IBD Drive Time: Megan Riehl, PsyD, on Mental Health and IBD

Clinical psychologist Megan Riehl, Psy D, talks with IBD Drive Time host Raymond Cross, MD, about the prevalence of anxiety and depression and even post-traumatic stress disorder among patients with inflammatory bowel disease--and how gastroenterologists can get patients the help they need.

Megan Riehl, Psy.D., is a licensed clinical health psychologist with University of Michigan Medicine. Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland.

• Anxiety (~33%), depression (~25%), and PTSD (~33%) are significantly more common in patients with inflammatory bowel disease (IBD) than in the general population. Routine mental health screening at least once or twice annually—especially after hospitalization or disease activity change—using tools such as PHQ-9 or GAD-7 is recommended. Clinicians should review suicidal ideation items and address any signs of hopelessness promptly.
• Clinicians can offer assistance by compiling a list of mental health providers in the region that are willing to see your patients. Online resources such as gipsychology.com, which has a list of providers by area, offer a good starting point. 
• Psychological stress can worsen inflammation, visceral pain, and disease outcomes via brain–gut axis dysregulation. Proactive management includes patient education on the bidirectional relationship, early referral to GI psychology or primary care mental health providers, and use of gut-directed hypnotherapy or cognitive-behavioral therapy (CBT). Low-dose tricyclic antidepressants or SNRIs may aid pain, anxiety, depression, and sleep.
• Evidence-based digital adjuncts include Nerva (gut-directed hypnotherapy), CBT-I (insomnia), Curable (pain management), and Belly Biofeedback (breathing training). Patients should optimize sleep (7–9 h/night), maintain Mediterranean-style nutrition, engage in regular exercise, and practice emotion-focused coping for uncontrollable stressors to improve overall disease control and quality of life.

Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center in Baltimore and I'm delighted to have Megan Riehl, who's a GI psychologist at University of Michigan who I was fortunate enough to meet at the regional AIBD in Detroit. Megan, welcome to IBD Drive Time.

Dr Riehl:  Thanks so much. It's a pleasure to be here.

Dr Cross: So obviously we have a psychologist on the episode, so we're going to talk about mental health. So I think most in the audience are aware that there's a high prevalence of anxiety and depression in patients with IBD, but how common are they in our patients with IBD?

Dr Riehl:  Yeah, it's important to know, and I think roughly 1 in 3 of your patients living with IBD are going to have anxiety, and 1 in 4 are going to have depression. About 1 in 3 may also have post-traumatic stress disorder or PTSD. So we have to throw trauma in there as well as a consideration. So I think it's pretty common and these are numbers that are higher than in our general patient population.

Dr Cross: So I think awareness is important in understanding the scope of the problem. And I generally think most gastroenterologists, particularly those that are more recently trained, get that. But I think there's some reservations about screening, because there's concern that you're not going to know what to do with the results. So what should we tell our audience about that? I mean, I don't think we're expecting them to manage depression and anxiety. I think we weren't trained to do that, but I personally feel strongly we should be doing some screening. But how would you answer that, Megan, putting you on the spot?

Dr Riehl: Well, you know, I think, so the research shows that certainly if you're a patient has recently been hospitalized or they've had a recent change in their disease, then that's a very important time to be talking about their mental health. But I think if we take a step back and you think about your relationship as their gastroenterologist, it's so important to highlight for patients that their mental health is just as important as their physical health. You're going to manage the majority of the physical health with other subspecialists, primary care. But there's such a bidirectional relationship between somebody's mental health and their IBD, that if we start to destigmatize and normalize questions around how have you emotionally been doing lately? Or have you had any increased anxiety or depressive symptoms that you think that you could benefit from some additional support around? Please let me know so that I can help facilitate that for you. So if we start with just kind of human to human conversation and normalizing that in here is an okay place to bring up not just your physical symptoms, but your emotional ones as well, that can go a long way outside of doing like a PHQ 9 or a GAD 7, which can very easily screen for anxiety and depression. So my preference would be as we're asking about it.

But the reality is, you know, at least once or twice a year using some form of a screening measure can be helpful to just kind of look at trends as well as before you see that patient in clinic, if you scan the questionnaires that they've filled out, it may give you a second to, you know, grab your resources that you have for mental health care, get them connected with or be to get them connected with a social worker or maybe even connect them to a GI psychologist.

Dr Cross: Yeah, I like that. And I think that if we're setting sort of the bar low, just, and I don't think that's a low bar, I don't mean it in a negative way, but just asking about depressive and anxiety symptoms, particularly if something's changed significantly is very straightforward. We do a PHQ Q9 for every visit for our patients and we do a quality of life questionnaire which has one question about anxiety and then under review of symptoms they also can answer depressed mood and anxiety, and I try to pay attention to that. Now one of the challenges of the PHQ9 is there is a suicidal thought question in the PHQ9 so when I instruct the trainees and the APPs and myself, you have to look at that response because if you ignore that, God forbid something happens and you missed it, it doesn't mean you have to send everyone to the emergency room, but you can ask them if they have a plan, if they have a way of doing that, do they have psych support already set up so you can ask a couple simple questions without sort of getting caught in a quicksand with that?

Dr Riehl: That's a really important point that you have to know what screeners your patients are filling out and I think in especially in some of our larger academic institutions, sometimes they're adding screeners to your clinic and you might not even know about it. So, you know, really looking at your patients check-in, paperwork is important. The other kind of word that I like people to be in tune with is the idea of hopelessness. So there's some connection to suicidality and verbalized hopelessness. And so that would certainly make kind of your ears perk up in tuning into that patient, spending a couple of minutes to make sure that they have great mental health resources and maybe following a little bit closer with that patient.

But, you know, I think the reality is that anxiety and depression are very commonly connected with inflammatory bowel disease. Those types of symptoms and psychopathology are going to increase if a patient is having worsened flaring or their health is worse. And so, again, I like to be a bit proactive with our patients as much as we possibly can to get them connected to resources for some things I think we'll talk about in a little bit around coping and stress management and optimizing their general lifestyle before maybe they get to, they're flaring, and now they're backing up and trying to figure out their mental health at that point too.

Dr Cross: Yeah, and if you're, if you're not lucky enough to have Megan in your practice, integrated in your practice, which most places aren't, you still have the primary care providers. You can try to figure out the mental health providers in your region that are willing to see your patients. Someone introduced me to gipsychology.org or .com, which has a list of providers and we've had at least one patient leverage that and have a good experience. And so I think developing your list of resources in your area, something that doesn't take a whole lot of time, but is dynamic and will change.

You mentioned the bidirectionality, and when I first started this years ago now, patients would correlate stress with a flare, and I always thought it was functional overlap, IBS, and the longer I've been in practice, I have seen patients that were doing quite well and had a significant mental health stressor—a breakup, a divorce, something awful with a child—where they've gone out of remission. So can you talk a little bit about that bidirectional relationship?

Dr Riehl: Yeah, so the brain is constantly interpreting what's happening in your gut along our brain-gut access and the brain can either downregulate those signals or it can amplify them. And especially when you're under intense stress with-- again, maybe it's chronic stress or an acute stressor, which dysregulates our nervous system. It can alter the neurochemicals that are happening in our body, it can increase visceral pain, it can increase our inflammation. It can also then change some of our behaviors—worse sleep, not taking care of yourself, maybe not being as adherent with your medications. So there's an actual kind of biological medical impact and then this environmental component as well.

And so I really like to help patients understand that, you know, you're not making this up. This isn't in your head. You didn't cause this, meaning a flare because stress is happening in your life. It just so happens though, that this is the way our brain and our body operate. They're highly interconnected with the brain and the gut. And that, I think, can validate a patient experience. It can help them understand their symptoms better. And then it also starts to give us a roadmap that, you know, working with your gastroenterologist to help get the flare kind of better under control with medication or whatever the medical treatment team suggests.

But there's also room then for working with a mental health provider, or a GI psychologist, where we can begin maybe by giving you some lifestyle strategies, some kind of diving a little bit into how we're thinking about our stressors to help optimize your health. But we may also, depending on whatever the life stress is, connect you to more of a general provider to help you also go, you know, down that road of mental health treatment as well.

So you asked about kind of the brain-gut connection and the bidirectionality, but it always extends oftentimes based on whatever the individual's need is and what might be contributing to those biopsychosocial factors.

Dr Cross: And I'm not suggesting to the listeners that you attribute every change in GI symptoms to a flare. I think you want to still be thoughtful in doing your diagnostics, ruling out infection, confirming disease activity, whether it's do noninvasive ultrasound, endoscopy, whatever you need to do. But there was a really interesting study. I'm almost certain it was from Australia where they looked at a cohort of patients and they broke them into 4 groups. They had patients that had neither GI symptoms nor mental health symptoms. They had patients with both. Obviously the patients with both did the worst. The patients who had neither did the best. But the ones that were discordant—gut without mental health, mental health without gut—were sort of in this intermediate path and they were overlapping. And it was interesting that when you even took the symptoms out and looked at the calprotectins— when you looked at a symptom relapse, it wasn't just symptoms, it was even biomarker relapse. So mental health symptoms at baseline predicts a worse outcome. So this is really important, and I think it's clearly a real phenomenon.

Before we move on to the next question, I just want to remind the listeners that IBD Drive Time is sponsored by the AIBD Network, and we are on Spotify and Apple Podcasts, and the national AIBD meeting will be in Orlando, December 8th through December 10th, and we have some interesting and important premeetings on December 7th as well. So we hope to see you there.

So, Megan, beyond anxiety, depression, PTSD, our IBD patients often have a number of other, can have other troubling problems, including chronic abdominal or joint pain, fatigue, sleep disorders, and there's more than that, disordered eating and others. What is your approach for these problems? And you're not prescribing medications necessarily, but you may be recommending them to a provider to prescribe. So maybe particularly focused on pain, what's your go to for those disorders?

Dr Riehl: So again, you hit on it, you have to rule out any active inflammation and any other contributors. But shifting into more of a gut-brain behavioral therapy approach, specifically for abdominal pain or other pain. I love engaging with patients utilizing gut-directed hypnotherapy, which is evidence-based. There's a large body of research supporting it for the use of IBS with some studies looking at use for IBD. And so we have targeted tailored scripts that we'll use that really get at the way the brain and the gut are communicating along the subconscious part of our mind to really retrain how your brain is interpreting those signals that are coming up from the gut. So you can think about it as our body feels that pain, that chronic pain, and the brain is interpreting that as an internal threat and our body responds to that by amplifying the pain. Things like gut-directed hypnosis are very good at retraining how our brain can down -regulate those threats. So I think that, you know, maybe we'll get a little bit deeper into the brain gut behavioral therapies, but they're very effective.

From a medication point as a complement, I think neural modulators can be very effective. So low-dose tricyclic antidepressants, SNRIs, those can be helpful in terms of addressing the pain. But sometimes they kill 2 birds or 3 birds with one stone. A patient that might have anxiety and depression may respond well to those medications from that perspective, it might help optimize sleep. So thinking about how it all interconnects a lot of our patients that are in pain also tend to have mood or anxiety symptoms and they don't sleep well. And so to address the pain, we oftentimes really,—oh, and they don't eat well. There's another kind of factor that we can ask about and make sure that we're addressing all of those areas of a patient's health.

Dr Cross: Yeah, I think I explained it similarly. I tell them with a little bit of preamble that basically the medications are chemical distracted from a signal that is not helpful. Typically pain signals are supposed to warn you that there's something horrible that's going to happen and this signal and for whatever reason in these patients is not helpful at all and it helps to decrease that signal and CBT and other techniques do it similarly without medications. So that's the way I explain it to patients and I think, I don't think, I would recommend that anyone who sees IBD patients you should feel comfortable with one at least one neuromodulator and be able to use it, understand the basic side effects, when to expect those, when to expect treatment effect, how to titrate, and I use all, I use mirtazapine, duloxetine, and tricyclics, and it depends on some of the other symptoms they have, and they can be very, very helpful, and particularly if you don't have easy access to psychiatry or psychologists or some things you can do.

What about fatigue, Megan? Do you get referred patients with fatigue that they've looked for active disease, they've rolled out vitamin and mineral deficiencies, we've checked the thyroid 6 times, we've asked them about sleep, and I found the patients are very resistant to sleep being a cause of fatigue, which is bizarre to me. They don't want to think that they have sleep apnea or something else but let's say all that's been done and you're just left with fatigue and it's really troublesome. Do you get those patients and what do you do?

Dr Riehl: Yeah we do and again we're looking holistically so what's the timing of their eating? Are they restricting most of the day because they're trying to avoid symptoms that are driven by food and so they're not properly fueling their body which impacts their fatigue and their energy levels because of pain, are they sedentary during a lot of the day? And so they're not moving their body, they're not getting a lot of outside time to kind of activate with energy in the sun. And so it's getting a little deeper into what does your day-to-day look like? Where are there areas where we can build in some we call it behavioral activation or activity pacing because sometimes people just will say I don't feel good and doing X, Y, and Z is overwhelming and so I just I don't do it. And or they're there's this concept of spending the spoons too quickly. They have to save their energy for certain things. And so I think it's looking at each individual and what their lifestyle is and what they're trying to accomplish and what role might anxiety or depression, particularly depression, which can really contribute to fatigue and sleep difficulties. And sometimes patients don't even identify themselves as depressed. Or they'll say, you know, I just don't want to do things, I feel so tired, my energy is low, my mood is fine. And when we start to dig a little bit more, there is a low level of depression that as we optimize that the fatigue, the energy level may increase.

So I think it, I always say when, especially when I'm talking with gastroenterologists, as a psychologist, I have the luxury of time, like I get patients for an hour. And so I can dig a little bit more and identifying some entrance points where we might be able to address the fatigue outside of all the important medical things that you have already recommended that we assess. But certainly, fatigue is common. And I like to highlight that for our patients with IBD, too, that this is common and it certainly can have an impact on your quality of life and let's optimize it the best that we can.

Dr Cross: Megan, there's a lot of online resources, apps and things like that. It can be a little overwhelming at times, but there are some things out there that patients can use sort of as an adjunct. Are there a couple that you really like that you think are effective and sort of maybe been vetted a little bit?

Dr Riehl: Yeah, I think so it's not an app but you did mention the gipsychology.com group and so I think to start there with anybody looking for a gipsychologist if any of the things I've been talking about sound interesting or helpful they do offer services one-to-one or in groups with trained GI mental health providers. So that's if you're really looking for a mental health provider.

But taking a step back, so I mentioned gut-directed hypnotherapy. There's an app called Nerva that is evidence -based. They use scripts that have been researched and have really good outcomes. Again, the app is driven for patients with IBS. But I do find that my patients with IBD enjoy that, especially if they're looking to learn more and go through the process of gut-directed hypnotherapy.

If you're struggling with sleep, there's a really good app out there called CBTI, which is free and uses evidence-based cognitive behavioral therapy strategies for insomnia and sleep difficulties. So sometimes kind of walking yourself through a self -guided program can be very helpful. For chronic pain management, there's an app called Curable, which is going to again utilize behavioral therapy strategies like CBT and relaxation training. And then, you know, there are breathing apps. There's a thousand breathing apps out there. One of my favorites, though, is called Belly Biofeedback, where you actually put the phone on your belly, and it will kind of help give you a biofeedback device through your phone to learn how to do diaphragmatic breathing.

And so, you know, there, as you said, there's thousands and thousands of apps out there, but those are some that I recommend to my patients and I've even used some of them myself.

Dr Cross: So I saw a relatively newly diagnosed young man today, and they have questions about, you know, why, they have the disease and what can they do. And my spiel is generally straightforward. Come for monitoring, take your meds 80% of the time or more and if you have Crohn's, don't smoke. If you do that, it covers 95% of what I need from you and this is not your fault. But if you want to do 100%, sleep well, manage your mental health, eat more of a Mediterranean type diet, eat real food, and exercise. And that doesn't have to be flipping tires at a Crossfit. It can be walking the dog for an hour and just getting some exercise.

The troubling thing with stress and mental health is what makes you stressed and me stressed is different from another person and some people can tolerate that just fine and other people don't. So how do you deal with that? And you gave me some good advice over dinner about some of the things we talked about in our day-to-day as clinicians and not stressing about things that are out of your control. And you gave me that nice little PowerPoint slide—if it's raining and then like someone catastrophizing about the rain. So I don't want to steal your thunder, but how do you approach that?

Dr Riehl: Yeah, you know, in today's world and probably every generation before us, we all have stress. You're right, what stresses you out might be fine for me. And again, somebody living with a chronic health condition, some of their stressors may be different than their partner or another family member. But there are some basics to stress management that we all can benefit from.

We all can benefit from good sleep. We really should ideally be aiming for 7 to 9 hours of sleep. A sleep neurologist that I was with this weekend just literally gave that talk—nobody is immune to needing good sleep. We can again think about how to work that in. Eating well—so if you're living with a gastrointestinal condition, I think at least once in your life you should consult with a GI dietitian and just make sure that nutritionally you're fueling your body. You're aware of some of the foods that are more gentle on your body so that you don't have to stress as much about what to eat when you're out and about and things that might cause symptoms.

The thing... my bread and butter in teaching people stress management and the tip and trick that that you and I covered was this idea that starting with what are the stressors that are within your control. Those are oftentimes, you know, it could be paying a bill, it could be, you know, having to call an insurance company. You might have to spend that afternoon on the phone and that's stressful, but there does tend to be an endpoint. So identifying that as a controllable stressor, you can kind of strategize there's an endpoint, there's a solution and a resolution.

What a lot of us have to do more work in the area of is our uncontrollable stressors, which require what we call emotion-focused coping. And this is a development of strategies that include relaxation training, engaging with your social support, using constructive self-talk, realizing that at some point you may have to let it go and accept what it is is what it is, and being okay with that, even if it's something that's really challenging. And so I'll work with patients on developing those skills. And I don't think a single person that I work with isn't familiar with the use of diaphragmatic breathing to just kind of have something in your back pocket that can help to regulate your autonomic nervous system and really work on, you know, calming things down before you then respond. So there's, you know, I could obviously talk about this for hours and hours, but I'll stop it at those tips and tricks.

Dr Cross: Well, it's one nice thing about being back in person in meetings again, particularly. I got to have dinner with Megan and others. And I only had one very brief session with her and I use her tips already when I'm stressing the endoscopy suite. I try to break it down as this is something I can control. Do I have a slow anesthesiologist today?

If so, I'm going to be behind. It's not my fault. And I'm going to take a deep breath and we're just going to get through the day. And I was listening to a podcast the other day and they said that when you wake up in the morning you need to say the words, “today is going to be a good day.” You need to speak it out loud, and then the second point was say to yourself that something fantastic is going to happen today, and it's a way of retraining your brain And I've been doing that for a few days. And I had a you know fairly long afternoon clinic and I came into my office and there was a coffee on my desk and I just thought wow what an awesome thing, like I have a coffee just when I need it, it's right there for me. It's funny how you can reframe your brain to take something that really isn't that big of a deal and you make it your brain recognizes it's something special for the day.

Dr Riehl: Yeah it makes a difference.

Dr Cross: All right. This is what everyone listens for—well they listen for more than this— but what's your fun fact? Tell a listener something about yourself that they may not know.

Dr Riehl: Okay. I grew up golfing and there were many times where I'd be the only girl on the golf course and people probably don't know that I've won against my male counterparts some long drive competitions And this was in my late teens, early 20s. So I could hit a golf ball pretty well.

Dr Cross: Do you still play?

Dr Riehl: Kids came around. I have 3 little kids. And so 3 kids on a golf course doesn't really work very well. But what I love about golf is, what inspired me to get going in it is my grandpa started to golf after he retired. And so, you know, you can play it at any time. So I'm in an early retirement, but I will come out of retirement when my kids get a little bit older.

Dr Cross: And you definitely need a psychologist to play golf, for sure.

Dr Riehl: Sure do.

Dr Cross: There are things in the golf course that you cannot control and being able to. I think you're the first, I don't think anyone before you has mentioned being a golfer and certainly not long drive. So that's a first. So I'm glad you shared that.

Megan, this has been really great. I'm so glad I got to meet you this year and hopefully we'll have you back on IBD Drive Time again.

Dr Riehl: Likewise. Thank you so much.