AIM: To study statements and recommendations on psychosocial issues as presented in international evidence-based guidelines on the management of inflammatory bowel diseases (IBD).

METHODS: MEDLINE, guidelines International Network, National Guideline Clearing House and National Institute for Health and Care Excellence were searched from January 2006 to June 30, 2013 for evidence-based guidelines on the management of IBD.

RESULTS: The search yielded 364 hits. Thirteen guidelines were included in the review, of which three were prepared in Asia, eight in Europe and two in the United States. Eleven guidelines made statements and recommendations on psychosocial issues. The guidelines were concordant in that mental health disorders and stress do not contribute to the aetiology of IBD, but that they can influence its course. It was recommended that IBD-patients should be screened for psychological distress. If indicated, psychotherapy and/or psychopharmacological therapy should be recommended. IBD-centres should collaborate with mental health care specialists. Tobacco smoking patients with Crohn’s disease should be advised to quit.

CONCLUSION: Patients and mental health specialists should be able to participate in future guideline groups to contribute to establishing recommendations on psychosocial issues in IBD. Future guidelines should acknowledge the presence of psychosocial problems in IBD-patients and encourage screening for psychological distress.

Psychosocial issues are a significant dimension of inflammatory bowel diseases (IBD), chronic conditions of the gastrointestinal tract with an unknown aetiology and unpredictable course. Two main subtypes of IBD are Crohn’s disease (CD) and ulcerative colitis (UC). A systematic review of qualitative studies exploring the phenomenon of living with IBD demonstrated a highly negative impact of the disease on the overall quality of life[1]. In the European Federation of Crohn’s and Ulcerative Colitis Associations (EFCCA) patient survey (n = 5576 participants), 75% of patients reported that symptoms affected their ability to enjoy leisure activities and 69% felt that symptoms affected their ability to perform at work[2]. In a survey of the French association of IBD patients (n = 1663), 12% of IBD patients reported depression and 41% reported anxiety[3]. Other studies reported that as many as 75% of IBD patients believe that stress is a major contributor to the development of their disease and up to 90% of patients believe that stress triggers flares of their disease[4-6]. In the recent study, 30% of patients (of n = 302) expressed the need for psychological interventions[7] while in another paper it was demonstrated that 60% of IBD patients did not receive adequate help for their psychological problems[8].

The importance of psychosocial issues as perceived by individual patients is also supported by cohort studies with IBD populations. There is a strong evidence for the high comorbidity of anxiety and depression with IBD, indicating also that the symptoms of these mental health conditions are more severe during periods of active IBD and that the course of the disease worsens in depressed patients[9]. Health-related quality life in IBD-patients is not only negatively affected by disease activity but also by depression[10] and psychological distress has been found to be associated with non-adherence to medical treatment[11]. A recent systematic review demonstrated that 13 of 18 prospective studies reported significant relationships between stress and adverse outcomes in IBD[12].

Evidence-based guidelines gain growing recognition in providing patients and physicians with recommendations on diagnosis and treatment of the most frequent clinical situations based on the best available knowledge. Given the importance of psychosocial issues in IBD for the disease prognosis and management, this systematic review aims to assess the role of psychosocial issues in the course of IBD and explore the recommendations on the diagnosis and treatment of psychosocial problems as presented in the recent international evidence-based guidelines on the management of IBD.

The search of the literature yielded 364 hits. One hit (guideline of the Finnish Society of Gastroenterology) was not available by libraries or the website of the Finnish Society of Gastroenterology. Thirteen guidelines were included into the review after screening of full papers (Figure 1). Three guidelines were prepared in Asia, eight in Europe and two in the United States. Three guidelines were on IBD and five each on UC and CD. The composition of the guidelines groups are outlined in Table 2. The methods used in the guideline process are outlined in Table 3.

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Figure 1 Preferred reporting items for systematic reviews and meta-analyses flow diagram. G-I-N: Guidelines International Network; NGC: National Guideline Clearing House; NICE: National Institute for Health and Care Excellence.

We present the statements and recommendations of the guidelines in the chronological order.

NICE guidelines on UC published in 2013 gave two recommendations on information provided to patients which should include impact of IBD on sexual functions, lifestyle, psychological wellbeing and sources of support and advice to be given before and after surgery (no EL reported). The NICE guidelines did not comment on psychological therapies in the summary of the topics which the guideline does not cover[15].

European Crohn’s Colitis Organization (ECCO) guidelines on UC published in 2013 included three statements on the impact of psychosocial factors on the disease, three recommendations on psychosocial diagnostics and two statements on psychological treatment (Table 4)[16].

The Japanese guidelines on CD published in 2013 made one statement on HRQOL and gave three recommendations on life style modification: (1) in the active phase of the disease, patients face restrictions of social activities, such as school or work, due to treatment or hospitalization (no EL reported); (2) upon diagnosis, the patient with CD should quit smoking (EL3); (3) patients should be advised to avoid irregular lifestyle and eating habits, and to refrain from excessive alcohol drinking (no EL reported); and (4) patients should be advised to adopt a lifestyle without excessive mental stress, to have as little stress as possible (no EL reported)[17].

NICE guidelines on CD published in 2012 gave two recommendations on treatment decisions including psychosocial issues. If appropriate, age-appropriate multidisciplinary (gastroenterologist, surgeon, IBD-nurse specialist) support to deal with any concerns about the disease and its treatment, including concerns about body image, living with a chronic illness, and attending school and higher education should be offered. If appropriate, information, advice and support in line with published NICE guidance on smoking cessation and patient experience should be given. No levels of evidence were reported for these recommendations. The guidelines did mention psychological therapies in the summary of the topics which the guideline does not cover. However, mental health specialists were not mentioned in the context of the multidisciplinary team[18].

British Society of Gastroenterology Guidelines for the management of inflammatory bowel disease in adults published in 2011 included two statements and three recommendations on psychosocial issues (Table 5)[19].

The German Society of Gastroenterology guidelines on UC published in 2011 included three statements on the impact of psychosocial factors on the disease, three recommendations on psychosocial diagnostics and two statements on psychological treatment (Table 6)[20].

The Asia-Pacific consensus statements on UC published in 2010 did not include any statement or recommendations on psychosocial issues[21].

The American College of Gastroenterology ulcerative colitis practice guidelines published in 2010 did not include any statements or recommendations on psychosocial issues[22].

The Dutch practice guidelines on Diagnostics and treatment of inflammatory bowel diseases for adults published in 2010 gave three statements on the impact of psychosocial factors on the disease and five statements on psychological treatment (Table 7)[23].

ECCO guidelines on CD published in 2010 included three statements on the impact of psychosocial factors on the disease, three recommendations on psychosocial diagnostics and two statements on psychological treatment (Table 8)[24].

The American College of Gastroenterology Crohn’s disease practice guidelines published in 2009 included one statement on psychosocial issues: Although many patients (and family members) are convinced that stress is an important factor in the onset or course of illness, it has not been possible to correlate the development of disease with any psychological predisposition to or exacerbations of stressful life events. No levels of evidence were reported for this statement[25].

The German Society of Gastroenterology guidelines on CD published in 2008 included three statements on the impact of psychosocial factors on the disease, three recommendations on psychosocial diagnostics and three statements on psychological treatment (Table 9)[26].

There is a growing body of evidence demonstrating the role of stress, anxiety and depression in IBD presentation and progression[9,12,27,28]. Evidence-based guidelines are increasingly becoming the major source of recommendations on diagnosis and treatment not only in IBD but also in other conditions and that is why it is important that problems of clinical significance (such as the role of psychosocial issues in IBD management) are included and commented on in the guidelines. This is the first review which has summarised current guidelines on the management of IBD with respect to psychosocial issues.

The most striking observation arising from this review was that as many as 10 out of 13 guidelines provided comments on the psychosocial issues demonstrating the recognition of their importance in IBD management. However, the published guidelines differed in the inclusion of psychosocial topics, particularly between Asia/Pacific, Europe and the United States, with European guidelines more likely to discuss the issue. In the cases where psychosocial issues were included in the guidelines, the statements and recommendations were similar between the countries. ECCO[16,24], Dutch[23] and German guidelines[20,26] made the most extensive statements and recommendations on psychosocial issues. In contrast, three guidelines[15,21,22] did not include any statements or recommendations on psychosocial issues. Seven guidelines included patient representatives[15,17,18,20,21,26]. However, the composition of the guidelines group (i.e., types of professionals involved and/or inclusion of patients) did not affect the role of psychosocial issues in the guideline. Importantly, only six guidelines included comments regarding mental health specialists[15,16,20,23,24,26].

The major statements and recommendations on psychosocial issues were as follows: (1) psychosocial factors such as mental disorders or stress do not play a role in the aetiology of IBD[15,19,20,23-26]; (2) psychosocial factors such as mental health disorders or stress may have a negative impact on the course of IBD[15,19,20,23,24,26]; (3) physicians should screen IBD-patients for psychological distress and the psychological care recommended when required[15,19,24,26]; (4) if indicated, psychosocial care (psychotherapy, psychopharmacotherapy) should be offered[15,19,20,23,24,26]; (5) IBD-centres should collaborate with mental health specialists[15,19,20,24,26]; and (6) smoking CD-patients should be advised to quit[17,18,23,26].

The major statements and recommendations included in the guidelines were in line with the recent systematic reviews demonstrating that the role of psychological distress and personality as predisposing factors for the development of IBD remains controversial. Attempts to investigate the role of psychological factors in IBD exhibited rather conflicting results. Among the studies concerning the effects of stress or depression on the course of IBD, the majority suggest that stress worsens IBD, the rest produce either negative or inconclusive results[29]. Eighteen randomized controlled studies (19 papers) were included in a review on psychological therapies in IBD. Psychotherapy was found to have minimal effect on measures of anxiety, depression, quality of life and disease progression although showed promise in reducing pain, fatigue, relapse rate and hospitalisation, and improving medication adherence. It may also be cost effective[30]. Smoking remains the most important environmental factor in IBD. Active smoking increases the risk of developing CD. Moreover, CD patients who start or continue smoking after disease diagnosis are at risk for poorer outcomes such as higher therapeutic requirements and disease-related complications, as compared to those patients who quit smoking or who never smoked[31].

Psychosocial issues are discussed in the majority (10/13) of recently published evidence-based guidelines, supporting their important role in IBD management. There is a need for interdisciplinary evidence-based guidelines in Asia and the United States to provide specific recommendations on the aetiology and management of psychosocial issues in IBD. Patients and mental health specialists should be able to participate in guideline groups to contribute perspectives on psychosocial issues to the guidelines.

There is strong evidence on co-morbidity of IBD with mental disorders which have been shown to impact the disease course. Future guidelines should acknowledge the presence of psychosocial problems in IBD-patients and encourage screening for psychological distress. The best treatment of psychosocial problems of IBD-patients is yet to be determined.