Research Update: Mindfulness based cognitive therapy for youth with inflammatory bowel disease and depression – Findings from a pilot randomized controlled trial

Research Update articles are produced in order to keep practitioners up to date on impactful research that is relevant to the field of integrative medicine. These articles may contain summaries of recent studies, events, or other industry news that advance current knowledge and standards of care.

The following article summarizes the research conducted by Ewais et al. titled “Mindfulness based cognitive therapy for youth with inflammatory bowel disease and depression – Findings from a pilot randomized controlled trial,” which was published in the Journal of Psychosomatic Research in 2021. (2)

Overview

Background

Inflammatory bowel disease (IBD) is a significant public health problem affecting one in every 300 people many Westernized countries. (10) It is an immune-mediated disease characterized by chronic inflammation of the gastrointestinal tract and high rates of extraintestinal manifestations and mental health comorbidities. (2) Patients affected by this condition typically experience a wide array of abdominal symptoms, including diarrhea, abdominal pain, bloody stools, and vomiting. (4) 

This idiopathic inflammatory condition commonly manifests between the ages of 15 and 29. IBD has two major forms: Crohn’s disease and ulcerative colitis. (2)(4) Due to the age of the onset of the condition, IBD can have a negative impact on the development and psychosocial adjustment of adolescents and young adults (AYAs). (2) This is potentially due to adolescents with IBD reporting worse anxiety and/or depression as well as social problems than adolescents without IBD. (9) Unfortunately, these social problems may be associated with AYAs potentially experiencing two to three times higher rates of depression than their healthy peers, as well as a worse perception of illness, decreased coping, and lower internal locus of control than youth with other chronic illnesses. (2) While there are currently few studies, existing studies of AYAs with IBD demonstrate a higher rate of depression and anxiety in comparison to a control group without chronic medical conditions. (5) Therefore, this study was conducted to assess the outcomes of mindfulness-based cognitive therapy (MBCT) on AYAs with IBD and its preliminary efficacy in improving depression and other secondary psychosocial and biological outcomes. (2) 

Method

This randomized controlled trial (RCT) had a sample size of 64 AYAs with IBD, out of which 33 were randomly allocated to MBCT. The MBCT included an eight-week group intervention program that focused on depression with the addition of cognitive behavioral therapy methods. (2) The remaining participants continued their treatment as usual (TAU), which consisted of eight weeks of standard medical and nursing care from the IBD team and standard psychosocial care from the consultation liaison team. (2) The researchers used the Depression, Anxiety and Stress Scale (DASS) to measure the primary outcome of depression. Additionally, the secondary outcomes that were measured included anxiety, stress, IBD-related quality of life, coping, mindfulness, post-traumatic growth, medication adherence, IBD activity, inflammatory markers, microbiome characteristics, and brain functional connectivity. (2) The authors utilized both the per protocol (PP) analysis and intention to treat (ITT) analysis in order to analyze the results. (2) These results were measured at baseline, upon completion of their respective programs at eight weeks, and at 20 weeks after baseline.   

Results

This study demonstrated that the MBCT group had significantly lower levels of DASS scores at 20 weeks post intervention in comparison to baseline. (2) Comparatively, although improvements were also seen post intervention with respect to depression and stress within the TAU group, they were not significant in comparison to baseline. It is important to note that although the DASS total score improved in both groups from baseline to post intervention (eight weeks), the positive trend did not continue to the 20-week mark. More specifically, the TAU group had a 5.2% decline between the eight-week and 20-week mark in the ITT analysis and a 4.8% decline in the PP analysis, while the MBCT group’s scores remained relatively stagnant within both analyses during this period of time.

With regard to active coping and mindful awareness, there were significant differences in scores between the MBCT and TAU groups at the 20-week mark post intervention in comparison with baseline in both the ITT and PP analyses. (2) In this case, active coping refers to strategies that the participants used to deal with stressful situations. Examples of this include coping styles that are characterized by solving problems, seeking information, seeking social support, seeking professional help, changing environments, planning activities, and reframing the meanings of problems. (8) On the other hand, mindful awareness is a person’s ability to be fully present to what is happening around them in addition to what that person is doing at a moment in time. These findings are consistent with those reported in older age groups, which highlight the positive impact of therapy that utilizes adaptive coping and mindfulness strategies. (12) 

No significant differences were noted between the groups for inflammatory markers or microbiome composition. Although there were increases in microbiome diversity, the amount was not enough to be statistically significant. (2) 

Critical analysis

Some studies have been conducted on the effectiveness of MBCT with IBD patients; however, this is one of the only studies that specifically targets AYAs. Although the results of the study are positive, it is important to consider the strengths and limitations of the evaluation. 

The study utilized youth-friendly and versatile recruitment strategies, which resulted in high recruitment rates, as well as an adapted MBCT program, which was well accepted by AYAs with IBD and resulted in high attendance rates. (2) The high attendance rates are particularly important when dealing with AYAs. This is because consistent group psychotherapy among young people of similar ages is a useful clinical practice for adolescents with mental health issues. (1) More specifically, they worked with an integrated and youth-friendly IBD service in conjunction with social media such as Facebook and the Crohn’s and Colitis Australia websites. (2) This enabled them to foster close connections between the participants and it is believed to have been a reason for high session attendance rates. (2)

The sample size of the study was fairly low. Pilot RCTs have been recommended to have a sample size of 60 to 90 participants, but it is further recommended that there should be at least 70 measured subjects (35 per group). (11) Although the current study meets the minimum requirement size for a pilot RCT, with only 64 active participants, the higher variability may impact the reliability of the results.  This is because small samples can undermine the internal and external validity of a study and increase the chance that the proposed therapy has no disadvantages compared to the traditional therapy. (3) 

Attrition is an additional factor that affected the outcome of this study. It was attributed to the lack of improvements in DASS depression and stress scores and rapidly changing work and study circumstances for the study participants. However, once committed to the MBCT program, AYAs found the program enjoyable and beneficial as reflected in high attendance rates and their positive focus groups reflections. (2)

Lastly, the results of this study are subjective as they are primarily based on numerous self-reported questionnaires such as the DASS and mindfulness on the Five Facets of Mindfulness Questionnaire. The validity of these questionnaires are highly reliant on the recall ability and the honesty of the participants, potentially leading to biased results when being used alone. (6) It can, however, be argued that utilizing the DASS questionnaire augments the reliability and validity of the study. This is because it has been deemed suitable for use to assess symptoms of common mental health problems in adolescents. (7) In addition, it is one of the most commonly used scales for detection of mental health problems. (7)

The bottom line

IBD is a highly debilitating disease, often contributing to thethe need for psychosocial, depression, and anxiety relief for AYAs. It has been estimated that the long-life prevalence of major depression and anxiety disorders can affect more than 30% of patients in clinical remission and up to 60 to 80% of patients with active CD. (12) Thus, the addition of MBCT or a similar treatment plan to AYAs suffering from IBD and depression may be essential to effectively addressing this condition. This study demonstrated promise regarding the relief of psychological comorbidities associated with IBD. However, further studies should be conducted with a larger sample size in order to solidify that MBCT should be integrated into the treatment plan of these patients.