Psychological disability in IBD discussed at meeting

Non-pharmacological treatments could significantly help patients with inflammatory bowel disease (IBD), the recent Irish Society of Gastroenterology (ISG) Summer Meeting heard.

Prof Hugh Mulcahy, Consultant Gastroenterologist, St Vincent’s University Hospital (SVUH), discussed psychological disability in IBD, saying there were high rates in patients with the disease.

“The sources of stress are generally similar to the normal population, just a bit more severe,” he said of IBD patients, adding that the addition of the disease was a further cause of stress.

Through the use of acceptance and commitment therapy in IBD patients, stress had decreased by approximately 45 per cent three months after the intervention, with depression decreasing by a similar percentage, he told the meeting.

Evidence from the OECD indicates that about 12 per cent of the Irish population were clinically depressed compared to 21 per cent in studies carried out in the IBD population. Prof Mulcahy asked his colleagues could stress lead to Crohn’s Disease and colitis and whether psychological dysfunction was associated with subsequent IBD activity.

Stress, anxiety, and depression rates were higher in IBD subjects when compared with controls. Psychological disability likely had a modest effect on disease causation and likely had an effect on disease activity.

He said that while quality-of-life may be a useful measure of global wellbeing, it was a very poor measure of psychological dysfunction, as it does not reveal how the patient thought about themselves, their disease, or their treatment.

“It is suggested that this could be augmented by other more distinct measures of psycho-social dysfunction,” the meeting was told. “And this is really where we come to stress, anxiety and body image.”

There was a relationship between stress, anxiety, depression, and body image through various different mechanisms. By various pathways, stress could lead to anxiety and both stress and anxiety could lead to depression.

Prof Mulcahy explained that stress could be measured in a number of different ways, including the symptoms of stress and perceived stress. Objective measures such as skin conductance and hair cortisol which “serves as a diary of stress over time” were also used. The depression anxiety stress scale (DASS) was also highlighted.

“But to know stress in the IBD population you have got to know it in the normal population,” he told the meeting.

He said the most stressed people in a western country’s population were young females and this group was concerned about interpersonal relationships, diet and body image issues. Young males tended to be comparatively unstressed, but this increased with age due to work-related and financial issues. Urban living and a low income also increased stress levels.

A healthy psychological balance could be tipped over by many different factors, including chronic disease such as IBD.

“A lot of people would also suggest that increased stress may actually result in IBD,” he said. “Stress and the mechanisms of stress seem to be almost identical in the IBD patients when compared to the normal population.” For example, young males were also relatively unstressed by their disease, but this too tended to increase over time.

Prof Mulcahy said that disease, body image, and diet were associated with significant amounts of stress and that “lots of researchers believe that stress is causally associated with both disease onset and disease activity. That opens up a number of non-pharmacological treatment opportunities”.

He said laboratory tests found that stressed mice showed an increase in inflammation-promoting bacteri, and also that stress facilitates dextran sodium sulphate-induced colitis. If stressed, mice were subsequently co-housed with unstressed mice and a bidirectional transfer of microbiota between groups was observed.

“Furthermore if we treat these mice with antibiotics we find that not only does it reduce many of the inflammation inducing bacteria, but it also reduces the severity of the colitis,” Prof Mulcahy said. This suggested that stress-induced microbial dysbiosis was central to the association between stress and IBD.

It was recognised that breastfeeding and a vaginal delivery led to a more diverse microbiome, while early antibiotic exposure and urban living led to a less complete microbiome. Furthermore, breastfeeding and a vaginal delivery were associated with a decreased risk for Crohn’s disease.

During his presentation, Prof Mulcahy highlighted a Swedish study on stress resilience and the risk of IBD. The study sought to determine if low psychosocial stress resilience in adolescence, increasing chronic stress arousal throughout life, was associated with an increased IBD risk in adulthood. The authors found that lower stress resilience may increase the risk of diagnosis of IBD in adulthood, possibly through an influence on inflammation or barrier function.

Looking at IBD patients, he asked whether psychological dysfunction was associated with disease relapse. In the study, ‘Bi-directionality of Brain-Gut Interactions in Patients with Inflammatory Bowel Disease’, published in Gastroenterology in 2018, when the cohort was partitioned in terms of disease activity at the start of the study, researchers found that patients with disease activity were more likely to develop anxiety and depression than those with inactive disease.

“Conversely, when they separated their patients into anxious patients and non-anxious patients, they found that anxious patients were more likely to have an objective flare of their disease,” he said.

Body image dissatisfaction was a key issue for patients, Prof Mulcahy said, adding that there appeared to be an association between stress and body image dissatisfaction.

“And just like stress, anxiety and depression in IBD patients, we need to know about body image in the normal population before we can think about it in our IBD patients,” he said.

The majority of people had concerns about their bodies giving rise to the term normative discontent, most men wished for muscularity and most women wanted to be thin. It is estimated that 60 per cent of female and 50 per cent of males felt pressurised by the media and advertising to have the perfect body.

Cultural, genetic and environmental factors were important in influencing body image, as well as gender and innate personality type. He also highlighted that while more than 75 per cent of American Samoans were clinically obese, body mass was not an issue for Polynesian cultures.  Prof Mulcahy pointed to the media’s power over a society’s body image over any other factor and he cautioned vulnerable patients’ use of social media.

“In an IBD patient, we see that they have all the body image issues that the normal population has, except they have also got the addition of disease and the treatments we use,” he said.

He said that patients with active disease have body image dissatisfaction that was approximately twice as poor as patients with inactive disease.

He said that steroids were extensively used, although perhaps not in Ireland. They were the mainstay of treatments in countries such as the US, but patients were concerned about being prescribed them.

Discussing data from SVUH over the last 30 years, he said that patients were divided into three groups: Those diagnosed between 1989 and 1998, those who used biologics during 1999 to 2008, and finally patients from 2009 to 2018.

“We can see that immunomodulator use has risen from 14 per cent at five years in the first group to over 50 per cent at five years in our current group,” he said. “The data from biologics agents is even more impressive, just 2 per cent in five years in group one, up to over 60 per cent in group three have had a biologic agent within five years of diagnosis.”

The surgical rate had also improved considerably. While surgical rates were approaching 50 per cent in the first group, they were down to just over 20 per cent in the current group.

Those patients who had a second operation within five years of an initial operation had also fallen, 7 per cent in the latest group from 60 per cent in previous groups.

“It’s quite clear that we are already beginning to make an impact on this,” Prof Mulcahy argued.

He said that this was useful data for health funders to show that an “aggressive top-down strategy improves both a patient’s mental and physical condition”.

In terms of dealing with psychological disability in IBD, healthcare professionals could help increase a patient’s resilience. Acceptance and commitment therapy could help patients view negative thoughts as simply just a thought. He said a study was carried out of 120 patients, randomised into two groups one receiving the therapy, the other a control.

“Essentially what we found was stress decreased by approximately 45 per cent three months after the intervention, and depression decreased by a similar amount,” Prof Mulcahy said, adding that body image also improved significantly.

However, he cautioned that there was also evidence to suggest that acceptance and commitment therapy may also affect medication adherence.

Prof Mulcahy praised the advent of the nurse specialist role, saying it had done as much as anything to identify patients who had stress, anxiety, and depression.