Many patients with inflammatory bowel disease (IBD) have unmet needs which affect their emotional wellbeing. A review, published in Gastroenterology, highlighted the burdens caused by unaddressed or uncontrolled symptoms and suggested ways physicians could address these burdens in clinical practice.
IBD affects roughly 1% of the world population, with instances increasing among pediatric populations and those living in developing nations. Although medical management of IBD has advanced in recent years, there remains a gap in care for physical and emotional wellness; patients often report pain, fatigue, and need for psychosocial care.
The most recent Selecting Therapeutic Targets in IBD (STRIDE) guidelines emphasized a treat-to-target approach for IBD care which includes prompt diagnosis, early and effective intervention that maintains tight control over inflammation, and optimized management of clinical symptoms, all of which are aimed at reducing disability and improving quality of life (QOL).
Though recent guidelines have emphasized the importance of improving QOL, determining whether a patient’s clinical symptom targets are met along with reducing disability is difficult in clinical practice. This is partially due to the subjective nature of QOL symptoms and the fact that many symptoms overlap. Patients themselves are often unable to disentangle the cause and effect of symptoms and treatment, obscuring treatment outcomes from unaddressed symptoms.
The most commonly reported unmet needs include symptoms of pain, fatigue, depression, anxiety, sexual dysfunction, body image dissatisfaction, and disordered eating.
Pain lasting >6 months with no organic cause is reported by about 60% of patients. Pain can be caused by inflammation, stricture, obstruction, and fistula, among other causes, and can be perpetuated through mind-body pathways. Fatigue is reported by up to 50% of patients in IBD remission and can have major impacts on QOL. Listening to a patient’s concerns and acknowledging their experiences remain key aspects of pain and fatigue management. Clinicians should also try to maintain a balance between investigating possible routes of cause without subjecting patients to seemingly unending testing.
Depression and anxiety have been reported in between 25% to 80% of patients with IBD. These symptoms vary throughout the disease course and may be highly dependent on current symptomology, although some evidence suggests that many patients have chronic anxiety disease symptomology. Patients should be screened for psychological symptoms and referred for mental health care when appropriate.
A study found that most patients with IBD have a desire to discuss these psychosocial concerns with their clinician; however, these aspects of health are not part of routine clinical assessments. The reason for this is due in part to limited time during office visits as well as the common perception that psychosocial assessments are not robust.
The review authors suggest that clinicians ask simple questions, such as “How are you emotionally handling everything?” and/or “What other areas of your life have been impacted by your IBD?” By directly addressing the patient’s psychosocial health, rapport could be strengthened without consuming too much of the patient encounter time. In addition, allowing the patient to control the visit by first asking “What particular aspects would you like to cover today?” may allow patients with these concerns to bring them up at the start of an appointment.
If a patient discloses a psychosocial concern, clinicians should be prepared to validate the patient’s concern, assign a practitioner to follow-up on the patient’s wellbeing, and refer the patient to a mental health professional.
Some institutions have addressed this gap in care by delivering psychosocial care via fully or partially integrated gastro-psychology models. These models integrate a psychotherapist within the gastroenterology care center either full or part time. Some studies have found that unplanned healthcare needs were decreased when patients were screened for mental health comorbidities during their IBD consultation. Additional, long-term study is needed to assess the efficacy of these approaches.
Furthermore, there remains a need for more study on the interaction between psychosocial symptoms and the underlying pathophysiology of IBD. For example, it remains unclear why treatments which target inflammation improve psychological comorbidities for some patients. With improved understanding of the complex interaction between inflammation and psychology, more effective assessment and interventions will likely be derived.
“Pain, fatigue, depression, anxiety and emotional wellness often remain overlooked in the setting of IBD care and are also often perceived as untreatable issues to be endured by patients with IBD,” the authors noted. “While in some instances good control of inflammation leads to good symptom control and psychological wellness, in other circumstances, despite good disease control, the patient still suffers with pain, fatigue, depression, anxiety and reduced emotional wellness. This suggests that control of pain, fatigue, depression, anxiety and emotional wellness should be goals or targets of therapy in IBD in their own right,” they concluded.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Keefer L, Bedell A, Norton C, Hart AL. How should pain, fatigue and emotional wellness be incorporated into treatment goals for optimal management of IBD? Gastroenterol. Published online December 11, 2021. doi:10.1053/j.gastro.2021.08.060