The Relationship Between Anxiety and Depression and IBD: Focus on Management Issues

Transcription

1 The Relationship Between Anxiety and Depression and IBD: Focus on Management Issues Michael Vallis, PhD, R Psych Psychologist, Associate Professor Dalhousie University Halifax, Nova Scotia Canada tvallis@dal.ca Jennifer Jones, MD, MSc (FRCPC) Associate Professor Dalhousie University Halifax, Nova Scotia Canada jljones@dal.ca

2 Disclosures Michael Ad Boards: Novo Nordisk, Abbvie, Valeant, CSL Behring Consultant: Novo Nordisk and Abbvie on behavioural adherence Periodic speaking fees: Novo Nordisk, Abbvie, Sanofi, Merck, Pfizer Jennifer: Ad boards: Abbvie, Takeda, Pfizer, Janssen, Shire, Ferring Consultant: Abbvie, Takeda, Pfizer, Janssen, Shire, Merck Periodic speaking fees: Abbvie, Takeda, Pfizer, Janssen, Shire

3 Goals of this Workshop Provide a framework for assessing distress in IBD patients Address clinician competence vis a vis supporting distress management within the clinic Demonstrate how distress can be managed inside an IBD service in light of the time constraints of most practices. Outline how to identify the need for mental health referral and how to navigate referral options. Key References: Drossman D, Lesserman J, Li Z, Mithcell M, Zagami E, Patrick D. The Rating Form of IBD Patient Concerns: A New Measure of Health Status. Psychosomatic Medicine, 1991;53: Vallis M. (2013). Behaviour Change Counselling-How Do I Know If I Am Doing It Well? The Development of the Behaviour Change Counselling Scale (BCCS). Canadian Journal of Diabetes. 37(1): Vallis TM, Leddin D. (2004). What makes Crohn s disease patients difficult to manage? The role of psychosocial factors, Journal of Clinical Psychology in Medical Settings. 11 (4): Vallis TM, Greaven S, Leddin D. (2002). What are we going to do with you? GI service providers perceptions of difficult to manage IBD patients. Canadian Journal of Gastroenterology, 16, Vallis TM, Turnbull GK. (1992a). Clinical management of Inflammatory Bowel Disease: Beyond disease activity. Part I. Assessing psychosocial factors. Canadian Journal of Gastroenterology, 6, Vallis TM, Turnbull GK (1992b). Clinical management of Inflammatory bowel disease: Beyond disease activity: Part II: Strategies for maximizing psychosocial health. Canadian Journal of Gastroenterology, 6(2),

4 CASE - Background Ms. B High functioning, 38 year-old professional with a known diagnosis of ileal Crohn s disease s/p 2 previous, short-segment, ileocolonic resections for stricturing and inflammatory disease. Married with 2 young children ages 18 mos and 5 years The most recent ileal resection was 5 years ago. Had been doing well clinically for the past few years on maintenance therapy with adalimumab (past exposure to infliximab with loss of response). Over the past 2 months has been experiencing increased diarrheal symptoms, weight loss and fatigue.

5 Case Continued... She tells you that she has been trying to manage symptoms on her own with dietary manipulation and feels that this has helped to some extent You re-evaluate her CD disease activity through lab work and an ileocolonoscopy which she reluctantly agrees to o She has evidence of severely active ileal disease with large, focal, ulcerations extending to at least 10cm. Biopsies consistent with active CD. o CT enterography confirms inflammatory disease of the neoterminal ileum o CRP normal o Adalimumab trough level is 18

6 Case continued... You see her in clinic to discuss the results of the tests and to discuss alteration of medical therapy She is fearful of changing therapy and fearful of side effects of therapy When you relay the test results to her she seems doubtful since she feels that her symptoms are somewhat different from her past symptoms & questions the normal CRP She becomes tearful and asks many questions about her test results, questions their accuracy and significance She puts forth her theory that she has a yeast or a bacterial infection in her small bowel and wishes to take antibiotics to eradicate it even though the stool cultures were all negative. She asks about H pylori. As a compromise you agree to perform a fecal HP antigen

7 Case continued... Over the next few months you have some difficulty convincing Ms. B to start medical therapy She trialed nutrition intervention therapy with a few different diets She took time off work as she was convinced that stress was causing her symptoms and worsening her disease activity

8 Case continued... After 3 months when symptoms began to deteriorate further and her weight continues to drop, you see her in clinic. She is accompanied by her husband. She questions her diagnosis again She perseverates She is tearful, blames herself for her disease activity. She is frustrated that her efforts have not worked She is highly restricted at home and at work for fear of loss of bowel control She wonders if she is crazy She feels guilty that she is not present for her kids or family and that she is not performing to her standards at her job

9 Case continued... You listen You try to validate and reassure her After discussion she agrees to start an alternate medical treatment plan..

10 If you were this patient, how would you respond? Because of your condition, how concerned are you with Rate each item from 0 (Not at all) to 100 (A great deal) Impact of Disease 1. The uncertain nature of my disease.. Complications 10. Having surgery.. 2. The effects of medication 3. Loss of bowel control 4. Being a burden to others 5. Having access to quality medical care. 6. Feeling alone. 7. Intimacy. Sexual Intimacy 11. Having an ostomy bag 12. Developing cancer 13. Dying early. Body Stigma 14. Producing unpleasant odors. 15. Feeling feeling dirty of smelly. 8. Loss of sexual drive 9. Ability to perform sexually

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13 DISTRESS Depression Anxiety Hostility

14 Putting Emotion in Context: Where do we Draw the Line? Psychiatric Diagnosis Distress

15 Cognitive Psychology The normal emotional experience associated with the perception of loss. Depression The normal emotional experience associated with the perception of threat. Anxiety The normal emotional experience associated with the perception of intrusion. Anger

16 Emotions Primary Emotions Natural, appropriate emotional responses to live experiences Expressing and sitting with lead to transformation (grief) Secondary Emotions Often come from our thoughts when we review experiences Interpersonal Emotions Emotional displays that serve a purpose in terms of eliciting reactions from others

17 Distress QUALITY OF LIFE Well-Being

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19 The importance of communication Adherence depends on patient behaviour outside the clinical context The patient-provider relationship is the base of adherence Motivational interviewing for the busy clinician Ask, Listen, Summarise, Invite Communicate to negotiate The expert stance impairs honest communication The collaborator stance facilitates honest communication Use anchoring to support disclosure You don t have to agree to support changes in behaviour 1. Jones A et al. J Diabetes Res. 2016;2016: Vallis M. Can J Diabetes. 2015;39: Miller W, Rose G. Am Psychol. 2009;64:

20 Facilitating communication Adherence depends on patient behaviour outside the clinical context Why should you listen to anything I say to you? Move away from Teach and tell Taking the expert stance makes you dominant In relationships, dominance evokes submissiveness Move toward Collaborate and empower Ask permission before giving advice Summaries ensure listening Anchoring: Adding context to communication Most people struggle with taking all medication; given this... It is common to run into roadblocks in a clinical trial, can we work together to help you return to the reasons you joined this trial? 1. Jones A et al. J Diabetes Res. 2016;2016: Vallis M. Can J Diabetes. 2015;39: Miller W, Rose G. Am Psychol. 2009;64:

21 Case revisited... Despite initiating treatment with ustekinumab + low dose MTX with rapid dose escalation Ms. B, although initially responsive, loses response. Repeat colonoscopy reveals persistent ileal ulceration. At this point she has trialed and failed 2 anti-tnfs, anti-il12/23, and IM therapy. She begins to experience obstructive symptoms At this point you see her and attempt to engage her about next steps in therapy (clinical trial vs. LTI vs. off label use of medical therapy vs. surgery)

22 Case continued... Ms B. becomes unable to decide next steps. Her husband expresses concern for her physical and mental health She is always anxious, despondent, on edge, and disengaged She remains tearful but largely silent throughout the appointment

23 Psychosocial Problems that impact IBD

24 Incorporate into your interview Living with IBD can be difficult Have you been having difficulty with stress or worry? Have you been feeling anxious, tense, on edge much of the time? Have you felt down or depressed most of the day? Have you lost interest in most things or find you just don t enjoy things lately?

25 Screening for Anxiety and Depressive symptoms (PHQ4) Break into pairs, consider the case we began with (copied on next slide) and practice asking the questions, scoring and giving feedback to the patient Kroenke et al Psychosomatics 2009; 50: 613

26 Case revisited... You identify the high likelihood of significant anxiety or depression and administer the PHQ4 scale She scores high and you make a referral to a clinical psychologist With longitudinal follow-up with the psychologist who provides cognitive behavioral therapy as intervention Ms. B begins to reengage in medical decision making. Her husband reports improvement in family interactions at home. She begins a novel molecule in a phase 3 clinical trial and achieves clinical & endoscopic remission.

27 When to screen? Initial Diagnosis Active disease Refractory symptoms despite adequate therapy and absence of disease activity Patient presentation suggestive of anxiety or depression Consider routine screening

28 When to refer Severe anxiety or depression Any acute psychiatric risk Comfort level of GI, GP treating psychosocial issues Patient refractory to initial treatment Complex comorbidity Patient preference

29 Referral Options Mental Health Services Collaborative Care Services Shared care clinics Community Health Teams Social/community services Mental Health Clinics Consultation/Liason services

30 Questions?