Midwife, Community Mental Health student at An- Najah National University, Palestine
Published Date: 03/06/2021.
*Corresponding author: Manahel Saleh, Midwife, Community Mental Health student at An- Najah National University, Palestine
This study aimed to provide an overview of the established literature and studies on the relationship of celiac disease to mental health. Celiac disease is an immune disease in which people cannot eat gluten because it harms the small intestine, Celiac disease affects everyone differently. One person may experience physical symptoms such as diarrhea and abdominal pain, while another person may experience a mental health disorder as anxiety, depression or irritability.
Methods: PubMed, Science Direct, Google Scholar, CINAHL, Semantic Scholar, and Elsevier were used to search for articles.
Results and Conclusion: The study found is a significant association between celiac disease and psychological function. Anxiety, depression, eating disorder, and fatigue were common problems reported in celiac patients prior to diagnosis. We found that Celiac disease side effects can affect the brain in different ways, reducing the quality of life for people with celiac disease or even untreated or diagnosed. Persons with Celiac Disease should be subjected to psychological examination and evaluation, treatment of associated MHD and work to alleviate the psychosocial distress associated with GFD.
Keywords: Celiac disease, Eating disorders, Depression, Mental health, Gluten
Mental health is a state of well-being in which an individual can realize his or her own potential, cope with the normal stresses of life, work productively and make a contribution to the community. (Strengthening mental health promotion, Fact sheet No 220). Individuals with chronic diseases are at greater risk of physical and psychological difficulties that reduce their quality of life because of the discomfort they feel due to them restriction in managing symptoms resulting from their chronic disease . Celiac disease is a unique autoimmune disorder, formerly called celiac sprue, which is characterized by diarrhea, emaciation, aphthous stomatitis, malabsorption, and treatment for the disease is to follow a strict gluten-free diet. However, response to treatment is poor in up to 30% of patients, and failure to adhere to diet is the main cause of persistent or recurring symptoms .
In 20 years, the incidence of Celiac disease in children has increased 6.4- fold, indicating a true increase in the incidence of Celiac disease for children . The prevalence of celiac disease in the general population was 1٪  And 1 in 3 people still have undiagnosed celiac disease . Celiac disease is rare, but it occurs in adults. Therefore, patients with severe unexplained diarrhea and malabsorption should be tested and may cause patients to suffer from severe dehydration, renal impairment, electrolyte disturbances, and admission to hospital, intravenous fluid therapy, and nutrition. Nutritional support is often required in the short term, but most patients eventually respond to avoid gluten .
It has become known that there is a relationship between many mental disorders and gluten-related disorders and celiac disease, there is much evidence, which is not without contradictions . The quality of life of celiac patients in different areas of mental health is somewhat lower than that of healthy individuals in the general population. Following a strict gluten-free diet for life is the only safe and effective treatment available, but it results in a significant social and psychological burden such as depression and disordered eating . The mental health of Celiac disease patients and their families is affected, which causes many psychological problems such as anxiety, depression, and stress, which leads to a poor quality of life . If there are behavioral disorders and symptoms of depression, so celiac patients should take these symptoms into consideration and treat them quickly. A gluten-free diet can help improve symptoms of depression quickly .
One of the most common and frequent complaints in celiac patients is anxiety, depression and fatigue that contribute to poor quality of life. Aspects of these conditions may improve within a few months after starting a gluten-free diet and may not improve. Psychological symptoms affect the quality of life and adherence to the diet . On the other hand, it was found that people who suffer from celiac function are three times more likely to develop schizophrenia than the general population, although schizophrenia patients benefit from the gluten-free diet in reducing the symptoms of schizophrenia .
The literature review in this article was collected through searching electronic databases. The following electronic databases were searched: PubMed, Science Direct, Google Scholar, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Semantic Researcher, and Elsevier. Keywords included celiac disease, eating disorders, depression, mental health, and gluten. These words have also been used in Arabic searches to identify articles indexed in the An-Najah University Research Journal. The research included 20 articles. Eleven articles on celiac disease were discussed, including 5 articles on the mental health of celiac patients and their families, 6 articles on Depression and Anxiety is linked to Celiac Disease. For critical analysis of the pilot articles, the following aspects were considered: Study type, the survey tool used was the target, the sample, exclusion criteria, and the main results.
Exclusion criteria: Which is not in English or Arabic or duplicate or old articles.
Inclusion criteria: Articles about The Relation of Celiac Disease with Mental Health.
The mental health of celiac patients and their families
Byström and others in 2012 presented a crosssectional study with consecutive selection. A study aimed at examining how children and adolescents with celiac disease who followed a gluten-free diet assessed their health-related quality of life, and whether age and severity of disease initially affected the self-evaluation of children later in life. The study included 160 families who had a person with celiac disease, as it was found that parents rated their children's quality of life as lower than other children, but the result differed from the children's point of view as children who were diagnosed before the age of five years scored higher than children who were diagnosed after this age, and children who were diagnosed more than eight years ago, they scored higher than newly diagnosed children, and children who first showed classic symptoms of the disease scored higher than those who had atypical or no symptoms did not, and the age or gender of the patients did not affect the outcome .
Children who suffer from Celiac Disease and their families are common to have mental disorders, confirmed by the results reached by Coburn and others in 2020 through a study they conducted with 73 parents, mostly women of children with Celiac Disease between the ages of 3 and 18 years attending a clinic Multidisciplinary Celiac Disease Study data were collected and managed using REDCap tools to capture electronic data, mental and physical health history of children were taken, psychosocial experiences of children and parents, the result was 34% of children with celiac disease had a mental health disorder (MHD) such as anxiety disorders (16%) and attention deficit / hyperactivity disorder (ADHD; 16%). While the result of the parents was a quarter of parents having psychosocial distress for children present (28% - 39%). Almost half of them had parental stress (51%) and the financial burden (46%) associated with GFD. But MHD, stress, and financial burden did not differ over time since the celiac disease diagnosis, Children with MHD were more anxious, angry, general distress, and parental distress than those without MHD.
In another study Stojanović and others in 2019 presented to assess the level of health-related quality of life (QoL) and the presence of symptoms of anxiety and depression in Serbian children with celiac disease from the perspective of patients and their parents, the study included 116 children and adolescents between the ages of 5 and 18 years who were diagnosed with a CD and one parent for each child 76 % Of mothers and 24% of fathers The PedsQL questionnaire was filled out by the children and their parents, and there was no significant difference between the mean values of children and parents in the total PedsQL scores in addition to the individual measures (physical, emotional, social, school and psychosocial) and through the SCARED questionnaire. It indicated the presence of anxiety in 34.5% of children and 23.3% of parents. Using the MFQ questionnaire, which indicates depression, it was found that 32.8% of children had depression and 41.4% of parents .
Similarly, Celiac Disease patients at diagnosis and their parents suffer from psychological problems, including anxiety and depression, more than others, according to a Prospective study presented by Giannakopoulos and others in 2020 that aimed to estimate levels of mental health problems in children with celiac disease (CD) along with The mental health status of their parents, and to compare these levels with those in healthy controls and to check how these problems are affected by celiac disease. A gluten-free diet (GFD) and the study sample of three groups, the first group had 50 patients with CD at diagnosis before starting GFD (age 8.6 ± 3.7 years), and the second group had 39 patients with a CD on GFD for at least 12 months (age 10.4 ± 3.4 years) and the third group had 38 healthy controls (age 7.7 ± 3.8 years,), as well as their parents. One parent of each child completed the Child Behavior Checklist (CBCL) and Symptom Checklist 90 (SCL-90-R) to assess the child and parental mental health problems, respectively. At least 12 months after starting GFD for the first group, twenty patients were re-evaluated and the results were that the parents had mental health problems such as anxiety and depression compared to the parents of healthy controls (0.72 ± 0.49 versus 0.54 ± 0.58, P = 0.013). CD patients scores higher in CBCL are regarding absorption problems than healthy controls (55.7 ± 10.3 versus 47.9 ± 15.4, P = 0.007) .
In contrast, levels of depression and anxiety in children with celiac disease and their parents did not differ even after following a gluten-free diet, which was presented by Esenyel and others in a study that aimed to explore diet compliance and levels of depression and anxiety in children with celiac disease and their families after following a diet. The sample was 30 pediatric celiac patients, 17 children and 13 adolescents, 20 healthy controls, 11 children and 9 adolescents, which were studied as controls and the result was no significant difference in depression and anxiety among celiac patients in children who consumed a free diet of the gluten and health control group. Diet compliance was 73.3% in study participants. The anxiety levels of the parents of the CD patients were not statistically significantly different from those of the parents in the control group .
Depression and Anxiety are linked to Celiac Disease
Feelings of fatigue, feeling overwhelmed, chronic sadness, anxiety, insomnia, depression and even headaches are all too common among people with celiac disease. Arigo and others in 2012 conducted a study aimed at identifying psychological risks and comorbidities of women with celiac disease, who may be more at risk of psychological symptoms (such as depression, and disordered eating behaviors). The sample was 177 women from the United States, aged over 18 years, previously diagnosed with Celiac disease most of them Caucasian (98%), married (56%) Secondary education (75%); Average age the sample is 39.24 years old, The comprehensive web-based survey was used to assess dietary compliance, disease symptoms, psychological functioning, and disordered eating, More than one scale was used, namely Dietary Compliance Scale, Celiac Disease Symptom Questionnaire., Short-Form Health Survey, Perceived Stress Scale, Center for Disease Studies - Depression Scale and Eating Disorders Examination Questionnaire, The result was that most of the participants repeatedly stick to a glutenfree diet. And only 8% of the participants (n-14) from the current sample are not committed, despite the high compliance, but the participants asserted that the levels of symptoms of the disease are high and that there are concerns about body image (concern in particular about the shape of the person), and there are symptoms of disorders Psychological: 37% suffered from depression, 22% suffered from an eating disorder, and that level of physical and emotional health varied. But for many patients it suggests marked impairment in the areas of physical pain, vitality, and social function.
Patients with untreated celiac disease experience anxiety, depression, and fatigue are common complaints and this leads to poor quality of life. These conditions may improve within a few months after starting a gluten-free diet, but some patients suffer from significant mental illness despite the diet and psychological symptoms may affect the quality of life and adherence to the diet this is the result of a study presented by Zingone and others in 2015 which It was a literary review and aimed at reviewing the literature on the psychological morbidity of celiac disease and the search was on PubMed between the time period from 1900 until June 1, 2014, to study, research papers that talk about the psychological aspects of celiac disease and its relationship to quality of life, anxiety, depression and fatigue.
Similarly, the mental disorders experienced by celiac disease patients usually precede the diagnosis and treatment of celiac disease with a gluten-free diet. In a study presented by Pynnönen and others in 2004, where the study sample was 29 adolescents with celiac disease and 29 identical subjects, it was found that adolescent celiac disease had an increased prevalence of behavioral disorders Depressive and disruptive, especially in the pre-nutritional phase, where the prevalence of major depressive disorder was 31% and disruptive behavior disorders 28% .
Smith and Gerdes also conducted a 2011 study aimed at testing hypotheses regarding whether celiac disease in adults was reliably associated with anxiety and / or depression using a meta-analysis and used PubMed to search for reports on emotional disorders in adults with celiac disease and they read each report with relevance (n = 67). First, three criteria were applied to select appropriate criteria for meta-analysis. First, the study must have compared a group of adults with celiac disease with another group of healthy adults and adults with celiac disease or other medical disease. Second, the study must have presented the original findings, expressed in the form of dichotomous data and or continuous data, for anxiety and depression in the groups. Third: The study should have provided adequate data to estimate the effect size and confidence intervals. Eighteen studies of depression and eleven studies of anxiety in adults with celiac disease fulfilled the selection criteria, and the results of Meta-analyzes were that depression was significantly more common and more severe in adults with celiac disease than healthy adults. The data indicated that the gluten-free diet was in many cases. It was sometimes unable to relieve depression in adult celiac disease, while anxiety was not reliably different from healthy adults or adults with other physical illnesses ) Smith & Gerdes .
On the contrary, in 2010 Häuser and others conducted a study that proved that the level of anxiety among celiac disease patients is very high, unlike depression. A sample 441 was taken from German adult patients with CD on GFD. The majority of the sample was women, 78.5%. Potential demographic factors (age and sex) were tested. Social class, familial (and disease-related) status (latency to diagnosis, duration of GFD-free food, compliance with GFD, and thyroid disease) levels of anxiety, depression, potential anxiety or depressive disorder was assessed by the Anxiety and Depression Scale, and the outcome was anxiety predicted only by the female sex. It was at 84.8% of the total patients. Those who live alone are less likely to be anxious while depression was not significantly predicted by any of the medical and social-demographic variables tested .
On the other hand, in 2015, Simsek and others conducted a study aimed at investigating the level of depression and quality of life in children with celiac disease (CD) and examining the relationships between the level of depression and quality of life with adherence to a gluten free diet (GFD) 50 children were taken from child psychiatric clinics and systemic diseases. Digestive system for children at the Tigris University Hospital (Diyarbakir, Turkey) between the ages of 9 and 16 years, 25 children with celiac disease and 25 healthy children matched with age and gender and without chronic physical and psychological diseases. A form was used that contained information about social, demographic and clinical characteristics, and an inventory Child Depression (CDI), and the General-Purpose Children's Health-Related Quality of Life Questionnaire (Kid-KINDL). After giving recommendations for follow-up of GFD, patients with CD in the pediatric psychiatric clinic were re-evaluated using the same inventories after at least 6 months and the result of the study was that there were no statistically significant differences in depression scores between patients and control subjects (P> 0.05).). Total scores and scores for the Affective Well-Being Sub-Scale of the Children's Quality of Life Scale were significantly lower in patients with CD compared to the control group (P <0.05) And there was no significant improvement in depression scores or quality of life for the overall sub-sample of celiac patients, all of whom received Recommendation to follow GFD (P> 0.05). Significant reductions in depression scores were noted for celiac patients who were committed to GFD compared to non-compliant patients .
The following discussion will be divided into two thematic categories, discussing the relationship between celiac disease and the mental health of patients and their families, and the link between depression, anxiety, and celiac patients. The relationship between celiac disease and the mental health of patients and their families will be discussed. Through previous studies, there is a clear relationship between celiac disease and the mental health of patients with celiac disease and their families (Giannakopoulos et al., 2020) This is due to parental stress and financial burden. From the point of view of parents, the quality of life of their affected children is lower than that of other children. 34% of children with celiac disease had a mental health disorder and 39% of parents had psychosocial distress.
The mental health disorders experienced by people with Celiac disease are many, including anxiety, depression, attention deficit / hyperactivity disorder (ADHD), eating disorder, and stress and Prevalence of major depressive disorder, 31% and disruptive behavior disorder, 28% and It also causes a poor quality of life But children who were diagnosed before the age of 5 years, children who were diagnosed more than eight years ago, and children who had classic symptoms of the disease for the first time, had a better quality of life than others (Byström et al., 2012). The prevalence of anxiety among children with CD was 34.5% of their parents, 23.3% and the prevalence of depression, 32.8% of children and 41.4% of parents. Parents of celiac disease sufferers suffer from psychological problems such as anxiety and depression compared to the parents of others On the contrary, in another study, levels of depression and anxiety did not differ in children with celiac disease and their parents even after following a gluten-free diet.
The link between depression, anxiety, and celiac patients will be discussed
Anxiety and depression can be troublesome for any patient, but for those who suffer from celiac disease, it can be more upsetting. Untreated celiac disease patients experience anxiety, depression and fatigue are common complaints and this leads to poor quality of life. Depression was more common and more severe in adults with celiac disease than healthy adult. On the contrary, another study showed that the level of anxiety among celiac patients is very high, in contrast to depression. Psychiatric disorders experienced by celiac disease patients usually precede the diagnosis and treatment of celiac disease by following a gluten-free diet. Studies have shown that in 8% of patients, depression may be one of the main reasons why patients neglect their gluten-free diet, which only exacerbates their condition and worsens feelings of anxiety and depression. A gluten-free diet may be sufficient to relieve symptoms of depression in some patients. In fact, many studies have found no improvements after diagnosis and starting a gluten-free diet. Women with Celiac or their mothers had more anxiety and depression and on the contrary, another study showed that anxiety is more prevalent among women with Celiac Disease than depression.
A significant association between celiac disease and mental health was found. This disease not only affects the mental health of the patient, but also greatly affects their families. Anxiety, depression, eating disorder and fatigue were common problems that were reported in celiac patients before the diagnosis. The quality of life for people who suffer from celiac disease without treatment or even after diagnosis is poor. Women with celiac disease are more prone to anxiety and depression. For people with Celiac disease, a gluten-free diet can improve symptoms of depression and anxiety, but in some cases, it may make it worse.
People with celiac disease should undergo psychological examination and evaluation and treatment of mental health disorders that appear and work to reduce psychosocial distress, whether or not he is subject to a gluten-free diet.
This literature review is related to celiac disease and mental health. There are many studies about it around the world, but in Palestine there is a shortage of these studies. Moreover, the time granted for this study was very short.
Special thanks to Dr. Adnan Sarhan for his supervision of this work, which he did not hesitate to guide me, help me and enrich my research. Thanks, and appreciation to all colleagues for their continuous support.
There is no source of funding for this research.