Psychosocial issues in evidence-based guidelines on inflammatory bowel diseases: A review

Table 1 Search strategy used for PubMed

To locate guidelines

1 "Practice guidelines as topic"[MESH]

2 "Practice guideline"[Publication type]

3 "Consensus development conferences as topic"[MESH]

4 "Consensus development conferences, NIH as topic"[MESH]

5 "Consensus development conference, NIH "[Publication type]

6 "Consensus development conference "[Publication type]

7 or 1-6

To locate IBD

8 “Inflammatory bowel disease [MESH]”

9 “Colitis, ulcerative [MESH]”

10 “Crohn Disease [MESH]”

11 or 8-9

12, 7 and 11

IBD: Inflammatory bowel diseases.

Table 2 Overview of the methods of guidelines on the management of inflammatory bowel diseases: composition of guideline panel

Organization	Country/continent	Year	Type of IBD	Guideline group (number of persons, specialties)
Asia Pacific Working Group on inflammatory bowel diseases	Asia	2013	IBD	Number not reported: Gastroenterologist, pathologist, colorectal surgeon, pharmacist, nurse, patient support group representative
NICE	United Kingdom	2013	UC	13: Gastroenterologist, surgeon, pharmacist, nurse, general practitioner, psychiatrist, patient support group representative
ECCO	Europe	2013	UC	35: Gastroenterologist, surgeon, psychosomatic medicine
Japanese Society of Gastroenterology	Japan	2013	CD	18: Gastroenterologist, surgeon, general internal medicine
NICE	United Kingdom	2012	CD	19: Gastroenterologist, colorectal surgeon, pharmacist, nurse, dietician, health economist, patient support group representative
British Society of Gastroenterology	United Kingdom	2011	IBD	11: Gastroenterologist, surgeon, pediatrist
Asia Pacific Working Group on IBD	Asia and Australia	2010	UC	28: Gastroenterologist, colorectal surgeon, pathologist, pharmacist, nurse practitioners, patient support group representatives
German Society of Gastroenterology	Germany	2011	UC	71: Gastroenterologist, colorectal surgeon, pathologist, dietician, psychosomatic medicine, patient support group representative
Dutch Society for Gastroenteroolgy		2010		Number not reported: Gastroenterologist, general practitioner, psychologist, internist, dietician, pharmacist, occupational medicine, surgery, gynecologist, pathologist, radiologist, nurses, patients
American College of Gastroenterology	USA	2010	UC	No detailed information
American College of Gastroenterology	USA	2010	CD	30: No detailed information
German Society of Gastroenterology	Germany	2011	CD	49: Gastroenterologist, colorectal surgeon, pathologist, dietician, psychosomatic medicine, patient support group representative
ECCO	Europe	2007	CD	25: Gastroenterologist, surgeon, psychosomatic medicine

IBD: Inflammatory bowel diseases; ECCO: European Crohn’s Colitis Organization; NICE: National Institute for Health and Care Excellence; CD: Crohn’s disease; UC: Ulcerative colitis.

Table 3 Overview of the methods of guidelines on the management of inflammatory bowel diseases: databases, search and type of consensus

Organization	Country/continent	Year	Type of IBD	Databases used	Searches until	Type of consensus
Asia Pacific Working Group on inflammatory bowel diseases	Asia	2013	IBD	English language publications in MEDLINE, EMBASE and the Cochrane Trials Register in human subjects. All national and international guidelines on Ulcerative Colitis were solicited	Not reported	Modified Delphi process Canadian task force Grade A-E
NICE	United Kingdom	2013	UC	MEDLINE, Embase, Cinahl and the Cochrane Library	15th November 2012	Meta-analyses, grading the quality of evidence Evidence tables Formal consensus
ECCO	Europe	2013	UC	Medline, Central	December, 2010	Delphi process and structured consensus
Japanese Society of Gastroenterology	Japan	2013	CD	MEDLINE, the Cochrane Library, and the Japan Medical Abstracts Society	Up to 2007	Delphi process and structured consensus
NICE	United Kingdom	2012	CD	MEDLINE, Embase, Cinahl and The Cochrane Library	13th March 2012	Meta-analyses, grading the quality of evidence Evidence tables Formal consensus
British Society of Gastroenterology	United Kingdom	2011	IBD	PubMed, Medline and the Cochrane database	No details reported	Informal committee consensus
German Society of Gastroenterology	Germany	2011	UC	Medline, Central, PsycInfo	Until May 2009	Structured consensus process
Asia Pacific Working Group on IBD	Asia and Australia	2010	UC	English language publications in MEDLINE, EMBASE and the Cochrane Trials Register in human subjects. All national and international guidelines on Ulcerative Colitis were solicited	No details reported	Modified Delphi process
Dutch Society for Gastroenterology		2010		Central, Medline, PsychInfo	2007	Modified Delphi process
American College of Gastroenterology	United States	2010	UC	Medline	No details reported	Informal consensus
American College of Gastroenterology	United States	2010	CD	Medline	No details reported	Informal consensus
German Society of Gastroenterology	Germany	2011	CD	Medline, Central, PsycInfo	Until April 2007	Structured consensus process
ECCO	Europe	2007	CD	Medline, Central	No details reported	Delphi process and structured consensus

IBD: Inflammatory bowel diseases; ECCO: European Crohn’s Colitis Organization; NICE: National Institute for Health and Care Excellence; CD: Crohn’s disease; UC: Ulcerative colitis.

Table 4 European Crohn’s Colitis Organization guideline statements and recommendations on psychosocial issues in ulcerative colitis[15]

1 There is no conclusive evidence for anxiety, depression and psychosocial stress contributing to risk for UC onset (EL2)

2 Psychological factors may have an impact on the course of UC. Perceived psychological stress (EL2) and depression (EL2) are risk factors for relapse of the disease. Depression is associated with low health-related quality of life (EL3). Anxiety is associated with non adherence with treatment (EL4)

3 Psychological distress and mental disorder are more common in patients with active ulcerative colitis than in population-based controls, but not in patients in remission (EL3)

4 Clinicians should particularly assess depression among their patients with active disease and those with abdominal pain in remission (EL2)

5 The psychosocial consequences and health- related quality of life of patients should be taken into account in clinical practice at regular visits (EL3). Patients' disease control can be improved by combining selfmanagement and patient-centred consultations (EL1b)

6 Physicians should screen patients for anxiety, depression and need for additional psychological care and recommend psychotherapy if indicated (EL2). Patients should be informed of the existence of patient associations (EL 5)

7 Psychotherapeutic interventions are indicated for psychological disorders and low quality of life (EL1)

8 The choice of psychotherapeutic method depends on the psychological disturbance and should best be made by specialists (Psychotherapist, Specialist for Psychosomatic Medicine, Psychiatrist). Psychopharmaceuticals should be prescribed for defined indications (EL5)

UC: Ulcerative colitis; EL: Evidence level.

Table 5 British society of gastroenterology guidelines for the management of inflammatory bowel disease in adults[19]

1 The essential supporting services to which the IBD team should have access should include a psychologist/counsellor (no EL reported)

2 Stress and adverse life events do not appear to trigger the onset of Crohn’s disease or ulcerative colitis, but most reports indicate that they may be involved in triggering relapse of IBD. Furthermore, behaviour limiting exposure to stressful situations is associated with reduced symptomatic relapse, at least in Crohn’s disease (no EL reported)

3 Evidence indicates that psychosocial support is useful, particularly in adolescents. There is no definitive evidence that psychological interventions improve the course of IBD itself but they do usually improve patients’ quality of life and wellbeing (no EL reported)

4 Psychological support should be available to patients with IBD (no EL reported)

IBD: Inflammatory bowel diseases; EL: Evidence level.

Table 6 German guideline guideline statements and recommendations on psychosocial issues in the management of ulcerative colitis[20]

1 Adverse life events, psychological stress and mental health disorders are not aetiologically linked to the onset of UC (EL2)

2 Subjective stress and affective disorders may have a negative impact on the course of UC

3 High disease activity is associated with high psychological symptom burden EL2)

4 Mental health disorders have a negative impact on the course of the disease and quality of life EL2)

5 Patients with persistent abdominal pain or diarrhea which cannot be explained by disease activity or complications of the disease should be assessed for irritable bowel syndrome (IBS) or depressive disorder. If IBS or depressive disorder is diagnosed, these disorders should be treated according to guideline recommendations (EL2)

6 Psychosocial co-morbidities and health- related quality of life (accounting for gender differences) should be taken into account in clinical practice at regular visits (EL2)

7 Care should involve cooperations with specialists in psychotherapy or psychosomatic medicine (EL2)

8 Physicians should inform patients about IBD self-help organisations (EL5)

9 In the case of a mental health disorder, psychotherapy is recommended (EL2)

10 Psychosocial support should be offered to children and adolescents (EL1)

UC: Ulcerative colitis; EL: Evidence level.

Table 7 Summary of the dutch national practice guidelines on the management of inflammatory bowel diseases[23]

1 Personality traits do not contribute to the aetiology of IBD1

2 Psychosocial factors such as stress, depression/anxiety and coping have an impact on the course of IBD1

3 Health-related quality of life is influenced by disease activity but also by stress, anxiety/depression, social support and quality of treatment1

4 A positive relationship between patients and health care professionals characterized by mutual respect, communication, education and emotional support for patients and families is recommended1

5 Psychosocial problems associated with the disease should be treated by psychological interventions, e.g., stress management training, self-empowerment, cognitive-behavioural therapy1

6 Anxiety and depression should be treated according to appropriate guidelines

7 IBD-patients who smoke should be advised to quit smoking1

¹No level of evidence reported. IBD: Inflammatory bowel diseases.

Table 8 European crohn’s colitis organization guideline statements and recommendations on psychosocial issues in Crohn’s disease[24]

1 Psychological disturbances seem to be a consequence of the illness rather than the cause or specific to Crohn’s disease (EL1). The degree of psychological distress correlates with the disease severity (EL2)

2 An association between psychological factors and the aetiology of Crohn’s disease is unproven (EL3), but there is a moderate influence on the course of the disease (EL1)

3 Depression and perceived chronic distress seem to represent further risk factors for relapse of the disease (EL1). It remains unclear whether acute life events trigger relapses (EL1). Most patients consider stress to have an influence on their illness (EL2)

4 Physicians should assess the patient’s psychosocial status and request additional psychological care and psychotherapy if indicated. Integrated psychosomatic care should be provided in IBD centres (EL2)

5 Patients should be informed of the existence of patient associations (EL5)

6 The psychosocial consequences and health related quality of life of patients should be taken into account in clinical practice at regular visits (EL1)

7 Psychotherapeutic interventions are indicated for psychological disorders, such as depression, anxiety, reduced quality of life with psychological distress, as well as maladaptive coping with the illness (EL1)

8 The choice of psychotherapeutic method depends on the psychological disturbance and should best be made by specialists (psychotherapist, specialist in psychosomatic medicine, psychiatrist). Psycho-pharmaceuticals should be prescribed for defined indications (EL5)

EL: Evidence level; IBD: Inflammatory bowel diseases.

Table 9 German guideline statements and recommendations on psychosocial issues in the management of Crohn’s disease[26]

1 Mental health disorders are the sequelae rather than the cause of CD. Psychological distress is correlated with disease activity and has an impact on health-related quality of life and course of the disease (EL2)

2 Psychosocial factors (personality traits, adverse life events, daily hassles) do not contribute to the etiology of CD (EL4)

3 Depression, anxiety and perceived stress are risk factors for flares. It is not certain whether acute adverse life events trigger flares (EL3). Most patients believe that stress has an impact on the disease (EL4)

4 The psychosocial consequences and health- related quality of life of patients (accounting for gender differences) should be taken into account in clinical practice at regular visits (EL5)

5 Physcians should assess the psychosocial status of patients and their need for psychotherapy. If indicated, psychotherapy should be provided. IBD-centers should provide an integrated psychosomatic care EL2)

6 Patients should be informed on the existence of patient organisations and selfhelp groups (EL5)

7 Psychotherapy is indicated in the case of mental health disorders such as anxiety and depression, reduced health-related quality of life with psychological distress and maladaptive coping (EL2)

8 The choice of a psychotherapeutic method depends on the psychological disturbance and should best be made by a psychotherapist. The choice of psychopharmacotherapy should be at the discretion of a psychiatrist specialist in the case of comorbid mental health disorders (e.g., depression and anxiety) (EL5)

9 The increased risk of a mental health disorder is associated with an early manifestation of the disease. If needed, psychosocial support should be offered to the patient and their families (EL5)

10 Patients using tobacco products should be encouraged to quit smoking (EL2)

CD: Crohn’s disease; EL: Evidence level.