Psychological treatments for the management of irritable bowel syndrome

Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO

Published Online:

January 21, 2009

In this review, the effectiveness of psychological therapies for adult patients with irritable bowel syndrome was evaluated. Studies involving cognitive behavioural therapy, interpersonal psychotherapy and relaxation therapy or stress management were reviewed. Although it is difficult to draw conclusions because of differences between studies and quality issues, the results suggest that cognitive behavioural therapy and interpersonal psychotherapy may be effective immediately after finishing treatment. It is unclear whether the effects of these therapies are sustained thereafter. These results have to be interpreted with caution as the quality of the studies was sub-optimal. Physicians should be aware of the limitations of these therapies and should choose an appropriate therapy based on the individual patient's characteristics.

Abstract (click to read)

Background:

No consensus exists on the optimal treatment for irritable bowel syndrome (IBS). Psychological treatments are increasingly advocated but their effectiveness is unclear.

Objectives:

To evaluate the efficacy of psychological interventions for the treatment of irritable bowel syndrome.

Search strategy:

A computer assisted search of MEDLINE, EMBASE, PsychInfo, CINAHL, Web of Science, The Cochrane Library and Google Scholar was performed for the years 1966-2008. Local databases were searched in Europe.

Selection criteria:

Randomised trials comparing single psychological interventions with either usual care or mock interventions in patients over 16 years of age. No language criterion was applied.

Data collection and analysis:

The search identified 25 studies that fulfilled the inclusion criteria. The relative risk (RR), risk difference (RD), number needed to treat (NNT) and standardized mean difference (SMD) along with 95% confidence intervals were calculated using a random effects model for each outcome.

Main results:

Psychological interventions as a group
The SMD for symptom score improvement at 2 and 3 months was 0.97 (95% CI 0.29 to 1.65) and 0.62 (95% CI 0.45 to 0.79) respectively compared to usual care. Against placebo, the SMDs were 0.71 (95% CI 0.08 to 1.33) and -0.17 (95% CI -0.45 to 0.11) respectively. For improvement of abdominal pain, the SMDs at 2 and 3 months were 0.54 (95%CI 0.10 to 0.98) and 0.26 (95% CI 0.07 to 0.45) compared to usual care. The SMD from placebo at 3 months was 0.31 (95% CI -0.16 to 0.79). For improvement in quality of life, the SMD from usual care at 2 and 3 months was 0.47 (95%CI 0.11 to 0.84) and 0.31 (95%CI -0.16 to 0.77) respectively.

Cognitive behavioural therapy
The SMD for symptom score improvement at 2 and 3 months was 0.75 (95% CI -0.20 to 1.70) and 0.58 (95% CI 0.36 to 0.79) respectively compared to usual care. Against placebo, the SMDs were 0.68 (95% CI -0.01 to 1.36) and -0.17 (95% CI -0.45 to 0.11) respectively. For improvement of abdominal pain, the SMDs at 2 and 3 months were 0.45 (95% CI 0.00 to 0.91) and 0.22 (95% CI -0.04 to -0.49) compared to usual care. Against placebo the SMD at 3 months was 0.33 (95% CI -0.16 to 0.82). For improvement in quality of life, the SMDs at 2 and 3 months compared to usual care were 0.44 (95% CI 0.04 to 0.85) and 0.92 (95% CI 0.07 to 1.77) respectively.

Interpersonal psychotherapy
The RR for adequate relief of symptoms was 2.02 (95% CI 1.13 to 3.62), RD 0.30 (95% CI 0.13 to 0.46), NNT 4 for comparison with care as usual. The SMD for improvement of symptom score was 0.35 (95% CI -0.75 to 0.05) compared with usual care.

Relaxation/Stress management
The SMD in symptom score improvement at 2 months was 0.50 (95%CI 0.02 to 0.98) compared with usual care. The SMD in improvement of abdominal pain at 3 months was 0.02 (95%CI -0.56 to 0.61) compared with usual care.

Long term results
Very few long term follow-up results were available. There was no convincing evidence that treatment effects were sustained following completion of treatment for any treatment modality.

Authors' conclusions:

Psychological interventions may be slightly superior to usual care or waiting list control conditions at the end of treatment although the clinical significance of this is debatable. Except for a single study, these therapies are not superior to placebo and the sustainability of their effect is questionable. The meta-analysis was significantly limited by issues of validity, heterogeneity, small sample size and outcome definition. Future research should adhere to current recommendations for IBS treatment trials and should focus on the long-term effects of treatment.

This record should be cited as:

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, Issue 1. Art. No.: CD006442. DOI: 10.1002/14651858.CD006442.pub2

Assessed as up to date:

September 9, 2008

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Primary Review Group:

Inflammatory Bowel Disease and Functional Bowel Disorders Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are psychological interventions for the treatment of irritable bowel syndrome (IBS)?

Bottom line:

Psychological interventions (cognitive behavioural therapy and interpersonal psychotherapy) may be slightly superior to usual care or waiting list control conditions at the end of treatment, although the clinical significance of this is uncertain. Treatment duration and follow-up time varied from 6 weeks to 12 months. Except for a single study, these therapies were not superior to placebo and the sustainability of their effect is questionable.

Caveat:

The results of this meta-analysis should be interpreted with caution due to the low methodological quality of the included studies, variability in outcome definitions and small sample sizes which resulted in considerable heterogeneity.

Context:

IBS is a chronic functional gastrointestinal disorder, with an estimated prevalence in Europe of up to 24% in women and 19% in men.¹ No consensus exists on the optimal treatment for IBS. Psychological treatments are increasingly advocated but their effectiveness is unclear. 1. Drossman DA et al. Gastroenterology 1997;112:2120-2137

Cochrane Systematic Review:

Zildenbos IL et al. Psychological treatments for the management of irritable bowel syndrome. Cochrane Reviews 2009, Issue 1. Article No: CD006442. DOI: 10.1002/14651858.CD006442.pub2. This review contains 25 studies involving 1858 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Gastroenterology > Functional bowel disorders > Irritable bowel syndrome

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Psychological treatments for the management of irritable bowel syndrome

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