Cognitive Behavioral Therapy Associated with Irritable Bowel Syndrome Improvement

by | Sep 23, 2019 | 2019, Alternative Therapies, Digestive Health, Irritable Bowel Syndrome

Written by Angeline A. De Leon, Staff Writer. This study reinforces the National Institute for Health and Care Excellence guidance that patients with refractory irritable bowel syndrome (IBS) should be offered cognitive behavioral therapy (CBT) for IBS, which is currently not widely available and that both telephone therapist-delivered and web-based CBT for IBS can provide long-term benefits.

digestive health - IBSAt the global level, Irritable Bowel Syndrome (IBS) affects about 20% of the adult population 1. Involving not only uncomfortable physical symptoms such as abdominal pain and bloating, the disease also impacts social functioning and overall quality of life 2. While treatment options for refractory IBS (ongoing IBS after 12 months despite medication and lifestyle modifications) are limited, initial research from the National Institute for Health and Care Excellence (NICE) suggests that a particular type of psycho-social intervention, cognitive behavioral therapy (CBT), may be effective for IBS, at least in the short-term 3. Studies on CBT for IBS have typically been limited to a follow-up period of 6 months 3,4. A Cochrane review points out that the long-term sustainability of CBT treatment effects is less clear 5. The Assessing Cognitive Behavioral Therapy in IBS (ACTIB) trial, representing the largest randomized control trial of CBT for IBS worldwide, has shown that two modes of IBS-specific CBT (telephone-delivered CBT and web-based CBT) are associated with significant improvement in IBS symptom severity and quality of life in patients with refractory IBS at 12 months 6,7. In a follow-up to the ACTIB trial, a 2019 Lancet Gastroenterology Hepatology study 8 evaluated the longer-term clinical outcomes associated with IBS-specific CBT in adults with refractory IBS using a 24-month follow-up period.

A total of 558 adults with refractory IBS were recruited in a three-group, randomized, controlled trial in which they were randomly allocated to therapist-delivered telephone CBT with detailed self-management manual (telephone-CBT, involving six 1-hour telephone sessions with a trained therapist over the course of 9 weeks plus homework assignments), web-based CBT with minimal therapist support (web-CBT, including three 30-minute therapy-support phone calls over the course of 5 weeks), or treatment as usual (TAU, continuation of current medication). The core program of the two active treatment groups were similar, involving standard education regarding the gut-brain axis, stress management, and behavioral techniques to improve bowel habits. At baseline, Month 12, and Month 24, the IBS Symptom Severity Score (IBS-SSS) and Work and Social Adjustment Scale (WSAS, measuring impact of IBS on life) were administered. At 24 months, additional questionnaires evaluating mood (Hospital Anxiety and Depression Scale, HADS) and coping ability (Patient Enablement Questionnaire, PEQ) were issued.

Results show that at 24 months, IBS-SSS was lower in both groups, relative to TAU, the telephone-CBT group by 40.5 points (95% Confidence Interval: 15.0 to 66.0, p = 0.002) and the web-CBT group by 12.9 points (95% CI: -12.9 to 38.8, p = 0.33). From baseline to 24 months, 71% of patients in the telephone-CBT group and 63% of patients in the web-CBT group experienced a clinically significant change (50 points or greater) in IBS-SSS. For the WSAS, mean score was reduced by 3.1 points in the telephone-CBT group (95% CI: 1.3 to 4.9, p < 0.001) and by 1.9 points in the web-CBT group (95% CI: 0.1 to 3.7, p = 0.036), relative to TAU. At 24 months, secondary measures showed similar improvement in both groups, compared to TAU: mean HADS score reduced by 3.1 points in telephone-CBT (p < 0.001) and by 2.7 points in web-CBT (p = 0.002); odds ratio for PEQ was 8.3 for telephone-CBT (p < 0.001) and 3.3 for web-CBT (p = 0.001).

Based on study findings, researchers conclude that IBS-specific CBT, in both telephone-based and web-based forms, is associated with sustained improvement in clinical outcomes at 12 months up to 24 months. Improvement in both groups was detected as early as 2 weeks and was evident not only in terms of IBS symptoms, but also in mood and coping ability of patients. Findings underscore the clinical value of offering CBT as a form of treatment for IBS, one that is easily accessible to patients, clinically effective, and long-lasting. Potential limitations of the study noted by researchers are the lack of ethnic diversity among participants and the fact that a significant proportion of patients were lost from 12-month to 24-month follow-up (from 70% to 58%). Follow-up studies looking at potential moderating and/or mediating variables of clinical outcomes associated with refractory IBS would be helpful.

Source: Everitt HA, Landau S, O’Reilly G, et al. Cognitive behavioral therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomized trial. Lancet Gastroenterol Hepatol. 2019. DOI: 10.1016/s2468-1253(19)30243-2.

© 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

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Posted September 23, 2019.

Angeline A. De Leon, MA, graduated from the University of Illinois at Urbana-Champaign in 2010, completing a bachelor’s degree in psychology, with a concentration in neuroscience. She received her master’s degree from The Ohio State University in 2013, where she studied clinical neuroscience within an integrative health program. Her specialized area of research involves the complementary use of neuroimaging and neuropsychology-based methodologies to examine how lifestyle factors, such as physical activity and meditation, can influence brain plasticity and enhance overall connectivity.

References:

  1. Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clinical gastroenterology and hepatology. 2012;10(7):712-721. e714.
  2. Hellier M, Sanderson J, Morris A, et al. Care of patients with gastrointestinal disorders in the United Kingdom. BMJ PUBLISHING GROUP BRITISH MED ASSOC HOUSE, TAVISTOCK SQUARE, LONDON WC1H …; 2007.
  3. Ljótsson B, Hesser H, Andersson E, et al. Provoking symptoms to relieve symptoms: a randomized controlled dismantling study of exposure therapy in irritable bowel syndrome. Behaviour Research and Therapy. 2014;55:27-39.
  4. Lackner JM, Jaccard J, Keefer L, et al. Improvement in gastrointestinal symptoms after cognitive behavior therapy for refractory irritable bowel syndrome. Gastroenterology. 2018;155(1):47-57.
  5. Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO. Psychological treatments for the management of irritable bowel syndrome. Cochrane Database of Systematic Reviews. 2009(1).
  6. Everitt H, Landau S, Little P, et al. Assessing Cognitive behavioural Therapy in Irritable Bowel (ACTIB): protocol for a randomised controlled trial of clinical-effectiveness and cost-effectiveness of therapist delivered cognitive behavioural therapy and web-based self-management in irritable bowel syndrome in adults. BMJ open. 2015;5(7):e008622.
  7. Everitt HA, Landau S, O’Reilly G, et al. Assessing telephone-delivered cognitive–behavioural therapy (CBT) and web-delivered CBT versus treatment as usual in irritable bowel syndrome (ACTIB): a multicentre randomised trial. Gut. 2019:gutjnl-2018-317805.
  8. Everitt HA, Landau S, O’Reilly G, et al. Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trial. The Lancet Gastroenterology & Hepatology. 2019.