- Anxiety and depression have been extensively studied in patients with inflammatory bowel disease (IBD), but research has rarely investigated the pre-diagnostic period.
- In a Swedish cohort study, the relative rate of any psychiatric disorder started to increase 2-3 years before IBD diagnosis, peaked soon after diagnosis, and rapidly decreased post diagnosis, but remained elevated at 10 years.
- This increased risk was mainly driven by major depressive disorders, anxiety disorders, and substance misuse.
Patients with inflammatory bowel disease (IBD) were at increased risk for several psychiatric disorders both before and after diagnosis, according to results from a Swedish cohort study.
The relative rate of any psychiatric disorder started to increase 2-3 years before IBD diagnosis (HR 1.15, 95% CI 1.09-1.21, at -2 years), and peaked immediately after IBD diagnosis (HR 1.50, 95% CI 1.41-1.59, at 0.5 year), reported Jiangwei Sun, PhD, of the Karolinska Institutet in Stockholm, and colleagues.
That risk rapidly decreased in the years after IBD diagnosis, but remained elevated even at 10 years (HR 1.19, 95% CI 1.13-1.24), they wrote in Clinical Gastroenterology and Hepatology.
The increased risk was mainly driven by major depressive disorders, anxiety disorders, and substance misuse, while no increase was observed for psychotic disorders, personality disorders, and attention deficit-hyperactivity disorder. IBD patients were more likely to have autism spectrum disorders shortly after diagnosis, and eating disorders 5 or more years onwards.
“The clearly elevated risks observed in the pre-diagnostic period may reflect the impact of subclinical inflammation, gastrointestinal symptoms, and psychological stress experienced years before IBD diagnosis and during diagnostic workup,” Sun and colleagues noted.
“Since depressive symptoms and anxiety could complicate IBD management, predict adverse clinical outcomes (e.g., flare, escalation of therapy, hospitalization, surgery), and cause lower quality of life and death, organizing care to enable interaction between gastroenterologists and mental health professionals is essential for early identification of high-risk populations for adverse outcomes,” they wrote. “Our findings, particularly the long-term risk elevation following IBD diagnosis, highlight the importance of integrating psychological care into IBD routine practice and including mental illness assessment and management in IBD guidelines.”
While anxiety and depression — the most prevalent psychiatric comorbidities in IBD patients — have been extensively studied, research has mainly focused on the post-diagnostic period and has rarely investigated the pre-diagnostic period, the authors pointed out.
“Therefore, it remains uncertain whether psychiatric morbidity precedes IBD onset or arises consequently to IBD diagnosis,” they wrote.
Sun and colleagues included 48,230 patients with IBD and 210,582 matched reference individuals in their pre-diagnostic analysis. During a median follow-up of 5 years, 8.6% of IBD patients were diagnosed with any psychiatric disorder before IBD diagnosis compared with 6.8% of reference individuals.
After excluding those with any psychiatric disorder before the index date, the post-diagnostic analysis included 43,862 IBD patients and 178,821 matched reference individuals. Mean age at IBD diagnosis was 41.6 years, 47.3% were female, and 11.3% had childhood-onset IBD.
IBD patients tended to have more healthcare visits and more often a record of parental psychiatric history versus their matched counterparts (4.4% vs 3.1%).
During a median follow-up of 7.4 years, 16.5% of IBD patients were diagnosed with any psychiatric disorder after IBD diagnosis versus 12.8% of reference individuals. Major depressive disorders (4.6% vs 3.2%), anxiety disorders (7.3% vs 5.3%), and substance misuse (3.3% vs 2.7%) were most common.
The cumulative incidence of any psychiatric disorder was consistently higher in IBD patients, irrespective of IBD subtypes, with 10-year cumulative incidence differences of 3.21% in IBD, 4.23% in Crohn’s disease, 2.43% in ulcerative colitis, and 4.69% in patients with IBD-unclassified. This corresponded to one extra psychiatric disorder per 31 IBD patients, 24 Crohn’s patients, 41 ulcerative colitis patients, and 21 IBD-unclassified patients during a 10-year period.
Sun and colleagues also conducted a sibling comparison analysis that suggested that shared familial factors do not fully explain the associations between IBD and psychiatric disorders.
In the sibling-controlled cohort, 26,807 IBD patients with at least one IBD-free full sibling were identified. Although IBD patients were younger than their matched siblings, more of them developed a psychiatric disorder after IBD diagnosis (15.6% vs 12.6%). Significant pre- and post-diagnostic associations between IBD and any psychiatric disorder were observed, although hazard ratios were somewhat lower than those from the population-based comparison analysis (HR 1.27, 95% CI 1.15-1.41, at -0.5 year; HR 1.47, 95% CI 1.35-1.61, at 0.5 year; and HR 1.10, 95% CI 1.03-1.18, at 10 years). The cumulative incidence of any psychiatric disorder was also consistently higher in IBD patients versus their siblings, irrespective of IBD subtypes.
Sun and team pointed out that due to a lack of primary care data, their analyses may have missed some individuals with mild psychiatric symptoms or those not seeking healthcare, “which would underestimate the true absolute risk of psychiatric disorders in patients with IBD.”
“As a result, our findings should only be interpreted in context of cases that require specialist care,” they wrote.
