Mental health and sleep disorders are common in inflammatory bowel disease (IBD), and have been associated with a bidirectional relationship with intestinal symptoms and gut inflammation. Studies show that mental health is an important contributor to quality of life and clinical outcomes in IBD patients, and thus it has been recommended to be addressed as a part of routine clinical care. This review discusses simple tools that can be used by primary care and specialist clinicians to screen for mental health and sleep disorders. It also describes the approach for preliminary treatment in cases when such disturbances are detected, and briefly reviews some of the emerging research in the field of gut and brain health, which may have important clinical implications in the future.
Introduction
From the early days of medicine, gastrointestinal (GI) function and mental health were known to be very closely associated. This led to the presumption and belief that many GI symptoms were psychosomatic in nature. Over the years, as our understanding of diseases deepened, this psychosomatic conceptualization of GI disease has been critically re-evaluated and, in many cases, abandoned in favor of biological and neurochemical models of brain and gut interactions. Research in recent decades has started to decipher the biological basis of brain-gut communications, establishing a model of the “gut-brain axis”. The gut-brain axis is a bidirectional communication network that involves immunological, metabolic, neuronal, hormonal, and microbial components, all of which play an important role in both physiological and pathophysiological processes.1 It is now believed that psychological morbidities that commonly accompany GI disease, including IBD, may be reactive and associated with symptoms, but also have a “biological” component that is independent of symptoms. The growing interest in this gut-brain communication has laid the foundation for extensive clinical, translational, and basic research in the field. It has also highlighted the importance of the clinical aspects of the crosstalk between GI diseases and mental health. Specifically, in the field of IBD, it has led to the acknowledgment that psychological and social factors such as mood and sleep are important aspects of the disease which significantly affect quality of life and should be assessed and treated as a part of a holistic approach to patient care.
Here, we review common psychosocial health issues in IBD and the bidirectional relationship of gastrointestinal diseases and psychological morbidities. We discuss an approach to screening for mental health issues in the setting of primary care and GI clinics, and suggest preliminary approaches to treatment. We also introduce some of the ongoing research in the field which may have important clinical implications.
Common Psychosocial Issues in IBD
Patients with IBD face numerous psychosocial challenges that compound the physical symptoms of the disease (Figure 1). These issues, including mental health disorders, sleep disturbances, social stigma, and others significantly impact patients’ quality of life and well-being (definitions of common psychosocial issues outlined in Table 1).
Anxiety and depression are highly prevalent among IBD patients, though often undiagnosed and untreated. Approximately 20-32% of IBD patients experience symptoms of anxiety and 22-25% show symptoms of depression.2,3 Disease activity increases the risk, and patients with Crohn’s disease (CD) may be at greater risk than those with ulcerative colitis (UC). GI symptom-specific anxiety is also common, though its exact prevalence remains unclear.
Sleep disturbances are another major concern, with over half of IBD patients meeting the criteria for insomnia.4,5 Patients with active IBD, mood disorders, disability, and lower quality of life are particularly affected. Fatigue is also widespread, affecting 40-80% of IBD patients with active disease and 40-60% of those in remission.6,7
Stress and stigma greatly impact patients with IBD. Stress worsens disease activity, and patients with IBD experience higher stress levels than the general population. Around 10% of these patients may meet criteria for PTSD, often due to their disease experiences.8 In addition, many patients with IBD experience stigmatization, embarrassment and shame due to the unpredictable nature of bowel symptoms and potential social implications. Body image is also a concern for patients, with most patients reporting some form of concern about an aspect of their body image.9
Issues related to sexual function and satisfaction are common among patients with IBD, due to a combination of factors including active disease or surgical factors, body image concerns, or mental health comorbidities. Although sexual dysfunction is prevalent in IBD, it is infrequently discussed with their healthcare providers.
Concerns related to fertility is another common source of distress among individuals with IBD. While most IBD treatments do not impact fertility directly, voluntary childlessness is higher in this population, which may be, in part, due to misconceptions about disease heritability and transmission risks.10
In addition, patients with IBD have a significantly higher prevalence of disordered eating behaviors than the general population. Disordered eating may or may not be related to body image and in many cases, is thought to result from restrictions and modifications of diet resulting from attempts to control IBD and its symptoms.
Untreated psychosocial issues negatively impact quality of life and complicate IBD management for both the patient and their healthcare team. It is therefore imperative that we address these issues in our management strategies and care for our patients. Moreover, further research is needed to explore less-studied mental health conditions in the IBD population (e.g., obsessive-compulsive disorder, panic disorder) in order to better identify and address them.
The Impact of Mental Health on IBD
The nature of the association between IBD and psychological comorbidities remains an area of ongoing, active research, with many unanswered questions. Clinical and epidemiological studies in this field have been limited by the lack of a robust methodology, and results are therefore quite heterogeneous, as are the types and severities of IBD. Nonetheless, existing evidence supports a reciprocal relationship between IBD and mental health disorders, where one can trigger and modify the other.11
A study that evaluated patients with new-onset depression found that their risk to develop IBD within a mean follow-up time of 6.7 years was more than twice as high as the risk of patients with no depression.12 This was true for both CD and UC. Similarly, data from the U.S. Nurses’ Health Study showed that patients with CD were more likely be those with a prior diagnosis of depression compared to those without depression (HR 2.36; 95% CI 1.40-3.98).13 Interestingly, a similar association was not found in patients with UC in this study.
Conversely, some studies show that patients with IBD have an increased risk of developing mental health disorders after their diagnosis. Population-based studies from Canada and Sweden showed that the risk of patients with IBD developing depression or anxiety in the years following their diagnosis is about 50% greater than healthy matched controls.14,15 This was shown in adult-onset as well as in pediatric-onset IBD.
In patients with IBD, mental health disorders were shown to adversely affect the disease course of the IBD. In a meta-analysis of 12 longitudinal studies, IBD patients with depressive symptoms were at increased risk of flare, hospitalization, need for therapy escalation, and IBD-related surgery.16 Psychological stress was also identified to have adverse effects on IBD. In a prospective study that included 124 patients with IBD, disease activity after highly stressful life events was monitored. It was found that patients who experienced the death of a family member or close friend, change in residence or job status, birth of a child, personal or familial health concern, marriage or divorce, were more than twice as likely to present with active disease within a 6-month follow-up period compared to patients who did not experience such an event.17 A study that followed 677 patients with IBD in Japan after the Great East Japan Earthquake in 2011 found an increased risk for disease flare in the 2 months after the earthquake, compared to a corresponding period in the 1 and 2 years after the earthquake.18 Together, these data show that IBD disease course can both affect and be affected by mental health disorders and psychological stress. These studies highlight the importance of psychological assessment in IBD care.
Psychosocial Assessment in IBD Patients
Both self-report questionnaires and the clinical interview are valuable tools for the assessment of psychosocial concerns among patients with IBD. Direct patient-provider communication via the clinical interview lacks the uniformity of self-report questionnaires but is nonetheless a quick and useful method. This may require only a few questions, such as “How have you been coping with everything?” and “How has your IBD affected your life recently?” Direct communication strengthens the patient-provider relationship, demonstrates care to the patient, and can be easily integrated into the clinic visit (Table 2).
While self-report questionnaires offer a valid, uniform system of measurement that can be tracked over time both within and between patients, they are not without logistical and ethical burdens. Integration is challenging for many practices due to the time and personnel needed to administer, score, and document the assessments. Finally, the GI provider must have the time to review this information with the patient during the visit in order to have clinical utility, rather than become just a data point. Patients who are found to have more severe anxiety or depression, especially those who express suicidal ideation or plan, require an immediate action plan and intervention for the practice, resources that are not readily available or currently considered part of most primary or specialty practices.
There are several validated tools for the screening of mental health symptoms in IBD. The Patient Health Questionnaire-9 (PHQ-9) for depression,19 and the Generalized Anxiety Disorder scale-7 (GAD-7) for anxiety,20 are easy to administer and score on paper or virtually. These measures have scoring ranges that can be used to indicate the severity of symptoms and the likelihood of a clinical diagnosis. GI symptom-specific anxiety refers to anxiety and fear related to the disease, its symptoms, or the context in which the symptoms occur. This is a common form of anxiety seen among IBD patients and is best captured by the Visceral Sensitivity Index (VSI).21 Keefer and colleagues present a comprehensive list of suggestions on the assessment of other psychosocial issues.22
Management of Mental Health Disorders in IBD
The success of a screening program is dependent on what happens after a positive screen: ideally, a referral for comprehensive assessment and treatment with a mental health professional. New research highlights the bidirectionality of IBD and mental health conditions; psychological interventions may improve both mental health and inflammatory markers in IBD,23 while psychotropic medications may have protective effects in IBD.24
For many patients, and particularly those with more severe or longstanding depression or anxiety, a referral for psychotherapy with a general mental health therapist and/or a psychotropic medication evaluation with a psychiatry provider, is appropriate. If the GI provider is aware of a more specific issue such as an eating disorder or substance abuse, this may warrant referral to a more specialized clinic or provider. Developing relationships with mental health providers either within the institution, or with community partners, is paramount to referring patients appropriately.
For patients whose depression, anxiety, or overall stress level is closely related to their IBD experience, a gastrointestinal psychologist is an ideal referral. The growing specialty of gastrointestinal psychology includes psychologists who typically work with patients with IBD to develop stress management and adaptive coping strategies, reduce symptoms of anxiety and depression, and to utilize behavioral tools to cope with and reduce ongoing GI symptoms. IBD-specific virtual support programs exist and can help fill this gap if a gastrointestinal psychologist is not part of your practice.
Sleep Disturbances in IBD
Sleep is a major contributor to health and good quality of life. Increasing evidence shows that sleep disturbances are linked to dysfunction of multiple body systems, including the function of the immune system and the GI tract.25 This prompted further investigation into the effect of sleep on the course of IBD. The prevalence of sleep disorders in patients with IBD is believed to be high but is not well-defined. A study that prospectively screened 166 IBD patients found that 67.5% of them suffered from sleep disturbance.26 Studies assessing sleep quality in patients with IBD identified active IBD as a contributor to sleep deprivation. This may, in turn, trigger further immune activation and perpetuate a vicious cycle of worsening symptoms that would further adversely affect patients’ quality of life.25 In CD, poor sleep quality has been associated with disease activity and higher risk of hospitalization and surgery.27 Patients with active IBD were shown to have fewer episodes of deep sleep compared to patients in remission. Interestingly, patients in clinical remission who report abnormal sleep have a high likelihood of subclinical disease activity, indicating that poor sleep is not only driven by symptoms such as nocturnal diarrhea, but also may be affected by abnormal immune function.28 There are validated questionnaires such as the Pittsburgh Sleep Quality Index (PSQI) that can be used for assessing sleep quality. However, in everyday clinical practice, simple questions can be used, such as: “How do you sleep at night?”, “Any trouble falling asleep or staying asleep?” and “Do you wake up feeling refreshed?” (Table 2). All patients who report poor sleep quality should be educated on sleep hygiene practices. Referral to a sleep specialist for evaluation of specific sleep conditions, such as obstructive sleep apnea or restless legs syndrome (which may also be associated with iron deficiency), should be considered if clinically relevant. In patients with active disease, poor sleep may be a symptom of active inflammation, and should prompt optimization of the anti-inflammatory treatment. For patients with insomnia, cognitive behavioral therapy for insomnia (CBT-I) is a highly effective treatment, and should be considered in patients with insomnia related to IBD as well.29
Future Directions in Mental Health and IBD Research
Current research on the interface between gut and mental health focuses on elucidating a better understanding of the biological mechanisms and careful investigation of novel clinical interventions. A major interest in this field is the changes in gut-derived metabolites, which may mediate gut-brain interaction. Tryptophan is an example of such a mediator. It is metabolized by both host cells and the gut microbiome; both are affected by gut inflammation. It is a precursor of multiple neuroactive metabolites, including serotonin and melatonin, metabolites that play a central role in controlling mood and sleep. It was shown that tryptophan metabolism is altered in patients with active IBD.30 Whether it influences mental health in these patients is yet to be determined. Interestingly, it has been found that the penetrance of the blood-brain barrier31 and the choroid plexus32 changes in response to gut inflammation, which may alter the exposure of the central nervous system (CNS) to various peripheral compounds. Identifying key mediators that are relevant in this context may open the door for therapeutic interventions that target specific mediators and compounds.
Several studies have shown the benefits of incorporating psychological treatment into medical care in IBD patients.33 The growing number of GI-specialized therapists may significantly contribute to patient care and quality of life. Interestingly, there are ongoing studies that utilize virtual reality and artificial intelligence technologies to treat symptoms in patients with irritable bowel syndrome (IBS).34 Using these tools in IBD may increase the accessibility of psychological care and may be a novel approach to more effectively and extensively address mental health concerns.
Conclusion
Mental health conditions and sleep disorders are very common among patients with IBD. They have a bidirectional relationship with gut inflammation and intestinal symptoms, and current evidence supports the notion that one may trigger and modify the other. Given its clear impact on quality of life and the evolving understanding of the biological connection between the brain and gut, addressing psychosocial issues should be part of the comprehensive care for our patients with IBD. While standardized questionnaires may be time-consuming, simple questions can be easily incorporated into routine clinical practice and serve as a preliminary screening method. Identification of mental health conditions and sleep disorders in patients with active inflammation of the bowel should prompt optimization of their IBD treatment. Referral to a specialized GI therapist should be strongly considered when appropriate, but there is a clear need for additional research and resources for treatment and management in this evolving and clinically important field.
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