GI psychiatry

Suicide Attempts, Schizophrenia, and Depression Among Inflammatory Bowel Disease Patients
Vered Richter, Nechama Markovitz, Yoav Krupik, Noa Menkes-Caspi, Yarden Itzhaky, Daniel L Cohen, Haim Shirin, Roba Ganayem, Naim Abu-Freha

Abstract:

Background and Aims: 

Psychiatric disorders are more common in inflammatory bowel disease (IBD) patients compared with the general population. We aimed to investigate the prevalence and risk factors of depression, schizophrenia, and suicide attempts among IBD patients in Israel.

Methods: 

Data on IBD patients over 25 years (1999 to 2024) was extracted from the Clalit Health Maintenance Organization. Possible risk factors were investigated via multivariate analyses. A matched case-control analysis was performed of attempted suicide cases.

Results: 

A total of 3,262,623 adults were analyzed. The frequency rate of suicide attempts was 1.5%, schizophrenia 1.3%, and depression 25.7% among 19,100 Crohn’s disease (CD) patients compared with 1.1%, 1.4%, and 23.0% among 17,731 ulcerative colitis (UC) patients. In a multivariate analysis, female gender (OR 1.284, P<0.001), smoking (OR 1.479, P<0.001), CD (OR 1.274, P<0.010), schizophrenia (OR 7.69, P<0.001), and depression (OR 6.284, P<0.001) were found to be predictors of suicide attempts. Case-control analysis of 490 patients with a prior suicide attempt revealed significantly higher rates of schizophrenia (13.1% vs. 1.2%, P<0.001) and depression (70.0% vs. 19.6%, P<0.001) among the suicide group. In a multivariate analysis, schizophrenia (OR 9.873, P<0.001) and depression (OR 8.964, P<0.001) were significant risk factors for suicide attempts. The mortality rate among those with a suicide attempt (98/490, 20%) was significantly higher compared with those without a suicide attempt (5301/36,341, 14.6%, P<0.001).

Conclusion: 

The main risk factor for suicide attempts among IBD patients is comorbid psychiatric disease. Proactive mental health care by gastroenterologists and integrated psychology services is highly recommended.

Annotation

The finding:  This retrospective cohort study identified high frequencies of depressive symptoms and schizophrenia in individuals with IBD. The study also identified depression and schizophrenia as strong predictors of increased suicide attempt risk in all IBD patients, as well as CD and UC patients separately. Female gender and smoking status also emerged as significant risk factors in both CD and UC, while higher socioeconomic status appeared to be protective in CD. 

Strength and weaknesses: Limitations included the retrospective design and reliance on ICD coding with possible minor misclassification, and the lack of data regarding the severity of the IBD and psychiatric treatment. In addition, the authors could not adjust for certain unmeasured confounders such as detailed IBD activity indices, medication adherence, and psychiatric service accessibility. Moreover, because this study was retrospective and observational, causality cannot be inferred. However, the findings of the study on strong associations between psychiatric disorders and IBD highlight the importance of recognizing psychiatric comorbidities as powerful markers of risk.

Relevance: The study demonstrates the importance of proactively addressing the mental health aspects of IBD and integrating C/L psychiatrists into IBD care. The complex relationship between IBD and psychiatric comorbidities, including the specific impact on suicide risk, warrants further investigation.

Increased Disease Burden in Irritable Bowel Syndrome With Comorbid Conditions and Psychiatric Diagnoses in a Multinational European Cohort: Results From the DISCOvERIE Project
Irina Midenfjord, Mahrukh Khadija, Elias Sundelin, Inês A Trindade, Hans Törnblom, Javier Santos, Beatriz Lobo, Danique Mulder, Alejandro Arias Vasquez, Georgy Ruesing, Andreas Reif, Mareike Aichholzer, Maaike Van Den Houte, Lukas Van Oudenhove, Maria Chiara Matteucci, Giovanni Barbara , Michelle Bosman, Daisy Jonkers, Josep Antoni Ramos-Quiroga, Eva Jekkel, István Bitter, Andrei-Vasile Pop, Dan Lucian Dumitrascu, Carmen Alonso-Cotoner, Amanda Rodríguez-Urrutia, Magnus Simrén

Abstract:

Background: Patients with Irritable bowel syndrome (IBS) frequently suffer from comorbid psychiatric or somatic conditions, but the association with overall GI symptom severity and disease burden in IBS has not yet been established.

Objective: This pan-European project, the DISCOvERIE project, aimed to characterize IBS patients with and without comorbid psychiatric (anxiety, depression) and/or somatic (fibromyalgia, chronic fatigue syndrome) conditions, and to compare them with disease (psychiatric and/or somatic condition without IBS) and healthy controls to further elucidate the effect of comorbid conditions on the disease burden in IBS.

Methods: Participants from nine different European centers were included: IBS patients (Rome IV criteria) with and without comorbid conditions, disease controls, and healthy controls. The presence of comorbidities was assessed through the Mini International Neuropsychiatric Interview (MINI) for anxiety or depression or through diagnostic criteria for fibromyalgia or chronic fatigue syndrome. Validated questionnaires on IBS (IBS-SSS), depressive (PHQ-9), anxiety (GAD-7) and somatic symptom severity (PHQ-12), fibromyalgia symptoms (FIQ) and fatigue (MFI) were completed.

Results: In total, 842 participants were recruited between March 2021 and January 2023, of which 607 had IBS, 161 were disease controls and 74 were healthy controls. IBS, anxiety, depression, somatic symptoms and fatigue were more severe in IBS patients with comorbidities compared with IBS patients without comorbidities. The severity of the abovementioned symptoms all increased gradually with increasing number of comorbidities (all p < 0.001).

Conclusion: This large pan-European study highlights the significant impact of psychiatric and somatic comorbidities in IBS, and their strong link with outcomes and disease burden.

Annotation

The finding:  This observational cross-sectional study demonstrated that the disease burden of GI and non-GI symptoms is more severe in IBS patients with psychiatric and/or somatic comorbid conditions compared with IBS patients without these comorbidities. The severity of symptoms cumulatively increased with increasing number of comorbidities or psychiatric diagnoses among IBS patients. This clearly highlights the importance of these comorbid conditions for the overall disease burden in IBS. Strength and weaknesses:  One strength of the study was that diagnoses were based on current diagnostic criteria and standardized interviews for psychiatric diagnoses, instead of relying on symptom severity questionnaires. The participants were thoroughly characterized regarding a large number of factors potentially relevant for the disease using validated outcome measures. Furthermore, the inclusion of nine different European centres increased the generalizability of the findings across Europe. A limitation of the study was that it was not population-based, but the group sizes were decided before the study started. Hence, prevalence rates of comorbid conditions in IBS in the general population cannot be obtained from this study. Another limitation was that the COVID-19 pandemic restricted or paused inclusion at the centres at different time periods, prolonging the planned inclusion time.

Relevance:  This study showed that comorbid conditions are associated with more severe symptom and thus, more suffering among IBS patients. The findings from this study affirm the need to consider and systematically screen for comorbidities when managing IBS, and to use a multidisciplinary treatment focus for this large and complex group of patients, coordinated between gastroenterology and C/L psychiatrists.