The synthesis of the psychosocial and the physiological aspects of chronic digestive disease is at a crossroads

The field of psychogastroenterology, which focuses on the interplay of psychological, physiological, and social domains of gut health, is in its 6^th official year as of 2024 based on the inception of the Rome Foundation Psychogastroenterology Group in 2018 (see: https://theromefoundation.org/rome-gastropsych/). However, the field’s legacy really begins in the mid-1980s with the first research into using medical hypnosis as a treatment for irritable bowel syndrome (IBS) (1) and in the mid-1990s with the first studies evaluating cognitive behavioral therapy (CBT) for patients with IBS (2). Since these pioneering works, interest into the mental health burdens of patients with gastrointestinal (GI) illness has risen precipitously with an exciting evolution in its focus and conceptualization.

The statistics on the mental health burden of people with chronic GI illness are alarming. The most widely studied comorbidities, anxiety and depression, impact between 20% and 50% of patients, depending on the condition (3-6). Approximately 25% of patients with inflammatory bowel disease (IBD) report moderate to severe symptoms of chronic post-traumatic stress due to IBD-related medical trauma (7); rates are disproportionally higher in non-White patients (8). Patients with IBS are willing to take substantial risks from pharmacological treatments in order to relieve their symptoms (9), and one study remarkably found people with IBS are willing to give up 15 years of their lives in exchange for relief from their illness (10).

With numerous randomized controlled trials to date, brain-gut behavioral therapies (BGBTs) such as CBT for IBS, acceptance and commitment therapy (ACT) for IBD, and gut-directed hypnotherapy for most disorders of gut-brain interaction (DGBI), are exceedingly effective treatments for many chronic GI conditions (11-13). Results consistently show patients have clinically significant improvements in physical symptoms and/or in health-related quality of life domains. Some studies suggest BGBTs may positively alter the brain-gut-microbiome axis (14,15). The efficacy of BGBTs appears consistent whether delivered in-person or via the telephone or internet (16), an important discovery that may lead to technological innovations to deliver these treatments to scale. Many BGBTs are as effective as dietary treatments but without the potential negative effects of navigating a restricted diet (e.g., cost, social factors) (17). Further, BGBTs delivered in conjunction with dietary treatments could mitigate risks such as reduced food-related quality of life or the development of disordered eating behaviors in vulnerable patients. As such, BGBTs are incorporated into both the American Gastroenterological Association and American College of Gastroenterology guidelines for managing certain conditions such as IBS. Yet in 2024, most GI patients struggle to access to these treatments due to a variety of persistent barriers to care.

Much of the extant literature on mental health in GI disease focuses on anxiety and depression in Western societies (e.g., United States, Europe). However, very recent research seeks to align more with the complexity of the human experience and takes on deeper issues such as sexual health (18), including in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) populations (19), disordered eating (20), and disease stigmatization (21). Even our understanding of the “anxiety” GI patients may experience has evolved from a broad, generalized term to the nuance of symptom-specific anxiety and body hypervigilance. In fact, how a patient experiences and interprets their symptoms may be a bigger predictor of patient outcomes than traditional physiological testing or other psychological processes, as evidenced in esophageal diseases (22) and gastroparesis (23).

While it is exciting to report such a meteoric rise in the recognition of these psycho-physiological relationships in the gut and how they can be targeted with BGBTs, we must also recognize that with this attention comes risk for increased stigmatization and invalidation due to, in part, the broader societal stigma towards mental illness. Disease-related stigma impacts a significant proportion of people living with GI disease, and this stigma originates not only from those in the person’s social circles but also from the medical exam room (21). Further, certain GI conditions are more likely to be stigmatized (i.e., IBS and other DGBI) than others, which can even translate into reduced allocation of research grant funding (24) and attention at professional conferences.

The current series traverses the complex mental health issues patients with chronic digestive diseases face on a daily basis, underscoring the need to move beyond solely evaluating patients for “anxiety and depression” and inquiring about issues related to sleep, sexual health, and the nuanced subjective illness experience of each person. The series highlights effective interventions to mitigate mental health issues GI patients face, presenting theoretical frameworks more recently adapted for BGBTs including resilience-based interventions and body-focused treatments such as yoga. The series acknowledges the arduous realities and barriers of the modern U.S. healthcare system that often prevent translating psychogastroenterology research into clinical practice with recommendations for systemic change. Lastly, the series tackles the uncomfortable realities of medical invalidation and gaslighting, and how this relates to provider burnout and mounting strains within global healthcare systems. Collectively, we aspire for these articles to push the field of psychogastroenterology forward along novel lines of research inquiry and infuse a sense of urgency among key decision makers within gastroenterology to prioritize resources for true multidisciplinary care in all clinical practice settings.

Acknowledgments

Funding: This work was supported by National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) (No. 5R01DK092217 to S.H.M.).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Gastroenterology and Hepatology for the series “Social and Emotional Impacts of Chronic Digestive Diseases”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-24-102/coif). The series “Social and Emotional Impacts of Chronic Digestive Diseases” was commissioned by the editorial office without any funding or sponsorship. S.H.M. and T.H.T. served as the Guest Editors for the series. S.H.M. is the Co-Investigator on NIDDK-funded R01DK092217 grant entitled Targeting Hypervigilance and Autonomic Arousal: the Psycho-physiologic Model of GERD. T.H.T. is member of the scientific advisory board of Ayble Health and has 100% ownership interest in Oak Park Behavioral Medicine LLC. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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