Journal Article Annotations
2023, 2nd Quarter
Annotations by Ashwini Nadkarni, MD
This research team performed a prospective, interventional, longitudinal cohort study analyzing the psychopathological profiles of patients with ulcerative colitis (UC) as compared to a control group matched for age and sex and correlated their findings to specific signatures in their gut microbiota. Most patients in the UC experimental group had a high level of alexithymia (89.7% positive for TAS-20) and significantly relevant anxiety symptoms. Moreover, depressive symptoms were notable for 41.0% of the subjects affected by UC exceeding the cutoff on the HADS-D subscale. Analysis on the MMPI-2 test revealed a high percentage of patients with scores above the cutoff of 65 T-points in the following scales: Hypochondriasis (Hs), Psychasthenia (Pt), Obsessiveness (OBS), Depression (DEP), Health Concerns (HEA), Work Interference (WRK) and Negative Treatment Indicators (TRT). In the UC patient population, there were specific increases and decreases in specific species of gut microbiota and of note, an increase in Streptococcus was most strongly associated with depressive symptoms.
Strength and weaknesses:
This study provides a unique perspective on the role of dysbiosis and its link between IBD and psychiatric disorders. The authors achieved this by confirming a significant difference between the microbiota of UC patients compared with controls and association of particular species of microbiota in depressed UC patients. However, the sample size for this study was small; there was no comparison group of psychiatric patients and their available microbiota; and self-evaluation scales (rather than a structured clinical interview) were used to assess anxiety and depression.
Intestinal microbiome dysbiosis has been associated with different psychiatric disorders such as depression, anxiety, bipolarism, psychosis, and schizophrenia, though no specific association has been detected. Therefore, microbiome modulation through diet or probiotics may represent a preventive and therapeutic tool for psychiatric disorders. Additionally, this study confirms the presence of high levels of psycho-emotional distress in UC patients. This plays a role in treatment adherence, clinical outcomes and validates the approach for a “psycho-gastroenterological” approach to ensure optimal outcomes for patients with IBD.
In this population cohort based study, the research team aimed to examine the burden of anxiety, depression, and bipolar disorder longitudinally leading up to and following IBD diagnosis. They found that patients with IBD consistently have a higher occurrence of anxiety and depression starting at least five years before IBD diagnosis and continuing for at least ten years following IBD diagnosis compared with individuals from the general population. The pattern was present both for severe anxiety and depression as measured by hospital contacts and for a broader range of cases as measured by dispensed prescriptions for antidepressants. Bipolar disorder was not associated with IBD, except for patients with CD who had an increased risk of having a hospital contact for bipolar disorder in the years following IBD diagnosis. This could be an incidental finding, or it may be an effect of steroids given for CD that can lead to hypomania
Strength and weaknesses:
Unlike most previous population-based studies on this topic, the authors examined the occurrence of psychiatric diseases in the same population over time both before and after IBD diagnosis. Another strength is the authors’ use of the National Danish Registers, which contains complete information on all included individuals and allowing for large samples of patients with IBD. In addition, by using time-dependent matching, the authors were able to account for period effects. The cohort is thus representative for Denmark and also generalizable to other populations. Additionally, the authors used well-validated criteria for identifying patients with IBD ensuring a high validity (PPV 95%) and used both hospital contacts for anxiety, depression, and bipolar disorder as well as dispensed prescriptions for antidepressants as outcomes, which allowed capturing a large spectrum of outcome severity. Limitations included that the authors could not obtain granular data on disease activity, which would have been useful to include in the analyses. In addition, patients with IBD could be more frequently diagnosed with psychiatric diseases as an effect of more often being seen by a doctor resulting in surveillance bias.
This nationwide population-based study demonstrated results which reinforce that patients with IBD are vulnerable to mental health struggles and could benefit from comprehensive care that include evaluation and management of psychiatric comorbidity, with special attention at the time of IBD diagnosis. The high diagnostic frequency of psychiatric comorbidity around the time of IBD-diagnosis indicates a particularly intense strain from the bowel-symptoms and from dealing with being diagnosed with a chronic illness. It could also point to an early window of opportunity for managing the psychiatric comorbidities while potentially also improving the course of IBD, since psychiatric comorbidity has been suggested to increase risk of active IBD.