Psychotherapy with chronic inflammatory bowel disease patients: A Review

Psychotherapy with Chronic Inflammatory BowelDisease Patients: A Review

Jorn von Wietersheim, PhD and Henrik Kessler, MD

Abstract: Two distinct factors have lead in the past to the develop-ment of several psychotherapeutic treatments for patients withinflammatory bowel diseases (IBD). First, clinicians and researchersbelieve that psychologic and somatic factors in chronic IBD, Crohn’sdisease, and ulcerative colitis) are connected. In addition, IBD reducesthe health-related quality of life for these patients. The purpose of thepsychotherapies is to influence the somatic course of the disease, thepsychological state of the patients, or the patients’ health related qualityof life. This report evaluates the existing studies with regard to theeffectiveness of psychotherapy IBD patients received in addition tomedical treatment. We have identified 10 psychotherapy studies and 4additional studies on self management and patient education on thistopic. The studies significantly differ from each other in regard topsychotherapeutic methods, inclusion criteria, and outcome assess-ments. The results so far lead to the conclusion that psychotherapy doesnot have an impact on the course of the disease but, in some cases,positively influences the patient’s psychologic state (such as depres-sion, anxiety, and health related quality of life or coping with thedisease). Thus, psychotherapy cannot, in general, be recommended forall patients with chronic IBD. Patients, however, that display atendency toward psychologic problems, especially as it pertains totheir illness, might profit from it.

Key Words: Crohn’s disease, ulcerative colitis, psychotherapy,psychology, quality of life, review

(Inflamm Bowel Dis 2006;12:1175–1184)

A few years after Crohn’s disease had first been describedby Crohn et al,1 some publications speculated whether

psychosomatic factors caused this disease or influenced itscourse.2,3 Researchers also suspected that ulcerative colitiswas caused by psychologic factors.3Y5 As a result, researcherstried to identify typical personality traits, specific conflictconstellations, or psychiatric abnormalities in patients withinflammatory bowel disease (IBD). These attempts failed.6

First, the findings regarding personality traits and psychiatricsymptoms were inconsistent. In addition, it was found thathigher scores of neuroticism, depression, inhibition, andemotional instability, which were sometimes found, aretypical for many patients with chronic diseases and notspecific for IBD patients. In addition, researchers found thatthere was a correlation between the actual disease activityand the psychologic data that was being studied. Patientsundergoing an acute relapse showed more signs of depressionand anxiety while testing mostly normal when in remission.7

Also, it is possible that the manner in which patients wererecruited was biased. Patients with IBD who were recruitedfrom a gastroenterological outpatient center or an internalmedicine unit had significantly fewer mental problems thanIBD patients from psychosomatic clinics.8

Physical complaints as well as mental problems canadversely affect a patient’s quality of life. This has been shownby several studies of patients with ulcerative colitis andCrohn’s disease.9,10 Both diseases are mostly chronic, withrecurring relapses. Psychosomatic research hypothesized thatthere might be some psychosocial factors that help triggerrelapses. There are several studies and summaries on thisparticular subject.11Y20 It appears that increased stress couldhelp reactivate the disease. Clinical studies have shown thatelevated stress levels or life events can increase the relapseprobability in patients with ulcerative colitis.16,18 IBDpatients with higher depression scores also were more likelyto have a relapse.19 It is assumed that increased stress and lifeevents influence the endocrine and the immune system,which are mediators of the inflammatory process. Maunder21

showed which stress-related factors might affect the diseaseactivity in IBD patients (such as substance P, vasoactiveintestinal protein, tumor necrosis factor alpha). The suspectedconnection between psychologic factors and relapses led tothe question of whether psychotherapy is helpful for patientswith IBD. This review summarizes and evaluates the resultsof the published psychotherapy studies.

Studies were identified by searching the databasesMedline, Psychlit, and Psyndex. The search strategy combinedthe keywords (MESH) ulcerative colitis or Crohn disease withpsych* (as in psychotherapy, psychology, etc.). Anothersearch included this combination and the additional keyword

CLINICAL REVIEW

Inflamm Bowel Dis & Volume 12, Number 12, December 2006 1175

Received for publication January 26, 2006; accepted July 26, 2006.University Hospital for Psychosomatic Medicine and Psychotherapy, University

of Ulm, Ulm, Germany.Reprints: Jorn von Wietersheim, PhD, University Hospital for Psychosomatic

Medicine andPsychotherapy,AmHochstraess 8, 89081Ulm,Germany (e-mail:[email protected])

Copyright * 2006 by Lippincott Williams & Wilkins

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

stress management. The search included material from 1980 tothe end of 2005. In addition, the references list of each studywas screened for additional studies. In addition to studiesrelated to psychotherapeutic techniques, we found somestudies that are more related to patient education. Some ofthese were also included here, but we did not conduct a formalliterature search for that segment.

A meta-analysis did not appear appropriate because thereare only a few studies, and these differ from each other in manyrespects such as inclusion criteria (active disease, remission),sample selection (consecutive or self-selected), treatmentvariables (type of psychotherapy, duration of therapy, grouptherapy, individual therapy, or self help context, inpatient oroutpatient treatment), and outcome variables (disease course,IBD symptoms, health-related quality of life, psychopathology).

STUDIES REGARDING THE EFFECTIVENESSOF PSYCHOTHERAPEUTIC TREATMENTFOR PATIENTS WITH INFLAMMATORY

BOWEL DISEASESThe goal of psychotherapy with IBD patients could be to

improve the course of the disease, to change psychologicfactors such as depression and dysfunctional coping, or toimprove the patient’s quality of life. Our literature researchproduced 10 studies dealing with psychotherapeutic treat-ments of patients with IBD. We also found four additionalstudies that are more related to patient education and selfmanagement. It is important to point out that in all studies,psychotherapy was used as a supplementary treatment. Allpatients simultaneously received conservative therapy. Table 1shows an overview of the psychotherapy studies. These studiescan be divided into two subgroups: those using psychodynamictherapy (including psychoanalysis and supportive-expressivetherapy) and those using behavior therapy, predominantlystress management training. Psychodynamic therapy addressesmore underlying problems and conflicts, and the behaviortherapy addresses more specific problematic cognitions anddysfunctional behavior (e.g., problems in stress management).

Studies Involving PsychodynamicPsychotherapy

The earliest studies regarding the effectiveness ofpsychotherapy for ulcerative colitis were conducted 50 yearsago (1956), as published by O’Connor et al.22 They examinedthe impact psychoanalytic therapy had on somatic data(symptoms, proctoscopy) and the psychologic state of thepatients compared with a control group only receivingmedication. The researchers did not, however, use a random-ized design. There were 57 patients each in the therapy and thecontrol groups. Researchers concluded that the patients in thepsychotherapy group did better. Because of the specificmanner by which the patients had been referred (referral for

psychiatric consultation or directly to a psychoanalytic depart-ment), many of the patients in the therapy group weresuffering from severe psychiatric problems (19 patients withschizophrenia, 34 with personality disorders). As a result, thepatients included in this study did not constitute a representa-tive sample for ulcerative colitis patients. The researchers alsodid not conduct statistical significance testing.

Kunsebeck et al23 investigated the effects of supportivepsychotherapy on patients with Crohn’s disease with regard toits effect on the course of the disease and coping skills. At thebeginning of the study, all patients were experiencing an acuteepisode; in addition to medical treatment, they receivedpsychotherapy during their stay at the hospital. Twenty-ninepatients participated in this study. Patients were assigned to thetwo groups in the order they were admitted to the hospital. Theearlier patients were assigned to the intervention group (n = 15),and patients admitted to the hospital at a later point wereassigned to the control group (n = 14). The interventionconsisted of supportive psychotherapy. The data collected atadmission, discharge, and 4 months and 13 months afterdischarge consisted of disease activity, amount and duration ofhospitalizations and operations, depression, anxiety, and per-sonality traits. The data for both groups was comparable at thepoint of admission. The average disease activity indexes of 235(intervention group) and 214 patients (control group) were quitehigh. The scores for depression and anxiety were above normal.In the therapy group, the scores for depression and anxietydecreased significantly during the 13 months the study wasbeing conducted. The scores of the control group declined alsobut remained at a higher level with regard to depression andanxiety. There were no differences in regard to most of thesomatic data. The patients in the therapy group, however,required significantly less inpatient or outpatient treatments oroperations during the observation period. Half of the patients inthe therapy group continued with outpatient psychotherapyafter their discharge.

In a randomized, controlled, multicenter study, Jantscheket al7,24 investigated the effect of psychodynamic psycho-therapy on patients with Crohn’s disease in regard to the courseof the disease and to psychologic symptoms. The study lasted2 years. Patients were recruited from four German universityclinics. Overall, 108 (of 488 screened) patients fulfilled thestrict and precisely documented inclusion criteria and wererandomized into the control group (standardized medication)and the intervention group (standardized medication andadditional psychotherapy during the first of the 2 years ofthe study) at a 1:2 ratio. The intervention consisted of psycho-dynamic psychotherapy (e.g., approximately 26 therapysessions) and also autogenic training (approximately 17sessions) during the first year of the study. At the beginningof the study, there were no differences between the two groupswith respect to somatic, sociodemographic, and psychologiccriteria. After 2 years, 23% of the control group and 30% of the

von Wietersheim and Kessler Inflamm Bowel Dis & Volume 12, Number 12, December 2006

1176 * 2006 Lippincott Williams & Wilkins


therapy group had not experienced a relapse. Twenty-ninepercent of the control group and 17% of the therapy group hadto undergo surgery. In regard to the somatic course of thedisease, the therapy group did better than the control group butnot significantly (P G 0.125). After 1 year, the scores fordepression, anxiety, quality of life, and psychologic symptomsdid not differ significantly. It is important to mention that mostpsychologic data, particularly for patients in remission, werewithin the normal range.

The study conducted by Maunder and Esplen25 testedthe effect of supportive-expressive group psychotherapy forpatients with IBD. In this uncontrolled study, 30 subjectswith IBD (21 with Crohn’s disease, 9 with ulcerative colitis)underwent 20 weekly sessions of supportive-expressivegroup psychotherapy in a small group setting. The groupdiscussions were related to emotion-evoking issues anddiscussions about disease related topics such as self-image,stigma, and conflict with health care professionals. Psycho-logic variables were measured at the beginning and the end ofthe therapy. Scores regarding quality of life, anxiety, ordepression did not change significantly over the course oftreatment. Only the scores for maladaptive coping decreased.The authors did not provide any information about somaticchanges in the patients.

Studies Involving Behavior TherapyThe study by Milne et al26 examined the impact a stress

management program has on the course of the disease and onthe patient’s psychosocial level of functioning. The studyincluded 80 patients with IBD. The patients were randomizedinto an intervention and a control group. The interventiongroup received stress management training in a group setting(6 sessions, each lasting 3 hours). The training emphasizedplanning techniques (time management, problem solving),communication skills, and relaxation (autogenic training).Medical treatment was determined by the patient’s physicianand was not standardized. Patients from both groups wereinterviewed by Bblinded[ investigators after 4, 8, and12 months (course of disease, medication) and also filled outquestionnaires to provide additional psychologic data. Despitethe randomization of the two groups, they differed signifi-cantly. At the beginning of the study, the patients in theintervention group tested higher with regard to disease activity(Crohn’s Disease Activity Index, 143 vs. 90) and had a higherstress index (34 vs. 23). Over the course of the study, theintervention group improved significantly regarding diseaseactivity and stress index, whereas there was no change in thecontrol group.

Schwarz et al27 studied the effects of outpatient behaviortherapy in patients with Crohn’s disease and ulcerative colitis incomparison with a control group (waitlist control group). Thetwo groups with 11 and 10 patients, respectively, were verysmall. The therapy, consisting of 12 1 hour sessions, included

information about IBD, progressive muscle relaxation, thermalbiofeedback, and cognitive coping strategies. The patients kepta diary, in which they noted symptoms, nutrition, andmedication on a daily basis. They also completed a numberof psychologic questionnaires regarding depression, anxiety,and life stress at the beginning and the end of the study. Theresearchers found that psychotherapy had no significant effecton either the somatic symptoms or the psychologic variables.Most patients in the therapy group, however, believed that thetherapy had had a positive effect and indicated that they werebetter able to cope with the disease now.

Mussell et al28 studied 28 patients (14 with Crohn’sdisease, 14 with ulcerative colitis, no control group) toresearch whether 12 sessions of cognitive behavior therapyin a group setting would reduce illness-related anxiety andconcerns, help the patient cope more effectively, or would helpreduce the stress level. The treatment consisted of psycho-education about IBD provided by a gastroenterologist,information about how cognition and emotions generate stress,training regarding adaptive cognitive coping strategies fordisease-related and routine stress, and progressive musclerelaxation training. This treatment was followed by threeadditional sessions every 3 months. The researchers collecteddata at the beginning and the end of treatment and during thefollow-up sessions. Nine months after the conclusion of thetherapy, the patients had lower depression scores and werebetter able to cope, but the latter was only significant forwomen. Scores for illness-related anxiety had decreased in allpatients. The overall results for psychopathology and activecoping had not changed during this time period.

Larsson et al29 researched the impact of a group trainingprogram that had specifically been tailored toward IBDpatients with high anxiety scores. Forty-nine patients withIBD and high anxiety levels were randomized into the therapygroup. Seventeen patients were on a waiting list and served asthe control group. The training was conducted in a groupsetting and consisted of eight sessions dealing with somaticand psychosocial factors of IBD and stress management. Inaddition to anxiety and depression, the researchers alsoassessed the general and health-related quality of life and thepatient’s opinion about the training. Six months after thetraining, none of the psychologic instruments indicated asignificant change in the scores. The patients, however, weresatisfied with the training, which had provided them with moreinformation about their illness. The authors highlight howimportant it is that the patient is adequately informed about thedisease. However, they cannot claim that the training had asignificant impact on the psychologic state of the patients.They believe that there was no impact because the high levelof 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 bechanged by 8 hours of training.

Inflamm Bowel Dis & Volume 12, Number 12, December 2006 Psychotherapy with Chronic Inflammatory Bowel Disease Patients

* 2006 Lippincott Williams & Wilkins 1177


TABLE1.Overview

ofPsych

otherapyStudieswithPatients

withChronic

Inflammatory

BowelDisease

Study

Recruitmentof

StudyParticipan

tsDesignan

dAssessm

ents

Intervention

MeasuredFactors

MainFindings

O’Con

ner

etal,19

64UC

Partlymatched

controlgrou

pPsychoanalytically

oriented

PT

Ratings

ofsymptom

sandproctoscop

ySligh

tlybetter

diseasecourse

inthePTgrou

p,go

odrespon

seof

patientsto

PT

n=57

,therapy

Follow-upob

servations

to8years

Psycholog

icrespon

seto

psycho

therapy

n=57

,control

outpatientsin

psycho

analytic

unit

Kun

sebeck

etal,19

87CD

Con

trolled,

admission

,discharge,4and13

mo

postho

spitalization

Sup

portivePT

Disease

activity,course

ofdisease,

depression

,anxiety,

person

ality

PTim

proved

depression

and

anxiety;

noinfluenceon

somatic

data

butless

use

n=15

,therapy

n=14

,controlinpatient

internal

med.

Jantschek

etal,19

98CD

Multicenter

RCT

before

therapy

Psychod

ynam

icshort

therapy,

autogenic

training

Cou

rseof

disease,

depression

,anxiety,

qualityof

life,

mentalstatus

PTdidno

tinfluencepsycho

logic

orsomatic

factors;somew

hat

less

surgery,

positive

selfevaluation

n=72

,intervention

Follow-upevery3mo

for2yr

n=36,control

outpatientsof

internal

medicineunit

Maund

erand

Esplen,

2001

n=21

,CD

Prospective,no

control

Sup

portive-expressive

grou

ptherapy

IBD

concerns,

symptom

s,qu

alityof

life,depression

,anxiety,

maladaptive

coping

Onlyredu

ctions

inmaladaptive

coping

,no

tin

otherpsycho

logic

data

orin

qualityof

life

n=9,

UCou

tpatients

Pre-post

Milne etal,19

86CD/UC

RCTfollow

-upafter4,

8,and12

mo

Stressmanagem

ent

(problem

solving,

commun

ication,

autogenictraining

)

Disease

activity

stress

index

Stressmanagem

entim

prov

edCDAIandstress

index,

but

controlgrou

pvery

different

n=40

,therapy

n=40,control

outpatientsof

internal

medicineunit




Schwarz

etal,19

91IBD

RCTpre-po

st,follow

-up

after3mo

12sessions

PMR,

biofeedb

ack,

cogn

itive

coping

strategies

Disease

activity,

depression

,anxiety,

stress

index

Betterdevelopm

entin

waiting

list

grou

p,subjectively

better

coping

withIBD

intherapygrou

p

n=11,Therapy

n=10

,waiting

list

outpatients

Mussel

etal,20

03n=14

,CD

Prospective,no

control

Behaviortherapyin

grou

psetting(training,

coping

techniqu

es,PMR)

Psychop

atho

logy,coping

,disease-relatedconcerns

Reduced

illness-relatedconcerns,

inwom

en.additional

improv

ementof

depression

n=14

,UC

outpatientsin

clinical

remission

3mo,

pre,

post,3/6/9mo

follow

-up

Larsson

etal,20

03CD/UC

Prospective,rand

omized,sm

all

controlgrou

p(w

aiting

list)

before

training

and6months

follow

-up

Patient

training

,stress

managem

ent

Anx

iety,depression

,disease-specificqu

ality

oflife,ov

erallqu

ality

oflife

Traininghadno

impact

onmentalstate,

butpatients

enjoyedtraining

n=49

,intervention

n=17,controlinternal

medicineoutpatients

with

high

degree

ofanxiety

Garcia-Vega

and

Rodriguez,

2004

CD

RCTwith3grou

ps,pre,

post,

follow

-upafter6and12

mo

Stressmanagem

ent

treatm

ent,self-directed

stress

managem

ent

prog

ram

CD

symptom

ssuch

asdiscom

fort,tiredn

ess,

diarrhea

Inbo

thtreatm

entgrou

ps,

redu

ctionof

tiredn

ess,

constipation

,abdo

minal

pain;

nodifference

betweenthe

treatm

entgrou

ps

n=30

,intervention

n=15

,control

Eisenbruch

etal,20

05n=30

,UC

Prospective,rand

omized,

controlled

Bod

y-mind-therapy

(stressmanagem

ent,

exercise,diet,selfcare,

60ho

urs)

Quality

oflife,perceived

stress,diseaseactivity,

endo

crine,

and

labo

ratory

data

Improv

ementin

somequ

alityof

life

scales

andbo

welsymptom

s;no

grou

pdifferencesin

disease

activity,endo

crine,

and

immun

eparameters

n=15

,intervention

Pre,po

stn=15

,control

Firstfour

studiesaremorerelatedto

psychodynamic

therapies,thelatter

tobehavioral

therapies.

CD,Crohn

’sdisease;

UC,ulcerative

colitis;IBD,inflam

matorybo

wel

disease;

CDAI,Crohn

’sDisease

ActivityIndex;

RCT,rand

omized

controlled

trail;PT,psychotherapy;

PMR,progressive

musclerelaxation

.




Garcia-Vega and Fernandez-Rodriguez30 studied theeffectiveness of two stress management programs for patientswith Crohn’s disease. They compared three groups. The firstgroup received 6 individual sessions of manualized stressmanagement. The second group received a self-directed stressmanagement program, in which the patients followed a writtenguidebook on stress management techniques and worked withan audiotape for home practice relaxation (6 sessions). Thethird group was the control group and received conventionalmedical treatment. The groups were randomized and consistedof 15 patients each. None of the patients was experiencing anacute episode. They were asked to use a diary to documentsymptoms such as general discomfort, fatigue, diarrhea,constipation, abdominal pain, and distended abdomen on adaily basis. The study did not include any additionalpsychologic data. After the treatment, the patients who hadreceived stress management training were less fatigued, lessconstipated, and had less abdominal pain and a less distendedabdomen. The patients in the self-directed group had verysimilar results, whereas no significant changes were observedin the control group.

Elsenbruch et al31 researched the effect a BMind-Body-Therapy[ has on patients with ulcerative collitis in remission.The intervention group consisted of 15 patients, whereas 15patients on a waiting list served as the control group. Thetherapy consisted of a 60 hour training program, whichincluded stress management training, some exercise, Mediter-ranean diet, behavioral techniques, and self-care strategies.Quality of life, perceived stress, and disease symptoms wereassessed with standardized questionnaires. In addition, re-searchers also measured disease activity (Clinical ActivityIndex), endocrine laboratory parameters, leukocytes and lympho-cyte subsets in peripheral blood, and the b-adrenergic modu-lation of tumor necrosis factor-a production in vivo. The scoresfrom patients in the intervention group improved in regard tosome of the eight Short Form-36 quality of life scales, but onlythe changes regarding the mental health scale were statisticallysignificant. Researchers also noted significant changes in theinflammatory bowel disease quality of life index. In contrastwith these psychologic changes, however, there were nosignificant group differences regarding somatic data such asdisease activity, endocrine, and immune parameters.

As previously mentioned, our database research yieldednot only studies regarding psychotherapy of patient with IBD,but also some studies focusing on patient education and selfmanagement. Table 2 summarizes the details of those studies.

Kennedy et al32 conducted a multicenter, randomized,controlled study to assess the effectiveness and costs of apatient-orientated self management program for patients withIBD. Seven hundred patients were recruited and assigned toeither a control group or an intervention group. Cliniciansworking with the intervention group received a 2 hour trainingin patient-centered consultations. In collaboration with the

individual patient, they developed a self-management plan forthis patient, which was documented in a guidebook. Thisguidebook also contained information about research on,treatment of, and self management of IBD and indicated areaswhere the patient’s choices might influence treatment deci-sions. During the 1 year follow-up, self managing patients hadsignificantly fewer hospital visits without this leading to anincrease in the number of visits to their regular doctor. Thescores for quality of life, anxiety, and depression did not differbetween the intervention and control group. The authorsconclude that their new self management program is efficientin reducing health care costs for IBD patients.

In a randomized, controlled study, Waters et al33 assessedthe effects of a formal educational program for patients withIBD. Sixty-nine patients received a special IBD educationalprogram and standard care or just standard care alone. The12 hour educational program was divided into sessions lasting3 hours each and was administered over the course of 4 weeks.It included general information about anatomy, pathophysi-ology of IBD, therapy, and discussions about disease manage-ment. During the 8 week follow-up testing, the group that hadundergone the training scored significantly higher regardingknowledge about the disease and patient satisfaction. Thescores regarding quality of life and medication adherence weresimilar in both groups. In both groups, however, increasedhealth care use was associated with poorer medicationadherence and lower perceived health. Scores regarding thequality of life remained the same. There was no informationon somatic outcome variables.

In a prospective study by Bregenzer et al,34 73 patientswith IBD (40 Crohn’s disease, 33 ulcerative colitis) whoattended a training program were compared with 72 controlpatients. The training program, which was conducted in agroup setting, consisted of four 2 hour sessions. The maintopics of these sessions were information about the somaticaspects of IBD, nutrition, social problems, stress management,and training in coping techniques. Data was assessed at thebeginning of the study and after 3, 6, and 10 months. Thedisease activity remained unchanged in both groups. Through-out the study, the patients’ illness-related knowledge increased.Depression and quality of life parameter improved only inpatients with initially high results, but this was true for bothgroups. The patients of the intervention group reported,however, that they were satisfied with the training and thatthey would be able to accept more responsibility forthemselves and their illness.

Shepanski et al35 researched the effect of an IBDsummer camp on the health-related quality of life in childrenand adolescents with IBD. This was sponsored by the Crohn’sand Colitis Foundation of America, with all the families of thecampers being members of the foundation. Throughout theweek, the children participated in group activities such astubing, swimming, kayaking, miniature golf, basketball,




TABLE2.Overview

ofStudiesFo

cusedonPatientEducationandSelfManagement

Study

Recruitmentof

StudyParticipan

tsDesignan

dAssessm

ents

Intervention

MeasuredFactors

MainFindings

Kennedy

etal,20

0470

0IBD

patients

n=36

5,controls

n=27

0,intervention

Prospective,controlled,

rand

omized

centers,

12mofollow

-up

Selfmanagem

ent

prog

ram

Som

atic

data,nu

mber

ofvisits,costs,anxiety,

depression

,qu

alityof

life

Few

erho

spital

visits,fewer

repo

rted

relapses

inself

managem

entgrou

p

Waterset

al,

2005

69IBD

patients

n=45

,education

n=44

,control

Prospective,rand

omized

controlled

Pre,po

st,8weeks

follow

-up

Formal

education

prog

ram

Kno

wledg

e,patient

satisfaction

,medication

adherence,

health

care

use,

qualityof

life

Higherkn

owledg

escores

andpatient

satisfaction

;no

differencesin

qualityof

life

andmedication

nonadh

erence

Bregenzer

etal,20

05CD/UC

n=73

,intervention

n=72

,controlinternal

medicineoutpatients/

inpatients

Prospective,controlled,

notrand

omized

Pre,3/6/10

mo

follow

-up

Patient

training

(som

atic,nu

trition,

coping

)

Kno

wledg

eabou

tdisease,

diseaseactivity,

depression

,qu

ality

oflife,subjective

evaluation

*

Exceptforpo

sitive

subjective

self-

evaluation

,training

,hadno

specific

impact

onmentalor

somatic

factors

Shepanski

etal,20

05n=61

adolescent

IBD

patients

n=47

,CD

n=14

,CU

Naturalisticreport,

pre,

postcomparison

Sum

mer

campfor

children

and

adolescentsof

CCFA

Healthrelatedqu

ality

oflife,anxiety

Improv

ementin

HRQLscores;

nochangesin

anxietyscores

CD,Crohn

’sdisease;

UC,ulcerative

colitis;

IBD,inflam

matorybo

wel

disease;

RCT,rand

omized

controlled

trail;PT,psycho

therapy;

PMR,progressivemusclerelaxation

;CCFA

,Crohn

’sand

ColitisFou

ndationof

America.




adventure course, arts and crafts, dance, and cooking. Medicalsupervision was provided by experienced physicians andnurses. The campers had no formal IBD educational classes,but there were many informal conversations among thecampers and between campers and counselors about theirillness. The study evaluates questionnaires from 61 patients (of125 individuals who had consented to participate). Forty-sevenhad Crohn’s disease, and 14 had ulcerative colitis, ranging inage from 9 to 16 years. There were small, but statisticallysignificant, improvements regarding the total scores for healthrelated quality of life, bowel symptoms scores, socialfunctioning scores, and treatment interventions scores. Thescores for anxiety, however, did not change.

SUMMARY AND CONCLUSIONSThe results of the psychotherapy studies can be summar-

ized as follows: only one study23 showed an (indirect) influenceof psychotherapy on the somatic course of the illness (lessreadmissions 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. Theresults of the largest psychotherapy study24 showed tendenciesin that direction, but this were not statistically significant.Another study30 illustrated the impact of a stress managementprogram on disease related symptoms such as fatigue, diarrhea,constipation, and abdominal pain. Some studies showed thatpsychotherapy influences psychologic factors such as depres-sion, anxiety, coping, and stress index,23,26,28 but this could notbe repeated in others.24,25,27,29,33 In some studies,24,26,27,29,33,34

the patients themselves believed that they had subjectivelyprofited from the study.

The studies used very different psychotherapeutic methods(individual and group therapy, psychodynamic methods,behavior therapy, relaxation therapy, and special stress manage-ment training). Because of the lack of studies, it is not possibleto decide whether one therapy is superior to another. Psycho-dynamic therapies and behavior therapy appear to have hadsimilar results, but it appears that stress management trainingwas used more often than the other methods.

We therefore feel confident in making the followingassumptions:Psychotherapy mainly affects the psyche. There were only

very few and inconsistent somatic effects, such as amore favorable course of the disease. Psychotherapyappears to have a positive impact on the patients’depression and anxiety and helps patients cope withtheir illness. In most of the studies, patients indicatedhaving subjectively profited from the intervention andthat it had become easier for them to cope with theillness. From a methodologic viewpoint, these findingsdeal with the general problems of satisfaction studiesbecause the patients often give positive feed-back given

that this is socially desired. A possible conclusionwould be, however, that psychotherapy does not affectthe course of disease itself but influences the psyche ofthe 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 onpsychologic variables, patients usually were already inthe subclinical range before the intervention. Thiscould be interpreted as a Bground effect[ (no furtherimprovement possible). Because of this fact, somestudies concentrated on patients with initially clinicallyrelevant values for depression or anxiety.

The need for psychotherapy varies significantly. Miehsleret al36 developed a questionnaire regarding the need forpsychologic care for patients with IBD. The scales onthe questionnaire address the need for various types ofpsychosocial interventions: disease-oriented counseling,Bintegrated psychosomatic care[, which focuses on theinteraction of biological, psychologic, and social sub-systems as they pertain to the current situation thepatient finds him or herself in, and patients requiringintensive (professional) psychotherapy because of emo-tional stress or behavioral problems.

There is no proof that one therapy is superior to another.Different forms of treatment have been used (psycho-dynamic therapy, behavior therapy, relaxation, etc.). Sofar, there has not been a systematic comparisonbetween the various therapies.

Patients with Crohn’s disease or ulcerative colitis could responddifferently to psychotherapy. Post hoc analyses indi-cated different effects of psychotherapy on patientswith Crohn’s disease or ulcerative colitis. Overall,Crohn’s disease patients have more psychologic com-plaints,37 which indicates a different starting positionor 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 psychotherapeutictreatment. We suspect that there are Brisk patients[ in whompsychosocial components have a bigger influence on thecourse of disease than in other patients. That group wouldprobably benefit from psychotherapeutic treatment. Thefollowing 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 stressand symptoms, as well as dysfunctional coping techniques.

A gastroenterologist who is considering recommendingpsychotherapy or psychologic consultation to a patient withIBD should consider the following questions (and also askthe 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 patientand possibly a psychotherapist, which type of intervention(disease-oriented counseling, Bintegrated psychosomaticcare[, Bspecialized psychotherapy[) would be most appro-priate for this patient.

These recommendations are in concordance with theEuropean evidence based guideline on the management ofCrohn’s disease, which indicates that psychotherapy is usefulif IBD patients have an addition psychologic disorder, suchas depression, anxiety, or a reduced quality of life withpsychological distress, as well as maladaptive coping withthe illness.38

From a methodologic perspective, it is important to notethat IBD varies significantly throughout its course. This hasbeenwell documented and is influenced by somatic factors suchas localization, course of disease, immune parameter, andmedication. Therefore, the claim that psychotherapy has a(verifiable) influence on the course of the disease is veryambitious. This is especially true for the most common studydesign, a comparison between treatment with an effectivemedication and this medication with additional psychotherapy.For methodologic reasons alone, it is clear that the possibleadditive effects cannot be very strong. It would be more realisticto find out whether psychotherapy influences the patient’spsyche, health related quality of life, or disease coping.Although it could theoretically be expected that a betterpsychologic state would positively influence the course of thedisease, it would be very difficult to prove this scientifically.

Psychotherapeutic methods such as those presented inthis study have also been used with similar results inconnection with many other somatic illnesses such as coronaryheart disease, bronchial asthma, cancer, and skin diseases.39 Inthat context, chronic IBDs are probably no more or lessBpsychosomatic[ than other illnesses.

Further studies on psychotherapy with IBD patientsshould focus on the risk patients mentioned above. It would behelpful to recognize these (possible with an effective screeningprocedure) and to investigate the impact of a (manualized)psychotherapy in a controlled study. The main outcomevariables should be psychopathology, quality of life, or howthe patient deals with daily stress.

A large percentage of the patients would probablybenefit from detailed information about the illness and aconsultation regarding self-management of the illness. Onestudy illustrated that patient education programs reduceddoctor visits, and two studies indicated that it produced betterinformed patients. One study was able to show that the scoresregarding health related quality of life slightly improved.Therefore, these therapies could be recommended for manypatients (as opposed to more intensive psychotherapy).

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Psychotherapy with chronic inflammatory bowel disease patients: A Review

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