Why Addressing Mental Health Is Key in Ulcerative Colitis Care

Chang Kyun Lee, M.D., Ph.D.

Credit: Kyung Hee University

In a new study, the presence of common mental disorders (CMDs), such as anxiety and depression, at the time of ulcerative colitis (UC) diagnosis did not affect long-term clinical outcomes, although they consistently had a negative impact on health-related quality of life (HRQoL). Investigators say the findings highlight the importance of including psychological support as a standard part of long-term care for patients with moderate to severe UC.

Patients with moderate to severe UC often experience a more intense disease course, including upsetting symptoms such as bleeding, abdominal pain, urgency, tenesmus and increased stool frequency. These patients may also have worse response to treatment, leading to a greater impact on their mental health and HRQoL.

Additionally, recent data have revealed the bidirectional brain-gut interaction in inflammatory bowel disease (IBD), demonstrating how CMD can change the environment of the intestines, potentially impacting the disease course. Patients with concomitant CMDs were at an increased risk of flares, emergency room visits, hospitalizations and IBD-related surgery and were more likely to need to be prescribed corticosteroids.

“CMDs, including anxiety and depression, present major challenges for patients with IBD,” wrote a group of investigators including Chang Kyun Lee, M.D., Ph.D., a professor within the Department of Gastroenterology, Center for Crohn’s and Colitis, College of Medicine at Kyung Hee University in Korea. “These mental conditions can affect the patient’s ability to cope with the disease burden, leading to diminished treatment adherence and success. Advances in understanding the brain-gut axis have highlighted the role of changes in brain signaling and structure, gut microbiome impairments, inflammatory cytokines, and genetic predispositions in contributing to CMDs in patients with IBD.”

In the moderate-to-severe ulcerative colitis in Korea (MOSAIK) study, investigators assessed any differences in clinical outcomes and HRQoL using the Hospital Anxiety and Depression Scale (HADS) scores at UC diagnosis. Clinical outcomes were measured based on clinical response, medication use, relapse and hospitalization, while HRQoL was evaluated with the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Short Form 12 (SF-12). Disease severity was assessed using the Mayo score, in which a score of 6 to 10 indicated moderate severity and 11 or higher was defined as severe UC.

Among a cohort of 199 patients with UC, almost half (47.7%) reported significant psychological distress at the time of diagnosis. The mean age at diagnosis was 29.3 years and 60.3% were male. At the end of the three-year follow-up period, 73.6% of patients were in clinical remission.

There were no differences in outcomes, including response rates, hospitalization rates and remission rates, between patients with anxiety or depression and those without at diagnosis. However, the HRQoL at the end of the follow-up period was markedly lower in patients with baseline CMDs, especially for those with anxiety, across all domains of the IBDQ and SF-12 assessments.

Higher HADS scores and Mayo scores were independently linked to lower IBDQ scores as well as the summary domains of the SF-12. Additionally, patients who regularly attended follow-up visits had more improvements in their HRQoL.

Investigators noted the relatively small sample size as a limitation of the study, as it hindered their ability to fully evaluate the outcomes. However, the methods used were in alignment with similar real-world, noninterventional observational studies. Further, it is possible that CMDs were masked by severe physical distress, since the symptoms of CMDs can be difficult to identify among patients with chronic conditions who regularly experience pain, fatigue, sleep issues and loss of appetite due to their disease.

“Depression and anxiety are common consequences of UC and should be considered part of the disease course,” investigators concluded. “Therefore, integrating physical and mental health when caring for patients with moderate-to-severe UC is critical for improving their QoL.”