To our knowledge, this study firstly investigated the effectiveness of routine screening IBDs-patients for psychological distress on the course of IBDs in a large center for the management of IBDs. Our findings demonstrated a significant disparity in psychological problems screening, particular for those with active disease, hospitalized IBDs with routine screening reported a better outcome of progression-free survival without disease worsening during a 12-month follow-up.
The aetiology, severity and progression of such IBDs disorder are thought to be influenced by multiple factors, among which, psychological factors are identified as one of the major contributing factors based on the available evidence [13]. Based on data covering the UK primary care, which included 28,352 with UC and 20,447 with CD, patients with IBDs were more likely to develop anxiety (HR = 1.17 (95%CI: 1.11–1.24)) and depression (HR = 1.36 (95%CI: 1.31, 1.42)) as opposed to controls [14]. According to recent systematic review and meta-analysis, there was evidences for a significant association between symptoms of depression, anxiety and the risk of disease activity flare in IBDs during longitudinal follow-up, with an odds ratio of 1.69 (95%CI: 1.34, 2.13) [15]. In recent years, the brain-gut axis enabling the cross-talk between the nervous system, such as the central nervous system, autonomic nervous system and enteric nervous system, the endocrine system and the immune system was proposed to explain the above-mentioned observations. According to the preliminary study, psychological problems is involved in the permeability, motility, sensitivity and secretion of the intestine system, and then impacts neuroendocrine immune regulation and damages the intestinal immune function and microbiota homeostasis to promote the development and reactivation of intestinal inflammation in animal models [16, 17]. In turn, disordered gut homeostasis in IBD was responsible for driving the brain pathology, exacerbating inflammatory response in the central nerve system, and resulting in anxiety- and depression-like behavior [18]. Besides the gut-brain axis mechanism, chronic psychological problems could also activate inflammatory response through the sympathetic and parasympathetic nervous system, and a certain degree of inflammatory cytokines in the serum of depression and anxiety disorder patients were revealed in a systematic review published amongst 1718 studies [19]. Also, several results suggest that chronic psychological problems lead to activation of Hypothalamic-Pituitary-Adrenal Stress axis and increased glucocorticoid release failing to modulate inflammatory activity. The form of chronic inflammation will support the pathophysiologic cycle of neurotoxicity, structural neural damage, and diminish the activity and level of brain-derived neurotrophic factors leading to a significant decrease of the therapeutic factors in clinical depression [20]. As a result, identifying the temporal trajectory of psychological disturbances may allow greater insight into understanding the progression of subclinical events as potential ground for disease severity in IBDs. Furthermore, help better interventions in controlling disease to reduce burden of illness and improve quality of life.
As a result, there is a need for psychological distress screening in IBDs care settings. Whereas, the current approach to psychosocial intervention suggests that clinicians are intervening too late during patient care [6]. In order to address these gaps, we addressed mental-health disorders in time during busy clinical appointments and provided available resources for appropriate screening and treatment referrals to psychological doctors. According to our results, chose to 30.4% of cases were identified to be at risk of anxiety and 25.8% of depression in the screening group, which was consistent with previous researches [21], demonstrating that the implementation of routine psychological problems screening for hospitalized IBDs could effectively detect alterations in psychological status and distinguish cases presenting with risk of psychological problems hospitalized IBDs population to overlook patients who need and could benefit from early psychological interventions.
According to our results, patients in screening cohort were more likely to report a longer length of hospital stay, reflecting the fact that depression and/or anxiety disorder could contribute to exacerbating symptoms to prolong the hospital stay in hospitalized IBDs, which was consistent with previous research reporting the OR for hospital length-of-stay in cohort with anxiety and depression disorders amongst 1,718,736 IBDs were 0.05 (95%CI: 0.03, 0.07), p < 0.00122. As a result, the significantly longer hospital stay due to psychiatric comorbidities might also lead to a higher rate of hospital-acquired conditions including venous thromboembolism and difficile infection, which was observed in screening cohort than controls. Furter more, IBDs related psychological disorders were able to reduce medication adherence, which was considered as both an outcome and a risk factor of this vicious circle, and then result in worsening management and prognoses of disease [23]. Consequently, screening and managing psychological comorbidities in IBDs patients during the hospitalization could effectively reduce flare-ups, decrease non-adherence to medications and increase adherence for outpatient follow up, thus potentially improve clinical outcomes [22, 24]. Relaxation, IBD psychoeducation, cognitive restructuring, distraction and social skills were reported as the most utilized interventions for depression and anxiety in IBDs in systematic review, and have shown efficacy in decreasing psychological stress levels and effectively improves inflammatory biomarkers in IBDs [25, 26]. In accordance with the above-mentioned evidences, our findings also proved a wide impact in terms of long-term progression-free survival without IBDs-related emergency visits, readmission and surgeries after integrating screening and referral to treatment for psychological stress.
The previous nomogram model constructed based on the factors influencing the HR-QoL of early patients with IBDs showed that disease activity and psychological distress were the most significant factors affecting the QoL of cases with IBDs, with the highest proportions in the model [27]. On basis of current evidence from systematic review of prospective cohort studies, appropriate intervention for patients identified with psychological factors would reduce IBDs symptom exacerbation, and therefore improve patients’ quality of life [28]. Our results found that patients in screening group revealed a greater HR-QoL during a 12-month follow-up as compared to controls, which provided the evidence that patients with IBDs and anxiety and/or depression might benefit from certain routine screening for psychological issues and referral to effective interventions.
This study has several limitations. First, investigators responsible for outcome assessment failed to keep blind due to the nature of the retrospective study. Second, we did not enroll a healthy control. Third, we did not record the other confounders and infer causality for the described association. In the future, a well-designed, randomized, controlled study with a large sample was needed to verify the findings of the present study.
In conclusion, patients in screening cohort had a better progression-free survival from IBDs-related emergency visits, readmission and surgeries after discharge than those without these conditions, and also exhibited a better QoL during a 12-month follow-up period. It should be encouraged that hospitalized IBDs in active phase should be routinely screened for psychological problems that could influence disease course.