Charles Bernstein, MD, on Mental Health in IBD Treatment

When collaborating with patients with inflammatory bowel disease (IBD), it is of equal importance to go beyond the physical symptoms and screen the patients for depression and anxiety, Charles Bernstein, MD, stressed in his presentation at the Advances in Inflammatory Bowel Disease annual meeting in Orlando, Florida, on December 6.

Dr Bernstein is a professor of medicine, holds the Bingham chair in gastroenterology research, and serves as the director of the IBD clinical and research center at the University of Manitoba in Winnipeg, Canada.

“It's more important to know what sort of person has a disease than to know what sort of disease a person has,” said Dr Bernstein, whose extensive research related to IBD includes optimizing management approaches, exploring predictors of clinical outcomes, and disease etiology related to the gut microbiome. “To do so effectively, it is imperative to acknowledge mental health issues, inquire about new stressors, and develop referral sources for the patients”, he explained.

Citing results from research that he conducted with colleagues about the prevalence and risk factors of undiagnosed depression and anxiety disorders among patients with IBD, Dr Bernstein said that out of 242 participants who underwent a structured clinical interview for disorders (SCID), 40.1% met the criteria for depression and 30.6% met the criteria for anxiety.

However, more striking was the fact that one-third of participants with depression and two-thirds with anxiety were undiagnosed, accounting for 38.0% of the total study group. The study also highlighted that men were more likely to have undiagnosed depressive disorder, as well as patients with a lower education level.

A 2018 research study by Bernstein et al to evaluate the validity and reliability of screening measures for depression and anxiety disorders in IBD revealed that the anxiety scales did not perform as well as the depression scales. Having said that, “SCID was the gold standard,” Dr Bernstein said. “Of the depression scales, the PHQ-9 had the highest sensitivity (95.0%); and of the anxiety scales, PROMIS Anxiety had the highest sensitivity” at 79.0% he stated.

So to assess if patients have mental health issues? A prospective population-based study of triggers of IBD flares found through longitudinal assessment and surveys that personal characteristics such as disease activity, use of NSAIDs and antibiotics, recurrence of infections, and stressful life events contributed significantly to mental health issues. The top potential psychological triggers that contributed to IBD symptom flares included perceived stress (2.63), major life events (1.69), use of antibiotics (1.21), use of NSAIDs (1.07), and occurrence of infections (1.00).

Dr Bernstein shed light on the Manitoba Living with IBD study to evaluate the validity of a 7-point flare indicator relative to other measures of disease flare.

“Flare is a poorly defined term used by patients and clinicians to indicate IBD status,” Dr Bernstein said. “The 7-point flare indicator robustly identified symptomatic flares. This patient self-report indicator reflected meaningful changes in more complex clinical indices and had only weak concordance with the presence of inflammation.”

The survey allowed for 7 possible responses evaluated against 5 measures of disease activity: fecal calprotectin score (FCAL); a 2-point disease status indicator; a 4-point flare certainty indicator; the IBD Symptom Index short form (SIBDSI); and the short form IBD Questionnaire (SIBDQ). Results revealed that 50.0% of the 155 total participants experienced a flare. “Of those who flared, 97.0% endorsed active IBD on the 2-point indicator; 91.9% endorsed active IBD on the 4-point certainty indicator; 90.5% endorsed active disease on the SIBDSI; and 48.5% had an elevated FCAL,” Dr Bernstein stated. “The mean SIBDQ was lower for the flare group compared with controls (43.9 vs 58.3), indicating worse disease.”

Citing various studies, Dr Bernstein repeatedly stressed the important implications of untreated mental illness. Risk factors that contribute to missed diagnoses of mental illness are poorly understood, he said. In the treatment of mental health in IBD, it is imperative to acknowledge mental health issues, he stated, which requires the caregiver to inquire about new stressors and develop referral sources. Additionally, “social determinants of health may be as strong predictors of outcomes in IBD as any other reported to date,” Dr Bernstein said.

—Priyam Vora

Reference:
Bernstein C. Addressing mental health and psychiatric comorbidities in IBD. Presented at: Advances in Inflammatory Bowel Disease Annual Meeting; December 5, 2022. Orlando, Florida.