A study published in November 2019 in the journal Inflammatory Bowel Diseases showed that mental health problems among veterans with ulcerative colitis and Crohn’s disease are widespread. Researchers discovered that among 60,000 IBD patients listed in the Veterans Health Administration database, the overall prevalence of anxiety, depression, and post-traumatic stress disorder has more than tripled between 2001 and 2015 — climbing from 10.8 percent to 38 percent in that time period. About one-third of patients received a new anxiety, depression, or post-traumatic stress disorder diagnosis during that 14-year time frame. “Over time, the proportion of veteran patients with IBD diagnosed with mental health disorders has grown,” says study author Jason Hou, MD, director of inflammatory bowel diseases at the Michael E. DeBakey VA Medical Center in Houston. “This is very important to recognize as more and more of these patients will need to have access to resources to manage anxiety, depression, and PTSD.”
A Vicious Cycle for IBD Patients
For those with IBD, psychological pressures may worsen the disease and trigger IBD flares, while concerns about the illness can heighten psychological problems. Dr. Hou adds that patients who develop depression or anxiety may also be less likely to see a provider or take the medicines they are recommended, which may in turn worsen mental health symptoms. The relationship between IBD and mental health issues can cause a downward spiral that feeds on itself and is difficult to break. “Depression drives disease activity, relapses or flares in IBD, and increases rates of surgeries, hospitalizations, and emergency department visits,” says Laurie Keefer, PhD, a GI health psychologist and professor of medicine and psychiatry at the Icahn School of Medicine at Mount Sinai in New York City and a spokesperson for the American Gastroenterological Association. “However, when IBD is active, depression rates are also higher, suggesting that the inflammatory state drives mental health concerns.” While this investigation did not examine if IBD is more prevalent among veterans compared with the general population, Dr. Keefer suggests that “it is certainly something to be concerned about in this population.” She says that IBD often begins when a person is in his or her twenties (a time when many enlist in the military) and may be in response to an environmental trigger (such as a gut infection while deployed). Hou suggests that infections related to areas of deployment may be a trigger for IBD, but this has not been confirmed, and proving causality would be very difficult. Military personnel also tend to have more psychological problems than the general public. The National Alliance on Mental Illness (NAMI) states that the rate of PTSD may be up to 15 times higher in active duty service members compared with civilians, and the rate of depression may be up to 5 times higher. “Part of the difficulty interpreting this data is an absence of a control population [veterans without IBD] to see if these trends apply across the board or whether there’s some specific intervention tied to IBD patients who are veterans,” says Arun Swaminath, MD, director of the IBD program at Lenox Hill Hospital in New York City.
Some Data With Encouraging Signs
The findings in this study were not all bad news: The annual incidence rates of mental health problems among the veterans with IBD went from 6.1 percent in 2001 to 3.6 percent in 2015. This annual trend was largely driven by a decline in depression, according to study authors. Hou explains that even though incidence had a downward trend, prevalence (proportion of patients with the condition) was still climbing. “This is an important distinction because even if new cases or diagnoses of depression and anxiety are decreasing, the overall burden and number of cases will continue to increase,” he says. Still, while the decrease in new cases of depression among IBD patients was small over time, study authors see the trend as encouraging. Hou speculates that medical improvements in managing IBD and increasing resources that the VA has made available for addressing stressors may have led to this improvement. Keefer agrees that better care may be playing a role. “There is an increased awareness of the role of screening IBD patients for depression, and this is likely resulting in earlier, effective intervention for subclinical symptoms,” she says. RELATED: Your Everyday Guide To Living Well With Ulcerative Colitis
Tips for Patients to Manage IBD and Mental Health Conditions
The researchers recognize study limitations in that findings were based on previously recorded data and not on direct observation of patients. The study was primarily conducted with white male veterans, limiting its generalizability. Also, while this study shows a relationship between IBD and mental health, it does not demonstrate that IBD causes psychological problems or vice versa. Still, Hou suggests that treating one condition may help the other. Here are a few tips for veterans with IBD bases on Hou and Keefer’s advice: Look Into IBD treatments. “It is very difficult to ‘prove’ that IBD treatment itself can lower mental health problems,” says Hou. “Studies have shown that most medications used for IBD, however, can improve health-related quality of life, which may therefore result in improvements in stressors that contribute to anxiety, depression, and PTSD.” “We are fortunate to have access to these medications in the VA, and we have a growing number of IBD-GI specialists in the VA,” he says. Investigate anti-depression medication. Keefer indicates that treating depression may potentially reduce IBD symptoms, and singles out depression drugs such as infliximab that target inflammatory cytokines (proteins) and are used to improve treatment-resistant depression. Get professional medical help as early as possible. “Patients with IBD, who are often diagnosed earlier on in life, are often unprepared to deal with the adversity a diagnosis of chronic disease brings,” Keefer says. “If strategies to build resilience to adversity are not harnessed at the point of diagnosis, patients often go on to develop mental issues, disability, and poor quality of life.” Hou advises veterans to talk with their providers if their symptoms are not under total control. “Some patients may find talking about the bowels to be embarrassing so they do not share their symptoms with their healthcare providers,” he says.
