The degree of gastroesophageal reflux disease severity significantly correlated with the incidence and severity of anxiety and depression, according to a recent study. While links between the gut and mental health have been considered for some time, this study looked more directly at the severity of the common comorbidities.
The prevalence of GERD has been on the rise worldwide, affecting about 20% of the population in Western countries. Further, anxiety and depression are prevalent in people with GERD, thereby reducing overall quality of life in these individuals.
Degree of Acid Reflux Correlated with Severity of Anxiety and Depression
The new study analyzed the relationship between the severity of GERD and the severity of anxiety and depression among 518 individuals (224 males and 294 females between the ages of 48 and 65 years) at a tertiary hospital in Chengdu City, China. The researchers used 24-hour pH monitoring to assess the degree of reflux; scores for anxiety and depression were obtained through the Hospital Anxiety and Depression Scale.
They found that high scores for anxiety and depression correlated with a corresponding rise in the outcomes from the 24-hour pH-monitoring examination. The outcomes measured included: number of refluxes (pH < 4); percentage of time spent in reflux; and number of long refluxes (T ≥ 5 minutes).
Overall, moderate to severe depression was additionally associated with an increased incidence of GERD, at an odds ratio of 2.32 (95% CI 1.23, 4.37), and higher anxiety levels or depressive symptoms correlated with a rise in GERD symptom severity, using logistic regression modeling. Of note, older age and high body mass index were associated with developing GERD as well, while increasing age and low literacy levels raised the likelihood of depression.
The Gut-Brain Axis in Mood Disorders: What’s Known to Date
Several prior studies have demonstrated a link between GERD and anxiety/depression, however, the nature of this relationship has remained unclear.
The gut affects mood and human behavior through a complex interaction between the gut microbiome and the nervous system, explained Stephen Lupe, PsyD, a gastrointestinal psychologist and director of behavioral medicine in the department of gastroenterology, hepatology, and nutrition at the Cleveland Clinic. “The gut is a fully integrated part of the body; it is affected by and affects all other body parts,” he said, and “it constantly communicates with the brain, which can misinterpret messages, exaggerate threat responses, and send down messages that change the gut’s functioning.”
While the links are still in the early stages of exploration, “it seems [that] not only do lifestyle factors affect the gut, but the gut produces neuroactive metabolites that affect mood, behavior, and memory,” added Dr. Lupe. “So, people with GI disorders have a predictably disturbed GI microbiome that results in mood symptoms, exacerbated by the stress of a GI disorder.”
How to Treat Both GERD and Mental Health
Treatment of anxiety and/or depression can improve GERD symptoms. "The arrow is bidirectional… If someone is anxious, they tend to notice GERD symptoms more, and the communication between the gut and the brain changes due to the activation of the sympathetic nervous system,” explained Dr. Lupe. The situation is the same if someone is having high symptoms which tend “to cue anxiety which cues the sympathetic nervous system.”
Physical activity can help, he noted. “It is a first-line treatment for symptoms of depression and anxiety, and relieving such symptoms in people with GERD may reduce distress and help re-regulate the gut-brain axis.” One meta-analysis and systematic review suggested that physical activity might confer a protective benefit against GERD. However, Dr. Lupe emphasizes moderation because strenuous activities can exacerbate symptoms.
Dr. Lupe also recommends developing “collaborative relationships with a local behavioral health provider for assistance with interventions such as relaxation training, or adopt[ing] digital mental health platforms that assist with behavioral health interventions.”
John Nathanson, MD, a gastroenterologist with Columbia University Irving Medical Center in New York, said his approach is to ask individuals with GERD what makes their symptoms better or worse, which often leads to conversations about mental health. “If the conversation leads to a discussion about mental health, I will generally screen for anxiety or depression and then refer to a mental health specialist if indicated and if the individual is interested,” said Dr. Nathanson.
Remember: GERD Pathophysiology is Multifactorial
Anxiety and depression are often undiagnosed and untreated in people with GERD, primarily because physicians focus on the physical symptoms. Physicians can keep this in mind when treating individuals with GERD – which may be associated with gut microbial dysbiosis – thus making them susceptible to anxiety and depression.
“Looking at GI health in this way allows us to see problems like GERD as multifactorial, with multiple causes,” said Dr. Lupe. “Our job is to give individuals the best tools to modify as many of these causes as possible. We can learn to modify communication within the nervous system, modify biochemistry through medications, change diets to increase gut health, and improve overall health.”
Disclosures: Drs. Lupe and Dr. Nathanson reported no conflicts.