Cognitive-Behavioral Therapy for Adolescents With Inflammatory Bowel Disease and Subsyndromal Depression

doi:10.1097/chi.0b013e3180f6341f

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 46, Issue 10, October 2007, Pages 1290-1298

https://doi.org/10.1097/chi.0b013e3180f6341f Get rights and content

ABSTRACT

Objective

To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis.

Method

Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children.

Results

The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group.

Conclusions

Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI. Clinical trial registration information: URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.

Section snippets

Participants

Data were collected using identical procedures at two sites: Children's Hospital Boston (n = 30) and Children's Hospital of Pittsburgh (n = 11). This study was conducted in each hospital's gastroenterology clinic and was approved by the respective institutional review boards. Informed assent and consent were obtained.

Participants were recruited through a two-step screening process (Fig. 1). Step 1 consisted of screening adolescents with IBD for depressive symptoms using the Children's

Sample Characteristics

Of the 168 participants eligible to participate in the step 1 screening, 156 (93%) agreed to be screened (mean age 14.29 years, SD 1.97). Sixty-five participants (51%) met criteria for step 2; 56 of these participants (84.1%) completed the step 2 assessment. Forty-one participants were randomized to either modified CBT (n = 22) or the comparison treatment (n = 19). Seven of 56 participants (12.5%) were excluded for major depression, and the remainder declined due to time or distance factors (n

DISCUSSION

These findings demonstrate the feasibility and preliminary efficacy of a manual-based CBT intervention in reducing depressive symptoms and improving functioning in adolescents with IBD. These results are consistent with earlier findings in an open trial of PASCET-PI with clinically depressed adolescents with IBD (Szigethy et al., 2004b). This study furthers these results by showing that PASCET-PI effects could not be attributed alone to the passage of time.

Participants in the PASCET-PI group

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Cited by (147)

Efficacy of psychological therapies in people with inflammatory bowel disease: a systematic review and meta-analysis
2023, The Lancet Gastroenterology and Hepatology
There is increasing evidence for an influence of the gut–brain axis on the natural history of inflammatory bowel disease (IBD). Psychological therapies could, therefore, have beneficial effects in individuals with IBD, but data are conflicting. We aimed to update our previous systematic review and meta-analysis to assess whether the inclusion of more randomised controlled trials (RCTs) showed any beneficial effects and whether these effects varied by treatment modality.
In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials from Jan 1, 2016, to April 30, 2023, for RCTs published in any language recruiting individuals aged 16 years or older with IBD that compared psychological therapy with a control intervention or treatment as usual. We pooled dichotomous data to obtain relative risks (RR) with 95% CIs of inducing remission in people with active disease or of relapse in people with quiescent disease at final follow-up. We pooled continuous data to estimate standardised mean differences (SMD) with 95% CIs in disease activity indices, anxiety scores, depression scores, stress scores, and quality-of-life scores at completion of therapy and at final follow-up. We pooled all data using a random-effects model. Trials were analysed separately according to whether they recruited people with clinically active IBD or predominantly individuals whose disease was quiescent. We conducted subgroup analyses by mode of therapy and according to whether trials recruited selected groups of people with IBD. We used the Cochrane risk of bias tool to assess bias at the study level and assessed funnel plots using the Egger test. We assessed heterogeneity using the I² statistic.
The updated literature search identified a total of 469 new records, 11 of which met eligibility criteria. 14 studies were included from our previous meta-analysis published in 2017. In total, 25 RCTs were eligible for this meta-analysis, all of which were at high risk of bias. Only four RCTs recruited patients with active IBD; there were insufficient data for meta-analysis of remission, disease activity indices, depression scores, and stress scores. In patients with active IBD, psychological therapy had no benefit compared with control for anxiety scores at completion of therapy (two RCTs; 79 people; SMD –1·04, 95% CI –2·46 to 0·39), but did have significant benefit for quality-of-life scores at completion of therapy (four RCTs; 309 people; 0·68, 0·09 to 1·26), although heterogeneity between studies was high (I²=82%). In individuals with quiescent IBD, RR of relapse of disease activity was not reduced with psychological therapy (ten RCTs; 861 people; RR 0·83, 95% CI 0·62 to 1·12), with moderate heterogeneity (I²=60%), and the funnel plot suggested evidence of publication bias or other small study effects (Egger test p=0·046). For people with quiescent IBD at completion of therapy, there was no difference in disease activity indices between psychological therapy and control (13 RCTs; 1015 people; SMD –0·01, 95% CI –0·13 to 0·12; I²=0%). Anxiety scores (13 RCTs; 1088 people; –0·23, –0·36 to –0·09; 18%), depression scores (15 RCTs; 1189 people; –0·26, –0·38 to –0·15; 2%), and stress scores (11 RCTs; 813 people; –0·22, –0·42 to –0·03; 47%) were significantly lower, and quality-of-life scores (16 RCTs; 1080 people; 0·31, 0·16 to 0·46; 30%) were significantly higher, with psychological therapy versus control at treatment completion. Statistically significant benefits persisted up to final follow-up for depression scores (12 RCTs; 856 people; –0·16, –0·30 to –0·03; 0%). Effects were strongest in RCTs of third-wave therapies and in RCTs that recruited people with impaired psychological health, fatigue, or reduced quality of life at baseline.
Psychological therapies have beneficial, short-term effects on anxiety, depression, stress, and quality-of-life scores, but not on disease activity. Further RCTs in selected groups are needed to establish the place for such therapies in IBD care.
None.
Inflammatory bowel disease and cognitive behavioral therapy (CBT) in the young
2023, Handbook of Lifespan Cognitive Behavioral Therapy: Childhood, Adolescence, Pregnancy, Adulthood, and Aging
Youth with inflammatory bowel disease (IBD) are vulnerable for psychological problems. The brain-gut axis helps to understand the relationship between IBD disease activity and psychological problems, by proposing a bidirectional relationship between the brain and the gut. Psychological therapies, such as cognitive behavioral therapy (CBT), therefore, may be useful in the holistic treatment of these patients, in which the larger family system needs to be included. This chapter summarizes the evidence for the co-occurrence of IBD and psychological problems, other psychological aspects of the disease, and the evidence for CBT in youth with IBD. To date, literature suggests the importance of psychological factors in the management of IBD. Results on the effectiveness of CBT in improving psychological outcomes are mixed and the few studies executed often did not take into account the fluctuating disease course IBD can have.
Mood-congruent negative thinking styles and cognitive vulnerability in depressed COVID-19 survivors: A comparison with major depressive disorder
2022, Journal of Affective Disorders
COVID-19 is associated with depressive psychopathology in survivors. Negative thinking styles are a core feature of major depression, fostering the experience of negative emotions and affects and hampering recovery. This cognitive vulnerability has been observed in medical conditions associated with depression, but never explored in post-COVID depression.
We studied 729 participants: 362 COVID-19 survivors, 73 inpatients with Major Depressive Disorder (MDD), and 294 healthy participants (HC). Severity of depression was self-rated on the Zung Self-Rating Depression Scale (ZSDS). Neuropsychological bias toward negative emotional stimuli and the negative outlook on the self were tested in a self-description task, yielding latencies and frequencies of attribution of morally tuned elements. Dimensions of negative thinking and depressive cognitive style in evaluation of hypothetical events were measured on the Cognition Questionnaire (CQ).
22.4% COVID survivors self-rated depression above the clinical threshold. Frequencies and latencies of attribution of morally negative elements, and CQ scores, correlated between themselves and predicted ZSDS scores, with post-COVID depressed patients showing intermediate scores between the more severe MDD patients, and non-depressed post-COVID participants and HC.
Recruitment was in a single center, thus raising the possibility of population stratification.
The breadth of self-reproach and depressive cognitive style in evaluating events showed the same association with severity of depression in MDD and in post-COVID depressed patients, distributing along a gradient of severity, thus suggesting that individual features of negative thinking styles are shared in these conditions, and should be addressed as treatment targets in depressed COVID-19 survivors.
A Meta-analytic Review: Psychological Treatment of Subthreshold Depression in Children and Adolescents
2021, Journal of the American Academy of Child and Adolescent Psychiatry
Subthreshold depression has been found to be associated with considerable impairment and an increased risk of developing major depression. Although several randomized trials have examined the effects of psychological interventions for subthreshold depression in children and adolescents, no meta-analysis has integrated the results of these trials.
We searched 4 bibliographic databases and included randomized trials comparing psychological interventions with control conditions in children and adolescents scoring above a cut-off of a depression questionnaire but not meeting diagnostic criteria for major depression (or persistent depressive disorder) according to a diagnostic interview. Effect sizes and incidence rates of major depression were pooled with random effects meta-analyses.
A total of 12 trials with 1,576 children and adolescents met inclusion criteria. The overall effect size indicating the difference between treatment and control at post-test was g = 0.38 (95% CI = 0.14–0.63), which corresponds to a number-needed-to-treat (NNT) of 8.4. Heterogeneity was moderate to high (I² = 61; 95% CI = 28–79), and there was significant risk of publication bias (p < .04). The 2 studies in children less than 12 years of age showed nonsignificant effects (g = 0.01; 95% CI = –1.16 to 1.18). We found no significant effect on the incidence of major depression at follow-up (relative risk = 0.52; 95% CI = 0.25–1.08), although this may be related to low statistical power.
Interventions for subthreshold depression may have positive acute effects in adolescents. There is currently insufficient evidence, however, that these interventions are effective in children less than 12 years of age, or that they prevent the onset of major depression at follow-up.
Further Evidence that Subsyndromal Manifestations of Depression in Childhood Predict the Subsequent Development of Major Depression: A Replication Study in a 10 Year Longitudinally Assessed Sample
2021, Journal of Affective Disorders
Citation Excerpt :
Considering the morbidity and dysfunction associated with pediatric MDD, efforts aimed at the identification of children at high risk for MDD early on in their development are of high clinical, scientific, and public health relevance. Despite the large availability of studies that discuss intervention strategies (Szigethy et al., 2007; Brent et al., 2001; Ssegonja et al., 2019; Baldofski et al., 2019), very little research exists that examines the identification of these subthreshold symptoms in youth. Of the scant literature available, research has shown that depression onset can be identified by increased levels of self-reported hopelessness and lower levels of functioning (Weersing et al., 2016) or through specialized clinician interviews (Patra, 2019).
We have previously shown that subsyndromal scores on the Child Behavior Checklist (CBCL)-Anxiety/Depression (Anx/Dep) scale at baseline predicted the subsequent development of Major Depressive Disorder (MDD) in youth with ADHD. The present study aimed to replicate these findings in a separate, long-term, longitudinal sample of children at high- and low- risk for depression.
219 children of parents with and without depression and/or anxiety, ages 2-25, were stratified into 3 groups: 1) children with familial risk for depression (by presence of parental MDD) plus subsyndromal scores on the CBCL-Anx/Dep scale, 2) children with familial risk for depression without subsyndromal scores, and 3) children with neither familial risk for depression nor subsyndromal scores. Subjects were reassessed at both 5 and 10 year follow-ups.
Children with both subsyndromal scores on the CBCL-Anx/Dep plus a familial risk for depression were at greater risk for developing MDD at the 10 year follow-up when compared with all other groups. Those with familial risk but no subsyndromal scores had an intermediate risk that was greater than the controls, who had the lowest risk.
The recruitment of the study included families with parental panic disorder, so the sample likely included more families with anxiety disorders than the general population.
Our results showed that subsyndromal scores of the CBCL-Anx/Dep scale increased the risk for the subsequent development of MDD, particularly in children at high risk for depression. These results confirm the CBCL-Anx/Dep scale's utility in identifying children at high risk for developing MDD.
Empowered transitions: Understanding the experience of transitioning from pediatric to adult care among adolescents with inflammatory bowel disease and their parents using photovoice
2021, Journal of Psychosomatic Research
Citation Excerpt :
Importantly, these discussions require buy-in from pediatric and adult gastroenterologists who may require additional education on disorders of gut-brain interaction (DGBI) (previously called “functional GI disorders”) [46] as well as gut-brain dysregulation in IBD [36]. Physicians must validate patients' functional symptoms as ‘real’, treat patients accordingly (with neuromodulators [36] or referrals to the aforementioned therapies [30–35]) and fight dualistic thinking [47] (i.e. that symptoms are either from the mind or active disease) in favor of a more integrated understanding (i.e. these symptoms are real and warrant treatment). Table 3 contains a summary of novel psychosocial transition recommendations.
To identify barriers and facilitators of pediatric to adult transitions among adolescents with IBD and their parents.
This cross-sectional study used photovoice to explore adolescent and parent perspectives on transitions in IBD care. Adolescents with IBD aged 14–23 and their parents were recruited from an urban IBD center during clinic visits. Participants completed a survey, took photos, participated in a semi-structured interview, and optionally participated in a focus group. Interviews were recorded and transcribed. Two analysts coded interview data for themes using MAXQDA software.
Thirteen adolescents and eleven parents submitted photos and participated in an interview. The mean patient age was 19.0 ± 3.0. The mean parent age was 51.5 ± 5.4. Eleven (84.6%) adolescents were Caucasian; 12 (92.3%) privately insured; 4 (30.8%) in high school, 5 (38.4%) in college, and 4 (30.8%) in the workforce. Adolescent transition-readiness, resilience, and IBD-related self-efficacy scores were relatively high, with high agreement between patient self-report and parent-reported children's resilience; parents over-estimated their children's IBD-related self-efficacy. Participants discussed barriers to transitions including psychological distress, disease uncertainty, gut-brain axis-related issues, a lack of understanding by people unaffected by IBD, and frequent life disruptions. Facilitators of transitions included having a disease narrative, deliberately shifting responsibility for disease management tasks, positivity/optimism, social support, engagement with the IBD community, and mental health support.
Attention to psychosocial issues is warranted during the transition process from pediatric to adult IBD care, specifically related to understanding the gut-brain axis and accessing resources to optimize mental health and well-being among transition-aged adolescents and their caregivers.

View all citing articles on Scopus

Funding for this study was provided by NIMH K23 MH064604 and the Wolpow Family Fund. This research was supported by Jason Andrus, M.D., Julie Canfield, L.I.C.S.W., Robyn Claar, Ph.D., William Defranc, Ph.D., Elizabeth Wharff, Ph.D., Emily Baum, B.A., Lourival Baptista-Neto, M.D., Kimberlee Gauvreau, Sc.D., Sarah Whitton, Ph.D., and David Kupfer, M.D.

Disclosure: The authors have no financial relationships to disclose.

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ARTICLESCognitive-Behavioral Therapy for Adolescents With Inflammatory Bowel Disease and Subsyndromal Depression

ABSTRACT

Objective

Method

Results

Conclusions

Section snippets

Participants

Sample Characteristics

DISCUSSION

Facts for families-the depressed child

Quality of life in children with Crohn's disease: a pilot study

J Pediatr Gastroenterol Nutr

The impact of parental affective disorder on depression in offspring: a longitudinal follow-up in a nonreferred sample

J Am Acad Child Adolesc Psychiatry

Sustained change in parents receiving preventative interventions for families with depression

Am J Psychiatry

A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy

Arch Gen Psychiatry

Psychiatric risk factors for adolescent suicide: a case-control study

J Am Acad Child Adolesc Psychiatry

Depression and anxiety in pediatric inflammatory bowel disease and cystic fibrosis

J Am Acad Child Adolesc Psychiatry

Determinants of depression in recent onset pediatric inflammatory bowel disease

J Am Acad Child Adolesc Psychiatry

The Experience Journal: a computer-based intervention for families facing congenital heart disease

J Am Acad Child Adolesc Psychiatry

Family-based treatment research: a 10-year update

J Am Acad Child Adolesc Psychiatry

Mental health and psychological functioning in children and adolescents with inflammatory bowel disease: a comparison with children having other chronic illnesses and with healthy children

J Child Psychol Psychiatry

Inflammatory bowel disease in children and adolescents: mental health and family functioning

J Pediatr Gastroenterol Nutr

Quality of life in inflammatory bowel disease: background and definitions

J Pediatr Gastroenterol Nutr

Personal control and stress and coping processes: a theoretical analysis

J Pers Soc Psychol

Examining minor and major depression in adolescents

J Child Psychol Psychiatry

Self-schemas and vulnerability to specific life stress in children at risk for depression

Cogn Ther Res

A study of the association of Crohn's disease and psychiatric illness

Gastroenterology

Development and validation of a pediatric Crohn's disease activity index

J Pediatr Gastroenterol Nutr

Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data

J Am Acad Child Adolesc Psychiatry

Pediatric inflammatory bowel disease

Child Adolesc Psychiatr Clin N Am

Children's Depression Inventory (CDI) Manual

ARTICLES
Cognitive-Behavioral Therapy for Adolescents With Inflammatory Bowel Disease and Subsyndromal Depression