Journal Article Annotations
2021, 4th Quarter

GI psychiatry

Annotations by Ashwini Nadkarni, MD
December, 2021

The Association between Temperament, Chronotype, Depressive Symptoms, and Disease Activity among Patients with Inflammatory Bowel Disease-A Cross-Sectional Pilot Study.
Assessing the repercussions of COVID-19 pandemic on symptoms, disease management, and emotional well-being in patients with inflammatory bowel disease: a multi-site survey study.
Resilience-based Integrated IBD Care Is Associated With Reductions in Health Care Use and Opioids.

PUBLICATION #1 — GI psychiatry

The Association between Temperament, Chronotype, Depressive Symptoms, and Disease Activity among Patients with Inflammatory Bowel Disease-A Cross-Sectional Pilot Study.

Łukasz Mokros, Danuta Domżał-Magrowska, Tadeusz Pietras, Kasper Sipowicz, Renata Talar-Wojnarowska

Abstract: Life (Basel). 2021 Dec 5;11(12):1347. doi: 10.3390/life11121347.

The psychological aspect may play an important role in ulcerative colitis (UC) and Crohn’s disease (CD). The aims of this study were to explore the differences between patients with UC and CD regarding chronotype, temperament and depression, and to assess the psychological factors mentioned as predictors of disease activity. In total, n = 37 patients with UC and n = 47 patients with CD were included in the study. They underwent a clinical assessment, including the Mayo score or Crohn Disease Activity Index (CDAI), and completed questionnaires: a sociodemographic survey, Formal Characteristics of Behavior-Temperament Inventory (FCB-TI), Chronotype Questionnaire (CQ), and the Beck Depression Index II (BDI). The Sensory Sensitivity score was higher among patients with CD than UC (p = 0.04). The emotional reactivity and endurance scores were higher among women than men with CD (p = 0.028 and p = 0.012 respectively). CQ Morningness-Eveningness (ME) correlated with Endurance (p = 0.041), Emotional Reactivity (p = 0.016), and Activity (p = 0.004). ME correlated with Rhythmicity among CD patients (p = 0.002). The Mayo score was predicted by Perseverance. The CDAI score was predicted by the BDI score. The pattern of the relationship between chronotype and temperament may differentiate patients with UC and CD. Personal disposition may play a role in the clinical assessment of patients with IBD.

Annotation

The finding:
Patients with Crohn’s disease (CD) had a higher Sensory Sensitivity compared to UC patients. (High Sensory Sensitivity means having a low threshold for different stimuli, including sensitivity to subtle sounds, smells, and signs of the recurrence of the active phase of the disease). For patients with CD, only the severity of depressive symptoms predicted activity of the disease.

Strength and weaknesses:
The sample was small, non-random, and originated from a single center. In addition, there was a difference in mean age between the UC and CD groups. These factors diminish generalizability of the findings. A study with a prospective, multi-center design with a larger number of IBD patients would offer greater value in determining the predictive role of temperament and chronotype in disease activity.

Relevance:
This study explored the differences between patients with UC and CD regarding chronotype (personal disposition toward a certain circadian pattern of functioning), temperament and depression, and determined the role of such psychological factors as predictors of disease activity. This is one of the first studies investigating temperament among adult patients with IBDs. A notable finding of the study was that the severity of depressive symptoms predicted activity of disease for Crohn’s patients. Thus, the study’s findings validate the importance of C-L psychiatrists aggressively treating depression as a means to improve IBD outcomes.

PUBLICATION #2 — GI psychiatry

Assessing the repercussions of COVID-19 pandemic on symptoms, disease management, and emotional well-being in patients with inflammatory bowel disease: a multi-site survey study.

Mohammed El-Dallal, Ariana Saroufim, Hannah Systrom, Sarah Ballou, Adel Farhoud, Ravi Teja Pasam, Salini Samyuktha Gadupudi, Karim Osman, Khadija Chaudrey, Adam Cheifetz, Joseph D Feuerstein./span>

Abstract: Scand J Gastroenterol. 2021 Dec 11;1-9. doi: 10.1080/00365521.2021.2013527. Online ahead of print.

Abstract:
Coronavirus disease 2019 (COVID-19) pandemic has created numerous challenges in provision of safe and effective care for patients with Inflammatory Bowel Disease (IBD). In this study, we surveyed patients with IBD to highlight the impact of the pandemic on their IBD symptoms, management, and well-being.

Methods:
A multi-site survey was administered to patients with IBD. We evaluated patient’s symptoms, medications changes, seeking medical attention, eating behaviors, sleep patterns, stress, self-reported anxiety and depression. The survey also measured emotional impact of the pandemic using the validated Pandemic Emotional Impact Scale (PEIS) and resilience using the Brief Resilience Scale (BRS). Logistic, ordinal, and linear regression models were utilized to perform sensitivity analyses.

Results:
The response rate to the survey was 61%. Of 391 surveyed patients, 21.1% reported worsened gastrointestinal symptoms, 17.5% reported changing biologic medication infusion schedule, 18.7% reported changing medication regimen, 43.6% attended at least one telemedicine visit with their gastroenterologist, 16.5% reported a less healthy diet, 40.5% reported worsening sleep, 63.7% reported more stress, and 65.3% reported feeling more vulnerable than before the pandemic. Women and participants with self-reported anxiety and depression were more likely to have worse symptoms, psychological well-being and daily functioning. Increased PEIS scores and decreased BRS scores were associated with worse outcomes.

Conclusions:
COVID-19 pandemic has impacted symptoms, disease management and well-being for patient with IBD, more prominently in patients who suffer from anxiety and depression. Utilizing PEIS and BRS scores as screening tools could help better tailor outreach and follow-up to support these patients.

Annotation

The finding
This study assessed the impact of Covid-19 on a variety of indicators for illness including those related to self-care and stress management for IBD patients. The results indicate that for patients with pre-existing depression and anxiety, IBD symptoms, disease management patterns, stress levels and sleep patterns worsened.

Strengths and weaknesses
Generalizability is a concern in this study since it was limited to English-speaking patients seen at tertiary-care centers. Additionally, there was limited variation in participant racial and ethnic identity. Survey research methodologies also have inherent nonresponses, recency, and recall bias. Strengths were a large sample size and a questionnaire designed through collaboration between gastroenterology and psychology experts.

Relevance
Covid-19 has uniquely impacted patient with co-morbid psychiatric disorders and IBD. These patients are likely to require increased psychiatric outreach and follow up.

PUBLICATION #3 — GI psychiatry

Resilience-based Integrated IBD Care Is Associated With Reductions in Health Care Use and Opioids.

Laurie Keefer, Ksenia Gorbenko, Tina Siganporia, Laura Manning, Stacy Tse, Anthony Biello, Ryan Ungaro, Louis J Cohen, Benjamin L Cohen, Marla C Dubinsky.

Abstract: Clin Gastroenterol Hepatol. 2021 Nov 16;S1542-3565(21)01225-8. doi: 10.1016/j.cgh.2021.11.013. Online ahead of print.

Background & aims:
Integrated inflammatory bowel disease (IBD) care is effective but not routinely implemented. Validated methods that simultaneously address mind and body targets such as resilience may improve access and outcomes. We describe the development and implementation of the GRITT method and its impact on resilience, health care utilization (HCU), and opioid use in IBD.

Methods:
Consecutive patients from an academic IBD center were evaluated for low resilience on the basis of provider referral. Low resilience patients were invited to participate in the GRITT program. Primary outcome was % reduction in HCU. Secondary outcomes were change in resilience and corticosteroid and opioid use. Patients were allocated into 2 groups for analysis: GRITT participants (GP) and non-participants (NP). Clinical data and HCU in the year before enrollment were collected at baseline and 12 months. One-way repeated measures multivariate analysis of covariance evaluated group × time interactions for the primary outcome. Effect size was calculated for changes in resilience over time.

Results:
Of 456 screened IBD patients 394 were eligible, 184 GP and 210 NP. GP had greater reduction in HCU than NP: 71% reduction in emergency department visits, 94% reduction in unplanned hospitalizations. There was 49% reduction in opioid use and 73% reduction in corticosteroid use in GP. Resilience increased by 27.3 points (59%), yielding a large effect size (d = 2.4).

Conclusions:
Mind-body care that focuses on building resilience in the context of IBD care may be a novel approach to reduce unplanned HCU and opioid use, but large, multicenter, randomized controlled trials are needed.

Keywords:
Crohn’s Disease; Depression; Emergency Department Use; Hospitalizations; Mind-Body Intervention; Opioid Use; Positive Psychology; Ulcerative Colitis.

Annotation

The finding:
Integrated care programs which incorporate resilience training demonstrate reductions in unplanned hospitalizations, opioid use, and corticosteroid use for their patients. Such programs incorporate a multi-disciplinary team of gastroenterology, nursing, behavioural health, and nutritional specialists and reinforce positive health psychology with care personalized on therapeutic targets of disease acceptance, optimism/hope and future orientation, self-confidence, social support, and self-regulatory skills.

Strength and weaknesses:
The study did not randomize participants or make a comparison to non-randomized controls; thus, the study did not necessarily prove that such a model of care is in fact superior to usual care. Additionally, generalizability was limited given patients were from a large, urban academic center with biases toward lower resilience and higher health care usage. Finally, the study took place before the beginning of the pandemic.

Relevance:
When IBD patients with high hospitalization utilization and more frequent usage of opioids are evaluated by C-L psychiatrists, resiliency programs such as the one referenced in this article serve as a model for optimal care both in the inpatient setting as well as for longitudinal, ambulatory care planning.