Anxiety, Depression Linked to IBD Flare

BERLIN — Psychosocial factors, such as anxiety and depression, are associated with an increased risk for both self-reported “clinical” and symptomatic, or “hard,” flare in inflammatory bowel disease (IBD), suggested a study of UK patients.

The research was presented at the European Crohn’s and Colitis Organisation (ECCO) 2src25 Congress.

“Despite clinical remission, there is a significant burden of psychosocial comorbidity in IBD patients,” said study presenter Lauranne A.A.P. Derikx, PhD, a gastroenterology researcher at Erasmus University Medical Center, Rotterdam, the Netherlands.

“Anxiety, sleep, and somatization were associated with an increased risk of clinical flare, and depression and lack of exercise were associated with an increased risk of hard flare,” she said. “Altogether, this supports a holistic approach in IBD patients.”

Stephen E. Lupe, PsyD, director of Behavioral Medicine for the Department of Gastroenterology, Hepatology and Nutrition at the Cleveland Clinic, Cleveland, who was not involved in the study, agreed.

“Whole-person care is so important” in IBD, and this study is part of a growing literature making the connection between symptom flare and factors such as anxiety, depression, stress, and even trauma, he told Medscape Medical News.

Searching for Predictive Links

The relapsing and remitting disease course in IBD is dynamic and hard to predict, Derikx said. Unfortunately, clinicians don’t know which patients with IBD will develop a flare or when it will occur, she said.

There’s a high prevalence of psychosocial comorbidity among patients with IBD and a “bidirectional relationship between psychosocial vulnerabilities” and the disease course via the gut-brain axis, Derikx noted.

To determine which psychosocial factors may be associated with and predictive of IBD flare, researchers analyzed data from the PREdiCCt study, a large prospective study of patients with IBD from 47 centers across the United Kingdom that aims to determine the factors associated with developing a flare.

The median age of PREdiCCT study participants was 44 years, median duration of IBD was 1src years, and 35% were receiving advanced IBD therapy. The median fecal calprotectin level was 49 mcg/g, although 18% of patients had a level> 25src mcg/g, Derikx noted.

To be included in PREdiCCT, patients must have received the diagnosis of IBD more than 6 months previously, had not change their medication for more than 2 months, and answered “yes” to the question: Do you think your disease has been well controlled in the past 1 month? The question was chosen as a measure of clinical remission.

The team collected stool samples and gathered information via questionnaires about lifestyle, diet, and other factors.

Depression and Anxiety Increase Risk

Researchers included 1641 patients — 83src with Crohn’s and 811 with ulcerative colitis or IBD unclassified (IBDU) — with complete datasets in their analysis of associations between psychosocial factors and IBD flare.

Baseline questionnaires identified moderate anxiety in 18.8% of participants, severe anxiety in 16.1%, moderate depression in 9.8%, severe depression in 5.7%, sleep disturbances in 46.4%, moderate somatization in 22.8%, severe somatization in 7.9%, insufficient exercise in 22.2%, and consumption of more than 14 units of alcohol in 24%.

After 24 months of follow-up, 36% of patients had experienced a clinical flare, defined as answering “no” to the question: Do you think your disease has been well controlled in the past 1 month/since you last logged in to the [study] portal?

In addition, 13% of patients experienced a hard flare, defined as a clinical flare plus C-reactive protein levels> 5 mg/L and/or a calprotectin level> 25src mcg/g and a change in IBD therapy.

Survival analyses with Cox frailty models adjusted for baseline fecal calprotectin, sex, index of multiple deprivation, hospital site, and patient age revealed statistically significant associations between several psychosocial factors and increased risk for flare.

Moderate anxiety in Crohn’s disease increased clinical flare risk (adjusted hazard ratio [aHR], 1.64), as did severe anxiety in both Crohn’s disease (aHR, 1.86) and ulcerative colitis/IBDU (aHR, 1.46). Moderate depression and severe depression increased the flare risk in ulcerative colitis/IBDU (aHR, 1.72 and 1.67, respectively). Also increasing clinical flare risk was poor sleep quality in Crohn’s disease (aHR, 1.58), and severe somatization in Crohn’s disease (aHR, 3.86) and ulcerative colitis/IBDU (aHR, 1.96).

Fewer psychosocial factors were associated with increased risk for hard flare: Moderate depression in ulcerative colitis/IBDU (aHR, 2.5), severe somatization in Crohn’s disease (aHR, 2.34), and lack of exercise in ulcerative colitis/IBDU (aHR, 1.55).

Physician-Patient Disconnect

There is “very little correlation” between self-reported and symptomatic flare in IBD, Lupe said. “This happens all the time, where the gastroenterologist will come out of the endoscopy suite and go: ‘You’re in remission.’ And the patient goes: ‘What are you talking about? I’m still going to the bathroom 2src times a day,’” he said.

Now there are data showing that, if the care team undertakes behavioral work with patients who have IBD, “the medications work more effectively,” Lupe said.

“I think medicine is in a point of transition right now,” he added. “We’re (moving from) looking at people as disease states and ‘how do I treat the disease’ to ‘how do I take care of this human being,’ knowing that everything this human being does, including everything we put in our mouth, everything we experience, changes what happens inside our body, and it’s measurable.”

The PREdiCCt study is sponsored by the University of Edinburgh, Edinburgh, Scotland.

Derikx declared relationships with AbbVie, Janssen Pharmaceuticals, Sandoz, Galapagos, and Pfizer. Other authors also