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.
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- PATIENTS AND METHODS
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.