IBD and Mental Health: ‘The More We Look at This, the Crazier It Gets’

Research has suggested that inflammatory bowel disease (IBD) — Crohn’s disease and ulcerative colitis — boosts the risk of mental diseases such as depression and anxiety. Meanwhile, these conditions are tied to worsening IBD.

Now, to make things even more complicated, emerging research has suggested that the gut microbiome — not the brain — could be a major player in spurring the mental illnesses that are linked to IBD. Other factors could also be at play.

“Is inflammation within the whole body showing up behaviorally as depression? Is it the gut microbiome? Is there a role for lack of nutrition and fatigue? The answer is probably yes,” said Stephen Lupe, PsyD, a clinical health psychologist at Cleveland Clinic who treats patients with IBD, in an interview. “None of this is clear cut. The more we look at this, the crazier it gets.”

Depression and Anxiety Are Especially Common

In a 2016 systematic review of 171 studies of patients with IBD, the pooled prevalence estimates for anxiety disorders and depression disorders were 20.5% and 15.2%. The estimates for anxiety symptoms (35.1%) and depressive symptoms (21.6%) were higher, with patients with active disease facing even higher estimates (75.6% and 40.7%, respectively).

Furthermore, research has shown that patients with IBD have three to five times higher risk of developing anxiety and two to four times higher risk of developing depression in their lifetime compared with the general population.

The psychiatric burden even extends beyond depression and anxiety. “IBD is also linked to higher rates of post-traumatic stress, disordered eating, substance use, and obsessive-compulsive disorders,” psychologist Taryn Lores, PhD, of the Inflammatory Bowel Disease Center at Mount Sinai in New York City, told MedPage Today.

It’s Not Clear Why IBD Drives Psychiatric Distress and Vice Versa

As Lores explained, IBD is “chronic, relapsing, and unpredictable, and often has a long course. It can therefore be burdensome and disruptive for many people.”

Lupe described how his patients with IBD “know every single bathroom between their home and the Cleveland Clinic. That’s a function of anxiety.”

In a vicious loop, mental illness can worsen IBD. “We know that patients who get diagnosed with anxiety or depression are more likely to end up having surgery or end up in a hospital,” Lupe said. “And then as patients’ symptoms pick up, we know it’s more likely for depression and anxiety to show up.”

What’s going on? It’s possible that “anxiety and depression are primarily a response to symptoms, uncertainty, pain, fatigue, and loss of control,” Ahmed Nadeem, MD, a gastroenterology and hepatology fellow at the Cleveland Clinic, told MedPage Today.

Another theory is that inflammation causes both IBD and depression/anxiety, said Charles Bernstein, MD, of the Max Rady College of Medicine at the University of Manitoba in Winnipeg, in an interview. “Another theory is that alterations in the gut immune response — or gut microbiome changes acting through the gut immune response — send messages to the brain to trigger mental health diseases.”

As for how the bowel affects the mind, it’s possible that “neuroimmune messages from the brain in persons with mental health diseases impact the gut’s immune response and microbiome,” he said.

Consensus Guidelines Call for Routine Anxiety/Depression Screening

A 2025 consensus statement calls for routine screening of all patients with IBD for “mental and emotional well-being, including anxiety and depression.”

Lupe, who co-authored the statement, said physicians may fear that if they “open that box” of asking about mental illness, they’re “going to get stuck in the room forever.”

However, Lores noted that it’s “within the skill set of gastroenterologists to ask about, normalize, recognize, and refer patients to psychological services as part of IBD care.”

“There is a lot of research now showing that patients want their IBD providers to more routinely ask them about their mental health and provide pathways to treatment,” she added.

Nadeem said he likes to ask patients, “How is IBD affecting your sleep, mood, work, relationships, and day-to-day life?”

He also recommended using screening tools like the Patient Health Questionnaire-9 and General Anxiety Disorder-7. “Patients with active disease, early disease, steroid exposure, pain, frequent emergency department visits, poor sleep, or difficulty adhering to therapy deserve particular attention,” Nadeem noted.

Patients Often Benefit From Mental Health Care

With mental health treatment, “about 70% to 80% of the patients we see get at least some relief,” said Lupe.

Cognitive behavioral therapy is one strategy, he pointed out. “We’ll walk through exercises such as ‘Pretend I’m going to come pick you up and drive you 2 hours down Lake Erie.’ The patient tenses up. ‘What’s going through your mind right now?’ They say, ‘Where’s the bathroom?'”

The goal is to change the relationships that patients have with these thoughts rather than trying to make the thoughts disappear since that approach doesn’t work, Lupe said.

Another strategy is gut-directed hypnosis, which Lupe described as deep relaxation aimed at the gut.

Medications such as tricyclic antidepressants and selective serotonin reuptake inhibitors are also helpful, he added, and in some cases psychiatric drugs can help with symptoms such as diarrhea.