Table 2.

Considerations in the biopsychosocial assessment of people with irritable bowel syndrome and symptoms of anxiety or depression

Consideration	Rationale for considering	Recommended actions
		Medical	Dietary	Psychological
Physical health comorbidities	Health conditions such as diabetes mellitus, heart disease and metabolic syndrome are more common among people with mental illness than among people without mental illness140 Psychotropic medications often have cardiometabolic effects Individuals with mental illness are less likely than those without to participate in routine health screening	Encourage screening of physical health (e.g. cardiometabolic biochemistry) On referral, detail comorbidities and current medications, as these could influence dietary or psychological priorities	Use clinical judgement to determine priority target of dietary changes (physical comorbidity, gastrointestinal or psychological symptoms)	Consider impact of physical comorbidities on choice of brain–gut behaviour therapy (e.g. multiple somatic comorbidities lend themselves to gut-directed hypnotherapy)
Co-occurring mental health conditions	Depression and anxiety often co-occur with other mental illness and alcohol use121,122,141; the latter can affect irritable bowel syndrome symptoms and/or nutrition status	Detail comorbidities and alcohol use on referral to other clinicians, as these can influence treatment goals Refer to specialist services where appropriate
Co-occurring disordered eating or eating disorder	Disordered eating has a bidirectional relationship with common mental illnesses142 Eating pathology might be central to the mental illness143	Detail established comorbidities on referral to other clinicians	Screen for detrimental eating behaviours and beliefs Tailor intervention to include strategies for disordered eating or eating disorders and avoid restrictive approaches Prioritize management of disordered eating or eating disorders over that of gastrointestinal symptoms when severity is high Refer to specialist eating disorder dietitian where necessary	Prioritize eating disorder behaviours; refer to specialty centre if unable to provide sufficient care Exposure-based interventions to increase tolerance of restricted foods
Medications	Commonly used physical health medications can have unintended gastrointestinal effects	Encourage medication to be taken with food where appropriate	None	None
Nutritional deficiency	Depression is associated with an increased risk of vitamin D, folate and zinc deficiency144–146	Review biochemical measures for deficiencies and assess nutritional adequacy of diet		None
History of sexual, physical or emotional abuse	Adverse experiences can affect symptom perception, treatment response and the patient–provider relationship128	Screen for adverse experience and practice trauma-informed care
Insight into contribution of gut–brain axis	Insight facilitates readiness for treatments such as neuromodulators and psychological therapy	Master patient-friendly language to discuss gut–brain axis dysregulation and why behavioural therapies are part of integrated care; provide psychoeducation materials if necessary
Patient perspective on goals of treatment	Patient goals of treatment might differ from clinician goals	Use patient perspectives to formulate a person-centred care plan
Fatigue and cognitive factors	Fatigue, low motivation, impaired concentration and impaired memory are common in individuals with depression	Longer assessments or assessments over multiple appointments Formulate a care plan based on the patient’s cognitive factors and readiness to change
Food insecurity	Food insecurity is more common among individuals with depression than among people without a mental illness147	Assess the risk of food insecurity by using brief screening tools148 or questions about food availability