Ulcerative colitis and anxiety

The Link Between Mental Health Disorders and Ulcerative Colitis

There’s a clear connection between ulcerative colitis and mental health conditions like depression, but the reasons for this link aren’t fully understood.

Find out ways to cope with mental health problems when you have UC. iStock (2)

Ulcerative colitis (UC) can have a wide range of symptoms and complications — from rectal pain and bleeding to weight loss, skin sores, joint pain, and even kidney and liver problems.

Mental health problems also commonly overlap with ulcerative colitis, although it’s less clear that they develop as a direct result of the disease. Instead, many people may be somehow predisposed to both conditions.

But there’s no question that living with ulcerative colitis brings challenges that can lead to negative thoughts, which may exacerbate symptoms of depression or anxiety in people with these conditions.

It’s important to note, though, that there’s no evidence to support stress, tension, or anxiety causes ulcerative colitis. But these factors can have a major impact on how you experience and cope with the disease, notes the Crohn’s and Colitis Foundation. (1)

How Common Are Mental Health Issues With Ulcerative Colitis?

It’s difficult to know exactly how common mental health issues are in people with ulcerative colitis.

Some people with ulcerative colitis may not report psychological stress to their doctors, since they assume it’s a normal part of the illness or don’t want to show weakness.

Even when psychological issues are reported, this may not lead to a definitive diagnosis of anxiety or depression.

But a few studies have tried to estimate the prevalence of mental disorders in ulcerative colitis.

According to an article published in October 2017 in the Canadian Journal of Gastroenterology and Hepatology, the rate of anxiety and depression in patients with inflammatory bowel disease (IBD) may be as high as 21 percent and 26 percent, respectively. (2)

In another study published in 2015 in the Permanente Journal, researchers found that 82 percent of people with ulcerative colitis were also diagnosed with a mental disorder, compared with 54 of the general study population. (3) These disorders were more likely to be diagnosed before ulcerative colitis than after it, especially in women.

Not everyone with ulcerative colitis has the same risk of mental health issues.

According to a study published in the journal Inflammatory Bowel Diseases, factors associated with anxiety in ulcerative colitis include: (4)

  • Severe disease
  • Active flares
  • Not taking treatment as prescribed
  • Being disabled or unemployed
  • Having a low income

Factors associated with depression include:

  • Older age
  • Active flares
  • Being disabled or unemployed
  • Having a low income

How Mental Health and Ulcerative Colitis Interact

The links between ulcerative colitis and mental health disorders are complex, with each potentially having an impact on the other in several different ways.

A study published in May 2019 in the Journal of Clinical Medicine found that the risk of depression and anxiety increases after a diagnosis of IBD. (5)

Living with a chronic disease comes with many challenges, and in some people with ulcerative colitis, being diagnosed can bring about feelings of frustration or sadness, and cause them to become withdrawn.

Other people may be worried about specific aspects of the condition, such as having bouts of gas, diarrhea, or pain in a social situation or public place. This can directly bring about anxiety or lead them to become isolated, which may in turn cause feelings of loneliness and despair and contribute to depression. (1)

But as noted in a review paper published in the journal Gastroenterology Research and Practice, there’s evidence that both depression and anxiety are more common in people who later develop ulcerative colitis than in the general population. (6) This link seems to be strongest when the mental health conditions are diagnosed only a short time before ulcerative colitis.

These findings suggest that both mental health disorders and ulcerative colitis may have common risk factors, and that depression and anxiety may even contribute to ulcerative colitis.

The risk of anxiety also rises after a diagnosis of ulcerative colitis, though, which indicates that, in many people, the disease may contribute to anxiety.

It’s not just your risk of developing ulcerative colitis that may be affected by depression and anxiety. In a study published in June 2016 in the journal Clinical Gastroenterology and Hepatology, researchers found that depression was associated with a greater incidence of flares in ulcerative colitis. (7)

Anxiety was also associated with less time between flares, along with greater use of steroids in people with ulcerative colitis.

RELATED: Living With UC, Overcoming Thoughts of Suicide

What’s Behind the Link?

There are a number of potential scientific explanations for the links seen between ulcerative colitis and mental health disorders.

Psychological stress has been shown to increase the permeability of the intestines — how easy it is for nutrients and other particles to pass through. This can reduce the effectiveness of the mucosal lining as a barrier to various harmful substances.

There’s also evidence that stress can change the activity of cytokines, molecules in the immune system that may play a role in the onset of ulcerative colitis and its associated inflammation. (6)

Inflammatory cytokines may also play a role in the onset of mental health issues, contributing to anxiety when their levels go up due to intestinal inflammation, according to a review published in March 2015 in Clinical and Experimental Gastroenterology. (8)

Taking steroids to treat symptoms of ulcerative colitis can also have psychological effects, contributing to feelings of stress and anxiety.

Finally, anxiety can result in stronger perception of symptoms of ulcerative colitis — which can, in turn, further increase psychological distress. (8)

Recognizing and Treating Mental Health Issues

The following symptoms can indicate anxiety and depression in people with ulcerative colitis:

  • A spell of sudden fear or panic
  • Frequent nerves or anxious feelings for six months
  • Feeling anxious or uncomfortable around other people
  • Recurring dreams or nightmares about traumatic events
  • Avoiding reminders of traumatic events
  • Feeling down, hopeless, or uninterested in doing things for two weeks (8)

If you experience any of these symptoms, it’s important to discuss them with your primary care doctor or gastroenterologist.

According to the Crohn’s and Colitis Foundation, not everyone with a negative emotional response to ulcerative colitis will require a psychiatric consultation. Healthcare professionals that you already see may be able to provide the emotional support you need. (1)

But if you’re experiencing severe emotional difficulties or feel like you need to try new ways to cope with the disease, you may benefit from seeing a psychologist or psychiatrist.

It’s important to find a therapist who is familiar with ulcerative colitis, since it’s helpful to know about the disease’s symptoms, complications, and drug treatments when deciding how to address mental health issues.

Your gastroenterologist or primary care doctor can help you find the right therapist based on your symptoms and the type of treatment you’re looking for.

Treatments that you may decide to try with your therapist include:

  • Psychotherapy (talk therapy)
  • Relaxation training
  • Medication (1)

Additional reporting by Ashley Welch.

Ways to Feel Better

Breathe. You can trigger the body to relax when you take slow breaths that fill your belly with air. Called diaphragmatic breathing, some research shows that it can reduce anxious and depressed feelings. Here’s how you do it:

  1. Breathe in through your nose for 4 or 5 seconds.
  2. Place your handon your belly. Only your stomach should expand.
  3. Hold your breath for a couple of seconds.
  4. Breathe out through your mouth for about 6 seconds.
  5. Repeat for 5-15 minutes.

Focus your mind. Some studies found that mindfulness-based meditation, like paying attention to your breath, may:

  • Lessen feelings of anxiety and depression
  • Help you feel less pain

Brain scans show that people who pay attention to the moment tend to hurt less because the pain center in their brain is less active.

Intestinal behavioral therapy. You don’t have to have a mental illness to benefit from this kind of treatment. It’s designed for anyone who wants to deal with the stress around UC.

Ask your doctor about:

  • Cognitive behavioral therapy (CBT)
  • Gut-directed hypnotherapy
  • Stress-management therapy

Get moving. You probably already know that exercise is good for your mood. Studies show it works just as well as antidepressants for some people. But listen to your body. If you are really active for a long time, it can cause more inflammation and make some IBD symptoms worse. Marathon runners sometimes get diarrhea or intestinal bleeding. That might not be a great activity to do if you have UC.

Try this:

  • Moderate-intensity exercise like walking or yoga
  • High-intensity interval training (HIIT) is also safe for people with IBD
  • Weight training, also called resistance exercise, is another option that may lessen depression symptoms.

Reach out to someone. You might feel better if you talk to a therapist, especially one who’s familiar with UC. You can also meet up with people who know what you are going through. The Crohn’s & Colitis Foundation can help you find a support group in your area.

Antidepressants may help. There is evidence they might boost your spirits and ease the pain of your gut symptoms at the same time. But talk to your UC doctor before trying any mediations for your mood. Some can cause side effects that worsen IBD.

PMC

4.1. Prevalence of Anxiety and Depression in IBD Patients

The prevalence of anxiety (21.2%) and depression (25.8%) in IBD patients reported in this study is higher than that reported for the general Canadian population. According to the 2013 Statistics Canada Health Survey, the 12-month and lifetime prevalence of depression in the Canadian population were 4.7% and 11.3%, and the 12-month and lifetime prevalence of Generalized Anxiety Disorder were 2.6% and 8.7% . Our results are consistent with findings that patients with long term medical conditions are at increased risk of major depression and with studies that have found the prevalence of anxiety and depression to be higher in IBD patients compared with healthy controls .

There is variation in the rates of depression and anxiety reported in different studies likely due to differences in populations studied, methods used to assess depression and anxiety, and the period of time within which depression and/or anxiety was assessed (lifetime versus 12 months versus current) . Previous Canadian studies have assessed rates of depression and anxiety in survey samples of self-reported IBD patients and in an IBD patient cohort but none in consecutive patients attending an outpatient clinic. Our study is unique in that it is the first Canadian study to investigate the prevalence of anxiety and depression in consecutive outpatients attending a gastroenterology clinic. Screening for anxiety and depression in consecutive patients may provide a more accurate estimate of the prevalence as this design removes the selection bias introduced when depending on patients to volunteer to be part of a cohort or to reply to a survey. Therefore, our study should provide a more accurate estimate of the point prevalence of anxiety and depression in an outpatient IBD population.

Twelve-month rates of depression reported from two nationally representative surveys with patients identified through self-report of “a bowel disorder such as Crohn’s disease or colitis” were 14.7% and 16.3% . Our results show a higher prevalence of depression, likely due to the lack of specificity in the criteria used to diagnose IBD in these survey studies. Another study used survey samples of self-reported IBD patients to assess the prevalence of anxiety and found that IBD patients had 2.18 greater odds of anxiety compared to the general population . Limitations of these studies are that cases of IBD were not verified through medical records, and only 82.6%, 84.7%, and 79.8% of households responded to the surveys, potentially introducing bias due to differences between those who chose to respond and those who did not. It has been observed that those with less education, older age, and greater use of psychopharmaceutical drugs are less likely to participate in survey research .

A Canadian cohort study which drew on patients from the University of Manitoba Research Registry found lifetime rates of Generalized Anxiety Disorder (GAD) and major depressive disorder (MDD) in IBD patients to be 13.4% and 27.2% . IBD patients eligible for inclusion in the registry were identified through the database of Manitoba Health. A limitation of this study is that the registry is composed of a subset of IBD patients that may not be representative of all of those living in the community: patients had to be diagnosed within the past 7 years for inclusion and patients needed to agree to participate in the registry, which resulted in only just over half of eligible IBD patients being included. Further, of those eligible in the registry 14% declined to take part in the cohort study and a further 35 of 388 patients initially enrolled were lost throughout the 2-year duration. The characteristics of the patients who agreed and were able to meet the demands of inclusion in the registry and cohort study may vary from those unable or unwilling to participate. Research of nonparticipation in a prospective study on chronic respiratory and cardiovascular diseases found that patients who did not feel well and/or had been admitted to hospital during the last 12 months had lower participation rates .

Our study included IBD patients attending a gastroenterology outpatient clinic where all patients are asked to complete the GAD-7 and PHQ-9 questionnaires to limit selection bias. One limitation was that the patient population assessed was drawn from a tertiary IBD clinic; this may result in a patient population with more severe or active IBD, or more comorbidities compared to community samples. Additionally, this study did not include any patients that were currently hospitalized, and because anxiety and depression have been associated with disease flares and inpatient status, prevalence of anxiety and depression may be lower in the population studied compared to inpatient IBD populations .

As previously reported in the literature , we found that disease activity was significantly associated with increased risk of depression and anxiety in IBD patients. Häuser et al. (2011) found that IBD patients with moderate/severe disease activity had higher rates of depression and anxiety compared to both those with slight disease activity and to an age and sex matched representative sample of the general population. Patients in remission were not at an increased risk of depression and anxiety compared to the general population. We found that prevalence of anxiety and depression did not differ between UC and CD patients, which is consistent with previous research . Female sex was associated with increased risk of anxiety, which has been reported in other studies of patients with IBD , as well as in the general population .

Variation in methods of psychiatric assessment is likely partially responsible for the variation in reported prevalence of anxiety and depression in IBD patients between studies. Use of screening questionnaires may overestimate rates of depression and anxiety: when patients were assessed using both the DSM-3 criteria and the Hospital Anxiety and Depression Scale (HADS) screening questionnaire rates of psychiatric illness were lower using the DSM criteria . We used the GAD-7 and PHQ-9 screening questionnaires, which have been validated in the primary care setting, to assess anxiety and depression. When using a cut-off of 10 or greater as a positive result for both questionnaires, the GAD-7 has a sensitivity of 89% and a specificity of 82% , while the PHQ-9 has a sensitivity of 88% and a specificity of 88% . Some of the symptoms of depression used for screening, such as changes in appetite and fatigue, may overlap with IBD symptoms; therefore, the PHQ-9 may overestimate depression in IBD patients. Assessment of the accuracy of the PHQ-9 screening questionnaire in this population is important. In our study this screening tool seems to be accurate; of those patients who agreed to referral to a psychiatrist, 90% of patients who scored positive on the PHQ-9 had a diagnosis of depression confirmed by psychiatric interview.

The high prevalence of mental disorders we have found in our study is an important problem that requires further attention. A meta-analysis which investigated any correlation between depression and patient compliance in a variety of chronic disease patients (end stage renal disease, angina, cancer, renal transplant, and rheumatoid arthritis) with a variety of interventions (dietary and health behaviour interventions and medications) found that depression was associated with three times greater odds of noncompliance with treatment recommendation . Both depression and presence of psychiatric disorders have been associated with decreased treatment compliance in IBD patients. Adherence to medical treatment in IBD patients is important not only in the short term for preventing flares of disease activity but also to prevent long term complications. Identification and treatment of anxiety and depression in IBD patients may be important in improving treatment adherence and long term patient outcomes. Anxiety and depression in IBD have been shown to contribute to poor health related quality of life (HR-QOL) independent of disease severity . Zhang et al. (2013) examined the role of depression and disease activity as independent factors in predicting HR-QOL. Depression was found to be the most significant predictor of poor HR-QOL in IBD patients, with disease activity being only weakly predictive. Therefore, addressing mental health in patients with IBD may be important in maximizing patient quality of life. Additionally, psychiatric illness in IBD patients has been found to predict high cost outcomes including emergency department visits, IBD-related hospitalizations, and high treatment charges . The potential benefits of mental health treatment, along with the increased prevalence of anxiety and depression in IBD patients, suggest that screening for anxiety and depression in this population would be of value.

Depression and Anxiety

It is normal to feel sad and anxious as you live with inflammatory bowel disease (IBD). While some people may have fleeting bouts of sadness or stress relating to their IBD, it’s important to see a mental health professional if your symptoms last for several weeks or more at a time.

Rates of depression are higher among patients with Crohn’s disease and ulcerative colitis as compared to other diseases and the general population. Anxiety is also common in IBD patients.

It is important to recognize the signs that you are struggling emotionally and seek help just as you would for your physical symptoms. This fact sheet can help you understand and deal with the emotional impact of IBD.

If you have thoughts of self-harm or suicide, do not hesitate to reach out for help by calling 911, going to the closest emergency room, or calling the suicide hotline at 1-800-SUICIDE.

Mental health and IBD

Video Length 1:42

Mental health and IBD Managing Crohn’s disease and ulcerative colitis means focusing on more than just the physical symptoms. Your mental and emotional well-being are equally important. Hear how patients view their mental health as they live with inflammatory bowel diseases.

Transcript

for me personally my Crohn’s is very

affected by the state of my mental

health when you’re sick I constantly

have things in the back of your head

thinking about test results you have or

procedure you have there’s a lot of

stress and anxiety associated with that

more and more working with a

psychologist is considered part of

treatment when it comes to IBD because

we recognize that the emotional and the

physical are very interconnected and so

when you’re given a diagnosis initially

it can feel very overwhelming I was

diagnosed with Crohn’s disease about

four years ago I think it was a shock I

didn’t really understand medically what

it meant it’s normal to have you know

those emotions of feeling overwhelmed

feeling anxious feeling depressed it’s

sort of this vicious cycle that develops

between the gut and brain especially a

fear in pain you’re constantly thinking

about that pain and certainly in therapy

we work on a lot of strategies so that

you’re not perseverating on the pain got

directed relaxation diaphragmatic

breathing I try to meditate a couple

times a week stop and take a breath you

don’t have to figure everything out in

that moment in that day you’re still the

same person you just have this new label

you’re not alone just know that there

are a lot of other people out there that

have IBD

you

English (auto-generated)

Depression

Depression is a serious mood disorder that causes feelings of sadness and loss of interest. Depression can make you feel exhausted, worthless, helpless, and hopeless. It can also make dealing with daily tasks difficult. Tasks associated with managing a chronic illness may feel insurmountable.

Depression often gets worse if it is not treated. We encourage both patients and healthcare providers to assess not just the physical symptoms of IBD, but also the emotional symptoms.

If you experience five or more of these symptoms for a sustained period of longer than two weeks, we encourage you to seek an evaluation from a qualified professional:

  • Persistent sad, anxious, or “empty” mood

  • Feelings of hopelessness, negativity

  • Feelings of guilt, worthlessness, helplessness

  • Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex

  • Decreased energy, fatigue, being “slowed down”

  • Difficulty concentrating, remembering, making decisions

  • Insomnia, early-morning awakening, or oversleeping

  • Appetite and/or weight loss, or overeating and weight gain

  • Restlessness, irritability

Treatment for Depression

Depression is treatable. It is important to seek out a counselor who has experience in treating people who live with chronic illness. While it can take time for the symptoms of depression to go away, seeking treatment can help improve your mood, your quality of life, and your ability to cope with IBD.

  • Cognitive behavioral therapy (CBT) is an an evidence-based treatment for depression and anxiety. You will work with the therapist to identify and change negative thought patterns and behaviors which can contribute to depression.

  • Medication management may be necessary in addition to therapy with a trained professional. Your gastroenterologist may feel comfortable prescribing an antidepressant to help stabilize your mood, or may also suggest a consultation with a psychiatrist.

Managing Depression at Home

There are several things you can do at home to cope with negative feelings while you are getting treatment for depression.

Remember that feeling better takes time, and that your mood will likely improve gradually, not immediately. These tips have been adapted from the National Institute of Mental Health booklet on depression:

  • Set realistic goals, keeping your depression in mind, and take on a reasonable amount of responsibility in your daily life.

  • Set your priorities and break big tasks into smaller ones, doing the best you can to tackle them.

  • Make a point to spend time around other people. Confiding in a trusted friend or family member usually feels better than being alone and secretive.

  • Participate in activities that may make you feel better, such as mild exercise, seeing a movie, watching a sporting event, or participating in religious or social events.

  • Postpone major life decisions until your depression has lifted. These decisions may include changing jobs, getting married, or filing for divorce. Discuss important decisions with trusted friends or family members who may have a more objective view of your situation.

  • Don’t expect to “snap out of it.” Instead, expect to feel a little better each day.

  • Ask for and accept help from your family and friends.

  • Know that positive thinking will eventually replace negative thinking as your depression responds to treatment.

Anxiety

Anxiety consists of feelings of panic, worry, and nervousness. When anxiety becomes persistent and excessive, it can interfere with your mental and physical health.

If you have been bothered by some of these symptoms things for several days within the last two weeks and they have interfered with your ability to work and maintain relationships, you may consider an anxiety management program or seeking help from a mental health professional.

  • Feeling nervous, anxious, or on edge

  • Not being able to stop or control worrying

  • Worrying too much about different things

  • Trouble relaxing

  • Being so restless that it is hard to sit still

  • Becoming easily annoyed or irritable

  • Feeling afraid as if something awful might happen

Understanding Stress and Anxiety in IBD

Video Length 1:25

Understanding Stress and Anxiety in IBD While stress and anxiety has not been shown to cause Crohn’s disease or ulcerative colitis, they can certainly have an impact on your disease. Learn more!

Transcript

Dr. Megan Real and I’m a clinical

psychologist with specialization in the

treatment of gastrointestinal issues and

part of my daily work with patients is

to focus on helping them cope with their

disease the best they can and so once a

treatment plan is in place with a

gastroenterologist it’s nice for me to

be able to join the team to help with

the long term management of a chronic

disease so while we know that stress

does not cause IBD it certainly can

contribute to flares and having the most

kind of well-rounded toolbox in order to

manage stress and anxiety which is

inevitable at various life stages that’s

what I work on with patients so we work

on relaxation strategies cognitive

behavioral therapy giving people

strategies to help with coping in the

workplace and in relationships and we

know that stress and anxiety can

certainly lead to more functional bowel

symptoms if a chronic disease ulcerative

colitis Crohn’s as well-managed and in

remission so I’m really looking forward

to talking more today about why that’s

important and I’m really just having a

conversation about how stress can impact

your life and what you’re doing about

English (auto-generated)

The GI stress cycle in Crohn’s disease and ulcerative colitis

Video Length 2:41

The GI stress cycle in Crohn’s disease and ulcerative colitis Sometimes symptoms can lead to stress and anxiety as you try to manage your disease and go through daily living. Learn more about this cycle.

Transcript

so stress and anxiety can lead to

additional risk factors for people to

have IBD so patients that have increases

an anxiety are at more risk for surgery

they have a reduced medication adherence

sometimes a lower quality of life and

also a higher perceived level of stress

so basically that means that you feel

less capable of dealing with certain

stressors when your anxiety is too high

and so one of the ways that I talk with

patients about managing stress and how

to incorporate some of the stress and

cognitive behavioral strategies to

manage stress is the GI stress cycle so

with the GI stress cycle I often start

with where you how you’re feeling and if

you’re waking up in the morning and

you’re noticing that you’re feeling

maybe some urgent diarrhea or nausea

if you’re not physically feeling well

naturally that starts to lend itself to

some emotional and cognitive experiences

so if you’re feeling nauseous and having

heard of diarrhea and you have a meeting

later in the day you might start to go

oh gosh here we go again I’m gonna have

to postpone this meeting or miss this

meeting and so as those cognitions start

to rev they really are unhelpful

cognitions and as we have those

unhelpful thoughts it then leads to an

increase in emotions such as stress

anxiety frustration embarrassment

so really the unpleasant emotions that

can go along with negative cognitions

and as we feel anxious and stressed it

then starts to rev what’s called our

sympathetic system and our brain has

this ability in times of stress to begin

to produce sympathetic arousal and

that’s your body’s fight flight or

freeze response and as this happens it

begins to cause an increase in heart

rate your breathing may get short and

shallow

and it can really start to impact the GI

tract because it can clench and tense

the muscles in the digestive system

which can then lead to urgency and

diarrhea and even at time slowing things

down to have more constipation and as

all of that happens it begins to then

worsen symptoms and we get into this big

cycle of symptoms leading to emotions

which leads to a worsening experience of

the symptoms

English (auto-generated)

Breaking the GI stress cycle in Crohn’s disease or ulcerative colitis

Video Length 2:03

Breaking the GI stress cycle in Crohn’s disease or ulcerative colitis Hear important tips from a clinical psychologist on how to break the GI stress cycle, and the importance of support.

Transcript

you

so the wonderful thing about our brain

is that we have built-in mechanisms to

help us relax

so when your sympathetic system is

revving eventually it’s going to get to

a point where it says that’s enough and

the parasympathetic system can jump in

and that’s your body’s relaxation

response so simple techniques like

diaphragmatic breathing and different

muscle relaxation strategies when you

start to feel that muscle group tense

and tighten your heartbeat escalating

and your breathing getting short and

shallow can begin to calm down those

mechanisms in your body so we have

different relaxation strategies that can

help to break that cycle and they can be

implemented right away so while your

body will eventually allow that

parasympathetic system to kick in when

you have tools and strategies that are

easy to reach for such as diaphragmatic

breathing or muscle relaxation you can

begin to break that cycle a lot quicker

and gives you some control and if you

find that you know you need more

assistance and learning how to break

that cycle a psychologist or mental

health provider can certainly be helpful

to work from a cognitive behavioral

perspective on that cognition piece so

as you’re beginning to have that rev of

negative thoughts and emotions that can

begin when you’re feeling poorly there

are ways that you can learn more

adaptive ways of thinking about feeling

poorly so for example as you begin to

feel like oh gosh here we go again this

is going to be bad that can lead to some

catastrophic thoughts and negatively

predicting the future and anticipatory

anxiety and working with a therapist can

really help you to find new ways to

observe your negative thoughts and then

change them to more adaptive ways of

coping with those cognitions

English (auto-generated)

Managing Your Anxiety

It is common and understandable to worry and feel stress about managing your disease, but reducing your stress and anxiety can help you maintain a healthy emotional balance. There are many ways to try and reduce your stress. Keep trying until you find something that helps.

  • Relaxation and breathing exercises
  • Practicing yoga or tai chi
  • Light aerobic exercise, such as walking or swimming
  • Cognitive behavioral therapy or psychotherapy with a psychologist or social worker
  • Medication to address your emotional and mental state
  • Meditation or hypnotherapy
  • Biofeedback
  • Attending support groups online or in your local chapter
  • Books, recordings, guided imagery, or journaling
  • Creating a support network of friends, family, and health care professionals
  • Pursuing hobbies and activities you enjoyed before your diagnosis

Managing Stress

Stress is your body’s hormonal response to any situation that demands you take action, whether it’s getting to a meeting on time or dealing with a major medical issue. The release of those hormones is what’s known as “the fight or flight response.” They are responsible for physical reactions to stress, such as increased heart rate, perspiration, and tightening of your muscles.

Not all stress is bad! Everyone experiences some level of stress as they work to meet the demands of their day-to-day life. Small doses of “good stress” can motivate you to be productive, to avoid danger, and to even feel excited.

Prolonged exposure to stressors, such as a traumatic event or a negative lifestyle change, induces “bad stress” that can be harmful to your physical and mental health. Bad stress can be caused by demands of your IBD, especially when you worry how your symptoms will impact your daily plans.

There are emotion-focused strategies to help with stressors that you cannot control.

  • Acceptance of the situation

  • Utilizing social support, such as asking a friend to accommodate your needs

  • Relaxation

  • Constructive self-talk, such as “I did the best I could”

  • Let it go and move on

You can also reduce stress by planning ahead if episodes of diarrhea or abdominal pain make you fearful of being in public places.

  • Be aware of bathroom locations close to your destination

  • Carry extra underwear, toilet paper, or moist wipes

Prevalence of Anxiety and Depression in Patients with Inflammatory Bowel Disease

Abstract

Background. Inflammatory bowel disease (IBD) patients are not routinely screened for depression and anxiety despite knowledge of an increased prevalence in people with chronic disease and negative effects on quality of life. Methods. Prevalence of anxiety and depression was assessed in IBD outpatients through retrospective chart review. The presence of anxiety and/or depression was determined using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 self-report questionnaires or by diagnosis through psychiatric interview. Patient demographics, disease characteristics, and medication information were also collected. Multivariable analysis was used to determine associations between patient factors and depression and anxiety. Results. 327 patient charts were reviewed. Rates of depression and anxiety were found to be 25.8% and 21.2%, with 30.3% of patients suffering from depression and/or anxiety. Disease activity was found to be significantly associated with depression and/or anxiety (). Females were more likely to have anxiety (). Conclusion. A significant proportion of IBD patients suffer from depression and/or anxiety. The rates of these mental illnesses would justify screening and referral for psychiatric treatment in clinics treating this population. Patients with active disease are particularly at risk for anxiety and depression.

1. Introduction

The prevalence of depression and anxiety is higher in patients with chronic diseases compared to the general population and having a long term medical illness is a risk factor for depression . There is evidence that inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC), is associated with higher rates of anxiety and depression compared to the general population and that depression is associated with decreased quality of life in IBD patients . Research on patients with both chronic disease and IBD reveals that the presence of an anxiety or depressive disorder is associated with poor treatment compliance. In addition, depressive disorders are associated with poorer functioning and higher morbidity and mortality in persons with chronic medical conditions . Provision of treatment for mental disorders may improve long term outcomes, and it is therefore important to identify patients at greater risk of anxiety and depression so that they can be offered the appropriate treatment and support.

In a previous Canadian study, IBD cases were extracted from two nationally representative health surveys and depression rates were examined . Depression was diagnosed using a structured diagnostic interview and cases were identified based on self-report of “a bowel disorder such as Crohn’s disease or colitis” that has lasted longer than 6 months and been diagnosed by a health professional. The twelve-month depression rates were found to be 14.7% and 16.3% in the two survey samples for IBD patients, rates that are triple those in the general population. Depression rates were found to be higher among those that were female, single, and younger, had greater pain, and had functional limitations. A limitation of this study was that cases were identified through self-report without any medical record verification, and the nonspecific wording of the self-report question may have resulted in inaccurate reporting of IBD.

The primary aim of this study was to determine the prevalence of anxiety and depression in IBD patients attending a gastroenterology outpatient clinic. A secondary aim was identification of patient characteristics associated with increased rates of these mental disorders.

2. Methods

Prevalence of anxiety and depression was assessed in IBD outpatients attending a gastroenterology clinic associated with a tertiary care academic hospital (St. Paul’s Hospital, Vancouver, Canada) from January to July 2016. All consecutive IBD patients attending the outpatient clinic were asked to fill out the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) questionnaires at their medical appointments to screen for anxiety and depression. The GAD-7 and PHQ-9 are brief self-report scales used to identify Generalized Anxiety Disorder and depression, respectively. Validated in the primary care setting, the GAD-7 has a sensitivity of 89% and a specificity of 82% , and the PHQ-9 has a sensitivity of 88% and a specificity of 88% when using a cut-off of 10 or greater as a positive result. Patients were offered referral to psychiatry if they screened positive for anxiety and/or depression, if they discussed mood symptoms with the gastroenterologist, or if they requested referral. A psychiatric interview was then conducted and a diagnosis or lack thereof of Generalized Anxiety Disorder (GAD) or major depressive disorder (MDD) was recorded.

Information collected from patient charts included gender, age at time of mental health assessment, smoking status, disease duration, disease diagnosis (UC versus CD), Partial Mayo scores (UC patients), Harvey-Bradshaw Index (CD patients), previous surgical resection, disease phenotype according to the Montreal classification scores, c-reactive protein (CRP, a noninvasive marker of inflammation with a sensitivity of 60.7% and a specificity of 75.9% in IBD patients for endoscopic inflammation using a cut-off >0.5 mg/dL ), current medications, and past use of a biologic medication. Information regarding current psychiatric treatment (including pharmacotherapy or psychotherapy), the use of psychiatric drugs including antidepressants and anxiolytic medications, and history of past diagnosis of anxiety or depression were recorded. These variables were not formally assessed in gastroenterology appointments and were therefore only reliably assessed in patients who had appointments with psychiatry. Patients were considered to have anxiety and/or depression given they had a positive score (10 or greater) on the GAD-7 and/or PHQ-9 screening questionnaires and/or a diagnosis of anxiety or depression from psychiatric interview after referral to a psychiatrist. Both screening questionnaire administration and psychiatric interview took place between January 2016 and August 2016. Psychiatry evaluated referred patients for current presence of anxiety or depressive disorders at appointments, and a diagnosis was made based on physician assessment. Active disease was defined as a Partial Mayo score greater than 4 or a Harvey-Bradshaw Index greater than 7, both accepted cut-offs to indicate moderate to severe disease for these two disease activity measures .

Univariate and multivariable logistic regression was used to determine if associations existed between patient characteristics and depression and anxiety. The following potential risk factors, which were identified a priori, were investigated for association with mental disorders in IBD patients: gender, disease diagnosis, disease activity, perianal disease, current steroid use, current or previous biologics, current age, and disease duration. The results shown in the current manuscript are from complete case analysis. We recognized the missing data issues in the data set and the analyses based on the complete case might be biased. In order to examine the impact of the missing data on the results of the analyses, a multiple imputation using chained equations was applied as a sensitivity analysis. The imputation process was conducted in SAS and replicated 200 times.

3. Results

3.1. Study Population

A total of 327 IBD patients were included in the study, Table 1 describes clinical characteristics associated with our cohort. Disease activity is not formally assessed at each clinic visit; therefore, for some patients a Partial Mayo or Harvey-Bradshaw Index score was not provided or possible to calculate for the time of the mental health assessment. Sufficient information to determine disease activity was available for 170/327 patients in the study, 13% had at least moderately active disease using the Partial Mayo score (UC) and Harvey-Bradshaw Index (CD). Sixty-four percent of those with moderately to severely active disease had CRP lab value, 86% of which had a value over 5 mg/L indicating biochemical confirmation of inflammation.

Table 1 Characteristics of the patient population.

Past psychiatric history and treatment were not formally assessed in gastroenterology appointments; therefore information regarding psychiatric treatment and diagnosis is presented for patients who attended psychiatric appointments only, as these variables were more consistently assessed via psychiatry. Twenty-two patients attended an appointment with psychiatry; of those patients seven were taking an antidepressant medication, three were also taking benzodiazepines, and one patient was receiving cognitive behavioural therapy. Eleven patients had received psychiatric treatment in the past, two had previously been diagnosed with anxiety alone, five with depression alone, and two with anxiety and depression.

3.2. Prevalence of Anxiety and Depression

The presence or absence of depression could be assessed for 314 patients, anxiety for 322 patients, and depression and/or anxiety for 317 patients; missing data is due to lack of or incomplete questionnaires. Prevalence with 95% confidence intervals (CI) of anxiety was 21.1% (95% CI: 17.0%–25.9%), 25.5% (95% CI: 21.3%–30.9%) for depression, and 30.3% (95% CI 25.5%–35.6%) for depression and/or anxiety. Of the patients who screened positive for depression and/or anxiety and accepted referral to a psychiatrist, 18 of 20 patients (90%) with positive PHQ-9 scores had a diagnosis of depression confirmed, and 16 of 19 patients (84%) with positive GAD-7 scores had a diagnosis of anxiety confirmed.

3.3. Factors Associated with Anxiety and Depression

Univariate analysis found that presence of active disease was significantly associated with depression and/or anxiety (OR: 4.14, value: 0.003), as well as with depression (OR: 4.47, value: 0.002) and anxiety (OR: 3.37, value: 0.02). In multivariable analysis, presence of active disease was independently significantly associated with depression and/or anxiety (OR: 4.28, value: 0.01), as well as with depression (OR: 4.70, ) and anxiety (OR: 2.97, ). Male gender was protective from development of anxiety (OR: 0.29, ). None of the other variables investigated were found to be significantly associated with anxiety or depression. Odds ratios and values from multivariable analysis of each variable with anxiety and/or depression are described in Table 2.

Table 2 Multivariable logistic regression analysis of the association between patient demographic and disease characteristics and the presence of depression and/or anxiety.

Disease activity was significantly associated with increased risk of depression and anxiety in IBD patients. Figure 1 shows the percentage of patients with anxiety and/or depression with active disease and those with inactive disease.

Figure 1 Percentage of patients found to have anxiety and/or depression at present with active and inactive disease. Error bars represent 95% CI.

4. Discussion

The prevalence of anxiety (21.2%) and depression (25.8%) in IBD patients reported in this study is higher than that reported for the general Canadian population. According to the 2013 Statistics Canada Health Survey, the 12-month and lifetime prevalence of depression in the Canadian population were 4.7% and 11.3%, and the 12-month and lifetime prevalence of Generalized Anxiety Disorder were 2.6% and 8.7% . Our results are consistent with findings that patients with long term medical conditions are at increased risk of major depression and with studies that have found the prevalence of anxiety and depression to be higher in IBD patients compared with healthy controls .

There is variation in the rates of depression and anxiety reported in different studies likely due to differences in populations studied, methods used to assess depression and anxiety, and the period of time within which depression and/or anxiety was assessed (lifetime versus 12 months versus current) . Previous Canadian studies have assessed rates of depression and anxiety in survey samples of self-reported IBD patients and in an IBD patient cohort but none in consecutive patients attending an outpatient clinic. Our study is unique in that it is the first Canadian study to investigate the prevalence of anxiety and depression in consecutive outpatients attending a gastroenterology clinic. Screening for anxiety and depression in consecutive patients may provide a more accurate estimate of the prevalence as this design removes the selection bias introduced when depending on patients to volunteer to be part of a cohort or to reply to a survey. Therefore, our study should provide a more accurate estimate of the point prevalence of anxiety and depression in an outpatient IBD population.

Twelve-month rates of depression reported from two nationally representative surveys with patients identified through self-report of “a bowel disorder such as Crohn’s disease or colitis” were 14.7% and 16.3% . Our results show a higher prevalence of depression, likely due to the lack of specificity in the criteria used to diagnose IBD in these survey studies. Another study used survey samples of self-reported IBD patients to assess the prevalence of anxiety and found that IBD patients had 2.18 greater odds of anxiety compared to the general population . Limitations of these studies are that cases of IBD were not verified through medical records, and only 82.6%, 84.7%, and 79.8% of households responded to the surveys, potentially introducing bias due to differences between those who chose to respond and those who did not. It has been observed that those with less education, older age, and greater use of psychopharmaceutical drugs are less likely to participate in survey research .

A Canadian cohort study which drew on patients from the University of Manitoba Research Registry found lifetime rates of Generalized Anxiety Disorder (GAD) and major depressive disorder (MDD) in IBD patients to be 13.4% and 27.2% . IBD patients eligible for inclusion in the registry were identified through the database of Manitoba Health. A limitation of this study is that the registry is composed of a subset of IBD patients that may not be representative of all of those living in the community: patients had to be diagnosed within the past 7 years for inclusion and patients needed to agree to participate in the registry, which resulted in only just over half of eligible IBD patients being included. Further, of those eligible in the registry 14% declined to take part in the cohort study and a further 35 of 388 patients initially enrolled were lost throughout the 2-year duration. The characteristics of the patients who agreed and were able to meet the demands of inclusion in the registry and cohort study may vary from those unable or unwilling to participate. Research of nonparticipation in a prospective study on chronic respiratory and cardiovascular diseases found that patients who did not feel well and/or had been admitted to hospital during the last 12 months had lower participation rates .

Our study included IBD patients attending a gastroenterology outpatient clinic where all patients are asked to complete the GAD-7 and PHQ-9 questionnaires to limit selection bias. One limitation was that the patient population assessed was drawn from a tertiary IBD clinic; this may result in a patient population with more severe or active IBD, or more comorbidities compared to community samples. Additionally, this study did not include any patients that were currently hospitalized, and because anxiety and depression have been associated with disease flares and inpatient status, prevalence of anxiety and depression may be lower in the population studied compared to inpatient IBD populations .

As previously reported in the literature , we found that disease activity was significantly associated with increased risk of depression and anxiety in IBD patients. Häuser et al. (2011) found that IBD patients with moderate/severe disease activity had higher rates of depression and anxiety compared to both those with slight disease activity and to an age and sex matched representative sample of the general population. Patients in remission were not at an increased risk of depression and anxiety compared to the general population. We found that prevalence of anxiety and depression did not differ between UC and CD patients, which is consistent with previous research . Female sex was associated with increased risk of anxiety, which has been reported in other studies of patients with IBD , as well as in the general population .

Variation in methods of psychiatric assessment is likely partially responsible for the variation in reported prevalence of anxiety and depression in IBD patients between studies. Use of screening questionnaires may overestimate rates of depression and anxiety: when patients were assessed using both the DSM-3 criteria and the Hospital Anxiety and Depression Scale (HADS) screening questionnaire rates of psychiatric illness were lower using the DSM criteria . We used the GAD-7 and PHQ-9 screening questionnaires, which have been validated in the primary care setting, to assess anxiety and depression. When using a cut-off of 10 or greater as a positive result for both questionnaires, the GAD-7 has a sensitivity of 89% and a specificity of 82% , while the PHQ-9 has a sensitivity of 88% and a specificity of 88% . Some of the symptoms of depression used for screening, such as changes in appetite and fatigue, may overlap with IBD symptoms; therefore, the PHQ-9 may overestimate depression in IBD patients. Assessment of the accuracy of the PHQ-9 screening questionnaire in this population is important. In our study this screening tool seems to be accurate; of those patients who agreed to referral to a psychiatrist, 90% of patients who scored positive on the PHQ-9 had a diagnosis of depression confirmed by psychiatric interview.

The high prevalence of mental disorders we have found in our study is an important problem that requires further attention. A meta-analysis which investigated any correlation between depression and patient compliance in a variety of chronic disease patients (end stage renal disease, angina, cancer, renal transplant, and rheumatoid arthritis) with a variety of interventions (dietary and health behaviour interventions and medications) found that depression was associated with three times greater odds of noncompliance with treatment recommendation . Both depression and presence of psychiatric disorders have been associated with decreased treatment compliance in IBD patients. Adherence to medical treatment in IBD patients is important not only in the short term for preventing flares of disease activity but also to prevent long term complications. Identification and treatment of anxiety and depression in IBD patients may be important in improving treatment adherence and long term patient outcomes. Anxiety and depression in IBD have been shown to contribute to poor health related quality of life (HR-QOL) independent of disease severity . Zhang et al. (2013) examined the role of depression and disease activity as independent factors in predicting HR-QOL. Depression was found to be the most significant predictor of poor HR-QOL in IBD patients, with disease activity being only weakly predictive. Therefore, addressing mental health in patients with IBD may be important in maximizing patient quality of life. Additionally, psychiatric illness in IBD patients has been found to predict high cost outcomes including emergency department visits, IBD-related hospitalizations, and high treatment charges . The potential benefits of mental health treatment, along with the increased prevalence of anxiety and depression in IBD patients, suggest that screening for anxiety and depression in this population would be of value.

5. Conclusion

In summary, our study shows that a significant proportion (30.3%) of IBD outpatients suffer from anxiety and/or depression. The prevalence of anxiety and/or depression found in our study justifies screening and referral for psychiatric treatment in clinics treating this population. The finding that disease severity is associated with increased risk of depression and anxiety suggests that those with active disease may benefit from more intense psychiatric screening.

Conflicts of Interest

Dr. Brian Bressler is advisor/speaker at Shire, Pfizer, Merck, Ferring, Janssen, Abbvie, Takeda, Actavis, and Genentech and advisor in Pendopharm and Allergan. Research was supported by Janssen, Abbvie, GSK, BMS, Amgen, Genentech, Merck, RedHill Biopharma, BI, Qu Biologic, Celgene, and Alvine. Stock options were provided by Qu Biologic. Dr. Greg Rosenfeld is speaker/advisory board consultant at Abbvie, Janssen, and Takeda and advisory board consultant at Shire and Merck. Dr. Yvette Leung is advisor/speaker at Abbvie, Janssen, Takeda, Shire, Merck, and Pfizer.

IBD Patients Suffer from Anxiety

Inflammatory bowel disease (IBD) is a term that primarily refers to two diseases of the intestines: Crohn’s disease and ulcerative colitis. These diseases cause chronic inflammation, and include symptoms such as severe abdominal pain, diarrhea, and rectal bleeding. In Crohn’s disease, the inflammation can be anywhere in the digestive tract, and can extend right through the entire thickness of the bowel, occurring in multiple patches or one large patch. In ulcerative colitis, the inflammation is limited to the inner mucosa and begins at the anus, with the disease continuously progressing upward through the colon only.

The cause of IBD is still undetermined but there is considerable research evidence suggesting that interactions among environmental factors, intestinal microorganisms, immune dysregulation, and genetic predisposition are responsible.

A recent study1 analyzed the link between IBD and anxiety by looking at many studies published on the subject (meta-analysis), and found that along with the severe physical symptoms, patients with IBD frequently experience psychological comorbidities. One study found that up to 40% of those with IBD experience abnormal levels of anxiety. In another study, anxiety affected between 29-35% of IBD patients in remission, but this drastically increased to 80% of IBD patients during a flare-up. This anxiety prevalence is much higher than expected by chance, and it is especially high in patients with Crohn’s disease. In IBD, the severity of symptoms can be a factor in developing anxiety, although in some, the anxiety came first.

Emerging research shows that anxiety can even trigger a flare-up in IBD patients. One study found active mucosal inflammation to be associated with an increase in psychological symptoms. This research is helpful, because it shows just how important it is to get inflammation under control. Individuals with IBD who receive adequate treatment and stay in remission are less likely to experience anxiety.

There are certain risk factors that make someone with IBD more likely to develop an anxiety disorder, including psychological stress, increasing age, severe and active disease, surgery, lack of disease education, and poor socioeconomic status.

However, the patients at highest risk for developing anxiety are those who have had an ostomy. Ostomy patients are more likely to have a decreased quality of life and increased psychological problems, but they often don’t receive the psychological help that they need. Dealing with an ostomy can be tough on many aspects of life, and physicians should take steps to ensure that patients receive adequate treatment for all aspects involved.

What is an Ostomy?

The term ostomy refers to the surgical opening created for the elimination of body wastes. When the digestive system ceases to function properly due to disease or injury, a physician may recommend removing or bypassing portions of the small intestine or colon. When the surgeon removes or bypasses these sections, sometimes it may no longer be possible to eliminate waste (have a bowel movement) from the usual anatomic route. The surgeon will then re-direct the end of the remaining intestinal tract to the surface of the skin; this opening is a “stoma” or ostomy. When the small intestine connects with the surface it is called an ileostomy and when the colon (large intestine) connects with the surface it is called a colostomy. Ileostomies and colostomies may be either temporary or permanent, depending upon the particular situation.

The Influence of Functional GI Disorders

IBD is an organic bowel disease, which means that it has specific, measurable physiological effects on the body. Other disorders, such as irritable bowel syndrome (IBS), are functional conditions, where symptoms occur but there is no obvious physical reason. Typically, psychological symptoms are more common in those with functional GI disorders, so it is common for physicians to screen for anxiety in these patients. However, since IBD is an organic disease, physicians don’t often consider that these individuals experience anxiety, leaving some patients undiagnosed.

Interestingly, physicians frequently use a diagnosis of an organic GI disease to rule out a functional disorder. However, it is possible to have both, and it appears to occur quite frequently. One Australian study found that 66% of IBD patients also met criteria for at least one functional GI disorder, which was especially common in those who had both IBD and anxiety. It is important that physicians recognize the difference between normal IBD symptoms, and those that could be from irritable bowel syndrome or functional dyspepsia.

Treating IBD and Anxiety

The study authors say it is important for physicians to determine whether patients with IBD also have a functional disorder. Differentiating symptoms between the two can be difficult, so they suggest that doctors first look for signs of inflammation, treat those, and then if symptoms remain it could indicate a functional disorder, at which point they should consider treatment for this disorder as well.

Physicians typically involved in caring for IBD patients, such as general practitioners and gastroenterologists, sometimes don’t have much formal training in psychological disorders, and since patients are often hesitant to bring up psychological symptoms due to social stigma, they typically remain undiagnosed and untreated for too long. When IBD patients with an anxiety disorder experience stigma and therefore don’t seek treatment, it can lead to further disability. It is very important that physicians are aware of the increased risk of anxiety in IBD patients, and should be prompt in detecting and treating any coexisting anxiety disorders. Patients also have a responsibility to speak up and ask for help if they perceive that anxiety is a problem for them.

The study authors recommend physicians use formal screening questionnaires to detect anxiety in IBD patients. They suggest a few different types of questionnaires, preferably something simple, that is long enough to be accurate, but not so long that it is burdensome to the patients, could be an effective way to detect anxiety in IBD patients.

For patients who are anxious, management should involve a gastroenterologist and a psychologist or psychiatrist. Treatment should include medications for IBD along with therapy and medications for anxiety. However, studies show that psychological treatments have no benefit for those with IBD who don’t have anxiety or other psychiatric disorders, so it is important to have efficient screening methods to determine which patients should receive specific treatments.

Treating anxiety can even have extra beneficial effects by reducing IBD symptoms. One study found that using cognitive behavioural therapy (CBT) in adolescents with IBD and anxiety not only reduced anxiety, but also improved pain and disease severity in IBD. Studies have long supported the use of CBT in irritable bowel syndrome as well.

If you are an IBD patient and are concerned that you might have anxiety or a functional gastrointestinal disorder, speak with your doctor.

5 Item Anxiety and Depression Detector1

Have you:

  1. Had a spell or attack where all of a sudden you felt frightened, anxious, or uneasy?
  2. Been bothered by nerves or feeling anxious or on edge for 6 months or more?
  3. Had a problem being anxious or uncomfortable around people?
  4. Had recurrent dreams or nightmares of trauma or avoidance of trauma reminders?

Over the past 2 weeks, have you:

  1. Felt down depressed or hopeless with little interest or pleasure in doing things?
First published in the Inside Tract® newsletter issue 195 – 2015
Image Credit: © bigstockphoto.com/igor stevanovic
1. Bannaga AS et al. Inflammatory bowel disease and anxiety: links, risks, and challenges faced. Clinical and Experimental Gastroenterology. 2015:8;111-7.

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