TY - JOUR
AU - MD, Henrik Kessler,
AB - Abstract Two distinct factors have lead in the past to the development of several psychotherapeutic treatments for patients with inflammatory bowel diseases (IBD). First, clinicians and researchers believe that psychologic and somatic factors in chronic IBD, Crohn's disease, and ulcerative colitis) are connected. In addition, IBD reduces the health-related quality of life for these patients. The purpose of the psychotherapies is to influence the somatic course of the disease, the psychological state of the patients, or the patients' health related quality of life. This report evaluates the existing studies with regard to the effectiveness of psychotherapy IBD patients received in addition to medical treatment. We have identified 10 psychotherapy studies and 4 additional studies on self management and patient education on this topic. The studies significantly differ from each other in regard to psychotherapeutic methods, inclusion criteria, and outcome assessments. The results so far lead to the conclusion that psychotherapy does not have an impact on the course of the disease but, in some cases, positively influences the patient's psychologic state (such as depression, anxiety, and health related quality of life or coping with the disease). Thus, psychotherapy cannot, in general, be recommended for all patients with chronic IBD. Patients, however, that display a tendency toward psychologic problems, especially as it pertains to their illness, might profit from it. Crohn's disease, ulcerative colitis, psychotherapy, psychology, quality of life, review A few years after Crohn's disease had first been described by Crohn et al,1 some publications speculated whether psychosomatic factors caused this disease or influenced its course.2,3 Researchers also suspected that ulcerative colitis was caused by psychologic factors.3,–5 As a result, researchers tried to identify typical personality traits, specific conflict constellations, or psychiatric abnormalities in patients with inflammatory bowel disease (IBD). These attempts failed.6 First, the findings regarding personality traits and psychiatric symptoms were inconsistent. In addition, it was found that higher scores of neuroticism, depression, inhibition, and emotional instability, which were sometimes found, are typical for many patients with chronic diseases and not specific for IBD patients. In addition, researchers found that there was a correlation between the actual disease activity and the psychologic data that was being studied. Patients undergoing an acute relapse showed more signs of depression and anxiety while testing mostly normal when in remission.7 Also, it is possible that the manner in which patients were recruited was biased. Patients with IBD who were recruited from a gastroenterological outpatient center or an internal medicine unit had significantly fewer mental problems than IBD patients from psychosomatic clinics.8 Physical complaints as well as mental problems can adversely affect a patient's quality of life. This has been shown by several studies of patients with ulcerative colitis and Crohn's disease.9,10 Both diseases are mostly chronic, with recurring relapses. Psychosomatic research hypothesized that there might be some psychosocial factors that help trigger relapses. There are several studies and summaries on this particular subject.11,–20 It appears that increased stress could help reactivate the disease. Clinical studies have shown that elevated stress levels or life events can increase the relapse probability in patients with ulcerative colitis.16,18 IBD patients with higher depression scores also were more likely to have a relapse.19 It is assumed that increased stress and life events influence the endocrine and the immune system, which are mediators of the inflammatory process. Maunder21 showed which stress-related factors might affect the disease activity in IBD patients (such as substance P, vasoactive intestinal protein, tumor necrosis factor alpha). The suspected connection between psychologic factors and relapses led to the question of whether psychotherapy is helpful for patients with IBD. This review summarizes and evaluates the results of the published psychotherapy studies. Studies were identified by searching the databases Medline, Psychlit, and Psyndex. The search strategy combined the keywords (MESH) ulcerative colitis or Crohn disease with psych* (as in psychotherapy, psychology, etc.). Another search included this combination and the additional keyword stress management. The search included material from 1980 to the end of 2005. In addition, the references list of each study was screened for additional studies. In addition to studies related to psychotherapeutic techniques, we found some studies that are more related to patient education. Some of these were also included here, but we did not conduct a formal literature search for that segment. A meta-analysis did not appear appropriate because there are only a few studies, and these differ from each other in many respects such as inclusion criteria (active disease, remission), sample selection (consecutive or self-selected), treatment variables (type of psychotherapy, duration of therapy, group therapy, individual therapy, or self help context, inpatient or outpatient treatment), and outcome variables (disease course, IBD symptoms, health-related quality of life, psychopathology). Studies Regarding the Effectiveness of Psychotherapeutic Treatment for Patients with Inflammatory Bowel Diseases The goal of psychotherapy with IBD patients could be to improve the course of the disease, to change psychologic factors such as depression and dysfunctional coping, or to improve the patient's quality of life. Our literature research produced 10 studies dealing with psychotherapeutic treatments of patients with IBD. We also found four additional studies that are more related to patient education and self management. It is important to point out that in all studies, psychotherapy was used as a supplementary treatment. All patients simultaneously received conservative therapy. {L-End}Table 1 shows an overview of the psychotherapy studies. These studies can be divided into two subgroups: those using psychodynamic therapy (including psychoanalysis and supportive-expressive therapy) and those using behavior therapy, predominantly stress management training. Psychodynamic therapy addresses more underlying problems and conflicts, and the behavior therapy addresses more specific problematic cognitions and dysfunctional behavior (e.g., problems in stress management). Table 1. Overview of Psychotherapy Studies with Patients with Chronic Inflammatory Bowel Disease     View Large Table 1. Overview of Psychotherapy Studies with Patients with Chronic Inflammatory Bowel Disease     View Large Table 1. Continue     View Large Table 1. Continue     View Large Studies Involving Psychodynamic Psychotherapy The earliest studies regarding the effectiveness of psychotherapy for ulcerative colitis were conducted 50 years ago (1956), as published by O'Connor et al.22 They examined the impact psychoanalytic therapy had on somatic data (symptoms, proctoscopy) and the psychologic state of the patients compared with a control group only receiving medication. The researchers did not, however, use a randomized design. There were 57 patients each in the therapy and the control groups. Researchers concluded that the patients in the psychotherapy group did better. Because of the specific manner by which the patients had been referred (referral for psychiatric consultation or directly to a psychoanalytic department), many of the patients in the therapy group were suffering from severe psychiatric problems (19 patients with schizophrenia, 34 with personality disorders). As a result, the patients included in this study did not constitute a representative sample for ulcerative colitis patients. The researchers also did not conduct statistical significance testing. Künsebeck et al23 investigated the effects of supportive psychotherapy on patients with Crohn's disease with regard to its effect on the course of the disease and coping skills. At the beginning of the study, all patients were experiencing an acute episode; in addition to medical treatment, they received psychotherapy during their stay at the hospital. Twenty-nine patients participated in this study. Patients were assigned to the two groups in the order they were admitted to the hospital. The earlier patients were assigned to the intervention group (n = 15), and patients admitted to the hospital at a later point were assigned to the control group (n = 14). The intervention consisted of supportive psychotherapy. The data collected at admission, discharge, and 4 months and 13 months after discharge consisted of disease activity, amount and duration of hospitalizations and operations, depression, anxiety, and personality traits. The data for both groups was comparable at the point of admission. The average disease activity indexes of 235 (intervention group) and 214 patients (control group) were quite high. The scores for depression and anxiety were above normal. In the therapy group, the scores for depression and anxiety decreased significantly during the 13 months the study was being conducted. The scores of the control group declined also but remained at a higher level with regard to depression and anxiety. There were no differences in regard to most of the somatic data. The patients in the therapy group, however, required significantly less inpatient or outpatient treatments or operations during the observation period. Half of the patients in the therapy group continued with outpatient psychotherapy after their discharge. In a randomized, controlled, multicenter study, Jantschek et al7,24 investigated the effect of psychodynamic psychotherapy on patients with Crohn's disease in regard to the course of the disease and to psychologic symptoms. The study lasted 2 years. Patients were recruited from four German university clinics. Overall, 108 (of 488 screened) patients fulfilled the strict and precisely documented inclusion criteria and were randomized into the control group (standardized medication) and the intervention group (standardized medication and additional psychotherapy during the first of the 2 years of the study) at a 1:2 ratio. The intervention consisted of psychodynamic psychotherapy (e.g., approximately 26 therapy sessions) and also autogenic training (approximately 17 sessions) during the first year of the study. At the beginning of the study, there were no differences between the two groups with respect to somatic, sociodemographic, and psychologic criteria. After 2 years, 23% of the control group and 30% of the therapy group had not experienced a relapse. Twenty-nine percent of the control group and 17% of the therapy group had to undergo surgery. In regard to the somatic course of the disease, the therapy group did better than the control group but not significantly (P < 0.125). After 1 year, the scores for depression, anxiety, quality of life, and psychologic symptoms did not differ significantly. It is important to mention that most psychologic data, particularly for patients in remission, were within the normal range. The study conducted by Maunder and Esplen25 tested the effect of supportive-expressive group psychotherapy for patients with IBD. In this uncontrolled study, 30 subjects with IBD (21 with Crohn's disease, 9 with ulcerative colitis) underwent 20 weekly sessions of supportive-expressive group psychotherapy in a small group setting. The group discussions were related to emotion-evoking issues and discussions about disease related topics such as self-image, stigma, and conflict with health care professionals. Psychologic variables were measured at the beginning and the end of the therapy. Scores regarding quality of life, anxiety, or depression did not change significantly over the course of treatment. Only the scores for maladaptive coping decreased. The authors did not provide any information about somatic changes in the patients. Studies Involving Behavior Therapy The study by Milne et al26 examined the impact a stress management program has on the course of the disease and on the patient's psychosocial level of functioning. The study included 80 patients with IBD. The patients were randomized into an intervention and a control group. The intervention group received stress management training in a group setting (6 sessions, each lasting 3 hours). The training emphasized planning techniques (time management, problem solving), communication skills, and relaxation (autogenic training). Medical treatment was determined by the patient's physician and was not standardized. Patients from both groups were interviewed by “blinded” investigators after 4, 8, and 12 months (course of disease, medication) and also filled out questionnaires to provide additional psychologic data. Despite the randomization of the two groups, they differed significantly. At the beginning of the study, the patients in the intervention group tested higher with regard to disease activity (Crohn's Disease Activity Index, 143 vs. 90) and had a higher stress index (34 vs. 23). Over the course of the study, the intervention group improved significantly regarding disease activity and stress index, whereas there was no change in the control group. Schwarz et al27 studied the effects of outpatient behavior therapy in patients with Crohn's disease and ulcerative colitis in comparison with a control group (waitlist control group). The two groups with 11 and 10 patients, respectively, were very small. The therapy, consisting of 12 1 hour sessions, included information about IBD, progressive muscle relaxation, thermal biofeedback, and cognitive coping strategies. The patients kept a diary, in which they noted symptoms, nutrition, and medication on a daily basis. They also completed a number of psychologic questionnaires regarding depression, anxiety, and life stress at the beginning and the end of the study. The researchers found that psychotherapy had no significant effect on either the somatic symptoms or the psychologic variables. Most patients in the therapy group, however, believed that the therapy had had a positive effect and indicated that they were better able to cope with the disease now. Mussell et al28 studied 28 patients (14 with Crohn's disease, 14 with ulcerative colitis, no control group) to research whether 12 sessions of cognitive behavior therapy in a group setting would reduce illness-related anxiety and concerns, help the patient cope more effectively, or would help reduce the stress level. The treatment consisted of psychoeducation about IBD provided by a gastroenterologist, information about how cognition and emotions generate stress, training regarding adaptive cognitive coping strategies for disease-related and routine stress, and progressive muscle relaxation training. This treatment was followed by three additional sessions every 3 months. The researchers collected data at the beginning and the end of treatment and during the follow-up sessions. Nine months after the conclusion of the therapy, the patients had lower depression scores and were better able to cope, but the latter was only significant for women. Scores for illness-related anxiety had decreased in all patients. The overall results for psychopathology and active coping had not changed during this time period. Larsson et al29 researched the impact of a group training program that had specifically been tailored toward IBD patients with high anxiety scores. Forty-nine patients with IBD and high anxiety levels were randomized into the therapy group. Seventeen patients were on a waiting list and served as the control group. The training was conducted in a group setting and consisted of eight sessions dealing with somatic and psychosocial factors of IBD and stress management. In addition to anxiety and depression, the researchers also assessed the general and health-related quality of life and the patient's opinion about the training. Six months after the training, none of the psychologic instruments indicated a significant change in the scores. The patients, however, were satisfied with the training, which had provided them with more information about their illness. The authors highlight how important it is that the patient is adequately informed about the disease. However, they cannot claim that the training had a significant impact on the psychologic state of the patients. They believe that there was no impact because the high level of anxiety has become an integral part of the patients' personality because they had been sick for a long time (average 20 yr). This severe anxiety cannot perhaps not be changed by 8 hours of training. Garcia-Vega and Fernandez-Rodriguez30 studied the effectiveness of two stress management programs for patients with Crohn's disease. They compared three groups. The first group received 6 individual sessions of manualized stress management. The second group received a self-directed stress management program, in which the patients followed a written guidebook on stress management techniques and worked with an audiotape for home practice relaxation (6 sessions). The third group was the control group and received conventional medical treatment. The groups were randomized and consisted of 15 patients each. None of the patients was experiencing an acute episode. They were asked to use a diary to document symptoms such as general discomfort, fatigue, diarrhea, constipation, abdominal pain, and distended abdomen on a daily basis. The study did not include any additional psychologic data. After the treatment, the patients who had received stress management training were less fatigued, less constipated, and had less abdominal pain and a less distended abdomen. The patients in the self-directed group had very similar results, whereas no significant changes were observed in the control group. Elsenbruch et al31 researched the effect a “Mind-Body-Therapy” has on patients with ulcerative collitis in remission. The intervention group consisted of 15 patients, whereas 15 patients on a waiting list served as the control group. The therapy consisted of a 60 hour training program, which included stress management training, some exercise, Mediterranean diet, behavioral techniques, and self-care strategies. Quality of life, perceived stress, and disease symptoms were assessed with standardized questionnaires. In addition, researchers also measured disease activity (Clinical Activity Index), endocrine laboratory parameters, leukocytes and lymphocyte subsets in peripheral blood, and the β-adrenergic modulation of tumor necrosis factor-α production in vivo. The scores from patients in the intervention group improved in regard to some of the eight Short Form-36 quality of life scales, but only the changes regarding the mental health scale were statistically significant. Researchers also noted significant changes in the inflammatory bowel disease quality of life index. In contrast with these psychologic changes, however, there were no significant group differences regarding somatic data such as disease activity, endocrine, and immune parameters. As previously mentioned, our database research yielded not only studies regarding psychotherapy of patient with IBD, but also some studies focusing on patient education and self management. {L-End}Table 2 summarizes the details of those studies. Table 2. Overview of Studies Focused on Patient Education and Self Management     View Large Table 2. Overview of Studies Focused on Patient Education and Self Management     View Large Kennedy et al32 conducted a multicenter, randomized, controlled study to assess the effectiveness and costs of a patient-orientated self management program for patients with IBD. Seven hundred patients were recruited and assigned to either a control group or an intervention group. Clinicians working with the intervention group received a 2 hour training in patient-centered consultations. In collaboration with the individual patient, they developed a self-management plan for this patient, which was documented in a guidebook. This guidebook also contained information about research on, treatment of, and self management of IBD and indicated areas where the patient's choices might influence treatment decisions. During the 1 year follow-up, self managing patients had significantly fewer hospital visits without this leading to an increase in the number of visits to their regular doctor. The scores for quality of life, anxiety, and depression did not differ between the intervention and control group. The authors conclude that their new self management program is efficient in reducing health care costs for IBD patients. In a randomized, controlled study, Waters et al33 assessed the effects of a formal educational program for patients with IBD. Sixty-nine patients received a special IBD educational program and standard care or just standard care alone. The 12 hour educational program was divided into sessions lasting 3 hours each and was administered over the course of 4 weeks. It included general information about anatomy, pathophysiology of IBD, therapy, and discussions about disease management. During the 8 week follow-up testing, the group that had undergone the training scored significantly higher regarding knowledge about the disease and patient satisfaction. The scores regarding quality of life and medication adherence were similar in both groups. In both groups, however, increased health care use was associated with poorer medication adherence and lower perceived health. Scores regarding the quality of life remained the same. There was no information on somatic outcome variables. In a prospective study by Bregenzer et al,34 73 patients with IBD (40 Crohn's disease, 33 ulcerative colitis) who attended a training program were compared with 72 control patients. The training program, which was conducted in a group setting, consisted of four 2 hour sessions. The main topics of these sessions were information about the somatic aspects of IBD, nutrition, social problems, stress management, and training in coping techniques. Data was assessed at the beginning of the study and after 3, 6, and 10 months. The disease activity remained unchanged in both groups. Throughout the study, the patients' illness-related knowledge increased. Depression and quality of life parameter improved only in patients with initially high results, but this was true for both groups. The patients of the intervention group reported, however, that they were satisfied with the training and that they would be able to accept more responsibility for themselves and their illness. Shepanski et al35 researched the effect of an IBD summer camp on the health-related quality of life in children and adolescents with IBD. This was sponsored by the Crohn's and Colitis Foundation of America, with all the families of the campers being members of the foundation. Throughout the week, the children participated in group activities such as tubing, swimming, kayaking, miniature golf, basketball, adventure course, arts and crafts, dance, and cooking. Medical supervision was provided by experienced physicians and nurses. The campers had no formal IBD educational classes, but there were many informal conversations among the campers and between campers and counselors about their illness. The study evaluates questionnaires from 61 patients (of 125 individuals who had consented to participate). Forty-seven had Crohn's disease, and 14 had ulcerative colitis, ranging in age from 9 to 16 years. There were small, but statistically significant, improvements regarding the total scores for health related quality of life, bowel symptoms scores, social functioning scores, and treatment interventions scores. The scores for anxiety, however, did not change. Summary and Conclusions The results of the psychotherapy studies can be summarized as follows: only one study23 showed an (indirect) influence of psychotherapy on the somatic course of the illness (less readmissions to the hospital and fewer operations). However, this study had very small samples and was not randomized. Most other studies failed to show such an influence. The results of the largest psychotherapy study24 showed tendencies in that direction, but this were not statistically significant. Another study30 illustrated the impact of a stress management program on disease related symptoms such as fatigue, diarrhea, constipation, and abdominal pain. Some studies showed that psychotherapy influences psychologic factors such as depression, anxiety, coping, and stress index,23,26,28 but this could not be repeated in others.24,25,27,29,33 In some studies,24,26,27,29,33,34 the patients themselves believed that they had subjectively profited from the study. The studies used very different psychotherapeutic methods (individual and group therapy, psychodynamic methods, behavior therapy, relaxation therapy, and special stress management training). Because of the lack of studies, it is not possible to decide whether one therapy is superior to another. Psychodynamic therapies and behavior therapy appear to have had similar results, but it appears that stress management training was used more often than the other methods. We therefore feel confident in making the following assumptions: Psychotherapy mainly affects the psyche. There were only very few and inconsistent somatic effects, such as a more favorable course of the disease. Psychotherapy appears to have a positive impact on the patients' depression and anxiety and helps patients cope with their illness. In most of the studies, patients indicated having subjectively profited from the intervention and that it had become easier for them to cope with the illness. From a methodologic viewpoint, these findings deal with the general problems of satisfaction studies because the patients often give positive feed-back given that this is socially desired. A possible conclusion would be, however, that psychotherapy does not affect the course of disease itself but influences the psyche of the patients and how they deal with their illness. Psychotherapy is especially beneficial for those who need it. In studies that showed no effect of psychotherapy on psychologic variables, patients usually were already in the subclinical range before the intervention. This could be interpreted as a “ground effect” (no further improvement possible). Because of this fact, some studies concentrated on patients with initially clinically relevant values for depression or anxiety. The need for psychotherapy varies significantly. Miehsler et al36 developed a questionnaire regarding the need for psychologic care for patients with IBD. The scales on the questionnaire address the need for various types of psychosocial interventions: disease-oriented counseling, “integrated psychosomatic care”, which focuses on the interaction of biological, psychologic, and social subsystems as they pertain to the current situation the patient finds him or herself in, and patients requiring intensive (professional) psychotherapy because of emotional stress or behavioral problems. There is no proof that one therapy is superior to another. Different forms of treatment have been used (psychodynamic therapy, behavior therapy, relaxation, etc.). So far, there has not been a systematic comparison between the various therapies. Patients with Crohn's disease or ulcerative colitis could respond differently to psychotherapy. Post hoc analyses indicated different effects of psychotherapy on patients with Crohn's disease or ulcerative colitis. Overall, Crohn's disease patients have more psychologic complaints,37 which indicates a different starting position or a mentally and physically more challenging illness. Future studies should take this into consideration. Overall, the existing results give no general indication that patients with IBD should undergo psychotherapeutic treatment. We suspect that there are “risk patients” in whom psychosocial components have a bigger influence on the course of disease than in other patients. That group would probably benefit from psychotherapeutic treatment. The following risk factors, which can also appear in combination, can be drawn from the existing literature and cited research: obvious psychopathology, especially depressive symptoms, (chronic) mental stress, indication for an interaction of stress and symptoms, as well as dysfunctional coping techniques. A gastroenterologist who is considering recommending psychotherapy or psychologic consultation to a patient with IBD should consider the following questions (and also ask the patient): Is the patient under a lot of stress that could possibly trigger relapses? How is the patient coping with the disease? Does he or she show signs of depression? Does the patient have a social support system? The physician then can decide, together with the patient and possibly a psychotherapist, which type of intervention (disease-oriented counseling, “integrated psychosomatic care”, “specialized psychotherapy”) would be most appropriate for this patient. These recommendations are in concordance with the European evidence based guideline on the management of Crohn's disease, which indicates that psychotherapy is useful if IBD patients have an addition psychologic disorder, such as depression, anxiety, or a reduced quality of life with psychological distress, as well as maladaptive coping with the illness.38 From a methodologic perspective, it is important to note that IBD varies significantly throughout its course. This has been well documented and is influenced by somatic factors such as localization, course of disease, immune parameter, and medication. Therefore, the claim that psychotherapy has a (verifiable) influence on the course of the disease is very ambitious. This is especially true for the most common study design, a comparison between treatment with an effective medication and this medication with additional psychotherapy. For methodologic reasons alone, it is clear that the possible additive effects cannot be very strong. It would be more realistic to find out whether psychotherapy influences the patient's psyche, health related quality of life, or disease coping. Although it could theoretically be expected that a better psychologic state would positively influence the course of the disease, it would be very difficult to prove this scientifically. Psychotherapeutic methods such as those presented in this study have also been used with similar results in connection with many other somatic illnesses such as coronary heart disease, bronchial asthma, cancer, and skin diseases.39 In that context, chronic IBDs are probably no more or less “psychosomatic” than other illnesses. Further studies on psychotherapy with IBD patients should focus on the risk patients mentioned above. It would be helpful to recognize these (possible with an effective screening procedure) and to investigate the impact of a (manualized) psychotherapy in a controlled study. The main outcome variables should be psychopathology, quality of life, or how the patient deals with daily stress. A large percentage of the patients would probably benefit from detailed information about the illness and a consultation regarding self-management of the illness. One study illustrated that patient education programs reduced doctor visits, and two studies indicated that it produced better informed patients. One study was able to show that the scores regarding health related quality of life slightly improved. Therefore, these therapies could be recommended for many patients (as opposed to more intensive psychotherapy). References 1. Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis. JAMA.  ( 1932); 99: 1323– 1329. Google Scholar CrossRef Search ADS   2. Bockus HL. Present status of chronic regional or cicatrizing enteritis. JAMA.  ( 1945); 127: 449– 456. CrossRef Search ADS   3. Alexander F. Psychosomatic Medicine . New York: Norton; (1950). 4. Engel GL. 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TI - Psychotherapy with chronic inflammatory bowel disease patients: A Review
JF - Inflammatory Bowel Diseases
DO - 10.1097/01.mib.0000236925.87502.e0
DA - 2006-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/psychotherapy-with-chronic-inflammatory-bowel-disease-patients-a-3MkLWqwX8v
SP - 1175
EP - 1184
VL - 12
IS - 12
DP - DeepDyve
ER -