SMT alone.

METHODS

A two-arm, single-centre, randomised, controlled trial was conducted in 60 IBD AYA in clinical remission. Patients were randomised to receive an 8-week STPP + SMT [n = 30] or SMT alone [n = 30]. The primary outcome was the steroid-free remission rate at 52 weeks after treatment. Secondary outcomes included the overall hospitalisation rate within 52 weeks after treatment, and medication adherence obtained from patient's electronic medical records.

RESULTS

Intention-to-treat analysis showed significant improvement in maintaining disease remission rates in the 8-week STPP + SMT group compared with the control one. The proportion of patients maintaining steroid-free remission at 52 weeks was higher in patients in STTP group [93.1%] compared with patients randomised to control group [64.3%; p = 0.01]. There were no significant differences in secondary outcomes, except for depression reduction in STPP + SMT group.

CONCLUSIONS

An 8-week STPP intervention in addition to SMT effectively increases the steroid-free remission rates in AYA with quiescent IBD. Results do not support effects for other secondary outcomes, except for depression reduction.

Virtual adjunctive gut-directed hypnotherapy for people with Crohn's disease: A randomized controlled pilot and feasibility trial

BACKGROUND

Gut-directed hypnotherapy appears to be a promising adjunctive treatment for people with Crohn's disease. The primary objective of this pilot trial was to evaluate feasibility and acceptability of virtually delivered hypnotherapy to determine the parameters for a future definitive trial.

METHODS

This prospective, single-site, randomized controlled pilot and feasibility trial compared a 7-week course of virtually delivered adjunctive gut-directed hypnotherapy to standard medical treatment only for adults with Crohn's disease. Primary outcomes were study feasibility and intervention acceptability. Secondary outcomes were objective disease activity and patient-reported outcomes. Assessments took place at five time-points: baseline, post-intervention, and follow-up three-, six-, and 12-months post-intervention.

KEY RESULTS

Recruitment took place between July 2020 and August 2021 at a tertiary hospital. Recruitment was initially slow and subsequently expanded to community settings. Thirty-seven participants were enrolled in the trial: 95% were retained at post-intervention and 76% at 12-months. Completion of online assessments was high (97-100% across all time-points) whilst objective data collection was low (34-44%). Most intervention participants completed all hypnotherapy sessions (88%) and reported being extremely satisfied (73%), despite 60% experiencing technical issues.

CONCLUSION & INFERENCES

Virtually delivered hypnotherapy was acceptable to participants. Certain aspects of the trial including online assessment were feasible, while recruitment and objective data collection were challenges. Undertaking a future definitive trial will require broader recruitment scope and significant funding for widespread objective data collection.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ANZCTR#1260000348954.

Chronic abdominal pain in inflammatory bowel disease: a practical guide

Pain is common in inflammatory bowel disease (IBD), yet many patients feel their pain is not addressed by healthcare professionals. Listening to a patient's concerns about pain, assessing symptoms and acknowledging the impact these have on daily life remain crucial steps in addressing pain in IBD. While acute pain may be effectively controlled by pain medication, chronic pain is more complex and often pharmacological therapies, particularly opioids, are ineffective. Low-dose tricyclic antidepressants and psychological approaches, including cognitive-behavioural therapy, have shown some promise in offering effective pain management while lifestyle changes such as a trial of low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet in those with overlapping irritable bowel syndrome may also reduce pain. Patients benefit from a long-term, trusting relationship with their healthcare professional to allow a holistic approach combining pharmacological, psychological, lifestyle and dietary approaches to chronic pain. We present a practical review to facilitate management of chronic abdominal pain in IBD.

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.

Abdominal Pain in Inflammatory Bowel Disease: An Evidence-Based, Multidisciplinary Review

Abdominal pain is one of the most common and impactful symptoms associated with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. A great deal of research has been undertaken over the past several years to improve our understanding and to optimize management of this issue. Unfortunately, there is still significant confusion about the underlying pathophysiology of abdominal pain in these conditions and the evidence underlying treatment options in this context. There is also a relative paucity of comprehensive reviews on this topic, including those that simultaneously evaluate pharmacological and nonpharmacological therapeutic options. In this review, our multidisciplinary team examines evidence for various currently available medical, surgical, and other analgesic options to manage abdominal pain in IBD.

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.

Hypnotherapy for chronic pelvic pain: A scoping systematic review and meta-analysis

BACKGROUND

Chronic pelvic pain (CPP) is typically managed with anti-inflammatory analgesics and opioids; however, these do not adequately manage the pain or address the associated negative impact on quality of life. Hypnotherapy has been found to reduce pain associated with a range of disorders, including some with symptoms of chronic pain.

AIM

The aim of this review is to systematically scope research investigating the use of hypnosis on chronic pelvic pain, quality of life, anxiety, depression and fatigue.

METHOD

The scoping review was guided by the method described by Arksey and O'Mallee [1]. A systematic search was conducted in six databases. The Covidence Risk of Bias tool and the National Institutes of Health (NIH) quality assessment tool were used.

RESULTS

Nine studies (four RCT's and five case series) were suitable for inclusion. Meta-analysis of the RCT's found no significant difference in pain or quality of life for the intervention group compared to controls. Only one study reported a reduction in pain after hypnotherapy and did not outperform controls. These results are limited due to lack of a standardised intervention and heterogeneity of the included studies.

CONCLUSION

There is a need for further research using well designed randomized controlled trials with validated measures of pain, quality of life, anxiety, depression and fatigue. Hypnotherapy interventions utilised in further research should be grounded in evidence-based best practice for dealing with pain.

A whole new world of healing: exploring medical hypnotherapy for pediatric patients : A review

This narrative review aims to unravel the potential of medical hypnotherapy for the treatment of children with a variety of diseases and symptoms. Going beyond its history and assumed neurophysiology, the chances of success for hypnotherapy will be outlined per pediatric speciality, accentuated by clinical research and experiences. Future implications and recommendations are given on extracting the positive effects of medical hypnotherapy for all pediatricians.    Conclusion: Medical hypnotherapy is an effective treatment for children with specified conditions such as abdominal pain or headache. Studies suggest effectiveness for other pediatric disciplines, from the first line up to third line of care. In a time in which health is defined as 'a state of complete physical, mental and social well-being', hypnotherapy stays an underrated treatment option for children. It is a unique mind-body treatment, which true potential still needs to be unraveled. What is Known: • Mind-body health techniques become a more relevant and accepted part of treatment in pediatric patients. • Medical hypnotherapy is an effective treatment for children with specified conditions such as functional abdominal pain. What is New: • Studies suggest the effectiveness of hypnotherapy in a high variety of pediatric symptoms and disease. • Hypnotherapy is a unique mind-body treatment which potential goes far beyond its current utilization.

Patients' experiences with virtual group gut-directed hypnotherapy: A qualitative study

Background

Hypnotherapy is a useful treatment for a variety of gastrointestinal conditions. While there is strong evidence for delivering other treatments virtually and in groups, there is no research thus far on delivering hypnotherapy in this format. Given the growth of both psychogastroenterology and telehealth, these methods should be explored as they have great potential for increasing access and cost-effectiveness of intervention.

Aims

This qualitative study was developed to help understand patients experiences in virtual, group-based, gut-directed hypnotherapy (GDH) in two different institutions.

Methods

Authors developed a qualitative interview with the assistance of two patient partners and then recruited patients from New York University and Dartmouth Health to participate. Interviews were completed one-on-one with patients who started and then completed GDH (≥5 visits) and who did not complete GDH (≤3 visits). Data were coded and then analyzed using thematic analysis.

Results

Twenty-one patients from NYU and Dartmouth participated in qualitative interviews. Broadly, patients reported coming to GDH because they believed in the importance of the mind-body connection or were desperate for treatment. Regardless of why patients came to GDH, they generally reported positive outcomes for GI symptoms and for other physical and mental health conditions. Most patients appreciated the group and virtual formats, though some concerns about inflexible schedules and lack of anonymity were voiced. Despite these concerns, there was broad support for virtual, group-based GDH and general excitement for behavioral health programming.

Conclusion

Virtual, group-based GDH is an acceptable treatment for patients from rural and urban settings. Given the possible improvements in access and cost-effectiveness that this treatment modality can provide, GI practices may want to consider it in lieu of or in addition to the traditional one-on-one treatment format. Barriers and facilitators and recommendations for practice are discussed.

A Systematic Review of Self-Management Interventions for Patients with Inflammatory Bowel Disease

Introduction

Previous studies have reported the effectiveness of inflammatory bowel disease (IBD) self-management. However, it is unclear which types of self-management interventions are effective. We conducted a systematic literature review to clarify the status and efficacy of self-management interventions for IBD.

Methods

Searches were performed in databases including Embase, Medline, and Cochrane Library. Randomized, controlled studies of interventions in adult human participants with IBD involving a self-management component published in English from 2000 to 2020 were included. Studies were stratified based on study design, baseline demographic characteristics, methodological quality, and how outcomes were measured and analyzed for statistically significant improvements in outcomes, such as psychological health, quality of life, and healthcare resource usage.

Results

Among 50 studies included, 31 considered patients with IBD and 14 and 5 focused on patients with ulcerative colitis and Crohn's disease, respectively. Improvements in an outcome were reported in 33 (66%) studies. Most of the interventions that significantly improved an outcome index were based on symptom management and many of these were also delivered in combination with provision of information. We also note that among effective interventions, many were conducted with individualized and patient-participatory activities, and multidisciplinary healthcare practitioners were responsible for delivery of the interventions.

Conclusion

Ongoing interventions that focus on symptom management with provision of information may support self-management behavior in patients with IBD. A participatory intervention targeting individuals was suggested to be an effective intervention method.

Behavioral Digital Therapeutics in Gastrointestinal Conditions: Where Are We Now and Where Should We Go?

Behavioral digital therapeutics represents a diverse range of health technology tools that can offer beneficial options for patients with gastrointestinal disorders, particularly with the shortage of mental health providers. Challenges to the uptake of behavioral digital interventions exist and can be addressed with mobile device applications, improved interoperability of technology platforms, and flexible integration into clinical practice.

Psychological stress in inflammatory bowel disease: Psychoneuroimmunological insights into bidirectional gut–brain communications

Inflammatory bowel disease (IBD), mainly including ulcerative colitis (UC) and Crohn’s disease (CD), is an autoimmune gastrointestinal disease characterized by chronic inflammation and frequent recurrence. Accumulating evidence has confirmed that chronic psychological stress is considered to trigger IBD deterioration and relapse. Moreover, studies have demonstrated that patients with IBD have a higher risk of developing symptoms of anxiety and depression than healthy individuals. However, the underlying mechanism of the link between psychological stress and IBD remains poorly understood. This review used a psychoneuroimmunology perspective to assess possible neuro-visceral integration, immune modulation, and crucial intestinal microbiome changes in IBD. Furthermore, the bidirectionality of the brain–gut axis was emphasized in the context, indicating that IBD pathophysiology increases the inflammatory response in the central nervous system and further contributes to anxiety- and depression-like behavioral comorbidities. This information will help accurately characterize the link between psychological stress and IBD disease activity. Additionally, the clinical application of functional brain imaging, microbiota-targeted treatment, psychotherapy and antidepressants should be considered during the treatment and diagnosis of IBD with behavioral comorbidities. This review elucidates the significance of more high-quality research combined with large clinical sample sizes and multiple diagnostic methods and psychotherapy, which may help to achieve personalized therapeutic strategies for IBD patients based on stress relief.

Systematic review: the role of psychological stress in inflammatory bowel disease

BACKGROUND

Psychological stress is a possible factor in the disease course and poor psychosocial outcomes in inflammatory bowel disease (IBD). Understanding the exact relationship between stress and health has been hampered by methodological issues and how stress has been defined and measured.

AIMS

To explore the association between stress and disease outcomes, investigate the impact of stress on psychosocial outcomes, and evaluate the efficacy of interventions in reducing stress for people with IBD METHODS: We performed a systematic review, searching Medline, CINAHL, Embase and PsycInfo databases on 21 January 2021. We included prospective studies that recruited people with IBD who were aged 16 or over and that measured psychological stress or distress. Analyses included Critical Appraisal Skills Programme quality assessments of included studies and narrative analyses against each research question.

RESULTS

We reviewed 38 studies with 4757 people with IBD, and included 23 observational and 15 interventional studies using 36 different instruments to measure stress. Perceived stress was the most frequently studied concept and preceded IBD exacerbation. Only three studies examined the relationship between stress and psychosocial factors. Cognitive behavioural interventions may reduce stress and other interventions with disease-specific stress, but more studies are needed where groups have comparable baseline characteristics and potential harms are considered alongside benefits.

CONCLUSION

Psychological stress appears to precede IBD exacerbation, although what role it plays in psychosocial outcomes and how it is best managed is unclear. Further research needs to examine the differential effects of stress on disease subtypes and IBD in flare and remission.

A randomized controlled trial of a multicomponent online stress reduction intervention in inflammatory bowel disease

BACKGROUND

Psychological stress negatively impacts inflammatory bowel disease (IBD) outcomes. Patients have prioritized access to online interventions; yet, the data on these have been limited by mixed in-person/online interventions, low adherence, and non-randomized controlled trial (RCT) design.

OBJECTIVES

We assessed the efficacy of and adherence to a 12-week online multicomponent stress reduction intervention in IBD.

DESIGN

This is a RCT.

METHODS

Adult participants on stable IBD medical therapy with elevated stress levels from four centers were randomized to intervention or control groups. Intervention participants received a 12-week online program including a weekly yoga, breathwork and meditation video (target 2-3 times/week), a weekly cognitive behavioral therapy/positive psychology informed video activity, and weekly 10-min check-ins by a study team member. Control participants received weekly motivational messages by email. All patients received standard of care IBD therapy. The primary outcome was Cohen's Perceived Stress Scale (PSS). Secondary outcomes evaluated mental health, resilience, health-related quality of life (HRQoL), symptom indices, acceptability, adherence, and inflammatory biomarkers. Analysis of covariance was used to determine between-group differences.

RESULTS

Of 150 screened patients, 101 were randomized to the intervention (n = 49) and control (n = 52) groups (mean age: 42.5 ± 14.1 years; M:F 1:3, 48% with ulcerative colitis and 52% with Crohn's disease). The between-group PSS improved by 22.4% (95% confidence interval, 10.5-34.3, p < 0.001). Significant improvements were seen in mental health, resilience, and HRQoL measures, with a median satisfaction score of 89/100 at the end of the 12 weeks. In the 44/49 patients who completed the intervention, 91% achieved program adherence targets.

CONCLUSION

This 12-week online intervention improved perceived stress, mental health, and HRQoL, but did not impact IBD symptom indices or inflammatory biomarkers. The program was readily adopted and adhered to by participants with high retention rates. After iterative refinement based on participant feedback, future studies will evaluate the impact of a longer/more intense intervention on disease course.

REGISTRATION

ClinicalTrials.gov Identifier NCT03831750.

PLAIN LANGUAGE SUMMARY

An online stress reduction intervention in inflammatory bowel disease patients improves stress, mental health, and quality of life People with inflammatory bowel disease (IBD) have high levels of stress, anxiety, and depression. Although IBD patients have expressed the need for online mental wellness interventions, the existing data to support these interventions in IBD are limited. In this trial, 101 IBD patients had the chance to participate in a 12-week online stress reduction intervention. In those patients randomly selected to participate in the online intervention, each week they received the following: a 20- to 30-min yoga, breathwork, and meditation video that they were asked to do 2-3 times a week, a 10- to 20-min mental wellness activity they were asked to do once during the week, and a 10-min telephone check-in with a study team member. Participants who were not selected to use the online intervention received a weekly motivational message by email. In all, 90 of the 101 participants (89%) completed the study with the mean age of participants being 43 years and the majority being females (75%). Ninety-one percent of participants who completed the intervention met the program target of doing the yoga, breathwork, and meditation video at least 2 times per week. Significant improvements were seen in perceived stress (by 22.4%), depression (by 29.5%), anxiety (by 23.7%), resilience (by 10.6%), and quality of life (by 8.9%). No changes were seen in IBD severity or in blood markers of inflammation. In conclusion, this study demonstrates evidence that a 12-week online stress reduction intervention had low dropout rates, high adherence and beneficial effects on stress, mental health, and quality of life measures. Continued feedback will be sought from study participants and our IBD patient partners to refine the intervention and assess the impact in future studies of patients with active IBD, as well as the impact of a longer/more intense intervention.

Development and Validation of a Japanese Version of the Inflammatory Bowel Disease Self-efficacy Scale and Cross-culture Study in Japan and the United States

BACKGROUND

Self-efficacy is an important health outcome for patients with inflammatory bowel disease (IBD). We aimed to develop a Japanese version of the IBD-Self-Efficacy Scale (IBD-SES.J) and compare characteristics of self-efficacy of IBD patients with previously reported results from patients in the United States.

METHODS

We conducted a questionnaire survey of patients with IBD from a specialized IBD clinic and respondents recruited online. Self-efficacy of patients in Japan and the United States were compared by Student t test and Cohen d coefficient to gauge effect size.

RESULTS

A total of 919 valid responses were obtained: 482 patients from the specialized IBD clinic and 437 patients from the online survey. Significant differences (P < .01) were observed in the following 3 subscales: "managing stress and emotions," "managing symptoms and disease," and "maintaining remission" when comparing remission and active periods; and known-group validity was mostly confirmed. Cronbach's alpha coefficients of each subscale ranged between 0.85 and 0.94. Intraclass correlation coefficients (95% confidence intervals [CIs]) to assess test-retest reliability of each item were between 0.56 (95% CI, 0.47-0.64) and 0.78 (95% CI, 0.73-0.82). Self-efficacy scores for most items in Japanese patients with IBD were lower compared with patients in the United States, with moderate effect size (Cohen d > 0.5), especially in the subscale "managing stress and emotions."

CONCLUSIONS

The study demonstrates the reliability and validity of the IBD-SESJ. Self-efficacy scores for most items in Japanese patients were lower than those of patients in the United States. Further investigation is required to understand cross-cultural score differences.

Resilience-based Integrated IBD Care Is Associated With Reductions in Health Care Use and Opioids

BACKGROUND & AIMS

Integrated inflammatory bowel disease (IBD) care is effective but not routinely implemented. Validated methods that simultaneously address mind and body targets such as resilience may improve access and outcomes. We describe the development and implementation of the GRITT method and its impact on resilience, health care utilization (HCU), and opioid use in IBD.

METHODS

Consecutive patients from an academic IBD center were evaluated for low resilience on the basis of provider referral. Low resilience patients were invited to participate in the GRITT program. Primary outcome was % reduction in HCU. Secondary outcomes were change in resilience and corticosteroid and opioid use. Patients were allocated into 2 groups for analysis: GRITT participants (GP) and non-participants (NP). Clinical data and HCU in the year before enrollment were collected at baseline and 12 months. One-way repeated measures multivariate analysis of covariance evaluated group × time interactions for the primary outcome. Effect size was calculated for changes in resilience over time.

RESULTS

Of 456 screened IBD patients 394 were eligible, 184 GP and 210 NP. GP had greater reduction in HCU than NP: 71% reduction in emergency department visits, 94% reduction in unplanned hospitalizations. There was 49% reduction in opioid use and 73% reduction in corticosteroid use in GP. Resilience increased by 27.3 points (59%), yielding a large effect size (d = 2.4).

CONCLUSIONS

Mind-body care that focuses on building resilience in the context of IBD care may be a novel approach to reduce unplanned HCU and opioid use, but large, multicenter, randomized controlled trials are needed.

Abdominal Pain in Inflammatory Bowel Diseases: A Clinical Challenge

Up to 60% of inflammatory bowel disease (IBD) patients experience abdominal pain in their lifetime regardless of disease activity. Pain negatively affects different areas of daily life and particularly impacts the quality of life of IBD patients. This review provides a comprehensive overview of the multifactorial etiology implicated in the chronic abdominal pain of IBD patients including peripheral sensitization by inflammation, coexistent irritable bowel syndrome, visceral hypersensitivity, alteration of the brain-gut axis, and the multiple factors contributing to pain persistence. Despite the optimal management of intestinal inflammation, chronic abdominal pain can persist, and pharmacological and non-pharmacological approaches are necessary. Integrating psychological support in care models in IBD could decrease disease burden and health care costs. Consequently, a multidisciplinary approach similar to that used for other chronic pain conditions should be recommended.

Relative Contribution of Disease Activity and Psychological Health to Prognosis of Inflammatory Bowel Disease During 6.5 Years of Longitudinal Follow-Up

BACKGROUND & AIMS

Symptoms of common mental disorders, such as anxiety or depression, are common in inflammatory bowel disease (IBD) and may affect prognosis. However, unlike clinical or biochemical markers of disease activity, psychological health is not a recommended therapeutic target. We assessed relative contribution of poor psychological health and clinical or biochemical activity to prognosis.

METHODS

Demographic features, IBD subtype, treatments, and anxiety and depression scores were recorded at baseline for 760 adults, with clinical activity determined using validated scoring systems. Fecal calprotectin was analyzed in 379 (49.9%) patients (≥250 μg/g used to define biochemical activity). Glucocorticosteroid prescription or flare, escalation, hospitalization, intestinal resection, or death were assessed during 6.5 years of follow-up. Occurrence was compared using multivariate Cox regression across 4 patient groups according to presence of disease remission or activity, with or without symptoms of a common mental disorder, at baseline.

RESULTS

In total, 718 (94.5%) participants provided data. Compared with clinical remission without symptoms of a common mental disorder at baseline, need for glucocorticosteroid prescription or flare (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.58-3.54), escalation (HR, 1.65; 95% CI, 1.14--2.40), and death (HR, 4.99; 95% CI, 1.80-13.88) were significantly higher in those with clinical activity and symptoms of a common mental disorder. Rates in those with clinical remission and symptoms of a common mental disorder at baseline or those with clinical activity without symptoms of a common mental disorder were not significantly higher. Similarly, with biochemical activity and symptoms of a common mental disorder, rates of glucocorticosteroid prescription or flare (HR, 2.48; 95% CI, 1.38-4.46), escalation (HR, 2.97; 95% CI, 1.74-5.06), hospitalization (HR, 3.10; 95% CI, 1.43-6.68), and death (HR, 6.26; 95% CI, 2.23-17.56) were significantly higher.

CONCLUSIONS

Psychological factors are important determinants of poor prognostic outcomes in IBD and should be considered as a therapeutic target.

Hypnobiome: A New, Potential Frontier of Hypnotherapy in the Treatment of Irritable Bowel Syndrome-A Narrative Review of the Literature

Increasing evidence suggests that the gut-brain axis may play a key role in health and disease via a bidirectional communication network involving neural and immunoendocrine pathways. This complex interplay deeply influences both gut microbiota and brain behavior. Pathobiome or gut dysbiosis is relevant for the pathogenesis of functional gastrointestinal disorders, such as IBS, chronic pain syndromes, and neurological and mental disorders. As a consequence, targeting the gut microbiota is emerging as a novel, effective therapeutic perspective. Among many treatment options, psychological interventions, including hypnosis, have been used to target the so-called psychobiome and its hypnotic analogue, i.e., hypnobiome, referring to their potential efficacy to modulate the mind-gut axis in IBS patients. A narrative review of the recent literature is provided and circumstantial evidence suggests that hypnobiome may represent a new promising frontier of hypnotherapy.

systematic review on role of hypnotherapeutic intervention in promoting positive psychological health

In this world of fast moving day to day activities, it is of utmost importance that every individual is aware of their personal well- being and take steps towards improving these over the course of time (Al-Asmi et al., 2015; Amato et al., 2001). The state of well – being can be described as understanding the quality of life led by various individuals (Statham & Chase, 2010). The concept of well- being in humans is broadly classified into two aspects - the first one is associated with having life satisfaction and a positive effect in one’s life.the study here is only focused towards the use of hypnotherapeutic interventions in the process of promoting a positive psychological heath scenario all across. The study undertakes a systematic review approach with 51 articles and aims to put forward a summarised version of the literature in the aspect of  hypnotherapeutic interventions.The result of the study identifies a total of three themes from the systematic literature review conducted. It is found that the three identified themes have been put forward by researchers as the most effective impact of hypnotherapeutic interventions. 

Psychological and Nutritional Factors in Pelvic Floor Disorders

This article discusses the role of psychological and nutritional factors in gastrointestinal pelvic floor disorders such as dyssynergic defection and explores the use of multidisciplinary strategies to enhance treatment.

High Levels of Psychological Resilience Are Associated With Decreased Anxiety in Inflammatory Bowel Disease

BACKGROUND

Anxiety and depression are comorbid disorders with IBD and are associated with poor outcomes. Resilience is an innate but modifiable trait that may improve the symptoms of psychological disorders. Increasing resilience may decrease the severity of these comorbid disorders, which may improve IBD outcomes. The aim of this study was to describe the association between resilience, anxiety, and depression in IBD patients.

METHODS

We performed a cross-sectional study of IBD patients. Patients completed a questionnaire consisting of the Connor-Davidson Resilience Scale (CD-RISC), a measure of resilience, the Generalized Anxiety Disorder 7 (GAD-7), and the Patient Health Questionnaire-9. Primary outcome was severity of anxiety and depression in patients with high resilience. Multivariable linear regression analysis evaluated the association between severity of anxiety and depression and level of resilience.

RESULTS

A sample of 288 patients was analyzed. Bivariable linear regression analysis showed a negative association between resilience and anxiety (Pearson rho = -0.47; P < .0001) and between resilience and depression (Pearson rho = -0.53; P < .0001). Multivariable linear regression indicated that high resilience is independently associated with lower anxiety and that for every 1-unit increase in CD-RISC, the GAD-7 score decreased by 0.04 units (P = .0003). Unlike anxiety, the association between resilience and depression did not remain statistically significant on multivariable analysis.

CONCLUSIONS

High resilience is independently associated with lower anxiety in IBD patients, and we report a quantifiable decrease in anxiety score severity for every point of increase in resilience score. These findings suggest that IBD patients with higher resilience may have better coping mechanisms that buffer against the development of anxiety.

Psychological comorbidity in gastrointestinal diseases: Update on the brain-gut-microbiome axis

The high comorbidity of psychological disorders in both functional and organic gastrointestinal diseases suggests the intimate and complex link between the brain and the gut. Termed the brain-gut axis, this bidirectional communication between the central nervous system and enteric nervous system relies on immune, endocrine, neural, and metabolic pathways. There is increasing evidence that the gut microbiome is a key part of this system, and dysregulation of the brain-gut-microbiome axis (BGMA) has been implicated in disorders of brain-gut interaction, including irritable bowel syndrome, and in neuropsychiatric disorders, including depression, Alzheimer's disease, and autism spectrum disorder. Further, alterations in the gut microbiome have been implicated in the pathogenesis of organic gastrointestinal diseases, including inflammatory bowel disease. The BGMA is an attractive therapeutic target, as using prebiotics, probiotics, or postbiotics to modify the gut microbiome or mimic gut microbial signals could provide novel treatment options to address these debilitating diseases. However, despite significant advancements in our understanding of the BGMA, clinical data is lacking. In this article, we will review current understanding of the comorbidity of gastrointestinal diseases and psychological disorders. We will also review the current evidence supporting the key role of the BGMA in this pathology. Finally, we will discuss the clinical implications of the BGMA in the evaluation and management of psychological and gastrointestinal disorders.

The Effect of Psychotherapy on Quality of Life in IBD Patients: A Systematic Review

BACKGROUND

Patients with inflammatory bowel disease (IBD) express a need for additional psychotherapy; however, psychological support is not incorporated in the routine care of persons with IBD. This systematic review aims to assess the effect of psychotherapy on quality of life (QoL).

METHODS

A systematic search was conducted on October 7, 2019, using Embase, Medline (Ovid), PubMed, Cochrane, Web of Science, PsycInfo, and Google Scholar to collect all types of clinical trials with psychotherapeutic interventions that measured QoL in patients with IBD aged ≥18 years. Quality of evidence was systematically assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria.

RESULTS

Out of 2560 articles, 31 studies (32 articles) were included with a total number of 2397 patients with active and inactive IBD. Of the 31 eligible studies, 11 reported a significant positive effect and 6 had ambiguous results regarding the impact of psychotherapeutic interventions on QoL. Treatment modalities differed in the reported studies and consisted of cognitive-behavioral therapy, psychodynamic therapy, acceptance and commitment therapy, stress management programs, mindfulness, hypnosis, or solution-focused therapy. All 4 studies focusing on patients with active disease reported a positive effect of psychotherapy. Trials applying cognitive-behavioral therapy reported the most consistent positive results.

CONCLUSIONS

Psychotherapeutic interventions can improve QoL in patients with IBD. More high-quality research is needed before psychological therapy may be implemented in daily IBD practice and to evaluate whether early psychological intervention after diagnosis will result in better coping strategies and QoL throughout life.

Therapeutic Potential of Vagus Nerve Stimulation for Inflammatory Bowel Diseases

The vagus nerve is a mixed nerve, comprising 80% afferent fibers and 20% efferent fibers. It allows a bidirectional communication between the central nervous system and the digestive tract. It has a dual anti-inflammatory properties via activation of the hypothalamic pituitary adrenal axis, by its afferents, but also through a vago-vagal inflammatory reflex involving an afferent (vagal) and an efferent (vagal) arm, called the cholinergic anti-inflammatory pathway. Indeed, the release of acetylcholine at the end of its efferent fibers is able to inhibit the release of tumor necrosis factor (TNF) alpha by macrophages via an interneuron of the enteric nervous system synapsing between the efferent vagal endings and the macrophages and releasing acetylcholine. The vagus nerve also synapses with the splenic sympathetic nerve to inhibit the release of TNF-alpha by splenic macrophages. It can also activate the spinal sympathetic system after central integration of its afferents. This anti-TNF-alpha effect of the vagus nerve can be used in the treatment of chronic inflammatory bowel diseases, represented by Crohn’s disease and ulcerative colitis where this cytokine plays a key role. Bioelectronic medicine, via vagus nerve stimulation, may have an interest in this non-drug therapeutic approach as an alternative to conventional anti-TNF-alpha drugs, which are not devoid of side effects feared by patients.

Clinical Hypnosis in Pediatric Crohn's Disease: A Randomized Controlled Pilot Study

OBJECTIVE

The aim of this study was to implement clinical hypnosis (CH) as an adjunctive therapy for adolescents with Crohn's disease (CD) and to assess the impact of CH on quality of life (QoL), abdominal pain, psychosocial measures, and disease activity compared with standard care.

METHODS

Forty adolescents with CD were randomized to a hypnosis intervention (HI) or waitlist control (WC) group. The intervention consisted of 1 in-person CH session, self-hypnosis education, and recordings for home practice. Data was collected at baseline, after the 8-week intervention, and at week 16. The primary outcome was patient- and parent-reported QoL; secondary outcomes were patient-reported abdominal pain, depression, anxiety, and sleep; school absences; and disease activity by Pediatric Crohn's Disease Activity Index. Paired and independent t-tests were used to compare differences from baseline to postintervention within and between groups.

RESULTS

Forty patients (50% girls, mean 15.8 years) were enrolled from February to May 2019. Seventy-eight percent had inactive disease, and 55% had abdominal pain. Post intervention, significant improvements were noted in HI parent-reported QoL compared with WC in total score (P = 0.05), social functioning (P = 0.01), and school functioning (P = 0.04) but patient-reported QoL was unchanged. Abdominal pain severity significantly improved in HI compared with WC (P = 0.03). School absences decreased in significantly more intervention than control patients (P = 0.01). Patients who practiced self-hypnosis consistently showed a trend toward greater QoL improvement than those who did not (P = 0.1).

CONCLUSIONS

CH is an acceptable and feasible adjunct in CD and may improve psychosocial QoL and abdominal pain. Further research is warranted.

The Brain-Gut Axis: Psychological Functioning and Inflammatory Bowel Diseases

The brain-gut axis represents a complex bi-directional system comprising multiple interconnections between the neuroendocrine pathways, the autonomous nervous system and the gastrointestinal tract. Inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, is a chronic, relapsing-remitting inflammatory disorder of the gastrointestinal tract with a multifactorial etiology. Depression and anxiety are prevalent among patients with chronic disorders characterized by a strong immune component, such as diabetes mellitus, cancer, multiple sclerosis, rheumatoid arthritis and IBD. Although psychological problems are an important aspect of morbidity and of impaired quality of life in patients with IBD, depression and anxiety continue to be under-diagnosed. There is lack of evidence regarding the exact mechanisms by which depression, anxiety and cognitive dysfunction may occur in these patients, and whether psychological disorders are the result of disease activity or determinants of the IBD occurrence. In this comprehensive review, we summarize the role of the brain-gut axis in the psychological functioning of patients with IBD, and discuss current preclinical and clinical data on the topic and therapeutic strategies potentially useful for the clinical management of these patients. Personalized pathways of psychological supports are needed to improve the quality of life in patients with IBD.

Integrated Psychological Care Reduces Health Care Costs at a Hospital-Based Inflammatory Bowel Disease Service

BACKGROUND & AIMS

Inflammatory bowel diseases (IBD) are associated with high psychosocial burden and economic cost. Integrating psychological care into routine management might lead to savings. We performed a 2-year investigation of the effects of integrated psychological care in reducing healthcare use and costs.

METHODS

We performed a prospective study of 335 adult patients treated at a hospital-based IBD service in Australia. Participants were recruited between September 2015 and August 2016 and completed screening instruments to evaluate mental health and quality of life. Data on healthcare use and costs for the previous 12 months were also collected. Patients found to be at risk for mental health issues were offered psychological intervention. Patients were followed up 12 months after screening (between September 2016 and August 2017).

RESULTS

A significantly higher proportion of subjects at risk for mental health issues had presented to an emergency department in the 12 months before screening (51/182; 28%) compared to psychologically healthy subjects (28/152; 18%; X²(1) = 4.23; P = .040). Higher levels of depression and general distress (but not anxiety) were related to increased odds of hospital admission (adjusted odds ratios, 1.07 and 1.05, respectively). Among the patients who accepted psychological intervention, the number who presented to emergency departments was reduced significantly in the 12 months after screening (follow-up) compared to the 12 months before screening (P = .047), resulting in a cost saving of AU$30,140 ($20,816 USD). A cost-benefit analysis of the integrated psychological care model revealed a net saving of AU$84,905 ($58,647 USD) over a 2-year period.

CONCLUSIONS

Risk for mental health issues is associated with higher healthcare costs in people with IBD. Providing integrated psychological care to individuals at risk for mental health issues can reduce costs, particularly by decreasing visits to emergency departments. Further studies are required to determine the best care to provide to reduce costs.

The LIFEwithIBD Intervention: Study Protocol for a Randomized Controlled Trial of a Face-to-Face Acceptance and Commitment Therapy and Compassion-Based Intervention Tailored to People With Inflammatory Bowel Disease

Background: There is ample evidence of the high mental health burden caused by Inflammatory Bowel Disease (IBD). Several constructs such as experiential avoidance, cognitive fusion, shame, and self-criticism have recently emerged as potential intervention targets to improve mental health in IBD. Psychotherapeutic models such as Acceptance and Commitment Therapy and compassion-based interventions are known to target these constructs. In this protocol, we aim to describe a two-arm Randomized Controlled Trial (RCT) testing the efficacy of an ACT and compassion-focused intervention named Living with Intention, Fullness, and Engagement with Inflammatory Bowel Disease (LIFEwithIBD) intervention + Treatment As Usual (TAU) vs. TAU in improving psychological distress, quality of life, work and social functioning, IBD symptom perception, illness-related shame, psychological flexibility, self-compassion, disease activity, inflammation biomarkers, and gut microbiota diversity. Methods: This trial is registered at ClinicalTrials.gov (Identifier: NCT03840707, date assigned 13/02/2019). The LIFEwithIBD intervention is an adaptation to the IBD population of the Mind programme for people with cancer, an acceptance, mindfulness, and compassion-based intervention designed to be delivered in a group format. The LIFEwithIBD intervention's structure and topics are presented in this protocol. Participants were recruited at the Gastroenterology Service of the Coimbra University Hospital between June and September 2019. Of the 355 patients screened, 61 participants were selected, randomly assigned to one of two conditions [experimental group (LIFEwithIBD + TAU) or control group (TAU)] and completed the baseline assessment. Outcome measurement took place at baseline, post-intervention, 3- and 12-month follow-ups. Discussion: Results from this RCT will support future studies testing the LIFEwithIBD intervention or other acceptance and/or compassion-based interventions for IBD.

Hypnotherapy for Irritable Bowel Syndrome-Type Symptoms in Patients with Quiescent Inflammatory Bowel Disease: A Randomized, Controlled Trial

BACKGROUND AND AIMS

Many inflammatory bowel disease [IBD] patients in remission have persisting symptoms, compatible with irritable bowel syndrome [IBS-type symptoms]. We aimed to compare the effectiveness of gut-directed hypnotherapy vs standard medical treatment [SMT] for IBS-type symptoms in IBD patients.

METHODS

In this multicentre, randomized, controlled, open-label trial, patients aged 12-65 years with IBD in clinical remission [global assessment] and biochemical remission [faecal calprotectin ≤100 µg/g, or ≤200 µg/g without inflammation at endoscopy] with IBS according to Rome III criteria were randomized to hypnotherapy or SMT. Primary outcome was the proportion with ≥50% reduction on a visual analog scale for symptom severity, as measured with the Irritable Bowel Syndrome Severity Scoring System [IBS-SSS] at week 40 [i.e. 6 months after finishing the intervention], compared to baseline. Secondary outcomes included total IBS-SSS score, quality of life, adequate relief, IBS-related cognitions, and depression and anxiety scores.

RESULTS

Eighty patients were included, of whom 70 received at least one session of the allocated treatment and were included in the modified intention-to-treat-population. Seven patients were excluded because of missing baseline data required for the primary outcome. The primary outcome was met in nine [27%] of 33 patients randomized to SMT and nine [30%] of 30 patients randomized to hypnotherapy [p = 0.81]. Adequate relief was reported in 60% and 40% of subjects, respectively. Exploratory analyses of secondary outcomes revealed no apparent differences between the two treatment groups.

CONCLUSIONS

Hypnotherapy was not superior to SMT in the treatment of IBS-type symptoms in IBD patients. Both treatment strategies are reasonable options from a clinical perspective.

Implementing psychological therapies for gastrointestinal disorders in pediatrics

INTRODUCTION

The brain-gut axis refers to complex and reciprocal interactions that impact symptom presentation and disease course within the GI tract. Psychological therapies included in the treatment of functional gastrointestinal disorders (FGIDs) as well as chronic gut disorders including inflammatory bowel disease (IBD) address environmental and psychological factors impacting patients' symptoms and overall functioning.

AREAS COVERED

Employing a biopsychosocial approach, this review focuses on the evidence for and implementation of psychological therapies across pediatric gastrointestinal disorders.

EXPERT OPINION

By developing a working knowledge of evidence-based psychological therapies applicable to pediatric gastrointestinal disorders, clinicians have the opportunity to comprehensively treat patients' symptoms and distress. Regular communication and coordination between pediatric gastroenterology clinicians and providers of psychological therapies offers the greatest likelihood for successfully implementing psychological therapies into treatment plans.

Correlation of menstrual distress to severity of gastrointestinal symptoms in inflammatory bowel disease patients

Inflammatory bowel diseases (IBD), namely, Crohn's disease (CD) and ulcerative colitis (UC) are idiopathic chronic, relapsing, inflammatory diseases of the gastrointestinal (GI) tract. Triggers for disease flares include medications, infection, acute stress, and the menstrual cycle. Varying ovarian hormone levels i.e. prostaglandins and progesterone may exaggerate GI symptoms in IBD. We aimed to determine the relationship between quality of life, endoscopic and clinical disease activity and the menstrual cycle among females with IBD through a questionnaire based cross-sectional study. The first 75 women of child-bearing age seen at IBD clinic completed a questionnaire incorporating the short IBD questionnaire (SIBDQ). Menstrual symptoms were evaluated using the validated Moos Menstrual Distress Questionnaire (MDQ) to measure cyclical peri-menstrual symptoms. Endoscopic disease severity was assessed using the Rutgeert's score (post ileo-cecal resection patients) or Simple Endoscopic Score for CD and the Mayo score for UC. There was a statistically negative correlation between MDQ and SIBDQ scores (p<0.001); i.e. patients with lower menstrual distress scores had better quality of life. We found no correlation between the SIBDQ, MDQ and endoscopic scores (p = 0.094, 0.626 respectively). Previous studies suggest that the severity of menstrual symptoms correlate with a poorer quality of life among women with IBD. However, this may not be reflective of the endoscopic disease severity. Larger studies are necessary to evaluate adjusting medication closer to menstrual period and adding supportive therapy peri-menstrually in anticipation of symptoms.

Hypnosis and Cognitive Behavioral Therapies for the Management of Gastrointestinal Disorders

PURPOSE OF REVIEW

To review the nature, current evidence of efficacy, recent developments, and future prospects for cognitive behavioral therapy (CBT) and gut-directed hypnotherapy, the two best established psychological interventions for managing gastrointestinal (GI) disorders.

RECENT FINDINGS

New large randomized controlled trials are showing that cost-effective therapy delivery formats (telephone-based, Internet-based, fewer therapist sessions, or group therapy) are effective for treating GI disorders. CBT and hypnotherapy can produce substantial improvement in the digestive tract symptoms, psychological well-being, and quality of life of GI patients. However, they have long been hampered by limited scalability and significant cost, and only been sufficiently tested for a few GI health problems. Through adoption of more cost-effective therapy formats and teletherapy, and by expanding the scope of efficacy testing to additional GI treatment targets, these interventions have the potential to become widely available options for improving clinical outcomes for patients with hard-to-treat GI disorders.

Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

PURPOSE OF REVIEW

This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies.

RECENT FINDINGS

Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.

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.

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.

Nuances of the psychogastroenterology patient: A predictive model for gastrointestinal quality of life improvement

BACKGROUND

Gastrointestinal conditions are multifactorial in nature, and certain patients can benefit greatly from brain-gut psychotherapies delivered by mental health professionals who specialize in psychogastroenterology. This study aimed to identify features associated with improvements in GI-specific quality of life scores following behavioral health interventions (BHI). The second aim was to create a psychogastroenterology referral care pathway incorporating identified characteristics for greatest benefit from GI-specific behavioral therapy.

METHODS

We performed a prospective observational study of 101 (63 women; median age, 45 years) gastroenterology patients referred for psychogastroenterology consultation at a single center. Patients attended an average of seven sessions with a single GI psychologist where evidence-based brain-gut psychotherapies were employed. GI-specific quality of life (IBS-QOL) and psychological distress (BSI-18) were assessed before and after BHI. Patients completed self-reported questionnaires. We performed a multivariable analysis to determine predictors associated with IBS-QOL score improvement.

KEY RESULTS

A total of 53 (52.5%) patients experienced improvement in IBS-QOL score. Patients with improved IBS-QOL scores had significantly higher baseline BSI general domain T-scores (61.9 vs. 56.9, P = 0.002). Female gender (odds ratio [OR], 3.2), pretreatment BSI somatization T-score ≥63 (OR, 3.7), and a diagnosis of depression (OR, 4.2) were associated with greater odds of IBS-QOL score improvement following BHI.

CONCLUSIONS AND INFERENCES

We identified factors associated with response to GI-specific BHI to aid in optimizing the utilization of psychogastroenterology services and provide referring providers with information to inform treatment recommendations. Female patients with disorders of gut-brain interaction (DGBIs), high somatization, and depression should be considered a priority for brain-gut psychotherapies.

Integrated Psychological Care is Needed, Welcomed and Effective in Ambulatory Inflammatory Bowel Disease Management: Evaluation of a New Initiative

BACKGROUND AND AIMS

Inflammatory bowel disease is associated with psychosocial issues which reduce quality of life and impair medical management. However, these issues are rarely addressed in routine care. A model of integrated psychological screening and intervention was trialled to measure prevalence, patient participation, and potential benefits to mental health and/or quality of life.

METHODS

During a 12-month period, 490 adult patients at an established hospital-based service were approached to complete screening instruments for anxiety, depression, general distress, quality of life and medication adherence. Disease-specific and demographic data were also collected. Patients who scored highly on screening questionnaires were offered psychological intervention (in-service or externally referred). Participants were reassessed after 12 months.

RESULTS

Psychological screening was well accepted with 68% (N = 335) participating. Psychological care was 'needed', with 55% (N = 183) scoring highly for anxiety, depression and/or general distress. Half of those 'in need' (N = 91) accepted intervention. In those who accepted, levels of anxiety (mean at intake [M1] = 12.11 vs mean at follow-up [M2] = 9.59, p < 0.001), depression (M1 = 8.38 vs M2 = 6.42, p < 0.001), general distress (M1 = 17.99 vs M2 = 13.96, p < 0.001), mental health quality of life (M1 = 54.64 vs M2 = 59.70, p < 0.001) and overall quality of life (M1 = 57.60 vs M2 = 64.10, p < 0.001) each improved between intake and follow-up. Engagement in psychological intervention was six times greater for those treated in-service vs externally referred (χ2[1] = 13.06, p < 0.001, odds ratio = 6.47).

CONCLUSIONS

Mental health issues are highly prevalent in people with inflammatory bowel disease. Patients are open to psychological screening and treatment. Psychological care can improve patient mental health and quality of life, and works best when integrated into routine management.

Brain-Gut Therapies for Pediatric Functional Gastrointestinal Disorders and Inflammatory Bowel Disease

PURPOSE OF REVIEW

The purpose of this review is to discuss current knowledge of brain-gut therapies (BGT) in pediatric functional gastrointestinal disorders (FGID) and inflammatory bowel disease (IBD), including their evidence base, the common psychopathology that they address, and the integration of this knowledge into medical settings.

RECENT FINDINGS

Cognitive behavioral therapy (CBT), hypnotherapy (HT), mindfulness-based therapy (MBT), and exposure-based therapy (EBT) have the most data supporting their use in children, particularly in FGID, more so than in IBD. This difference is most likely because of the increased role of psychological factors in FGID, though these same factors can be seen comorbidly in IBD. Integrative BGT treatment strategies with the collaboration of clinicians across disciplines may provide the most benefit to patients. This review details our current understanding of the evidence for BGT in pediatric FGID and IBD and how they may best be used in treatment strategies.

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

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