Irritable Bowel Syndrome- Depression and Anxiety: Treatment Options

Irritable Bowel Syndrome, depression, and anxiety often occur simultaneously.

And it is unclear if this is a causal link or if each condition only serves to worsen the other. Given that these conditions do make the symptoms of each other worse it is important to know some treatment options to help feel better.

Irritable Bowel Syndrome may have predominant diarrhea or constipation, or a combination of symptoms. 

For either type of IBS if the symptoms are mild or intermittent and do not negatively impact the person’s quality of life, the first line treatment should be lifestyle and dietary modifications. Even if medication is needed these lifestyle and dietary modifications are an important part of the treatment plan.  

Trying a Low-FODMAP diet is recommended and sometimes lactose or gluten avoidance may also be tried to see if they are of benefit to rule out additional intolerances. A traditional IBS diet includes regular meal patterns, avoiding large meals, and reducing consumption of fat, insoluble fibers, caffeine, and gas producing foods. Followers of both a Low-FODMAP and a traditional IBS diet have shown to receive benefits in studies (Gastroenterology, 2015). 

For individuals with IBS-C, slowly adding a fiber supplement to their daily diet has been shown to have a benefit. Studies have also shown that regular physical exercise, three to five days per week of moderate to vigorous exercise for 20-60 minutes decreases IBS symptoms. 

If lifestyle and dietary interventions are not enough then medications are added to the treatment plan. The medications used are determined by the primary symptoms of IBS, diarrhea, constipation, or mixed. 

For IBS–C some medications that are used include:

Polyethylene glycol (MiraLax) – an “osmotic laxative” meaning it adds water to the stool in the intestines, gentler with fewer side effects than some other osmotic laxatives but can cause bloating and abdominal discomfort.

Lubiprostone (Amitiza) – increases intestinal fluid secretion.

Linaclotide (Linzess) and Placanatide (Trulance) – work similarly to each other by stimulating intestinal fluid secretion and movement of solids through intestines.

Tegaserod (Zelnorm)– stimulate the release of neurotransmitters and increase movement in the colon, has been shown to reduce abdominal pain as well as improve constipation (also an option for IBS mixed).

For IBS–D some medications that are used include:

Loperamide (Imodium) – an anti-diarrheal, decreases and slows movement of food through intestinal tract.

Eluxadoline (Viberzi) – combines opioid receptor agonists, slowing intestinal movements contraindicated in patients who have had their gallbladder removed.

Cholestyramine (Questran) colestipol (Colestid) colesevelam (Welchol) – all work similarly as “bile acid sequestrants”, because up to 50% of patients with IBS-D have bile acid malabsorption. Bile acids stimulate secretions in the colon and movement thus causing diarrhea.

Alosetron (Lotronex) – only for women, controls sensory nerve fiber activity in the gastrointestinal tract and can decrease movement and secretions in the colon as well as improving abdominal pain. Significant potential side effects and is not a first line treatment.

Dicyclomine (Bentyl) hyoscyamine (Levbid) – antispasmodics are usually used on an as needed basis, e.g. before meals, or during stressful activities to decrease symptoms. They have different mechanisms of action but ultimately the goal is to increase intestinal smooth muscle relaxation.

Mental Health medications have many options.  

Treatment of depression and anxiety is individualized depending on the symptoms a person is experiencing. There is one class of antidepressants called “tricyclic antidepressants” which have been studied and show benefit for the abdominal pain and GI symptoms of IBS. These medications include amitriptyline (Elavil), and nortriptyline (Pamelor).

With IBS, depression, and anxiety- a person’s quality of life can seriously be affected. It is important that all symptoms, not just GI symptoms, affecting them are discussed with their medical provider(s) so an appropriate plan of care can be developed for maximum benefit.