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Correspondence to: Simon R Knowles, PhD, Senior Lecturer, Department of Psychological Sciences, Swinburne University of Technology, Hawthorn, Victoria 3122, Australia. ua.ude.niws@selwonks
Telephone: +61-3-92148206 Fax: +61-3-98190574
To systematically review literature addressing three key psychologically-oriented controversies associated with gastroparesis.
A comprehensive search of PubMed, CINAHL, and PsycINFO databases was performed to identify literature addressing the relationship between gastroparesis and psychological factors. Two researchers independently screened all references. Inclusion criteria were: an adult sample of gastroparesis patients, a quantitative methodology, and at least one of the following: (1) evaluation of the prevalence of psychopathology; (2) an outcome measure of anxiety, depression, or quality of life; and (3) evidence of a psychological intervention. Case studies, review articles, and publications in languages other than English were excluded from the current review.
Prevalence of psychopathology was evaluated by three studies (n = 378), which found that combined anxiety/depression was present in 24% of the gastroparesis cohort, severe anxiety in 12.4%, depression in 21.8%-23%, and somatization in 50%. Level of anxiety and depression was included as an outcome measure in six studies (n = 1408), and while limited research made it difficult to determine the level of anxiety and depression in the cohort, a clear positive relationship with gastroparesis symptom severity was evident. Quality of life was included as an outcome measure in 11 studies (n = 2076), with gastroparesis patients reporting lower quality of life than population norms, and a negative relationship between quality of life and symptom severity. One study assessed the use of a psychological intervention for gastroparesis patients (n = 120) and found that depression and gastric function were improved in patients who received psychological intervention, however the study had considerable methodological limitations.
Gastroparesis is associated with significant psychological distress and poor quality of life. Recommendations for future studies and the development of psychological interventions are provided.
Core tip: Gastroparesis is associated with significant psychological distress and poor quality of life. Literature indicates that quality of life is lower in gastroparesis patients than population norms. Further, gastroparesis symptoms are adversely associated with increased anxiety and depression and impaired quality of life. Rates of psychopathology in gastroparesis cohorts range between 21.8% to 50%. Although a psychological intervention for gastroparesis has found improvements in depression and gastric function, it has not been replicated. Further research into potential mediating factors and the development of psychological interventions for individuals with gastroparesis is warranted.
Gastroparesis is a gastrointestinal disorder involving delayed gastric emptying in the absence of a mechanical obstruction of the stomach. Patients living with gastroparesis typically experience chronic nausea, vomiting, early satiety, postprandial fullness, and in some cases abdominal pain and fatigue[2-6]. The mean age of diagnosis ranges between 40-45.5 years, with 67%-88% of gastroparesis patients being female[5-12].
In Australia, the prevalence of gastroparesis is unknown, however in 2006 the Australian government provided an estimate that 120000 Australians suffered from severe gastroparesis. The only study to investigate the prevalence of gastroparesis was conducted using medical records in Minnesota (United States) from 1996 to 2006. Jung et al found that after adjusting for age and gender (to 2000 US Caucasians), the incidence of definite gastroparesis per 100000 person years was 9.8 in women, and 2.4 in men. In patients over the age of 60 years, the incidence peaked at 10.5 per 100000. It has been estimated that approximately one third of gastroparesis patients will be admitted to hospital for the condition, with a disease burden likened to that of Inflammatory Bowel Disease. In terms of financial burden, Wang and colleagues reported that in 1995 the costs of gastroparesis in the United States were 47.7 million dollars (primary diagnosis) and 863.3 million dollars (secondary diagnosis), while in 2004 costs were significantly higher at 208.3 million dollars (primary diagnosis) and 3.3 billion dollars (secondary diagnosis).
Individuals living with chronic gastrointestinal illness must make considerable physical, psychological, and social adjustments in order to manage their often debilitating symptoms[16,17]. Not surprisingly, patients suffering from chronic gastrointestinal conditions frequently report psychological symptoms, such as anxiety, depression, and impaired quality of life (QoL)[17-26]. With limited treatment options available for gastroparesis, the importance of psychological support or intervention has been repeatedly emphasized in the literature[8,27,28]. A systematic review of the gastroparesis literature exploring relationships between psychological distress, psychological processes, and gastroparesis has not yet been conducted.
The current systematic review will explore three key questions in relation to psychological features and processes associated with gastroparesis: (1) what is the prevalence of psychopathology in gastroparesis cohorts and how does it compare to other gastroenterological conditions? (2) what are the levels of anxiety, depression, and QoL in gastroparesis cohorts and do they differ with respect to gastroparesis symptom severity, etiology, degree of gastric retention, and duration of symptoms/disease? And (3) do psychological interventions for gastroparesis patients reduce gastroparesis symptoms, anxiety, depression, and improve QoL?
For this review, a comprehensive search of PubMed, CINAHL, and PsycINFO databases was performed. Search criteria used were: (“gastroparesis” OR “gastric delay” OR “gastric emptying” OR “gastric motility” OR “gastric timing”) AND (“anxiety” OR “affective state” OR “cognition” OR “control” OR “coping” OR “depression” OR “distress” OR “emotion” OR “helplessness” OR “illness perception” OR “life events” OR “mastery” OR “mental” OR “mood” OR “neuropsychological” OR “panic” OR “personality” OR “psycholog” OR “psychosocial” OR “quality of life” OR “self-efficacy” OR “stress”). Research papers retrieved through the search were also reviewed for further relevant references.
Inclusion criteria were: an adult sample of gastroparesis patients, a quantitative methodology, and at least one of the following: (1) evaluation of the prevalence of psychopathology; (2) an outcome measure of anxiety, depression, or QoL; and (3) evidence of a psychological intervention. Case studies, review articles, and publications in languages other than English were excluded from the current review.
Two researchers (Woodhouse S, Knowles SR) independently screened all references retrieved through the search and categorized them according to the inclusion and exclusion criteria. The researchers also extracted data from the papers independently, including participant information, methodology, assessment tools, and study outcomes.
After 73 duplicates were removed, a total of 2388 citations were identified through database searches and review of other relevant references. Of these, 2372 were excluded due to: (1) not meeting the inclusion criteria; or (2) lack of information (Figure (Figure11 for PRISMA diagram). This resulted in a total of 16 research reports which are summarized in Table Table11.
Of these reports, three (18.75%) identified the prevalence of psychopathology in a gastroparesis cohort[6,12,14], 13 (81.25%) assessed levels of anxiety, depression, or QoL[2,7,8,10,12,26,29-35], and one (6.25%) involved a psychologically-based intervention for gastroparesis patients. A summary of the studies’ participant characteristics is presented in Table Table22.
Three studies reported on the prevalence of psychopathology in a gastroparesis cohort (n = 378). Using the Center for Epidemiologic Studies Depression Scale (CES-D) and the hospital records of 52 idiopathic gastroparesis (IG) patients, Soykan et al note that 23% had a history of depression or antidepressant therapy, and 50% displayed clinically significant somatization using the SCL-90. The authors state that somatization was higher in the IG population than in the gastrointestinal population, however the difference was not significant.
In an exploration of the epidemiology of gastroparesis, Jung et al identified that 25 out of 83 patients with definite gastroparesis (30%) had evidence of psychiatric comorbidity in their medical records. Twenty of these patients had evidence of anxiety or depression, and five had other psychiatric illness. This study did not compare the prevalence of psychopathology in gastroparesis to other gastroenterological cohorts.
In a larger sample of 243 IG patients, Parkman et al identify comorbid major depression in 21.8% of patients, and severe anxiety in 12.4% of patients through face-to-face interviews between patients and study physicians or coordinators. This study did not compare the prevalence of psychopathology in gastroparesis to other gastroenterological cohorts, however it was shown that females were more likely to report comorbid anxiety disorder than males, and patients with severe symptom severity or severe gastric retention were more likely to report major depression than those with milder symptoms. Participants in this study were mainly recruited from tertiary referral centers and therefore may not be representative of the general gastroparesis community.
Studies measuring anxiety and/or depression in gastroparesis cohorts: A total of six studies measured the level of anxiety and/or depression in gastroparesis cohorts (n = 1408)[2,7,8,12,26,29]. Of these studies, two used the Hospital Anxiety and Depression Scale (HADS)[2,8]. Bielefeldt et al used a cut-off score of > 8 and found that of the 55 participants, 74% met the criteria for either anxiety or depression, and 29% met the criteria for both conditions. No differences across etiology, gastric retention, or duration of symptoms/disease were reported, however symptom severity did correlate positively with depression score. Cherian et al used a cutoff score of > 10 and found that of 156 participants, 99% met the criteria for depression and anxiety. Differences across etiology, symptom severity, gastric retention, and duration of symptoms/disease were not reported in the study.
A further four studies measured depression using the Beck Depression Inventory (BDI)[7,12,26,29]. Parkman et al found that the average BDI score was 18.6 and 18% of the 243 IG participants fell into the range of 29-63 to indicate severe depression. Depression levels increased across mild to moderate symptom severity, however no difference was found in depression levels across degree of gastric retention. In a study of 299 gastroparesis patients by Hasler et al, BDI scores of ≥ 20 were present in 41.5% of participants. Higher BDI scores were associated with increased gastroparesis severity, nausea and vomiting, bloating, and postprandial fullness. The BDI scores were similar across diabetic gastroparesis (DG) and IG etiology, and degree of gastric retention. Self-reported gastroparesis severity and use of antiemetic/prokinetic medications were predictive of a BDI score ≥ 20. Another study by Hasler et al did not report overall BDI scores, but compared scores across pain severity, etiology, and symptom predominance. Hasler et al found that in a study of 393 gastroparesis patients, increased BDI scores were associated with greater pain severity in both DG and IG patients. The most recent study by Pasricha et al identified that 41.6% of 262 gastroparesis patients had BDI scores greater than 20, indicating moderate to severe depression. Unlike the aforementioned studies, this study also examined the impact of duration of disease on gastroparesis outcomes, finding no significant change in depression levels after 48 wk of standard medical care for gastroparesis. However, depression level at baseline was a significant predictor of symptomatic improvement at 48 wk.
Finally, four studies used the State-Trait Anxiety Inventory (STAI) to measure anxiety[7,12,26,29]. Parkman et al found that the average state anxiety score was 45.2 while trait anxiety was 43.9. Using an STAI score of ≥ 50 to denote severe anxiety, Parkman et al identified that 36% of 243 IG patients reported severe state anxiety, while 35% reported severe trait anxiety. State anxiety levels increased across mild to moderate symptom severity, however no difference was found in state or trait anxiety levels across degree of gastric retention. Hasler et al noted that 50.2% of participants reported state anxiety ≥ 46, and 51.5% reported trait anxiety ≥ 44. Higher state and trait anxiety was associated with increased gastroparesis severity, bloating, and postprandial fullness. Increased self-reported gastroparesis severity and use of anxiolytic medications were predictive of higher state anxiety, while use of antidepressant medications was predictive of higher trait anxiety. State and trait anxiety were similar across DG and IG etiology, and degree of gastric retention. Hasler et al found that increased STAI state and trait scores were associated with greater pain severity in both DG and IG patients. Finally, Pasricha et al identified that 32.8% of participants reported state anxiety ≥ 50 at baseline, and 30.5% reported trait anxiety ≥ 50 with no significant change in state or trait anxiety levels after 48 wk of standard medical care for gastroparesis. However, use of anxiolytics at baseline was a negative predictor of symptomatic improvement at follow-up.
Studies measuring QoL in gastroparesis cohorts: Eleven studies included an outcome measure of QoL (n = 2076)[2,8,10,26,29-35]. The two earliest studies to measure QoL in gastroparesis used the SF-12. Harrell et al found that in a sample of 100 gastroparesis patients, SF-12 subscale scores and component summary scores were significantly lower in gastroparesis patients when compared to population norms, with a negative relationship to upper GI symptom severity. Similarly, in a study of 55 gastroparesis patients, Bielefeldt et al found that both the physical and mental component scores of the SF-12 were lower than population norms, with no significant difference between DG and IG groups. Symptom severity was negatively correlated with the physical component score. The authors also identified that nausea and bloating severity, combined with the HADS score for depression, best predicted the physical health component score of the SF-12. The influence of gastric retention and duration of symptoms/disease on QoL was not assessed in either study.
Of the five studies that used the SF-36, Jaffe et al found that both the mental and physical component scores were impaired in a sample of 59 gastroparesis patients compared to population norms. The study indicated that nausea and vomiting severity was inversely related to QoL, with no significant difference in QoL between DG and IG patients, or across degree of gastric retention. In a larger study of 335 patients, Hasler et al noted that physical and mental component scores were negatively correlated to bloating severity, with higher mental component scores predicting greater bloating severity. Another study by Hasler et al identified that physical and mental component scores were lower in both DG and IG patients with increased pain/discomfort scores. Additionally, when comparing between pain/discomfort predominant versus nausea/vomiting predominant symptoms, pain predominance was associated with greater impairment in the physical component score.
More recently, Pasricha et al identified mild improvement in SF-36 scores (physical and mental components) after 48 wk of standard medical care for gastroparesis. A 2016 study by Cutts et al explored the relationships between symptom severity and the SF-36 subscales in a cohort of 235 gastroparesis patients, finding primarily negative correlations between symptom severity and Physical Functioning, Bodily Pain, Social Functioning, Role Emotional and Mental Health subscales (Table (Table11 for details). The only positive correlation was between Role Emotional and epigastric pain severity. Finally, the most recent study using the SF-36 was conducted by Lacy et al and identified that in 250 gastroparesis patients, those with IG had better physical functioning, mental health, and role-physical than patients with DG. Similarly DG patients had lower physical component summary scores than patients with IG or gastroparesis from other causes, while DG patients and patients with gastroparesis from other causes also had lower mental component summary scores than those with IG.
Seven studies used the Patient Assessment of Upper Gastrointestinal Disorders Quality of Life (PAGI-QOL) to measure QoL. Using this assessment tool, Hasler et al reported impaired QoL in individuals with gastroparesis. Cherian et al assessed QoL across etiologies and found that, in their sample of 68 patients, IG patients scored significantly lower than DG patients on PAGI-QOL measures of diet, daily activities, and relationships. In addition, significant negative correlations have been identified between the PAGI-QOL and total upper GI symptom severity, pain/discomfort severity[10,29], fatigue, bloating severity, and nausea/vomiting severity. Similar to their findings using the SF-36, Pasricha et al identified mild improvement in PAGI-QOL scores after 48 wk of standard medical care for gastroparesis. Despite these improvements in QoL over time, the authors note that QoL remained impaired in relation to the general population.
Only one study involved a psychological intervention for gastroparesis patients. Liu et al conducted a randomized controlled trial (RCT) with 120 post-surgical gastroparesis patients. Sixty patients were allocated to a control group that received conventional therapy (gastric tube, fasting, parenteral and enteral nutrition, routine nursing care, health guidance), while another 60 were allocated to a “comprehensive mental intervention” group that received conventional therapy in addition to: supportive mental consultation, bedside symptomatic mental intervention, music and abdominal massage, and mental intervention for patients’ families. While the groups had comparable CES-D scores at baseline, the mental intervention group scored significantly lower than the control group on days 3, 7, 10, and 17 after the intervention. The intervention group also had significantly improved gastric function following the intervention compared to the control group. The study did not include measures of anxiety or QoL.
Conclusions are presented according to the key questions of the systematic review. This is followed by a discussion of the strengths and limitations of the literature, and suggestions for future research in the area.
This review found three studies that investigated the prevalence of psychopathology in gastroparesis patients. The reported prevalence of these psychopathologies were: combined anxiety/depression 24%, severe anxiety 12.4%, depression 21.8%-23%[6,12], somatization 50%, other 5%. Parkman et al reported that females were more likely to report comorbid anxiety disorder, and patients with greater symptom severity and gastric delay were more likely to report major depression. Soykan et al identified a non-significant difference in the prevalence of somatization in the gastroparesis cohort compared to other gastroenterological cohorts, while Parkman et al and Jung et al did not make such comparisons.
It must be acknowledged that in addition to using the CES-D, Soykan et al assessed whether patients had a medical history of either depression or anti-depressant use, which does not necessarily indicate prevalence of depression. Parkman et al only reported on severe anxiety, which is likely to underestimate the prevalence of anxiety in the cohort, and two studies[6,12] only assessed psychopathology in IG patients so findings may not be representative of approximately two-thirds of gastroparesis patients. Finally, all three studies lacked clarity around how patients obtained a psychiatric diagnosis, and two[6,12] limited the psychopathologies that were included in the study. Based on these findings, it can be concluded that while there is psychopathology in gastroparesis patients, there has not been enough research conducted to provide a reliable prevalence rate. Further, no conclusion to date can be made with regard to whether rates of psychopathology are higher or lower in gastroparesis compared to cohorts that are healthy, chronically ill, or have other gastrointestinal conditions.
Overall, it is difficult to be definitive regarding the level of anxiety and depression in gastroparesis cohorts given the limited research conducted to date. Based on one study, 18% of gastroparesis patients have severe depression, 36% have severe state anxiety, and 35% have severe trait anxiety. Another study reported that 41.6% of patients had moderate to severe levels of depression at baseline, and identified that the percentage of patients scoring equal to or greater than 50 on the STAI at baseline was 32.8% for state anxiety, and 30.5% for trait anxiety. While other studies also measured and reported on anxiety and depression, they did not identify levels of severity. Three studies[7,12,29] indicated that anxiety was positively associated with gastroparesis symptom severity , and one did not, while four[7,8,12,29] indicated that depression increased with gastroparesis symptom severity. Two studies reported on the influence of gender on anxiety and depression levels, with one stating that females displayed less clinically severe depression, and the other indicating that male gender was associated with higher state anxiety. One study demonstrated that depression and anxiety levels were similar across DG and IG etiologies, and two showed consistency across degree of gastric retention[7,12]. Only one study assessed the influence of duration of symptoms/disease, finding no significant improvement in anxiety or depression levels from baseline to follow-up at 48 wk. However, depression level and use of anxiolytics at baseline were significant predictors of symptomatic improvement at 48 wk.
The six studies that measured anxiety and/or depression in a gastroparesis cohort used a variety of assessment tools and cut-off scores, which makes it difficult to interpret the results as a whole. For example, the two studies employing the HADS each used a different cut-off score and did not give enough information to compare results across the studies. Similarly, of the four studies using the BDI and STAI only two reported the level of anxiety and depression in the sample, while the other two primarily used the scores for correlation analyses. Thus, although studies have been conducted on the severity of anxiety and depression in gastroparesis patients, the lack of consistency and scoring information limits the conclusions that can be made. With this being said, there is evidence to indicate that levels of psychopathology and gastroparesis symptom severity were positively correlated, and that this relationship tends to be consistent across the different forms of gastroparesis.
The eleven studies investigating QoL in gastroparesis demonstrated that QoL was lower in gastroparesis patients than population norms[8,31,33], and that there was generally a negative relationship between QoL and gastroparesis symptom severity[2,8,10,29-34], although one study found a weak positive relationship between the Role Emotional subscale of the SF-36 and epigastric pain severity. Two studies found no significant difference in QoL between DG and IG patients[8,33], however one found that IG scored lower than DG on measures of diet, daily activities, and relationships, and conversely, another found IG scored higher than DG on both physical and mental components of QoL. Only one study assessed the relationship between degree of gastric retention and QoL, with no significant relationship demonstrated. One study assessed the impact of duration of symptoms/disease, finding a mild improvement in QoL after 48 wk of standard medical care for gastroparesis.
Based on these results, it can be concluded that QoL is lower in the gastroparesis cohort than the general population, and greater gastroparesis symptom severity is associated with lower QoL. At this point, there is not enough evidence to make conclusions about the influence of etiology, gastric retention, or duration of symptoms/disease on QoL.
Only one study has reported on a psychological intervention for gastroparesis patients. Liu et al found that depression scores and gastric function were significantly improved in patients who received a psychological intervention compared to those who received standard care, however the study had considerable methodological limitations. Firstly, the study was conducted only on post-surgical patients, making the results difficult to generalize to other etiologies. The study also utilized a number of different factors in the intervention condition (e.g., supportive mental consultation, abdominal massage, music) making it impossible to ascertain the impact of any one component of the intervention. Additionally, the study did not utilize long-term follow-up. While the results of this study are promising, there is currently limited evidence for the use of psychological intervention in gastroparesis, and measures of other important psychological factors such as anxiety and QoL have yet to be assessed in this context.
Currently the literature indicates that QoL is lower in gastroparesis patients than population norms, and that as gastroparesis symptom severity increases, anxiety and depression also increase while QoL decreases. The studies are few in number, with variability in the assessments used and etiologies studied, making it difficult to form further conclusions. It also appears that five of the 15 studies[7,12,26,29,32] have used overlapping samples as they were all recruited via the Gastroparesis Registry. Consequently, findings may not be reflected across different samples. The evidence for the use of psychological intervention in gastroparesis is minimal and is further weakened by significant methodological limitations in the single relevant study.
Inconsistency in the assessment of gastroparesis must also be considered when interpreting these findings. While the majority of studies used self-report in conjunction with a scintigraphic study where > 60% retention at two hours, and/or > 10% retention at four hours indicated gastroparesis, there was some variation in assessment[6,8,31,34].
In order to move forward in understanding this area, future research would benefit from undertaking the following recommendations. When assessing the prevalence of psychopathology in gastroparesis cohorts, studies should consider the broad range of psychopathologies, which should be diagnosed by an appropriately qualified individual. To gain greater insight into the relationship between psychological factors and gastroparesis, studies should use standardized assessment tools and cut off scores, and provide clear scoring information. Studies are also invited to look beyond basic correlation analyses, and explore possible mediating factors. Information regarding mediating factors would be especially useful in designing individualized psychological interventions for gastroparesis patients. To promote consistency and future comparison, recommendations for studies are summarized in Table Table3,3, along with suggestions for the development of psychological interventions and future research questions.
In conclusion, increased levels of psychopathology are evident in patients suffering from gastroparesis, with associations between the severity of psychological factors and the severity of gastroparesis symptoms. Although only one study has utilized a psychologically-based intervention for gastroparesis patients to date, the intervention was associated with improvement in both gastroparesis symptoms and levels of depression. The results of this systematic review indicate the importance of further research into the relationship between psychological factors and gastroparesis, especially given that current medical treatments for gastroparesis are limited. In particular, further exploration of the prevalence of psychopathology in gastroparesis compared to other conditions is warranted, as well as an assessment of the factors that may mediate an individual’s ability to adapt to, and manage, gastroparesis.
Gastroparesis is a gastrointestinal disorder involving delayed gastric emptying in the absence of a mechanical obstruction of the stomach. Typical symptoms include: chronic nausea, vomiting, early satiety, postprandial fullness, and in some cases abdominal pain and fatigue. Patients suffering from chronic gastrointestinal conditions frequently report psychological symptoms, such as anxiety, depression, and impaired quality of life (QoL).
With limited treatment options available for gastroparesis, the importance of psychological support or intervention for gastroparesis patients has been repeatedly emphasized in the literature. This is the first systematic review of the literature to explore the relationship between psychological factors and gastroparesis.
This systematic review reveals that QoL is lower in gastroparesis patients than population norms, and that as gastroparesis symptom severity increases, anxiety and depression also increase while QoL decreases. Recommendations for the development of future research questions and psychological interventions are provided to encourage progress in this important research area.
The results of this systematic review indicate that further exploration of the prevalence of psychopathology in gastroparesis is warranted, as well as an assessment of the factors that may mediate an individual’s ability to adapt to, and manage, gastroparesis. Better understanding of these factors will assist in the development of targeted psychological support programs for the gastroparesis cohort.
This paper conducted for systematic review of psychological aspects of gastroparesis. Authors concluded that “gastroparesis is associated with significant psychological distress and poor quality of life. Recommendations for future studies and the development of psychological interventions are provided”.
Manuscript source: Invited manuscript
Specialty type: Gastroenterology and hepatology
Country of origin: Australia
Peer-review report classification
Grade A (Excellent): A, A
Grade B (Very good): B
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Conflict-of-interest statement: The authors have no conflicting interests to declare.
Data sharing statement: No additional data are available.
Peer-review started: December 2, 2016
First decision: December 28, 2016
Article in press: February 8, 2017
P- Reviewer: Choi YS, Isik A, Okubo Y S- Editor: Qi Y L- Editor: A E- Editor: Wang CH