Journal Article Annotations
2023, 4th Quarter

GI Psychiatry

Annotations by Ashwini Nadkarni, MD
January, 2024

Association between inflammatory bowel disease and subsequent depression or anxiety disorders – A retrospective cohort study of 31,728 outpatients.
People with IBD evidence more micro-arousals during sleep architecture assessments.

PUBLICATION #1 — GI Psychiatry

Association between inflammatory bowel disease and subsequent depression or anxiety disorders – A retrospective cohort study of 31,728 outpatients.

Christoph Roderburg, Kaneschka Yaqubi, Marcel Konrad, Petra May, Tom Luedde, Karel Kostev, Sven H Loosen.

Abstract: J Psychiatr Res. 2024 Jan:169:231-237. doi: 10.1016/j.jpsychires.2023.11.026. Epub 2023 Nov 22.

Background:
Crohn’s disease (CD) and ulcerative colitis (UC) are characterized by chronic intestinal and systemic inflammation. The extraintestinal sequelae of inflammatory bowel disease (IBD) are major contributors to disease morbidity and significantly affect patients’ quality of life. Here, we evaluated the association between IBD and subsequent depression or anxiety disorder in a large outpatient collective from Germany.

Methods:
15,864 individual IBD patients (CD: n = 6,791, UC: n = 9073) and 15,864 nearest neighbor propensity score matched patients without IBD were included from the Disease Analyzer database (IQVIA). Diagnoses of depression and anxiety disorders were compared between IBD and non-IBD patients during a five-year follow-up period using Kaplan-Meier estimators and Cox-regression models.

Results:
After 5 years of follow-up, depression was diagnosed in 14.4% of CD patients versus 10.2% of matched pairs (p < 0.001) and in 13.1% of UC patients versus 10.1% of matched pairs (p < 0.001). In line, the incidence of anxiety order was significantly higher among CD (4.7% vs. 4.4%, p = 0.009) and UC patients (4.3% vs. 3.5%, p = 0.005). Regression analysis confirmed a significant association between IBD and both mental conditions (Hazard Ratio (HR)_{CD/depression}: 1.40, HR_{UC/depression}: 1.32, HR_{CD/anxiety disorder}: 1.21, HR_{UC/anxiety disorder}: 1.28). Subgroup analyses revealed a stronger association for CD and depression (HR: 1.51) and UC and depression (HR:1.49) among male patients as well as UC and anxiety disorders (HR: 1.51) among female patients.

Conclusion:
Our data argue for a significant association between IBD and mental diseases including depression and anxiety disorders. Although further pathophysiological research is warranted, we hypothesize that specific psychological screening measures in IBD patients could improve quality of life and outcome.

Keywords:
CD; Crohn’s disease; IBD; Neurodegenerative disease; UC; Ulcerative colitis.

Annotation

The finding:
This research team aimed to conduct a more comprehensive investigation into the potential links between inflammatory bowel disease (IBD) and the subsequent diagnosis of anxiety and/or depression in a sizable group of outpatients in Germany. The present study offers additional support for the epidemiological association between IBD) and a subsequent diagnosis of depression and/or anxiety within a primary care patient cohort of 16,257 IBD individuals in Germany.

Strength and weaknesses:
The disease database utilized did not contain information on relevant elements such as patient socioeconomic status (such as education and income) or risk factors related to lifestyle (such as smoking, alcohol use, and physical activity), which could introduce bias. Additionally, there was no information provided regarding the diagnostic techniques used to establish the diagnosis of depression, leading to a diagnostic bias. In addition, due to the design of the study, the authors could only infer connections and associations between variables, and not causal links.

Relevance:
The study has important clinical implications in the appropriate screening, management and treatment of patients with IBD and depression and anxiety disorders – pointing to the importance of performing such screening and value of psychiatric care of patients with IBD.

PUBLICATION #2 — GI Psychiatry

People with IBD evidence more micro-arousals during sleep architecture assessments.

Jessica K Salwen-Deremer, Matthew J Reid, Sarah J Westvold, Corey A Siegel, Michael T Smith.

Abstract: BMJ Open Gastroenterol. 2023 Dec 28;10(1):e001249. doi: 10.1136/bmjgast-2023-001249.

Objective:
Poor sleep is common in inflammatory bowel disease (IBD) and may be associated with overall worse disease outcomes. While the sleep/IBD literature is growing, the data are often self-reported. Further, much of the research using objective measures of sleep architecture, or the overall pattern of sleep depth, rely on single-night assessments, which can be of questionable validity.

Design:
Participants with IBD and healthy controls were recruited from Dartmouth-Hitchcock Medical Center as part of a two-phase clinical trial. Sleep architecture was assessed using three nights of in-home electroencephalographic monitoring and scored according to the American Academy of Sleep Medicine guidelines.

Results:
Our sample included 15 participants with IBD and 8 healthy controls. Participants with IBD were more psychiatrically complex, with more self-reported insomnia, anxiety and depression. Participants with IBD evidenced greater micro-arousals than healthy controls. In participants with IBD, micro-arousals were associated with lower insomnia and greater depression scores. Within IBD, participants with clinically significant insomnia evidenced trend towards lower sleep efficiency, while self-reported disease activity did not significantly impact findings.

Conclusions:
The methodology of past research may have impacted findings, including the reliance on single-night assessments and limited generalisability. Future research that uses robust, multinight assessments of sleep architecture in large, diverse samples is clearly warranted, as is research exploring the impact of cognitive and behavioural factors on sleep architecture and arousal

Annotation

The finding:
To advance the current understanding of sleep architecture in inflammatory bowel disease (IBD) and produce more methodologically sound results, this study used in-home, multi-night wireless sleep-EEG testing to evaluate sleep architecture across three nights in people with and without IBD. Many of the analyses did not replicate prior research, with the only significant finding indicating that participants with IBD evidenced more micro-arousals than healthy controls.

Strength and weaknesses:
The strengths of the study include its value in the growing body of literature pointing to differences in sleep architecture in patients with IBD. The weaknesses include a small, homogeneous sample that limited power and generalizability.Additionally, the assessment of disease activity was not objective; future research including measures of inflammation such as C reactive protein are needed to better understand the relationships among sleep disturbances, inflammation and IBD symptoms. Further, the findings on psychosocial and behavioral contributors to micro-arousals in IBD are novel but preliminary.

Relevance:
Sleep is a complex phenomenon in patients with IBD who may often wake up during the night due to a need to go to the bathroom. However, this study validates that separately, patients with IBD have differences in their sleep architecture (micro-arousals – which are associated with depression). This study offers C-L psychiatrists emerging data on the need to consider the nature of sleep disturbance in patients with IBD.