Lauren George, MD, on Psychosocial Aspects of IBD

Dr George talks about the prevalence of psychosocial complications in patients with inflammatory bowel disease (IBD) and how gastroenterologists can use available tools and techniques to assess patients for anxiety, depression, and other mental health issues, and help them find effective therapy.

Lauren George, MD, is an assistant professor and a gastroenterologist at the IBD Center at the University of Maryland School of Medicine in Baltimore, Maryland.

TRANSCRIPT

Hi, my name is Lauren George. I'm an Assistant Professor of Medicine at the University of Maryland School of Medicine in Baltimore. I'm here today to discuss a very important topic on the care of our patients. That's managing psychosocial health in inflammatory bowel disease patients.

This topic is relatively new in the world of GI, but equally recognized as important as our patients experience their inflammatory bowel disease and their GI symptoms throughout their daily lives.

I just want to give some tips, and some recommendations for how to address this with patients, what options are out there for therapies, and how to recognize when psychosocial health is playing a large role in your patient's symptoms.

As we know, from treating many types of patients, that functional GI disorders are very prevalent in America. We often think of patients with functional GI disorders as having a large psychologic component to their symptoms.

We're also learning that even patients with so-called organic disorders or inflammatory disorders such as inflammatory bowel disease, also have a large role of psychologic health on their symptoms and their disease.

We need to pay attention to all of our patients and their mental health. Studies have shown that IBD patients do have increased rates of mental health conditions and symptoms, such as depression and anxiety, compared to the general population.

This is even more prevalent in Crohn's disease than ulcerative colitis, but affects both types of IBD patients. We know that our patients have some risk factors for developing depression or anxiety, and that includes being a female, or having prior surgeries, or at the time of diagnosis, which is a very stressful time for patients.

Patients also undergoing surgeries or hospitalized are at increased risk of having feelings of helplessness, depression, and anxiety related to their GI health. Additionally, our patients experience many other psychologic concerns during the course of their disease.

IBD patients have increased rates of sexual dysfunction, and decreased rates of sexual satisfaction, which they may be uncomfortable bringing up. However, it's important to consider the role that various conditions that come along with inflammatory bowel disease such as perianal disease,or having a stoma will affect our patients.

Similarly to this, our patients experience significant body image disturbances. Up to two-thirds of inflammatory bowel disease patients will report dissatisfaction with their overall body image. This can lead again to feelings of depression, and hopelessness, and social isolation.

Additionally, in survey studies, our patients have many concerns on their mind, including how their symptoms prevent them from going out into public, or how their symptoms will affect their daily life and prohibit them from doing the activities that they once found joyful.

It's very important that we recognize that all of these aspects are playing in our patient's head in addition to their medical therapy and their inflammatory burden. Therefore, it's very important for the gastroenterologist to have a strategy on how to approach these topics, and how to appropriately manage and refer patients.

When a patient comes to clinic, the first step is we have to screen them for underlying psychosocial factors that are concerning them. In our clinic at the University of Maryland IBD program, we use a very simple questionnaire called the PHQ-9, which is a depression screening tool that has been validated for use.

This is a 9-question questionnaire that we give to the patient in the waiting room, and they fill it out while waiting to be roomed for their appointment. We then quickly review it at the time of their appointment and if their score is moderately elevated, which would be greater than 10, or if they have any evidence of suicidal behavior, we're able to address it right at that time.

Another questionnaire we give to our patients in the waiting room is the SIBDQ or The Short Inflammatory Bowel Disease Questionnaire. This is another validated questionnaire that assesses health-related quality of life in our patients.

This is especially important, as many health psychologists will recommend that we should always screen for symptom-based anxiety as well as the effect of symptoms on activities of daily life.

This simple 10-question item asks patients about their symptoms, including fatigue and bowel habit disturbances, as well as abdominal pain, and how these limit their ability to do activities they like or cancel social engagements.

This is, again, another quick, easy to review stepping tool for starting the conversation. Other questionnaires that may be used are The Generalized Anxiety Disorder Scale, or the GADS questionnaire for anxiety. Once you have these questionnaires, it's easier to open the conversation with the patient in the room.

A simple way to start this is to use 1 or 2 open ended questions. Sometimes I like to ask the patient just, "How are things going?" and see if they bring up a concern. If this does not raise a concern from the patient, you can ask something like, "How are your symptoms affecting your ability to do the things you like to do?"

You can also ask them, "What are your concerns about your symptoms in relation to your life?" These types of open-ended yet simple questions will often get many patients revealing information you won't get on a standard medical interview.

Once the patient has divulged that information, it's important to take a few other steps. One is every patient, especially if they're experiencing active mental health symptoms, should be screened for a history of abuse or trauma.

We know that many patients in GI and outside of GI, who have a history of psychological or emotional or physical trauma as a child or young adult, will manifest their trauma as physical symptoms, which many times can involve abdominal pain and diarrhea.

If we identify trauma, this patient should certainly be referred to a mental health professional. Once you've identified a mental health concern, certainly as gastroenterologists, we are not fully trained to manage mental health disturbances.

However, there are a few take-home points and strategies we can have to send our patients to the appropriate referral. The first step is we should always understand what our referral base is in the community.

This includes familiarizing yourself and introducing yourself to one or two mental health professionals that you can get to know and trust. Obviously, it would be ideal if these were GI psychologists who have specific medical-based training in managing patients with chronic illnesses and health conditions and their psychosocial care.

However, this is obviously not always feasible, as these mental health professionals can be very geographically limited. Therefore, even finding a provider who specializes or is aware of chronic illnesses, and how health can affect mental health, will be important.

Once you identify these providers, reaching out and introducing yourself, and having them available, is important. The providers you refer to should have your contact information. They should feel comfortable contacting your office to ask questions about the patient, and also to provide feedback after they have assessed the patient.

This will be very important in establishing a relationship and will also make your patients feel more comfortable, if you're able to say to them that this is a provider you work with all the time. It probably is not as effective to just simply refer a patient to, "Find a therapist." Many patients will not take the initiative on their own to do this, and may get lost in the vast amount of options and resources and put this lower on the priority list. Other than establishing a connection with a mental health provider, sometimes in GI we need to be familiar with the use of pharmacologic agents to assist with the GI symptoms that come along with psychosocial disturbance.

All of this is related to the mind-gut interaction, or the brain-gut access, as some call it. As we know, and what I tell patients, is there is an extensive network of nerves that connect our GI system to our brain. Signals are constantly going back and forth between the nerves from the brain and the gut and vice versa. Our gut is constantly providing feedback to our brain, letting our brain know that we've eaten, that we're getting full, that particles, bacterias and food is moving through our digestive tract.

Our brain is then choosing to ignore or desensitize to these signals, so that we don't feel discomfort or pain. Separate from this, our brain is constantly monitoring what we do in our external world. Our brain tells our gut we're about to eat, and we should secrete some stomach acid, or other such signals.

A lot of times, external factors can play a large role in altering this connection. There's a impact of stress in our lives, as well as sleep disturbances, maladaptive eating patterns, lack of physical activity can all adjust how our brain and our gut communicate.

Any disturbance in this cycle may lead to increased pain sensation, decreased desensitization, and overall an increased awareness of how our GI tract is functioning, which can lead to symptoms. Many of our patients have bloating, or diarrhea, or postprandial abdominal pain, which can be simply an alteration in the normal signal that is sent from our gut to our brain.

Therefore, I always explain to patients that seeing a mental health provider for your GI symptoms does not mean that it's, "All in your head." It means that we know that there is a significant neurologic and hormonal component between the brain and the gut.

When this is altered, we must reset ourselves. The best way to do this is by resetting either the brain or the nerves that cross between. This can be done with neuromodulators, such as SSRIs, or SNRIs, or TCAs. We should be comfortable with prescribing these for other conditions such as irritable bowel syndrome or functional dyspepsia.

In addition, this is how the use of gut-directed therapies and the use of a health psychologist helps these symptoms. Health psychologists have special training in using cognitive behavioral therapy, as well as gut-directed hypnotherapy. Cognitive behavioral therapy is assisting the patient in resetting their coping. They're adapting to the signals that their gut is telling their brain, as well as allowing them to increase their resiliency.

Separately, mind-directed hypnotherapy or gut-directed hypnotherapy is useful in helping us turn off that signal again, helping us learn to ignore those sensations coming from our gut and provide our focus to other aspects of our life that are more rewarding.

This is how I sell these strategies to patients. It's very important that the patient feels from the beginning that this is not you giving up on them, and this is not the gastroenterologist telling them that it's not a significant condition that impacts their life.

They need to feel that the gastroenterologist believes very strongly in the mind-gut connection, and that these are true validated researched therapies.

There are multiple clinical trials that are randomized that have shown benefit for both cognitive behavioral therapy and gut-directed hypnotherapy for the use in inflammatory bowel disease.

It's very important that we stress this to our patients, that just like surgery, just like biologics, and anti-inflammatories, this is an additional aspect of our arsenal to treat inflammatory bowel disease. That really goes to treating the whole patient and I think that is where the future of gastroenterology and inflammatory bowel disease care needs to go.

It's not just about treating inflammation, which obviously is our main goal and of upmost importance, but it's also about recognizing the many concerns that our patients have, and the way that stress, and sleep, and the external world will implicate themselves in both patient's symptoms, and potentially their inflammatory burden and their disease.

Therefore, it's really about treating overall well-being. I hope that some of these strategies will be helpful to you.

I would encourage everyone to at least develop, number one, a tool to screen patients and learn how to ask the simple question of how are you doing and how is this impacting your life, and then to find one or two professionals that you can collaborate with to treat these patients. Thank you.