The objective of the review was to describe and to explore the level of implementation of recommendations related to the psychological management of patients with SpA and IBD in routine clinical practice. We designed various search strategies in PubMed using the Clinical Queries function that combines Medical Subject Headings (MeSH) and free-text terms. Terms used included “spondyloarthritis”, “inflammatory boweldisease”, “psychological” and “emotional”.

The following eligibility criteria were applied: (1) Regarding the population, we included studies of adult patients (>18 years old) with SpA and IBD (according to international criteria), regardless of disease duration, severity or pharmacological treatment; (2) The interventions were required to involve either previously published or new recommendations on the psychological management of these patients; (3) No restrictions were set concerning the comparator (not even requiring there to be one); (4) As outcome measures, any related to the development and/or level of implementation of recommendations were allowed, including the evaluation of the efficacy of the implementation (early detection of depression, patient satisfaction, etc.). Regarding the type of study, we included meta-analyses, systematic literature reviews, clinical trials, and observational and qualitative studies, but excluded animal studies and basic research.

All the records retrieved using the search strategy were entered into Endnote® reference Management software. First, duplicates were removed. After this, two reviewers (EL and TO) screened the references independently and in duplicate and subsequently analysed the articles included in detail. The search results were first screened by title and abstract or by full text reading, if there was no abstract, in sessions lasting no longer than 60min. After this process, the articles selected were analysed in detail (full text reading).

The two reviewers independently and in duplicate collected data from the studies included using forms developed for the purposes of this review. The 2011 Oxford Centre for Evidence-Based Medicine Levels of Evidence were used to assess the methodological quality of the studies included.26 A qualitative descriptive analysis was performed.

The aim of the survey was to analyse current level of knowledge and implementation of the recommendations regarding the psychological management of patients with SpA or IBD and related documents that were found in the literature review.21–24 We followed general recommendations for the development of surveys,27 and used a web-based tool (SurveyMonkey©), that generated structured and closed questions (a total of 30). In a first step, based on the published documents,21–24 we identified the recommendations and developers comments suggesting further difficulties regarding their implementation. Therefore, we also evaluated barriers and facilitators to the implementation of the recommendations. Then, taking into account care decentralisation in our country, it was decided to collect data connected to participants regional and hospital characteristics background. Questions were direct and short. Depending on the objective, closed-ended questions included one choice, multiple choice, checkboxes, and ranking questions. The survey as organised in 4 sections that included several questions to collect the following variables: (1) sociodemographic data like age, sex, region of residence, type of hospital (primary, secondary or tertiary level, private clinic or other), years worked, and whether working in an SpA specialised clinic or as part of a multidisciplinary team; (2) assessment of patients’ emotional/psychological status including frequency, impact, person(s) responsible, methods, relationship with SpA, IBD or both, use of effective communication models, motivational interview, and the evaluation of patients’ environment; (3) variables concerning the management and prevention of emotional/psychological problems, such as whether achieving a euthymic state is a treatment goal, shared decision making, allowance of time in appointments for informing patients, people responsible for managing psychological disorders, other related recommendations, and the existence of protocols for referral to mental health professionals; and (4) barriers and facilitators to the implementation of recommendations.21,22 A pilot study was carried out. Two rheumatologists outside the study completed the survey and provided comments. There was no formal validation of the survey.

Given the characteristics of the survey and its objectives, we used a convenience sampling based on a list of members of the Spondylarthritis Research Group of the Spanish Society of Rheumatology (GRESSER), inviting each of them to complete the questionnaire by email. GRESSER includes an extensive group of health professionals with interest in SpA from all around the country. Some of the members are well-recognized experts on the disease (including rheumatologists but also other specialists like gastroenterologist and health professionals as nurses) but in GRESSER there are also many clinicians and health professionals that are not considered experts or researchers. The survey front page included information about the survey, describing the objectives of the project and asking for their voluntary participation. By reading and responding, the health professionals gave their consent. The survey was run between 30 October and 17 November 2021.

Data were downloaded from SurveyMonkey© in Excel format. Data analysis was performed using Stata 12© statistical package (Stata Corporation, College Station, TX, USA). A descriptive analysis of the data was carried out. Quantitative variables were described using means (standard deviations) and qualitative variables using frequencies (percentages).

We stablished a multidisciplinary group of 9 expert rheumatologists and gastroenterologists. The criteria for the selection were: (1) clinical experience ≥8 years and/or ≥35 publications on SpA or IBD in the last 5 years; (2) work in a SpA/IBD unit or multidisciplinary team; and (3) members of National and International Societies and related working groups. First, the results of the narrative review were presented by the project methodologists in a nominal group meeting. Then the experts analysed and discussed all of this information. Afterwards, the methodologists opened a discussion about the characteristics of the provision of clinical care across the country. One of the methodologists assured participation of all of the experts during the meeting. If necessary direct questions were performed. Following the experts, guided by the methodologists, and based on the previous discussions formulated the strategies and actions to improve the psychological management of patients with SpA and IBD. There was no limit to the number or type of strategies. Each strategy was closed only once all of the experts verbally agreed with the message and wording. Thus, we did not performed a Delphi process.

Our search identified 27 records. After removing 5 duplicates, the remaining articles were read in detail. Finally, we included 4, all of which were high quality consensus reports or similar types of document; 3 focused on IBD and the other on rheumatic diseases.21–24 Two of these documents contained recommendations focused on the psychological management of patients, while in the other two, the recommendations concerned patients’ preferences and improving treatment adherence. None of the documents analysed the level of implementation of the recommendations made. The main conclusions are summarised in Table 1 (see Tables 1 and 4 in the Supplementary Material for further information).

In general, the recommendations address the detection/identification, management (including referral to mental health specialists) and prevention of psychological problems in this group of patients. They also indicate the need to take special care in certain circumstances such as the diagnosis, during disease flares, and when a patient is admitted to hospital.21–24

Regarding what is to be identified, considering prevalence rates, impact and tools to assess their presence, the authors of the documents recommend the screening for depression, anxiety, and specifically, sexual problems.21–24 If such psychological problems are identified, their impact on individual patients should also be evaluated.21−24 In order to analyse psychological needs, the recommended approach is to use a clinical interview and questionnaires such as the Hospital Anxiety and Depression Scale (HADS) for depression.21,22 In this context, it is also recommended to examine patients’ family, social and work environments.

The included documents place particular importance on the information given to patients,21–24 more specifically, the type of information that should be given at each moment and how. The more this information and communication is tailored to patients’ characteristics and preferences, the less psychological impact and the more improvement on treatment adherence.23,24

On the other hand, in general, all the documents mention the use of effective models of communication (active listening, use of open questions) and motivational interviews to contribute positively not only to identify and manage psychological problems but also to prevent them.21–24 It is also highlighted that all of this is responsibility of all health professionals involved in the management of patients with SpA and IBD,21–24 but also that the specific management of psychological and psychiatric problems should be undertaken by mental health professionals, and for this reason, various referral criteria have been proposed. Some of the authors recommend as well to analyse the needs and psychological well-being of patients’ relatives, given that family members’ problems might be a source of stress for the patient and they might also need psychological support.22

Some of the documents identify barriers and facilitators to the implementation of the recommendations. One of the included articles showed certain barriers to the incorporation of patients’ preferences into routine clinical practice.24 In relation to clinicians, the lack of empathy and/or knowledge of the psychological and affective needs of patients were considered major barriers, and concerning the health system, the limited human resources, short appointment times, especially in primary care, and the variability in the access to services between regions, and even among hospitals within the same region, were identified as barriers to the incorporation of patients’ preferences.24 In this document, the panel highlighted that both nurses and primary care physicians could play a key role as facilitators in this context, the same as training clinicians in motivational interviewing and the development of specific protocols that integrate patients’ preferences into the decision making.

A total of 35 surveys were completed corresponding to health professionals from most of the country regions. The main results are summarised in Table 2 (see Tables 5 to 30 in the supplementary material for more information).

More than 90% of participants were not aware of the published recommendations on the psychological management of SpA and IBD. Further, despite recognising the relevance of patients’ psychological wellbeing (considered as a treatment goal), the emotional/psychological status of patients with these conditions is not routinely assessed in clinical practice. The same regarding the psychological needs of patient's family and environment. In line with this, the level of knowledge and comfort connected to the identification and management of psychological factors in patients with SpA and IBD was generally low. Lack of time, resources and recognition of psychological problems are considered the main barriers to the proper identification and management of psychological problems in this population.

The aspects of emotional well-being/psychological health most commonly assessed in daily practice were patients’ mood, work environment, daily activities and sleep quality. Others such as anger, frustration and sexual problems were rarely evaluated. If an emotional/psychological is detected, nearly a third (30%) of participants did not evaluate its impact on patients, and around three-quarters (76%) lacked a protocol for referring patients with psychological problems to a mental health professional. We also found that most of participants do not use effective communication models, motivational interviews or related tools.

Table 3 summarises the strategies and other actions proposed to improve the recommendations on the identification and management of psychological problems in patients with SpA and IBD. The panel of experts recognises a lack of knowledge and implementation of the recommendations published on the psychological management of patients with SpA and IBD, even in highly specialised units, and despite emotional/psychological problems are considered very relevant by clinicians.

For this reason, and as a first step, the panel considered it essential to include mental health as part of the knowledge and skills of medical specialists involved in the management of these patients. They should acquire, since the medical training, relevant general knowledge; and more specifically, social and communication skills including how to conduct motivational interviews and their use in routine clinical practice. Although no studies have yet demonstrated their efficacy, the panel stated that their use might save time in the mid- to long term. All this could be accomplished through courses, workshops, masters’ programmes, etc.

For routine clinical practice, as well as what has been mentioned above, the panel proposed the generation and addition of specific questionnaires, questions or other resources related to the psychological status and needs of patients (simple, implementable). For example the HADS to suspect depression or the ASAS Health Index (ASAS-HI). On the other hand, the recruitment of clinical psychologists is currently very complicated due to lack of resources, but it might be possible to find ways to collaborate directly with psychologists through universities, masters’ courses, etc. Along with this, the panel consider it very important to establish clear referral pathways for patients in whom psychological problems are detected and who, according to established criteria, require specialised mental health care.

From a more institutional perspective, and in close collaboration with scientific societies, working groups and patients’ associations, a series of activities are proposed including the development of overall management guidelines for psychological problems, courses, and specific sessions in national scientific meetings and conferences.