Chronic diseases can trigger negative emotions and self-talk in patients, preventing or eroding clinical improvement. With inflammatory bowel disease (IBD), this tendency is exacerbated by the nature of the symptoms and their social impact.
Fifteen years ago, David Schwartz, M.D., of Vanderbilt University Medical Center was ahead of his time in establishing an IBD clinic that paired a psychologist with the gastroenterologist. Today the Vanderbilt Inflammatory Bowel Disease Clinic consists of six physicians as well as nurse practitioners, physician’s assistants, dieticians and social workers. Gastroenterologist Dawn Beaulieu, M.D., is involved in the research that underlies their model of care.
“The less patients struggle with mental health problems, the better care they take of themselves – they eat better, sleep better and are more medically compliant. This affects their disease progression,” Beaulieu said. “We are tracking and participating in research that affirms what we have seen anecdotally for years.”
Roots of the Vicious Cycle
Studies over the past few years show that symptom management has a high association with depression, anxiety, degree of social support, socioeconomic status and other factors. Lawrence Gaines, Ph.D., a psychologist and fifteen-year veteran with the Vanderbilt IBD Clinic, has analyzed these relationships.
About 30 percent of people with IBD report symptoms of anxiety and depression, and those who do have significantly worse symptoms and outcomes. “This puts the vicious cycle of stress and IBD flare-ups in a clearer light,” Gaines said. “It may begin with idiopathic IBD, but we know that improving a patient’s mental health is pivotal in helping them keep their disease well managed.”
“The less patients struggle with mental health problems, the better care they take of themselves – they eat better, sleep better and are more medically compliant. This affects their disease progression.”
A 2020 paper by Gaines et al., asking if reverse causality accounts for the depression-Crohn’s disease (CD) relationship, strengthens confidence in the assertion that depression reliably predicts worsening CD more than CD predicts worsening of depression.
“The most common complaint of patients with Crohn’s disease is chronic fatigue that results in a sense of disappointment with oneself, or a belief that they are disappointing others in their role as mother, father, husband, wife, worker, etc. This negativity to the self is the essence of depression.”
In the Clinic – Whole Person Care
Often inextricably bound with stress and depression, sleep disturbances, infection and medications are common triggers for flares and worsening symptoms. Beaulieu says that self-care in avoiding these triggers and good sleep hygiene are where mental health therapy can impact the disease the most.
“Patients who are stressed or depressed tend not to exercise, follow a prescribed diet or get quality sleep. If they are smokers, they are more likely to stop a cessation program or never start in at all,” she said.
At the Vanderbilt IBD Clinic, patients meet with Gaines or an IBD social worker before they see a physician. When needed, the IBD team refers the patient to a mental health provider for ongoing therapy. “This help, plus whatever they can do to garner and accept social support from their family and friend groups, can make a tremendous difference in lowering psychological stress,” Beaulieu explained.
The initial sessions with a mental health provider give Beaulieu a sense for the patients’ mental state and life stressors before she sees them and prescribes or adjusts IBD medications.
She and a dietician then work together to outline dietary recommendations, which vary depending on whether the patient is in a flare-up or remission. “In addition to dietary intervention, we also focus on educating them about how what we feed ourselves affects our microbiome in negative or positive ways so they understand and can buy into the dietary plans going forward,” Beaulieu said.
Coping with the Unknown
Even with therapy, a degree of social stress is ever-present with IBD. Decisions to go out in public are always shadowed by the threat of an incontinence incident or multiple trips to the restroom.
“The strength my patients show is continually inspiring,” Beaulieu said. “Despite all the emotional impact IBD has on their lives, our one common message is to not give up – trust in yourself and your care team. Although this disease will impact all facets of your life, it does not need to control you. You have power.”
