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Journal of Integrated Pest Management

Editor-in-Chief

Laurence J. Egan, Ireland

Associate Editors

Shomron Ben-HorinSilvio DanesePeter LakatosMiles ParkesGijs van den BrinkSéverine VermeireMaria T. Abreu, USA

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Published on behalf of

Do Inflammatory Bowel Disease patients with anxiety and depressive symptoms receive the care they need?

F. Bennebroek Evertsz', N.A.M. Thijssens, P.C.F. Stokkers, M.A. Grootenhuis, C.L.H. Bockting, P.T. Nieuwkerk, M.A.G. Sprangers
DOI: http://dx.doi.org/10.1016/j.crohns.2011.07.006 68-76 First published online: 1 February 2012

Abstract

Background and aims: Inflammatory Bowel Disease (IBD) patients with anxiety and/or depressive symptoms may not receive the care they need. Provision of care requires insight into the factors affecting these psychiatric symptoms. The study was designed to examine the extent to which: (1) IBD patients with anxiety and/or depressive symptoms receive mental treatment and (2) clinical and socio-demographic variables are associated with these symptoms.

Methods: 231 adult IBD patients (79% response rate), attending a tertiary care center, completed standardized measures on anxiety and depressive symptoms (HADS), quality of life (SF-12) and mental health care use (TIC-P). Diagnosis and disease activity were determined by the gastroenterologist.

Results: 43% had high levels of anxiety and/or depressive symptoms, indicative of a psychiatric disorder (HADS ≥ 8), of whom 18% received psychological treatment and 21% used psychotropic medication. In multivariate analysis, high disease activity was associated with anxiety (OR = 2.72 | p < 0.03) and depression (OR = 3.36 | p < 0.01), while Crohn's disease was associated with anxiety (OR = 2.60 | p < 0.03).

Conclusions: Despite high levels of anxiety and depressive symptoms and poor quality of life, psychiatric complaints in IBD patients were undertreated. Screening for and treatment of psychiatric symptoms should become an integral part of IBD medical care.

Highlights: ► 18 % of IBD patients with high levels of anxiety and depression receive mental help. ► Higher levels of depression and anxiety are associated with having active disease. ► Screening should become an integral part of IBD medical care. ► Psychological interventions for anxiety and depression in IBD patients are needed.

Keywords
  • Inflammatory Bowel Disease
  • Anxiety
  • Depression
  • Psychological treatment

1 Introduction

Inflammatory Bowel Disease (IBD) has a profound impact on the life of a patient. The disease is mostly diagnosed at a young age, is of chronic nature and follows an unpredictable course with exacerbations and remissions, with approximately 25–50% of patients relapsing annually.1,2 Moreover, disease flares can be intense and the related physical symptoms, such as (bloody) diarrhea, abdominal pain, fistulas and fatigue can greatly challenge daily functioning. In most cases, life-long medical treatment is required, which is often accompanied by severe side effects, such as weight gain, a moon face, eczema and acne. Extra-intestinal manifestations such as spondylarthropathy may cause significant morbidity. On top, many patients require surgery in the course of their disease, frequently resulting in a permanent ileostoma or colostoma.3,4 Further, chronic immune suppression increases the risk of hematological malignancies. Finally, since colitis is associated with an increased risk of colorectal cancer, patients need to undergo frequent endoscopic surveillance.5,6

Thus, IBD affects patients' daily life due to physical impairments, the unpredictable course, lifelong surveillance, treatment side effects and the risk of malignancy. As a consequence, IBD patients frequently experience psychological and social problems.7 Research over the past decade has mainly focused on anxiety and depression. The general conclusion of these studies is that IBD patients show elevated levels of depression and anxiety.813 According to self report, lifetime prevalence of depression has been found to be at least two times higher in IBD patients, than in the general population, i.e. 27% against 12%. Likewise, prevalence of self-reported anxiety was higher in IBD patients (8%) than in the general population (4.7%).8,12

IBD also impacts quality of life adversely. Moreover, higher levels of anxiety and depression are associated with poorer quality of life.14,15

Whereas many previous studies have investigated anxiety and depression in IBD patients, their methodological limitations or restricted research foci leave room for further scrutiny. For example, the studies employing population-based samples rely on patients' self-reports regarding their diagnosis of IBD instead of clinical examinations.1012 The studies that did recruit IBD patients from clinical samples, often used restricted inclusion criteria (e.g., no prior surgery, longstanding remission, or a recent diagnosis of IBD), impeding generalization of results and comparison across studies.13 Moreover, with the exception of one study,9 most studies employed small sample sizes (ranging from 32 to 116).13,16

A number of pertinent questions surrounding anxiety and depression of IBD patients remain. First, IBD patients with a long-lasting, complicated and severe disease have received relatively little attention. The chronic and serious character of their disease poses risk factors for poor response to medical treatment and for developing recurrent anxiety and/or depression disorder.1719 Many studies have underlined that these patients in particular are in need for psychosocial treatment.813,2022 Furthermore, under-treatment of anxiety or depressive symptoms often results in unnecessary disability, sick leave and loss of employment, and high use of health care services leading to unnecessary high societal costs.13,23,24 The extent to which IBD patients with advanced and severe disease receive the mental care they need is still a pressing question. Second, our ability to alleviate anxiety and depression of IBD patients requires insight into the demographic and clinical factors that affect these problems. However, data from literature are equivocal.9,11,12,14,15,2530

We aimed to address these pertinent topics in a clinical sample of IBD patients with severe disease. Our objectives were: 1) to examine the extent to which IBD patients with anxiety and/or depressive symptoms receive mental treatment and 2) to assess the degree to which clinical and socio-demographic variables are associated with anxiety and/or depressive symptoms in IBD patients.

2 Materials and methods

2.1 Patients and procedures

Between July 2006 and January 2008, consecutive series of IBD patients attending the outpatient clinic of the Academic Medical Center, a top referral center, were invited by their gastroenterologist to participate in this study. Inclusion criteria were a minimum age of 18, a sufficient command of Dutch and a diagnosis of either Crohn's disease (CD) or ulcerative colitis (UC). The gastroenterologist completed a case report form, which included clinical information. Participants signed an informed consent form and received a set of questionnaires to be completed at home. Participants were asked to return the completed questionnaires within two weeks in a pre-stamped envelope. Non-respondents were sent a reminder by e-mail once.

2.2 Measures

2.2.1 Anxiety- and depressive symptoms, quality of life and health care use

Anxiety and depressive symptomatology were assessed with the standardized and validated Hospital Anxiety and Depression Scale (HADS).31 Its 14 items were combined to form an anxiety (7 items) and depression scale (7 items), which range from 0 (no complaints) to 21 (maximum complaints). A score ≥ 8 on either subscale means a symptom severity indicative of a possible psychiatric disorder, anxiety disorder and/or depressive disorder and a score > 11 indicates a probable psychiatric disorder in the same category.32,33 The cut-off score of 8 was chosen, because it has been widely validated and detects anxiety and depressive disorders at an early stage.32 The general population norms of the HADS were derived from 3492 respondents who attended general practices. A subgroup was used of 199 respondents, 18–65 years, of whom 46.2% were male and who had a mean age of 39.9, SD = 12.4.31

Generic health-related quality of life was assessed with the SF-12, a shortened version of the SF-36. Its items are combined to form the physical health component (PCS) and the mental health component (MCS). The SF-12 is validated for Dutch patients.34,35 The general population norms of the SF-12 were derived from 5823 respondents, who were randomly selected from a sample of Dutch households drawn from the national telephone registry (n = 1771 of whom 56% were male and had a mean age of 47.6, SD = 18), and from a sample of Amsterdam residents drawn from the municipal registry (n = 4059 of whom 46% were male and had a mean age of 43.1, SD = 18.1). A Dutch norm score of 49.4 on the PCS and a score of 51.6 on the MCS indicates average physical and mental health-related quality of life, respectively.34

Mental health care and psychiatric medicine utilization were assessed with the Trimbos/iMTA questionnaire for Costs associated with Psychiatric illness (TiC-P).36 We used the first part of the TiC-P that asks about contacts with a psychiatrist, psychologist and psychotherapist, and about the use of medication during the prior four weeks. We assessed whether patients received psychological treatment (yes or no), and whether they used psychiatric medication, i.e. antidepressants and/or anxiolytica (yes or no).

2.2.2 Socio-demographic variables and clinical outcomes

Socio-demographic variables were self-reported by patients and included gender, age, marital status and educational level. Clinical variables, i.e. disease activity, disease type, number of (IBD related) operations, duration of disease in years, having a stoma (yes/no), and medication use with psychological side effects (anxiety and depression) were assessed by the gastroenterologist. Disease activity of patients with CD was assessed by the gastroenterologist with the Harvey–Bradshaw Index (HBI) 37, which is based on 5 items including general well-being, abdominal pain, number of liquid stools a day, abdominal mass and a set of complications. A score higher than 6 indicates that CD is active. The HBI is a widely-used questionnaire and correlates highly with validated questionnaires such as the Crohn's Disease Activity Index.38,39 Disease activity of patients with UC was assessed by the gastroenterologist with the Truelove and Witts Index (MTWSI also known as the Lichtiger score).4042 The MTWSI is a 21-point symptomatic index that measures daily diarrhea, nocturnal diarrhea, visible blood in stool, fecal incontinence, abdominal pain or cramping, general well-being, abdominal tenderness and the need for antidiarrheal drugs. A score higher than 6 is indicative of active UC.42

2.3 Statistical analyses

We used descriptive statistics to assess the demographic and clinical characteristics of our sample. To characterize our sample, we first compared the levels of anxiety, depression and quality of life with those of previously published general population norms. We used one sample t-tests to compare mean anxiety, depression and quality of life scores of IBD patients against the mean norms of the general population. In addition, Cohen's d effect sizes were calculated, with 0.3 indicating a small effect size, 0.5 a moderate effect size and 0.8 a large effect size.

We investigated whether the following socio-demographic and clinical characteristics were significantly associated with a HADS anxiety or depression score ≥ 8 using univariate logistic regression analyses: gender, age in years, marital status (together vs alone), educational level (lower education, primary and secondary vs higher education, college or university), disease activity (yes vs no), disease type (CD vs UC), number of IBD-related operations (none vs more than one), disease duration (up to three years vs more than three years) and having a stoma (yes vs no). Variables yielding a liberal p-value of < 0.20 in the univariate analyses were subsequently included in a multivariate logistic regression analysis.43 Associations are presented as ORs with 95% confidence intervals. All multivariate tests were two-sided and conventional p-values < 0.05 were considered to indicate statistical significance.

The statistical Package for Social Sciences (SPSS) Windows version 16.0 was used for all analyses. Patients with missing values were excluded from the statistical analyses.

2.4 Ethical considerations

The study was conducted according to the principles of the Declaration of Helsinki and in accordance with the Medical Research Involving Human Subjects Act (WMO). The Medical Ethics Committee of the Academic Medical Centre provided an exemption for the study to seek formal approval.

3 Results

3.1 Sample characteristics

Of the 299 IBD patients who were invited to participate, 236 patients returned the set of questionnaires (response rate CD 85% and CU 75%). Since five questionnaires had more than 50% missing values, the data of 231 patients could be used for further analyses. Approximately half of the sample was female (56.3%), and the mean age was 43.4 (18–78). As our sample included only 13 patients in the age of 65 and higher, comparison with the general population norms was restricted to the age group 18–65. Furthermore, most patients reported having a spouse or significant relationship (69.7%). The distribution of educational level within the IBD patients was almost equally divided between low and high education (see Table 1).

View this table:
Table 1

Socio-demographic and clinical patient characteristics.

IBD (n = 231)
n%MeanSDRange
Socio-demographic variables
GenderMale10143.7
Female13056.3
Age21743.413.818–78
Marital statusTogether16169.7
Alone7030.3
Educational levelLowPrimary education4419.0
Secondary education6929.9
HighHigher education208.7
College/University8135.1
Clinical characteristics
Disease typeCrohn's Disease13859.7
Colitis Ulcerosa9340.3
Years of disease21515.610.8
Disease activityActive disease3213.9
Inactive disease15768.0
OperationsNone12755.0
≥ 110143.8
ImmunosuppressiveNone11951.1
MedicationAzathioprine8939.2
Methotrexate125.3
6-Mercaptopurine52.2
6-Tioguanine20.9
BiologicalNone19081.5
MedicationAdalimumab41.7
Infliximab2812.0
Infliximab with premedication52.1
Stoma177.4

Note: Numbers do not add up due to missing values.

    Most IBD patients were diagnosed as having CD (59.7%). The mean duration of IBD was approximately 15 years, with only 27 patients (12.6%) recently diagnosed (within the prior three years). The majority of IBD patients had an inactive disease (68%). In addition, nearly half of the patients had undergone one or more operations (43.8%) (see Table 1).

    3.2 Anxiety- and depressive symptoms and quality of life

    IBD patients scored significantly higher on the anxiety and depression subscales of the HADS compared to the general population norms, with small effect sizes of 0.29 and 0.32 respectively. Furthermore, IBD patients scored significantly lower on the PCS and MCS of the SF-12 as compared to the general population norms, with moderate effect sizes of 0.70 and 0.58 respectively (see Table 2).

    View this table:
    Table 2

    Comparison of anxiety and depressive symptoms and quality of life scores between IBD patients and the general population norms.

    VariablesIBDGPIBD/GP
    mSDmSDtpCohen's d
    Psychological variables
    HADS
    Anxiety symptoms6.214.125.103.604.050.000.29
    Depressive symptoms4.634.063.403.604.520.000.32
    Quality of Life variables
    SF-12
    PCS42.4010.9849.408.80−9.690.000.70
    MCS46.249.4351.609.20−8.640.000.58

    Note: IBD = Inflammatory Bowel Disease. GP = General Population. HADS = Hospital Anxiety and Depression Scale. SF-12 = Short Form Quality of Life Survey. PCS = Physical Component Scale. MCS = Mental Component Scale.

      When inspecting the number and percentage of IBD patients who scored ≥ 8 on either subscale of the HADS (indicative of a possible psychiatric disorder): 39 patients (17.5%) had high levels of anxiety, indicative of an anxiety disorder, 14 patients (6.3%) were marked as having high levels of depressive symptoms indicative of a depressive disorder, whereas 42 patients (18.8%) had both high levels on anxiety and depression, indicative of both psychiatric disorders. Hence, in total 95 (42.6%) IBD patients with high levels of anxiety and/or depression indicated at least one of these psychiatric disorders.

      3.3 Mental help and medication for anxiety and depressive symptoms

      Of the 95 IBD patients with high levels of anxiety and/or depression indicative of anxiety and/or depressive disorder, only 17 patients (17.9%) received psychological or psychiatric help in the prior four weeks, while 4 patients (3.1%) received help of the lower levels of the anxiety/depression group (see Table 3). Of the 95 IBD patients with higher levels of anxiety and/or a depression, 10 patients (10.5%) used antidepressants, 7 patients (7.4%) used anxiolytics and 3 patients (3.2%) used both antidepressants and anxiolytics in the prior four weeks. Of the 128 patients with lower levels of anxiety and depression, 6 patients (4.7%) received either antidepressants (2.3%) or anxiolytics (2.3%). The antidepressants used were Amitriptyline, Nortrilen and Setraline and the anxiolytics used were Oxazepam, Temazepam, Bromazepam and Diazepam. Only 2.7% of the patients used medication (i.e. prednisone) that may induce a psychological side effect as reported by the gastroenterologists.

      View this table:
      Table 3

      Mental help and psychotropic medication use within IBD patients with low levels versus high levels of anxiety and depression.

      n = 223*Low levels of anxiety/depression**High levels of anxiety/depression***
      128 (57.4%)95 (42.6%)
      Mental helpNo mental helpMental helpNo mental helpMental help
      Psychological and psychiatric help124 (96.9%)4 (3.1%)78 (82.1%)17 (17.9%)
      Psychotropic medication useNo medicationMedicationNo medicationMedication
      Only antidepressants125 (97.7%)3 (2.3%)82 (86.3%)10 (10.5%)
      Only anxiolytics125 (97.7%)3 (2.3%)85 (89.5%)7 (7.4%)
      Antidepressants and anxiolytics128 (100.0%)0 (0.0%)97 (96.8%)3 (3.2%)
      Total122 (95.3%)6 (4.7%)75 (78.9%)20 (21.1%)
      • * n = 8 missings were excluded from the analysis.

      • ** Low levels: No indication of a disorder = HADS < 8.

      • *** High levels: Indicative of a disorder = HADS ≥ 8.

      3.4 Factors associated with anxiety and depressive symptoms

      A higher score of anxiety (HADS anxiety subscale ≥ 8), was significantly associated with disease type (Crohn's disease), having undergone more than one operation and having a higher disease activity (see Table 4). Furthermore, trends signified a possible association between higher levels of anxiety indicative of an anxiety disorder and being of younger age and having a lower educational level. After the multivariate logistic regression analysis (see Table 4), an active disease (OR = 2.72 | 95%CI: 1.14–6.52 | p ≈ 0.024) and Crohn's disease (OR = 2.60 | 95%CI: 1.10–6.13 | p ≈ 0.029) remained significantly associated with higher levels of anxiety. The percentage with higher levels of anxiety, indicative of an anxiety disorder, within active IBD patients (56.3%) was significantly higher than that within inactive IBD patients (31.8%).

      View this table:
      Table 4

      Factors associated with high levels of anxiety (HADS anxiety subscale ≥ 8, indicative of an anxiety disorder).

      UnivariateMultivariate
      Total n = 228*84 (36.8%)ORCI(95%)pORCI(95%)p
      Demographic variables
      GenderMale35.0%
      Female38.3%0.9140.647–1.2920.710
      Age0.9820.962–1.0020.078**0.9850.959–1.0120.281
      Marital statusTogether36.5%
      Alone37.7%1.0530.587–1.8890.981
      Educational levelLow39.6%1.6080.904–2.8590.140**1.3780.658–2.8860.395
      High29.0%
      Clinical characteristics
      Disease typeUC25.0%
      CD44.9%2.4401.366–4.3600.004***2.6031.104–6.1340.029***
      Years of disease> 436.0%
      ≤ 338.5%1.1100.477–2.5840.980
      Disease activityNo31.8%
      Yes56.3%2.7551.268–5.9890.016***2.7231.138–6.5170.024***
      Operations030.4%
      ≥ 146.0%1.9501.128–3.3720.023***0.8940.398–2.0100.787
      StomaNo35.5%
      Yes52.9%2.0400.756–5.5080.242

      Note: OR = Odds Ratio, CI (95%) = 95% Confidence Interval.

      • * n = 3 missings were excluded from the analysis.

      • ** p < 0.2 according to logistic regression analyses, indicating a possible trend.

      • *** p < 0.05 according to logistic regression analyses, indicating a significant outcome.

      Having higher levels of depression, indicative of a depressive disorder (HADS depression subscale ≥ 8), was significantly associated with having an active disease. Moreover, trends suggested a possible association between having higher levels of depression and having a lower educational level, the number of operations and presence of a stoma. However, after the multivariate logistic regression analysis (see Table 5), only active disease (OR = 3.36 | 95%CI: 1.38–8.21 | p ≈ 0.008) remained significantly associated with higher levels of depression. A high level of depression, indicative of a depressive disorder was significantly more prevalent in IBD patients with an active disease (41.9%) than in IBD patients with an inactive disease (21.1%).

      View this table:
      Table 5

      Factors associated with high levels of depression (HADS depression subscale ≥ 8 indicative of a depressive disorder).

      UnivariateMultivariate
      Total n = 223*56 (25.1%)ORCI(95%)pORCI(95%)p
      Demographic variables
      GenderMale25.3%
      Female25.0%0.9870.537–1.8141.000
      Age0.9950.973–1.0170.649
      Marital statusTogether24.7%
      Alone26.1%1.0770.562–2.0650.954
      Educational levelLow28.4%1.6320.850–3.1300.188**1.5530.714–3.3820.267
      High19.6%
      Clinical characteristics
      Disease typeUC21.1%
      CD27.8%1.4400.765–2.7110.329
      Years of disease> 425.7%
      ≤ 328.0%1.1250.442–2.8630.996
      Disease activityNo21.1%
      Yes41.9%2.7081.201–6.1060.026***3.3621.376–8.2140.008***
      Operations021.3%
      ≥ 130.6%1.6290.885–2.9980.156**1.1510.522–2.5400.727
      StomaNo23.8%
      Yes41.2%2.2430.811–6.2060.194**1.2800.219–7.4740.784

      Note: OR = Odds Ratio, CI (95%) = 95% Confidence Interval.

      • * n = 8 missings were excluded from the analysis.

      • ** p < 0.2 according to logistic regression analyses, indicating a possible trend.

      • *** p < 0.05 according to logistic regression analyses, indicating a significant outcome.

      4 Discussion

      This study confirmed previous findings that IBD patients report more anxiety and depressive symptoms and poorer quality of life than the general population.811,1315

      Our first aim of the study was to examine the extent to which IBD patients with anxiety and/or depressive symptoms receive mental treatment. We found that only 18% of the IBD patients with higher levels of anxiety and/or depression as such indicative of an anxiety and/or depressive disorder, received mental help and only 21% used psychotropic medication (antidepressants and/or anxiolytics). National health surveys conducted in Australia, the UK, the USA and the Netherlands on anxiety and depression in the general population have shown that only one-third received treatment.4448 To the best of our knowledge, only one population-based study has examined the use of treatment for depression in IBD patients. The study indicated that 40% of depressed IBD patients received antidepressants. Moreover, one-third to one-half of IBD patients who suffered from depression did not consult a mental health professional, while 40% of these patients felt that mental health care was needed. A major drawback of this study is that diagnosis was based on patient self-report.11

      In our study the percentage of treated IBD patients even with anxiety and/or depression is remarkably lower. It should be noted that the prevalence of treated patients could be an underestimation because we only asked about psychological help in the preceding four weeks. Yet this finding is disconcerting since this patient group does not only have a higher risk of anxiety and depression, but is also seen regularly by a medical specialist, thus increasing the chance of detection.1719 Patients themselves have already indicated their need for psychotherapy.11,21,49,50 Clearly, the low percentage of IBD patients with high levels of anxiety and depression receiving mental help highlights the urge for screening as part of standard medical care.

      Our second aim was to assess the degree to which clinical and socio-demographic variables are associated with high levels of anxiety and/or depressive symptoms in IBD patients.

      In line with previous findings, high disease activity was significantly associated with having high levels of anxiety and/or depressive symptoms, as such indicative of an anxiety disorder and/or a depressive disorder.9,15,25,26 This relationship may be bi-directional, involving a combination of biological and psychosocial mechanisms. Furthermore, Crohn's disease was only significantly associated with having high levels of anxiety symptoms. One should expect recent diagnosis to induce anxiety and depressive symptoms in IBD.30 However, no such significant effects were found in patients who were diagnosed within the prior three years (n = 27). Consistent with data from a recent clinical study,9 none of the socio-demographic variables were associated with high levels of anxiety and/or depressive symptoms indicative of an anxiety disorder and/or a depressive disorder. Interestingly, two Canadian population-based studies found that depression was more prevalent in female than in male IBD patients.11,22 The divergent findings could be due to the different populations under study, i.e. clinical versus general population.

      Some limitations of this study merit attention. First, we deliberately chose to accrue patients who generally have a complicated and severe form of IBD and hence enrolled patients attending a top referral (academic) center for IBD patients. Our results can therefore only be generalized to similar patients and not to patients with more mild forms of IBD attending peripheral hospitals or receiving primary care. Second, a non-respondent analysis was not possible. Perhaps, patients with more severe disease or without IBD complaints were less likely to complete and return questionnaires. Fortunately, the response rate was high (79%). Third, we only measured the psychological treatment and psychotropic medication in the preceding four weeks. Therefore, we have no information about the duration of these treatments. Fourth, to assess the prevalence of anxiety and/or depressive disorders in IBD patients a structured interview might be needed, such as the Structural Clinical Interview for DSM disorders (SCID). Fortunately, the HADS gives an indication for psychopathology and it is easily administered by medical specialists. Moreover the used cut off score of the HADS ≥ 8 is a widely used validated score indicating an anxiety and/or depressive disorder.33

      Our study also has several strengths. First, instead of patients' self-report, diagnosis was ascertained by the gastroenterologist. The diagnosis was based on clinical history, physical examination, lab tests, negative stool cultures, radiological imaging and endoscopic examinations of the gastrointestinal tract. Second, the study employed a sufficiently large sample for our two main objectives. For example, our sample size of 231 patients and a total number of 10 predictors satisfies the general rule of thumb to have at least 10 cases per predictor in the regression analyses. 51 Third, all adult patients with a confirmed diagnosis of IBD attending the outpatient clinic were eligible for the study, facilitating generalization of results and comparison across studies. Fourth, many studies over the past decade have investigated quality of life, anxiety and depression in patients with IBD living in the US, Australia, UK, Sweden, Spain and Italy.9 This is the first study that examines these outcomes in “Dutch IBD patients”.

      4.1 Implications for clinical practice

      Our study underscores the urgency to screen for anxiety and depression and reduced quality of life and developmental delays in IBD patients. However, psychological screening is currently not a routine part of clinical practice. The key question is how to best integrate psychological screening and treatment into standard medical care to better address psychological complaints in IBD patients. One study recommended screening only those IBD patients with active disease for anxiety and depression.9 However, based on our results we recommend a routine screening for anxiety and depression in IBD patients with active as well as with inactive disease, since the percentage of psychological symptoms was remarkably high in patients with both active and inactive disease. When considering disease type, our results indicate that screening for depression is crucial in both CD and UC patients, while screening for anxiety is most important in patients with CD. A routine screening in IBD patients by gastroenterologists may be possible by the brief, 4-item screening scale for anxiety and depression (PHQ-4) or by more elaborate interviews, such as Luebeck Semistructured Interview for Psychosocial Screening in IBD.49,52 If required, a more elaborate screening (i.e. Structural Clinical Interview for DSM disorders) could be performed by the medical psychologist. Moreover, one study recommended that the involved physician should facilitate decision making for IBD patients by evaluating the advantages and disadvantages of both pharmacological and psychological treatments for anxiety and depression.8 Furthermore, a recent Cochrane Review on psychological treatment in IBD emphasized the importance of letting patients assess their own need for psychological intervention, rather than applying psychological interventions to IBD patients in general.53

      Screening for anxiety and depression in IBD is only useful if we have effective tools to treat them. A meta-analysis on the effects of psychological treatments of depressive symptoms in patients with various chronic illnesses report similar effects as those found in healthy patients.54 In addition, in a recent randomized control trial on collaborative care, care as usual of patients with chronic illnesses (poorly controlled diabetes and coronary heart disease or both) and co-occurring depression was compared with an intervention involving nurses. In the intervention, nurses closely collaborated with (primary) physicians and provided patient-centered guidelines for depression and chronic disease. The results indicated that the patients in the collaborative care group significantly improved control of medical disease (such as medication adherence) and depression.55

      When focussing on IBD patients, one study reported practical recommendations for gastroenterologists in managing anxiety and depression in IBD patients. These recommendations pertained to, for example, understanding and accepting the disease, managing diarrhea and pain, maintaining physical and social activities, learning problem solving skills and focusing on life goals.8 Other studies indicate positive effects of psychological treatment on reducing anxiety and depression in IBD patients, mainly by cognitive behavioral therapy (CBT). However, these studies suffer from various methodological shortcomings. 8,5660 In addition, targeted psychological interventions should be developed further to effectively treat anxiety and depression in IBD patients, to prevent chronicity of these mental health problems and to improve quality of life.8,13,53,61,62

      4.2 Future research

      Our study has generated several important questions that may be of interest for further research. Why are anxiety and depressive symptoms in IBD patients under-treated? What is the best method of screening for psychiatric disorder in IBD patients as part of standard medical care? How can collaborative care programs (combining medical and psychological care), or psychological interventions best be adapted to the specific psychiatric concerns of IBD patients?

      Acknowledgments

      The authors acknowledge the contribution of the research assistant Msc. C.C.M.Q. Hoeks for her support in the literature searches, reference preparation, data analyses and review of earlier drafts of the article. We also received research support from Dr E.M.A. Smets in reviewing earlier drafts of the article. We thank the gastroenterologists and especially Prof. J.F.W.M. Bartelsman of the outpatient clinic of the Academic Medical Center, for their collaboration and recruitment of patients for this study.

      Bennebroek Evertsz', F: Conception and design of the study, statistical analysis, data interpretation and critical revision of the manuscript.

      Thijssens, NAM: Statistical analysis, data interpretation and critical revision of the manuscript.

      Stokkers, PCF: Conception and design of the study, data collection and critical revision of the manuscript.

      Grootenhuis, MA: Statistical analysis, data interpretation and critical revision of the manuscript.

      Bockting, CLH: Data interpretation and critical revision of the manuscript.

      Nieuwkerk, PT: Statistical analysis, data interpretation and critical revision of the manuscript.

      Sprangers, MAG: Conception and design of the study, data interpretation and critical revision of the manuscript.

      References

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