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Original Investigation
August 19, 2019

Association of Childhood-Onset Inflammatory Bowel Disease With Risk of Psychiatric Disorders and Suicide Attempt

Author Affiliations
  • 1Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
  • 2Department of Child Psychiatry, Medical University of Warsaw, Warsaw, Poland
  • 3Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
  • 4Sachs’ Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
  • 5Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
  • 6Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
  • 7Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  • 8School of Medical Sciences, Örebro University, Örebro, Sweden
  • 9Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
  • 10Lung and Allergy Unit, Astrid Lindgren Children’s Hospital, Stockholm, Sweden
  • 11Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
  • 12Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
  • 13Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
  • 14Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
JAMA Pediatr. 2019;173(10):969-978. doi:10.1001/jamapediatrics.2019.2662
Key Points

Questions  Are patients with childhood-onset inflammatory bowel disease at increased risk of psychiatric disorders and suicide attempt, and is familial confounding important in this association?

Findings  In this population-based cohort study, childhood-onset inflammatory bowel disease was associated with increased risk of any psychiatric disorder and suicide attempt, as well as several specific psychiatric disorders. The association was observed when patients with inflammatory bowel disease were compared with the general population and with siblings without inflammatory bowel disease.

Meaning  Long-term psychological support should be considered for patients with childhood-onset inflammatory bowel disease.


Importance  Inflammatory bowel disease (IBD) has been associated with psychiatric morbidity in adults, although previous studies have not accounted for familial confounding. In children, IBD has an even more severe course, but the association between childhood-onset IBD and psychiatric morbidity remains unclear.

Objective  To examine the risk of psychiatric morbidity in individuals with childhood-onset IBD, controlling for potential confounding shared between siblings.

Design, Setting, and Participants  A population-based cohort study was conducted using data from the Swedish national health care and population registers of all children younger than 18 years born from 1973 to 2013. The study included 6464 individuals with a diagnosis of childhood-onset IBD (3228 with ulcerative colitis, 2536 with Crohn disease, and 700 with IBD unclassified) who were compared with 323 200 matched reference individuals from the general population and 6999 siblings of patients with IBD. Cox proportional hazards regression was used to estimate hazard ratios (HRs) with 95% CIs. Statistical analysis was performed from January 1, 1973, to December 1, 2013.

Main Outcomes and Measures  The primary outcome was any psychiatric disorder and suicide attempt. Secondary outcomes were the following specific psychiatric disorders: psychotic, mood, anxiety, eating, personality, and behavioral disorders; substance misuse; attention-deficit/hyperactivity disorder; autism spectrum disorders; and intellectual disability.

Results  The study included 6464 individuals with a diagnosis of childhood-onset IBD (2831 girls and 3633 boys; mean [SD] age at diagnosis of IBD, 13 [4] years). During a median follow-up time of 9 years, 1117 individuals with IBD (17.3%) received a diagnosis of any psychiatric disorder (incidence rate, 17.1 per 1000 person-years), compared with 38 044 of 323 200 individuals (11.8%) in the general population (incidence rate, 11.2 per 1000 person-years), corresponding to an HR of 1.6 (95% CI, 1.5-1.7), equaling 1 extra case of any psychiatric disorder per 170 person-years. Inflammatory bowel disease was significantly associated with suicide attempt (HR, 1.4; 95% CI, 1.2-1.7) as well as mood disorders (HR, 1.6; 95% CI, 1.4-1.7), anxiety disorders (HR, 1.9; 95% CI, 1.7-2.0) eating disorders (HR, 1.6; 95% CI, 1.3-2.0), personality disorders (HR, 1.4; 95% CI, 1.1-1.8), attention-deficit/hyperactivity disorder (HR, 1.2; 95% CI, 1.1-1.4), and autism spectrum disorders (HR, 1.4; 95% CI, 1.1-1.7) Results were similar for boys and girls. Hazard ratios for any psychiatric disorder were highest in the first year of follow-up but remained statistically significant after more than 5 years. Psychiatric disorders were particularly common for patients with very early-onset IBD (<6 years) and for patients with a parental psychiatric history. Results were largely confirmed by sibling comparison, with similar estimates noted for any psychiatric disorder (HR, 1.6; 95% CI, 1.5-1.8) and suicide attempt (HR, 1.7; 95% CI, 1.2-2.3).

Conclusions and Relevance  Overall, childhood-onset IBD was associated with psychiatric morbidity, confirmed by between-sibling results. Particularly concerning is the increased risk of suicide attempt, suggesting that long-term psychological support be considered for patients with childhood-onset IBD.