The role of stress in the development and clinical course of inflammatory bowel disease: epidemiological evidence.
BACKGROUND
It is unclear whether psychological stress contributes to the inflammatory process in the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD). This review assesses the epidemiological evidence regarding a causal link between stress and gut inflammation in IBD.


METHODS
A Medline search identified prospective studies of the effects of stress on subsequent disease activity and randomized controlled studies of the effects of psychological interventions on disease course in IBD. Controlled retrospective studies were included in the review of aspects of the stress-inflammatory relationship for which few prospective studies are available (e.g. the link between stress and disease onset). Studies were assessed qualitatively.


RESULTS
Among 9 longitudinal studies of stress or depression and disease course, a significant stress-inflammation relationship has been found when UC and CD are studied independently (4 of 4 studies positive) but studies of mixed samples of CD and UC have mostly had negative results (1 of 5 studies positive). Evidence of a contribution of stress to disease onset is very weak. The results of 5 studies of psychological interventions in IBD have been negative or modestly supportive of benefit. Confidence in therapeutic benefits of psychological interventions results is limited by methodological weaknesses in these studies.


CONCLUSIONS
There is consistent evidence for a contribution of psychological factors to IBD disease course, especially stress in UC and depressive symptoms in CD. More rigorous tests of psychological interventions in IBD are needed.
Maunder
Robert G
RG
Department of Psychiatry, Mount Sinai Hospital, 600 University Ave., Toronto, Canada, M5G 1X5. RMaunder@mtsinai.on.ca
Levenstein
Susan
S
D000818:Animals; D003093:Colitis, Ulcerative / Q000453:epidemiology / Q000209:etiology / Q000276:immunology / Q000523:psychology; D003424:Crohn Disease / Q000453:epidemiology / Q000209:etiology / Q000276:immunology / Q000523:psychology; D003863:Depression / Q000150:complications; D015212:Inflammatory Bowel Diseases / Q000453:epidemiology / Q000209:etiology* / Q000276:immunology / Q000523:psychology; D012008:Recurrence; D013315:Stress, Psychological / Q000150:complications* / Q000276:immunology / Q000628:therapy