Richard Pollok on How Stoma Formation Post Crohn's Surgery Could Lead to Depression

About three-quarters of patients with Crohn's disease eventually develop complications of stricturing or penetrating disease, resulting in intestinal surgery for many, and the possibility that surgery may result in the formation of either a temporary or permanent stoma. One question that hasn't been answered, however, is the impact that a temporary or permanent stoma may have on mental health.

In a study published in Clinical Gastroenterology and Hepatology, researchers including Richard Pollok, PhD, of St. George's, University of London, in England, identified 1,272 patients who underwent intestinal surgery for Crohn's disease, and, after stratifying them into three groups -- no stoma, temporary stoma, and permanent stoma -- analyzed the effect each of these outcomes had on the use of antidepressant medications.

Pollok elaborated on the study in the following interview with the Reading Room.

What kinds of issues do Crohn's disease patients face with intestinal surgery?

Pollok: To put it into context, about 50% of persons with Crohn's disease have surgery within the first 10 years of their diagnosis. And of that proportion of people, maybe about 20% will have surgery that results in the formation of a stoma. That roughly equates to about a 2% risk of stoma formation every year from the time of diagnosis.

There are a number of issues. It obviously has quite an impact on a person's body image, and 40% of people who have a stoma report that it has a negative impact on their sex life. And this is for a cohort of individuals who are often very young -- this disease normally presents in the second, third, and fourth decade of life. So, it's quite traumatic.

At the same time, for some persons who are suffering from symptoms like pain and diarrhea, having a stoma is sometimes better than anticipated because it relieves their symptoms, and because of this, those with a temporary stoma may choose not to have the surgery reversed.

How does this relate to the issue of depression and mood disorders?

Pollok: We already know that persons with chronic disorders like Crohn's disease have much higher rates of depression compared with the general population. So, 20% or 30% of persons with Crohn's disease will have depression or symptoms of depression, depending on how you define it.

Within that group of individuals, if you have a stoma formed, then your risk is even still higher. So, this is the first study comparing persons who've had a temporary stoma with those having a permanent stoma [and the impact on mental health].

What did your study show regarding those risks?

Pollok: There does seem to be a bit of a difference between the two groups. The take-home message is that individuals who have a permanent stoma formed after their Crohn's disease surgery are substantially more likely to require antidepressants.

If you have a long-term stoma, there is a very significant increase in depression and a need to use an antidepressant. Over a 10-year period, about 40% of individuals with a permanent stoma will be on antidepressants compared with 20% to 30% of matched controls. This really has quite a bearing on your quality of life and really underscores that this is a condition that affects you both clinically and psychologically.

And, interestingly, individuals who have a temporary stoma that is reversed in less than a year don't have an increased risk of antidepressant medication use compared with individuals who have surgery without the formation of a stoma. [However], individuals with temporary stomas with late reversals have a significantly increased risk of antidepressant medication use after surgery.

What are the clinical implications of your results?

Pollok: It flags the need to be aware that Crohn's disease is not just a physical illness. It affects you both mentally and physically. You need to look at the patient holistically in terms of what we call the bio/psychosocial model, and be aware that individuals may develop these disorders after surgery, particularly if they are contemplating a permanent stoma. Clinicians should make sure these patients are screened for mood disorders and treated accordingly.

You can read the abstract of the study here, and about the clinical implications of the study here.