LAS VEGAS — While depression and anxiety are common in veterans with inflammatory bowel disease, data from a longitudinal study presented at Crohn’s & Colitis Congress 2019 demonstrated that symptoms significantly varied by gender, dietary modifications and work status.
“IBD impacts physical, psychological, and social wellbeing and the reverse is true as well –psychological health affects IBD,” Niharika (Rika) Mallepally, MD, an internal medicine resident at Baylor College of Medicine, said during her presentation. “Clinically, this is evident. Both conditions are chronic with medication regimens and symptomatic control that vary over time, requiring changes in management and constant adjustment for patient and provider.”
Mallepally noted, however, that current literature lacks a uniform explanation of the relationship between IBD and psychological health.
“Most studies explore IBD and psychological health with one measure or one point in time,” she said. “But depression and anxiety symptoms are dynamic, and we believe that changes are best captured in a longitudinal study with a multifactorial lens.”
Mallepally and colleagues conducted a prospective, longitudinal study from August 2014 to June 2018 on patients who presented to the IBD clinic at the Michael E. DeBakey VA Medical Center.
The goal was to assess the dynamic nature of psychological health in a veteran patient population with IBD over time.
Patients were included in the study if they had a diagnosis of Crohn’s disease or ulcerative colitis, were aged at least 18 years and had at least one clinic visit during the study period where a psychological health evaluation was completed.
Patients were excluded if they had an undetermined IBD diagnosis.
Depression symptoms were assessed using the Patient Health Questionnaire 8 (PHQ-8) and anxiety symptoms were assessed using the Generalized Anxiety Disorder 7 (GAD-7).
Less than 200 patients (n = 187) enrolled in the study, and 159 were included as the other patients did not have a completed set of psychological health data. The researchers included a subset of patients (n = 80) who had at least three completed visits where psychological health data was available.
Change in depression and anxiety symptoms over time served as the study’s primary endpoint.
Additional secondary endpoints included the association of depression and anxiety symptoms over time with clinical characteristics in patients with at least three visits.
Less than a quarter of patients had a diagnosis of anxiety (16.8%) or depression (23.7%) at baseline. An even smaller percentage (8.9%) had an existing diagnosis of both anxiety and depression at baseline.
More than half (55%) of patients who had at least three visits where psychological health data was available had a PHQ-8 score of less than 9, which was considered as having no depressive symptoms. Fifteen percent of those with at least three visits were considered to have moderate to severe persistent depressive symptoms.
“What we found most interesting was this 30% of patients that remained whose depressive symptoms when viewed longitudinally changed between different categories of severity,” she said. “In this subset, there’s still not perfect uniformity, but there’s a clear picture of what might be happening at the patient level. At a glance, of the patients whose symptoms changed between mild, moderate and severe, most of the transition happens between mild and moderate and most movement is not unidirectional. Patients move back and forth between different buckets of severity. Though some patients do seem to be getting worse, some do seem to be getting better over time and it’s not in a uniform direction. Understanding as much ... can significantly alter a patient’s symptom and disease management.”
Female gender was associated with a higher maximum anxiety score (12.8; n = 22, P = .04) and a higher proportion of visits with moderate or severe anxiety symptoms (0.43; P = .01). Patient-reported dietary restrictions and disability work status were associated with higher maximum depression and anxiety symptom scores, as well.
Mallepally acknowledged there were some limitations with the study.
“As this was an observational study, we could not prove causation,” she said. “For example, considering how dietary modifications were correlated with severe anxiety scores. It's hard to know which came first, did the anxious patient change diet in an attempt to change their IBD symptoms or did the IBD symptoms cause a certain level of distress that promoted anxiety symptoms. Also, our veteran population is predominantly male and psychological health burden of that is very different than from the general population. So further studies are certainly required to externally validate [these results].” – by Ryan McDonald
Mallepally N, et al. Abstract 15. Presented at: Crohn’s & Colitis Congress; Feb. 7-9, 2019; Las Vegas.
Disclosure: Mallepally reports no relevant financial disclosures.