This paper is the first to explore patients’ views on the role of antidepressant drug therapy in IBD and one of very few human clinical studies exploring the use of antidepressants in IBD sufferers.
The paper documents that IBD patients are prescribed antidepressants for mental health issues rather than somatic symptoms which contrasts slightly with their typical use in patients with functional gastrointestinal disorders (FGIDs), and irritable bowel syndrome (IBS) in particular, who are frequently offered antidepressants to treat both somatic and psychological complains . Due to the proposed aetiology of IBS symptoms which includes psychological factors and also thanks to several studies into the efficacy of antidepressants in FGIDs, antidepressants have now become a part of the standard treatment for IBS, offering significant benefits to patients . Previous work has shown that gastroenterologists commonly use antidepressants in IBD patients for symptoms commonly encountered in IBS . IBD and IBS share symptomatology and some other characteristics  and some researchers have argued they may, in fact, be two different ends of the spectrum of the same condition; one with lesser symptoms and greater inflammation, the other with greater symptoms and minimal inflammation [18, 19].
Moreover there is now a growing appreciation that IBS can occur in healed IBD [11, 12] and that without endoscopic examination, the precise cause of symptoms in a patient with IBD is frequently uncertain at any particular point in time. Yet, there are very few studies that have critically examined the role of antidepressants in IBD. In support of the concept that antidepressant therapy may be of real efficacy in IBD, and in fact offer a more specific benefit here than in IBS, several studies have now reported anti-inflammatory properties in certain antidepressants [5, 20, 21]. Moreover, in animal models antidepressant therapy has now been documented to ameliorate visible GI inflammation [22, 23]. Thus, antidepressants may potentially offer additional benefit to IBD patients with active inflammation, assisting with mental health but also directly reducing inflammation. For this reason clinical trials in this area are needed and are likely to be conducted in the future.
However, since antidepressants have been shown to have a high occurrence of side-effects [24, 25], many leading to medication changes or intolerance , it seems prudent to examine patients’ perspectives on the use of antidepressants in IBD and collect their observations prior to planning future trials, to better inform their design. This paper has shown that patients do not report many side-effects and if they experience any, these do not seem to significantly impact them. However, one of the weaknesses of the current study is that we have, as yet, only sought the opinions of patients who have chosen to continue to take antidepressants (leading perhaps to an overly optimistic outlook). In future, it would also be informative to seek to interview those who either were not offered antidepressants, and others who may have been prescribed these agents, yet did not continue therapy. Patients also report medication side effects from standard IBD treatments and it is sometimes difficult to judge which side-effect comes from which medication. Clearly, this is a highly medicated group of patients and thus the risk of causing more side-effects must be considered when planning future studies. Yet, this group of interviewed patients lists more advantages than disadvantages of treatment with antidepressants.
Even though patients observe benefits to their mental health and overall quality of life, only five of them commented on the drug impacting on their disease course. In the remaining patients, the medication was thought to offer psychological benefit, also with respect to motivation and cognitive functions. In terms of physical symptoms, antidepressants were noted to improve sleep. This observation was previously made by interviewed gastroenterologists  who emphasised that their patients while on antidepressants had not reported needing to visit a toilet during night with better controlled bowel functions – which could be either due to better sleep or improved disease control or both – emphasizing the difficulty in present data in determining whether antidepressants improve only symptoms, or also disease activity. The five patients reporting reduction in IBD symptoms, and improvement in pain, fewer bowel movements and less frequent relapses of IBD in particular, interestingly conceptualised that this was due to a reduction in perceived stress. And this was thought to mediate the influence of antidepressants on disease course. This observation will need to be however confirmed in clinical trials as the present design does not allow for testing this hypothesis.
With respect to patients’ attitudes towards antidepressants, these were largely positive. However, patients discussed their worries that the treatment could be only superficial, offering relief while ongoing and they clearly feared dependence. There is an ongoing debate on whether antidepressants may in fact cause dependence , and in any case, presenting problems when tapering off , with significant numbers of patients no longer needing an antidepressant for their mental health problem yet suffering unbearable withdrawal effects while discontinuing and thus remaining on treatment . Nevertheless, patients participating in this study reported antidepressants to be a medication worth recommending to fellow IBD sufferers as long as the decision of their use was taken after consideration. Although studies exploring attitudes to antidepressant use in larger samples or in samples recruited in primary care (and thus with possibly better controlled IBD) are not available, studies conducted in the general population in primary care showed a less receptive attitude to antidepressants. For example, a survey of 1,054 primary care users showed that over 20% of them did not disclose depressive symptoms to their doctors out of the fear antidepressants will be prescribed . Other studies have reported non-adherence to treatment with antidepressants due to patient beliefs or misconceptions about this type of medication [31, 32]. In light of these findings, the positive attitudes to antidepressants identified in the present study should be interpreted with caution and confirmed by larger quantitative studies with more representative IBD samples.
The most positive outcome in this study was patients’ positive attitude towards clinical trials with the use of antidepressant. Overall, 80% of this study’s participants reported willingness to participate in such trials with the hope such studies could help other people but also their own quality of life. Those few rejecting the idea of participating in such a study reported lack of faith in antidepressants really being effective in IBD or claiming the benefits were not worth the harm caused by the side-effects. However, these patients agreed to participate in the present research study and thus there is a potential that they are generally more willing to participate in studies than an average IBD patient and thus this result should be interpreted with caution. Further studies should be conducted to explore the attitudes of general IBD population towards antidepressants.