Managing Mental Health in UC: Tips for Clinicians
You've worked extensively with patients who have chronic digestive conditions. What unique mental health challenges do individuals with UC typically face?
Alissa K. Hershberger, MSN, RN, CCRN, CNE
Right off the bat, among individuals with UC, there are higher rates of depression and anxiety as well as posttraumatic stress disorder symptoms related to the medical condition. Part of that is because of the emotional impact of hearing the initial diagnosis and the condition flares that require a shift in coping. However, there is also a biological pathway which is particularly linked with depression. Depression can drive inflammation, and inflammation can also drive depression, so there's a reciprocal relationship. And on top of that, getting diagnosed with a lifelong medical condition requires some psychological adjustment.
Other unique mental health challenges might include limitations on travel or specific foods for certain periods of time, and if nutrition support is required, there might be an impact on body image or sexual functioning. Additionally, pain can be difficult to cope with from a psychological perspective, leading to increased anxiety and depression. Fatigue can also be an issue, both during flares and when UC is in remission. For the most part, though, once UC is under control, patients can feel relatively normal compared to what they expect when they first get the diagnosis. So, while there are certainly unique mental health challenges, there are also plenty of people who adjust to the diagnosis and live a full life.
How do you approach conversations about mental health with patients who may not initially see the connection between their physical condition and emotional well-being?
The first thing that I do is establish some credibility and buy-in for working with a psychologist. I provide some background about how long I've been working with people with UC, how large and well known our psychology program is, and that UC can affect mental health, and mental health can also impact the disease. We get very scientific and describe the research and statistics behind why it is important to manage mental health in chronic GI disorders. This helps normalize the process and prevents people from feeling like they are being 'sent to a psychologist' because there is something wrong with them, or that these symptoms are all in their head. It can be tricky, though, because even after being told they are in remission, they might still be experiencing symptoms. In that case, it can be easy for people to feel like they are being told that things are all in their head, but we explain that this is where the brain-gut connection comes in.
Many people with inflammatory bowel disease (IBD) have overlapping mind-gut disorders in addition to the IBD. That means they could be in remission from a pathology and colonoscopy perspective, but they are still experiencing symptoms like urgency, diarrhea, or abdominal pain. The patient's physical symptoms are potentially related to changes in the enteric nervous system, leading to these symptoms even in the absence of inflammation. This is where interventions from a psychological and behavioral standpoint can help.
Can you speak about the importance of routine mental health screening in gastroenterology practices, particularly for patients with UC?
This is one of my favorite questions because routine screening is so important. We have actually been working on a quality improvement project to implement regular screening through the electronic medical record for our patients with UC. The goal is to make it a seamless process where the patient can fill out an evidence-based questionnaire before their appointment, and the provider is notified so they can review it. If they have a high score, something that requires a little bit more care, then our GI psychology team also receives a notification. This helps normalize the idea that mental health symptoms can be a part of the condition.
Untreated anxiety, depression, and trauma can impact patients' quality of life and their ability to cope with and adhere to recommended medical treatments, so screening and intervention is incredibly important. Around 95% of patients want to be asked about mental health by their gastroenterologist, so there has been a call for this to be part of routine care. I recently contributed to a consensus statement that emphasizes the importance of screening for and treating depression and anxiety in gastroenterology practices.
What role can cognitive-behavioral therapy or acceptance-based approaches play in helping patients manage both UC symptoms and emotional distress?
There are a lot of different evidence-based treatments available to help address the mental health aspects of IBD. As a cognitive-behavioral therapist, I would say that they mostly fall under the umbrella of cognitive-behavioral therapy. We also do a lot of acceptance and commitment therapy and mindfulness-based interventions. Another huge component of treatment can be relaxation training and gut-directed hypnotherapy.
As far as the specific treatment plan, it really depends on the patients' presenting issue. We do an initial intake and evaluation where we have a conversation about the patient's goals and possible interventions that could help them manage symptoms and live the fullest life possible. We know that a variety of lifestyle factors can impact the symptom experience of UC and the likelihood of relapsing, so behaviorally, we really work on stress management, improving sleep, setting boundaries, coping with pain, and diet. We've seen that addressing mental health alongside medical treatment can improve outcomes in terms of patient adherence, including regularly taking prescribed medications, stress management, and lifestyle changes.
Can you share any practical strategies or tools that patients with UC can use at home to reduce stress or anxiety tied to symptom flares?
One of the first strategies we recommend is diaphragmatic breathing, which is a specific breathing technique that promotes digestion and reduces pain and stress through stimulation of the vagus nerve and activation of the parasympathetic nervous system response. Another strategy we suggest is optimizing sleep because UC flares can have a big impact on sleep, often causing people to wake up in the middle of the night because of pain.
There are also benefits related to learning about UC and connecting with others who have the condition. The Crohn's & Colitis Foundation has an incredible website where they help connect people with support groups. There are also several mobile apps that have come out recently that target coping skills, help promote self-management, and reduce anxiety and stress related to the condition. Additionally, Melissa Hunt, a psychologist at the University of Pennsylvania, wrote, Coping with Crohn's and Colitis: A Patient and Clinician's Guide to CBT for IBD, a book that acts as a self-help guide for people with IBD; it is an excellent resource for patients to use at home.
Is there anything else you'd like to discuss related to the maintenance of mental health in patients with UC?
I think it is important to remember that there is such a wide range of experiences for people with UC; it can be mild or, at the more severe end, require surgery. There is a lot of variation in between, so I think it's important to consider that when thinking about how mental health and body image can be affected. Often, the big fear for patients with UC is surgery, but many people who have had the surgery are relieved that they are now living their full life again and not suffering with so much pain and discomfort. This is another reason I would suggest having patients talk to their provider, a psychologist, or other people with the condition — to work through some of those fears.
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