Editorial: anxiety and depression in inflammatory bowel disease – authors’ reply

We thank Mikocka‐Walus and Knowles1 for their editorial about our systematic review and meta‐analysis on anxiety and depression in children and adolescents with inflammatory bowel disease (IBD).2 Indeed, anxiety and depression are common in IBD, and the bidirectional relationship between anxiety/depression and intestinal inflammation can be explained in terms of the “brain‐gut‐axis”.3, 4 In adult (and less so in paediatric) IBD, the association between anxiety/depression and clinical recurrence of IBD has been confirmed.5, 6 In almost 25% of patients, IBD presents in childhood or adolescence with a disease course often more severe than in adults.7, 8 In addition, adolescence is a challenging life phase with many biological and psychosocial changes. IBD disrupts normal psychosocial development, and increases the vulnerability to developing anxiety/depression. Furthermore, anxiety/depression in adolescence is associated with anxiety/depression in adulthood,9, 10 affecting quality of life, work participation and socioeconomic status11 with subsequent high societal costs.12 There are several ways to integrate psychosocial support into the care of paediatric IBD patients. First, for early detection, patients should be regularly screened for anxiety/depression symptoms. In our Dutch cohort, we systematically screened 374 IBD patients aged 10‐25 years, and found that 47% had symptoms of anxiety and/or depression, with the highest prevalence of anxiety,13 and females and patients with active disease having the highest risk. Ideally, mental health screening is done routinely in the out‐patient clinic using a short and easy‐to‐use screening tool. Second, we fully agree with Mikocka‐Walus and Knowles that, in case of elevated symptoms, a psychiatric interview should check if symptoms are mild/subclinical or severe as in a clinical disorder. It is important to make this difference in order to determine the best treatment strategy. Third, mental health specialists should be part of the multidisciplinary team for young patients, to evaluate the outcome of screening and to provide psychosocial care if necessary. In paediatric IBD, Szigethy et al found promising results of two psychological therapies in obtaining remission of clinical depression (cognitive behavioural therapy [CBT]: 67.8%, and supportive nondirective therapy: 63.2%).14 However, in our recently published multicentre trial, we did not find an additional effect of CBT over usual care in improving subclinical anxiety and depressive symptoms in 10‐ to 25‐year‐old IBD patients directly post treatment,15 as patients in both groups improved. Whether psychosocial interventions also have an effect on inflammatory disease course remains questionable. In conclusion, future studies investigating anxiety and depression in paediatric IBD patients should use validated instruments cross‐culturally, and, importantly, with similar cut‐offs. For patients with subclinical anxiety/depression, screening and monitoring may be sufficient to prevent their development into disorders, but this group could also benefit from e‐health (Internet‐CBT) interventions. Patients with clinical anxiety/depression should be referred for CBT. Future research will unravel the “dose” and modality of CBT that should be provided to patients with (sub)clinical anxiety/depression and the long‐term effects of CBT on the course of disease.

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