Application of the common sense model in inflammatory bowel disease: A systematic review

Highlights

• First systematic review of the Common Sense Model in Inflammatory Bowel Disease.

• The Common Sense Model is adaptive and valuable to explore psychosocial processes.

• Psychosocial processes mediate the impact of disease severity on patient outcomes.

• Illness perceptions and coping influence psychological distress and quality of life.

• Interventions should utilise the Common Sense Model to improve outcomes.

Abstract

Background and aims

The aim of this paper was to undertake a systematic review of the research utilizing the Common Sense Model (CSM) involving IBD cohorts to explain the psychosocial processes, including illness perceptions and coping styles, that underpin patient reported outcomes (PROs) - psychological distress (PD) and quality of life (QoL).

Methods

Adult studies were identified through systematic searches of 8 bibliographic databases run in August 2020 including Medline, Embase, and PsychINFO. No language or year limits were applied.

Results

Of 848 records identified, 516 were selected with seven studies evaluating the CSM mediating pathways for final review (n = 918 adult participants). Consistent with the CSM, illness perceptions were associated with PD and QoL in six and five studies respectively. Illness perceptions acted as mediators, at least partially, on the relationship between IBD disease activity and PD and/or QoL in all seven studies. Coping styles, predominantly maladaptive-based coping styles, were found to act as mediators between illness perceptions and PD and/or QoL in five studies. Perceived stress was identified in one study as an additional psychosocial process that partially explained the positive influence of illness perceptions on PD, and a negative impact on QoL. Five studies were classified as high quality and two as moderate.

Conclusions

The CSM can be utilised in IBD cohorts to evaluate key psychosocial processes that influence PROs. Future research should explore additional psychosocial processes within the CSM and evaluate the efficacy of targeting CSM processes to promote psychological well-being and QoL in IBD cohorts.

Introduction

Inflammatory bowel disease (IBD) is a chronic, relapse-remitting condition involving inflammation of the gastrointestinal tract. Crohn's disease (CD) and ulcerative colitis (UC) are the two main subtypes, which are typified by symptoms including diarrhea, blood in stools, abdominal pain, malnutrition, anaemia, and arthralgia [1]. Globally, the prevalence of IBD is around 0.3%, and its incidence is increasing around the world [2]. As the costs for new treatment medications (e.g., biologics) escalate, and multifaceted models of care are increasingly required to manage the disease, the associated economic burden is also high [3].

The burden in terms of patient reported outcomes (PROs) such as psychological distress (PD; anxiety, and depression) and quality of life (QoL; self-reported well-being) is significant. In a recent systematic review, Mikocka-Walus, Knowles, Keefer and Graff [4] reported significantly higher rates of anxiety and depression for individuals with IBD compared to healthy controls (anxiety 19.1% vs 9.6%, depression 21.2% vs 13.4%). Further, anxiety and depression were found to be higher in individuals with active versus inactive disease (anxiety 66.4% vs 28.2%, depression 34.7% vs 19.9%) [4]. Sexual health, personal relationships and family functioning can be adversely affected as a result [5]. The symptoms (e.g., fatigue, pain) and unpredictable nature of IBD can also compromise work hours and career choices, therefore personal finances and security [6,7], and is understandably associated with poorer QoL [[8], [9], [10], [11]].

Given the impact of IBD on PROs, identification of targetable psychosocial processes (e.g., individuals' beliefs and behaviours) that either directly or indirectly influence these relationships is crucial to successful psychological intervention. To evaluate these relationships effectively, well-validated frameworks, such as the Common Sense Model (CSM), must be utilised. Developed by Leventhal and colleagues (1980), the CSM posits that the relationships between illness stimuli (e.g., IBD activity) and health outcomes (e.g., PD, QoL) are either directly and/or indirectly affected by (i.e., mediated; the influence or impact one factor has on the relationship between two or more other factors) psychosocial factors, including illness perceptions and coping styles. For example, when confronted with illness stimuli, an individual experiences concurrent cognitive and affective illness perceptions, such as beliefs about the cause of IBD and emotions relating to having the disease (see Table 1).

These illness perceptions influence PROs directly, and act also as mediators between illness stimuli and coping styles. Coping styles (see Table 1) in turn act as mediators between illness perceptions and health outcomes. Multiple feedback loops facilitate simultaneous processing of each key psychosocial component in sequence, enabling appraisal integration at each stage of the model, see Fig. 1.

The Common Sense Model (CSM) has been successfully applied across multiple chronic health-related conditions to explore the psychosocial processes underpinning PROs such as PD and QoL. Among the CSM investigations evaluating PD and/or QoL in chronic conditions, studies have examined diabetes, hepatitis, pain, heart disease, hypertension, arthritis, eating disorders, chronic fatigue, fibromyalgia, and gastrointestinal disorders (e.g., Irritable bowel syndrome, Coeliac disease) [17], which are often comorbid with IBD [[18], [19], [20], [21], [22], [23], [24]].

Despite the evidence supporting the efficacy of the CSM in chronic illness, particularly those comorbid with IBD [17], a systematic review of the application of this model in IBD cohorts has yet to be undertaken. Given this, a systematic review of the research that has applied the CSM in IBD cohorts was undertaken to explore three questions:

Question 1: What is the evidence for the role of illness perceptions as mediators on coping styles and as having a direct impact on PD and QoL?

Question 2: What is the evidence for the role of coping styles as mediators on PD and QoL?

Question 3: What additional psychosocial variables have been examined within the CSM framework and what has been found in relation to its role as a mediator upon outcomes PD and QoL?