Original Contribution

Inflammatory Bowel Disease

Depression Is Associated With More Aggressive Inflammatory Bowel Disease

  • The American Journal of Gastroenterology volume 113, pages 8085 (2018)
  • doi:10.1038/ajg.2017.423
  • Download Citation



Depression is prevalent in inflammatory bowel disease (IBD) patients. The impact of depression on IBD is not well-studied. It is unknown how providers should assess depression.


We used data from the Sinai–Helmsley Alliance for Research Excellence cohort, to assess methods of diagnosing depression and effects of baseline depression on disease activity at follow-up. A patient health questionnaire (PHQ-8) score ≥5 was consistent with mild depression. Relapse was defined as a modified Harvey–Bradshaw Index ≥5 or Simple Clinical Colitis Activity Index >2. We performed binomial regression to calculate adjusted risk ratios (RRs).


We included 2,798 Crohn’s disease (CD) patients with 22-month mean follow-up and 1,516 ulcerative colitis (UC) patients with 24-month mean follow-up. A total of 64% of CD patients and 45% of UC patients were in remission at baseline. By self-report, 20% of CD and 14% of UC patients were depressed. By PHQ-8, 38% of CD and 32% of UC patients were depressed (P<0.01). Adjusted for sex, remission, and disease activity, CD patients with baseline depression were at an increased risk for relapse (RR: 2.3; 95% confidence interval (CI): 1.9–2.8), surgery, or hospitalization (RR: 1.3 95% CI: 1.1–1.6) at follow-up. UC patients with baseline depression were also at increased risk for relapse (RR: 1.3; 95% CI: 0.9–1.7), surgery, or hospitalization (RR: 1.3; 95% CI: 1.1–1.5) at follow-up.


Baseline depression is associated with a higher risk for aggressive IBD at follow-up. A single question is not a sensitive method of assessing depression. Providers should consider administering the PHQ-8 to capture those at greater risk for aggressive disease.

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  1. 1.

    , , et al. Long-term medical conditions and major depression: strength of association for specific conditions in the general population. Can J Psychiatry 2005;50:195–202.

  2. 2.

    , , . Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management. Inflamm Bowel Dis 2009;15:1105–1118.

  3. 3.

    , , et al. Anxiety and depression in patients with inflammatory bowel disease: comparisons with chronic liver disease patients and the general population. Inflamm Bowel Dis 2011;17:621–632.

  4. 4.

    , . Depression and inflammatory bowel disease: findings from two nationally representative Canadian surveys. Inflamm Bowel Dis 2006;12:697–707.

  5. 5.

    , , et al. The effects of psychiatric treatment on depression, anxiety, quality of life, and sexual dysfunction in patients with inflammatory bowel disease. Neuropsychiatr Dis Treat 2016;12:673–683.

  6. 6.

    , , et al. Symptoms of depression and anxiety are independently associated with clinical recurrence of inflammatory bowel disease. Clin Gastroenterol Hepatol 2016;14:829–835 e1.

  7. 7.

    , , et al. Sexual dysfunctions in men and women with inflammatory bowel disease: the influence of IBD-related clinical factors and depression on sexual function. J Sex Med 2015;12:1557–1567.

  8. 8.

    , , et al. The incidence and risk factors for developing depression after being diagnosed with inflammatory bowel disease: a cohort study. Aliment Pharmacol Ther 2014;39:802–810.

  9. 9.

    , , et al. Impact of depressive mood on relapse in patients with inflammatory bowel disease: a prospective 18-month follow-up study. Psychosom Med 2004;66:79–84.

  10. 10.

    , , et al. Factors associated with anxiety and depression in Korean patients with inactive inflammatory bowel disease. Gut Liver 2016;10:399–405.

  11. 11.

    , , et al. Inflammatory bowel disease and completed suicide in Danish adults. Inflamm Bowel Dis 2010;16:2158–2161.

  12. 12.

    , , et al. Radiation exposure in patients with inflammatory bowel disease and irritable bowel syndrome in the years 2001-2011. Scand J Gastroenterol 2016, 1–6.

  13. 13.

    , , et al. Risk factors for depression in the elderly inflammatory bowel disease population. J Crohns Colitis 2014;8:113–119.

  14. 14.

    , , et al. Inflammatory bowel disease: a study of the association between anxiety and depression, physical morbidity, and nutritional status. Scand J Gastroenterol 1997;32:1013–1021.

  15. 15.

    , , et al. Depression subtypes in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2014;58:574–581.

  16. 16.

    , , et al. The influence of depression on quality of life in patients with inflammatory bowel disease. Inflamm Bowel Dis 2013;19:1732–1739.

  17. 17.

    , , et al. Risk factors of anxiety and depression in inflammatory bowel disease. Inflamm Bowel Dis 2012;18:2086–2091.

  18. 18.

    , , et al. Depression and anxiety levels in therapy-naive patients with inflammatory bowel disease and cancer of the colon. World J Gastroenterol 2007;13:438–443.

  19. 19.

    , , et al. Depression and anxiety in people with inflammatory bowel disease. J Epidemiol Community Health 2001;55:716–720.

  20. 20.

    , . A simple index of Crohn’s-disease activity. Lancet 1980;1:514.

  21. 21.

    , , et al. A simple clinical colitis activity index. Gut 1998;43:29–32.

  22. 22.

    , , et al. The PHQ-9 versus the PHQ-8—is item 9 useful for assessing suicide risk in coronary artery disease patients? Data from the Heart and Soul Study. J Psychosom Res 2012;73:163–168.

  23. 23.

    , , . Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item. Am J Manag Care 2004;10:839–845.

  24. 24.

    , , et al. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010;32:345–359.

  25. 25.

    , . The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann 2002;32:509–515.

  26. 26.

    , , et al. Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract 2008;58:32–36.

  27. 27.

    , , . Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease. Gen Hosp Psychiatry 2007;29:417–424.

  28. 28.

    , , et al. The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009;114:163–173.

  29. 29.

    , , et al. Are depression and anxiety associated with disease activity in rheumatoid arthritis? A prospective study. BMC Musculoskelet Disord 2016;17:155.

  30. 30.

    , , et al. Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: secondary analysis of a randomized controlled trial. Rheumatology (Oxford) 2016;55:268–278.

  31. 31.

    , , et al. Self-reported depression in psoriasis is associated with subclinical vascular diseases. Atherosclerosis 2016;251:219–225.

  32. 32.

    , , et al. Reactivation of inflammatory bowel disease in a mouse model of depression. Gastroenterology 2009;136:2280–2288 e1-4.

  33. 33.

    , , et al. Depression moderates the associations between beliefs about medicines and medication adherence in patients with rheumatoid arthritis: cross-sectional study. J Health Psychol 2016 [e-pub ahead of print].

  34. 34.

    , , et al. Effect of psychotherapy on healthcare utilization in children with inflammatory bowel disease and depression. J Pediatr Gastroenterol Nutr 2016;63:658–664.

  35. 35.

    , , et al. Narcotic use for inflammatory bowel disease and risk factors during hospitalization. Inflamm Bowel Dis 2012;18:869–876.

  36. 36.

    , , . Narcotic use in patients with Crohn’s disease. Am J Gastroenterol 2005;100:2225–2229.

  37. 37.

    , , et al. Serious infections and mortality in association with therapies for Crohn’s disease: TREAT registry. Clin Gastroenterol Hepatol 2006;4:621–630.

  38. 38.

    , , et al. Variation in treatment of patients with inflammatory bowel diseases at major referral centers in the United States. Clin Gastroenterol Hepatol 2015;13:1197–1200.

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Author information


  1. Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA

    • Bharati Kochar
    • , Edward L Barnes
    • , Millie D Long
    • , Joseph Galanko
    • , Christopher F Martin
    •  & Robert S Sandler
  2. Division of Gastroenterology, Washington University at St Louis, St Louis, MO, USA

    • Kelly C Cushing
  3. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

    • Laura E Raffals


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Competing interests

Guarantor of the article: Robert S. Sandler, MD, MPH.

Specific author contributions: Bharati Kochar: planning and conducting the study, interpreting data, drafting the manuscript, and critical revisions of the manuscript. Edward L. Barnes: interpreting data, drafting the manuscript, and critical revisions of the manuscript. Millie D. Long: planning and conducting the study, collecting the data, interpreting data, and critical revisions of the manuscript. Kelly C. Cushing: interpreting data, and critical revisions of the manuscript. Joseph Galanko: conducting the study, interpreting data, and critical revisions of the manuscript. Christopher F. Martin: collecting the data, conducting the study, interpreting data, and critical revisions of the manuscript. Laura E. Raffals: collecting the data, interpreting data, and critical revisions of the manuscript. Robert S. Sandler: planning and conducting the study, interpreting data, and critical revisions of the manuscript. All authors approved the final manuscript.

Financial support: This research was supported by grants from the National Institutes of Health (P30DK034987, T32DK07634, T32DK007130, and UL1TR000448) and by the Helmsley Charitable Trust.

Potential competing interests: Bharati Kochar: none. Edward L. Barnes: none. Millie D. Long: Consultant Abbvie, Takeda, and Theravance. Kelly C. Cushing: none. Joseph Galanko: none. Christopher F. Martin: none. Laura E. Raffals: none. Robert S. Sandler: none.

Corresponding author

Correspondence to Robert S Sandler.