Abstract & Commentary
Synopsis: Although irritable bowel syndrome (IBS) is mostly viewed as a nuisance disease without serious consequences, a surprisingly large number of IBS patients may suffer severe depression, hopelessness, and consequential suicidal ideation.
Source: Miller LV, et al. Clinical Gastroenterology and Hepatology. 2005;2:12:1064-1068.
Without any doubt, IBS is the most common gastrointestinal condition seen by primary care physicians and gastroenterologists. Patients with this condition often describe symptoms as severe and disabling. Quality of life in IBS patients can be as bad as diabetes or renal failure. Medical therapy for IBS has been mostly ineffective. Miller and colleagues, concerned by suicides by IBS patients in their own tertiary population, decided to analyze pertinent parameters in tertiary care IBS patients, secondary care IBS patients, primary care IBS patients, and in patients with active inflammatory bowel disease (IBD). In this study, 100 patients were anonymously surveyed in each of these groups; 67-79% of surveys were returned. Questions involved demographic data, severity of illness symptoms, anxiety, and depression. Patients with IBD and primary care IBS patients were younger than the secondary and tertiary IBS groups. Disease history was longer in tertiary IBS patients and in IBD patients. IBS was associated with more anxiety and depression. Primary care IBS patients and IBD patients rated symptoms as less severe than tertiary IBS patients. Tertiary IBS patients were most likely to be unemployed. Suicide related specifically to disease symptoms had been contemplated by 38% of tertiary IBS patients vs 4% of primary care IBS patients and 16% of IBS patients in secondary IBS care settings. IBD patients described disease-related suicidal ideation in 15% of cases. For demographic reasons, it appears that 5 times more IBS patients are suicidal vs IBD patients. Overall, Miller et al point out a striking prevalence of suicidal ideation in severe IBS. Although there is some correlation with depression and suicidal ideation in these patients, these authors believe that suicidal ideation may be most closely linked to the hopelessness of a disease from which recovery or respite seem impossible. Miller et al believe that suicidal ideation is more a marker for distress than an invariable harbinger of actual suicide (although 5 tertiary IBS patients had actually attempted suicide vs only one other patient in the study—an IBD sufferer). These English gastroenterologists suggest that direct personalized supportive therapy may be our best currently available approach to these unhappy patients.
Comment by Malcolm Robinson, MD, FACP, FACG
This paper serves as a reminder that benign disease can be perceived as overwhelmingly severe by our patients. Gastroenterologists in tertiary care settings may be the most likely to see the worst of the worst of these patients. However, even in primary care, awareness of the distress that may be felt by IBS patients remains important. The regular use of simple self-administered tests for anxiety and depression in our patients may be appropriate. This has always been my practice and I have found it to be extremely helpful.
Clearly, there is a place for the judicious use of anxiolytic and antidepressant medications, but I agree with the authors that supportive caregivers may ultimately do more good than any of our current drugs. A great deal remains to be learned about IBS and its treatment, including the management of potentially serious emotional disturbances in these patients.
Dr. Robinson, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.