Jayasooriya N, Blackwell J, Saxena S, et al.
Aliment Pharmacol Ther 2022;55:1330–41.
© Esha Sharma
Inflammatory Bowel Disease (IBD) is a long-term condition of the gut which is known to impact the quality of life and social functioning of those affected due to the chronic nature of symptoms. These factors, along with communication across the gut–brain axis, cause many patients to suffer from mental health disorders such as anxiety and depression . Previously, the magnitude of these comorbidities had not been established, but recent studies [1, 2] have found the prevalence to be high: a third of all patients and a half of those with an active IBD flare have been found to suffer from anxiety, while depression has been found to affect a quarter of patients and a third of those with active symptoms.
Furthermore, compared with controls, patients with IBD and mental health disorders show increased use of healthcare resources (both primary care visits and emergency secondary care visits) and increased use of antidepressant and anxiolytic medications . While antidepressant medications are commonly used to treat anxiety and depression in IBD , understanding of how effectively these treatments are prescribed remains limited, and this is particularly true regarding the adequacy of duration of treatment in this cohort.
This population-based study was performed in the United Kingdom and used data from the primary care setting that was routinely collected electronically in general practices as part of the Clinical Practice Research Datalink (CPRD). The authors looked to review the antidepressant prescribing in primary care for those diagnosed with IBD. They focused on the rate of antidepressant treatment initiation following IBD diagnosis, the duration of antidepressant treatment according to international guidelines, potential risks of inadequate antidepressant treatment duration and general trends in antidepressant prescribing.
During a median follow-up of 7.7 years, antidepressant use was found to be 19.54 vs 16.94/1000 person years amongst those with IBD compared to the control cohort. The risk of antidepressant use increased by more than half during the 12-year study period for those with IBD. The highest risk of antidepressant use was observed in the first year following diagnosis (aHR = 1.34, 95% CI 1.21–1.49). The incidence of tricyclic antidepressant use was considered separately (as such antidepressants are commonly prescribed at low doses for conditions other than mental health disorders) and was 17.76 vs 8.41/1000 person years in the IBD cohort and the control cohort, respectively.
An antidepressant episode was the term used to describe the period between initiation and cessation of the drug. The median episode was 98 days (interquartile range 28–317 days; total range 28–4977 days). Two-thirds (67%) of the IBD cohort received antidepressant treatment for less than seven months, the minimum recommended duration according to international guidance. Individuals aged 18–24 years at IBD diagnosis were twice as likely to discontinue antidepressant treatment early compared with those aged 40–60 years at diagnosis (aHR = 2.03, 95% CI 1.40–2.95). Furthermore, 78% of 18- to 24-year-olds received an antidepressant treatment course lasting less than the recommended guidance compared with 61% of 40- to 60-year-olds.
A third (34%) of individuals commenced on antidepressant medication received a single prescription in their first treatment episode, equating to a duration of treatment of 28 days or less. Of these, only 7% went on to receive a course lasting 7 months or longer. An alternative antidepressant class was given to 11% of patients following their initial treatment episode. Early antidepressant discontinuation after a single prescription was observed at a higher rate in those living in areas of greater socioeconomic deprivation.
The study demonstrated that over the 12-year study period there have been changes in choice of antidepressant, with serotonin re-uptake inhibitors (SSRIs) predominantly prescribed more recently, consistent with prescribing in the general population.
The authors highlight the increased burden of depression and anxiety in those with IBD and subsequent antidepressant use, especially in the first year following diagnosis. They were not able to identify the use of psychological therapy as part of the treatment for mental health disorders as they were limited by use of primary care records as the data source for the study. Psychotherapy has been shown to be effective in improving anxiety, depression and quality of life as well as symptoms of disease  and could be a more effective early intervention than antidepressant medication. The authors rightly highlight that only 2% of IBD services in the United Kingdom have access to a psychologist according to the recent benchmarking exercise carried out by IBD UK, and this affirms the need for integrated services .
Two-thirds of individuals who started antidepressant medication did not receive an adequate duration of treatment. It is recommended that most people continue to take their antidepressant for six to nine months after their symptoms subside. Those with repeated episodes of depression may require courses of two years or longer . The authors suggest lack of timely response, concerns regarding dependency and side-effects as potential reasons for early cessation of treatment. In addition, poor adherence to medication is increased in those with IBD  and this may contribute to suboptimal antidepressant duration. Lack of consistent healthcare provision due to relocation for purposes of education or employment may offer an explanation for shorter treatment durations in younger patients, while those with low-income backgrounds may be influenced by the affordability of repeated prescription charges.
As mentioned above, changes in the choice of antidepressant prescribed over the 12-year study period match changes in the prescription of antidepressants in the general population. Given the small number of randomised controlled trials of antidepressants in patients with IBD , choice of treatment for depression in IBD is based on efficacy and tolerability data from the non-IBD population and this explains the observed changes in prescribing.
Given that the prevalence of mental health disorders in individuals with IBD is increasing and that suboptimal use of antidepressant was observed in two-thirds of patients in this study, future strategies should include better integration of services and use of psychotherapy. These measures have the potential to improve outcomes for patients as well as to reduce the burden on healthcare systems [2, 9].
Esha Sharma - Short Biography
Esha Sharma is a senior specialist Pharmacist for Gastroenterology at Guy’s and St Thomas’ NHS Foundation Trust. She has a specialist interest in Inflammatory Bowel Disease, is an independent prescriber in this field and working to develop the role of IBD pharmacists further. She is a pharmacy representative for IBD UK and research lead for the UK Clinical Pharmacy Association Gastroenterology and Hepatology Group.