Psychological stress has long been suspected as a key factor in the pathophysiology of inflammatory bowel disease (IBD) and may represent a key trigger for symptom flares, based on findings from a large body of research dating back to the 1930s.1 In a 2022 systematic review of 38 studies with a combined total of 4,757 participants, the study authors found that high levels of psychological stress often preceded symptom exacerbation in IBD.1
Accordingly, researchers have explored the effect of mind-body (or integrative) treatment strategies on psychological functioning, quality of life (QOL), and other outcomes in patients with IBD, a population with high rates of comorbid mental health disorders, such as depression and anxiety.1
In a 2022 randomized controlled trial (RCT), 101 patients on standard medical therapy for IBD were assigned to a control group receiving weekly motivational messages via email or to a 12-week online intervention consisting of video-based yoga, meditation, breathwork, and cognitive behavioral therapy (CBT) activities, as well as weekly check-ins from a member of the study team.2
In addition to high program adherence and low dropout rates, those in the treatment group showed significant improvements in perceived stress (22.4%), anxiety (23.7%), depression (29.5%), resilience (10.6%), and QOL (8.9%).2 Although no effect on disease severity or inflammatory blood markers was observed in this study,2 other findings have demonstrated a link between mind-body therapies and reductions in levels of inflammatory markers. A 2-armed, single-center RCT published in 2020, for example, assigned patients with IBD to receive standard medical care (n=20) or standard care plus an 8-week mindfulness-based intervention (n=37) consisting of digital modules and face-to-face group support.
At a 6-month follow up, the intervention group showed significant reductions in fecal calprotectin (-367 µg/g; 95% CI, -705 to -29; P =.03) and C-reactive protein -2.82 mg/dL; 95% CI, -5.70-0.08; P =.05) levels compared with the control group, with moderate-to-large effect sizes (ηp2=0.085 and ηp2=0.066, respectively).3
In other recent research, mindfulness-based cognitive therapy (MBCT) led to reduced subjective fatigue in IBD (36% vs 10% in controls), and a pilot RCT linked MBCT with improvements in stress, depression, mindfulness, and active coping in adolescents and young adults with IBD, compared with usual treatment.4,5
Studies have also demonstrated favorable results with CBT-based approaches in patients with IBD, including a 2021 RCT reporting improvements in stress levels, QOL, and relapse rates after participation in group-based CBT.6
In research published in 2022, Laurie A. Keefer, PhD, academic health psychologist and director of psychobehavioral research in the division of gastroenterology at the Icahn School of Medicine at Mount Sinai in New York, and colleagues investigated the effects of a mind-body approach with elements of CBT and mindfulness (the Gaining Resilience through Transitions [GRITT] method) in 394 patients with IBD. The intervention was associated with a 59% increase in resilience and significant reductions in emergency department visits (71%), unplanned hospitalizations (94%), opioid use (49%), and corticosteroid use (73%).7
For further discussion about the role of mind-body approaches in IBD treatment, Gastroenterology Advisor interviewed Dr. Keefer as well as Ann Ming Yeh, MD, clinical professor of pediatric gastroenterology at Stanford University School of Medicine in California, and Stephen E. Lupe, PsyD, clinical health psychologist and director of behavioral medicine in the department of gastroenterology, hepatology, and nutrition in the Digestive Disease and Surgery Institute at Cleveland Clinic in Ohio.
What does the available evidence suggest about the benefits of mind-body approaches in the treatment of IBD? Which strategies appear to be most effective, and what are the proposed mechanisms involved?
Dr. Lupe: The evidence suggests a bidirectional relationship between “psychological functioning” and gastrointestinal (GI) symptoms.1 The more symptoms someone experiences, the more psychological distress they tend to have. This is also true in reverse — the more psychological distress someone has, the more altered the functioning of the GI tract and the more symptoms they tend to experience. This has been found to lead to more complications in treatment, such as increased need for surgical intervention.8
The relationship between the brain and the gut is complicated. The gut is sending up signals about functioning, which the central nervous system (CNS) has to interpret. The CNS then sends down messages about functioning, which alters the functioning of the gut through the sympathetic nervous system (SNS).9 This is exacerbated by the fact that stress also affects the immune system, creating pro-inflammatory cytokines that data suggest exacerbates symptoms in IBD.9
Much of this is mediated through the hypothalamic pituitary adrenal (HPA) axis within the CNS.9 Furthermore, stress and psychological functioning are linked to unhealthy behavioral patterns and less adherence to treatment, which alter the course of disease.
Several studies have shown that psychological approaches to treating these aspects of living with IBD are helpful. The most studied are cognitive behavioral therapy (CBT) and gut-directed hypnosis, but more evidence is starting to emerge for mindfulness therapies and Acceptance and Commitment Therapy (ACT).10,1
The psychological therapies address the thoughts and anxieties surrounding living with IBD and seek to re-engage the person with what is important in life. This tends to help with living with the stress related to IBD and allow for more of parasympathetic nervous system (PNS) response.
In the case of gut-directed hypnosis, the deep relaxed state associated with hypnosis is associated with a decrease in symptoms such as pain, cramping, and motility problems. It has also been shown to help maintain remission in people diagnosed with IBD.11
Dr. Keefer: Mind and body approaches are gaining interest in the management of IBD given the known impact of emotional well-being on outcomes, and vice versa. The brain and gut are also very much intertwined, so even when a person’s IBD is perfectly managed, they can still experience ongoing GIsymptoms.
There is a lot of heterogeneity in studies of mind-body approaches, which unfortunately makes the “scientific” evidence for them weaker. The most effective mind-body approaches for IBD are CBT, especially for patients who have comorbid mood or anxiety, and mindfulness-based interventions.
Despite the lack of “high-grade” scientific evidence, recommending mind-body interventions for IBD is still widely encouraged. They are low harm, have been shown to impact GI symptoms including, abdominal pain, bowel urgency, and fatigue, and can improve quality of life.
It is important to recognize, however, that mind-body approaches are expected to be used in conjunction with effective medical and surgical therapy, not as an “alternative.”12
Dr. Yeh: The available evidence suggests that mind-body approaches such as mindfulness-based stress reduction (MBSR), cognitive-behavioral therapy (CBT), and yoga may offer some benefits in the treatment of IBD.8,13
Many patients also exhibit an overlap between IBD and irritable bowel syndrome (IBS) — their IBD may be under good control and there may not be active inflammation, but there may still be significant GI symptoms. There is significant data in the literature to support the use of mind-body interventions to treat IBS with clinical hypnosis, mindfulness, and relaxation techniques.8 In fact, IBS is now under the category of “disorders of gut-brain interaction” in the Rome IV consensus definition.12
The proposed mechanisms involved in the beneficial effects of mind-body approaches in IBD are not fully understood but may involve changes in the brain-gut axis, the immune system, and the stress response.9 For example, mindfulness meditation and other mind-body practices have been shown to activate the PNS, which is involved in promoting relaxation and reducing inflammation. Additionally, mind-body approaches may help people with IBD cope with the emotional and psychological stress associated with their condition, which in turn may improve their overall health outcomes.
To your knowledge, how often are these approaches being used in practice? Are most gastroenterologists open to using these strategies, or is there some resistance or doubt about their role in IBD treatment?
Dr. Lupe: These approaches are being used more and more, and the number of mental health care workers and psychologists that are trained in psychogastroenterology is increasing, but they are not utilized as much as they should be. The reasons are multifactorial: First, even though the number of people trained to offer these interventions is growing, there still are not enough providers. Outside of major academic medical centers such as the Cleveland Clinic, Mount Sinai, and the University of Chicago, these services are limited.
Most GI providers I speak with are open to referring people for these treatments, but the treatments may not be top of mind. Medical doctors are trained in using pharmaceuticals and the use of other treatments such as diet, and behavioral health interventions may not come to mind. Most of the providers I speak with absolutely believe the interventions are helpful, but they need help in determining who to refer people to.
Dr. Keefer: [Gastroenterologists] are increasingly enthusiastic about strategies that improve their patients’ symptom burden and quality of life and — perhaps even more importantly — empower them to manage their disease. There are a lot of behavior changes that have to occur to take care of a chronic, unpredictable condition, and the earlier patients feel confident and supported in managing their disease, the better the outcomes.7
I think skepticism mostly arises when mind-body interventions are proposed in lieu of effective medical therapy. The other resistance relates to how the [gastroenterologist] is supposed to determine which therapies to recommend to patients.
Dr Yeh: When we surveyed pediatric IBD providers several years ago, there was an awareness and belief that it could help patients, but the main barrier to utilizing them or recommending them was due to lack of education — 64% of physicians wanted more data for evidence of safety and efficacy. This unpublished data was presented at the ImproveCareNow Community Conference in the spring of 2018.14
Certain larger academic centers like Stanford Children’s have IBD psychologists and social workers who might be savvier at addressing this in an IBD-specific population. Outside of this, there are helpful interventions that physicians can provide.
What are recommendations for clinicians in terms of integrating these strategies into IBD treatment? How can clinicians learn more about these approaches and increase their competence in applying them in practice?
Dr. Lupe: The Rome Foundation is a great place to start. This will connect providers with a directory of people trained in some of the interventions used to assist people diagnosed with GI disorders. Rome has also produced several trainings designed to help providers obtain training in behavioral health interventions for the GI tract.
Outside of this, there is a growing number of talks by myself and my colleagues being presented at most of the professional conferences.
I also encourage providers to speak with a mental health provider in their region about setting up a collaborative relationship where providers can refer people for behavioral health treatment, and both sides can help educate the other about IBD and behavioral health.
Several digital apps have also been released that have a GI behavioral health component and these can be of assistance as well.
Dr. Keefer: There are a few ways clinicians can incorporate these strategies. First, they should be asking about emotional wellbeing at all maintenance visits as part of their review of systems.15 It is also important that they recognize that depression and anxiety disorders are more often a consequence of poorly managed emotional health or self-management behaviors and that identifying earlier “precursors” to emotional distress, such as lack of disease acceptance or low social support, can be particularly valuable.
A co-located gastropsychologist is the ideal strategy, and several academic IBD centers now have that service.16 However, there are some other ways to connect patients with self-management support, including my digital self-management company, Trellus Health. In this approach, based on the Mount Sinai GRITT Method, patients keep their trusted GI provider and then leverage the expertise of coaches, nutritionists, and nurse educators to improve their self-management and emotional wellbeing in between office visits.
Dr. Yeh: If clinicians want to learn more and get training, here are some resources:
- Take an 8-week MBSR class or Mindful Self-Compassion class to start.
I also co-authored a new paper on implementing clinical hypnosis in pediatric GI patients, by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) special interest group on integrative medicine. 17
What are important ongoing needs in terms of education and future research regarding mind-body therapies in IBD?
Dr. Lupe: I think continuing to educate providers and patients is crucial. We need to make sure the whole-person approach to medicine continues to grow to best help people diagnosed with IBD. Understanding that people are complicated and function in a context, and that this affects health outcomes, allows people within the medical profession to improve communication with patients, build trust, and improve outcomes.
In the area of research, more work needs to be continued in establishing how these interventions work and how the stress associated with living with IBD affects the disease state. Through the knowledge we gain in this arena, we can grow the presence of psychogastroenterology and improve the lives and medical outcomes of people diagnosed with IBD.
Multidisciplinary treatment involving psychologists, dieticians, physical therapists, and others is the future of care and the best way to reduce complications and improve quality of life for the people we serve.
Dr. Keefer: It is really important that we stay focused on emotional healing in addition to our other quality metrics. However, we need more research on how to define and potentially reduce the emotional impact of the disease by fostering resilience early on in care.
Dr. Yeh: There are so many needs. With precision medicine, which patients would benefit the most from which mind-body modality? Is it dependent on comorbidities? Disease type? Personality type? Interest? Motivation?
We also need a good, reliable, and valid easy-to-measure biomarker for stress.
From our survey, providers clearly need to be educated on safe, effective, nonpharmacologic modalities. There is so much money and research going into new drugs for IBD — literally 4 or 5 great new medications since the start of the pandemic, but there is no “big mindfulness” or “big meditation” to fund mind-body research.
Disclosures: Dr. Lupe is a scientific advisor for Abyle Health. Dr. Keefer is cofounder and equity owner in Trellus Health. Dr. Yeh reports no disclosures.
This article originally appeared on Gastroenterology Advisor
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- Nemirovsky A, Ilan K, Lerner L, et al; Israeli IBD Research Nucleus (IIRN). Brain-immune axis regulation is responsive to cognitive behavioral therapy and mindfulness intervention: Observations from a randomized controlled trial in patients with Crohn’s disease. Brain Behav Immun Health. 2021;19:100407. doi:10.1016/j.bbih.2021.100407
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