In the JournalsPerspective

Undiagnosed anxiety, depression common in IBD

Anxiety and depression remain undiagnosed in large portions of patients with inflammatory bowel disease, according to recent data.

Charles N. Bernstein, MD, of the University of Manitoba in Canada, and colleagues wrote that IBD can compound the effects of mental disorders, reducing quality of life and worsening the disease course of IBD.

“Despite the important implications of untreated mental illness, prior studies suggest that depression and anxiety disorders remain underdiagnosed in the IBD population,” they wrote. “Risk factors that contribute to missed diagnoses of mental illness are poorly understood.”

Researchers evaluated the prevalence of undiagnosed depression and anxiety by analyzing data from a cohort study of psychiatric comorbidity in immune-mediated disorders, including IBD.

Patients (n = 242) underwent a Structure Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) to identify which patients met lifetime criteria for a diagnosis of depression or anxiety. Researchers classified patients as diagnosed or undiagnosed based on a participant report of a physician diagnosis. They also evaluated demographic and clinical factors for links to undiagnosed mental disorders.

Ninety-seven patients (40.1%) met the criteria for depression and 74 (30.6%) met the criteria for anxiety. Among those patients, approximately one-third of those with depression and about two-thirds of those with anxiety were undiagnosed.

Bernstein and colleagues found that men were more likely to have undiagnosed depressive disorder (OR = 3.36; 95% CI, 1.28–8.85), while non-white patients were less likely to have an undiagnosed anxiety disorder (OR = 0.17; 95% CI, 0.042–0.72).

“The personal impacts of an undiagnosed mental illness can be devastating, frustrating, and confusing for the affected person,” they wrote. “This study highlights the importance of screening for mental illness in the IBD population, using any of several validated instruments, 22 particularly in males and whites.” – by Alex Young

Disclosures: Bernstein reports being on advisory boards for AbbVie Canada, Ferring Canada, Janssen Canada, Napo Pharmaceuticals, Pfizer Canada, Shire Canada and Takeda Canada. He also reports receiving educational grants from AbbVie Canada, Janssen Canada, Pfizer Canada, Shire Canada and Takeda Canada. Additionally, he reports being on speakers’ panels for Ferring Canada, Medtronic Canada, Shire Canada and Takeda Canada. Please see the full study for all other authors’ relevant financial disclosures.

Anxiety and depression remain undiagnosed in large portions of patients with inflammatory bowel disease, according to recent data.

Charles N. Bernstein, MD, of the University of Manitoba in Canada, and colleagues wrote that IBD can compound the effects of mental disorders, reducing quality of life and worsening the disease course of IBD.

“Despite the important implications of untreated mental illness, prior studies suggest that depression and anxiety disorders remain underdiagnosed in the IBD population,” they wrote. “Risk factors that contribute to missed diagnoses of mental illness are poorly understood.”

Researchers evaluated the prevalence of undiagnosed depression and anxiety by analyzing data from a cohort study of psychiatric comorbidity in immune-mediated disorders, including IBD.

Patients (n = 242) underwent a Structure Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) to identify which patients met lifetime criteria for a diagnosis of depression or anxiety. Researchers classified patients as diagnosed or undiagnosed based on a participant report of a physician diagnosis. They also evaluated demographic and clinical factors for links to undiagnosed mental disorders.

Ninety-seven patients (40.1%) met the criteria for depression and 74 (30.6%) met the criteria for anxiety. Among those patients, approximately one-third of those with depression and about two-thirds of those with anxiety were undiagnosed.

Bernstein and colleagues found that men were more likely to have undiagnosed depressive disorder (OR = 3.36; 95% CI, 1.28–8.85), while non-white patients were less likely to have an undiagnosed anxiety disorder (OR = 0.17; 95% CI, 0.042–0.72).

“The personal impacts of an undiagnosed mental illness can be devastating, frustrating, and confusing for the affected person,” they wrote. “This study highlights the importance of screening for mental illness in the IBD population, using any of several validated instruments, 22 particularly in males and whites.” – by Alex Young

Disclosures: Bernstein reports being on advisory boards for AbbVie Canada, Ferring Canada, Janssen Canada, Napo Pharmaceuticals, Pfizer Canada, Shire Canada and Takeda Canada. He also reports receiving educational grants from AbbVie Canada, Janssen Canada, Pfizer Canada, Shire Canada and Takeda Canada. Additionally, he reports being on speakers’ panels for Ferring Canada, Medtronic Canada, Shire Canada and Takeda Canada. Please see the full study for all other authors’ relevant financial disclosures.

    Perspective
    Sarah Kinsinger

    Sarah Kinsinger

    It has been well-established that having a chronic illness such as inflammatory bowel disease is a risk factor for psychological distress. Several studies have demonstrated higher rates of anxiety and depression in patients with IBD compared with healthy individuals. The current study by Lewis and colleagues is important because it highlights the prevalence of undiagnosed depression and anxiety in this patient population. Their results replicate findings from prior studies identifying high rates of comorbid depression and anxiety in patients with IBD (50% of patients in this study had a lifetime diagnosis of either anxiety or depression). 

    Further, these psychological disorders were undiagnosed in one-third of patients with depression and two-thirds with anxiety. These numbers are alarming given the potential negative impact that psychological factors can have on the disease course as well as on patients' quality of life. Psychological factors such as depression have been shown in prior studies to influence disease outcomes, including rates of recurrence, escalation of therapy, hospitalization and surgery. 

    Unfortunately, the findings of undiagnosed psychological disorders are not surprising. Although there is greater awareness of the prevalence and role of psychological factors in IBD, the integration of mental health resources into clinical practice has been lacking. Only a limited number of gastroenterology practices have a dedicated psychologist on staff and patients often do not feel comfortable bringing up mental health concerns in a physician office visit. My hope is that these findings will encourage gastroenterology practices to routinely assess quality of life and psychological distress in patients with an IBD diagnosis and to have a clear referral pathway established with a mental health provider.

    Ideally, the mental health provider would be co-located as a member of the gastroenterology team, which greatly de-stigmatizes mental health treatment and increase the likelihood that patients will use the services. Although there is cost associated with providing this type of integrated GI psychology care, we need to be thinking about the many advantages it can offer, including improved quality of life, less health care utilization, and better disease management for our patients. 

    References:

    • Gaines LS, et al. Am J Gastroenterol. 2016;doi:10.1038/ajg.2016.98.
    • Gracie DJ, et al. Gastro. 2019;doi:10.1053/j.gastro.2018.01.027.
    • Kessler R. J Am Board Fam Med. 2012;doi:10.3122/jabfm.2012.02.100125.
    • Micocka-Walus A, et al. Clin Gastroenterol Hepatol. 2016;doi:10.1016/j.cgh.2015.12.045.
    • Sarah Kinsinger, PhD
    • Director, Behavioral Medicine for Digestive Health
      Loyola University Medical Center

    Disclosures: Kinsinger reports no relevant financial disclosures.