Magdalena Grzesiak
1, Jan A. Beszłej
1, Marcin Szechiński
1,
Monika Szewczuk-Bogusławska
1, Ewa Waszczuk
2, Agata Mulak
2,
Monika Kantorska
1Depressive Disorders in Patients
with Irritable Bowel Syndrome Diagnosed Using
the Composite International Diagnostic Interview*
Zaburzenia depresyjne u pacjentów z zespołem jelita drażliwego
diagnozowane na podstawie badania z zastosowaniem
Złożonego Międzynarodowego Wywiadu Diagnostycznego
1 Department of Psychiatry, Wroclaw Medical University, Poland
2 Department of Gastroenterology and Hepatology, Wroclaw Medical University, Poland
Abstract
Background. Irritable bowel syndrome (IBS) is among the most widespread gastrointestinal motility disorders. Its prevalence in the general population ranges from 5 to 22%. Among patients with a diagnosis of IBS, mental disor-ders occur more frequently than in the general population, with a prevalence estimated between 50 and 90%.
Objectives. To assess the lifetime prevalence of depressive disorders in a group of IBS patients, using a standard-ized diagnostic instrument based on the ICD-10 diagnostic criteria – the Composite International Diagnostic Interview (CIDI) – and to compare the frequency of depression in that group and in a control group with a diag-nosis of GERD.
Material and Methods. Two groups – 107 patients with a diagnosis of IBS and 69 patients with a diagnosis of GERD – were recruited through a gastroenterology clinic. IBS was diagnosed according to the Rome II criteria. Depressive disorders were diagnosed in accordance with the ICD-10, using the CIDI.
Results. Lifetime depressive disorders were diagnosed in 35 (33%) of the patients with IBS: 49% of them had had only one episode of depression during their lifetime; in 45% recurrent depressive disorder was diagnosed, and dys-thymia in 6%. In the control group with GERD, lifetime depressive disorders were diagnosed in 11 patients (16%), while the majority (84%) had no such diagnosis. The difference observed between the two groups of patients was statistically significant (p-value < 0.05).
Conclusions. The prevalence of depressive disorders in the IBS patients was higher than in the general popula-tion (33% vs. 16–18%), while the rate of depressive disorders in the control group with GERD (16%) was similar to the prevalence in the general population. This may suggest that patients with IBS are more likely to have co-morbid depression than patients suffering from other gastroenterological illnesses (Adv Clin Exp Med 2010, 19, 5, 601–605).
Key words: depression, IBS, CIDI.
Streszczenie
Wprowadzenie. Zespół jelita drażliwego należy do najczęstszych chorób motoryki przewodu pokarmowego. Jego rozpowszechnienie w populacji ogólnej wynosi 5–22%. Wśród pacjentów z IBS częściej niż w populacji ogól-nej występują zaburzenia psychiczne, szczególnie depresyjne i lękowe; ich rozpowszechnienie jest oceniane na 50–90%.
Cel pracy. Ocena rozpowszechnienia w ciągu życia zaburzeń depresyjnych wśród pacjentów z IBS w badaniu z zastosowaniem CIDI, strukturyzowanego narzędzia diagnostycznego opartego na kryteriach diagnostycznych ICD-10, oraz porównanie częstości występowania depresji w grupie badanej z IBS i grupie kontrolnej z GERD.
Adv Clin Exp Med 2010, 19, 5, 601–605 ISSN 1230-025X
ORIGINAL PAPERS
© Copyright by Wroclaw Medical University
Irritable Bowel Syndrome (IBS) is character-ized by chronic and recurrent abdominal pain associated with altered bowel habits. It occurs in three distinct forms: diarrhea-predominant, constipation-predominant and a form in which diarrhea and constipation alternate. Bowel symp-toms are not accompanied by any organic or bio-chemical irregularities. IBS is among the most widespread gastrointestinal motility disorders: Its prevalence in the general population ranges from 5% to 20% [1–3]. Women are affected by IBS more often than men. In the United States it is the second most frequent reason for absen-teeism from work, after the common cold [4]. It significantly disrupts the daily functioning of many patients and negatively affects the quality of life. Among persons with a diagnosis of IBS, mental disorders occur more frequently than in the general population, with a prevalence esti-mated between 50% and 90% [5, 6]. The higher rates are usually found in patients with IBS who seek treatment [7]. In the 1990s over 20 research studies were carried out evaluating the preva-lence of mental disorders – primarily depression and anxiety disorders – among patients with IBS [eg. 8–10]. In most of those studies, screening tests (e.g., the Hospital Anxiety and Depression Scale) or psychopathological scales (such as the Beck Depression Scale, Zung Depression Scale or Hamilton Depression Scale) were used as diag-nostic instruments. In only a few of these stud-ies mental disorders were diagnosed according to the criteria of the DSM-III-R, DSM-IV or ICD-10 using structured diagnostic instruments (the DIS, SCID or SCAN) [6, 11, 12]. The most common disorders found were depression, dysthymia and anxiety disorders. In two studies carried out in Poland, only the depressive symptoms [13] and personality profiles of patients with IBS were analyzed [14].
Material and Methods
The aim of the study was to assess the lifetime prevalence of depressive disorders in a group of IBS patients and to compare the frequency of de-pression in that group and in a control group with a diagnosis of gastroesophageal reflux disorder (GERD). The study was approved by the Ethics Committee of the Wroclaw Medical University.
Patients with a diagnosis of IBS or GERD were recruited through a gastroenterology clinic. IBS was diagnosed according to the Rome II criteria. In all the IBS patients, other bowel disorders were excluded on the basis of colonoscopies performed within the last five years. GERD was diagnosed on the basis of classic reflux symptoms and en-doscopic findings of esophageal mucosal changes that were assessed according to the Los Angeles classification. All the patients were competent to sign informed consent to participate in the study, and did so after receiving verbal and written in-formation about the study. Patients with cognitive disturbances and those with other serious medical conditions were excluded from the study.
Depressive disorders were diagnosed accord-ing to the ICD-10 international classification of mental disorders, using the computerized Munich version of the Composite International Diagnos-tic Interview (CIDI) [15]. The CIDI is a modern comprehensive and fully-structured diagnostic instrument developed by the World Health Orga-nization (WHO) for identifying mental disorders according to the diagnostic criteria of the ICD-10 and DSM-IV classifications [16, 17]. The CIDI is designed for use by trained interviewers who read closed-ended questions and record responses. It allows the lifetime prevalence of mental disorders, and the severity of those disorders, to be evaluated. The instrument was intended for use in epidemio-logical studies, as well as for clinical and research purposes. The reliability and validity of the CIDI has been confirmed in several studies [15, 18–20]. Materiał i metody. Do badania włączono 107 pacjentów z IBS i 69 z rozpoznaniem GERD zgłaszających się do kli-niki gastroenterologii. IBS rozpoznano na podstawie kryteriów rzymskich II. Rozpoznanie zaburzeń depresyjnych stawiano na podstawie badania narzędziem CIDI, zgodnie z kryteriami diagnostycznymi ICD-10.
Wyniki. Zaburzenia depresyjne rozpoznano u 35 pacjentów z IBS (33%); w tej grupie 49% pacjentów miało w ciągu życia tylko jeden epizod depresji, u 45% rozpoznano zaburzenie depresyjne nawracające, a u 6% dystymię. U więk-szości osób z grupy kontrolnej (84%) nie rozpoznano w ciągu życia żadnych zaburzeń depresyjnych. Zaburzenia depresyjne występowały jedynie u 11 pacjentów (16%). Różnice w występowaniu depresji między grupą badaną i kontrolną są istotne statystycznie (p < 0,05).
Wnioski. Rozpowszechnienie zaburzeń depresyjnych wśród pacjentów z IBS było większe niż populacji ogólnej (33% vs 16–18%). Zaburzenia depresyjne u pacjentów z IBS występowały znacznie częściej niż w grupie kontrolnej z GERD (16%). Wskaźnik rozpowszechnienia depresji w grupie kontrolnej był podobny do wskaźników w popu-lacji ogólnej. To sugeruje, że u pacjentów z IBS częściej może współwystępować depresja niż u osób cierpiących na inne choroby przewodu pokarmowego (Adv Clin Exp Med 2010, 19, 5, 601–605).
It has been used in many epidemiological research studies in the general population, and also in stud-ies evaluating mental disorders among patients with various medical conditions. It is the only di-agnostic instrument in Poland certified for epide-miological research, validated by Wroclaw Medi-cal University’s Department of Psychiatry.
The data were analyzed using Statistica 6.0 soft-ware. The significance of the observed differences was determined by the chi-square test; a p-value < 0.05 was considered statistically significant.
Results
A total of 107 IBS patients were recruited for the study: 90 women (84%) and 17 men (16%). The mean age was 49 years with an age range of 18–73 years. The diarrhea-predominant form was diagnosed in 32.6% of the patients, the constipa-tion-predominant form in 33.3% and the alternat-ing form in 34.1%. The control group consisted of 69 patients diagnosed with GERD: 43 women (62%) and 26 men (38%), with a mean age of 44.7 years and an age range of 19–69 years. There was no statistically significant difference in the mean age among patients with IBS and those with GERD (χ² = 51, p-value = 0.48). The IBS group includ-ed a higher percentage of females than the con-trol group, which reflects the higher rates of IBS among women than men in the general popula-tion. However, we did not find a statistically sig-nificant difference (χ² = 0.54, p-value = 0.46) in the prevalence of depression among men (25%) and women (34%). Lifetime depressive disorders were diagnosed in 35 (33%) of the patients with IBS: 17 (49% of all the depressive IBS patients) with one episode of depression (29% mild, 24% moder-ate and 47% severe); 16 (45% of all the depressive IBS patients) with recurrent depressive disorders (25% mild, 6% moderate and 69% severe) and two (6%) patients with dysthymia. In the control group with GERD, lifetime depressive disorders were di-agnosed in 11 patients (16%), while the majority (84%) had no such diagnosis. Six patients (9%) had experienced only one episode of depression (mild in four patients and severe in one patient) and recurrent depressive disorders were diagnosed in five patients (8%), with mild (one person) or se-vere (four persons) episodes.
Discussion
Overall, the prevalence of depressive disorders among the IBS patients participating in this study was 35%. This rate is higher than in the general
population (population studies have estimated the rates of depressive disorders as 16–18%) [21]. In a population-based study conducted in the Unit-ed States (the Epidemiological Catchment Area Study), the lifetime rate of major depression was higher in persons with functional gastrointesti-nal symptoms than among persons without those symptoms (8% vs. 3%) [22]. In some studies the findings suggest that mental disorders – particu-larly depressive and anxiety disorders – are more common in IBS patients seeking medical care than in those who do not seek treatment [7]. For ex-ample, Cole et al. [23] examined the prevalence of depression in large cohorts of individuals with IBS (over 97,000 people) and without IBS (over 27,000 people). They found depression (diagnosed by mental health providers) in 12.8% of IBS pa-tients. This rate of depression was lower than in our study and in other studies based on treatment-seeking groups of IBS patients, but higher than in the non-IBS cohort (6%).
Depressive disorders were more common in individuals with the alternating form of IBS (37% of the patients with the alternating form) than in individuals with the diarrhea-predominant form (25%) or the constipation-predominant form (33%). The difference is not statistically signifi-cant (χ² = 1.131, p-value = 0.57). Ladep et al. [11] also found no significant relationship between the form of IBS and depression, but – in contrast to our findings – they reported that patients with the constipation-predominant form were more likely to be depressed (61%, compared to 53% of those with the diarrhea-predominant form and 53% of those with the alternating form).
Our findings are comparable to those reported in many other studies. For example, in a study by Creed et al. in which mental disorders were di-agnosed according to ICD-10 criteria using the Schedules for Clinical Assessment in Neuropsy-chiatry (SCAN), depressive disorders occurred in 29% of the patients with IBS [6]. Similar findings were reported in a study by Guthrie et al.: Using the SCAN, they found depressive disorders in 28 out of 107 (mostly female) IBS patients (29%) [12]. In other studies the rates of depression among IBS patients ranged from 15% to 41%. [8, 24, 25]. It seems that differences in rates of depression may be associated at least partly with the tools used to assess depression. In general, the use of struc-tured diagnostic instruments (such as CIDI or SCAN) results in lower rates than in studies us-ing screenus-ing tests or psychopathological scales as diagnostic instruments (e.g., the Hospital Anxiety
and Depression Scale), since the latter assess the severity of symptoms rather than diagnosing the disorder.
IBS is a common and potentially debilitating disorder. Depression occurs in IBS patients more frequently than in the general population. The re-sults of our study indicate that clinicians should consider depressive disorders when assessing pa-tients with IBS.
In our study only 13 out of the 35 patients with lifetime depression had previously been diagnosed and treated. Among these 13, eight had been di-agnosed by general practitioners. These findings suggest that most patients with IBS and depres-sion are not diagnosed and treated properly. Thus, awareness of the high prevalence of depression in IBS is very important, because depressive disorders can worsen IBS symptoms and the general medical condition of the patient.
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Address for corespondence:
Magdalena Grzesiak Kraszewskiego 25 50-229 Wrocław Poland
E-mail: [email protected] Conflict of interest: None declared Received: 23.11.2009
