Mental Health, Psychiatric Comorbidities in IBD, Crohn Disease

In this podcast, Charles Bernstein, MD, speaks about psychiatric comorbidities that occur in patients with Crohn disease and how they differ from other IBD disorders, the collaboration necessary within the clinician care team managing patients with IBD, and the connection between IBD symptoms and mental health. Dr Bernstein also spoke about these topics during his session at The Advances in Inflammatory Bowel Diseases (AIBD) conference 2022 titled “Addressing Mental Health and Psychiatric Comorbidities in IBD.”

Additional Resource: 

• Bernstein C. Addressing mental health and psychiatric comorbidities in IBD. Talk presented at: AIBD 2022; December 5-7, 2022; Orlando, FL. Accessed November 3, 2022. https://www.advancesinibd.com/

Charles Bernstein, MD, is a gastroenterologist and the Director of the IBD Clinical Research Center at the University of Manitoba (Winnipeg, Canada).

TRANSCRIPTION:

Jessica Ganga: Hello everyone, and welcome to another installment of Podcast360, your go-to resource for medical news and clinical updates. I'm Jessica Ganga, along with your moderator Jessica Bard with Consultant360, a multidisciplinary medical information network.

Dr Charles Bernstein is here to speak with us today about his session at AIBD 2022 titled: “Addressing Mental Health and Psychiatric Comorbidities in IBD.” Dr Bernstein is a gastroenterologist and the Director of the IBD Clinical Research Center at the University of Manitoba in Winnipeg, Canada. Let's listen in.

Jessica Bard: Well, thank you again for joining us on the podcast today. If you don't mind just providing us with a brief overview of your session addressing mental health and psychiatric comorbidities in IBD.

Charles Bernstein, MD: Well, our group here at the University of Manitoba has had a long interest in exploring mental health as it relates to persons with IBD and persons with other chronic immune diseases, quite frankly, for well over 20 years. And I've had the great, great fortune of collaborating with two very special people: Dr Lesley Graff, who is the current department head of clinical health psychology at our university, but she was a young clinical psychologist that I got my hooks into the 1990s to work with us in GI, and the late Dr John Walker, who was really a magnificent, wonderful guy who both was a wonderful clinician and a wonderful researcher and a really thoughtful, thoughtful guy.

So I've been working with clinical psychologists for a long time, both researching and also caring for patients, and in the last five to ten years, I've also developed a collaboration with a number of wonderful psychiatrists here in Winnipeg: Jitender Sareen, Marie [inaudible 00:01:51], James Bolton, and together as a group both with us and IBD, and also with Ruth Ann Marrie in multiple sclerosis and Carol Hitchen [inaudible 00:02:05] in rheumatoid arthritis, we've really also looked at the intersection between psychiatric comorbidity and chronic immune diseases, because the overlap is quite great. And I think any lessons that we bring forward in IBD really pertain to anyone with a chronic immunoinflammatory disease.

Jessica Bard: So we know that managing patients with IBD, there are many layers: historically, gastroenterologists, PCP, possibly a surgeon. Is that still what the care team looks like today?

Dr Bernstein: It's a great point, Jessica, because they are still the core of the care team, those three types of physicians. And especially in our group, we've identified a long time ago that we needed a lot of help in managing patients, for instance, their mental health, that I, myself and my colleagues have some skills in identifying mental health issues, but we don't have the skills in managing them and managing them over the long term. And so a very key piece of a care team should be a clinical health psychologist or a therapist of some kind, who can help identify actual specific diagnoses and the types of management approaches that are appropriate.

We also have a clinical dietician who does research with us who's a very important member of our team. Every IBD patient has a question, almost within the first several minutes post-diagnosis, of: what should I eat and what shouldn't I eat? And quite frankly, there are just underweight IBD patients who need advice on nutrition and to gain weight, and there are overweight IBD patients. And interestingly, there is this intersection between nutrition and body weight and health and mental health, and we have to work as a team.

Most recently, especially after a paper that we had reported on the importance of socioeconomic status and outcomes in IBD, a social worker is really a critical part of the team as well, because there are patients who just can't afford what we're planning for them, can't get to appointments, can't care for their children, can't care for their aged parents if they're unwell. There are all kinds of social issues that emerge for patients with IBD, and we've shown that patients of a lower socioeconomic status, with all other things being equal, do worse and have worse outcomes.

Jessica Bard: So we know that the manifestation of psychiatric comorbidities in patients with IBD, they might be a little more problematic in patients with Crohn's disease versus UC. Can you talk to us about the differences in that and the gaps in the research of that?

Dr Bernstein: Well, psychiatric comorbidity and mental health issues are a problem for both patients with UC and Crohn's. They're certainly not specific to Crohn's over UC. It's possible that we may see a little bit more mental health comorbidity in Crohn's disease on the basis of AE. The peak age of incidence of Crohn's diseases, in the third decade or the twenties. They're younger, they're forming their careers, their educational paths, their life partners, potentially. And for ulcerative colitis, the age of incidence is a little bit more, even right from the twenties to the sixties or seventies. And so you see patients, on average, maybe older. It's a bit of a loaded question to dissect age and mental health. There's often more mental health problems in teenagers and young adults, but it can recur, of course, in one's older life. So there's an age issue, and that may affect the way we perceive Crohn's disease to maybe carry more mental health burden.

Crohn's disease patients may have some complications that make it especially difficult, including with interpersonal relationships, for instance, perianal or genital fistulas, that up to 20% or 30% of patients with Crohn's disease may have. Those are a unique problem beyond just belly pain or diarrhea, for example. But the issues of, for instance, fatigue are issues in both Crohn's disease and ulcerative colitis. That's a difficult issue. Sometimes the fatigue is reflecting some mental health issues.

And we've done a lot of work on stress as it relates to symptoms in IBD, and people with UC and people with Crohn's disease, other than their disease, have the same stressors that we all have, and we've reported this. The top five stressors for a large cohort of patients with IBD that we reported over a decade ago were the things that you'd think of: family stress, job stress, worried about health but not necessarily IBD, finances. IBD-related worries was not in the top five. And so people have stressors, whether they have Crohn's disease or UC. So there may be a slight increase in mental health issues related to Crohn's disease, but they're germane to both, for sure.

Jessica Bard: What would you say is next for research on this topic?

Dr Bernstein: Well, we've done a lot of work, as have others, and there are some wonderful groups around the world, in the United States and elsewhere in Canada and the UK, that have been exploring mental health in IBD. So there's been a lot of work defining the burden of psychiatric comorbidity. There's been a lot of work exploring the interconnectedness and interrelationship between symptoms and stress, symptoms and mental health outcomes, adverse outcomes in people who have psychiatric comorbidity, more use of biologic agents, more hospitalizations, more healthcare utilization, et cetera.

What we don't understand, and we're lagging behind, is the biology of mental health disorders and how that biology may impact on the biology of IBD. So as an example, we've reported in two different studies that patients with IBD may have psychiatric diagnoses many years before their IBD is actually diagnosed. So it's not that they have psychiatric comorbidity as a response to now having a chronic disease. They've had depression or mood disorders for some years at an increased rate over the general population. So it begs the question as to: is there something biologically going on when one has depression, perhaps that's inflammatory, that syncs with the inflammatory process in IBD and ultimately facilitates that trigger?

There's so much to learn about the biology of mental health and how it relates to a chronic immune disease. I think that's really a giant frontier. We're doing some work related to brain imaging, both structural and functional MRI, as it relates to mental health and it relates to chronic immune disease. We'd like to do more. We've done some work with neuropeptides in relation to IBD. We'd like to do more work in relation to the actual inflammatory response in mental health.

So that's from an ideologic, biologic perspective. And then there's a huge field awaiting to be tapped into really explore the optimal treatments of mental health disorders in IBD, because right now what we're doing is we're treating patients with IBD the way we would treat somebody in the general population, because that's all we know. We're extrapolating that the treatments are going to work the same. It's possible, because of the underlying chronic immune disease and the systemic immune response, the treatments may work differently. We just don't know.

Jessica Bard: This is so fascinating. I feel like we could talk about this for the rest of the day here, but what would you say are the overall take-home messages from our conversation today and from your session?

Dr Bernstein: I've been saying this for probably a decade. People who have heard me speak before have probably heard me say this, that as gastroenterologists, we have to be better. We have to do a lot more than just ask people, "Are you having belly pain? How many bowel movements are you having per day?" We have to ask people, "Are you having any issues with depression or anxiety? Are there any stressors going on? Anything new happening in your life?" We have to recognize that a lot of symptoms are driven by stress, but don't necessarily mean that their disease, their IBD, is active.

So I think that we just have to be better at identifying, at least engaging in the conversation, and I think we have to learn in our own practice communities if we don't have our own favorite psychologists to have our hooks into to work with him or her, that we need to learn what's in our community to access, because it's a guarantee that a third of your patients, at least, if not half, may need that at some time.

Jessica Bard: Well, thank you so much for being on the podcast today, Dr Bernstein. Anything else you'd like to add in this portion here?

Dr Bernstein: As you say, we could talk about it for hours. We'll talk about it for an hour in Orlando, but I'm happy to chat about this.