Journal Article Annotations
2024, 4th Quarter

GI Psychiatry

Annotations by Ashwini Nadkarni, MD
January, 2025

Anxiety and Depression Are Associated with Poor Long-term Quality of Life in Moderate-to-Severe Ulcerative Colitis: Results of a 3-Year Longitudinal Study of the MOSAIK Cohort.
Rates of colorectal cancer diagnosis and mortality in people with severe mental illness: results from Australia’s National Bowel Cancer Screening Programme.

PUBLICATION #1 — GI Psychiatry

Anxiety and Depression Are Associated with Poor Long-term Quality of Life in Moderate-to-Severe Ulcerative Colitis: Results of a 3-Year Longitudinal Study of the MOSAIK Cohort.

Shin Ju Oh, Chang Hwan Choi, Sung-Ae Jung, Geun Am Song, Yoon Jae Kim, Ja Seol Koo, Sung Jae Shin, Geom Seog Seo, Kang-Moon Lee, Byung Ik Jang, Eun Suk Jung, Youngdoe Kim, Chang Kyun Lee.

Abstract: Gut Liver. 2024 Nov 7. doi: 10.5009/gnl240146. Online ahead of print.

Background/aims:
We previously reported that patients with moderate-to-severe ulcerative colitis (UC) often experience common mental disorders (CMDs) such as anxiety and depression, necessitating immediate psychological interventions within the first 4 weeks of diagnosis. In this 3-year follow-up study of the MOSAIK cohort in Korea, we examined the effects of CMDs at initial diagnosis on clinical outcomes and health-related quality of life (HRQoL)

Methods:
We examined differences in clinical outcomes (evaluated based on clinical response, relapse, hospitalization, and medication use) and HRQoL (assessed using the Inflammatory Bowel Disease Questionnaire [IBDQ] and Short Form 12 [SF-12]) according to Hospital Anxiety and Depression Scale (HADS) scores at diagnosis.

Results:
In a study involving 199 UC patients, 47.7% exhibited significant psychological distress (anxiety and/or depression) at diagnosis. Clinical follow-up showed no major differences in outcomes, including remission rates, response rates, or hospitalization rates, between patients with anxiety or depression at diagnosis and patients without anxiety or depression at diagnosis. The HRQoL at the end of follow-up was notably lower in those with baseline CMDs, particularly anxiety, across all domains of the IBDQ and SF-12. Linear mixed-effect models revealed that higher HADS scores, as well as higher Mayo scores, were independently associated with lower IBDQ scores and both summary domains of the SF-12. Additionally, regular attendance at follow-up visits during the study period was also related to improvements in HRQoL (all p<0.05).

Conclusions:
While CMDs present at the time of UC diagnosis did not influence long-term clinical outcomes, they persistently impaired HRQoL. Our findings support the routine incorporation of psychological interventions into the long-term management of moderate-to-severe UC.

Annotation

The finding:
This prospective cohort study assessed how psychological distress at the time of diagnosis affected disease course and health-related quality of life (HRQoL). The study found that, in moderate-to-severe ulcerative colitis (UC), the presence of anxiety or depression at diagnosis had no effect on clinical outcomes. However, among patients who experienced relapse, those with anxiety and depression were more likely to experience multiple relapses than those without these conditions (p=0.026).

Strength and weaknesses:
The study’s strength is that it’s one of the first to investigate the relationship between depression or anxiety and long-term disease outcomes in non-Western patients with UC, and in those with moderate or high disease activity. The study’s limitations are that first, while 354 patients initially enrolled, only 199 were successfully followed over a 3-year period. This smaller sample size might have reduced the power to fully evaluate outcomes. Second, recognizing common mental disorders (CMDs) can be particularly difficult for people with chronic conditions such as fatigue, pain, loss of appetite, sleep disturbances, depression/anxiety, and other physical illnesses. Thus, psychiatric illnesses could have been masked by severe physical distress. Third, the remission rate at the 3-year follow-up in this study is very high without confirmation of whether factors related to disease severity or status, impairing generalization.

Relevance:
This study highlights that among patients who experienced relapse of UC, concurrent anxiety and depression made that relapse more likely, demonstrating the need for improved screening and treatment of mood disorders in patients with inflammatory bowel disease (IBD).

PUBLICATION #2 — GI Psychiatry

Rates of colorectal cancer diagnosis and mortality in people with severe mental illness: results from Australia’s National Bowel Cancer Screening Programme.

S Kisely, K Spilsbury, C Bull, S Jordan, B J Kendall, D Siskind, G Sara, M Protani, D Lawrence.

Abstract: Epidemiol Psychiatr Sci. 2024 Dec 17:33:e79. doi: 10.1017/S2045796024000787.

Aims:
Studies show that people with severe mental illness (SMI) have a greater risk of dying from colorectal cancer (CRC). These studies mostly predate the introduction of national bowel cancer screening programmes (NBCSPs) and it is unknown if these have reduced disparity in CRC-related mortality for people with SMI.

Methods:
We compared mortality rates following CRC diagnosis at colonoscopy between a nationally representative sample of people with and without SMI who participated in Australia’s NBCSP. Participation was defined as the return of a valid immunochemical faecal occult blood test (iFOBT). We also compared mortality rates between people with SMI who did and did not participate in the NBCSP. SMI was defined as receiving two or more Pharmaceutical Benefits Scheme prescriptions for second-generation antipsychotics or lithium.

Results:
Amongst NBCSP participants, the incidence of CRC in the SMI cohort was lower than in the controls (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.61-0.98). In spite of this, their all-cause mortality rate was 1.84 times higher (95% CI 1.12-3.03), although there was only weak evidence of a difference in CRC-specific mortality (HR 1.82; 95% CI 0.93-3.57). People with SMI who participated in the NBCSP had better all-cause survival than those who were invited to participate but did not return a valid iFOBT (HR 0.67, 95% CI 0.50-0.88). The benefit of participation was strongest for males with SMI and included improved all-cause and CRC-specific survival.

Conclusions:
Participation in the NBCSP may be associated with improved survival following a CRC diagnosis for people with SMI, especially males, although they still experienced greater mortality than the general population. Approaches to improving CRC outcomes in people with SMI should include targeted screening, and increased awareness about the benefits or participation.

Trial registration:
Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12620000781943).

Keywords:
NBCSP; cancer treatment; colorectal cancer; mortality; screening; severe mental illness; treatment disparities.

Annotation

The finding:
This study aimed to compare mortality rates following (colorectal cancer) CRC diagnosis between national bowel cancer screening programmes (NBCSP) participants with positive immunochemical faecal occult blood test(iFOBT), with and without (severe mental illness) SMI. The major finding of the study was that the rate of CRC diagnosis in people with SMI following colonoscopy as part of the NBCSP was lower than that of the non-SMI cohort. However, subsequent all-cause mortality was significantly higher, and CRC-specific mortality rates were non-significantly greater.

Strength and weaknesses:
The study’s strength is that this is the first Australia-wide study to report on mortality following a CRC diagnosis after the introduction of the NBCSP. The study’s limitations arise from its use of linked administrative data. For instance, through use of prescriptions instead of medical records to identify SMI, the study’s case definition was limited to people prescribed lithium or atypical antipsychotic agents. The study’s case definition may also have overlooked individuals with SMI who received private prescriptions or were not prescribed any medications.

Relevance:
This study highlights the need for greater action to improve cancer outcomes for people with SMI and presents an opportunity for C/L psychiatrists to build awareness among PCPs and gastroenterologists that patients with SMI have an increased risk of mortality from CRC and require regular screening and early detection initiatives tailored to their population.