Reviewer's report 
 "It doesn't do any harm, but patients feel better": a qualitative exploratory study on Title: 
gastroenterologists' perspectives on the role of antidepressants in inflammatory bowel disease 
 1  14 June 2007 Version: Date: 
 roger jones Reviewer: 
Reviewer's report: 
General 
This exploratory, qualitative research study examines the views held by gastroenterologists about the role of psychological disorders and their treatment, including the use of anti-depressants, in patients with inflammatory bowel disease (IBD). This is an important area, and the conclusion that most of the 
gastroenterologists surveyed in this study support more formal trials aimed at delineating the central role of 
anti-depressants paves the way for further research, which is likely to be valuable. 
The ‘theoretical framework’ in which this study was set up and has been analysed is a little confusing. It 
might have been helpful to think of IBD as just one of the many chronic diseases in which psychiatric 
co-morbidity, generally depression, frequently occurs. These conditions include coronary heart disease, stroke, renal failure and others. It is conceivable that in at least some of these patients the ‘dual diagnoses’ are aetiologically distinct, and that each requires treatment on its own merits. Accurate diagnosis of 
depression, using formal diagnostic criteria becomes important, because of the likely need for either 
effective drug therapy at a proper therapeutic dose or a combination of drug therapy with ‘talk therapy’ such 
as CBT or psychotherapy. 
This study is, however, more focused on a poorly understood interplay between psychological state and 
‘physical’ illness, with the possibilities of causation running in both directions, so that troublesome disease can lead to psychiatric disorder and, reciprocally, psychiatric disorder can be related to increased disease activity. As the authors point out, the data to pin these relationships down, in either direction, are few and 
far between. Nonetheless the clinical observation that anti-depressants are sometimes helpful in IBD 
patients has been made by most of the respondents. 
The further complexity, of course, is that patients with IBD also have IBS-like symptoms, and there is 
somewhat better randomised controlled trial evidence of the efficacy of anti-depressant agents, generally 
given at low doseage, which would be regarded as sub-therapeutic by psychiatrists, having a positive effect 
on symptoms and well being in IBS. These IBS/IBD patients probably represent a sub group of the IBD 
population, in which anti-depressant therapy might have a different therapeutic action. 
1. In terms of methodology the sample size is adequate, and saturation was achieved. The median duration 
of interviews of 10 minutes made me wonder how thorough some of these interviews were, and whether 
further information could have been gleaned by further questioning. The description of the qualitative 
content analysis is satisfactory. 
2. The results are clearly presented, and the authors have done a good job in identifying the main themes 
emerging from the interviews. It was, however, disappointing that doseage as well as type of 
anti-depressant had not been identified, and, from a UK perspective at least, it was surprising that many of 
the respondents seemed not to be familiar with agents such as paroxetine. Overall, the results are well presented with one or two telling quotations from respondents. 
3. In terms of further research and the design of further trials the authors have certainly prepared the 
ground for a study in which anti-depressant therapy could be seen as an adjunct to ‘treatment as usual’ in IBD patients, and in any such trial formal measures of depression and anxiety, as well as health-related quality of life will be essential. Given the discussion above, about the IBS/IBD population, the ‘dual 
diagnosis’ population and the remainder, a fairly complex trial, with sub-group stratification and multiple 
arms is likely to be required, which could prove logistically challenging if more than one dose of anti-depressant was also investigated. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be 
reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No, the manuscript does not need to be seen by a statistician. Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
Reviewer's report 
 "It doesn't do any harm, but patients feel better": a qualitative exploratory study on Title: 
gastroenterologists' perspectives on the role of antidepressants in inflammatory bowel disease 
 1  14 June 2007 Version: Date: 
 roger jones Reviewer: 
Reviewer's report: 
General 
This exploratory, qualitative research study examines the views held by gastroenterologists about the role of psychological disorders and their treatment, including the use of anti-depressants, in patients with inflammatory bowel disease (IBD). This is an important area, and the conclusion that most of the 
gastroenterologists surveyed in this study support more formal trials aimed at delineating the central role of 
anti-depressants paves the way for further research, which is likely to be valuable. 
The ‘theoretical framework’ in which this study was set up and has been analysed is a little confusing. It 
might have been helpful to think of IBD as just one of the many chronic diseases in which psychiatric 
co-morbidity, generally depression, frequently occurs. These conditions include coronary heart disease, stroke, renal failure and others. It is conceivable that in at least some of these patients the ‘dual diagnoses’ are aetiologically distinct, and that each requires treatment on its own merits. Accurate diagnosis of 
depression, using formal diagnostic criteria becomes important, because of the likely need for either 
effective drug therapy at a proper therapeutic dose or a combination of drug therapy with ‘talk therapy’ such 
as CBT or psychotherapy. 
This study is, however, more focused on a poorly understood interplay between psychological state and 
‘physical’ illness, with the possibilities of causation running in both directions, so that troublesome disease can lead to psychiatric disorder and, reciprocally, psychiatric disorder can be related to increased disease activity. As the authors point out, the data to pin these relationships down, in either direction, are few and 
far between. Nonetheless the clinical observation that anti-depressants are sometimes helpful in IBD 
patients has been made by most of the respondents. 
The further complexity, of course, is that patients with IBD also have IBS-like symptoms, and there is 
somewhat better randomised controlled trial evidence of the efficacy of anti-depressant agents, generally 
given at low doseage, which would be regarded as sub-therapeutic by psychiatrists, having a positive effect 
on symptoms and well being in IBS. These IBS/IBD patients probably represent a sub group of the IBD 
population, in which anti-depressant therapy might have a different therapeutic action. 
1. In terms of methodology the sample size is adequate, and saturation was achieved. The median duration 
of interviews of 10 minutes made me wonder how thorough some of these interviews were, and whether 
further information could have been gleaned by further questioning. The description of the qualitative 
content analysis is satisfactory. 
2. The results are clearly presented, and the authors have done a good job in identifying the main themes 
emerging from the interviews. It was, however, disappointing that doseage as well as type of 
anti-depressant had not been identified, and, from a UK perspective at least, it was surprising that many of 
the respondents seemed not to be familiar with agents such as paroxetine. Overall, the results are well presented with one or two telling quotations from respondents. 
3. In terms of further research and the design of further trials the authors have certainly prepared the 
ground for a study in which anti-depressant therapy could be seen as an adjunct to ‘treatment as usual’ in IBD patients, and in any such trial formal measures of depression and anxiety, as well as health-related quality of life will be essential. Given the discussion above, about the IBS/IBD population, the ‘dual 
diagnosis’ population and the remainder, a fairly complex trial, with sub-group stratification and multiple 
arms is likely to be required, which could prove logistically challenging if more than one dose of anti-depressant was also investigated. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be 
reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No, the manuscript does not need to be seen by a statistician. Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
Please review this paper.
user
Reviewer's report 
 "It doesn't do any harm, but patients feel better": a qualitative exploratory study on Title: 
gastroenterologists' perspectives on the role of antidepressants in inflammatory bowel disease 
 1  14 June 2007 Version: Date: 
 roger jones Reviewer: 
Reviewer's report: 
General 
This exploratory, qualitative research study examines the views held by gastroenterologists about the role of psychological disorders and their treatment, including the use of anti-depressants, in patients with inflammatory bowel disease (IBD). This is an important area, and the conclusion that most of the 
gastroenterologists surveyed in this study support more formal trials aimed at delineating the central role of 
anti-depressants paves the way for further research, which is likely to be valuable. 
The ‘theoretical framework’ in which this study was set up and has been analysed is a little confusing. It 
might have been helpful to think of IBD as just one of the many chronic diseases in which psychiatric 
co-morbidity, generally depression, frequently occurs. These conditions include coronary heart disease, stroke, renal failure and others. It is conceivable that in at least some of these patients the ‘dual diagnoses’ are aetiologically distinct, and that each requires treatment on its own merits. Accurate diagnosis of 
depression, using formal diagnostic criteria becomes important, because of the likely need for either 
effective drug therapy at a proper therapeutic dose or a combination of drug therapy with ‘talk therapy’ such 
as CBT or psychotherapy. 
This study is, however, more focused on a poorly understood interplay between psychological state and 
‘physical’ illness, with the possibilities of causation running in both directions, so that troublesome disease can lead to psychiatric disorder and, reciprocally, psychiatric disorder can be related to increased disease activity. As the authors point out, the data to pin these relationships down, in either direction, are few and 
far between. Nonetheless the clinical observation that anti-depressants are sometimes helpful in IBD 
patients has been made by most of the respondents. 
The further complexity, of course, is that patients with IBD also have IBS-like symptoms, and there is 
somewhat better randomised controlled trial evidence of the efficacy of anti-depressant agents, generally 
given at low doseage, which would be regarded as sub-therapeutic by psychiatrists, having a positive effect 
on symptoms and well being in IBS. These IBS/IBD patients probably represent a sub group of the IBD 
population, in which anti-depressant therapy might have a different therapeutic action. 
1. In terms of methodology the sample size is adequate, and saturation was achieved. The median duration 
of interviews of 10 minutes made me wonder how thorough some of these interviews were, and whether 
further information could have been gleaned by further questioning. The description of the qualitative 
content analysis is satisfactory. 
2. The results are clearly presented, and the authors have done a good job in identifying the main themes 
emerging from the interviews. It was, however, disappointing that doseage as well as type of 
anti-depressant had not been identified, and, from a UK perspective at least, it was surprising that many of 
the respondents seemed not to be familiar with agents such as paroxetine. Overall, the results are well presented with one or two telling quotations from respondents. 
3. In terms of further research and the design of further trials the authors have certainly prepared the 
ground for a study in which anti-depressant therapy could be seen as an adjunct to ‘treatment as usual’ in IBD patients, and in any such trial formal measures of depression and anxiety, as well as health-related quality of life will be essential. Given the discussion above, about the IBS/IBD population, the ‘dual 
diagnosis’ population and the remainder, a fairly complex trial, with sub-group stratification and multiple 
arms is likely to be required, which could prove logistically challenging if more than one dose of anti-depressant was also investigated. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be 
reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No, the manuscript does not need to be seen by a statistician. Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests 
assistant