Does psychological status influence clinical outcomes in patients with inflammatory bowel disease (IBD) and other chronic gastroenterological diseases: an observational cohort prospective study

Depression is associated with increased disease activity in patients with ulcerative colitis: A propensity score-matched analysis using a nationwide database in Japan

Background and Aim

The incidence and prevalence of psychiatric disorders are elevated in patients with inflammatory bowel disease (IBD). Whether psychiatric disorders could affect the clinical course of IBD is uncertain and controversial. We aimed to evaluate the impact of psychiatric disorders, particularly depression, on the clinical course of IBD using a nationwide database in Japan.

Methods

We collected data on admissions with IBD using the Diagnosis Procedure Combination database system introduced in Japan. We divided eligible admissions into IBD with and without depression groups using propensity score matching and compared the rates of surgery, use of molecular targeted drugs and biologics, systemic steroid administrations, and in-hospital death. We also conducted a logistic regression analysis to identify clinical factors affecting surgery, the use of molecular targeted drugs and biologics, and systemic steroid administrations.

Results

The rates of surgery, use of two or more molecular targeted drugs, systemic steroid administrations, and in-hospital deaths in the ulcerative colitis (UC) with depression group were higher than in the UC without depression group. Multivariate analysis of UC showed that depression increased the odds of systemic steroid administrations, use of two or more molecular targeted drugs, and surgery. However, analysis of Crohn's disease showed that only steroid administrations were associated with depression.

Conclusion

Our study demonstrated an association between a worse clinical course of UC and depression. Although this result indicates that depression might be associated with increased disease activity in patients with UC, the causal relationship is still unclear. Further prospective studies are warranted.

Psychological mediators of psychological distress and quality of life in inflammatory bowel disease

BACKGROUND AND AIMS

Using the Common Sense Model (CSM), this study aimed to examine the extent to which illness beliefs, coping styles, self-efficacy, and mindfulness mediate this relationship.

METHODS

Two hundred and sixty-one adults (198 females; 169 with Crohn's Disease) with IBD participated in this cross-sectional study. Measures used in this study were the short Crohn's Disease Activity Index, Ulcerative Colitis Lichtiger Index, Inflammatory Bowel Disease Questionnaire, New General Self-Efficacy Scale, Carver Brief COPE scale, Mindful Attention Awareness Scale, Brief Illness Perceptions Questionnaire, and the Depression and Anxiety Stress Scales.

RESULTS

Using structural equation modelling, the final model indicated IBD symptoms had a significant direct influence only on illness perceptions (β = 0.66, p < .001). In turn, illness perceptions had a significant direct influence on depression and anxiety (β = 0.34, p < .001) and QoL (β = -0.67, p < .001), and was also linked to higher maladaptive coping (β = 0.28, p < .001) and lower self-efficacy (β = -0.49, p < .001), but not with mindfulness or adaptive coping (p > .05). Maladaptive coping (β = 0.46, p < .001) and mindfulness (β = 0.23, p < .001) were linked with increased distress. QoL was influenced by distress (β = -0.40, p < .001).

CONCLUSIONS

Consistent with the predictions of the CSM, the relationships between IBD symptoms and depression and anxiety, and between IBD symptoms and quality of life, are statistically mediated via psychological variables including illness perceptions and maladaptive coping.

Assessment of causal link between psychological factors and symptom exacerbation in inflammatory bowel disease: a systematic review utilising Bradford Hill criteria and meta-analysis of prospective cohort studies

BACKGROUND

Psychological stress is a prevalent factor in inflammatory bowel disease (IBD) with detrimental effects on patients' quality of life and possibly disease course. Although the aetiology of symptom exacerbation in IBD has been explored, determining any causation between psychological stress and symptom worsening remains challenging and requires a methodologically rigorous approach.

AIM

The aim of this systematic review with meta-analysis was to determine a causal relationship between psychological stress and symptom exacerbation in IBD, subsequently utilising Bradford Hill's criteria (approach never used in this topic area before) to evaluate the likelihood of causal associations.

METHODS

Medline, EMBASE, CINAHL and PsycInfo were searched for relevant studies up to July 20, 2019. Data extraction and quality appraisal were performed by two independent reviewers. Results of all retained papers were presented as a narrative synthesis. A random-effect meta-analysis was conducted on studies meeting the criteria for meta-analysis. Bradford Hill criteria were applied to assess the causality of the relationship between all psychological factors and symptom exacerbation.

RESULTS

The searches yielded 2472 potential articles. Nineteen clinical prospective cohort studies were eligible for the narrative review with five suitable for the meta-analysis. Meta-analysis showed depression, anxiety and perceived stress did not have a statistically significant association with an increased risk of symptom exacerbation. Four of the Bradford Hill criteria were met which indicates that there is weak to moderate evidence of a causal association between all the psychological factors and disease activity. Inconsistent results and a dearth of studies using the same tools for measuring psychological factors suggest the need for more research to be done to facilitate more conclusive findings.

CONCLUSIONS

This original review utilising Bradford Hill criteria in addition to meta-analysis to evaluate the causality of relationship between psychological factors and symptom exacerbation in IBD provides evidence that psychological factors have a weak to moderate causal involvement in IBD symptom exacerbation. However, when combining this finding with the outcomes of the meta-analysis, we can say that the results were inconclusive. Interventions to reduce the associated psychological impact should be part of the treatment plan for patients with IBD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42012003143.

Psychologic stress and disease activity in patients with inflammatory bowel disease: A multicenter cross-sectional study

Background and aims

Psychologic stress can affect the pathogenesis of inflammatory bowel disease (IBD), but the precise contribution of psychologic stress to IBD remains unclear. We investigated the association of psychologic stress with disease activity in patients with IBD, especially in terms of mental state and sleep condition.

Methods

This was a multi-center observational study comprising 20 institutions. Data were collected using survey forms for doctors and questionnaires for patients, and the association of psychologic stress with clinical parameters was investigated. Mental state was evaluated using the Center for Epidemiologic Studies Depression (CES-D) scale, and sleep condition was evaluated by querying patients about the severity of insomnia symptoms.

Results

A total of 1078 IBD patients were enrolled, including 303 patients with Crohn’s disease and 775 patients with ulcerative colitis. Seventy-five percent of IBD patients believed that psychologic stress triggered an exacerbation of their disease (PSTE group) and 25% did not (non-PSTE group). The CES-D scores were significantly higher for patients with clinically active disease than for those in remission in the PSTE group (median (interquartile range) = 7 (4–9.5) vs. 5 (3–7), p < .0001), but not in the non-PSTE group (5 (2–8) vs. 4 (3–7), p = 0.78). Female sex and disease exacerbation by factors other than psychologic stress were independent factors of psychologic stress-triggered disease exacerbation. Also, patients with insomnia had higher disease activity than those without insomnia, especially in the PSTE group.

Conclusions

A worsened mental state correlates with disease activity in IBD patients, especially those who believe that their disease is exacerbated by psychologic stress.

Pioglitazone Metformin Complex Improves Polycystic Ovary Syndrome Comorbid Psychological Distress via Inhibiting NLRP3 Inflammasome Activation: A Prospective Clinical Study

Objective

This study aimed at investigating the therapeutic effect and mechanism of pioglitazone metformin complex preparation (PM) in polycystic ovary syndrome (PCOS) comorbid psychological distress.

Methods

Seventy-five patients with PCOS comorbid psychological distress were randomly allocated into the PM, metformin, and placebo groups. The primary efficacy measure was the change from baseline to week 12 on the Symptom Checklist 90-R (SCL-90-R) scores. NLRP3 inflammasome, IL-1β, IL-6, TNF-α, and biochemical parameters were determined at baseline and at week 12. The participants were required to meet the criteria for PCOS (Rotterdam, NIH) and psychological distress (any factor scores of SCL − 90 − R > 2).

Results

The participants had significantly high scores on the SCL-90-R scales of anxiety and depression. PM significantly decreased anxiety and depression symptom severity (from 2.31 ± 0.75 to 1.65 ± 0.38, p < 0.001, and from 2.08 ± 0.74 to 1.61 ± 0.46, p = 0.010, at week 12, respectively). PM significantly decreased the expression of NRPL3 and caspase-1. Patients in the PM group experienced a significant reduction in IL-1β (from 98.42 ± 14.38 to 71.76 ± 13.66, p = 0.02), IL-6 (from 87.51 ± 8.74 to 71.98 ± 15.87, p = 0.02), and TNF-α (from 395.33 ± 88.55 to 281.98 ± 85.69, p = 0.04). PM was superior to metformin in reducing total testosterone (2.24 ± 0.74 versus 3.06 ± 0.83, p = 0.024, at week 12).

Conclusions

This study is the first to reveal that PM alleviates psychological distress via inhibiting NLRP3 inflammasome and improves several markers, including total testosterone.

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.

Systematic Review: Components of a Comprehensive Geriatric Assessment in Inflammatory Bowel Disease-A Potentially Promising but Often Neglected Risk Stratification

BACKGROUND

The population of older patients with inflammatory bowel disease [IBD] is increasing. Patient age does not fully account for poor outcomes and its clinical utility for risk stratification is limited. Comprehensive geriatric assessment [CGA], comprising a somatic, functional, mental, and social assessment or frailty, could be a predictor tool.

AIMS

To systematically review literature on the kind of components of a CGA being used in adult IBD patients and the association of these components with adverse health outcomes.

METHODS

An electronic literature search was performed on January 16, 2018, using PubMed, Embase, Web of Science, the Cochrane Library, CENTRAL, Emcare, and PsycINFO. Longitudinal studies relating somatic, functional, mental, and social assessment or frailty to adverse health outcomes during follow-up in IBD patients were included. The Newcastle-Ottawa scale was used to assess individual study quality.

RESULTS

Of 4080 identified citations, 27 studies were included, reporting 169 associations. Median sample size was 108 patients (interquartile range [IQR] 60-704). No studies performed subgroup analyses on older patients, and the highest mean age reported was 52.7 years. Somatic and functional assessments were used in three studies, mental in 24, and social in five. No study assessed cognitive status, functional performance, or frailty. In 62 associations [36.7%], components of a CGA were significantly associated with adverse health outcome measurements.

CONCLUSIONS

Components of a CGA were associated with adverse health outcomes in IBD patients, but older patients were under-represented. More studies among older patients with IBD are warranted to further establish the clinical impact of a CGA.

The Influence of Antidepressants on the Disease Course Among Patients With Crohn's Disease and Ulcerative Colitis-A Danish Nationwide Register-Based Cohort Study

BACKGROUND

Psychiatric comorbidity might modify the disease course adversely in patients with inflammatory bowel disease (IBD). Treatment options include antidepressants, which, apart from improving mood, have anti-inflammatory properties that might modify the disease course. This nationwide study aimed to examine the influence of antidepressants on the disease course among patients with ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

Patients registered with an incident diagnosis of CD or UC in the Danish National Patient Register (2000-2017) were included. Information on antidepressant use and proxy measures of disease activity (health care and drug utilization) was extracted from national population registers. Poisson regression was performed to estimate disease activity rates by antidepressant use adjusted for confounders. Furthermore, the analyses were performed stratified by IBD subtype and type of antidepressants.

RESULTS

A total of 42,890 patients were included (UC: 69.5%; CD: 30.5%). When adjusted for confounders, a lower incidence rate of disease activity was found among antidepressant users compared with nonusers in both CD (incidence rate ratio [IRR], 0.75; 95% confidence interval [CI], 0.68-0.82) and UC (IRR, 0.90; 95% CI, 0.84-0.95) patients. Further, markedly lower rates of disease activity were found among CD (IRR, 0.51; 95% CI, 0.43-0.62) and UC (IRR, 0.67; 95% CI, 0.59-0.75) patients with no use of antidepressants before IBD onset.

CONCLUSIONS

In this nationwide study, antidepressant use was found to be beneficial on the disease course among patients with UC and CD, particularly in patients with no use of antidepressants before IBD onset. Randomized controlled trials are warranted to investigate the potential of antidepressants being an adjunct treatment to conventional IBD therapy.

Predictors of Impaired Mental Health and Support Seeking in Adults With Inflammatory Bowel Disease: An Online Survey

This study explored the possible factors associated with psychological distress in adults with inflammatory bowel disease (IBD) and also engagement in mental health services (MHS) in those reporting distress in a large Australian cohort. Participants with IBD completed an online survey assessing perceived IBD activity (Manitoba Index; MI), mental health status (K10), demographic details, and engagement with MHS for IBD-associated issues. Of 336 participants, 76.5% perceived themselves as having active disease over the past 6 months, and on K10 scores, 51.8% had a mental health issue. Of participants with a mental health issue, only 21.3% were currently receiving mental health support. A stepwise logistic regression analysis correctly classified 78.7% of the status of receiving mental health support, with lower income (<$60,000 per annum) the only significant predictor. Paradoxically, the degree of psychological distress did not correlate with seeking mental health support. The data show that in individuals with ongoing symptoms attributed to active IBD, mental health issues are highly prevalent, with older age and higher income being additional drivers of mental health issues. The greater challenge, however, seems not to be identifying mental health issues, but in getting those in need to engage in MHS.

Evaluation of Brain Activity Using Near-infrared Spectroscopy in Inflammatory Bowel Disease Patients

Depression is implicated as a risk factor for the recurrence of inflammatory bowel disease (IBD). Near-infrared spectroscopy (NIRS) and brain-derived neurotrophic factor (BDNF) are useful tools for evaluation of brain activity and a depressive state, respectively. The aim of this study was to clarify the association between brain activity or depressive symptoms and IBD using NIRS and BDNF. This study included 36 ulcerative colitis (UC) patients, 32 Crohn’s disease (CD) patients, and 17 healthy controls (HC). Center for Epidemiologic Studies Depression Scale (CES-D) scores were determined, NIRS was performed, and serum BDNF levels were measured in all subjects. NIRS showed that the mean oxygenated hemoglobin concentration was significantly lower in the frontal lobe in the UC group than in the HC group (HC 167 ± 106 vs. UC 83.1 ± 85.3, p < 0.05). No significant difference was seen between the HC and CD groups. There were also no significant differences in CED-D scores and BDNF levels among the groups. Changes in the NIRS values of the UC group may indicate decreased brain activity and a fundamental difference between UC and CD, which are often lumped together as two types of IBD.

High Demand for Psychotherapy in Patients with Inflammatory Bowel Disease

BACKGROUND

The relative contribution of psychological factors to the onset and course of inflammatory bowel diseases (IBD) is a matter of constant debate since its beginning, as is the clinical need and the efficacy of psychotherapeutic interventions. However, the perspective of patients with IBD has largely been ignored in this debate.

METHODS

Psychometric tests including the Short-Form IBD Questionnaire (SIBDQ), the ADAP test measuring demand for psychotherapy, and the Fear-of-Progression Questionnaire Short Form as well as disease-related questions were positioned on the internet between December 2014 and January 2016. The study was advertised through DCCV (German branch of the European Federation of Crohn's and Ulcerative Colitis Associations).

RESULTS

n = 631 patients responded, and complete data from n = 578 (356 Crohn's disease, 219 ulcerative colitis, 3 unclear) were available for analysis. n = 296 had previous experiences with psychotherapy, whereas n = 282 had not. This distribution clearly determined the factor "demand for psychotherapy" (chi-square = 23.7, P < 0.001). When all available data were entered into a (stepwise-forward) regression model, psychotherapy demand was dependent on previous experience (P < 0.001), fear of progression (P < 0.001), quality of life (P = 0.001), smoking (P = 0.003), and previous surgery (P = 0.005) with the total model explaining 29.7% of the variance. The total explained variance of this model was higher in ulcerative colitis (37.6%) than in Crohn's disease alone (25.4%).

CONCLUSIONS

The demand for psychotherapy as additional therapy in IBD depends on previous experience with psychotherapy, fear for disease progression but also other disease or social characteristics and quality of life.

Systematic review with meta-analysis: the impact of a depressive state on disease course in adult inflammatory bowel disease

BACKGROUND

Despite a higher prevalence of psychosocial morbidity in Inflammatory Bowel Disease (IBD), the association between depressive state and disease course in IBD is poorly understood.

AIM

To investigate the impact of depressive state on disease course in IBD.

METHODS

We conducted a systematic review in MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and PsychINFO for prospective studies evaluating the impact of baseline depressive state on subsequent disease course in adult IBD.

RESULTS

Eleven studies matched our entry criteria, representing 3194 patients with IBD. Three reported on patients with ulcerative colitis (UC), four included patients with Crohn's disease (CD) exclusively, and four studies included both UC and CD. Five studies reported an association between depressive state and disease course. None of the UC-specific studies found any association. In three of four CD-specific studies, a relationship between depressive state and worsening disease course was found. In four of five studies including patients in remission at baseline, no association between depressive state and disease course was found. Pooled analysis of IBD studies with patients in clinical remission at baseline identified no association between depressive state and disease course (HR 1.04, 95%CI: 0.97-1.12).

CONCLUSION

There is limited evidence to support an association between depressive state and subsequent deterioration in disease course in IBD, but what data that exist are more supportive of an association with CD than UC. Baseline disease activity may be an important factor in this relationship. Further studies are needed to understand the relationship between mental health and outcomes in IBD.

ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease

Recent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services at the same rate as general medical patients. Patients with IBD often consider their gastroenterologist to be the primary provider of care. To improve the care delivered to IBD patients, health maintenance issues need to be co-managed by both the gastroenterologist and primary care team. Gastroenterologists need to explicitly inform the primary care provider of the unique needs of the IBD patient, especially those on immunomodulators and biologics or being considered for such therapy. In particular, documentation of up to date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations. Health maintenance issues addressed in this guideline include identification, safety and appropriate timing of vaccinations, screening for osteoporosis, cervical cancer, melanoma and non-melanoma skin cancer as well as identification of depression and anxiety and smoking cessation. To accomplish these health maintenance goals, coordination between the primary care provider, gastroenterology team and other specialists is necessary.

Symptoms of Depression and Anxiety Are Independently Associated With Clinical Recurrence of Inflammatory Bowel Disease

BACKGROUND & AIMS

We examined the relationship between symptoms of depression and anxiety and clinical recurrence of inflammatory bowel disease (IBD) in a large patient cohort. We considered the progression of depression and anxiety over time.

METHODS

We collected clinical and treatment data on 2007 adult participants of the Swiss IBD study (56% with Crohn's disease [CD], 48% male) performed in Switzerland from 2006 through 2015. Depression and anxiety symptoms were quantified by using the Hospital Anxiety and Depression Scale. The relationship between depression and anxiety scores and clinical recurrence was analyzed by using survival-time techniques.

RESULTS

We found a significant association between symptoms of depression and clinical recurrence over time (for all patients with IBD, P = .000001; for subjects with CD, P = .0007; for subjects with ulcerative colitis, P = .005). There was also a significant relationship between symptoms of anxiety and clinical recurrence over time in all subjects with IBD (P = .0014) and in subjects with CD (P = .031) but not ulcerative colitis (P = .066).

CONCLUSIONS

In an analysis of a large cohort of subjects with IBD, we found a significant association between symptoms of depression or anxiety and clinical recurrence. Patients with IBD should therefore be screened for clinically relevant levels of depression and anxiety and referred to psychologists or psychiatrists for further evaluation and treatment.

Unrevealed Depression Involves Dysfunctional Coping Strategies in Crohn's Disease Patients in Clinical Remission

Background and Aims. This study investigated the proportion of CD patients in clinical remission with clinical depression, and coping strategies in those with severe depressive disorders. Materials and Methods. One hundred consecutive CD patients in clinical remission were screened for anxiety and depression by using Hospital Anxiety and Depression Scale and patients with depressive symptoms were further investigated by means of Cognitive Behavioural Assessment 2.0 and Beck Depression Inventory (BDI). Afterwards the coping strategies were assessed through the Brief-COPE questionnaire. Results. Twenty-one patients had anxious symptoms and 16 had depressive symptoms with or without anxiety. Seven of these patients (43.8%) showed significant depressive symptoms. Compared to patients without psychiatric disorders, these patients showed significant lower score in “positive reframing” (p: 0.017) and in “planning” (p: 0.046) and higher score in “use of instrumental social support” (p < 0.001), in “denial” scale (p: 0.001), and in “use of emotional social support” (p: 0.003). Conclusions. Depressed CD patients in clinical remission may have dysfunctional coping strategies, meaning that they may not be able to implement functional strategies to manage at best stress related with their disease.

Psychological status in Iranian patients with ulcerative colitis and its relation to disease activity and quality of life

BACKGROUND

Psychological profile of inflammatory bowel disease patients is not well studied in Iran. We investigated the psychological status of Iranian patients with ulcerative colitis (UC) and its relationship with disease activity and quality of life (QOL).

MATERIALS AND METHODS

A cross-sectional study was conducted on adult UC patients. The Lichtiger Colitis Activity Index, Hospital Anxiety and Depression Scale, General Health Questionnaire-12, and WHOQOL-BREF, were completed by the patients.

RESULTS

From 120 studied patients, 35 (29.2%), 48 (40.0%), and 46 (38.3%) had significant anxiety, depression, and psychological distress, respectively. Anxiety, depression, and psychological distress were strongly correlated with disease activity (r = 0.357 to 0.439, P < 0.01). Disease activity was negatively correlated with all QOL dimensions (r = -0.245 to -0.550, P < 0.01). Anxiety, depression, and psychological distress were also negatively correlated with all QOL domains (r = -0.356 to -0.789, P < 0.01). In the regression models, anxiety was independently associated with active disease (β = 4.150, P = 0.049). Furthermore, disease activity was associated with the physical health (β = -0.371, P < 0.001). For almost all of the QOL domains, depression and psychological distress were independent predictors (β = -0.296 to -0.453, P < 0.001).

CONCLUSION

Anxiety, depression, and psychological distress are highly frequent in UC patients of our society and are strongly associated with disease activity. Depression and psychological distress are important predictors of poor QOL in these patients. Further prospective studies, as well as clinical trials, are warranted in this regard.

An Aggravated Trajectory of Depression and Anxiety Co-morbid with Hepatitis C: A Within-groups Study of 61 Australian Outpatients

Background: This study aimed to explore the course of depression and anxiety in chronic hepatitis C patients. Methods:  Data were combined from two studies: (1) Hospital Anxiety and Depression Scale (HADS) scores in 395 consecutive Australian outpatients from 2006 to 2010 formed the baseline measurement; and (2) Depression Anxiety Stress Scales (DASS) scores in a survey of a sub-sample of these patients in 2011 formed the follow-up measurement. After converting DASS to HADS scores, changes in symptom scores and rates of case-ness (≥8), and predictors of follow-up symptoms were assessed. Results:  Follow-up data were available for 61 patients (70.5% male) whose age ranged from 24.5 to 74.6 years (M=45.6). The time to follow-up ranged from 20.7 to 61.9 months (M=43.8). Baseline rates of depression (32.8%) and anxiety (44.3%) increased to 62.3% and 67.2%, respectively. These findings were confirmed, independent of the conversion, by comparing baseline HADS and follow-up DASS scores with British community norms. Baseline anxiety and younger age predicted depression, while baseline anxiety, high school non-completion, and single relationship status predicted anxiety. Conclusion:  This study demonstrated a worsening trajectory of depression and anxiety. Further controlled and prospective research in a larger sample is required to confirm these findings.

Psychosocial Support of the Inflammatory Bowel Disease Patient

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

Coping Strategies and Psychological Outcomes of Patients with Inflammatory Bowel Disease in the First 6 Months After Diagnosis

BACKGROUND

Inflammatory bowel disease (IBD) is associated with reduced physical and mental well-being. The first 6 months after diagnosis is an important time in a patient's life with IBD. On top of the physical symptoms, psychological characteristics, such as coping strategies and personality, may contribute to impaired or improved health-related quality of life (HRQOL), anxiety, and depression. This study aimed to measure the stability of coping strategies and personality over the first 6 months after diagnosis and identify the associations of coping strategies and personality traits with the level of HRQOL and degree of anxiety and depression. This study aimed to measure HRQOL, anxiety, depression, IBD symptoms, coping, and personality at baseline and 6 months.

METHODS

Questionnaires about HRQOL, anxiety, depression, IBD symptoms, coping, personality, and demographic information were administered to patients at baseline and 6 months after diagnosis.

RESULTS

Personality characteristics were stable over the first 6 months but coping strategies were not. Maladaptive coping strategies were associated with worse outcomes but adaptive coping strategies were not associated with better outcomes. All measures of HRQOL improved. Neuroticism was associated with worse psychological anxiety, depression, and HRQOL outcomes.

CONCLUSIONS

This is the first study to psychologically test patients with IBD during the first 6 months after diagnosis. Generally, the HRQOL of patients with IBD improves over this time. Maladaptive coping is associated with worse psychological anxiety, depression, and HRQOL physical outcomes; although until an interventional study is performed, reverse causation cannot be ruled out.

Symptom management in inflammatory bowel disease

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

Concerns and worries in people living with inflammatory bowel disease (IBD): A mixed methods study

OBJECTIVE

This mixed-methods study aimed to explore concerns and worries related to living with inflammatory bowel disease (IBD).

METHODS

Overall, 294 patients with a clinically established diagnosis of IBD were enrolled in this cross-sectional study. Concerns and worries were measured with one open-ended question. Measures of anxiety and depressive symptoms and disease activity were also administered. A thematic analysis was conducted and thematic map created. Spearman's rho was used to identify univariate correlations between predictors and the main themes. Binary logistic regression was used to test the predictors of the main themes.

RESULTS

Despite the majority of study participants being in IBD remission (74%, n=217), all but 11 reported significant IBD-related concerns. Twenty two percent reported symptoms of depression and 41% of anxiety. Four themes were identified: Quality of life (51%); Unpredictability (35%); Symptoms (34%) and Treatments (19%). Males and older people were less concerned about Quality of life (OR=.597, 95% CI: .363-.980 and OR=.980, 95% CI: .965-.995, respectively). Those in remission were less concerned about Symptoms (OR=.510, 95% CI: .281- .926) while those with longer disease duration worried more about the Symptoms (OR=1.035, 95% CI: 1.010-1.061). Males were less concerned about Treatments (OR=.422, 95% CI: .229-.777).

CONCLUSION

IBD patients report significant disease-related concerns even when in remission. Further exploration of what predicts patient concerns may help in shaping health-care delivery so that it better addresses patient needs.

Endometriosis and perceived stress: impact of surgical and medical treatment

BACKGROUND

The aim of the study was to investigate the levels of perceived stress in a group of women with a long-term history of endometriosis in conjunction with surgical and/or medical treatments.

METHODS

A clinical trial was conducted at the Department of Molecular and Developmental Medicine, University of Siena, in collaboration with a non-profit association of women with endometriosis, A.P.E. Onlus. Patients (n = 204) with a previous diagnosis of endometriosis (for at least 3 years) were included in this study. Each patient completed a semi-structured questionnaire and a validated scale to assess perceived stress, the Perceived Stress Scale (PSS) by e-mail.

RESULTS

The study showed that in women with a long-term history of endometriosis, the level of perceived stress was increased by repeated surgical treatments and reduced by some medical treatments. The median PSS value was 23 (range 9-36) and 30.6% of the study population were included in the highest stress category (>26). The highest levels were found in patients who had undergone the most surgery. The use of progestins was associated with a lower perceived stress (p = 0.004) than in the patients treated with gonadotropin-releasing hormones.

CONCLUSIONS

Long-term endometriosis has a relevant impact on perceived stress, in particular in those undergoing repeated surgery.

Perianal disease is associated with psychiatric co-morbidity in Crohn's disease in remission

BACKGROUND AND AIM

Crohn's disease is a life-long inflammatory disease which can impair quality of life, in particular in patients with psychiatric co-morbidities such as depression and anxiety. The aim of this prospective cohort study was to assess the prevalence of depression and anxiety and related risk factors in patients with quiescent Crohn's disease.

METHODS

A consecutive series of adult patients with confirmed diagnosis of Crohn's disease, in clinical remission, were included and investigated during ambulatory visits using a standard questionnaire assessing demographic and clinical features of the disease. Within 1 month after the ambulatory visit, all patients were interviewed by phone to assess the presence of psychiatric disorders using standardized questionnaires. The questionnaire assessed the development of psychiatric disorders after the diagnosis of Crohn's disease, the use of antidepressant or antianxiety therapy and current anxiety or depression by means of the Hospital Anxiety and Depression Scale.

RESULTS

One hundred and ninety-five patients were included. Seventy-two (36.9 %) patients showed anxiety and/or depression symptoms, 46 (23.6 %) patients showed anxiety symptoms, 6 (3.1 %) patients showed depression symptoms and 20 (10.3 %) patients showed both symptoms. Forty-eight of these patients (58 %) were without any antidepressive or antianxiety treatment. Anxiety with or without depression was significantly correlated with female sex (p = 0.017), history of perianal disease (p = 0.003) and perianal surgery (p = 0.042).

CONCLUSION

Anxiety is a frequent, often untreated, condition in patient affected by Crohn's disease in clinical remission. Female sex, history of perianal disease and perianal surgery are major risk factors for anxiety.

Factors associated with physical and cognitive fatigue in patients with Crohn's disease: a cross-sectional and longitudinal study

BACKGROUND

Fatigue commonly impairs quality of life in patients with Crohn's disease (CD). This study aimed to evaluate the prevalence and severity of fatigue in CD (compared with ulcerative colitis [UC] and healthy controls) and to identify potentially modifiable factors associated with global, physical, and cognitive dimensions of fatigue.

METHODS

Clinic attendees with confirmed CD or UC and healthy volunteers were surveyed on fatigue (Fatigue Impact Scale, FIS), psychological comorbidity, sleep quality, medication, and other clinical information. A CD subgroup also completed a similar follow-up survey.

RESULTS

In 379 responders (181 CD, 113 UC, and 85 controls), global, physical, and cognitive FIS scores were highest in CD followed by UC and controls (P < 0.01), with a prevalence of global fatigue (total FIS ≥ 40) in 57% of CD patients. On multivariate analysis, concurrently active disease, poor sleep quality, and mental illness were significantly associated with all the 3 fatigue dimensions: regular vitamin B group supplementation was inversely associated with physical fatigue in the CD cohort and those of older age or with previous resection(s) (P = 0.05) were independently associated with cognitive fatigue only. Longitudinally in CD, fatigue scores remained constant between original and follow-up surveys (mean change in total FIS score +0.9; 95% confidence interval, -4.6 to 6.3). Factors independently associated with improved physical fatigue between surveys included avoidance of corticosteroids and establishment of regular exercise and with improved cognitive fatigue included cessation of immunomodulator therapy.

CONCLUSIONS

Fatigue is highly prevalent and more severe in CD. Anticipated and novel associations with improvement of physical and/or cognitive fatigue were identified, offering clues to potential therapeutic approaches to ameliorating fatigue for clinical evaluation.

Environmental influences on the onset and clinical course of Crohn's disease-part 1: an overview of external risk factors

The pathogenesis of Crohn's disease (CD) involves host, genetic, and environmental factors. These factors result in disturbances in the innate and adaptive immune systems and composition of the intestinal microbiota. Epidemiologic and migration studies support an environmental component in the development of CD. Environmental risk factors include childhood hygiene, air pollution, breastfeeding, smoking, diet, stress, exercise, seasonal variation, and appendectomy. This review, part 1 of a 2-part series, provides an overview of these external contributors to the development or exacerbation of CD. Part 2, which will be published in a subsequent issue, will discuss the influences of infections, vaccinations, and medications (including antibiotics, nonsteroidal anti-inflammatory agents, and oral contraceptives) on CD.

Short-term stress, but not mucosal healing nor depression was predictive for the risk of relapse in patients with ulcerative colitis: a prospective 12-month follow-up study

BACKGROUND

Ulcerative colitis (UC) is a chronic relapsing inflammatory bowel disease. Psychological factors such as depression and stress are under debate to contribute to the risk of relapse. The impact of mucosal healing to reduce the risk of relapse had not been studied prospectively. The aim of this study was to identify whether depression and stress increase and mucosal healing reduces the risk of clinical relapse in patients with UC in clinical remission.

METHODS

Patients in clinical remission were followed prospectively for 1 year, or less if they relapsed. Endoscopy and histology score and long-term perceived stress (Perceived Stress Questionnaire) were measured at baseline. Mucosal healing was defined by a Mayo Endoscopy score of 0-1. Depression (Hospital Anxiety and Depression Scale) and acute perceived stress (Cohen Perceived Stress Scale) were measured at baseline and after 1, 3, 6, 9, and 12 months. A time-dependent multivariate Cox regression model determined the predictors of time to relapse.

RESULTS

Seventy-five patients were included into final analysis, of which 28 (37.3%) relapsed. Short-term stress at the last visit before relapse (hazard ratio [HR] = 1.05, 95% confidence interval [CI] = 1.01-1.10) and male gender (HR = 2.38, 95% CI = 1.01-5.61), but not baseline mucosal healing (HR = 0.86, 95% CI = 0.35-2.11), baseline long-term stress (HR = 0.20, 95% CI = 0.01-3.31), and depression at the last visit before relapse (HR = 1.08, 95% CI = 0.95-1.22) were predictive for a relapse.

CONCLUSIONS

Short-term stress but not depression nor mucosal healing was predictive for the risk of relapse in patients with UC in clinical remission. Larger multicentre studies are necessary to confirm our findings.

Psychiatric co-morbidity is associated with increased risk of surgery in Crohn's disease

BACKGROUND

Psychiatric co-morbidity, in particular major depression and anxiety, is common in patients with Crohn's disease (CD) and ulcerative colitis (UC). Prior studies examining this may be confounded by the co-existence of functional bowel symptoms. Limited data exist examining an association between depression or anxiety and disease-specific endpoints such as bowel surgery.

AIMS

To examine the frequency of depression and anxiety (prior to surgery or hospitalisation) in a large multi-institution electronic medical record (EMR)-based cohort of CD and UC patients; to define the independent effect of psychiatric co-morbidity on risk of subsequent surgery or hospitalisation in CD and UC, and to identify the effects of depression and anxiety on healthcare utilisation in our cohort.

METHODS

Using a multi-institution cohort of patients with CD and UC, we identified those who also had co-existing psychiatric co-morbidity (major depressive disorder or generalised anxiety). After excluding those diagnosed with such co-morbidity for the first time following surgery, we used multivariate logistic regression to examine the independent effect of psychiatric co-morbidity on IBD-related surgery and hospitalisation. To account for confounding by disease severity, we adjusted for a propensity score estimating likelihood of psychiatric co-morbidity influenced by severity of disease in our models.

RESULTS

A total of 5405 CD and 5429 UC patients were included in this study; one-fifth had either major depressive disorder or generalised anxiety. In multivariate analysis, adjusting for potential confounders and the propensity score, presence of mood or anxiety co-morbidity was associated with a 28% increase in risk of surgery in CD (OR: 1.28, 95% CI: 1.03-1.57), but not UC (OR: 1.01, 95% CI: 0.80-1.28). Psychiatric co-morbidity was associated with increased healthcare utilisation.

CONCLUSIONS

Depressive disorder or generalised anxiety is associated with a modestly increased risk of surgery in patients with Crohn's disease. Interventions addressing this may improve patient outcomes.

Life-event stress induced by the Great East Japan Earthquake was associated with relapse in ulcerative colitis but not Crohn's disease: a retrospective cohort study

OBJECTIVE

Stress is thought to be one of the triggers of relapses in patients with inflammatory bowel disease (IBD). We examined the rate of relapse in IBD patients before and after the Great East Japan Earthquake.

DESIGN

A retrospective cohort study.

SETTINGS

13 hospitals in Japan.

PARTICIPANTS

546 ulcerative colitis (UC) and 357 Crohn's disease (CD) patients who received outpatient and inpatient care at 13 hospitals located in the area that were seriously damaged by the earthquake. Data on patient's clinical characteristics, disease activity and deleterious effects of the earthquake were obtained from questionnaires and hospital records.

PRIMARY OUTCOME

We evaluated the relapse rate (from inactive to active) across two consecutive months before and two consecutive months after the earthquake. In this study, we defined 'active' as conditions with a partial Mayo score=2 or more (UC) or a Harvey-Bradshaw index=6 or more (CD).

RESULTS

Among the UC patients, disease was active in 167 patients and inactive in 379 patients before the earthquake. After the earthquake, the activity scores increased significantly (p<0.0001). A total of 86 patients relapsed (relapse rate=15.8%). The relapse rate was about twice that of the corresponding period in the previous year. Among the CD patients, 86 patients had active disease and 271 had inactive disease before the earthquake. After the earthquake, the activity indices changed little. A total of 25 patients experienced a relapse (relapse rate=7%). The relapse rate did not differ from that of the corresponding period in the previous year. Multivariate analyses revealed that UC, changes in dietary oral intake and anxiety about family finances were associated with the relapse.

CONCLUSIONS

Life-event stress induced by the Great East Japan Earthquake was associated with relapse in UC but not CD.

Mood disorders in inflammatory bowel disease: relation to diagnosis, disease activity, perceived stress, and other factors

BACKGROUND

Anxiety and depression are common in patients with inflammatory bowel disease (IBD); however, the factors associated with mood disorders in patients with ulcerative colitis (UC) and Crohn's disease (CD) are poorly defined.

METHODS

In all, 103 patients with UC, 101 with CD, and 124 healthy controls completed the Hospital Anxiety and Depression Scale (HADS). Disease activity was defined both from symptom scores and in UC endoscopically, and in CD by fecal calprotectin and/or serum C-reactive protein. Multivariate regression analyses were used to identify factors associated with anxiety and depression.

RESULTS

In both UC and CD, anxiety (HADS-A) and depression (HADS-D) scores were higher than in controls (HADS-A: 8.5 ± 4.1 [mean ± SD], 8.6 ± 3.9, 3.2 ± 1.8, P < 0.001; and HADS-D: 4.1 ± 3.3, 4.7 ± 3.3, 1.7 ± 1.4, P < 0.001, respectively). There were no differences in the prevalence of mild, moderate, and severe anxiety and depression in UC and CD. In UC, anxiety scores were associated with perceived stress and a new diagnosis of IBD; depression was associated with stress, inpatient status, and active disease. In CD, anxiety was associated with perceived stress, abdominal pain, and lower socioeconomic status, and depression with perceived stress and increasing age.

CONCLUSIONS

Anxiety and depression are common in IBD. Perceived stress is associated with mood disturbances in both UC and CD, but the other associated factors differ in the two diseases. Gastroenterologists should look for mood disorders in IBD and consider stress management and psychotherapy in affected patients.

Integrated models of care in managing inflammatory bowel disease: a discussion

The World Health Organization has recommended the integrated model of care as the current best practice of care, and, in recent years, it has been gaining popularity worldwide in various settings. However, there have been very few reports on applications of this model to the care of patients with gastrointestinal problems and no reports in the case of inflammatory bowel disease (IBD). However, several IBD centres worldwide have been using the model as part of their standard care. This discussion paper aims to bring together these units' shared experiences with a range of integrated models of care in order to identify common features and provide recommendations on aspirational care for IBD patients.

An integrated model of care for inflammatory bowel disease sufferers in Australia: development and the effects of its implementation

BACKGROUND

Psychological comorbidities are associated with poor outcome and increased healthcare utilization in patients with inflammatory bowel disease (IBD). However, a model of care addressing the biopsychosocial dimension of disease is not routinely applied in IBD. This review describes the development of such a model and the effects of its implementation in a hospital-based cohort of patients with IBD.

METHODS

Three different approaches were used: 1) collecting baseline epidemiological data on mental health comorbidities; 2) raising awareness of and targeting mental health problems; 3) examining the effects of the model implementation.

RESULTS

High rates of anxiety and depressive symptoms (36% and 13%, respectively) that are maintained over time were identified in IBD patients presenting at a metropolitan teaching hospital. Patients with documented psychological comorbidities were more likely to be hospitalized than those without (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.25, 13.61). Improvements in disease activity, anxiety, depression, quality of life, and coping have been noted when cognitive-behavioral therapy (CBT) was provided to patients. A drop in the use of opiates (P = 0.037) and hospitalization rates (from 48% to 30%) in IBD patients has been noted as a result of introduction of the changed model of care. In addition, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 [US$15,236.79] vs. US$ 30,467.78 [US$ 53,760.20], P = 0.005).

CONCLUSION

Our data to date suggest that an integrated model of care for patients with IBD may yield superior long-term outcomes in terms of medication use and hospitalization rates and reduce healthcare costs.

Do antidepressants influence the disease course in inflammatory bowel disease? A retrospective case-matched observational study

BACKGROUND

Depression, like adverse events and psychological stress, can trigger relapse in inflammatory bowel disease (IBD); however, the effects of psychoactive drugs on disease course are unclear.

METHODS

Using retrospective electronic case note review, after exclusion of five patients on low-dose tricyclic antidepressants we compared the course of IBD in 29 patients (14 ulcerative colitis and 15 Crohn's disease), during the years before (year 1) and after (year 2) they were started on an antidepressant for a concomitant mood disorder to that of controls matched for age, sex, disease type, medication at baseline, and relapse rate in year 1.

RESULTS

Patients had fewer relapses and courses of steroids in the year after starting an antidepressant than in the year before (1 [0-4] (median [range]) vs. 0 [0-4], P = 0.002; 1 [0-3] vs. 0 [0-4], P < 0.001, respectively); the controls showed no changes between years 1 and 2 in relapses (1 [0-4] vs. 1 [0-3], respectively) or courses of steroids (1 [0-2] vs. 0 [0-3]). Although there were no differences in the use of other relapse-related medications, outpatient attendances, or hospital admissions, the number of endoscopies fell significantly in the antidepressant group in year 2 compared with year 1 (P < 0.01). No such changes were seen in the controls.

CONCLUSIONS

Antidepressants, when used to treat concomitant mood disorders in IBD, seem to reduce relapse rates, use of steroids, and endoscopies in the year after their introduction. These results suggest the need for a prospective controlled trial to evaluate their effects on disease course in patients with IBD.

Psychiatric comorbidities in women with celiac disease

OBJECTIVE

Although the physical consequences of Celiac Disease are well studied, less is known about co-occurring psychiatric symptoms. This study examines psychiatric risk and comorbidities of women with Celiac Disease, who may be at increased risk for psychiatric symptoms (e.g. depression, and disordered eating behaviours).

METHODS

Women (N = 177) with Celiac Disease responded to an extensive web-mediated survey assessing dietary compliance, illness symptoms, psychiatric functioning, and disordered eating.

RESULTS

Despite high reported dietary compliance, patients reported marked illness symptoms and impaired quality of life. A substantial minority endorsed symptoms that met criteria for the diagnosis of psychiatric disorders: 37% (n = 65) met the threshold suggesting depression, and 22% (n = 39) for disordered eating. Participants whose symptoms exceeded these clinical thresholds reported greater perceived stress and reduced overall mental health, relative to women below the clinical cutoffs.

CONCLUSIONS

Despite largely adhering to a gluten-free diet, a substantial subset of women with Celiac Disease report clinically relevant symptoms of depression and disordered eating; such symptoms are associated with increased psychosocial distress in other domains. These results suggest potential to improve the patient well-being through attention to psychosocial care, in addition to existing dietary recommendations for individuals with Celiac Disease.

Specific alternation of rhythm in temperature (SART) stress-induced irritable bowel syndrome-like changes in mice and effects of drugs

Stress is closely associated with the manifestation and progress of irritable bowel syndrome (IBS). For the purpose of establishing experimentally the relationship between IBS and stress, the transportation capacity of the small intestine in specific alternation of rhythm in temperature (SART)-stressed animals was studied using charcoal transportation method. The charcoal suspension was administered orally into the stomach of fasting mice. Mice were sacrificed after a certain time and %charcoal transit (%CT) of the small intestine was measured. The %CTs in SART-stressed mice were greater than those in unstressed or continuously cold-stressed mice. This increase in %CT remained for 1 week after discontinuation of SART stress loading. Cholinergic blockers decreased %CTs in SART-stressed mice. Increases in %CT by a cholinesterase inhibitor were less in SART-stressed mice than in unstressed mice. Increases of %CT in SART-stressed mice were suppressed by Neurotropine. These results suggested that the parasympathetic hypertonicity, not just cold, played a role in the increases in the transportation capacity in SART-stressed mice and that these animals can be a useful tool for elucidation of the mechanism of IBS.

Management of stress in inflammatory bowel disease: a therapeutic option?

There is increasing evidence that psychological stress and associated mood disorders are linked with, and can adversely affect the course of, inflammatory bowel disease (IBD). Unfortunately, owing to methodological difficulties inherent in undertaking appropriately targeted and blinded trials, there are limited high-quality data regarding the effects on IBD of interventions aimed to ameliorate stress and mood disorders. Nevertheless, patients want psychological intervention as well as conventional medical strategies. Emerging trial evidence supports the suggestion that psychologically orientated therapy may ameliorate IBD-associated mood disorders, but there are no strong data as of yet to indicate that stress management has a beneficial effect on the activity or course of IBD. As yet, which, when and how interventions targeted at psychological stress and mood disturbances should be offered to individual patients with IBD is not clear.

Stress coping, distress, and health perceptions in inflammatory bowel disease and community controls

OBJECTIVES

This study compares a community inflammatory bowel disease (IBD) sample of individuals with a matched non-IBD community sample of individuals on psychological functioning and health perceptions.

METHODS

Participants in the population-based Manitoba IBD Cohort Study (n=388) were directly compared with sex-, age-, and region-matched controls from a national random-sample health survey on the aspects of psychological health, coping, and perceived general health.

RESULTS

Overall, the IBD sample had lower psychological well-being and mastery, as well as higher distress than did the non-IBD controls (P<or=0.02). Those with IBD used avoidant coping significantly more often, and active coping modestly more often than did the non-IBD sample; both had similar levels of "self-soothing" behaviors. Patients with Crohn's disease and ulcerative colitis had similarly poor levels of functioning along these dimensions compared with the non-IBD sample, as did those with active disease (P<0.01). However, those with inactive disease were similar to the non-IBD sample, and had modestly higher mastery levels. Whereas nearly half of the non-IBD group reported chronic health conditions, those with IBD were threefold more likely to report poorer health (odds ratio 3.07, 95% confidence interval: 2.10-4.47). Psychological factors explained a greater amount of variance in perceived health for the IBD than for the non-IBD sample.

CONCLUSIONS

Those with IBD have significantly poorer psychological health than do those without IBD and view their general health status more negatively, although adaptive stress-coping strategies were similar. However, when disease is quiescent there is little detriment to functioning. Active disease should be a flag to consider psychological needs in the care of an IBD patient.

Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management

While there has been a great deal of speculation over the years on the importance of emotional factors in inflammatory bowel disease (IBD), it is only in the last decade or so that studies with stronger designs have been available to clarify the nature of this relationship. This review considers recent evidence on the prevalence of anxiety and depressive disorders in IBD, the role of these disorders as a risk factor for IBD onset, the degree to which they affect the course of the IBD, and the contribution of corticosteroid treatment to psychiatric symptom onset. There is evidence that anxiety and depression are more common in patients with IBD and that the symptoms of these conditions are more severe during periods of active disease. The few studies that address the issue of anxiety and depression as risk factors for IBD do not yet provide enough information to support definite conclusions. There is evidence, however, that the course of the disease is worse in depressed patients. Treatment with corticosteroids can induce mood disorders or other psychiatric symptoms. The second part of the review focuses on patient management issues for those with comorbid anxiety or depression. Practical approaches to screening are discussed, and are recommended for routine use in the IBD clinic, especially during periods of active disease. We review evidence-based pharmacological and psychological treatments for anxiety and depression and discuss practical considerations in treating these conditions in the context of IBD to facilitate overall management of the IBD patient.

The reliability and validity of a Japanese version of symptom checklist 90 revised

Objective

To examine the validity and reliability of a Japanese version of the Symptom Checklist 90 Revised (SCL-90-R (J)).

Methods

The English SCL-90-R was translated to Japanese and the Japanese version confirmed by back-translation. To determine the factor validity and internal consistency of the nine primary subscales, 460 people from the community completed SCL-90-R(J). Test-retest reliability was examined for 104 outpatients and 124 healthy undergraduate students. The convergent-discriminant validity was determined for 80 inpatients who replied to both SCL-90-R(J) and the Minnesota Multiphasic Personality Inventory (MMPI).

Results

The correlation coefficients between the nine primary subscales and items were .26 to .78. Cronbach's alpha coefficients were from .76 (Phobic Anxiety) to .86 (Interpersonal Sensitivity). Pearson's correlation coefficients between test-retest scores were from .81 (Psychoticism) to .90 (Somatization) for the outpatients and were from .64 (Phobic Anxiety) to .78 (Paranoid Ideation) for the students. Each of the nine primary subscales correlated well with their corresponding constructs in the MMPI.

Conclusion

We confirmed the validity and reliability of SCL-90-R(J) for the measurement of individual distress. The nine primary subscales were consistent with the items of the original English version.