Stress & UC relapses

Stress & UC relapses

May 16, 2023

Issue 10

Clinical Question

Are ulcerative colitis patients with higher perceived stress at greater risk of active disease?

Editor’s Bottom Line

Perceived stress among patients with ulcerative colitis is associated with an increased rate of symptomatic relapse, but not with changes in objective measures of inflammation. Whether stress alone can truly reactivate inflammatory bowel disease remains to be proven.


Sauk JS, Ryu HJ, Labus JS, et al. High Perceived Stress is Associated with Increased Risk of Ulcerative Colitis Clinical Flares. Clin Gastroenterol Hepatol. 2023;21:741–49;


This prospective study enrolled 110 adults with ulcerative colitis (UC) treated at the University of California Los Angeles Center for Inflammatory Bowel Diseases between 2018 and 2020. The participants, who were a mean 37.5 years of age, were in clinical remission at the time of study enrollment. Clinical remission was defined as a Simple Colitis Clinical Activity Index (SCCAI) score <5.

During a mean follow-up of 65.6 weeks, patients underwent clinical and psychological assessments, provided stool, blood and saliva specimens, underwent cardiac testing and brain magnetic resonance imaging. Patients also completed several self-report psychosocial inventories during the study. The mean duration of disease was 11 years and most individuals were being treated with mesalamine, while 42.7% were receiving an immunosuppressant alone or in combination.

Results showed 63 patients had high levels of perceived stress and 47 had low levels of perceived stress. Higher perceived stress was related to early life adversity, poor sleep, cognitive function and resilience, and lower quality of life scores.

During the study period, 38.2% of patients experienced clinical relapse and 14.5% experienced biochemical relapse. Unadjusted analysis according to perceived stress showed 50.8% of those with high perceived stress had a clinical relapse during the study, compared to 21.3% of those with low perceived stress (p=0.003). There was no statistical difference in rates of biochemical relapse, defined as a rise in fecal calprotectin levels. 

Binary logistic regression analysis revealed a 3.6-fold higher risk of clinical relapse among those with high perceived stress at baseline, compared to those with lower levels (p=0.008). Removing patients with baseline high fecal calprotectin levels (>150 microgram/gram) from the analysis did not affect the correlation between perceived stress and clinical relapse.


Study Design: Prospective cohort

Funding: The Crohn’s and Colitis Foundation Environmental Triggers Research Initiative and the National Institutes of Health.

Allocation: Not applicable

Setting: Single-center

Level of Evidence: 1b