Widespread availability of OTC agents to combat gastroesophageal reflux disease (GERD) may conceal the severity of the condition, which affects between 8.1% and 27.8% of North Americans. While drugs such as antacids, proton pump inhibitors, and H2 antagonists may offer some relief from stomach pain, heartburn, and reflux, research indicates that these interventions do less to address another group of GERD-related complications.
Chronic GERD symptoms have been shown to affect mental health, well-being, and health-related quality of life. GERD can even diminish a person’s ability to function and work. Effective disease management requires clinicians to also take these impacts into account.
Understanding the connection
The brain and gastrointestinal tract are closely related. Stress and emotions can affect GI function, and the state of GI organs can affect mood. Psychological factors could mediate the severity of functional gastrointestinal disease by changing pain perception via the gut-brain axis. The combination of psychological factors and GERD makes for challenging management, with poorer outcomes, according to the authors of a study published in the Journal of Neurogastroenterology and Motility.
In animal models, psychological stress has been shown to disrupt the tight junctions of the esophageal epithelium, impairing barrier function of the esophageal mucosa and increasing the chance of reflux.
Hypochondriasis can result from anxiety and depression, which decreases the threshold for influx perception and increases the sensation of reflux symptoms compared with controls. The authors of the study cited research demonstrating that although anxiety and depression did not affect acid exposure time and number of reflux episodes, reflux severity was significantly correlated with anxiety levels in GERD patients. Conversely, reflux symptoms may cause distress and trigger anxiety and depression.
“The relationship between anxiety, depression, and GERD involves a complex interplay of various mechanisms, and a multidisciplinary approach is needed to understand this relationship,” the authors wrote.
Research on the relationship
In the aforementioned study, researchers examined the ties between anxiety and depression and erosive reflux disease (ERD), non-erosive reflux disease (NERD), asymptomatic erosive esophagitis (AEE), and controls in 19,099 participants. The volunteers underwent esophagogastroduodenoscopy (EGD) and completed symptom questionnaires.
The authors found that anxiety and depression were much higher in patients with ERD. This association was even more pronounced in those with NERD. No associations were observed in those with AEE.
In a cross-sectional 2019 study published in Cureus, Pakistani researchers assessed the prevalence of anxiety and depression in GERD patients with or without chest pain. In total, 112 of 258 volunteers complained of chest pain, with 41.4% of all patients exhibiting depression, 34.4% exhibiting anxiety, and 27.13% exhibiting depression and anxiety.
The researchers found that anxiety and depression were significantly more prevalent in patients with GERD. These numbers were even higher in those with chest pain. They recommended interventions to reduce stress and anxiety in GERD patients to cope with activities of daily living and improve quality of life.
As for why those patients with chest pain were particularly prone to experiencing mental health issues, the authors hypothesized that patients may perceive chest pain as a symptom of serious disease, which may contribute to psychological burden, manifesting as anxiety and depression.
The role of antidepressants
Authors of a 2018 study published in Medicine suggested that in addition to avoiding certain foods, changing diet, and taking antacids, H2 blockers, and PPIs, selective-serotonin reuptake inhibitors (SSRIs) may help with GERD. These agents may influence esophageal perception as well as treat depressive disorders.
Notably, due to their perceived analgesic properties, antidepressants are also prescribed in other GI disorders including functional dyspepsia and irritable bowel syndrome.
Authors of a 2020 article published in the Journal of Internal Medicine provided guidance on using antidepressants to treat GERD.
“Unless there are contraindications, starting with a low-dose tricyclic antidepressant at night before bed and building up the dose slowly is a reasonable course of action to minimize side effects and maximize tolerability in refractory GERD or functional heartburn. Efficacy may take weeks to appear in practice if it occurs at all. If an SSRI is to be prescribed, a full antidepressant dose is usually recommended even in the absence of clinical evidence of depression.”
Channa SM. Depression and Anxiety in Patients with Gastroesophageal Reflux Disorder With and Without Chest Pain. Cureus.
Choi JM. Association Between Anxiety and Depression and Gastroesophageal Reflux Disease: Results From a Large Cross-sectional Study. Journal of Neurogastroenterology and Motility.
Lee Ys. Comorbid risks of psychological disorders and gastroesophageal reflux disorder using the national health insurance service—National Sample Cohort. Medicine.
Talley NJ. Optimal management of severe symptomatic gastroesophageal reflux disease. Journal of Internal Medicine.