Abstract
Goals:
The goal of this study was to describe the influence of the COVID-19 pandemic on ability to engage in activities and the influence on psychological distress and gastrointestinal symptoms among individuals with irritable bowel syndrome (IBS) and comorbid anxiety and/or depression.
Background:
Individuals with IBS and comorbid anxiety and/or depression report increased symptoms and decreased quality of life compared to individuals with IBS alone. The current COVID-19 pandemic has the potential to further influence symptoms among individuals with IBS and comorbid anxiety and/or depression
Study:
Individuals who met the Rome-IV IBS criteria and reported mild to severe anxiety and/or depression were included. Participants completed an online survey with questions about anxiety, depression, impact of COVID on activities and symptoms, and demographics.
Results:
Fifty-five individuals participated in the study. The COVID-19 pandemic most commonly influenced their ability to spend time with friends and family, shop for certain types of food, and access healthcare. Participants also reported increased stress (92%), anxiety (81%), and depressive symptoms (67%). Finally, around half the sample reported increases in abdominal pain (48%), diarrhea (45%), or constipation (44%).
Conclusions:
The COVID-19 pandemic is related to self-reported increases in psychological distress and gastrointestinal symptoms among individuals with IBS and comorbid anxiety and/or depression. Additional research is needed to intervene on these symptoms.
Introduction
The COVID-19 pandemic has drastically altered daily life with limitations in travel, changes in the economy, and uncertainty regarding the future.1 Rates of anxiety and/or depression among the general population are higher than previous years.2, 3 Adults with irritable bowel syndrome (IBS), a disorder of the gut-brain interaction, are already more likely than the general population to report distress, with up to 50% of individuals with IBS reporting anxiety and depression.4, 5
IBS is characterized by abdominal pain accompanied by an altered bowel pattern (constipation, diarrhea, or mixed)3 and diagnosed with the consensus-driven ROME IV criteria.6 Individuals with IBS and comorbid anxiety and depression report increased gastrointestinal (GI) symptoms, reduced quality of life, and greater healthcare utilization compared to individuals with IBS without anxiety/depression.7–9 Therefore, we sought to determine, among individuals with irritable bowel syndrome and comorbid anxiety and/or depression, how the COVID-19 pandemic further affected their perceived ability to engage in activities and the influence on psychological distress and gastrointestinal symptoms.
Materials and Methods
Design and Participants
Potential participants were recruited online between May and August 2020 using ResearchMatch, a national health volunteer registry that was created by several academic institutions and supported by the U.S. National Institutes of Health as part of the Clinical Translational Science Award program. Participants were also recruited from the University of Washington Institute of Translational Health Sciences (ITHS) website. At the time of screening, individuals met the Rome-IV IBS criteria10 and had a diagnosis of IBS by a healthcare provider. Individuals were between the ages of 18 – 70 years old and reported mild to severe anxiety and/or depression (Generalized Anxiety Disorder-7 >411; Patient Health Questionnaire-9 >412) at screening. Individuals were excluded from the study if they had a first degree relative with colorectal cancer before the age of 60 or reported three or more “Red Flag” symptoms (i.e., loss of 10 pounds without trying, blood in stool, anemia).
Procedures
Institutional Review Board approval was obtained for this study. Study procedures were completed online. Participants first viewed information about the survey and received the researchers contact information. Those interested in participating selected “submit” to continue to the online surveys.
Measurements
Demographics.
Participants responded to questions about age, gender, race, ethnicity, and IBS subtype (IBS-Constipation, IBS-Diarrhea, or IBS-Mixed).
Anxiety.
Anxiety was measured using the General Anxiety Disorder-7 (GAD-7) questionnaire.11 Participants were asked how often they had been bothered by a list of seven symptoms over the past two weeks. Symptoms included: feeling nervous, anxious, or on edge and worrying too much about different things. Response options are on a 4-point Likert scale ranging from not at all to nearly every day. Responses were scored as minimal anxiety (score: 0-4), mild anxiety (score: 5-9), moderate anxiety (score 10-14), or severe anxiety (15-21).
Depression.
Depression was measured using the Patient Health Questionnaire (PHQ-9).12 Participants were asked how often they were bothered by a list of nine problems over the past two weeks including feeling tired or having little energy or feeling down, depressed, or hopeless. Response options are on a 4-point Likert scale ranging from not at all to nearly every day. Responses were scored as minimal depression (score: 0-4), mild depression (score: 5-9), moderate depression (score: 10-14), moderately severe depression (score: 15-19), or severe depression (score: 20-27).
Impact of COVID-19.
The Impact of COVID-19 was assessed using an investigator-developed questionnaire which was comprised of three parts. Part one asked participants “has the COVID-19 pandemic influenced your ability to” engage in 11 different activities such as: access healthcare, manage symptoms, and spend time with friends. Participants responded on a four-point Likert scale: not at all, very little, somewhat, a lot. Part two asked “Do you believe that the COVID-19 crisis has contributed to changes in any of the following symptoms:” anxiety, depression, and stress. Participants responded on a five-point Likert scale: decrease, slight decrease, no change, slight increase, and increase. Finally, part three focused on GI symptoms and asked: “Have the following GI symptoms changed since the COVID crisis?” and asked about three GI symptoms: abdominal pain, constipation, and diarrhea. Participants responded on a five-point Likert scale: decrease, slight decrease, no change, slight increase, and increase.
Statistical Analysis
R was used for data analysis. Data were presented as means and standard deviations for continuous variables and numbers and percentages for categorical data. All items had less than 4% missing data.
Results
Demographic Characteristics
Fifty-five individuals participated in the study (Table 1). The mean age was 39.6 (SD=14.0). The sample was predominantly female (82%) and white (84%). Participants had high school or some college (16%), a college degree (56%), or graduate school (27%) and were located across the United States with the majority from the West (34%) and Southeast (25%).
Table 1:
Demographic Characteristics of Individuals with Irritable Bowel Syndrome and Comorbid Anxiety/Depression
| M (SD) | Range | |
|---|---|---|
| Age | 39.6 (14.0) | 20-67 |
| N | % | |
| Gender | ||
| Females | 45 | 81% |
| Male | 8 | 15% |
| Not reported | 2 | 4% |
| Race | ||
| African American/Black | 5 | 9% |
| Asian | 6 | 11% |
| White | 46 | 84% |
| Other | 3 | 6% |
| Ethnicity | ||
| Hispanic/Latinx | 4 | 7% |
| Non Hispanic/Latinx | 51 | 93% |
| Region | ||
| Midwest | 10 | 19% |
| Northeast | 7 | 13% |
| Southeast | 13 | 25% |
| Southwest | 5 | 9% |
| West | 18 | 34% |
| IBS Subtypes | ||
| IBS-Constipation | 9 | 16% |
| IBS-Diarrhea | 24 | 45% |
| IBS-Mixed | 21 | 38% |
| IBS-Unclassified | 1 | 2% |
| Anxiety | ||
| Minimal | 5 | 9% |
| Mild | 22 | 41% |
| Moderate | 15 | 28% |
| Severe | 12 | 22% |
| Depression | ||
| Minimal | 4 | 8% |
| Mild | 21 | 40% |
| Moderate | 13 | 25% |
| Moderately Severe | 11 | 21% |
| Severe | 3 | 6% |
Of the IBS subtypes, IBS-diarrhea was the most common (44%) followed by IBS-mixed (38%). For anxiety severity levels, 9% reported minimal, 41% mild, 28% moderate, and 22% severe anxiety. For depression levels, 8% minimal, 40% mild, 25% moderate, 21% moderately severe, and 6% severe depression.
Impact of COVID on Activities
Individuals with IBS and comorbid anxiety or depression most commonly reported the COVID-19 pandemic influenced their ability to spend time with friends (80%), spend time with family (64%), shop for certain types of food (40%), and access healthcare (31%) (Table 2). Among the 16 participants who had children living at home, 56% reported experiencing increased stressors caused by their child’s school or daycare situation.
Table 2:
Impact of COVID on Activities among Individuals with Irritable Bowel Syndrome and Comorbid Anxiety and/or Depression
| % | N | |
|---|---|---|
| Spend time with friends | 80 | 44 |
| Spend time with family | 64 | 35 |
| Shop for certain types of food | 40 | 22 |
| Access healthcare | 31 | 17 |
| Manage your symptoms | 24 | 13 |
| Communicate with your healthcare provider | 20 | 11 |
| Obtain medication | 15 | 8 |
| Pay for food | 15 | 8 |
| Pay rent | 15 | 8 |
| Pay for gas | 13 | 7 |
| Have a regular place to sleep or stay | 6 | 3 |
Note: percentages reported for participants reporting somewhat/a lot
Impact of COVID on Psychological Distress Symptoms
Participants self-reported the impact of COVID on symptoms of anxiety, depression, and stress. Ninety two percent of the sample reported a slight increase or increase in stress. Anxiety symptoms were slightly increased or increased among 81% of participants and depressive symptoms were slightly increased or increased among 67% of participants. Psychological distress symptoms were similar across IBS subtypes.
COVID and Gastrointestinal Symptoms
Individuals with IBS-constipation (n=9) reported increases in constipation (88%), abdominal pain (77%), and diarrhea (22%) (Table 3). Among individuals with IBS-diarrhea (n=24), 50% reported increased in diarrhea, 41% reported increase in abdominal pain, and 25% reported increase in constipation. Individuals with IBS-mixed (n=21) reported increase in diarrhea (48%), constipation (45%), and abdominal pain (42%).
Table 3:
Percentage of individuals with irritable bowel syndrome and comorbid anxiety/depression reporting changes in constipation, diarrhea, and abdominal pain since the COVID crisis
| IBS-C | IBS-D | IBS-M | Total Sample | |
|---|---|---|---|---|
| Constipation | ||||
| Decrease | 0 | 8 | 0 | 4 |
| Slight Decrease | 0 | 0 | 5 | 2 |
| No change | 11 | 67 | 50 | 50 |
| Slight Increase | 56 | 25 | 25 | 31 |
| Increase | 33 | 0 | 20 | 12 |
| Diarrhea | ||||
| Slight Decrease | 11 | 0 | 5 | 4 |
| No change | 67 | 50 | 48 | 51 |
| Slight Increase | 22 | 25 | 33 | 29 |
| Increase | 0 | 25 | 14 | 16 |
| Abdominal Pain | ||||
| Slight Decrease | 0 | 0 | 5 | 2 |
| No change | 22 | 58 | 52 | 51 |
| Slight Increase | 67 | 33 | 19 | 33 |
| Increase | 11 | 8 | 24 | 15 |
Discussion
The prevalence of depression symptoms in the US during the COVID-19 pandemic has been reported as: 47% none, 25% mild, 15% moderate, 8% moderately severe, and 5% severe.13 Prior to the COVID-19 pandemic, depression rates were lower: 75% none, 16% mild, 6% moderate, 2% moderately severe, and 1% severe.13 Younger age, being separated or widowed, cannabis and alcohol consumption, and previous symptoms of depression are associated with higher levels of mental distress during the COVID-19 pandemic.14 The majority of participants in the current study, all of whom had IBS and comorbid anxiety or depression, also reported increases in anxiety, depression, and stress due to COVID-19. In addition, participants reported the pandemic has adversely influenced many of their activities, specifically, their ability to spend time with friends and family as well as shop for certain types of food and access healthcare. Finally, and potentially relatedly, they reported the pandemic was related to increased gastrointestinal symptoms of abdominal pain, constipation, and diarrhea.
A recent study in Japan recruited adults in May 2020 and assessed IBS using the Rome III criteria.15 Around 31% of individuals with IBS only reported worsening gastrointestinal symptoms. Among those with an overlap between IBS and functional dyspepsia, 50% reported worsening gastrointestinal symptoms.15 Similarly, individuals with IBS as well as comorbidities such as anxiety, depression, and functional dyspepsia may be more likely to report increased gastrointestinal symptoms during COVID compared to individuals with IBS alone.
The reported increases in both psychological distress and gastrointestinal symptoms in the context of the COVID-19 pandemic are likely related to the gut-brain axis. Stress perceptions can influence the gut-brain axis and exacerbate IBS symptoms.16 Therefore, individuals with IBS and comorbid anxiety and/or depression may be particularly vulnerable to adverse health outcomes due to the COVID-19 pandemic. Existing interventions such as cognitive behavioral therapy and stress coping could be used to address these health concerns.17
This descriptive study highlights the self-reported increase of psychological distress and gastrointestinal symptoms among individuals with irritable bowel syndrome and comorbid anxiety and/or depression. Limitations of this study include self-report data and the absence of independent pre-pandemic levels of anxiety and depression. Additionally, it is not known whether or not participants contracted SARS-CoV-2 in the previous months.
In conclusion, given that individuals with IBS and depression and/or anxiety reported pandemic conditions affected many of their normal activities and exacerbated their psychologic distress and physical symptoms, healthcare providers should recognize the pre-existing vulnerabilities with which these IBS patients in particular are entering into the pandemic environment. Therefore, it is important that providers be aware of this situation and be prepared to address the increased challenges of the COVID-19 pandemic for them.
Funding:
Research reported in this presentation was supported by the National Institute of Mental Health [grant number P50MH115837] and the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Conflict of Interest:
The Authors have no conflicts of interest to disclose.
Contributor Information
Kendra J. Kamp, Division of Gastroenterology, School of Medicine, University of Washington.
Rona L. Levy, School of Social Work, University of Washington.
Sean A. Munson, Department of Human Centered Design and Engineering, University of Washington.
Margaret M. Heitkemper, Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington.
References
- 1.Rettie H, Daniels J. Coping and tolerance of uncertainty: Predictors and mediators of mental health during the COVID-19 pandemic. American Psychologist. 2020:No Pagination Specified-No Pagination Specified. doi: 10.1037/amp0000710 [DOI] [PubMed] [Google Scholar]
- 2.Serafini G, Parmigiani B, Amerio A, Aguglia A, Sher L, Amore M. The psychological impact of COVID-19 on the mental health in the general population. QJM: An International Journal of Medicine. 2020;113(8):531–537. doi: 10.1093/qjmed/hcaa201 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Xiong J, Lipsitz O, Nasri F, et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of Affective Disorders. 2020/December/01/ 2020;277:55–64. doi: 10.1016/j.jad.2020.08.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Changhyun L, lt, sup, et al. The Increased Level of Depression and Anxiety in Irritable Bowel Syndrome Patients Compared with Healthy Controls: Systematic Review and Meta-analysis. J Neurogastroenterol Motil. 07 2017;23(3):349–362. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Arasteh P, Maharlouei N, Eghbali SS, Amini M, Lankarani KB, Malekzadeh R. A Comprehensive Look at Irritable Bowel Syndrome and its Associated Factors Considering the Rome IV Criteria: A Penalized Smoothly Clipped Absolute Deviation Regression Approach in the Pars Cohort Study. Middle East journal of digestive diseases. Jul 2018;10(3):149–159. doi: 10.15171/mejdd.2018.104 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Mearin F, Lacy BE, Chang L, et al. Bowel Disorders. Gastroenterology. Feb 18 2016;doi: 10.1053/j.gastro.2016.02.031 [DOI] [PubMed] [Google Scholar]
- 7.Kopczynska M, Mokros L, Pietras T, Malecka-Panas E. Quality of life and depression in patients with irritable bowel syndrome. Przeglad gastroenterologiczny. 2018;13(2):102–108. doi: 10.5114/pg.2018.75819 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Cho HS, Park JM, Lim CH, et al. Anxiety, depression and quality of life in patients with irritable bowel syndrome. Gut and liver. Mar 2011;5(1):29–36. doi: 10.5009/gnl.2011.5.1.29 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Midenfjord I, Polster A, Sjovall H, Tornblom H, Simren M. Anxiety and depression in irritable bowel syndrome: Exploring the interaction with other symptoms and pathophysiology using multivariate analyses. Neurogastroenterol Motil. May 5 2019:e13619. doi: 10.1111/nmo.13619 [DOI] [PubMed] [Google Scholar]
- 10.Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. Feb 19 2016;doi: 10.1053/j.gastro.2016.02.032 [DOI] [PubMed] [Google Scholar]
- 11.Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. May 22 2006;166(10):1092–7. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
- 12.Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi: 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. JAMA Netw Open. Sep 1 2020;3(9):e2019686. doi: 10.1001/jamanetworkopen.2020.19686 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Holingue C, Kalb LG, Riehm KE, et al. Mental Distress in the United States at the Beginning of the COVID-19 Pandemic. Am J Public Health. Nov 2020;110(11):1628–1634. doi: 10.2105/ajph.2020.305857 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Oshima T, Siah KTH, Yoshimoto T, et al. Impacts of the COVID2019 pandemic on functional dyspepsia and irritable bowel syndrome: A population-based survey. J Gastroenterol Hepatol. Nov 16 2020;doi: 10.1111/jgh.15346 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical Features, and Rome IV. Gastroenterol. 2016/May/01/ 2016;150(6):1262–1279.e2. doi: 10.1053/j.gastro.2016.02.032 [DOI] [PubMed] [Google Scholar]
- 17.Shah K, Ramos-Garcia M, Bhavsar J, Lehrer P. Mind-body treatments of irritable bowel syndrome symptoms: An updated meta-analysis. Behav Res Ther. May 2020;128:103462. doi: 10.1016/j.brat.2019.103462 [DOI] [PubMed] [Google Scholar]