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Intest Res > Volume 22(1); 2024 > Article
Chang: The impact of sleep quality on the prognosis of inflammatory bowel disease commonly overlooked by gastroenterologists
Recently, interest regarding the impact of sleep quality on the prognosis of inflammatory bowel disease (IBD) has been intensifying. Approximately 70% of patients with IBD experience sleep disturbances [1]. Moreover, poor sleep is associated with increased risk of flaring of the disease [2,3], need for surgical intervention and hospitalization [2], increased incidence of depression [3,4], and use of opioids [5]. Pain and depression, which are related to poor quality of life, are present in 70% [6] and 21.2% [7] of patients with IBD, respectively. Interestingly, sleep disturbance is more common in patients with inactive IBD than in the healthy population, suggesting an underlying mechanism of subclinical inflammation [4].
In the current issue of Intestinal Research, Barnes et al. [8] investigated the correlation between insomnia and IBD-related disabilities using an online questionnaire. Clinically significant insomnia, defined as an Insomnia Severity Index score > 10 was prevalent in 62% of a cohort of 670 respondents. Clinically significant depression, defined as a Patient Health Questionnaire-9 score > 15 and anxiety, as determined by a score of > 10 on the Generalized Anxiety Disorder 7-Item Scale were observed in 18% and 29% of the patients, respectively. The severity of insomnia was positively correlated with the disability score, which was determined by the IBD-disability index selfreport, with the disability scores worsening with increasing severing of insomnia (F(3,619) = 20.99, P< 0.001). Active IBD, abdominal pain, and clinically significant anxiety and clinically significant depression were correlated with clinically significant insomnia, nonetheless, clinically significant depression (odds ratio, 3.32; 95% confidence interval, 1.89-5.83; P< 0.001) exhibited the highest odds ratio. When separate analyses were performed for ulcerative colitis and Crohn’s disease, clinically significant anxiety and clinically significant depression were found to be correlated with the severity of insomnia in both diseases.
Thus, these findings support previous evidence regarding the important interactions of depression and anxiety with insomnia in patients with IBD. According to a recent study [9], patients with IBD are left feeling helpless and concerned, due to the consequences associated with their lack of sleep. Furthermore, they exhibit behaviors that perpetuate the insomnia and somatoform pain disorders. Two-thirds of the patients believe that physicians should enquire about potential sleep disturbances and provide recommendations for improving sleep. Unfortunately, patients frequently feel frustrated when they believe that their sleep disturbances cannot be managed. Thus, physicians should be ready to assess and screen for sleep quality as part of the standard clinical care.
Simple questions could include, “Are you experiencing any problems with sleep or are you feeling fatigued?” and, “How much do your weekday and weekend schedules vary?” The corresponding recommendation would be to advise the patient on keeping the same schedule for 7 days a week. Another question could be posed: “When you are worn out or in pain, which part of the house do you resign to?” The corresponding recommendation could be to resign to the couch and not the bed [9]. The modifiability of insomnia should be ensured when the provision of the appropriate treatment is available.
Barnes et al. [8] recommended cognitive behavioral therapy for insomnia (CBTi) which is the first-line treatment for insomnia, to improve sleep quality, mood, and pain. CBTi includes four to eight consultations with a sleep psychologist or another trained provider, sleep restriction and cognitive therapies, stimulus control, relaxation training, and sleep hygiene education [10]. CBTi is considered additionally suitable in patients with concomitant IBD and insomnia who exhibit cognitive and behavioral traits consistent with the general concept of insomnia [9].
The current study is an important reminder to gastroenterologists to focus on concomitant depression, anxiety, and insomnia associated with gastrointestinal symptoms, as pillars of IBD treatment. As Barnes et al. observed, questionnaire-based studies could result in biased inclusion of study participants and lack of objective measures. However, the advantages of this novel study include the large sample size in comparison with that of previous studies and the validated scales used to evaluate the disease activity, insomnia severity, and disability index. Because the existing literature regarding sleep disturbances in cases of IBD is predominantly limited to surveys, future studies should focus on screening for sleep disorders in clinical practice, using both self-reported and objective measures. Moreover, the effectiveness of CBTi in patients with IBD should be evaluated.

ADDITIONAL INFORMATION

Funding Source

The author received no financial support for the research, authorship, and/or publication of this article.

Conflict of Interest

Chang JY is currently working for the Intestinal Research and Korean Society of Gastrointestinal Endoscopy Publication Committee; however, she was not involved in the peer reviewer selection, evaluation, or decision-making process regarding this article. No other potential conflicts of interest relevant to this article were reported.

Data Availability Statement

Not applicable.

Author Contributions

Writing and approval of the final manuscript: Chang JY.

REFERENCES

1. Marinelli C, Savarino EV, Marsilio I, et al. Sleep disturbance in inflammatory bowel disease: prevalence and risk factors: a cross-sectional study. Sci Rep 2020;10:507.
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2. Sofia MA, Lipowska AM, Zmeter N, Perez E, Kavitt R, Rubin DT. Poor sleep quality in crohn’s disease is associated with disease activity and risk for hospitalization or surgery. Inflamm Bowel Dis 2020;26:1251-1259.
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3. Ananthakrishnan AN, Long MD, Martin CF, Sandler RS, Kappelman MD. Sleep disturbance and risk of active disease in patients with Crohn’s disease and ulcerative colitis. Clin Gastroenterol Hepatol 2013;11:965-971.
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4. Barnes A, Mountifield R, Baker J, Spizzo P, Bampton P, Mukherjee S. Systematic review and meta-analysis of sleep quality in inactive inflammatory bowel disease. JGH Open 2022;6:738-744.
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5. Barnes A, Spizzo P, Bampton P, et al. Examining the influence of inflammatory bowel disease medications on sleep quality. JGH Open 2023;7:190-196.
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6. Zeitz J, Ak M, Müller-Mottet S, et al. Pain in IBD patients: very frequent and frequently insufficiently taken into account. PLoS One 2016;11:e0156666.
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7. Mikocka-Walus A, Knowles SR, Keefer L, Graff L. Controversies revisited: a systematic review of the comorbidity of depression and anxiety with inflammatory bowel diseases. Inflamm Bowel Dis 2016;22:752-762.
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8. Barnes A, Andrews JM, Mukherjee S, et al. Insomnia is common in inflammatory bowel disease (IBD) and is associated with mental health conditions as well as IBD activity. Intest Res 2024;22:104-114.
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9. Salwen-Deremer JK, Godzik CM, Jagielski CH, Siegel CA, Smith MT. Patients with IBD want to talk about sleep and treatments for insomnia with their gastroenterologist. Dig Dis Sci 2023;68:2291-2302.
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10. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2016;165:125-133.
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