In this podcast, Charles Bernstein, MD, discusses psychiatric comorbidities that occur in patients with Crohn’s disease and how they differ from other IBD disorders. the necessary collaboration within the healthcare team managing patients with IBDand 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) 2022 conference titled “Addressing Mental Health and Psychiatric Comorbidities in IBD.”
Additional resource:
- Bernstein C. Approach to psychiatric and mental health comorbidities in IBD. Talk presented at: AIBD 2022; December 5-7, 2022; Orlando, Florida. Accessed November 3, 2022. https://www.advancesinibd.com/
Dr Charles Bernstein, is a gastroenterologist and 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 her moderator Jessica Bard with Consultant360, a multidisciplinary medical information network.
Dr. Charles Bernstein is here to talk to us today about his session at AIBD 2022 titled: “Addressing Mental Health and Psychiatric Comorbidities in IBD.” Dr. Bernstein is a gastroenterologist and director of the IBD Clinical Research Center at the University of Manitoba in Winnipeg, Canada. Let’s listen inside.
Jessica Bardo: Well, thanks again for joining us on today’s podcast. If you don’t mind, please give us a brief overview of your session on mental health and psychiatric comorbidities in IBD.
Dr Charles Bernstein: Well, our group here at the University of Manitoba has had a great interest in exploring mental health as it relates to people with IBD and other chronic immune diseases, frankly, for over 20 years. And I’ve had the great, great fortune to collaborate with two very special people: Dr. Lesley Graff, who is the current head of the department of clinical health psychology at our university, but she was a young clinical psychologist that I hitch. 1990 to work with us at GI, and the late Dr. John Walker, who was really a wonderful, magnificent guy who was both a wonderful doctor and a wonderful researcher and a very thoughtful guy.
So I’ve been working with clinical psychologists for a long time, both doing research and caring for patients, and in the last five to 10 years, I’ve also developed a collaboration with several wonderful psychiatrists here in Winnipeg: Jitender Sareen, Maria [inaudible 00:01:51]James Bolton, and together as a group with both us and IBD, and also Ruth Ann Marrie on MS and Carol Hitchen [inaudible 00:02:05] in rheumatoid arthritis, we’ve really seen the intersection between psychiatric comorbidity and chronic immune diseases as well, because the overlap is quite large. And I think any lesson that we present on IBD really applies to anyone with a chronic immunoinflammatory disease.
Jessica Bardo: So we know that the management of IBD patients has many layers: historically, gastroenterologists, PCP, possibly a surgeon. Is the care team still like this today?
Dr Bernstein: That’s a great point, Jessica, because they’re still the core of the care team, those three types of doctors. And especially in our group, we identified a long time ago that we needed a lot of help managing patients, for example, their mental health, that myself and my colleagues have some skills in identifying mental health issues, but you don’t have the skills to manage and manage them for the long term. So a key piece of a care team should be a clinical health psychologist or therapist of some kind, who can help identify actual specific diagnoses and the kinds of management approaches that are appropriate.
We also have a clinical dietitian who does research with us and is a very important member of our team. Every IBD patient has a question, almost within the first few minutes after diagnosis, of: what should I eat and what should I not eat? And frankly, there are only underweight IBD patients who need advice on nutrition and weight gain, and there are overweight IBD patients. And interestingly, there’s this intersection between nutrition and body weight and health and mental health, and we have to work as a team.
More recently, especially after an article that we 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, they can’t keep appointments, they can’t take care of their children, they can’t take care of their elderly parents if they are unwell. There are all sorts of social issues that arise for IBD patients, and we have shown that patients of lower socioeconomic status, other things being equal, fare worse and have worse outcomes.
Jessica Bardo: So we know that the manifestation of psychiatric comorbidities in patients with IBD may 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 on that?
Dr Bernstein: Well, psychiatric comorbidity and mental health issues are a problem for both UC and Crohn’s patients. They are certainly not specific to Crohn’s disease on UC. We may see a little more mental health comorbidity in Crohn’s disease on the basis of AEs. The maximum age of incidence of Crohn’s disease, in the third decade or in the twenties. They are younger, they are shaping their careers, their educational trajectories, their life partners, potentially. And for ulcerative colitis, the age of incidence is a little higher, even from the twenties to the sixties or seventies. And so you see patients, on average, maybe older. It’s a bit of a tricky question looking at age and mental health. Often there are more mental health problems in adolescents and young adults, but it can of course recur in adulthood. So there’s an age issue, and that may affect how we perceive that Crohn’s disease perhaps carries a greater mental health burden.
Patients with Crohn’s disease can have some complications that make it especially difficult, even with interpersonal relationships, for example, perianal or genital fistulas, which may have as many as 20-30% of Crohn’s disease patients. Those are a unique problem beyond stomach ache or diarrhea, for example. But the problems of, for example, fatigue are problems in both Crohn’s disease and ulcerative colitis. That is a difficult subject. Sometimes fatigue reflects some mental health problems.
And we’ve done a lot of work on stress in relation to IBD symptoms, and people with UC and Crohn’s disease, aside from their disease, have the same stressors that we all have, and we’ve reported it. The top five stressors for a large cohort of IBD patients that we reported over a decade ago were the things you would think about: family stress, job stress, health concerns but not necessarily IBD, finances. IBD-related concerns were 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 problems related to Crohn’s disease, but they are certainly related to both.
Jessica Bardo: 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 other parts of Canada and the United Kingdom, that have been exploring mental health in IBD. So there’s been a lot of work to define the burden of psychiatric comorbidity. There has been a lot of work exploring the interconnectedness and interrelationship between symptoms and stress, mental health symptoms and outcomes, adverse outcomes in people who have psychiatric comorbidity, more use of biologics, more hospitalizations, more health care utilization. , and so on.
What we don’t understand, and we’re falling behind, is the biology of mental health disorders and how that biology can affect the biology of IBD. So, as an example, we have reported in two different studies that IBD patients can have psychiatric diagnoses many years before their IBD is actually diagnosed. So it is not that they have psychiatric comorbidity as a response to now having a chronic disease. Have had depression or mood disorders for a few years at a higher rate than the general population. So the question arises: Is there something biologically going on when you have depression, maybe that’s inflammatory, that is synchronizing with the inflammatory process in IBD and ultimately facilitating that trigger?
There is much to learn about the biology of mental health and how it relates to chronic immune disease. I think that’s really a giant frontier. We are doing work related to brain imaging, both structural and functional MRIs, as it relates to mental health and chronic immune diseases. We would like to do more. We have worked with neuropeptides in relation to IBD. We would like to do more work in relation to the actual inflammatory response in mental health.
So that’s from an ideological, biological perspective. And then there’s a huge field waiting to be tapped to really explore the optimal treatments of mental health disorders in IBD, because right now what we’re doing is treating IBD patients the same way we treat someone in the general population, because that’s all we know. We are extrapolating that the treatments will work the same. It is possible, due to the underlying chronic immune disease and systemic immune response, that the treatments work differently. We just don’t know.
Jessica Bardo: 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 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 much more than just ask people, “Do you have a stomach ache? How many bowel movements do you have a day?” We have to ask people, “Do you have any depression or anxiety issues? Are you going through something stressful? Is there something new going on in your life?” We have to recognize that many of the symptoms are triggered by stress, but they don’t necessarily mean that your disease, your IBD, is active.
So I think we just have to be better at identifying, at least participating in the conversation, and I think we have to learn in our own communities of practice if we don’t have our own favorite psychologists to work with. he or she, 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 point.
Jessica Bardo: Well, thank you very much for being on today’s podcast, Dr. Bernstein. Anything else you would like to add in this part 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 talk about it.
