Editorial: anxiety and depression associated with mucosal healing in coeliac disease

The relationship between coeliac disease and psychological comorbidity is complex, with symptoms of anxiety and depression commonly identified in coeliac cohorts1 and associated with poorer gluten-free diet (GFD) adherence.2-4 However, while maintaining a GFD is ideal for disease management, it is also recognised to be challenging both practically and emotionally.5 The study conducted by Ludvigsson et  al6 provides a valuable exploration of the relationship between psychological comorbidity and mucosal healing associated with maintaining a GFD.

In a nationwide longitudinal population-based cohort study involving 7648 individuals, Ludvigsson et  al6 explored the association between diagnosis of anxiety or depression and its relationship to mucosal healing. The authors found that the risk of developing anxiety was 2.8 per 1000 person-years of follow-up in the mucosal healing group (n = 4331) vs 2.1 per 1000 in the group identified with persistent villous atrophy (n = 3317). Likewise, rates of depression were higher in the mucosal healing vs persistent villous atrophy group (3.8 vs 3.3 per 1000 person-years of follow-up). Both anxiety and depression were not common in the sample (3% and 4% respectively), and as the diagnostic codes and medications rather than screening scales or psychological/psychiatric interviews were used, the low prevalence may reflect a more severe symptomatology.

While there was some evidence for a higher psychotropic prescription rates in the persistent villous atrophy group vs mucosal healing group, these findings were not significant. The authors concluded that mucosal healing was associated with a greater risk of developing anxiety and depression, and that this may be due to the burden of the treatment or individuals living with anxiety/depression being more attentive to maintaining a GFD.

Indeed, for some patients, the everyday burden to maintain a GFD may lead to depression and ongoing anxiety about food choices, potential cross-contamination, accidental, or deliberate GFD transgressions. The development of anxiety and/or depression may also promote adherence to a GFD. This may be due to a fear of coeliac symptoms or as a way to maintain or have some control in their life. Both purported mechanisms relating to the development of anxiety and depression in mucosal healing are not necessarily independent of each other and may well also be influenced by multiple factors unexplored in the research by Ludvigsson et  al, including anxiety and depression symptom severity, other psychological and physiological comorbidities, illness perceptions, self-efficacy, and coping styles. Further longitudinal research which accounts for the identified limitations is likely to better elucidate the mechanisms underpinning anxiety and depression in coeliac cohorts and how it relates to mucosal healing.

Nevertheless, Ludvigsson et  al6 provide important evidence for the interplay between mucosal healing and psychological comorbidity, and the significant psychological costs associated with maintaining a GFD. Given this, along with utilising a GFD as directed by dieticians and gastroenterologists, it seems that the integration of mental health professionals to identify and address psychological comorbidities is not only warranted but also likely to lead to improved physical and psychological health.