Mindfulness-based Cognitive Therapy for Patients With Inflammatory Bowel Disease

Considering the limited availability of psychosocial interventions for IBD, this study aims to investigate MBCT as an adjunctive treatment to treatment as usual to reduce psychological stress and improve sleep quality/regularity in patients with IBD who report elevated stress levels. The study will have a follow-up duration of 12 months from baseline.

Introduction:

Inflammatory bowel diseases (IBD) are chronic inflammatory diseases of the intestinal tract, consisting of crohn's disease (CD) and ulcerative colitis (UC). In The Netherlands, there are about 90,000 IBD patients, mainly young adults who are in a turbulent part of their life with starting a family and career. The prevalence of IBD seems to be rising. The peak incidence is between 15 and 30 years. The disease is characterized by periods of disease activity (flares) alternating with periods of (clinical) remission. Physical symptoms include abdominal pain, diarrhea, rectal bleeding and fatigue. Although the arsenal of drugs has increased in recent decades, there is no cure for the disease and patients are usually long-term treated with different (immunosuppressive) medications. Nevertheless, at this moment, we are only partially able to keep our IBD patients in remission.

Even in those in remission, IBD is associated with increased levels of psychological stress, with estimated prevalence rates of 21% for depressive symptoms and 35% for anxiety symptoms. In periods of disease activity, prevalence of elevated anxiety levels was even found to be as high as 75.6%. Besides psychological stress, IBD patients in remission report lower quality of life compared to the general population. This is due to the physical symptoms but also to fatigue, worries, anxiety, depression, impaired satisfaction with social role and sleep disturbances. More than 40 % of the IBD patients experience fatigue. This may contribute to the higher sick leave days and higher work impairment rates in quiescent IBD, causing high societal costs. In addition, poor sleep seems common in individuals with IBD and has been linked to disease activity and shown as a predictor for subclinical inflammation and a risk factor for relapse and poorer outcomes.

Mindfulness training, typically in the form of mindfulness-based stress reduction (MBSR) or mindfulness-based cognitive therapy (MBCT), is a psychosocial group-based intervention that has been shown to reduce psychological distress and improving quality of life, both in patients with mental health problems and those with chronic diseases such as diabetes, cancer, cardiovascular disease, rheumatoid arthritis and fibromyalgia. Mindfulness training focuses on the progressive acquisition of mindful awareness to better cope with negative repetitive thoughts and feelings, and for that reason may be a good option to reduce psychological stress and fatigue, and improve quality of life in patients with chronic conditions including IBD.

Although the available literature on the effectiveness of mindfulness-based interventions for IBD is still relatively scarce, a recent meta-analysis showed significant benefits in terms of stress, depression, and quality of life. However, the variety in types of interventions was rather high, and individual studies typically suffered from methodological limitations, including small sample size, poor blinding of the outcome assessors, incomplete data reporting and a relative lack of fidelity measures. Therefore, it seems warranted to conduct a high-quality, multicenter randomized controlled trial investigating the effectiveness of MBCT to improve stress, sleep quality, and quality of life.

Aims:

Considering the limited availability of psychosocial interventions for IBD, this study aims to investigate MBCT as an adjunctive treatment to TAU to reduce psychological stress in patients with IBD who report elevated stress levels. In addition, we aim to improve sleep quality/regularity and fatigue, IBD-related quality of life, perceived control over IBD, clinical indicators (fecal calprotectin, c-reactive protein levels, Harvey Brashaw Index for CD, Simple Clinical Colitis Activity Index for UC), IBD-related flare. We also aim to improve repetitive negative thinking, mindfulness skills, self-compassion skills, and positive mental health. We will investigate whether improving sleep quality may be one of the pathways through which mindfulness may help reduce psychological distress and improve quality of life in IBD (working mechanism).

Method:

A two-armed randomized, multicenter, parallel group pragmatic trial comparing Mindfulness-Based Cognitive Therapy (MBCT) vs. Treatment As Usual (TAU) for reducing psychological distress in distressed patients with Inflammatory Bowel Disease (IBD). Assessments will be conducted at baseline, post treatment (3 months) and follow-ups at 6, 9, and 12 months. Objective sleep measures will be taken at baseline, post treatment and 12 months.

The control group will receive treatment as usual (TAU) according to Dutch and European IBD treatment guidelines. The intervention group will receive Mindfulness-Based Cognitive Therapy (MBCT) in addition to TAU. The MBCT protocol that will be used is based on the protocol published by Segal, Williams and Teasdale. MBCT consists of eight weekly 2.5h group sessions, a six-hour silent day and daily home practice assignments guided by audio files. Mindfulness is characterized by deliberate, non-judging and sustained moment-to-moment awareness. Health related benefits include enhanced emotional processing and coping regarding the effects of chronic illness and stress, improved self-efficacy and control, and a more accepting attitude towards difficult emotions, thought and bodily sensations. Psycho-education and interactive dialogue typically focus on stress management, balancing activities, lifestyle factors, and strategies to stay well in the future (relapse prevention). Each group will be comprising 8-12 participants. MBCT courses will be taught on site by qualified mindfulness teachers. Teacher competency will be assessed with the Mindfulness-Based Interventions - Teaching Assessment Criteria, using a random selection of videotaped sessions, assessed by expert teachers who have been trained to use these assessment criteria.

Eligibility Criteria:
Inclusion Criteria:

* Confirmed IBD diagnosis of Crohn's disease (CD), Ulcerative colitis (UC) or Indeterminate colitis (IC)
* Current IBD remission (Calprotectin \< 250 mg/kg) since at least three months
* Hospital Anxiety and Depression Scale-score of \>=11, indicating at least mild levels of psychological distress (Vodermaier 2011).
* Age of 16 or older
* Taking no IBD medication or on a stable dose of 5-ASA products, immunosuppressive medication, or biologics for at least three months prior to enrollment.

Exclusion Criteria:

* Severe psychiatric disorders (e.g. acute suicidality, psychosis)
* Current alcohol or drug dependency
* Untreated anemia
* Prior participation in an 8-week MBSR or MBCT-programme