Assessment of causal link between psychological factors and symptom exacerbation in inflammatory bowel disease: a systematic review utilising Bradford Hill criteria and meta-analysis of prospective cohort studies

Abstract

Background: Psychological stress is a prevalent factor in inflammatory bowel disease (IBD) with detrimental effects on patients' quality of life and possibly disease course. Although the aetiology of symptom exacerbation in IBD has been explored, determining any causation between psychological stress and symptom worsening remains challenging and requires a methodologically rigorous approach.

Aim: The aim of this systematic review with meta-analysis was to determine a causal relationship between psychological stress and symptom exacerbation in IBD, subsequently utilising Bradford Hill's criteria (approach never used in this topic area before) to evaluate the likelihood of causal associations.

Methods: Medline, EMBASE, CINAHL and PsycInfo were searched for relevant studies up to July 20, 2019. Data extraction and quality appraisal were performed by two independent reviewers. Results of all retained papers were presented as a narrative synthesis. A random-effect meta-analysis was conducted on studies meeting the criteria for meta-analysis. Bradford Hill criteria were applied to assess the causality of the relationship between all psychological factors and symptom exacerbation.

Results: The searches yielded 2472 potential articles. Nineteen clinical prospective cohort studies were eligible for the narrative review with five suitable for the meta-analysis. Meta-analysis showed depression, anxiety and perceived stress did not have a statistically significant association with an increased risk of symptom exacerbation. Four of the Bradford Hill criteria were met which indicates that there is weak to moderate evidence of a causal association between all the psychological factors and disease activity. Inconsistent results and a dearth of studies using the same tools for measuring psychological factors suggest the need for more research to be done to facilitate more conclusive findings.

Conclusions: This original review utilising Bradford Hill criteria in addition to meta-analysis to evaluate the causality of relationship between psychological factors and symptom exacerbation in IBD provides evidence that psychological factors have a weak to moderate causal involvement in IBD symptom exacerbation. However, when combining this finding with the outcomes of the meta-analysis, we can say that the results were inconclusive. Interventions to reduce the associated psychological impact should be part of the treatment plan for patients with IBD.

Systematic review registration: PROSPERO CRD42012003143.

Keywords: Crohn’s disease; Inflammatory bowel disease; Meta-analysis; Psychological factors; Symptom exacerbation; Systematic review; Ulcerative colitis.

Fig. 1

PRISMA flow diagram of studies

Fig. 2

Forest plot for the effect of perceived stress on symptom exacerbation in IBD. Tools to measure perceived stress: PSS Perceived Stress Scale, PSQ Perceived Stress Questionnaire

Fig. 3

Forest plot for the effect of depression on symptom exacerbation in IBD. Tools to measure depression: SCL Symptom Checklist Scale, CES-D Center for Epidemiological Studies Depression Scale, HADS Hospital Anxiety and Depression Scale

Fig. 4

Forest plot for the effect of anxiety on symptom exacerbation in IBD. Tools to measure anxiety: SCL Symptom Checklist Scale, HADS Hospital Anxiety and Depression Scale

Fig. 5

Forest plot of perceived stress on symptom exacerbation in UC (subgroup analysis). Tools to measure perceived stress: PSS Perceived Stress Scale, PSQ Perceived Stress Questionnaire

Fig. 6

Forest plot for the effect of depression on symptom exacerbation in UC (subgroup analysis). Tools to measure depression: SCL Symptom Checklist Scale, CES-D Center for Epidemiological Studies Depression Scale