Journal Article Annotations
2023, 1st Quarter

GI Psychiatry

Annotations by Ashwini Nadkarni, MD
April, 2023

Patients with IBD Want to Talk About Sleep and Treatments for Insomnia with Their Gastroenterologist.
Depression and anxiety are associated with poor outcomes in patients with inflammatory bowel disease: A nationwide population-based cohort study in South Korea.

PUBLICATION #1 — GI Psychiatry

Patients with IBD Want to Talk About Sleep and Treatments for Insomnia with Their Gastroenterologist.

Jessica K Salwen-Deremer, Cassandra M Godzik, Christina H Jagielski, Corey A Siegel, Michael T Smith

Abstract: Dig Dis Sci. 2023 Feb 25;1-12. doi: 10.1007/s10620-023-07883-8. Online ahead of print.

Background and aims:
Poor sleep may be prospectively associated with worse disease course in inflammatory bowel disease (IBD). Chronic insomnia is the most common cause of poor sleep complaints in IBD and is theorized to be maintained by dysfunctional thoughts and behavioral patterns. However, data characterizing patterns specific to insomnia in IBD are lacking. Understanding the nuances of insomnia and patients’ preferences for treatment is critical for addressing this significant comorbidity in IBD.

Methods:
We conducted an anonymous, mixed-method online survey of people with IBD and asked questions about sleep patterns, thoughts, and behaviors related to sleep, treatment preferences, and barriers to treatment.

Results:
312 participants (60.9% Crohn’s, 66.3% women, mean age of 48.62 years) were included in this study. Participants with insomnia were significantly more concerned about the consequences of sleep loss, felt more helpless about their sleep, and were more likely to engage in behaviors known to perpetuate insomnia (e.g., spending time in bed in pain; ps ≤ 0.001) than those without insomnia. 70.3% of participants were interested in discussing sleep as part of IBD care, 63.5% were interested in receiving sleep recommendations from their gastroenterologist, and 84.6% of those with insomnia were interested in participating in sleep treatments.

Conclusion:
Participants with IBD and insomnia are interested in treatment and reported patterns that can be targeted in Cognitive Behavioral Therapy for Insomnia, as opposed to traditional sleep hygiene guidelines. Additionally, people with insomnia engaged in several sleep-interfering behaviors related to pain. Clinical trials that target insomnia in people with IBD should include pain management in the intervention.

Keywords:
Crohn’s disease; Inflammatory bowel disease; Pain; Psychogastroenterology; Sleep; Ulcerative colitis.

Annotation

The finding:
This cross-sectional mixed-method study found that people with inflammatory bowel disease (IBD) and insomnia worried more about their sleep, worried more about the consequences of insomnia, and attributed insomnia more to medical explanations. They were also engaging in several behaviors known to maintain insomnia, including taking daytime naps and doing things other than sleeping in their beds. People with insomnia also engaged in pain-related behaviors including spending time in bed/in the bedroom, while in pain and using pain medications to help them sleep. Importantly, the only items where people with active IBD scored higher than those with inactive IBD were those pertaining to spending time in bed in pain.

Strength and weaknesses:
This study highlights a common psychiatric concern among patients with IBD and obtained survey responses from more than 300 patients. Limitations include homogeneity of the population assessed. This limitation was due to the location of the medical center. Additionally, the topic of the study (sleep and pain in IBD) could have resulted in a biased sample, selecting for participants who want to report and think about their problems with sleep and/or pain. Additionally, qualitative data were obtained through written surveys, whereas verbal communication via individual interviews or focus groups might reveal additional themes.

Relevance:
The results of this study highlights individual, provider, and system-level factors that can contribute to lack of insomnia care in IBD. Individually, access to care including affordability, flexible scheduling options (e.g., weekends, weeknights), and appointment delivery (e.g., telehealth, phone call) are important. There is also a lack of understanding about the relationship between sleep and IBD. Patients are interested in treatment; however, they often do not know what their options are or even how to go about asking the appropriate questions to get help. They want to learn about ways to improve their mental health symptoms (stress and anxiety) so that they can improve their insomnia. Such findings provide a basis for psychiatrists treating patients with IBD to both screen and treat patients with IBD for insomnia but also consider quality improvement interventions to improve practice.

PUBLICATION #2 — GI Psychiatry

Depression and anxiety are associated with poor outcomes in patients with inflammatory bowel disease: A nationwide population-based cohort study in South Korea.

Seulji Kim, Seungwoo Lee, Kyungdo Han, Seong-Joon Koh, Jong Pil Im, Joo Sung Kim, Hyun Jung Lee.

Abstract: Gen Hosp Psychiatry. 2023 Mar-Apr;81:68-75. doi: 10.1016/j.genhosppsych.2023.01.015. Epub 2023 Feb 3.

Background:
Prevalence of depression and anxiety are known to be increased in patients with inflammatory bowel disease (IBD), but it is unclear whether such elevations adversely affect IBD outcomes.

Objective:
We aimed to investigate the association between depression or anxiety and clinical outcomes of IBD.

Method:
Using claims data from the South Korean National Health Insurance Service (NHIS), patients with IBD were identified by codes of the International Classification of Disease, 10th Revision (ICD-10) and the Rare/Intractable Disease (RID) registration program for years 2010 to 2017. ICD-10 codes were also used to identify depression and anxiety in this population. Primary study endpoints were IBD-related outcomes, including emergency room (ER) visits, hospitalizations, and surgeries during the follow-up period.

Results:
Our cohort included 32,867 patients with IBD, of whom 3794 (11.5%) experienced depression and anxiety during the 6-year median follow-up period. In multivariate analysis, comorbid depression and anxiety were associated with increased risks of ER visits (hazard ratio [HR] = 1.34, 95% confidence interval [CI]: 1.19-1.51) and hospitalizations (HR = 1.24, 95% CI: 1.12-1.37), whereas surgical risk was not different for IBD patients with and without depression and anxiety. There was no differential effect of depression and anxiety on outcomes in IBD patients, but depression was more closely associated with outcomes in CD patients and anxiety in UC patients.

Conclusion:
In patients with IBD, comorbid depression and anxiety are associated with increased risks of ER visits and hospitalizations, but not surgery. These associations are more pronounced for depression in CD patients and for anxiety in UC patients.

Keywords:
Anxiety; Depression; Emergency room visits; Hospitalization; Inflammatory bowel disease; Surgery.

Annotation

The finding:
In this retrospective cohort study, the authors investigated the association between he co-morbidities of anxiety and depression and clinical outcomes for South Korean patients with IBD. Such outcomes included emergency department (ED) visits, hospitalizations and surgeries. They found that in Corhn’s disease (CD) patients, depression, not anxiety, was related to increased risks of ED visits and hospitalizations, while conversely, in ulcerative coliitis (UC) patients, anxiety showed a stronger association with poor outcomes than depression. All subgroups of IBD with comorbid depression and anxiety were at higher risk of ER visits, and the impact on hospitalizations was greater in those with one or more comorbidities.

Strength and weaknesses:
This is the largest nationwide population-based study on the associations of depression and anxiety with the clinical outcomes of IBD in South Korea. Another strength was providing further, up-to-date evidence that depression and anxiety have significant associations with the clinical outcomes of Asian IBD patients. Furthermore, the authors assessed the related impact on IBD outcomes in a clearer manner by selecting critical endpoints, specifically ED visits, hospitalizations, and surgical procedures. These better reflect the natural history of IBD, more so than symptom-based disease activity and quality-of-life parameters applied in prior studies. The study was highly representative and reliable, utilizing claims data generated for nearly the entire South Korean population. Limitations include the lack of patient stratification by IBD severity, because the dataset used by the study authors did not include objective findings such as inflammatory markers or endoscopic results. Second, because anxiety and depression were identified on the basis of a diagnostic code, only those who received active medical treatment were included. This may be associated with a risk of under-diagnosis because patients with mild symptoms or remission might not be treated nor seek medical attention. One last issue was the authors’ inability to discern exact causes of ED visits, hospitalizations, or surgical procedures under the constraints of administrative data.

Relevance:
Stigma against psychiatric treatments remain a barrier to improved care for patients with complex medical illnesses. The study provides up-to-date research confirming the impact of psychiatric disorders such as anxiety and depression on outcomes for IBD, reinforcing that treatment for mood disorders can alter the course of illness for IBD.