Journal Article Annotations
2021, 2nd Quarter

GI Psychiatry

Annotations by Ashwini Nadkarni, MD
April, 2021

Developing an Online Program for Self-Management of Fatigue, Pain, and Urgency in Inflammatory Bowel Disease: Patients' Needs and Wants.
Depressive Symptoms Predict Clinical Recurrence of Inflammatory Bowel Disease.
Eating Disorders: Diagnosis and Management Considerations for the IBD Practice.
Distinct basal brain functional activity and connectivity in the emotional-arousal network and thalamus in patients with functional constipation associated with anxiety and/or depressive disorders.

PUBLICATION #1 — GI Psychiatry

Developing an Online Program for Self-Management of Fatigue, Pain, and Urgency in Inflammatory Bowel Disease: Patients' Needs and Wants.

Sophie Fawson, Lesley Dibley, Kaylee Smith, Joanna Batista, Micol Artom, Sula Windgassen, Jonathan Syred, Rona Moss-Morris, Christine Norton

Abstract: Dig Dis Sci. 2021 Jun 19;1-14. doi: 10.1007/s10620-021-07109-9. Online ahead of print.

Background:
Inflammatory bowel disease (IBD) is a lifelong relapsing–remitting condition, characterized by troublesome symptoms including fatigue, pain, and bowel urgency. These symptoms can persist even in clinical remission and have a debilitating impact on social, work-related and intimate domains of life. Symptom self-management can be challenging for some patients, who could potentially benefit from an online self-management tool.

Aims:
We aimed to understand patients’ symptom self-management strategies and preferred design for a future online symptom self-management intervention. Methods Using exploratory qualitative methods, we conducted focus group and individual interviews with 40 people with IBD recruited from UK clinics and from community-dwelling members of the Crohn’s and Colitis UK charity; data were collected using a digital audio recorder, and transcribed and anonymized by a third party (professional) transcriber. We used framework analysis for focus group data and thematic analysis for interview data.

Results:
The data provided three core themes: ways of coping; intervention functionality; and intervention content. Participants attempt to manage all three symptoms simultaneously, recognizing the combined influence of factors such as food, drink, stress, and exercise on all symptoms. They wanted an accessible online intervention functioning across several platforms, with symptom and medication management, and activity-tracking features.

Conclusions:
Patients reported numerous ways of self-managing symptoms of fatigue, pain, and urgency/incontinence related to IBD and expressed their needs for content, design, and functionality of the proposed intervention. Based on this and existing intervention development literature, the IBD-BOOST online self-management intervention has now been developed and is undergoing testing.

Annotation

The finding:
In this qualitative study, the investigators sought to identify ways to help patients cope with fatigue and pain, common problems in patients with IBD which often occur in the absence of objective laboratory or colonoscopy results. The investigators conducted focus groups exploring how patients achieve greater self-efficacy and symptom self-management. Tracking the impact of food, drink, stress and exercise on symptoms such as fatigue and pain through an online management portal was identified as one opportunity to aid patients in self-management.

Strength and weaknesses:
Online tools may serve a function for self-empowerment for patients with intractable pain and fatigue, common challenges for patients with IBD. This initial, proof-of-concept study included feedback from 40 patients. Further development and study of an online tool, through a randomized controlled trial, could offer additional evidence to support recommending such a tool to patients.

Relevance:
This qualitative study sought to identify symptom self-management strategies to help patients cope with fatigue and pain, common findings in IBD.

Type of study (EBM guide):
Other - cross-sectional qualitative study

PUBLICATION #2 — GI Psychiatry

Depressive Symptoms Predict Clinical Recurrence of Inflammatory Bowel Disease.

Sebastian Bruno Ulrich Jordi, Brian Matthew Lang, Bianca Auschra, Roland von Känel, Luc Biedermann, Thomas Greuter, Philipp Schreiner, Gerhard Rogler, Niklas Krupka, Michael Christian Sulz, Benjamin Misselwitz, Stefan Begré, Swiss IBD Cohort Study Group

Abstract: Inflamm Bowel Dis. 2021 Jun 7;izab136. doi: 10.1093/ibd/izab136. Online ahead of print.

Background:
Inflammatory bowel disease (IBD) patients are at high risk for depression, and depression has been shown to affect disease course. We examined interrelations between depression, genetic risk factors for depression, and IBD flares.

Method:
In 1973 patients (1137 Crohn's disease, 836 ulcerative colitis) of the Swiss IBD Cohort Study (SIBDCS), depressive status (hospital anxiety and depression subscale for depression, HADS-D ≥11) was assessed on a yearly basis. We investigated the impact of depression on IBD-relevant clinical outcomes in Cox proportional hazards models. We used active disease (CDAI ≥150 or MTWAI ≥10) and 2 published composite flare definitions - FNCE (physician-reported flare, nonresponse to therapy, new complication, or extraintestinal manifestation) and AFFSST (active disease, physician-reported flare, fistula, stenosis, and new systemic therapy) - as clinical end points. Additionally, 62 preselected single nucleotide polymorphisms (SNPs) were screened for cross-sectional associations with depression, and if present, their predictive value for future depression and clinical deterioration was assessed.

Results:
Depression was a strong risk factor for disease-related end points, including active disease (adjusted hazard ratio [aHR], 3.55; P < 0.001), AFFSST (aHR, 1.62; P < 0.001), and FNCE (aHR, 1.35; P = 0.019). The SNP rs2522833 was significantly associated with depression at enrollment (q = 0.059). The TC allele of rs588765 was negatively associated with the presence of depression at enrollment (q = 0.050) and after enrollment (aHR, 0.67; P = 0.035) and with fewer active disease states (aHR, 0.72; P = 0.045) during follow-up.

Conclusion:
In IBD, depressive symptoms and inflammatory activity are intimately related. Depressive symptoms were a strong predictor of clinical deterioration, and genetic markers may play a role in this relationship.

Annotation

The finding:
Depression increases the risk for IBD flares with an adjusted hazard ratio of 3.55.

Strength and weaknesses:
Strengths include the longitudinal measurement of depressive symptoms and IBD-related outcomes, the excellent clinical characterization of IBD-related outcomes, and the long follow-up period. Limitations include (1) the relatively small sample size for genetic analyses, yielding lower statistical power for some analyses; (2) the yearly measurement of recent depressive symptoms does not consider chronicity of potential depression; and (3) the measure of depressive symptoms (the Hospital Anxiety and Depression Scale depression subscale) - though dichotomized at a “severe” level, the HADS-D is not a diagnostic instrument

Relevance:
The idea that psychiatric disorders impact the course of IBD is not new; however, the data on this are still emerging. Therefore, rigorous studies confirming this point can do a lot to lay the groundwork for new treatments in the care of patients with co-morbid psychiatric disorders and IBD.

Type of study (EBM guide):
Cohort study

PUBLICATION #3 — GI Psychiatry

Eating Disorders: Diagnosis and Management Considerations for the IBD Practice.

Graziella Rangel Paniz, Jocelyn Lebow, Leslie Sim, Brian E Lacy, Francis A Farraye, Monia E Werlang

Abstract: Inflamm Bowel Dis. 2021 Jun 7;izab138. doi: 10.1093/ibd/izab138. Online ahead of print.

The first step to better management of eating disorders among general GI and IBD patients is increasing awareness among providers: clinicians must remain aware of the high prevalence of these conditions in their population of patients and about the potential consequences of undiagnosed—and consequently unaddressed—eating disorders. The next step is to offer quick diagnostic tools to implement in daily practice, recognizing that symptomatology of eating disorders and IBD can overlap and lead to a more challenging diagnosis. Each individual provider has different resources available for the treatment of eating disorders, but a multidisciplinary approach involving trained dietitians, psychologists, psychiatrists, and primary care physicians should be the goal.

Annotation

The finding:
This review article outlines an approach to eating disorders in patients with IBD. The authors examine challenges in diagnosing and treating patients whose chronic medical illnesses pose an independent risk to weight restoration.

Strength and weaknesses:
This article highlights unique points for caring for patients with eating disorders who have IBD. The strengths of this review are its recommendations on empirically supported diagnostic tools for screening and recognition of the need for a multidisciplinary approach involving multiple specialists. Additionally, the literature review is comprehensive and up-to-date.

Relevance:
Eating disorders in patients with IBD can be obfuscated as a result of the medical symptoms of IBD, which include reduced appetite and weight loss. Recognition of the prevalence of eating disorders in IBD is critical; moreover, learning an approach to diagnosing and treating such patients is key. This article provides an overview of such an approach.

Type of study (EBM guide):
Other - Review/perspective

PUBLICATION #4 — GI Psychiatry

Distinct basal brain functional activity and connectivity in the emotional-arousal network and thalamus in patients with functional constipation associated with anxiety and/or depressive disorders.

Guanya Li, Wenchao Zhang, Yang Hu, Jia Wang, Jingyuan Li, Zhenzhen Jia, Lei Zhang, Lijuan Sun, Karen M von Deneen, Shijun Duan, Huaning Wang, Kaichun Wu, Daiming Fan, Guangbin Cui, Yi Zhang, Yongzhan Nie

Abstract: Psychosom Med. 2021 Jun 11. doi: 10.1097/PSY.0000000000000958. Online ahead of print.

Objective:
Functional constipation (FC) is a common gastrointestinal disorder. Anxiety and/or depressive disorders are common in patients with FC (FCAD). Brain dysfunction may play a role in FC, but the contribution of comorbid anxiety and/or depression in patients with FC is poorly understood.

Methods:
Sixty-five FC patients and forty-two healthy controls (HC) were recruited, and hierarchical-clustering algorithm was used to classify FC patients into FCAD and patients without anxiety/depressive status (FCNAD) based on neuropsychological assessment. Resting-state functional Magnetic Resonance Imaging measures including fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity were employed to investigate brain functional differences.

Results:
37 patients were classified as FCAD and 28 patients were classified as FCNAD; both groups showed decreased activity (fALFF) than HC in the perigenual anterior cingulate cortex (pACC), dorsomedial prefrontal cortex (DMPFC) and precuneus; enhanced precentral gyrus (PreCen)-thalamus connectivity and attenuated precuneus-thalamus connectivity in FCAD/FCNAD highlighted the thalamus as a critical connectivity node in the brain network (PFWE < .05). FCAD also had decreased fALFF than FCNAD/HC in the orbitofrontal cortex (OFC) and thalamus, and increased OFC-hippocampus connectivity. In the FCNAD group, brain activities (pACC/DMPFC) and connection (precuneus-thalamus) had correlations only with symptoms; in the FCAD group, brain activities (OFC, pACC/DMPFC) and connectivities (OFC-hippocampus/PreCen-thalamus) showed correlations with both constipation symptoms and anxiety/depressive status ratings. Mediation analysis indicated the relationship between abdominal distension and OFC activity was completely mediated by anxiety in FCAD.

Conclusions:
These findings provide evidence of differences in brain activity and functional connectivity between FCAD and FCNAD. It might help portray important clues for improving new treatment strategies.

Annotation

The finding:
Patients with functional constipation and anxiety/depression had decreased fractional amplitude of low-frequency fluctuation as compared to patients with functional constipation but not anxiety/depression in the orbitofrontal cortex (OFC) and thalamus, and increased OFC-hippocampus connectivity.

Strength and weaknesses:
An understanding of brain dysfunction in patients with functional disorders and co-morbid mood disorders might one day assist researchers in identifying novel treatments. This study provides some intellectually interesting findings but does not lead to practical interventions other than teaching patients that their illnesses may have a basis in brain functioning.

Relevance:
Understanding the neuropathology of functional GI disorders may help develop new treatments. Studies like this offer objective correlations to patients’ subjective experiences of GI pain, bloating, and discomfort.

Type of study (EBM guide):
Other - cross-sectional study