Assessing the Effectiveness of Psycho-Social Interventions in Reducing Symptom Severity in IBS

Recent study results suggest that treatment that includes patient education, cognitive behavioral therapy, and other psycho-social modalities can help reduce symptom severity and improve quality of life in patients with irritable bowel syndrome (IBS).

With the prevalence of irritable bowel syndrome (IBS) reported as high as 15% in some studies, and patients suffering from IBS experiencing chronic recurrent abdominal pain and discomfort and other symptoms that seriously impact their quality of life (QoL), there is a great need for effective treatments for IBS.

However, the authors of “Randomised clinical trial: symptoms of the irritable bowel syndrome are improved by a psycho-education group intervention,” published in Alimentary Pharmacology & Therapeutics, note that the current options for pharmacologic therapy of IBS “beyond symptomatic treatment for constipation or diarrhea” are unsatisfactory because “few studies have demonstrated an effectiveness of available treatments over placebo effects.” A slightly different picture emerges when one considers non-pharmacologic modalities for managing IBS. Treatments including hypnotherapy and mindfulness, patient-focused cognitive behavioral therapy (CBT), and patient education “have all shown effectiveness in alleviating IBS related symptoms.” Patients have not benefited fully from these approaches in part because their use “has been hindered by factors such as added cost, unavailability of trained clinicians, inadequate reimbursement for psychosocial interventions and a general bias towards pharmacotherapy among patients and providers.”

The research on the effectiveness of education based IBS treatment approaches has yielded “mixed outcomes,” with some research “suggesting that cognitive, behavioural, psychodynamic, educational and hypnotherapy based treatments worked in alleviating IBS symptoms.” While this is true, the literature also points to a great deal of uncertainty regarding the specific factors that contribute to successful treatment. Accordingly, the authors of this study sought to find out whether “a short course of group psycho-educational treatment consisting of combined CBT and basic relaxation techniques result in sustained, clinically relevant improvement of IBS symptom severity and health-related quality of life.” They also tried to ascertain “the factors that predict a positive outcome (moderators), and the factors that mediate the positive outcomes of the intervention.”

Researchers enrolled 69 patients who had been diagnosed with IBS and asked them to complete a symptom diary each day for two weeks prior to initiating therapy, recording information about “severity of GI symptoms, and frequency and consistency of stool.” Based on their symptoms, patients were randomized into one of three groups:

• Diarrhea predominant patients (IBS-D; 28 patients)
• Constipation predominant (IBS-C; 24 patients)
• Alternating type IBS (IBS-A; 17 patients)

Patients were randomized to receive either psycho-educational treatment or no additional care (both groups continued their current care for managing IBS symptoms).

Participants were assessed at baseline, following the five-week treatment, and again after three months using several instruments, including a 20-point Global GI symptom severity scale, the Irritable Bowel Syndrome Quality of Life (IBS-QoL) questionnaire, and the Hospital Anxiety and Depression Scale.

The psycho-educational course was led by a gastroenterologist and a therapist, and consisted of five weekly two-hour group sessions that included lectures on “the neurobiology of the stress response, the bio-psychosocial model of IBS, and self-management of diet and medication;” breathing and relaxation exercises; and instruction on “the role of beliefs and attitudes in IBS.” The instruction provided patients with guidance on the use of effective coping styles and outlined a “neurobiological mind/brain/body model linking IBS to the interactions between emotions, stress and abdominal symptoms with an emphasis on highlighting the nervous system's ability to self-regulate.” Patients also had to complete “homework assignments” that included breathing exercises and symptom monitoring and documentation.

The majority of participants reported their overall symptoms as being moderate to severe, with no significant differences between the intervention group and the control group. Both groups “displayed clinical levels of anxiety, but not depression.”

After controlling for baseline levels of overall symptom severity, the authors report a “significant’ effect on symptom severity in the intervention group; this group “demonstrated lower overall severity ratings compared with the control group at the end of the intervention,” with the effects enduring at the three-month follow-up assessment. Patients in the intervention group reported significantly higher QoL scores compared to the control group following the five-week treatment and also at three months. Patients in the intervention group also reported lower depression scores, significantly less visceral sensitivity, improved coping skills, and improvements in catastrophizing.

In their summary of the study results, the authors wrote that patients who participated in the psycho-education classes “improved on all key measures by the end of the intervention, and demonstrated lower overall symptom severity ratings than those in the control group.” These outcomes suggest that “a brief CBT group psycho-educational model is an efficient, efficacious and clinically useful treatment that can provide symptom reduction, and improvement in quality of life of patients.” Furthermore, when combined with pharmacologic treatment for IBS, this intervention may help reduce the cost of treatment, the need for follow-up visits, and medication side effects, while increasing the effectiveness of the drug and patient medication compliance.