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Keywords:

  • anxiety;
  • depression;
  • risk factors;
  • IBD

Abstract

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Background:

Little is known in inflammatory bowel disease (IBD) regarding risk factors for psychological distress. The aim of this work was to study the disease characteristics and socioeconomic factors associated with anxiety and depression in IBD.

Methods:

From December 2008 to June 2009, 1663 patients with IBD (1450 were members of the Association Francois Aupetit, French association of IBD patients) answered a questionnaire about psychological and socioeconomic factors and adherence to treatment. In this study we focused the analysis on the characteristics of IBD (type, location, severity, treatment) and socioeconomic factors (professional, educational, and marital status and Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES] score of socioeconomic deprivation; score established in medical centers in France; http://www.cetaf.asso.fr) associated with depression and anxiety. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale. Comparison between groups according to the existence of depression or anxiety was carried out using univariate and multivariate analysis.

Results:

In all, 181 patients (11%) were depressed; 689 patients (41%) were anxious. By multivariate analysis, factors associated with anxiety were: severe disease (P = 0.04), flares (P = 0.05), nonadherence to treatment (P = 0.03), disabled or unemployed status (P = 0.002), and socioeconomic deprivation (P < 0.0001). Factors associated with depression were: age (P = 0.004), flares (P = 0.03), disabled or unemployed status (P = 0.03), and socioeconomic deprivation (P < 0.0001).

Conclusions:

In this large cohort of IBD patients, risk factors for anxiety and depression were severe and active disease and socioeconomic deprivation. Psychological interventions would be useful when these factors are identified. (Inflamm Bowel Dis 2012;)

Crohn's disease (CD) and ulcerative colitis (UC), referred to as inflammatory bowel diseases (IBDs), are chronic inflammatory conditions of the gastrointestinal tract with a strong impact on quality of life.

As observed in many other chronic diseases, psychological distress is highly prevalent in IBD1–9: the rate of anxiety and/or depression has been estimated at 29%–35% during periods of remission and as high as 80% for anxiety and 60% for depression during relapses.1–9

However, little is known in IBD regarding risk factors for psychological distress and especially socioeconomic factors associated with psychological distress. We conducted a survey, the ISSEO (Impact de la Situation Socio Économique sur l'Observance) cohort, to assess the impact of socioeconomic and psychological status on adherence to treatment.10

The aims of this study were to analyze the disease characteristics and socioeconomic factors associated with anxiety and depression in the ISSEO cohort in order to identify patients who would benefit the most from psychological support.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Recruitment and Data Collection

The survey was performed from December 2008 to June 2009. As a first step, the questionnaire was available on the website of the AFA (Association François Aupetit, the French IBD patients' association: http://www.afa.asso.fr/). It could be completed anonymously and returned by email or mail. As a second step, the questionnaire was mailed to 4000 patients belonging to the AFA who were asked to complete and return it to the association by mail. Information about the goals of the study was available at the beginning of the questionnaire.

This standardized questionnaire was composed of four parts: the first concerning the characteristics of the disease, the second regarding the treatment, the third on the psychological aspects, and the last on socioeconomic aspects.

Demographic and Disease Characteristics

The following data were collected: age, gender, marital, education, and employment status, type of IBD, disease duration, family history of IBD, age at diagnosis, anoperineal lesions, hospitalization for flare-up, remission or symptomatic relapse, surgical resection, and medical treatments. Clinical remission was assessed by the patients themselves. CD was defined as severe when at least one of the following criteria was present: more than two steroid courses required and/or dependence on steroids; further hospitalization after diagnosis for flare-up or complication of the disease; need for immunosuppressive therapy or biotherapy; or intestinal resection or surgical operation for perianal disease.11

Treatment

Treatment during the previous 2 months was reported (5-aminosalicylate [5-ASA], corticosteroids, thiopurines, methotrexate, anti-tumor necrosis factor alpha [TNF-α]).

Assessment of Adherence to Treatment

Patients were asked to assess their adherence to treatment during the previous 8 weeks by a visual analog scale (rating from 0 to 10). Self-assessment of adherence ≥80% was considered satisfactory, as previously published.12

Assessment of Psychological Aspects

Patients were requested to grade their mood during the previous week on a visual analog scale from 0 to 10. A score <7 was taken to reflect a bad mood as it corresponded to the median in our cohort. Anxiety and depression were evaluated using the HAD (Hospital Anxiety and Depression) scale.13 This is a self-screening questionnaire for depression and anxiety. The HAD scale contains 14 items and consists of two subscales: anxiety and depression. Each item is rated on a 4-point scale, giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered “significant” cases of psychological morbidity, while scores of 8–10 represent “borderline” and 0–7 “normal” cases. (HAD).

Assessment of Deprivation

Deprivation was assessed using the “Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé” (Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES]) score computed on the basis of individual conditions of deprivation.14–17 The EPICES score was used as a quantitative or as a dichotomous variable with the EPICES median considered the cutoff value to divide the population into two subgroups: the less deprived with a score of 30.17 and the more deprived with a score of >30.17.

Statistical Analysis

Analyses were conducted with anxiety and depression as the primary dependent variable. Variables were coded both categorically and continuously. Data were expressed as mean ± standard deviation or as median and range. Comparison between anxious and depressed patients with nonanxious and nondepressed patients was made using Student's t-test and analysis of variance (ANOVA) for quantitative variables and the chi-square test or Fisher's exact test for qualitative variables. Individual odds ratio (OR) and their 95% confidence intervals (CI) were computed for each variable. A two-tailed P-value of <0.05 was considered statistically significant. If any of the variables were significantly associated with adherence to treatment they were included as a covariate in subsequent analyses. A stepwise logistic regression analysis was performed to identify factors associated with anxiety and depression. The following variables were considered for analysis: age, gender, smoking status, activity of the disease, severity of the disease, duration of the disease, past history of surgery, anti-TNF treatment, corticosteroid treatment, aminosalicylates treatment, thiopurine treatment, adherence to treatment, marital status, educational status, employment status, deprivation status, and membership of an association of patients (AFA). For each independent factor the OR and 95% CI were calculated. Statistical analysis was performed with SPSS software (v. 18.0, Chicago, IL).

RESULTS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Disease Characteristics

A total of 1663 questionnaires were analyzed. In all, 312 questionnaires were answered online via the AFA website and 1351 (33.7%) of the respondents of the 4000 to whom questionnaires were mailed completed and returned these questionnaires. The main results are presented in Table 1. There were 63.9% CD and 37.1% UC or indeterminate colitis. The majority of the patients were females (n = 1068; 64.2%) and disease duration was 13.4 ± 9.9 years. Most of the patients had severe disease (90.5%) but 80% were in clinical remission at the time of the survey. Eighteen percent of the patients had perianal disease. Thirty-nine percent of the patients had at least one surgical intervention. About half (53.8%) of them took an immunosuppressant and one-third anti-TNF-α (34.5%). More than-two thirds of them took 5-ASA and 24.2% corticosteroids. Ninety percent of the patients declared taking at least 80% of the prescribed treatment.

Table 1. Main Characteristics of the ISSEO Population
 Data AvailableTotal
N1663 
Mean age166343.6 ± 15.4
Gender (female)166364.2%
Crohn's disease166363.9%
Smoking use161914.4%
Family history of IBD166216.2%
Disease duration163513.4 ± 10
Active disease160319.7%
Severe disease165090.5%
Anoperineal location161418.4%
Past history of surgery166238.8%
Treatment with corticosteroids86824.2%
Treatment with thiopurines105953.8%
Treatment with anti-TNF93034.5%
Treatment with 5-ASA121867.7%
Education status: high school graduation or higher164269.0%
Employment status: working122359.3%
Unemployed or disabled16406.6%
Married164965.9%
Membership of the AFA162287.2%
Socioeconomic deprivation166026.0%
Good adherence to treatment166389.6%

Socioeconomic Factors

Sixty-six percent were married or in a couple, 24.8% single, 6.4% separated or divorced, and 2.9% widowed. Concerning employment status: 59.3% were employed, 4.6% unemployed, 6.6% disabled, 3.4% homemaker, 6.5% student, and 18.9% retired. Concerning education status: 69% had high school graduation level or higher. Twenty-six percent were deprived (EPICES score >30.17).

In all, 1450 patients (87.2%) were members of the AFA. Self-evaluation of mood showed a good mood (score >7) for 38.5% of patients. Eleven percent of the patients were depressive (HAD Depressive scale ≥11) and 41% were anxious (HAD Anxiety scale ≥11).

Factors Associated with Anxiety

Data are presented in Tables 2–4. The following disease characteristics were associated with anxiety by univariate analysis: female (OR 1.24; CI 1.01–1.52), smoking use (OR 1.5; CI 1.14–1.99), disease duration (OR 1.34; CI 0.05–1.7), active disease (OR 1.9; CI 1.49–2.45), and severe disease (OR 2.8; CI 1.3–6).

Table 2. Anxiety and Depression According to Disease Characteristics
 AnxiousNonanxiousORCI 95%PDepressedNondepressedORCI 95%P
  1. OR: odds ratio; CI: confidence interval. The column “total“ represents the percentage of patients who present the studied item. The columns “anxious” and “nonanxious” represent the percentage of anxiety by item.

N679984   1811482   
Mean age (yrs)42.4 ± 13.944.4 ± 16.4  0.0145.4 ± 15.143.3 ± 15.4  0.09
Gender (female)67.1%62.2%1.241.01–1.520.0464.3%63.3%0.90.7–1.30.8
Crohn's disease63.8%63.9%0.990.81–1.220.960.8%64.2%0.860.62–1.20.4
Smoking use17.5%12.3%1.51.14–1.990.00413.2%14.5%0.90.56–1.420.6
Family history of IBD15.5%16.7%0.90.7–1.20.519.9%15.7%1.30.9–1.90.15
Disease duration12.7 ± 9.113.9 ± 10.5  0.0213.1 ± 9.413.4 ± 10  0.7
Active disease25.8%15.4%1.911.49–2.45<0.000131.8%18.1%2.11.5–2.9<0.0001
Severe disease92.3%89.3%1.431.01–2.020.0496.1%89.9%2.81.3–60.007
Anoperineal location18.0%18.6%0.960.74–1.240.821.4%18.0%1.20.8–1.80.3
Table 3. Anxiety and Depression According to Treatment of the Disease
 AnxiousNonanxiousORCI 95%PDepressedNondepressedORCI 95%P
  1. OR: odds ratio; CI: confidence interval. The column “total” represents the percentage of patients who present the studied item. The columns “anxious” and “nonanxious” represent the percentage of anxiety by item.

N679984   1811482   
Past history of surgery35.3%41.3%0.770.63–0.940.0237.0%39.0%0.90.7–1.30.6
Treatment with corticosteroids28.5%20.9%1.51.1–2.060.00925.0%24.1%1.50.64–1.70.8
Treatment with thiopurines54.0%53.7%1.010.8–1.30.953.8%53.9%0.960.65–1.40.8
Treatment with anti–TNF37.7%32.1%1.280.97–1.680.0739.8%33.8%1.30.86–1.90.2
Treatment with 5–ASA64.6%69.7%0.80.62–1.010.0769.2%67.5%1.10.73–1.590.7
Table 4. Anxiety and Depression According to Psychosocial Factors
 AnxiousNonanxiousORCI 95%PDepressedNondepressedORCI 95%P
  1. OR: odds ratio; CI: confidence interval; 1 AFA (French association of IBD patients). The column “total” represents the percentage of patients who present the studied item. The columns “anxious” and “nonanxious” represent the percentage of anxiety by item.

Education status: high school graduation or higher65.8%71.2%0.780.62–0.960.0260.6%70%0.660.48–0.900.009
Employment status: working59.0%59.4%0.90.8–1.20.942.5%61.3%0.470.34–0.64<0.0001
Unemployed or disabled11.6%3.2%3.982.5–6.1<0.000118.2%5.1%4.12.6–6.4<0.0001
Married66.5%65.5%1.040.84–1.280.760.2%66.6%0.750.54–1.030.08
Membership of the AFA87.5%87.1%1.010.77–1.410.887.4%87.2%1.010.63–1.630.9
Socioeconomic deprivation37.7%17.9%2.82.2–3.4<0.000156.4%22.2%4.53.3–6.2<0.0001
Good adherence to treatment85.5%92.4%0.50.35–0.62<0.000186.7%89.9%0.730.46–1.160.2

Corticosteroids (OR 1.5; CI 1.1–2.06) were associated with anxiety while a past history of surgery was not (OR 0.77; CI 0.63–0.94). Other treatments were not significantly associated with anxiety. Disability (OR 3.98; CI 2.5–6.1) and socioeconomic deprivation (OR 2.8; CI 2.2–3.4) were associated with anxiety; while high school graduation level (OR 0.75; CI 0.62–0.92) and good adherence to treatment (OR 0.5; CI 0.35–0.62) did not. Factors associated with anxiety (Table 5) by multivariate analysis were: severe disease (OR 2.01; CI 95% 1.03–3.92; P = 0.04), flares (OR 1.51; CI 95% 0.98–2.32; P = 0.06), nonadherence to treatment (OR 1.78; CI 95% 1.05–2.94; P < < 0.0001), disabled (OR 3.32; CI 95% 1.57–7.02; P = 0.002) or unemployed status (OR 2.25; CI 95% 1.43–3.56; P < 0.0001) and socioeconomic deprivation (OR 1.99; CI 95% 1.35–2.92; P < 0.0001).

Table 5. Predictive Factors of Anxiety and Depression by Multivariate Analysis
 Anxiety  Depression 
 ORCI 95%PORCI 95%P
LowerUpperLowerUpper
  1. OR: odds ratio; CI: confidence interval.

Sex0.870.611.230.80.461.340.40.4
Age0.990.981.011.041.011.060.0040.6
Duration of disease1.010.991.030.990.961.020.50.3
Smoking use1.280.792.080.570.251.300.20.3
Active disease1.510.982.321.971.083.590.030.06
Severe disease2.011.033.923.10.8511.280.080.04
Anoperineal location1.260.792.011.30.652.530.50.3
Past history of surgery0.470.310.710.930.501.720.8<0.0001
Treatment with thiopurines1.040.721.521.090.621.920.80.8
Treatment with anti-TNF1.230.771.961.0020.511.970.90.4
Treatment with corticosteroids1.210.732.000.380.150.940.040.4
Unemployed2.251.433.562.250.793.890.2<0.0001
Disabled3.321.577.023.321.064.970.030.002
Socioeconomic deprivation1.991.352.921.992.206.45<0.0001<0.0001
Good adherence to treatment0.560.340.950.560.542.770.60.03

Factors Associated with Depression

Data are presented in Tables 2–4. The following disease characteristics were associated with anxiety by univariate analysis: active disease (OR 2.1; CI 1.5–2.9) and severe disease (OR 2.8; CI 1.3–6).

None of the treatments were associated with depression. Disabled (OR 4.1; CI 2.6–6.4) and socioeconomic deprivation (OR 4.5; CI 3.3–6.2) were associated with depression; while high school graduation level (OR 0.7; CI 0.52–0.96) and employed status (OR 0.25; CI 0.2–0.4) did not. Factors associated with depression (Table 5) were by multivariate analysis: age (OR 1.04; CI 95% 1.01–2.06; P = 0.004), flares (OR 1.97; CI 95% 1.08–3.59; P = 0.03), disabled or unemployed status (OR 1.04; CI 95% 1.01–2.06; P = 0.03) and socioeconomic deprivation (P < 0.0001).

DISCUSSION

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

In this large cohort study we identified that severe and active disease and socioeconomic deprivation were risk factors for anxiety and depression. In this population we found a high frequency of anxiety up to 40% and a low frequency of depression around 10%.

The rate of anxiety was higher than that observed in a representative national survey of the French adult population which was estimated to be 21.6%.18 This rate of depression is in line with the overall rate observed in a French general practice survey.19 Some studies have reported higher rates of psychiatric disorders in IBD compared with other chronic illnesses or healthy controls.1–3 Bernstein and his team published a population-based cohort of IBD cases with diagnoses confirmed on chart review to a matched sample of community controls from a population-based national health survey that did not have IBD. Diagnosis of lifetime and recent anxiety or depressive disorders was determined using the structured diagnostic interview used in the national study.5 There was a significantly higher lifetime prevalence of major depression for the IBD cases compared with the community cases (27% vs. 12%).

The prevalence of anxiety and depression that we observed is lower than that reported in the majority of studies, but is, however, in agreement with those observed in a German study and an Australian study.3, 8

In patients with a chronic illness, risk factors for anxiety and depression were the following: demographic characteristics, disease activity and severity, treatments, and psychosocial factors.1, 2, 9

Concerning the sex ratio, we did not observe a female predominance among anxious and depressed patients as has been reported in other studies.1, 2, 5–7 As previously reported in the literature, we observed in our survey that anxiety and depression were more frequent during flares and when patients had more severe disease.1–8 In our study a high proportion (80%) of the patients were in remission and this finding could explain the low rates of anxiety and depression in our study just as in the German study.3 Indeed, disease activity seems to be a main factor associated with anxiety and depression.

In contrast, anoperineal localization or long disease duration were not factors associated with anxiety or depression. A past history of surgery was associated with a decrease of anxiety, a result in accordance with a previous study showing that health-related quality of life is greatly improved after surgery for CD.20

Treatments for IBD include aminosalicylates, corticosteroids, immunosuppressors, and biotherapy. Anxiety and depression may be an adverse effect of the treatment itself or related to the fear of serious adverse effects, in particular risk of cancer and lymphoma and serious infection with immunosuppressors and biotherapy. Only corticosteroids may induce psychiatrics disorders such as mood disturbance.21–23 In a meta-analysis of 11 uncontrolled studies involving 935 adult patients, Lewis and Smith23 found incidences of psychiatric reactions ranging from 13%–62% with a weighted-average incidence of 27.6%.

In our survey only corticosteroids were associated with a higher prevalence of anxiety but were not associated with an excess of depression. Anxiety in IBD patients treated by corticosteroids may be related to the treatment itself and the fear of side effects induced by the drug, especially cosmetic side effects and weight gain.

Immunosuppressors and biotherapy use was not associated with a higher risk of mood disturbance. This result is in accordance with a Spanish study where remission on thiopurinic immunomodulators normalized quality of life and psychological status in CD patients.24 Finally, we found that anxious patients were less compliant with treatment.

Socioeconomic deprivation, whether it is in working conditions, housing, or income, is associated with anxiety and increased depression. In our work socioeconomic deprivation evaluated by the EPICES score (score validated in France for the measurement of the socioeconomic deprivation in health centers) was associated with IBD patient anxiety and depression, as reported in other chronic diseases.9 In the work by Hauser et al3 the social class index and family status were not risk factors for anxiety or depression.

The strengths of this work are the large number of patients and the utilization of validated questionnaires to assess anxiety and depression (HAD scale) and socioeconomic deprivation (EPICES score).13–17

The weaknesses of the study are related to the fact that this is a study in a selected population of patients since they belong in part to the French association of IBD patients. Therefore, it is difficult to make generalizations of these results to the overall population of IBD patients in France. However, patients belonging to the AFA (French association of IBD patients) were neither more anxious nor more depressed than those who did not belong to the association.

In conclusion, in this large cohort of IBD patients disease activity and severity as well as socioeconomic deprivation are risk factors for anxiety and depression. Psychological support could be proposed to IBD patients when these factors are identified.

Acknowledgements

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES

Author contributions: Stéphane Nahon: conception, design, collection and interpretation of data, and article preparation; Pierre Lahmek: statistical analysis and interpretation of data; Christelle Durance: data collection; Alain Olympie: conception and design; Bruno Lesgourgues: interpretation of data; Jean-Frédéric Colombel: article preparation; Jean-Pierre Gendre: conception, design, article preparation. All authors reviewed and approved the final draft submitted.

REFERENCES

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. REFERENCES