Antidepressant treatment
Reasons for taking antidepressant treatment
Patients reported between one and three (M = 1.63, SD = 0.81) reasons for taking an antidepressant. The most commonly stated reasons were depression or depressed mood, reported by 10 patients (66.7%), and anxiety or anxious mood, reported by seven patients (46.7%). Other reported reasons included sleeping problems, stress, diarrhoea, anger, Asberger’s syndrome, and obsessive compulsive disorder.
Antidepressant treatment history
For the majority of patients (13, 86.7%) their current or recent treatment with antidepressants was the first time they had received the treatment. The duration of antidepressant treatment ranged from four and a half months to 13 years, with an average of 5.6 years (SD = 4.8). The most commonly prescribed medications were Amitriptyline and Sertraline, with three patients (20.0%) each, followed by Paroxetine and Escitalopram with two patients (13.3%) each, and Duloxetine, Nortriptyline, Fluoxetine, Citalopram, and Mirtazapine being used by one patient each.
The majority of patients (10, 66.7%) reported experiencing no side effects from antidepressant therapy. Five patients (33.3%) reported experiencing between one and three distinct side effects (M = 2.3, SD = 0.6), with two patients reporting dry mouth, and one patient each reporting diarrhoea, abdominal pain, headaches, weight gain, heart burn, emotional numbness, and anhedonia. One patient reported a cessation of the side effects of antidepressant treatment after a change in the type of antidepressant he was using from Mirtazapine to Sertraline. Three patients (20.0%) discussed the difficulty in dissociating symptoms that may be side effects of antidepressant treatment from the side effects of other medications they were using, or IBD symptoms.
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“It can be difficult to tell when you’ve got something like Crohn’s because anything could be an effect of the- I’m on three different medications. Four if you count the Loperamide. So anything could be a side effect of one of those or it could be the Crohn’s itself.” (Patient 14)
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The efficacy of antidepressant treatment
When asked if treatment with antidepressants had helped them or improved their QoL, all fifteen patients indicated that it had. The areas of improvement cited were primarily psychological, but some patients indicated social as well as biological areas of improvement in their lives. Three patients expressed some uncertainty in dissociating the causes for their improvements from the three areas of antidepressant treatment, other psychotropic medications, and psychological treatment. The most common area of improvement was a reduction in anxiety, anxious mood, or stress, and an increase in the ability to relax, reported by ten patients (66.7%).
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“…it definitely curbs… you know the anxiety sort of panic attack type stuff… Look I’d have to say it’s working cause I don’t notice it anymore so…” (Patient 5)
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Eight patients (53.3%) reported a reduction in depression or depressed mood.
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“I mean I tend to get fairly depressed in the evenings. More than anything, you know, it does tend to help that…” (Patient 6)
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Five patients (33.3%) felt that antidepressant treatment had reduced their irritability or anger.
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“Definitely stops me from being bad-tempered or moody.” (Patient 2)
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Four patients (26.7%) described subsequent improvements in: their capacity to do more housework, paid work, or education; their ability to engage with partners, family, or friends; and their capability to participate in social or recreational activities.
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“…I think my relationship with my husband has improved a lot because I… when I’m at my lowest, I’m pushing him away. Whereas, now that I’m actually… feeling closer towards him and, you know, feeling like I want him to be part of my life now more than I did at the beginning of the year when I wanted to push him away so… I think it improves relationships. I mean I guess that’s just because of my mental attitude has changed so much.” (Patient 1)
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Similarly, two patients reported increased energy and motivation to engage in these activities.
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“So I definitely feel more energy. I’m positive now. I don’t look at everything as a negative anymore. If I have a flare-up, I might get down about it. But then, you know, move on straight away. I’m still doing things like working, making an effort to go to my shifts even when I’m unwell. I’m just pushing myself that little bit extra. So it’s definitely given me more of a quality of life.” (Patient 4)
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Three patients (20.0%) felt that the antidepressant treatment had improved their cognitive processes by giving them increased control over their thoughts, improving the clarity of their thoughts, and reducing irrational thought processes. Three other patients described improvements in their sleeping patterns, although this may have been associated with coinciding improvements in other areas of functioning such as improvements in the ability to relax and reductions in the experience of anxiety and pain.
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“Yep. I find I relax a lot better at night. I get a better night’s sleep. There’s obviously still nights where I toss and turn and I wake up and the ileostomy could be playing up, so that’s a big factor in the sleep problem too. But otherwise, nah I feel like I’ve got some sort of routine within my body so I do get at least seven hours of sleep at night instead of the two.” (Patient 12)
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Finally, three patients also discussed how the antidepressant treatment had helped them cope with the stressors in their life, particularly those posed by their disease.
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“Yes… It’s helping me cope with what’s wrong with me. It’s hard to- to deal with sometimes…” (Patient 9)
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Improvements in disease function
Three patients (20.0%) raised, unprompted, the feeling that the antidepressant treatment had ameliorated physical symptomatology associated with their disease, including reducing the frequency of symptoms or flare-ups of disease.
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“And I honestly believe it helps me with this disease.” (Patient 2)
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When asked specifically whether the antidepressant had influenced their IBD in terms of pain, frequency of bowel movement, or frequency of relapses, 10 patients (66.7%) felt that the antidepressant treatment had not influenced their disease course. Two patients (13.3%) described again how it was difficult to dissociate the effects of the antidepressant on the disease course from other possible causal mechanisms. Of the five patients who felt the antidepressant had influenced their disease course, three discussed how the reduction in feelings of stress mediated the influence of the antidepressant on improving the disease course.
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“… when the OCD was full-blown, naturally that was incredibly stressful and I was very sick at the time. So I suppose the main effect of it is just to calm me down and take away that aspect.” (Patient 14)
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Of the five patients (33.3%) who felt the antidepressant had improved their disease course, three patients described a reduction in pain, two described reductions in the frequency of bowel movement, one described a reduction in nausea, and one patient also felt that the frequency of relapses of disease had reduced.
Attitudes towards antidepressants
Patients’ responses on the VAS summarising their acceptance of antidepressants are presented in Table
1. Patients reported a reasonable level of acceptance of the treatment with antidepressants. Patients’ perceived advantages and disadvantages of the treatment are listed in Table
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Despite every patient indicating earlier that antidepressants had increased their quality of life, patients’ views or attitudes towards antidepressants in general were not as unilaterally positive. Nine patients (60.0%) had a generally positive attitude, four patients (26.7%) were ambivalent, and two patients (13.3%) held a negative view towards antidepressants. Nine patients (60.0%) felt that the potential benefits need to be contrasted against the costs of antidepressant treatment in the individual context of each person. Potential benefits listed included an improvement in mood and functioning, while the potential costs included side effects and the concern of becoming dependent. Some patients also raised the concern that while antidepressants may superficially fix a problem, they did not solve the underlying cause.
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“Obviously because they can be addictive and, from what I hear, you know you get on them and then you think you’re okay so you stop them and then you go downhill again and you gotta basically stay on them to flatline. But, yes I didn’t want them. I don’t wanna be walking around zombified or making some pill make me feel happy when it shouldn’t be a pill. It should be just because life’s good… It just depends on the person I suppose.” (Patient 12)
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One patient felt that there may be a perception that antidepressants are a ‘magic pill’ which may be perpetuated by doctors and could need dispelling.
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“Yeah. Cause it’s like “Okay take this pill and-” Not that they say that but… you know, it’s more or less “Alright take this medication and things are going to get better” and stuff like that, so you have your hopes up high and if you don’t have a GP that’s on it and knows what they’re doing and what ones are best for you… like I think you can get worse off than where you first started. But I’m sure they are beneficial, I mean I know people that have been on them… that have had a lot of benefit out of them… I just wasn’t one of those people I guess.” (Patient 3)
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Despite the sizeable minority who expressed ambivalent or negative attitudes regarding antidepressant use, fourteen patients (93.3%) stated that they would recommend antidepressants to other IBD patients. However, of these, four patients (36.4%) expressed some reluctance and placed certain provisos on this recommendation, whereby antidepressant treatment would depend on the individual’s circumstances.
Potential clinical trials
Finally, patients were asked whether they would be willing to potentially participate in a clinical trial if there were evidence for antidepressants to play a role in the management of IBD. Twelve patients (80.0%) stated that they would while three would not. Six patients (40.0%) stated that they would in order to help improve treatment for other IBD patients. Four patients (26.7%) said they would be interested in order to improve their own quality of life.
Of the factors which detracted from their willingness to participate in a future trial, two patients felt that the side-effects of antidepressants were not worth the potential benefit.
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“…for some reason medication doesn’t sit well with me. And like I’ve got to the point now where, as I said, I’d rather just live with my disease than all the other side effects that come from all the… medication.” (Patient 3)
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Two patients did not want to change their current antidepressant medication due to their success with it.
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“I might but as I say I’m so suited with the Zoloft I’m sort of edgy about the idea of changing it.” (Patient 14)
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One patient (6.7%) felt that because their antidepressant use hadn’t affected their IBD in any way they would not wish to participate, and one patient felt too unwell to undertake the travel commitment necessary for participation in a trial.