Mental Health & IBD
Living with a long-term health condition such as Inflammatory Bowel Disease can often have an impact on our mental health.
Yesterday was world mental health awareness day and as people with Inflammatory Bowel Disease are more than twice as likely to be diagnosed with a mental health disorder than the general population (1), I thought it would be a good opportunity to raise awareness on the link between Inflammatory Bowel Disease and mental health.
What exactly do we mean by mental health?
Being able to cope with the normal stresses of everyday life, bring productive and engaged with the world around us, and being able to adapt to change in a positive way are all signs of mental health (2). Feeling positive about ourselves, feeling valued and having a good support network of family and friends also contribute towards our wellbeing.
Signs to look out for which may indicate you need support.
Our home life, social environment and personal circumstances can all influence our mental health. If you are experiencing negative thoughts and emotions, low mood, feelings of worthlessness, lack of interest and ability to focus, low energy/ fatigue, overwhelming worry, nervous for no particular reason or afraid that something awful might happen (2), then this could be signs of depression and anxiety and you may need to seek advice and support from a healthcare professional.
The connection between IBD and Mental Health
Depression and anxiety are the two leading mental health disorders. Studies have found that more than 1 in 4 people (27%) with IBD experience depression, which is more than double that of the general population (3). When we are experiencing a flare-up of symptoms it can be much higher, with a reported 80% of us experiencing anxiety and 60% depression (4).
Mental health issues are also more common during the first year after diagnosis, as we try and come to terms with an uncertain diagnosis, side effects of medications, an overwhelming amount of information and fear over what the future may hold.
Living with IBD may also lead to social isolation, as we avoid leaving the house or participating in social events, such as meals out with friends, due to a fear of food and embarrassment that we may lose control of our bowels in public.
We may not feel positive about ourselves and our appearance, due to surgery, weight-gain caused by medications, weight-loss from malabsorption, and other medication side effects. We feel different to friends and find it difficult to open up, share and discuss what we are going through. All of this can increase feelings of loneliness, isolation and anxiety.
Post-Traumatic Stress and IBD
Although there has been very little research and discussion around IBD and PTSD, it is estimated that 32% of people with IBD may experience post-traumatic stress symptoms, which include physical pain manifestations, flashbacks, nightmares and avoidance of certain situations. These symptoms are brought about by traumatic events we may have experienced related to our disease (10). Events such as surgery, hospitalisations, bad flare-ups and even situations where we might not have been able to get to or find toilet facilities when required, could all contribute to mental trauma.
Having PTSD symptoms is also associated with worse IBD outcomes and lower medication response rates, so it may be important to recognise these symptoms and to seek professional help from a healthcare professional (6).
The Gut/Brain Axis.
Everything we have discussed above possibly does not come as a surprise, given what we deal with on a day-to-day basis when living with IBD. However, there may be more to the link between IBD and Mental Health than meets the eye.
Our brains are connected to our guts (stomach and intestines) by something called the vagus nerve. It has been understood for a long time that our thought process may influence our guts (have you ever experienced butterflies in your stomach when feeling nervous about something?). However more recently researchers have started to believe that our gut activity may also affect our brains, which could mean that what we eat has an influence on our mood (3).
The ‘smiles’ trial was a first of its kind, a 12-week randomised control trial comparing traditional counselling methods with dietary interventions in people with clinical depression. The result of which showed dietary therapy to be more effective than counselling, with a direct correlation between how closely the participants followed the dietary advice and the improvement they made (8). This is one of the first trials in humans which adds support to the hypothesis that improving gut health can have a positive impact on how we feel.
The Gut/Brain/Microbiome Axis
As researchers progress in their understanding of the gut microbiome (community of bacteria/virus/parasites living in our gut), they have uncovered one of the likely mechanisms behind how our gut and brain communicate to each other. As living organisms our gut bacteria need to eat to produce energy and as they do so they produce chemicals, namely, short chain fatty acids (SCFAs), which appear to play a significant role in our health.
For people like us with IBD this leads to a chicken and egg type situation. Do I experience depression or anxiety because of my IBD and the way it impacts my life or is my depression and anxiety triggering or making by IBD worse? Interestingly, several studies have found that mental health episodes pre dated IBD diagnosis by several years (5).
Either way, it looks like it is important to address any mental health issues in order to improve disease prognosis, as studies have shown IBD with a secondary diagnosis of depression, both lowers medication response and increases the risk of requiring surgery in Crohn’s disease by 28% (6).
What can we do?
Although we may feel like we are not in control of our disease, the good news is we may be able to change our microbiome and how we think. For centuries the brain was considered to be fixed, but advances in neuroscience have highlighted its ability to change and adapt as a result of our internal and external environment. Research has also shown that we are likely to be able to influence our microbiome diversity by making diet and lifestyle changes (11).
Where can we get help?
If you feel you need support with your mental health you can get in touch with your GP or IBD team and ask to be referred for help. There is also some great information on the MIND (mental health charity) website particularly on how to find a therapist.
If you would like help and support with your IBD and what dietary and lifestyle changes would be appropriate for you, please get in touch with me. You can book a free call, where I can get to know you, your journey, your struggles, your life, and we can chat about the best route forward for you. You can also ask any questions you have about working with me.
This article was written by Helen Morris (MSc, ANutr) who is our wonderful intern at The NALM Clinic. She's passionate about IBD nutrition research and sharing evidence based IBD nutrition information having lived with Crohn's Disease since 2018.
References
www.crohnsandcolitis.org.uk/about-crohns-and-colitis/publications/mental-wellbring
https://www.euro.who.int/__data/assets/pdf_file/0004/404851/MNH_FactSheet_ENG.pdf
Regueiro, M. (2017). Review Etiology and Treatment of Pain and Psychosocial Issues in Patients with Inflammatory Bowel Diseases. Gastroenterology. 152(2):430-439.e4.
Walker, J.R. (2008). The Manitoba IBD cohort study: a population-based study of the prevalence of lifetime and 12-month anxiety and mood disorders. Am J Gastroenterol. 103(8):1989-97.
Fuller-Thomson E, (2015). Robust Association Between Inflammatory Bowel Disease and Generalized Anxiety Disorder: Findings from a Nationally Representative Canadian Study. Inflam Bowel Dis. 21(10):2341.
Ananthakrishnan, A.N. (2013). Psychiatric comorbidity is associated with increased risk of surgery in Crohn’s disease. Aliment Pharmacol Ther 37:445–454.
Walker, J.R. (2008). The Manitoba IBD cohort study: a population-based study of the prevalence of lifetime and 12-month anxiety and mood disorders. Am J Gastroenterol. 103(8):1989-97.
Jacka, F.N. (2017). A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial). BMC Med 15, 23.
Addolorato, G. (1997). Inflammatory bowel disease: a study of the association between anxiety and depression, physical morbidity, and nutritional status. Scand J Gastroenterol. 32(10):1013-21.
Tiffany, H. (2019). Initial Assessment of Post-traumatic Stress in a US Cohort of Inflammatory Bowel Disease Patients, Inflammatory Bowel Diseases, 25(9), 1577–1585,
Leeming, E.R. (2019). Effect of Diet on the Gut Microbiota: Rethinking Intervention Duration. Nutrients, 11(12), 2862