Management of psycho-social issues in IBD patients: Case series

Eva Szigethy MD, PHD, FACG

Associate Professor of Psychiatry, Pediatrics and Medicine, University of Pittsburgh

Marla C. Dubinsky MDDivision Chief, Pediatric GI and Hepatology, Mount Sinai Hospital

December 5,2014

Disclosure: Szigethy

• Sources of Funding– CCFA Senior Investigator Award– NIMH R01 Grants– American Psychiatric Press Inc., Book Editor– Merck- Consultant, Advisory Board– AbbVie- Consultant, Advisory Board– GI Health Foundation- Honorarium– iHope Network Inc. Scientific Advisor

• All medication suggestions in this presentation are off-label uses unless noted otherwise.

Disclosure: Dubinsky

• Consultant for–Janssen, Abbvie, UCB, Pfizer, Takeda,

Shire, Genentech, Prometheus Labs, Salix

Objective

• Use case examples to illustrate key diagnostic and treatment decisions in addressing psychosocial concerns in patients with IBD

– Anxiety– Depression– Chronic Pain

Case # 1: “I can’t stop worrying about getting sick again”

• 13 year old female (Ann) with inactive ulcerative colitis presents with extreme anxiety about having a flare which significantly worsened over the past year.

• ᵠsxs: worrying, restless, muscle tension, poor sleep, avoidance of public bathrooms, less social with friends due to worry about not being accepted.

• Diagnosed with IBD when she was 5 years old• Current medications: Azathioprine• No past medical or psychiatric history• Social history- good social support, intact family, adequate

functioning in school.

Spectrum of Anxiety Psychopathology in IBD

• Mild Moderate Severe

• Age appropriate worry

• Adjustment disorder

• Sick role behavior (parental modeling

• Generalized Anxiety Disorder

• Panic Attacks

• Illness Anxiety Disorder (somatization)

• Obsessive compulsive disorder

• Panic attacks

• Post traumatic stress disorder

Functioning OK Poor functioning (avoidance)

Ann

Generalized Anxiety Disorder (GAD)

• Excessive worry (apprehensive expectation) about several events or activities for at least 6 months

• At least 3 of following symptoms:– Restless– Fatigue– Concentration– Irritable– Muscle tension– Sleep disturbance

Behavioral Interventions First• Listening to Ann process experience with IBD in

empathic.• Cognitive behavioral therapy for 8-12 sessions over 3

months to teach Ann:– Relaxation techniques to target autonomic arousal– Cognitive restructuring to alter anxious reactions to anxiety

provoking situations (socializing with friends)– Graduated controlled exposure tasks to prevent avoidance.

• Family education

• 70% response rate after 3-6 months of behavioral treatment

Augmentation with antidepressant• Ann has 50%

improvement in anxiety but now is starting to avoid school due to anxiety about upcoming colonoscopy.

• Add Fluoxetine (SSRI) up to 40 mg by week 12 or Sertraline 100-150mg by week 8

• If no response, switch to Venlafaxine (SNRI) up to 225 mg by week 12.

Possible Side Effects• Activation common 10-

15%• Bipolar switch

uncommon (< 1%)• GI side effects early• Easy bruising and

bloody noses• Suicidal activation

Ann’s case continued:

• Ann’s mother reports that she woke up during a colonoscopy 4 years ago and was extremely nervous about it then but now over past 3 weeks has started to have nightmares about it and is saying she is going to refuse the upcoming colonoscopy. She has also become more tense and irritable.

• Consider acute stress disorder or reactivation of perceived “traumatic” event- Traumatic or Stress DO– Re-experiencing– Avoidance– Hyperarousal

• In DSM-5- PTSD no longer anxiety disorder. Unspecified Trauma and Stressor-related Disorder now also a consideration.

Treatment plan for Ann

• SSRIs can cause activation and nightmares so may consider lowering her dose.

• School 504 plan to facilitate school attendance• Add trauma-focused elements to her cognitive behavioral

therapy– Education about trauma and reactions– Additional relaxation techniques (hypnosis)– Help her identify feelings and tell her story while creating

corrective narrative– In vivo mastery of trauma reminders

• Consider post-poning colonoscopy if feasible

Medications for Pediatric PTSD

• There are no “magic pills” for PTSD. Medications are used to target specific persistent symptoms.

• Mood stabilizers (Lamotrigine) for irritability

• Beta blockers (propranolol) or alpha-adrenergic agonists (guanfacine) for hyperarousal.

Which team member to diagnose and treat?

Psychiatrist-psychiatric medication and complex case consultation

Psychologist-behavioral management and coordination

Social worker- life management and team coordination; transition of care; caregiver burnout

GI Nurses- Medical education

Gastroenterology- Medical decision-making

©Szigethy and Regueiro 2014

Mild

Moderate

Severe

Case #2 “ I just want to die. I feel like such a freak compared to the other kids”

• 16 year old male (Joe) with Crohn’s disease who presents depressed and suicidal.

• Diagnosed at age 13. Initial good response to infliximab but lost response and required surgical resection 1 year ago.

• Ongoing active disease (inflammation) and just learned that his ostomy will not be reversed.

• Denies pain or other medical symptoms.

Joe’s depressive symptoms

• Irritable mood• Anhedonia (no pleasure

or motivation• Poor sleep• Fatigue• Low self-esteem• Suicidal (no plan or

previous attempts)• No guns at home

• Switched to home schooling and social isolation from friends

• No previous psychiatric history

• Denies alcohol or drug use including marijuana

• Negative family psychiatric history

Spectrum of Depressive Psychopathology in IBD

• Mild Moderate Severe

• Age appropriate mood lability

• Adjustment disorder

• Brief sickness behavior during acute IBD flare

• Major Depression (>2 weeks)

• Dysthymia (> 1 year)

• Chronic sickness behavior +/-IBD flare

Major depression with suicidality

+/-Comorbid psychiatric

disorder+/-

Extreme life stress (ostomy)

Joe

Suicide Assessment:Root Cause Chain Analysis for Suicide

• Identify series of events that led to recent suicidal crisis

• Aims to identify Joe’s precipitating thoughts, feelings, and actions

Joe’s Case:Hate IBD embarrassed by ostomy rejected by love interest for prom wants to die

Treatment Steps for Joe

• Treat underlying inflammation- GI team• Facilitate education about ostomy and help Joe process his

story but “I don’t want to talk about it” common.• Psychotherapy (12-20 sessions) to help him problem-solve

using cognitive behavioral therapy.– Root cause chain analysis, Safety planning, education, reasons for

living– Cognitive behavioral skills training, family work

• Activity Selection• Goal-setting• Problem-solving training• Identify and alter negative cognitive distortions

• 65% of depressed/suicidal patients respond to psychotherapy alone

Stanley 2009; Maalouf & Brent, 2012; Szigethy 2012; 2014

Medication decisions for depression in pediatric IBD

• If inactive IBD.......then SSRI first line if does not work switch to different class SNRI (duloxetine 20-40mg)

• If active IBD………then bupropion first line (150-300mg)

• If comorbid pain….then SNRI first or low dose TCA added

Case # 3: “The pain is constant and ruining my life. I hate how they treat me like an addict when I go to the ER for relief.”

• 28 year old female (Sue) with inactive Crohn’s disease but over past year abdominal pain is constant, “10 out of 10 severity”.

• Mild increase in pain with eating. No change with defecation. Had intermittent pain with disease activity in past. This new bout of constant pain started after C-diff infection.

• CD diagnosed 4 years ago. No surgeries.• Medications: Fentanyl patch and oxymorphone pills prn x 6 months.

Citalopram-started 1 year ago for pain, 6-MP• Other pain syndromes- fibromyalgia and chronic headaches. No

other medical diagnoses.• Patient goes to multiple ERS to get narcotics and "fights" with

staff/MDs when time comes to cut down meds. • Feels depressed and fatigue but no current psychiatric diagnoses.

Pain also interferes with sleep.

Sue’s formulation• Has many characteristics of “central” pain

prone phenotype (CNS mediated pain)– Female, history of other chronic pain syndromes,

catastrophizing– Also assess for early life trauma

• IBD-IBS pain from peripheral nerve sensitization after C-diff exposure also possible.

• Need to assess if narcotic use has evolved into substance abuse/dependence.

Spectrum of Pain Psychopathology in IBD

• Mild Moderate Severe

• Brief pain related to gastroenteritis or IBD flare (CD > UC)

• Sick role behavior (parental modeling

• IBD- IBS (irritable bowel syndrome)- possible post-infectious

• Somatic symptom disorder (somatization)

Central chronic pain +/-

Multiple pain syndromes+/-

Childhood trauma+/-

Psychopathology+/-

Narcotic use

SUE

Treatment Plan for Sue• Build a strong therapeutic relationship to improve

motivation and educate about neurobiology of pain circuits.

• Teach behavioral interventions for pain management- distraction techniques and hypnosis so “brain” can be less reactive to “false alarm” pain signals.

• Behavioral sleep interventions and sleep hygeine• Begin appropriate alternative non-opioid pain

medications.• Explore willingness to come off opiates

Concerns with Opiates in IBD• No evidence of efficacy

for chronic abdominal pain

• Psychological/physical dependence

• Higher rates of infection/mortality

• Narcotic Bowel Syndrome (NBS) versus Tolerance

Grunkmeier 2007; Lichenstein 2006;

Non-opioid pharmacotherapy for Sue

• SSRIs (citalopram) can help anxiety and depression but rarely help pain directly.

• Add a tricyclic antidepressant at night.• Start low and go slow. Usual dose range

between 50-150 mg/day• Analgesia starts to occur after a week and can

take 3 weeks to reach max efficacy.• Amitriptyline (3 ◦) more sedating• Nortriptyline (2◦) less sedating• Desipramine (2◦) least sedating

Drossman 2009; Dekel 2013; Szigethy & Drossman 2014

Other Pharmacological options (off-label): Visceral Pain

CLASS TYPE MECHANISMS for PAIN CONTROL

Antidepressants TCAs

SNRIs

Increased SE, endogenous opioid release, anti-inflammatory?

Stimulants MethylphenidateD-amphetamine

Influence NE, SE, DA, endogenous opioids

Mood stabilizers Gabapentin/pregabalin Central voltage-gated calcium channels?

Atypicals Quetiapine? DA, SE, Adrenergic antagonism

Glutaminergic Memantine ? Glutamate antagonism

Anti-inflammatory

Doxcycline ? Central or peripheral inflammation

Ford, 2008; Drossman 2002; Taylor 2007; Houghton 2011; Grover 2009; Szigethy and Drossman, 2014

Opioid Detoxification for Sue

• Attempt outpatient taper but inpatient medical hospitalization if necessary

• 10-33% daily reduction of i.v. morphine or hydromorphine equivalent

• Clonidine for withdrawal symptoms• Benzodiazepines for extreme anxiety• Continue non-opioid pain medications• Appropriate management of bowel motility

(constipation or diarrhea)• Continue behavioral interventions• 70% success rate but high recidivism at 3 months if

aggressive non-opiate pain management not continued.

Rational Approach to Chronic pain

• Address false expectations or beliefs of patients• Provide neurobiological explanation of patient’s

symptoms that psychopharmacological agent would target

• Provide information/rationale aligned with patient’s interests/concerns

• Negotiate treatment plan– Benefit in 4-6 weeks– Most side effects decrease in 1-2 weeks– Consider previous drugs that works and family history of drug

response

Personalized Psychosocial Management Pathways

Active IBD

IBD Meds Coping therapy

Psychotropic medication

Inactive IBD

Cognitive behavioral

therapy

Psychotropic medication

Hypnosis

Exercise