By Will Boggs MD
NEW YORK (Reuters Health) - 23/4/2019
Cognitive behavioral therapy (CBT) delivered by phone or online leads to improvements in patient-reported outcomes in irritable bowel syndrome (IBS), according to a clinical trial from the U.K.
"The most important new findings from this research are long-term benefits from a relatively short course of CBT for IBS undertaken with remote telephone support rather than face-to-face therapy," Dr. Hazel Anne Everitt from Southampton University told Reuters Health by email. "This is exciting because it potentially enables many more patients to be supported."
Dr. Everitt and colleagues in the ACTIB randomized trial compared the effectiveness of telephone-delivered CBT (TCBT) and web-based CBT (WCBT) with minimal therapist support at reducing IBS symptoms and impact, compared with treatment as usual, in their 12-month study of 558 patients with refractory IBS.
In the intervention groups, CBT consisted of education, behavioral, and cognitive techniques aimed at improving bowel habits, developing stable healthy eating patterns, addressing unhelpful thoughts, managing stress, reducing symptom focusing, and preventing relapse.
IBS Symptom Severity Scores (IBS-SSS), which range from 0 to 500, were 61.6 points lower (better) than with usual treatment at 12 months in the TCBT group and 35.2 points lower in the WCBT group, the researchers report in Gut, online April 10. These differences were statistically significant.
Nearly three-quarters of patients in the TCBT group (72.8%) and 66.1% in the WCBT group had clinically significant improvements in IBS-SSS (at least 50 points lower) at 12 months, compared with 44.3% of patients treated as usual.
Work and Social Adjustment Scale scores at 12 months were also significantly lower in the TCBT and WCBT groups than in the treatment as usual group.
The odds of achieving responder status based on the subjects' global improvement of symptoms outcome were 6.1-fold greater for TCBT and 3.6-fold greater for WCBT than for treatment as usual (P<0.001).
Hospital Anxiety and Depression Scale (HADS) scores at 12 months averaged 15.0 in the usual-treatment group and were 2.8 points lower with TCBT and 2.3 points lower with WCBT.
"Currently there is poor access for patients to CBT for IBS," Dr. Everitt said. "We are hoping that this research will encourage health commissioners to increase provision, as there are many patients living with ongoing troublesome IBS symptoms."
"We are hoping to make the web-based CBT for IBS commercially available in the relatively near future, and then health care providers will be able to buy the services," she said.
Dr. Jeffrey M. Lackner from Jacobs School of Medicine, University of Buffalo, New York, who has also shown that a primarily home-based version of CBT improves outcomes in patients with IBS (versus education alone), told Reuters Health by email that with that treatment, "Patients with some of the most challenging, complex GI symptoms can achieve very real improvements in IBS symptoms that do not respond to standard conventional treatments."
"The challenge is that the telehealth condition still requires a large workforce of trained providers who are proficient in delivering CBT for IBS," he said. "Unfortunately, we just don't have a sufficient number of providers, whether they administer treatment face-to-face or via telehealth."
Dr. Lackner added, "The study really does not tell us what is the comparative advantage of web-based versus telehealth treatment versions of CBT."
Dr. Sarah W. Kinsinger from Loyola University Medical Center, in Maywood, Illinois, who recently reviewed CBT for patients with IBS, told Reuters Health by email, "The results are exciting because they demonstrate that when a standardized CBT protocol for IBS is delivered remotely, it can benefit a large portion of patients from both primary care and tertiary care settings. This approach has potential to reach far more patients than would typically have access to a highly specialized GI psychotherapist that may only be available at an academic medical center. Furthermore, it is cost-effective and likely very appealing to patients due the decreased time and burden associated with in-person treatment."
"A key point about this study is that the treatments still required involvement from a therapist that had received training and supervision in a CBT protocol for IBS (8 hours therapist contact in telephone-based treatment and 2.5 hours therapist contact in web-based treatment)," she said. "Therefore, in terms of treatment dissemination, we still need to work towards providing more training opportunities for therapists to learn evidence-based psychological treatments for GI disorders so that these types of protocols can be delivered effectively by more clinicians."
The study did not have commercial funding. Some of the researchers report income from training in IBS interventions.