Abstract
BackgroundInflammatory bowel disease is a chronic relapsing condition that affects both physical health and daily life. In many patients, the course of disease is not explained by biological factors alone. Long-term psychological stress may disturb the gut-brain axis, worsen immune imbalance, and increase the burden of symptoms. In developing countries, where patients often face financial strain, delayed care, and limited mental health support, this issue may carry even greater importance. However, local evidence from Pakistan remains limited, especially from tertiary care settings.
Objective
This research investigates how chronic psychological stress exacerbates symptoms and accelerates disease progression in patients with IBD, with the goal of developing stress management interventions.
Methods
This cohort study was conducted at a tertiary care hospital in Lahore, Pakistan, among adult patients with confirmed inflammatory bowel disease, including ulcerative colitis and Crohn’s disease. Patients with established disease were enrolled through consecutive sampling and followed over the study period. Chronic psychological stress was assessed using a standard perceived stress measure, and participants were grouped into low, moderate, and high stress categories. Baseline demographic and clinical information was recorded through interview and file review. Disease progression was assessed through flare episodes, need for hospitalization, treatment escalation, and laboratory indicators including C-reactive protein, erythrocyte sedimentation rate, hemoglobin, and serum albumin. Statistical analysis was performed to compare outcomes across stress groups and to evaluate the independent association between stress and adverse disease outcome after adjustment for confounding variables.
Study Type: Cohort Study
ResultsA total of 180 patients were included in the study. The mean age was 34.8 ± 11.2 years, and 57.8% were male. Ulcerative colitis was present in 65.6% of patients, while 34.4% had Crohn’s disease. Based on stress assessment, 25.6% of patients had low stress, 43.9% had moderate stress, and 30.6% had high stress. During follow-up, 40.0% of patients developed at least one disease flare. Flare frequency increased with stress burden, occurring in 21.7% of the low stress group, 39.2% of the moderate stress group, and 56.4% of the high stress group (p = 0.003). Hospitalization was also more frequent among highly stressed patients (10.9%, 20.3%, and 32.7% across low, moderate, and high stress groups respectively; p = 0.021). Treatment escalation showed a similar trend (17.4%, 30.4%, and 43.6%; p = 0.009). Higher stress levels were additionally associated with higher mean CRP and ESR values and lower hemoglobin and albumin levels. On multivariable analysis, high stress remained independently associated with flare (adjusted OR 3.74, 95% CI 1.73–8.09, p = 0.001), hospitalization (adjusted OR 2.96, 95% CI 1.22–7.18, p = 0.016), and treatment escalation (adjusted OR 2.58, 95% CI 1.19–5.58, p = 0.017).
ConclusionChronic psychological stress was strongly associated with a poorer clinical course in inflammatory bowel disease. Patients with greater stress burden experienced more frequent flare, more hospital admissions, more treatment escalation, and worse inflammatory profiles. These findings suggest that stress is not only a parallel emotional concern but an important factor linked with disease progression.
RecommendationsRoutine stress screening should be included in IBD follow-up, especially in tertiary care settings. A more integrated care model that combines gastroenterology services with psychological support may improve outcomes. Further multicenter studies in Pakistan are needed to confirm these findings and to test whether stress management interventions can reduce relapse and improve quality of life