From the AGA Journals

Less than 20% report serious disability 13 years after IBD diagnosis

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Further studies needed to examine changes in disability over time

Dr. Raymond K. Cross
Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders characterized by periodic flares followed by symptom-free periods (remission), although some patients suffer from chronic symptoms. IBD patients most commonly report abdominal pain, diarrhea, fatigue, and extraintestinal manifestations of disease that have a negative impact on quality of life and can result in work disability. The present study utilized two validated questionnaires, the World Health Organization Disability Assessment Schedule v 2.0 and the Work and Social Adjustment Scale, to examine the impact of IBD across multiple domains of life including work, home activities, social activities, and relationships. Two hundred forty-four patients from the Manitoba IBD Cohort completed a one-time assessment of disability approximately a decade after diagnosis. Nineteen percent of patients with Crohn's disease (CD) and 11% of patients with ulcerative colitis (UC) had high disability scores. The proportion of patients with high disability scores was greater than those reported in the general population but less than other chronic illnesses such as multiple sclerosis and ankylosing spondylitis. Disability extended across multiple domains including social activities and relationships. Patients with higher disability scores reported higher perceived stress, emotional distress, and decreased quality of life. Fifty-seven percent of patients with CD and 37% of patients with UC and high disability scores met criteria for depression. Furthermore, a history of major depression and long-term disease activity were associated with high disability in patients with CD.

How should these results be interpreted? It is striking that 1 in 5 patients with CD and 1 in 10 patients with UC at any given time have high disability scores. The correlation of disability scores with disease activity, high stress, and poor quality of life is not surprisingly; however, the very high rates of depression in patients with high disability scores are notable. A question raised from this study is which comes first: disability or depression? This study cannot answer that question, but it is clear that disability and depression often coexist. Aside from identifying and treating disease activity, what can the gastroenterologist do to improve work and social function in patients with IBD? First, given the extent to which IBD affects multiple domains in a patient's life, providers should take the time to ask patients how symptoms affect their ability to function both at work and socially. Second, screening for depression in patients with high disability is warranted. Referring patients with depressive symptoms and/or high stress to a psychiatric provider may improve overall function and quality of life. Further studies are needed to examine changes in disability over time and whether psychological interventions improve outcomes in patients with IBD.

Dr. Raymond K. Cross, M.S., AGAF, is associate professor of medicine and director of the IBD Program at the University of Maryland, Baltimore, and codirector of the digestive health center at the University of Maryland Medical Center, also in Baltimore. He has no relevant disclosures.


 

FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

References

Only a minority of patients with longstanding inflammatory bowel disease – 19% of those with Crohn’s disease and 11% of those with ulcerative colitis – report having moderate to severe disability, Dr. Eran Israeli and his colleagues reported in the August issue of Clinical Gastroenterology and Hepatology (doi:10.1016/j.cgh.2013.12.009).

These rates compare favorably with those for patients with other chronic inflammatory diseases of long duration such as multiple sclerosis and ankylosing spondylitis, they noted.

Until now, most studies of IBD-related disability "have focused narrowly on work and employment," while data have been limited regarding home, social, and psychological domains. Dr. Israeli and his associates assessed IBD-related disability across all of these domains by analyzing information from the ongoing Manitoba IBD Cohort Study. This longitudinal cohort included patients aged 16 years and older who had had their disease for at least a decade when they enrolled in 2002.The MICS-enrolled patients from a population-based research registry who were representative of the general population of IBD patients in Canada, and tracked disease-related factors through semiannual questionnaires and annual in-person interviews.

For their study, Dr. Israeli and his colleagues assessed disability in 125 of these study patients with Crohn’s disease and 119 with ulcerative colitis 8 years after they had enrolled in the MCIS. Approximately 60% were women, and most of the participants were younger than 50 years, married, and working full- or part-time jobs. The median duration of IBD at the time of the disability assessment was 13 years, said Dr. Israeli of Hadassah-Hebrew University Medical Center, Jerusalem, and his associates.

Overall, 19% of the patients with Crohn’s disease and 11% of those with ulcerative colitis reported having significant disability across all spheres of life, as measured using the World Health Organization Disability Schedule and the Work and Social Adjustment Scale.

These rates were remarkably consistent across all domains studied, including patients’ perception of their stress level, as measured by the Cohen Perceived Stress Scale; current emotional distress, as measured by the Brief Symptom Inventory; and quality of life, as measured by the Inflammatory Bowel Disease Questionnaire.

Not only was the prevalence of disability higher in Crohn’s disease than in ulcerative colitis, but the severity of disability also was significantly greater in the realms of home management and social relationships. Patients with Crohn’s disease also reported greater emotional distress (depression and anxiety), higher stress levels, and poorer quality of life than those with ulcerative colitis.

Overall, 27% of the participants had a history of major depression, which often predated the development of IBD. This rate was much higher than that in the general population, and it was higher still in the subgroup of patients with the most significant disability: Depression was reported in 57% of the significantly disabled patients with Crohn’s disease and 37% among the significantly disabled patients with ulcerative colitis.

Both a history of depression and a higher degree of disease activity over time were significant predictors of disability. "The strong predictive effect of lifetime history of depression on disability in IBD suggests that when depression is identified, clinicians should be as aggressive in its treatment as they are in treating the luminal manifestations of the disease," the investigators said.

Somewhat surprisingly, a history of multiple IBD-related surgeries did not predict disability. This may be because surgical resection leads to long-term remission of symptoms, at least among patients with ulcerative colitis, they added.

ginews@gastro.org

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