Risk factors associated with anxiety and depression in patients with inflammatory bowel disease identified using structural equation modeling

Abstract

BACKGROUND

Anxiety and depression are common among patients with inflammatory bowel disease (IBD), negatively affecting their quality of life and disease prognosis. Previous studies have mainly focused on univariate analyses, with limited exploration of complex factor interactions. This study hypothesizes that sleep quality and coping styles directly and indirectly influence IBD-related anxiety and depression through structural equation modeling (SEM).

AIM

To construct a structural equation model to examine how various factors influence anxiety and depression in patients with IBD.

METHODS

An observational study involving 247 patients with IBD was conducted at Changde Hospital, Xiangya School of Medicine, Central South University (The First People’s Hospital of Changde City) from March 2023 to December 2024. Data were collected using a general information questionnaire, the Hospital Anxiety and Depression Scale, the Medical Coping Modes Questionnaire (MCMQ), and the Pittsburgh Sleep Quality Index (PSQI). Spearman correlation was used to assess variable relationships, and SEM was applied to analyze factors influencing anxiety and depression.

RESULTS

PSQI score [11 (10-13)] and MCMQ score [44 (43-45)] were significantly correlated with Hospital Anxiety and Depression Scale score [15 (13-20), P < 0.001]. The SEM demonstrated a good model fit (χ²/df = 1.039, root mean square error of approximation = 0.013, comparative fit index = 0.999). PSQI had a direct positive effect on anxiety and depression (β = 3.223, P < 0.01) and an indirect effect mediated through MCMQ (β = 2.335, P < 0.01). MCMQ also had a direct positive effect (β = 1.859, P < 0.01).

CONCLUSION

Poor sleep and maladaptive coping contribute to anxiety and depression in patients with IBD. Targeted psychosocial interventions may improve mental health outcomes in this patient population.

Key Words: Inflammatory bowel disease; Anxiety; Depression; Structural equation modeling; Influencing factors; Medical coping modes

Core Tip: This study applies structural equation modeling to explore factors influencing anxiety and depression in patients with inflammatory bowel disease. It identifies sleep quality and coping modes as key factors influencing anxiety and depression in patients with inflammatory bowel disease. These findings highlight the need for tailored interventions like sleep hygiene education and cognitive-behavioral strategies, could significantly alleviate anxiety and depression, thereby improving overall mental health outcomes and quality of life in this patient population.

INTRODUCTION

Inflammatory bowel disease (IBD) represents a group of non-specific inflammatory disorders of the gastrointestinal tract, mainly comprising ulcerative colitis and Crohn’s disease. Over the past three decades, the number of IBD patients in China has increased by 911000; it is projected that by 2035 annual new cases will reach 41901 and deaths 6568; thus, the population health burden and societal medical pressure will continue to rise[1,2]. The course of IBD is recurrent and protracted; patients suffer multiple symptoms such as abdominal pain, fatigue, diarrhea, bloody stools and insomnia, and require long-term maintenance therapy. This not only imposes heavy economic costs but also causes combined physical and psychological distress[3,4]. In addition, IBD patients often experience common psychological burdens (e.g., anxiety and depression), impaired quality of life and reduced social functioning[3,5]. Studies have found that anxiety and depression are frequent comorbidities in IBD, with prevalence rates twice or higher than those in the general population[3]. A meta-analysis reported pooled prevalence rates of 32.1% for anxiety and 25.2% for depression in IBD patients[6]. However, the relationship between IBD and depression/anxiety is bidirectional: The mechanisms underlying anxiety and depression are associated with higher inflammatory levels, intestinal dysbiosis and altered brain signaling in IBD patients[3,7], while depression and anxiety can in turn exacerbate IBD symptoms and worsen disease activity[7]. Moreover, patients with poor sleep quality are more prone to fatigue, anxiety and depression, further aggravating symptoms and reducing their quality of life; sleep deprivation may also impair immune function and increase the risk of IBD relapse[8]. Therefore, early identification of such patients and timely provision of appropriate psycho-emotional interventions are of great importance for improving prognosis and quality of life in IBD.

At present, research on anxiety and depression in IBD has mostly focused on single-factor or simple multifactor analyses, lacking in-depth exploration of the complex inter-relationships among factors, and the correlations and pathways of influence remain unclear. Structural equation modeling (SEM), a powerful multivariate statistical method, can simultaneously examine direct and indirect relationships among multiple variables, analyze the effects of observed variables on latent variables, and explore causal links between latent variables, thus offering a robust tool for studying risk factors of anxiety and depression in IBD. Therefore, this study employs SEM to investigate the relevant influencing factors of anxiety and depression in IBD patients and clarify the pathways and magnitude of effect among variables, to provide evidence for clinical management and treatment of IBD.

MATERIALS AND METHODS

General information

A total of 23 variables were analyzed in this study. The sample size was calculated as 5 times to 10 times the number of variables, yielding a minimum requirement of 150 participants to 230 participants. Considering 20% of the invalid questionnaires, the final sample size was 247 cases. The study population comprised 247 patients with IBD who visited Changde Hospital, Xiangya School of Medicine, Central South University (The First People’s Hospital of Changde City) between March 2023 and December 2024.

Inclusion criteria: (1) Meeting diagnostic criteria for IBD; (2) Having at least a primary school education; and (3) Being capable of completing the questionnaire independently.

Exclusion criteria: (1) Presence of other psychiatric disorders (excluding anxiety or depression); (2) History of gastrointestinal surgery unrelated to IBD; (3) History of major organ dysfunction; and (4) Current pregnancy or breastfeeding.

Survey tools

General information of patients (13 items): Demographic and clinical data collected included sex, age, educational level, family income, marital status, parity/number of children, employment status, body-mass index, disease duration, disease classification, place of residence, type of medical insurance, and current use of biological agents.

Hospital Anxiety and Depression Scale: The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depressive symptoms experienced during the past month. The scale comprises two subscales - anxiety and depression - each containing seven items, giving a total of 14 items. Every item is scored on a 4-point scale (0 = not at all, 1 = sometimes, 2 = most of the time, 3 = almost all the time), yielding subscale scores ranging from 0 to 21. A score of ≥ 8 on either subscale indicates the presence of clinically significant anxiety or depression: 0-7 = normal range, 8-10 = mild anxiety/depression, 11-14 = moderate anxiety/depression, and 15-21 = severe anxiety/depression[9,10].

Medical Coping Modes Questionnaire: The Medical Coping Modes Questionnaire (MCMQ) evaluated patients’ coping strategies toward illness. It includes three dimensions, avoidance, resignation, and confrontation, across 20 items. Each item is rated on a 4-point scale (1 to 4), with higher scores representing healthier coping strategies[11].

Pittsburgh Sleep Quality Index: The Pittsburgh Sleep Quality Index (PSQI) evaluated sleep quality among patients with IBD over the past month. It contains 19 self-rated and 5 observer-rated items. The 19^th self-rated item and the 5 observer-rated items are excluded from scoring. The remaining 18 items are grouped into seven components, each scored 0 to 3, yielding a total score of 0-21. Higher scores indicate poorer sleep quality, with a total score > 7 suggestive of sleep disturbance[12].

Data collection methods

The survey was administered through an electronic questionnaire using a face-to-face interview approach. Participants who met the inclusion criteria were enrolled, excluding those with IBD who were not first-time admissions during the study period. All investigators received standardized training and obtained informed consent from each patient before participation, providing clear explanations of the study’s objectives and essential items. For patients with reading or comprehension difficulties, the investigators verbally clarified the questions and recorded their responses according to their selections. Investigators also monitored the process to ensure that all questionnaires were accurately completed and submitted.

SEM construction

SEM posits causal relationships among latent variables, which are reflected by a set of observed indicators. Drawing on the SEM framework, construction principles, and previous psychiatric research, the following theoretical assumptions were proposed regarding the relationships between PSQI, anxiety, depression, and the related mediating factors: (1) PSQI may directly affect anxiety and depression, and (2) PSQI may also indirectly affect anxiety and depression through coping styles.

Statistical analysis

Data analysis was conducted using SPSS version 26.0, GraphPad Prism version 8.0, and Amos version 26.0 software. Continuous variables are summarized as mean ± SD or as median (interquartile range), and group comparisons were performed using independent-samples t-tests or non-parametric tests. Categorical variables are expressed as n (%) and analyzed using χ² tests. Correlation analyses were performed using Pearson or Spearman methods according to data distribution. Linear regression identified anxiety and depression as dependent variables, with influencing factors as predictors. Following prior literature, SEM was constructed in Amos version 26.0 for model fitting, modification, and path analysis, with parameters estimated via maximum likelihood, and mediating effects assessed using bootstrap. Statistical significance was set at P < 0.05.

RESULTS

Clinical characteristics

Among the 247 patients with IBD, there were 122 males (49.4%) and 125 females (50.6%). Seventy-seven patients (31.2%) were aged over 18 years, and 84 had ulcerative colitis (34.0%). Additional demographic and clinical details are presented in Table 1.

Table 1 Clinical characteristics.

Variable	Classification	n	%
Age	≥ 18 years	77	31.2
	≥ 40 years	82	33.2
	≥ 60 years	88	35.6
Sex	Male	122	49.4
	Female	125	50.6
BMI (kg/m2)	< 18.5	12	83.4
	18.5-23.9	206	11.7
	≥ 24.0	29	4.9
Course	< 1 year	109	44.1
	≥ 1 year	138	55.9
Disease classification	Crohn’s disease	163	66.0
	Ulcerative colitis	84	34.0
Working condition	Employed	114	46.2
	Unemployed	133	53.8
Place of abode	Urban	173	70.0
	Rural	74	30.0
Standard of culture	≤ Junior high	72	29.2
	High school/vocational	85	34.4
	≥ College	90	36.4
Marital status	Unmarried	97	39.3
	Married	89	36.0
	Divorced/widowed	61	24.7
Average monthly household income	< 3000 yuan	119	48.2
	≥ 3000 yuan	128	51.8
Use of biological agents	Yes	185	74.9
	No	62	25.1
Disease stage	Remission	142	57.5
	Active	105	42.5
Medical insurance	Yes	178	72.1
	No	69	27.9

BMI: Body mass index.

Anxiety, depression, and scale scores of patients

The total PSQI, HADS, and MCMQ scores among participants were 11 (10-13), 15 (13-20), and 44 (43-45), respectively, as shown in Figure 1. Of the 247 patients with IBD, 108 (43.7%) exhibited anxiety and 107 (43.3%) exhibited depression.

Figure 1 Scale scores of anxieties, depression, coping styles, and sleep quality in patients with inflammatory bowel disease. The bar graph illustrates variations in emotional and behavioral responses, showing scores across different psychological scales, median (interquartile range). HADS: Hospital Anxiety and Depression Scale; MCMQ: Medical Coping Modes Questionnaire; PSQI: Pittsburgh Sleep Quality Index.

Univariate analysis of factors influencing anxiety and depression in patients with IBD

Anxiety and depression scores were compared across age groups, sex, employment statuses, per capita monthly family incomes, disease stages, and marital statuses. Statistically significant differences were observed (P < 0.05), as shown in Table 2.

Table 2 Univariate analysis of factors influencing anxiety and depression in patients, median (interquartile rage).

Variable	n	HADS score	t/F	P value
Age			40.605	< 0.001
≥ 18 years	77	22.00 (14.00-25.00)
≥ 40 years	82	17.00 (14.00-19.00)
≥ 60 years	88	14.00 (13.00-16.00)
Sex			62.748	< 0.001
Male	122	14.00 (12.75-16.00)
Female	125	19.00 (15.00-23.00)
BMI (kg/m2)			2.184	0.336
< 18.5	12	18.50 (14.00-22.00)
18.5-23.9	206	16.00 (13.00-20.00)
≥ 24.0	29	14.00 (13.00-18.50)
Course			1.066	0.302
< 1 year	109	15.00 (13.00-20.00)
≥ 1 year	138	16.00 (13.00-20.25)
Disease classification			1.345	0.246
Crohn’s disease	163	15.00 (14.00-21.00)
Ulcerative colitis	84	15.00 (13.00-19.75)
Working condition			183.325	< 0.001
Employed	114	13.00 (12.00-14.00)
Unemployed	133	20.00 (17.00-24.00)
Place of abode			0.089	0.766
Urban	173	16.00 (13.00-20.00)
Rural	74	15.00 (14.00-20.00)
Standard of culture			3.431	0.180
≤ Junior high	72	15.00 (13.00-21.00)
High school/vocational	85	16.00 (14.00-21.00)
≥ College	90	14.00 (13.00-18.00)
Marital status			93.130	< 0.001
Married	89	13.00 (12.00-14.00)
Unmarried	97	18.00 (15.00-20.00)
Divorced/widowed	61	23.00 (15.00-25.00)
Average monthly household income			138.564	< 0.001
< 3000 yuan	119	13.00 (12.00-18.00)
≥ 3000 yuan	128	19.00 (16.25-23.75)
Use of biological agents			0.245	0.620
Yes	185	15.00 (13.00-20.00)
No	62	16.00 (13.00-22.00)
Disease stage			144.762	< 0.001
Remission	142	14.00 (12.75-14.00)
Active	105	21.00 (18.00-24.50)
Medical insurance			0.000	0.990
Yes	178	15.00 (13.00-20.00)
No	69	15.00 (13.00-21.00)

BMI: Body mass index; HADS: Hospital Anxiety and Depression Scale.

Correlation analysis

Sleep quality, coping styles, and anxiety and depression scores among patients with IBD were significantly interrelated (P < 0.001), fulfilling the prerequisite for mediation effect testing, as shown in Figure 2.

Figure 2 Correlation heatmap showing associations among sleep quality, coping styles, and anxiety and depression scores in patients with inflammatory bowel disease. The color scale represents correlation coefficients (r) ranging from -1 to +1, with blue indicating positive and red indicating negative correlations. ^aP < 0.05; ^bP < 0.01; ^cP < 0.001. HADS: Hospital Anxiety and Depression Scale; MCMQ: Medical Coping Modes Questionnaire; PSQI: Pittsburgh Sleep Quality Index.

Multivariate linear hierarchical regression analysis of influencing factors

Using the HADS score in patients with IBD as the dependent variable and age, gender, employment status, per capita monthly family income, disease stage, marital status, PSQI score, and MCMQ score as independent variables (coding shown in Table 3), the model accounted for 86.1% of the variance (Table 4).

Table 3 Coding of variables.

Variable	Coding
HADS score	Original value input
Age	≥ 18 years = 2; ≥ 40 years = 1; ≥ 60 years = 0
Sex	Male = 0; female = 1
Working condition	Employed = 0; unemployed = 1
Average monthly household income	< 3000 yuan = 1; ≥ 3000 yuan = 0
Disease stage	Active = 1; remission = 0
Marital status	Married = 0; unmarried = 1; divorced/widowed = 2
PSQI score	Original value input
MCMQ score	Original value input

HADS: Hospital Anxiety and Depression Scale; PSQI: Pittsburgh Sleep Quality Index; MCMQ: Medical Coping Modes Questionnaire.

Table 4 Hierarchical regression analysis of influencing factors.

Variable	B	SE	β	t	P value	95%CI
Constant	-17.281	4.695		-3.68	< 0.001	-26.531 to -8.031
Age	1.072	0.155	0.183	6.908	< 0.001	0.766-1.378
Sex	0.750	0.261	0.079	2.877	0.004	0.237-1.264
Working condition	1.118	0.556	0.117	2.009	0.046	0.022-2.213
Marital status	0.715	0.192	0.116	3.718	< 0.001	0.336-1.094
Average monthly household income	0.907	0.446	0.095	2.034	0.043	0.029-1.786
Disease stage	1.147	0.397	0.119	2.887	0.004	0.364-1.929
PSQI score	1.141	0.101	0.537	11.34	< 0.001	0.943-1.339
MCMQ score	0.403	0.112	0.117	3.597	< 0.001	0.182-0.624

F = 191.02, P < 0.01, R² = 0.865, △R² = 0.861. PSQI: Pittsburgh sleep quality index; MCMQ: Medical coping modes questionnaire; CI: Confidence interval.

Construction of a structural equation model for factors influencing anxiety and depression in patients

The structural equation model was developed using AMOS 26.0, with anxiety and depression among patients as dependent variables. Control variables that were statistically significant in the hierarchical regression analysis, PSQI as the independent variable, and MCMQ as the mediating variable were included to establish the initial model. Parameters were estimated using the maximum likelihood method. Guided by prior literature and path P values, only statistically meaningful variables and paths were retained to generate the final optimal model (Figure 3). The model demonstrated excellent fit, with χ²/df = 1.039 (Table 5).

Figure 3 Structural equation model of factors influencing anxiety and depression in patients with inflammatory bowel disease. The model illustrates the relationships between sleep quality, coping styles, and psychological outcomes. Poor sleep quality is associated with higher levels of anxiety and depression both directly and indirectly through maladaptive coping strategies. Standardized path coefficients are shown on the arrows. HADS: Hospital Anxiety and Depression Scale; PSQI: Pittsburgh Sleep Quality Index; MCMQ: Medical Coping Modes Questionnaire.

Table 5 Model fit indices.

Index	Reference standard	Observed result	Accept
χ2/df	< 3.00	1.039	Yes
RESEA	< 0.08	0.013	Yes
GFI	> 0.90	0.978	Yes
AGFI	> 0.90	0.949	Yes
NFI	> 0.90	0.976	Yes
IFI	> 0.90	0.999	Yes
CFI	> 0.90	0.999	Yes

RESEA: Root mean square error of approximation; GFI: Goodness of fit index; AGFI: Adjusted goodness of fit index; NFI: Normed fit index; IFI: Incremental fit index; CFI: Comparative fit index.

Path analysis of structural equation model

The bootstrap method was applied to examine mediating effects. Results indicated that PSQI (β = 3.223, P < 0.01) and MCMQ scores (β = 1.859, P < 0.01) exerted direct positive effects on anxiety and depression, whereas MCMQ also demonstrated an indirect positive effect on anxiety and depression (β = 2.335, P < 0.01; Tables 6 and 7).

Table 6 Path analysis results of factors influencing anxiety and depression in patients with inflammatory bowel disease.

Influence path	Estimate	SE	t	P value
PSQI to MCMQ	3.223	0.807	3.993	< 0.001
PSQI to HADS	1.859	0.740	2.512	0.012
MCMQ to HADS	0.724	0.121	6.001	< 0.001
Avoidance to MCMQ	1.000
Yield to MCMQ	0.946	0.025	37.275	< 0.001
Confront to MCMQ	-1.563	0.029	-53.412	< 0.001
Anxiety to HADS	1.000
Depression to HADS	0.833	0.085	9.787	< 0.001
Subjective sleep quality to PSQI	0.592	0.115	5.141	< 0.001
Daytime dysfunction to PSQI	0.726	0.158	4.589	< 0.001
Sleep time to PSQI	0.603	0.159	3.797	< 0.001
Time before falling asleep to PSQI	0.294	0.099	2.975	0.003
Sleep efficiency to PSQI	0.472	0.107	4.428	< 0.001
Hypnotic drugs to PSQI	-0.057	0.032	-1.796	0.072
Dyssomnia to PSQI	1.000

PSQI: Pittsburgh Sleep Quality Index; MCMQ: Medical Coping Modes Questionnaire; HADS: Hospital Anxiety and Depression Scale.

Table 7 Path effects of variables on anxiety and depression in patients with inflammatory bowel disease.

Path	Direct effect (β)	Indirect effect (β)	Total effect (β)
PSQI to MCMQ	3.223	0.000	3.223
MCMQ to HADS	1.859	2.335	4.194
PSQI to HADS	0.724	0.000	0.724

PSQI: Pittsburgh Sleep Quality Index; MCMQ: Medical Coping Modes Questionnaire; HADS: Hospital Anxiety and Depression Scale.

DISCUSSION

Compared with the general population, patients with IBD are more prone to developing negative emotional states such as anxiety and depression because of the chronic nature of the disease, which involves persistent symptoms including abdominal pain, diarrhea, and fatigue. These symptoms substantially impair quality of life[13,14]. In addition, psychological stressors can influence the brain through mechanisms involving the brain-gut-microbiota axis and the corticotropin-releasing factor system, thereby altering gut microbiota composition and precipitating gastrointestinal symptoms such as abdominal pain and diarrhea[15,16]. Consequently, early identification of risk factors and timely psychological assessment and intervention are essential for patients with IBD.

Age and gender as risk factors

Research has identified age as an independent predictor of anxiety and depression[17,18], consistent with the findings of this study. Younger individuals face a higher risk of IBD and are more likely to develop anxiety and depression, largely because of their involvement in crucial life stages such as education, career establishment, and family responsibilities, which often entail considerable financial strain. Moreover, younger patients may lack adequate understanding of IBD, making them more vulnerable to psychological distress. Conversely, older patients generally adapt more effectively to the disease, maintaining a healthier mindset and reducing the likelihood of adverse emotional reactions.

This study also confirmed that women are more susceptible to anxiety and depression than men, consistent with previous research[19]. Women tend to exhibit greater emotional reactivity and may experience heavier psychological burdens, resulting in more pessimistic outlooks when affected by IBD. Liu et al[20] reported that women demonstrated higher disease activity and more severe gastrointestinal symptoms than men, suggesting that differences in physical and psychological resilience contribute to heightened vulnerability. Possible mechanisms underlying this sex difference include hormonal regulation, immune modulation, gut microbiota diversity, and environmental influences[21]. Clinicians should therefore monitor the psychological well-being of female patients with IBD and provide timely education and supportive interventions.

Disease activity and psychological impact

Patients with IBD in the active disease phase exhibit a significantly higher prevalence of anxiety and depression than those in remission, and disease activity serves as an independent predictor of these psychological conditions, consistent with findings by Marrie et al[22]. The link between IBD activity and psychological disorders may reflect the bidirectional interactions of the brain-gut axis[23]. Inflammatory mediators originating in the gut can influence the central nervous system via complex neuroendocrine pathways, while psychological disorders can activate the hypothalamic-pituitary-adrenal axis, thereby worsening intestinal inflammation[24,25]. Continuous monitoring and timely intervention for anxiety and depression in active IBD are therefore crucial to reduce their adverse impact on disease progression.

Marital status and economic factors

Bisgaard et al[3] and Shah et al[26] reported that married patients with IBD benefit from ongoing emotional and practical support from their spouses, including daily care and companionship during treatment. Such support alleviates anxiety associated with the unpredictable course of IBD. Spousal involvement also promotes adherence to complex treatment regimens and dietary management, reducing relapse frequency and disease-related distress. Therefore, special attention should be given to unmarried patients with IBD by implementing targeted psychological interventions, such as disease education or peer-support programs, to enhance emotional resilience and reduce illness burden.

Regarding family income, this study found that lower monthly income was associated with a higher risk of anxiety, consistent with previous international research[27]. The chronic, relapsing nature of IBD necessitates long-term care, which can impose substantial financial strain on low-income families, often leading to guilt and heightened anxiety among patients[28]. Furthermore, unemployed patients with IBD are more likely to experience anxiety and depression than employed individuals, and unemployment serves as an independent predictor of these outcomes. Song et al[19] emphasized that employment supports daily functioning and social engagement, which lowers depression risk. Therefore, clinicians should evaluate socioeconomic stressors and offer tailored psychological support for unemployed patients when appropriate.

SEM analysis

SEM is a robust analytical approach frequently applied in social and behavioral sciences to examine multiple latent constructs concurrently and clarify intervariable relationships. This study demonstrated that both PSQI and MCMQ scores exerted statistically significant effects on anxiety and depression among patients with IBD. Model fit indices, including the goodness-of-fit index, the adjusted goodness-of-fit index, the root mean square error of approximation, the incremental fit index, the comparative fit index, and the normed fit index, indicated excellent fit, supporting the reliability and validity of the proposed SEM model. Findings revealed that sleep quality and coping strategies significantly affected anxiety and depression, with coping strategies showing a greater total influence than sleep quality.

Previous studies have shown that sleep disturbances not only exacerbate fatigue in patients with IBD but also elevate levels of pro-inflammatory cytokines and inflammatory markers, thereby increasing disease activity[29]. This underscores the need for clinicians to carefully monitor sleep quality in patients with IBD. According to Robbins’ stress theory, patients with IBD frequently experience prolonged sleep onset and reduced sleep efficiency because of recurrent diarrhea and repeated hospitalizations. These sleep difficulties, if unaddressed, can precipitate anxiety and depression. Evidence suggests that cultivating positive psychological traits such as resilience and post-traumatic growth enables patients with IBD to accept their illness, strengthen self-management, and enhance quality of life[30]. Consequently, clinicians may implement positive psychological interventions, including mindfulness therapy, positive cognitive-behavioral therapy, and expressive writing focused on positive emotion, to reduce distress and foster adaptive emotional states, thereby improving overall well-being. Nevertheless, research on these interventions remains limited, and standardized measures for assessing their effectiveness are lacking, warranting further investigation.

Limitations of the study

This study successfully identified several risk factors associated with anxiety and depression among patients with IBD, although certain limitations should be acknowledged. The sample was obtained from a single hospital, which may have restricted the representativeness of the findings. Patients from various regions may differ in living environments, dietary patterns, and healthcare accessibility, all of which can affect the development of anxiety and depression and their associated risk factors. For instance, individuals in economically developed regions often have greater access to psychological care and specialized mental health services, lowering their risk of emotional distress. Conversely, those in remote areas may face heightened vulnerability because of limited healthcare resources and insufficient disease awareness. Future research should therefore include larger, multicenter samples to improve the external validity and generalizability of the results.

CONCLUSION

This study identified both direct and indirect determinants of anxiety and depression among patients with IBD, offering a theoretical foundation for clinicians to design targeted intervention strategies. Although the examined variables contribute to the onset of anxiety and depression, additional psychosocial factors, such as perceived social support, stress, and loneliness, may also influence these outcomes. Therefore, future research should investigate these relationships from multidimensional perspectives to establish a more comprehensive scientific framework for the prevention and management of depressive and anxiety symptoms in patients with IBD.