Comprehensive disease control is a familiar phrase in inflammatory bowel disease (IBD) circles by now. Pairing standardized quality-of-life measures with symptom control and endoscopic healing brings the endpoint closer to what patients actually experience. What remains less familiar is the first step: asking patients what the disease is actually taking from them.

David T. Rubin, MD, argues the concept alone will not move outcomes without a method attached to it: specific screening questions, validated instruments, and a therapy choice tied to what the screen turns up. Without it, quality of life stays a talking point rather than a target.

Patients with IBD carry a significantly higher burden of anxiety and depression than the general population. In a 2026 Norwegian cohort, 37.4% of patients with Crohn's disease and 32.1% with ulcerative colitis screened positive for anxiety, compared with 17.5% among matched controls.¹ Despite this gap, the American Gastroenterological Association's recommendation of annual depression and anxiety screening for every adult with IBD is inconsistently followed in practice.²

Rubin is professor of medicine at the University of Chicago, director of the Inflammatory Bowel Disease Center, and chair of the International Organization for the Study of IBD (IOIBD). He built comprehensive disease control around three sequential tiers of remission: symptomatic relief, biological control of inflammation, and functional remission covering joint, mental, and sexual health. "If you don't ask, you won't know," Rubin said.

Below, Rubin walks through the specific questions and validated tools he uses to surface functional limitations patients rarely volunteer. He also explains why referral infrastructure and visit time work against routine screening, and how comorbid joint or skin disease guides his choice of therapy.

Q&A: IBD screening tools and biologic selection by comorbidity

HCPLive: Can you describe what comprehensive disease control means in inflammatory bowel disease?

Rubin: The topic is comprehensive disease control, sometimes called comprehensive disease management. It's the evolution of our attempt to provide improved quality of life for people living with Crohn's disease and ulcerative colitis.

It's based on the principle that ultimately, what we're trying to do for anybody suffering from anything, frankly, is improve their quality of life. As much as our many treatments for Crohn's and colitis have evolved and multiplied, they're focused on specific clinical trial endpoints centered on the bowel. But we recognize these conditions affect much more than the intestines. To take care of people properly, we need to think about the whole person.

The way I describe it is a more holistic approach to management. Thinking about the whole person means addressing coexisting extraintestinal manifestations, like joint pain or skin inflammation, but also going beyond that to what I've started calling atypical extraintestinal manifestations, or less traditional ones, like mental health disorders. People with inflammatory bowel disease have a higher prevalence of anxiety and depression than those without IBD. Sexual health is affected by bowel conditions, so is sleep quality. Ultimately, what we're trying to do is improve individuals' functioning and quality of life, what I usually describe as an unrestricted, high quality of life.

The way I break this down in my practice is by talking to my patients about three types of remission. This is a chronic inflammatory problem in which the immune system of their gut is trying to do its job when it's not really needed, meaning it's active when, as far as we can tell, there's no threat or infection, and it's chronic, meaning it's not shutting itself off.

So when we talk about remission, the first thing is turning off the inflammation so the patient feels perfect: no pain, no diarrhea, no bleeding, no urgency. Second, we want objective evidence that we're controlling the disease process. That means biological markers of inflammation are normalized, whether that's scopes, stool tests, or blood tests. In children, it's growth and development. Those markers show you've controlled the actual inflammation beyond symptoms. The reason you have to look at both is that 50% of people who feel well or feel better will still be inflamed, and if you're still inflamed despite feeling okay, you will relapse. There'll be progression of the disease to a complication, or there'll be a full relapse of clinical symptoms. So the way I say it to people is: I want you to feel perfect, but I want it to last forever, and that means we have to control the disease process.

The third type of remission I call functional remission. This is where we say no joint pain, no skin inflammation, no depression or anxiety, your sexual health is restored, and you're able to do everything else you want to do in life: have children, work, go to school, maintain your career, travel without worry. Functional remission is our ultimate goal, but you have to do them in order. You want the bowel symptoms to be better, you want to control the disease process, then you want to make sure you're addressing all these other problems.

So comprehensive disease control is a construct that looks at an endpoint that includes the usual clinical trial endpoints of patient-reported symptoms and disease control related to endoscopy or labs, but it adds a standardized version of quality of life. When you add IBD quality-of-life measures to symptoms and endoscopy or other biomarkers, that's what we're calling CDC.

When you raise the bar, you start to realize that even when you have people whose bowels are perfect, you're not improving their quality of life because you haven't addressed the other issues. It sounds obvious, but the reality is that until you start looking at it and combining it with these other measures, you're not going to get a full picture of what it takes to heal. Healing is different than just treating inflammation.

HCPLive: How are you individualizing treatment options, and are certain patients at higher risk or likely to need more time?

Rubin: Those are great questions, and really important ones. The answer is, first, that if you don't ask, you won't know, and it starts by making sure you're not losing sight of your ultimate goal: an improved quality of life. Sometimes both the patient and the clinician can become too focused on bowel symptoms, or bleeding, or anemia. The reality is you end up missing the main picture: the patient may be unable to leave the house, or their hands hurt so they can't type, which is part of their job. There are other pieces to this, so you have to start by knowing you need to ask.

There are different ways to do that. One question you can ask a patient is, "What does having this disease prevent you from doing that you would want to do?" Or, "What are you unable to eat that you would like to enjoy?" You start to learn about somebody's limitations from the disease so you can develop a treatment plan that addresses them.

The other part is incorporating standardized and validated screening tools. If you want to know if somebody is anxious or depressed, there are measures you can use in clinic: a generalized anxiety scoring system, or the health questionnaire called the PHQ-9, which detects depression. If you screen for it, you will find it, and I'd challenge my colleagues to consider doing this, not only because it's in the guidelines for management, but because they'll uncover that many of their patients screen positive even when they had no idea. I've had colleagues say, "I can tell when one of my patients is depressed." I'd challenge that. I think there are a lot of people who are depressed that you'd never be able to tell in a limited clinical encounter.

But the other reason people don't routinely ask is you also have to have a treatment option and the ability to provide care if you identify these issues. Where are you going to refer the patient if they have depression or anxiety? Very few centers like ours have a psychogastroenterologist to refer them to, so we need a system in our clinics if we're going to screen for it, so that we're able to refer people. Or asking about sexual health: we're not taught that in medical school, or we weren't when I was in training. So how do you ask about that?

Meanwhile, who has time? I don't mean that as though it's not important, so why make time? I mean in a busy clinical practice, when you have a 20-minute encounter if you're lucky, most people only get 15, and you're trying to figure out how to talk about a new therapy, the goals of management, when their scope is due, any pre-testing before a new treatment, what their insurance may or may not cover, how you'll follow up on lab results. How do you do all that, and by the way, tell me about your sex life, or fill out this survey and tell me if you're anxious or depressed?

There are some very big system issues preventing us from providing the care people need. Whether we measure it in clinical trials or in post-hoc analyses and call it CDC, the real issue isn't just that we're underestimating the prevalence of these other problems. The issue is we need a different care model to give clinicians the time and resources to manage these conditions properly.

Now, the last part of this is choosing therapies, and this factors into quality of life and a variety of other things. If a patient has inflammatory joint problems coexisting with their IBD, you'd want to choose a treatment likely to cover the joint inflammation too, which means leaning toward an anti-TNF or a JAK inhibitor. If they have coexisting skin problems, whether psoriasis, erythema nodosum, or pyoderma, you might lean toward an IL-23 inhibitor, which is effective for skin and bowel together. You can pick therapies based on knowing about some of these other challenges. A patient with IBD deserves care that tries to address these issues. The reason it's not routinely done, and the reason it's important for HCPLive to discuss and share, is it hasn't been incorporated into practice the way it should be.

Editor’s Note: Rubin reports relevant disclosures with AbbVie, Takeda, Pfizer, Janssen, Bristol Myers Squibb, and others.

References

1. Johansen I, Hagen MC, Løkkeberg ST, et al. Anxiety and depression in newly diagnosed patients with inflammatory bowel disease (the IBSEN III study) compared with the general population in Norway. J Crohns Colitis. 2026;20(3):jjag021. doi:10.1093/ecco-jcc/jjag021

2. Caldera F, Kane S, Hashash JG, et al. AGA Clinical Practice Update on Noncolorectal Cancer Screening and Vaccinations in Patients With Inflammatory Bowel Disease: Expert Review. Clin Gastroenterol Hepatol. 2025;23(5). doi:10.1016/j.cgh.2024.12.011