Two controlled evaluations of multicomponent psychological treatment of irritable bowel syndrome

Future of Brain-Gut Behavior Therapies: Mediators and Moderators

With growing evidence to support their efficacy, brain-gut behavior therapies are increasingly viewed as a key component to integrated care management of disorders of gut-brain interaction. However, the types of brain-gut behavior therapies differ in how and for whom they purportedly work. We provide a conceptual review of these brain-gut behavior therapies, with an emphasis on describing how (ie, mechanisms) and for whom (ie, moderators) they work as hypothesized and/or supported by evidence. Based on evidence to date, we recommend that brain-gut behavior therapies prioritize gastrointestinal-specific targets, such as gastrointestinal-specific anxiety.

Potential Benefit With Complementary and Alternative Medicine in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Patients with irritable bowel syndrome (IBS) may pursue complementary and alternative medicine (CAM). We conducted a comprehensive systematic review and meta-analysis examining efficacy of CAM vs. placebo or sham in adults with IBS.

METHODS

Publication databases were searched for randomized controlled trials of CAM therapies (herbal therapy, dietary supplements, mind-body based, body-based, and energy-healing) in adults with IBS. Data were extracted to obtain pooled estimates of mean improvement in abdominal pain (standardized mean difference [SMD]) and relative risk (RR) of overall response using random effects models. Sensitivity and subgroup analyses along with quality assessments were completed.

RESULTS

Among 2825 articles identified, 66 were included. Herbal therapy (SMD=0.47, 95% CI: 0.20 to 0.75, I²=82%) demonstrated significant benefit over placebo for abdominal pain (low confidence in estimates). Benefit with mind-body based therapy for abdominal pain was of borderline significance (SMD=0.29, 95% CI: -0.01 to 0.59, I²=78%). Herbal therapy (RR=1.57, 95% CI: 1.31 to 1.88, I²=77%), dietary supplements (RR=1.95, 95% CI: 1.02 to 3.73, I²=75%), and mind-body based therapy (RR=1.67, 95% CI: 1.13 to 2.49, I²=63%) showed benefit for overall response compared to placebo (low confidence in estimates). Body-based and energy healing therapies demonstrated no significant benefit over placebo or sham for abdominal pain or overall response.

CONCLUSIONS

CAM therapies such as herbal or dietary supplements and mind-body based approaches may be beneficial for abdominal pain and overall response in IBS. However, overall quality of evidence is low. Rigorous, high quality clinical trials are warranted to investigate CAM in IBS.

[A Meta-Analysis on the Effects of Mind-Body Therapy on Patients with Irritable Bowel Syndrome]

PURPOSE

Previous randomized controlled trials (RCT) found that mind-body therapy can improve the health outcomes of patients with irritable bowel syndrome (IBS). The purpose of this meta-analysis was to identify the combined effects of mind-body therapy on patients' IBS symptoms, quality of life, anxiety, and depression.

METHODS

A systematic literature search was conducted using various databases such as PubMed, EMBASE, CINAHL CENTRAL, DBpia, RISS, and KISS. The primary outcome variables were IBS symptoms and quality of life; the secondary outcome variables were anxiety and depression. Comprehensive Meta-Analysis version 3.0 was used to analyze the extracted data. The effect size was calculated using standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

Eleven final RCTs were used for this meta-analysis. Mind-body therapy was found to have a significant effect on the IBS patients' symptoms (SMD, -0.63; 95% CI, -0.77 to -0.48), quality of life (SMD, 1.03; 95% CI, 0.40 to 1.66), anxiety (SMD, -0.28; 95% CI, -0.47 to -0.09), and depression (SMD, -0.31; 95% CI, -0.06 to -0.12).

CONCLUSION

This meta-analysis reveals that mind-body therapy significantly improves IBS patients' symptoms, quality of life, anxiety, and depression. The results suggest that, in the future, appropriate mind-body therapy should be applied to Koreans suffering from IBS. Moreover, the therapy's long-term effects should be assessed.

Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis

OBJECTIVES

National guidelines for the management of irritable bowel syndrome (IBS) recommend that psychological therapies should be considered, but their relative efficacy is unknown, because there have been few head-to-head trials. We performed a systematic review and network meta-analysis to try to resolve this uncertainty.

DESIGN

We searched the medical literature through January 2020 for randomised controlled trials (RCTs) assessing efficacy of psychological therapies for adults with IBS, compared with each other, or a control intervention. Trials reported a dichotomous assessment of symptom status after completion of therapy. We pooled data using a random effects model. Efficacy was reported as a pooled relative risk (RR) of remaining symptomatic, with a 95% CI to summarise efficacy of each comparison tested, and ranked by therapy according to P score.

RESULTS

We identified 41 eligible RCTs, containing 4072 participants. After completion of therapy, the psychological interventions with the largest numbers of trials, and patients recruited, demonstrating efficacy included self-administered or minimal contact cognitive behavioural therapy (CBT) (RR 0.61; 95% CI 0.45 to 0.83, P score 0.66), face-to-face CBT (RR 0.62; 95% CI 0.48 to 0.80, P score 0.65) and gut-directed hypnotherapy (RR 0.67; 95% CI 0.49 to 0.91, P score 0.57). After completion of therapy, among trials recruiting only patients with refractory symptoms, group CBT and gut-directed hypnotherapy were more efficacious than either education and/or support or routine care, and CBT via the telephone, contingency management, CBT via the internet and dynamic psychotherapy were all superior to routine care. Risk of bias of trials was high, with evidence of funnel plot asymmetry; the efficacy of psychological therapies is therefore likely to have been overestimated.

CONCLUSIONS

Several psychological therapies are efficacious for IBS, although none were superior to another. CBT-based interventions and gut-directed hypnotherapy had the largest evidence base and were the most efficacious long term.

TRIAL REGISTRATION NUMBER

The study protocol was published on the PROSPERO international prospective register of systematic reviews (registration number CRD 42020163246).

Mind-body treatments of irritable bowel syndrome symptoms: An updated meta-analysis

Irritable bowel syndrome (IBS) is a widespread chronic functional gastrointestinal (GI) disorder having bidirectional comorbidity with psychiatric disorders. This review focuses on psychological treatment of IBS, focusing on symptom severity rather than IBS diagnostic criteria. We chose this dimensional approach in order to assess mind-body effects as an alternative or complement to conventional medical treatment, which focuses on symptom relief. We calculated the effect sizes for various psychosocial-mind-body therapies (MBTs) for IBS symptoms in both children and adults. Therapies included meditation, relaxation, yoga, autogenic training, progressive relaxation, general training in stress coping, hypnotherapy, biofeedback, psycho-education, psychodynamic psychotherapy, and cognitive behavioral therapy. We performed a meta-regression analyses and mixed effects contrasts to find various outcome differences, and we analyzed their relative efficacy in both children and adults. We found 53 studies in 50 reports describing randomized controlled trials. Medium to high effect sizes were found across all methods compared with various controls, with possibly higher effects for children. We found no systematic differences among treatment methods. Meta-regression analyses showed no significant effect for the presence of psychophysiological training, meditation or explicit exposure procedures as treatment components, although most MBTs include exposure as a nonexplicit treatment characteristic, and many relaxation techniques have meditative characteristics. We conclude that there is considerable evidence that an array of mind-body and other psychological therapies can be effective complements to medical treatment for IBS symptom severity, with little evidence for relative superiority of any particular approach. We suggest that the various methods may operate through different mechanisms.

Biofeedback for treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a prevalent condition that currently lacks highly effective therapies for its management. Biofeedback has been proposed as a therapy that may help individuals learn to exert conscious control over sympatho-vagal balance as an indirect method of symptom management.

OBJECTIVES

Our primary objective was to assess the efficacy and safety of biofeedback-based interventions for IBS in adults and children.

SEARCH METHODS

We searched the Cochrane Inflammatory Bowel Disease (IBD) Group Specialized Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Allied and Complementary Medicine Database (AMED) from inception to 24 July 2019. We also searched reference lists from published trials, trial registries, device manufacturers, conference proceedings, theses, and dissertations.

SELECTION CRITERIA

We judged randomized controlled trials to be eligible for inclusion if they met the Association for Applied Psychophysiology and Biofeedback definition of biofeedback, and if they compared a biofeedback intervention to an active, sham, or no-treatment control for the management of IBS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened trials for inclusion, extracted data, and assessed risk of bias. Primary outcomes were IBS global or clinical improvement scores and overall quality of life measures. Secondary outcome measures were adverse events, assessments of stool frequency and consistency, changes in abdominal pain, depression, and anxiety. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and 95% CI. We used GRADE criteria to assess the overall certainty of the evidence.

MAIN RESULTS

We identified eight randomized trials with a total of 300 adult participants for our analysis. We did not identify any trials in children. Four trials assessed thermal biofeedback. One trial assessed rectosigmoidal biofeedback. Two trials assessed heart rate variability biofeedback. Two trials assessed electrocutaneous biofeedback. Comparators were: no treatment (symptom monitoring group; three studies), attention control (pseudomeditation; two studies), relaxation control (one study), counseling (two studies), hypnotherapy (one study), standard therapy (one study), and sham biofeedback (one study). We judged all trials to have a high or unclear risk of bias. Global/Clinical improvement The clinical benefit of biofeedback plus standard therapy compared to standard therapy alone was uncertain (RR 4.20, 95% CI 1.40 to 12.58; 1 study, 20 participants; very low-certainty evidence). The same study also compared biofeedback plus standard therapy to sham biofeedback plus standard therapy. The clinical benefit in the biofeedback group was uncertain (RR 2.33, 95% CI 1.13 to 4.80; 1 study, 20 participants; very low-certainty evidence). The clinical benefit of heart rate biofeedback compared to hypnotherapy was uncertain when measured with the IBS severity scoring system (IBS-SSS) (MD -58.80, 95% CI -109.11 to -8.49; 1 study, 61 participants; low-certainty evidence). Compared to counseling, the effect of heart rate biofeedback was unclear when measured with a composite symptom reduction score (MD 7.03, 95% CI -51.07 to 65.13; 1 study, 29 participants; low-certainty evidence) and when evaluated for clinical response (50% improvement) (RR 1.09, 95% CI 0.48 to 2.45; 1 study, 29 participants; low-certainty evidence). The clinical benefit of thermal biofeedback used in a multi-component psychological intervention (MCPI) compared to no treatment was uncertain when measured with a composite clinical symptom reduction score (MD 30.34, 95% CI 8.47 to 52.21; 3 studies, 101 participants; very low-certainty evidence), and when evaluated as clinical response (50% improvement) (RR 2.12, 95% CI 1.24 to 3.62; 3 studies, 101 participants; very low-certainty evidence). Compared to attention control, the effects of thermal biofeedback within an MCPI were unclear when measured with a composite clinical symptom reduction score (MD 4.02, 95% CI -21.41 to 29.45; 2 studies, 80 participants; very low-certainty evidence) and when evaluated as clinical response (50% improvement) (RR 1.10, 95% CI 0.72 to 1.69, 2 studies, 80 participants; very low-certainty evidence). Quality of life A single trial used overall quality of life as an outcome measure, and reported that both the biofeedback and cognitive therapy groups improved after treatment. The trial did not note any between-group differences, and did not report any outcome data. Adverse events Only one of the eight trials explicitly reported adverse events. This study reported no adverse events in either the biofeedback or cognitive therapy groups (RD 0.00, 95% CI -0.12 to 0.12; 29 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently not enough evidence to assess whether biofeedback interventions are effective for controlling symptoms of IBS. Given the positive results reported in small trials to date, biofeedback deserves further study in people with IBS. Future research should include active control groups that use high provider-participant interaction, in an attempt to balance non-specific effects of interventions between groups, and report both commonly used outcome measures (e.g. IBS-SSS) and historical outcome measures (e.g. the composite primary symptom reduction (CPSR) score) to allow for meta-analysis with previous studies. Future studies should be explicit in their reporting of adverse events.

Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS)

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal (GI) disorders, affecting about 10% of the general population globally. The aim of this consensus was to develop guidelines for the management of IBS.

METHODS

A systematic literature search identified studies on the management of IBS. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a multidisciplinary group of clinicians and a patient.

RESULTS

Consensus was reached on 28 of 31 statements. Irritable bowel syndrome is diagnosed based on symptoms; serological testing is suggested to exclude celiac disease, but routine testing for C-reactive protein (CRP), fecal calprotectin or food allergies is not recommended. A trial of a low fermentable oligosaccharides, disaccharides, monosaccharides, polyols (FODMAP) diet is suggested, while a gluten-free diet is not. Psyllium, but not wheat bran, supplementation may help reduce symptoms. Alternative therapies such as peppermint oil and probiotics are suggested, while herbal therapies and acupuncture are not. Cognitive behavioural therapy and hypnotherapy are suggested psychological therapies. Among the suggested or recommended pharmacological therapies are antispasmodics, certain antidepressants, eluxadoline, lubiprostone, and linaclotide. Loperamide, cholestyramine and osmotic laxatives are not recommended for overall IBS symptoms. The nature of the IBS symptoms (diarrhea-predominant or constipation-predominant) should be considered in the choice of pharmacological treatments.

CONCLUSIONS

Patients with IBS may benefit from a multipronged, individualized approach to treatment, including dietary modifications, psychological and pharmacological therapies.

Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-Analysis

OBJECTIVES

Irritable bowel syndrome (IBS) is a chronic functional bowel disorder that is thought to be due to a disorder of brain-gut function. Drugs acting centrally, such as antidepressants, and psychological therapies may, therefore, be effective.

METHODS

We updated a previous systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, PsychINFO, and the Cochrane Controlled Trials Register were searched (up to July 2017). Trials recruiting adults with IBS, which compared antidepressants versus placebo, or psychological therapies versus control therapy or "usual management" were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI).

RESULTS

The search strategy identified 5316 citations. Fifty-three RCTs, reported in 51 separate articles, were eligible for inclusion: 17 compared antidepressants with placebo, 35 compared psychological therapies with control therapy or "usual management", and one compared both psychological therapy and antidepressants with placebo. Four of the trials of psychological therapies, and one of the RCTs of antidepressants, were identified since our previous meta-analysis. The RR of IBS symptoms not improving with antidepressants versus placebo was 0.66 (95% CI 0.57-0.76), with similar treatment effects for both tricyclic antidepressants and SSRIs, although with heterogeneity between RCTs of the latter (I(2) = 49%, P = 0.07). The RR of symptoms not improving with psychological therapies was 0.69 (95% CI 0.62-0.76). Cognitive behavioral therapy, relaxation therapy, multi-component psychological therapy, hypnotherapy, and dynamic psychotherapy were all beneficial when data from two or more RCTs were pooled. There was significant heterogeneity between studies (I(2) = 69%, P < 0.001) and significant funnel plot asymmetry. There were also issues regarding trial design, including lack of blinding.

CONCLUSIONS

Antidepressants are efficacious in reducing symptoms in IBS patients. Psychological therapies also appear to be effective treatments for IBS, although there are limitations in the quality of the evidence, and treatment effects may be overestimated as a result.

A Randomized Trial of a Group-Based Integrative Medicine Approach Compared to Waitlist Control on Irritable Bowel Syndrome Symptoms in Adults

INTRODUCTION

Irritable bowel syndrome (IBS) is a chronic debilitating functional gastrointestinal disorder that affects a large proportion of the general population. Dietary and mind-body approaches have shown some effectiveness in reducing IBS symptoms.

OBJECTIVES

The purpose of this project was to test the feasibility of a low cost, group-oriented integrative medicine approach to IBS, and to explore whether such an approach improves participant outcomes.

METHODS

This was a randomized-controlled trial involving a 4-week group-oriented treatment intervention combining dietary intervention and mind-body therapies followed by 8-weeks of telephonic health coaching. Differences between the intervention and control groups on IBS-specific measures were examined at baseline, 4, 8, and 12-week.

RESULTS

Fifty-two participants completed the study, 30 in the control group and 22 in the intervention group. On the IBS Symptom Severity Score, at 4 weeks the intervention group showed statistically significant improvement compared to the control group (p < .02), which was sustained at the 8 and 12-week data points as well, with the proportion of the intervention group experiencing moderate to severe symptoms decreasing from 81.3% at baseline to 45% at week 4 and 54.5% at week 12. A statistically significant improvement was also seen on the CES-D measure of depression between baseline and week 12 in the intervention group compared to controls. On the IBS Quality of Life measure we did not observe a statistically significant difference between the groups.

CONCLUSIONS

This low-cost, group-oriented intervention approach offers a strategy to address the challenge of access to this type of integrative approach for patients of low socioeconomic status or limited means.

Clinical Practice Guidelines for Irritable Bowel Syndrome in Korea, 2017 Revised Edition

In 2011, the Korean Society of Neurogastroenterology and Motility (KSNM) published clinical practice guidelines on the management of irritable bowel syndrome (IBS) based on a systematic review of the literature. The KSNM planned to update the clinical practice guidelines to support primary physicians, reduce the socioeconomic burden of IBS, and reflect advances in the pathophysiology and management of IBS. The present revised version of the guidelines is in continuity with the previous version and targets adults diagnosed with, or suspected to have, IBS. A librarian created a literature search query, and a systematic review was conducted to identify candidate guidelines. Feasible documents were verified based on predetermined inclusion and exclusion criteria. The candidate seed guidelines were fully evaluated by the Guidelines Development Committee using the Appraisal of Guidelines for Research and Evaluation II quality assessment tool. After selecting 7 seed guidelines, the committee prepared evidence summaries to generate data exaction tables. These summaries comprised the 4 main themes of this version of the guidelines: colonoscopy; a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; probiotics; and rifaximin. To adopt the core recommendations of the guidelines, the Delphi technique (ie, a panel of experts on IBS) was used. To enhance dissemination of the clinical practice guidelines, a Korean version will be made available, and a food calendar for patients with IBS is produced.

Pilot-RCT of an integrative group therapy for patients with refractory irritable bowel syndrome (ISRCTN02977330)

OBJECTIVE

Different forms of psychotherapeutic treatments have been proven effective in irritable bowel syndrome (IBS), but disorder-oriented and integrative concepts are still rare. Therefore, we implemented and evaluated an integrative group therapeutic concept within an interdisciplinary tertiary care clinic for functional gastrointestinal disorders (FGIDs).

AIMS

present our integrative group concept, assess feasibility issues, and evaluate efficacy.

METHODS

A pilot-RCT with a randomized controlled wait-listed group design was conducted. The treatment concept was a disorder-oriented multicomponent group therapy (12 90-min weekly sessions) integrating interactive psychoeducation, gut-directed hypnotherapy, and open group phases. All patients received enhanced medical care and completed a short online diary as an active wait-listed control condition.

INCLUSION CRITERIA

refractory IBS diagnosed as somatoform autonomic dysfunction of the lower gastrointestinal tract (SAD).

PRIMARY OUTCOME

IBS symptom severity (IBS-SSS).

RESULTS

Of 294 patients, 220 had IBS (ROME III), 144 were diagnosed as SAD (ICD-10), 51 were eligible regarding inclusion/exclusion criteria, and 30 consented to participate (group intervention: n=16, wait-listed control condition: n=14). Only 1 patient dropped out. Intention-to-treat-analysis with repeated-measures mixed ANOVA showed that the group intervention was not significantly superior to the wait-listed control condition. Nevertheless, the calculated effect size for the between-group difference in IBS-SSS at the end of treatment (post) was moderate (d=0.539).

CONCLUSION

Our disorder-oriented integrative group intervention for IBS proved to be acceptable and feasible in an interdisciplinary tertiary care setting. There is promise in this intervention, but a larger RCT may be needed to investigate efficacy.

Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis. Clin Psychol Rev. 2017;51:142-152. [PMID: 27870997 DOI: 10.1016/j.cpr.2016.11.001]

Previous meta-analyses have shown that psychotherapy improves gastrointestinal symptoms in adults with irritable bowel syndrome (IBS); however, the impact on functioning in daily activities is unknown. Meta-analysis was used to estimate the effect of psychotherapy on mental health and daily functioning in adults with IBS. An extensive literature search located 28 eligible randomized controlled trials (RCTs) providing outcome data for mental health and 18 RCTs providing data for daily functioning. Compared to a mixed group of control conditions, psychotherapy produced significantly greater improvements to mental health (d-=0.41) and daily functioning (d-=0.43). Cognitive behavior therapy (CBT) was evaluated in the largest number of trials (21 trials), followed by hypnosis (4 trials), psychodynamic (3 trials), and relaxation (2 trials). The psychotherapeutic modalities were comparable with respect to their effect on mental health. CBT produced the greatest improvements to daily functioning, and this effect was significantly larger than that produced by relaxation therapy. These results have important clinical implications for treatment of adults with IBS.

Short-term and Long-term Efficacy of Psychological Therapies for Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Several meta-analyses have demonstrated the efficacy of psychological therapies for reducing gastrointestinal (GI) symptoms in patients with irritable bowel syndrome (IBS). However, no meta-analysis has investigated the duration of these effects. We performed a meta-analysis to assess the immediate, short-term, and long-term efficacy of psychotherapy for reducing GI symptoms in adults with IBS.

METHODS

We searched PubMed, PsycINFO, Science Direct, and ProQuest Dissertations and Theses through August 15, 2015 for randomized controlled trials that compared psychological therapy with an active or non-active comparison (control) condition for treatment of GI symptoms in adults with IBS.

RESULTS

Forty-one trials were included in our meta-analysis, comprising data from 2290 individuals (1183 assigned to psychotherapy and 1107 assigned to a control condition). Compared with a mixed group of control conditions, psychological therapies had a medium effect on GI symptom severity (d¯ = 0.69) immediately after treatment. On average, individuals who received psychotherapy had a greater reduction in GI symptoms after treatment than 75% of individuals assigned to a control condition. After short-term follow-up periods (1-6 months after treatment) and long-term follow-up periods (6-12 months after treatment), this effect remained significant and medium in magnitude (d¯ = 0.76 and d¯ = 0.73, respectively).

CONCLUSIONS

Psychological therapies reduce GI symptoms in adults with IBS. These effects remained significant and medium in magnitude after short-term and long-term follow-up periods.

Identifying effective techniques within psychological treatments for irritable bowel syndrome: a meta-analysis

OBJECTIVES

Psychological interventions can alleviate the symptoms of irritable bowel syndrome (IBS) and psychological distress commonly reported among IBS sufferers. However, the theoretical underpinnings and intervention techniques used by such interventions vary considerably. This study aimed to identify which theoretical approaches and techniques lead to greater improvements in IBS symptoms and psychological well-being within psychological interventions for IBS.

METHODS

Outcome data were extracted from 48 randomized controlled trials testing psychological treatments for IBS. Theoretical intervention targets and intervention techniques of each study were identified. Cumulative effect sizes were calculated for pain, bowel dysfunction, composite symptom scores, psychological distress, and health-related quality of life. Comparative analyses contrasted the effect sizes of studies which included each intervention technique to those which did not.

RESULTS

Cumulatively, interventions significantly improved all outcomes, with effect sizes (Hedges' g) ranging from 0.32 to 0.64. Interventions which stated a theoretical intervention target, prompted self-monitoring of symptoms and cognitions, provided tailored feedback linking symptoms and cognitions, utilized problem solving or assertiveness training and provided general support had greater effects upon symptom and well-being outcomes than interventions which did not (all P<.05). Across all studies, improvements in psychological distress were associated with improvements in composite symptom scores (P<.01).

CONCLUSIONS

This study identifies a set of techniques associated with improvements in IBS symptoms and psychological well-being in existing interventions, and provides initial evidence for the link between improvements in psychological distress and IBS composite symptom scores. These findings can aid the development and refinement of psychological treatments for IBS.

Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis

OBJECTIVES

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. Evidence relating to the treatment of this condition with antidepressants and psychological therapies continues to accumulate.

METHODS

We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to December 2013). Trials recruiting adults with IBS, which compared antidepressants with placebo, or psychological therapies with control therapy or "usual management," were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI).

RESULTS

The search strategy identified 3,788 citations. Forty-eight RCTs were eligible for inclusion: thirty-one compared psychological therapies with control therapy or "usual management," sixteen compared antidepressants with placebo, and one compared both psychological therapy and antidepressants with placebo. Ten of the trials of psychological therapies, and four of the RCTs of antidepressants, had been published since our previous meta-analysis. The RR of IBS symptom not improving with antidepressants vs. placebo was 0.67 (95% CI=0.58-0.77), with similar treatment effects for both tricyclic antidepressants and selective serotonin reuptake inhibitors. The RR of symptoms not improving with psychological therapies was 0.68 (95% CI=0.61-0.76). Cognitive behavioral therapy, hypnotherapy, multicomponent psychological therapy, and dynamic psychotherapy were all beneficial.

CONCLUSIONS

Antidepressants and some psychological therapies are effective treatments for IBS. Despite the considerable number of studies published in the intervening 5 years since we last examined this issue, the overall summary estimates of treatment effect have remained remarkably stable.

Iyengar yoga for adolescents and young adults with irritable bowel syndrome

OBJECTIVES

Irritable bowel syndrome (IBS) is a chronic, disabling condition that greatly compromises patient functioning. The aim of this study was to assess the impact of a 6-week twice per week Iyengar yoga (IY) program on IBS symptoms in adolescents and young adults (YA) with IBS compared with a usual-care waitlist control group.

METHODS

Assessments of symptoms, global improvement, pain, health-related quality of life, psychological distress, functional disability, fatigue, and sleep were collected pre- and posttreatment. Weekly ratings of pain, IBS symptoms, and global improvement were also recorded until 2-month follow-up. A total of 51 participants completed the intervention (yoga = 29; usual-care waitlist = 22).

RESULTS

Baseline attrition was 24%. On average, the yoga group attended 75% of classes. Analyses were divided by age group. Relative to controls, adolescents (14-17 years) assigned to yoga reported significantly improved physical functioning, whereas YA (18-26 years) assigned to yoga reported significantly improved IBS symptoms, global improvement, disability, psychological distress, sleep quality, and fatigue. Although abdominal pain intensity was statistically unchanged, 44% of adolescents and 46% of YA reported a minimally clinically significant reduction in pain following yoga, and one-third of YA reported clinically significant levels of global symptom improvement. Analysis of the uncontrolled effects and maintenance of treatment effects for adolescents revealed global improvement immediately post-yoga that was not maintained at follow-up. For YA, global improvement, worst pain, constipation, and nausea were significantly improved postyoga, but only global improvement, worst pain, and nausea maintained at the 2-month follow-up.

CONCLUSIONS

The findings suggest that a brief IY intervention is a feasible and safe adjunctive treatment for young people with IBS, leading to benefits in a number of IBS-specific and general functioning domains for YA. The age-specific results suggest that yoga interventions may be most fruitful when developmentally tailored.

Mind/Body psychological treatments for irritable bowel syndrome

Currently, the goal of treatment for those with irritable bowel syndrome (IBS) is to improve the quality of life through a reduction in symptoms. While the majority of treatment approaches involve the use of traditional medicine, more and more patients seek out a non-drug approach to managing their symptoms. Current forms of non-drug psychologic or mind/body treatment for IBS include hypnotherapy, cognitive behavioral therapy and brief psychodynamic psychotherapy, all of which have been proven efficacious in clinical trials. We propose that incorporating the constructs of mindfulness and acceptance into a mind/body psychologic treatment of IBS may be of added benefit due to the focus on changing awareness and acceptance of one's own state which is a strong component of traditional and Eastern healing philosophies.

The use of psychotropic drugs in irritable bowel syndrome

INTRODUCTION

Irritable bowel syndrome (IBS), the most common functional gastrointestinal disorder, is manifested by chronic abdominal pain associated with irregular bowel movements. Although not life threatening, IBS is associated with impaired quality of life that ranges from mild to severe.

AREAS COVERED

The pathogenesis of IBS is not completely understood, but involves dysfunction of the "brain-gut axis" including peripheral visceral hypersensitivity and central maladaptive processing of visceral pain input. Stress and concomitant psychopathologies such as somatization, anxiety and depression are thought to play a major role in the development, clinical course and response to treatment. Psychopharmacological agents such as selective serotonin/serotonin-norepinephrine receptor antagonists, tricyclic antidepressants as well as other agents are commonly used in treating moderate to severe IBS. This review will provide the pathophysiological rationale for the use of psychopharmacological agents in IBS, review the main classes of drugs and evidence for their use in IBS and offer a practical approach to the use of these drugs.

EXPERT OPINION

Psychotropic drugs can play a pivotal role in the treatment of IBS patients, so doctors should be familiar with their use. Further research with these drugs is needed to solidify our current knowledge and increase our therapeutic options.

Association of participation in a mindfulness programme with bowel symptoms, gastrointestinal symptom-specific anxiety and quality of life

BACKGROUND

Stress perception and GI-specific anxiety play key roles in irritable bowel syndrome (IBS). Mindfulness-based stress reduction (MBSR) is a widely available stress reduction course, which has not been evaluated for IBS.

AIM

To determine whether participation in MBSR is associated with improvement in bowel symptoms, GI-specific anxiety, and IBS-Quality of Life.

METHODS

This is a prospective study of 93 participants in MBSR. We applied measures of Rome III IBS status, bowel symptoms (IBS-Severity Scoring System, IBS-SSS), IBS-Quality of Life (IBS-QOL), GI-specific anxiety (Visceral Sensitivity Index, VSI), mindfulness (Five Facet Mindfulness Questionnaire-FFMQ), and functional status (SF-8) at baseline and 2 and 6 months after enrolment.

RESULTS

At 2 months, participation in MBSR was associated with small nonsignificant changes in IBS-SSS, IBS-QOL and VSI: d = -0.25, d = 0.08, d = -0.16, respectively. At 6 months, there was no significant change in IBS-SSS (d = -0.36); whereas for IBS-QOL and VSI there were significant improvements (IBS-QOL: d = 0.33, P = 0.044; VSI: d = -0.40, P = 0.014). For patients meeting Rome III IBS criteria (n = 43), changes in IBS-SSS, IBS-QOL and VSI were not statistically significant, but there was a significant correlation between the change in VSI and the change in FFMQ across the three time periods (r = 0.33).

CONCLUSIONS

Participation in MBSR is associated with improvement IBS-related quality of life and GI-specific anxiety. Randomised controlled trials are warranted to further assess the role of MBSR for IBS symptomatology.

[Guidelines for the treatment of irritable bowel syndrome]

Traditional symptom-based therapies of irritable bowel syndrome (IBS) are directed at the relief of individual IBS symptoms, but they are often of limited efficacy in addressing the entire symptom complex. Combinations of drugs to target bothersome symptoms are suggested as the first-line pharmacologic treatment. Increasing knowledge of the pathophysiology and molecular mechanisms of IBS has resulted in the development of several new therapeutic approaches. Thirteen consensus statements for the treatment of IBS were developed using the modified Delphi approach. Exclusion diets have modest efficacy in improving symptoms in some IBS patients. Symptom-based therapies with dietary fiber, bulking agents, laxatives, antispasmodics and laxatives are effective in the improvement of some individual symptoms, e.g. dietary fiber and bulking agents for constipation, laxatives for constipation, antispasmodics for abdominal pain and discomfort, antidiarrheals for diarrhea. 5HT3 receptor antagonists and 5HT((4)) receptor agonists are effective in the relief of global IBS symptoms and individual symptoms such as abdominal pain and abnormal bowel habits. A short term course of nonabsorbable antibiotics may improve global IBS symptoms, particularly in patients with diarrhea- predominant IBS. Some probiotics appear to have the potential benefit in improving global IBS symptoms. Selective C-2 chloride channel activator is more effective than placebo at relieving global IBS symptoms in patients with constipation-predominant IBS. Both tricyclic antidepressants and selective serotonin reuptake inhibitors are equally effective in relieving global IBS symptoms, and have some benefits in treating abdominal pain. Certain types of psychologic therapy may be effective in improving global symptoms in some IBS patients. Further studies are strongly needed to develop better treatment strategies for Korean patients with IBS.

Intervening on cognitions and behavior in irritable bowel syndrome: A feasibility trial using PDAs

OBJECTIVE

Irritable bowel syndrome (IBS) is a common, chronic, and often disabling disorder. Cognitive-behavioral therapy (CBT) has been shown to be effective in alleviating IBS symptoms. The aim of this study was to establish the feasibility and the efficacy of a cognitive-behavioral e-intervention using personal digital assistants (PDAs) on the self-management of IBS patients.

METHODS

A feasibility trial was conducted with 38 control group patients receiving standard care and 37 intervention group patients receiving standard care supplemented with a 4-week CBT intervention on PDAs. All patients fulfilled the diagnostic Rome III criteria for IBS. At baseline, 4-week, and 3-month follow-up, patients' abdominal pain, dysfunctional cognitions, IBS quality of life, and pain catastrophizing thoughts were assessed using written questionnaires.

RESULTS

Between-group comparisons between baseline and 4 weeks showed more overall quality of life improvement, more improvement in catastrophizing thoughts, and more pain improvement in the intervention group. Only improvement in catastrophizing thoughts persisted in the long-term. No significant differences between groups were found for dysfunctional cognitions. As all 37 intervention group patients completed the intervention and completed diaries three times a day for 4 weeks, the e-health intervention seems feasible.

CONCLUSIONS

A cognitive-behavioral intervention on pocket-type computers appears feasible and efficacious for improving IBS-related complaints and cognitions in the short-term. The intervention group improved on several aspects, but most on catastrophizing thoughts, and these improvements even persisted after 3 months. Future studies should focus on unravelling the effective components of this innovative e-health intervention.

Treatment of irritable bowel syndrome: beyond fiber and antispasmodic agents

Irritable bowel syndrome (IBS) is a chronic functional disorder of the gastrointestinal tract of unknown etiology. The diagnosis of IBS is made clinically, using symptom-based criteria such as the Manning or Rome criteria. Medical therapy for this condition has traditionally been directed towards symptom relief, using fiber or antispasmodic agents. In recent years, emerging data have confirmed the efficacy of antidepressants, psychological therapies, 5-HT(3) antagonists, 5-HT(4) agonists, and probiotics in the short-term treatment of IBS, although whether these therapies influence the long-term course of the disease is unknown. Increasing knowledge regarding the pathophysiological mechanisms underlying IBS has resulted in a number of novel molecular treatments, which show promise. These include therapies targeting gastrointestinal mucosal chloride channels and guanylate cyclase-C receptors, as well as highly selective agents influencing serotonergic transmission that, at the time of writing, do not appear to have any severe deleterious effects. In this article we provide a summary of current and emerging therapies in this field.

Pathways connecting cognitive behavioral therapy and change in bowel symptoms of IBS

OBJECTIVE

A single previous paper on this topic found a direct pathway between cognitive behavioral therapy (CBT) and an irritable bowel syndrome (IBS) global symptom score. This is controversial since under the biopsychosocial model, the expectation is that CBT's effect would be mediated by mood. Using more sensitive bowel symptom scales and measurements at additional time points, we aimed to compare the relative strengths of direct pathways between CBT and change in IBS symptoms and indirect pathways that operate via mood state using structural equation modeling.

METHODS

Our data set included 105 people with Rome I IBS randomized to individual CBT (n=34), relaxation therapy (n=36), and usual medical care (n=35). The primary outcome was defined as adequate relief of IBS symptoms in terms of the distress, frequency, and impairment according to the Bowel Symptom Severity Scale. Outcomes in functional status (according to the 36-item Short-Form Health Survey) and psychological status (Hospital Anxiety and Depression Scale) were secondary outcomes.

RESULTS

Our data suggest indirect pathways that operate via mood, most clearly anxiety but to a lesser extent depression. Statistically significant pathways were identified that lead from CBT to change in mood state thence to change in bowel symptoms, followed by further changes in mood then changes in bowel symptoms. Our data provide no evidence of direct effect of CBT on bowel symptoms.

CONCLUSIONS

The present study suggests that CBT may operate via changes in mood state while not ruling out the possibility of direct effects. Our findings do not directly support, but are consistent with, a biopsychosocial model.

Centrally acting therapies for irritable bowel syndrome

Irritable bowel syndrome (IBS) and other functional gastrointestinal (GI) disorders typically defy traditional diagnostic methods based on structural abnormalities, and has led to the emergence of the discipline of neurogastroenterology or the study of the "brain-gut axis," which is based on dysregulation of neuroenteric pathways as a key pathophysiological feature of IBS. Centrally acting treatments can influence these pathways and improve the clinical manifestations of pain and bowel dysfunction associated with this disorder. To successfully implement these treatment strategies, it is important to recognize their dual effects on brain and gut, understanding the nature and severity of the GI symptoms and their psychosocial concomitants, and applying them within the context of the patient's understanding of their value.

Protocol for a randomized controlled study of Iyengar yoga for youth with irritable bowel syndrome

Introduction

Irritable bowel syndrome affects as many as 14% of high school-aged students. Symptoms include discomfort in the abdomen, along with diarrhea and/or constipation and other gastroenterological symptoms that can significantly impact quality of life and daily functioning. Emotional stress appears to exacerbate irritable bowel syndrome symptoms suggesting that mind-body interventions reducing arousal may prove beneficial. For many sufferers, symptoms can be traced to childhood and adolescence, making the early manifestation of irritable bowel syndrome important to understand. The current study will focus on young people aged 14-26 years with irritable bowel syndrome. The study will test the potential benefits of Iyengar yoga on clinical symptoms, psychospiritual functioning and visceral sensitivity. Yoga is thought to bring physical, psychological and spiritual benefits to practitioners and has been associated with reduced stress and pain. Through its focus on restoration and use of props, Iyengar yoga is especially designed to decrease arousal and promote psychospiritual resources in physically compromised individuals. An extensive and standardized teacher-training program support Iyengar yoga's reliability and safety. It is hypothesized that yoga will be feasible with less than 20% attrition; and the yoga group will demonstrate significantly improved outcomes compared to controls, with physiological and psychospiritual mechanisms contributing to improvements.

Methods/Design

Sixty irritable bowel syndrome patients aged 14-26 will be randomly assigned to a standardized 6-week twice weekly Iyengar yoga group-based program or a wait-list usual care control group. The groups will be compared on the primary clinical outcomes of irritable bowel syndrome symptoms, quality of life and global improvement at post-treatment and 2-month follow-up. Secondary outcomes will include visceral pain sensitivity assessed with a standardized laboratory task (water load task), functional disability and psychospiritual variables including catastrophizing, self-efficacy, mood, acceptance and mindfulness. Mechanisms of action involved in the proposed beneficial effects of yoga upon clinical outcomes will be explored, and include the mediating effects of visceral sensitivity, increased psychospiritual resources, regulated autonomic nervous system responses and regulated hormonal stress response assessed via salivary cortisol.

Trial registration

ClinicalTrials.gov NCT01107977.

Comprehensive self-management for irritable bowel syndrome: randomized trial of in-person vs. combined in-person and telephone sessions

OBJECTIVES

Psychological and behavioral therapies are being increasingly used for symptom management in patients with irritable bowel syndrome (IBS). The aims of this study were to compare two delivery modes for a comprehensive self-management (CSM) intervention, primarily by telephone vs. entirely in person, and to compare each with usual care (UC).

METHODS

Adults with IBS were recruited through community advertisement. Subjects (N=188) were randomly assigned to three groups: one in which all nine weekly CSM sessions were delivered in person, one in which six of the nine sessions were conducted over telephone, and one in which subjects received UC. Primary outcome measures were a gastrointestinal (GI) symptom score based on six symptoms from a daily diary and disease-specific quality of life (QOL). These and other outcomes were assessed at baseline and at 3, 6, and 12 months after randomization. Mixed model analyses tested for differences between the three groups in each outcome variable at the three follow-up occasions, controlling for the baseline level of each outcome.

RESULTS

Both GI symptom score and QOL showed significantly greater improvement in the two CSM groups than in the UC group (P<0.001), with the magnitude of this difference being quite similar for the three follow-up time points. The two CSM groups experienced a very similar degree of improvement, and there were no statistically significant differences between the two.

CONCLUSIONS

A CSM program is efficacious whether delivered primarily by telephone or totally in person, and there is no evidence that replacing six of the in-person sessions by telephone sessions reduces the efficacy of the intervention.

Cognitive Behavioural Therapy for Medically Unexplained Physical Symptoms: A Pilot Study

The aim of the study was to develop a cognitive behavioural treatment model for medically unexplained physical symptoms and assess its feasibility and effect in a small sample of patients. This study was the first step in the realization of a randomized controlled trial. The study population consisted of consecutive patients presenting at a general medical outpatient clinic, whose symptoms could not be explained by objective abnormal findings. The treatment was based on a general model of the disorder, consisting of the physical symptoms, the patient's attribution and perceived control and the cognitive, behavioural, physical and social consequences. It incorporated record keeping concerning physical symptoms and emotions, identification of cognitions about the symptoms, challenging dysfunctional thoughts and behavioural experiments. At 6–months follow-up, four of the five treated patients were improved with regard to frequency and intensity of the symptoms, psychological distress and functional impairment. The improvement was sustained at 1–year follow-up.

Psychological treatments for the management of irritable bowel syndrome

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.

Psychopharmacologic and behavioral treatments for functional gastrointestinal disorders

Functional gastrointestinal disorders (FGIDs) are commonly seen gastrointestinal (GI) conditions that are diagnosed using established symptom-based criteria. These disorders that typically defy traditional diagnostic methods based on structural abnormalities have intrigued researchers for several decades. This has led to the emergence of the current discipline of neurogastroenterology or the study of the "brain-gut axis," which is based on dysregulation of neuroenteric pathways as a key pathophysiologic feature of the FGIDs. Psychopharmacologic and behavioral treatments can influence the dysregulation of these pathways, especially at the severe end of the spectrum, and improve the clinical manifestations of these conditions, visceral discomfort or pain and bowel dysfunction. Their actions are mostly at spinal and supraspinal levels with some direct benefits at the level of the gut. Improvements in coping, global distress, and overall quality of life (QOL) have been shown more consistently with these treatments compared with improvement in GI symptoms. A successful approach to patients with these treatments requires a good physician-patient relationship. Strategizing treatments with these modalities is based on recognition of their dual effects on brain and gut, understanding the nature and severity of the GI symptoms and their psychosocial concomitants, and applying them within the context of the patient's understanding of their value.

Bacterial overgrowth and irritable bowel syndrome: unifying hypothesis or a spurious consequence of proton pump inhibitors?

Some studies indicate that small intestinal bacterial overgrowth (SIBO), as measured by hydrogen breath tests (HBT), is more prevalent in patients with irritable bowel syndrome (IBS) vs. matched controls without IBS. Although the data are conflicting, this observation has led to the hypothesis that SIBO may be a primary cause of IBS. Yet, it remains unclear whether SIBO is truly fundamental to the pathophysiology of IBS, or is instead a mere epiphenomenon or bystander of something else altogether. We hypothesize that SIBO might be a byproduct of the disproportionate use of proton pump inhibitors (PPIs) in IBS, as follows: (1) IBS patients are more likely than controls to receive PPI therapy; (2) PPI therapy may promote varying forms of SIBO by eliminating gastric acid; and (3) existing studies linking SIBO to IBS have not adjusted for or excluded the use of PPI therapy. When linked together, these premises form the basis for a simple and testable hypothesis: the relationship between SIBO and IBS may be confounded by PPIs. Our article explores these premises, lays out the argument supporting this "PPI hypothesis," discusses potential implications, and outlines next steps to further investigate this possibility.

Bacterial overgrowth and irritable bowel syndrome: unifying hypothesis or a spurious consequence of proton pump inhibitors?

Some studies indicate that small intestinal bacterial overgrowth (SIBO), as measured by hydrogen breath tests (HBT), is more prevalent in patients with irritable bowel syndrome (IBS) vs. matched controls without IBS. Although the data are conflicting, this observation has led to the hypothesis that SIBO may be a primary cause of IBS. Yet, it remains unclear whether SIBO is truly fundamental to the pathophysiology of IBS, or is instead a mere epiphenomenon or bystander of something else altogether. We hypothesize that SIBO might be a byproduct of the disproportionate use of proton pump inhibitors (PPIs) in IBS, as follows: (1) IBS patients are more likely than controls to receive PPI therapy; (2) PPI therapy may promote varying forms of SIBO by eliminating gastric acid; and (3) existing studies linking SIBO to IBS have not adjusted for or excluded the use of PPI therapy. When linked together, these premises form the basis for a simple and testable hypothesis: the relationship between SIBO and IBS may be confounded by PPIs. Our article explores these premises, lays out the argument supporting this "PPI hypothesis," discusses potential implications, and outlines next steps to further investigate this possibility.

Complementary and alternative medicine for IBS in adults: mind-body interventions

Standard treatment for IBS focuses on the management or alleviation of the predominant gastrointestinal presenting symptoms, such as diarrhea or constipation, often using pharmacological therapy. For many patients, this approach is unsatisfactory, and patients frequently seek the advice of complementary and alternative medicine (CAM) practitioners in order to explore other treatment options. CAM practices include a broad range of modalities, and mind-body interventions hold particular promise as treatment modalities for IBS because psychological factors could have an important role in IBS symptomatology and quality of life. Psychological stressors are postulated to result in gastrointestinal symptoms through alteration of intestinal function mediated by the autonomic nervous system, hypothalamic-pituitary-adrenal axis and immune system. Hypnotherapy has the strongest supportive evidence as a beneficial mind-body intervention for IBS. Clinical studies of hypnotherapy have uniformly shown improvement of gastrointestinal symptoms, anxiety, depression and quality of life in patients with IBS. Mindfulness meditation remains unstudied for IBS, but is theoretically attractive as a stress-reduction technique. There is a suggestion that relaxation therapy or multimodal therapy (a combination of relaxation therapy, education and psychotherapy) is beneficial for IBS. The most generally accepted psychological mind-body intervention is cognitive behavioral therapy, and clinical trials support the beneficial effects of cognitive behavioral therapy in patients with IBS.

The role of biofeedback in the treatment of gastrointestinal disorders

Biofeedback is a form of treatment that has no adverse effects and can be provided by physician extenders. The therapy relies on patients' ability to learn how to influence their bodily functions through dedicated machinery and teaching. This Review provides a comprehensive overview of all potential therapeutic applications of biofeedback for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia. Practical clinical applications of biofeedback therapy supported by randomized, controlled trials (RCTs) are limited to fecal incontinence and dyssynergic defecation. For fecal incontinence, RCTs suggest that biofeedback combining strength training and sensory discrimination training is effective in approximately 75% of patients and is more effective than placebo. However, verbal feedback provided by a therapist during extended digital examination may be equally effective, and children whose fecal incontinence is associated with constipation plus fecal impaction do no better with biofeedback than medical management. For dyssynergic defecation, RCTs show that biofeedback combining pelvic floor muscle relaxation training, practice in defecating a water-filled balloon, and instruction in effective straining is effective in approximately 70% of patients who have failed to respond to laxative treatment. For both incontinence and dyssynergic defecation, the benefits of biofeedback last at least 12 months.

A meta-analysis of the placebo response in complementary and alternative medicine trials of irritable bowel syndrome

Among patients with irritable bowel syndrome (IBS) enrolled in clinical trials of conventional medical therapy, the placebo response rate is high. IBS patients also frequently use complementary and alternative medicine (CAM), which may act through an 'enhanced placebo effect'. The purpose of this study was to estimate the magnitude of the placebo response rate in CAM trials for IBS and to identify factors that influence this response. We performed a systematic review and meta-analysis of randomized, placebo-controlled clinical trials of CAM therapies for IBS identified from MEDLINE/EMBASE/PsychLIT databases from 1970 to 2006. Placebo and active treatment response rates for global symptom improvement were assessed. Nineteen studies met the inclusion criteria. The pooled estimate of the placebo response rate was 42.6% (95% confidence interval, 38.0-46.5%). Significant heterogeneity existed across trials (range 15.0-72.2%, P < 0.00001). Higher placebo response rates correlated with a longer duration of treatment (r = 0.455, P = 0.05) and a greater number of office visits (r = 0.633, P = 0.03). Among IBS patients in CAM trials, the placebo response rate is high. That this rate is similar in magnitude to that seen in conventional medicine trials suggests that the placebo response is independent of the type of therapy used and that it is not particularly 'enhanced' in CAM trials.

Is there a benefit from intensified medical and psychological interventions in patients with functional dyspepsia not responding to conventional therapy?

AIM

In a prospective randomized, controlled trial, to compare the long-term outcome of intensive medical therapy (with or without cognitive-behavioural or muscle relaxation therapy) vs. standard medical therapy in patients with refractory functional dyspepsia (FD), referred to a tertiary referral medical center.

METHODS

A total of 100 consecutive FD patients were allocated to a standardized symptom-oriented 4 month therapy (SMT, n = 24), intensive medical therapy (IMT, medical therapy with testing-for and targeting-of abnormalities of motor-and-sensory function, n = 28) or IMT plus psychological interventions (either progressive-muscle relaxation (IMT-MR, n = 20) or cognitive-behavioural therapy (IMT-CBT, n = 28). The symptom intensity (SI) and health-related quality-of-life (HRQoL) after 12 months were prespecified primary outcome parameters.

RESULTS

After 12 months, significantly greater improvement of SI occurred in patients with IMT-all (with or without psychological interventions) compared with SMT (P < 0.025 vs. IMT-all). IMT, IMT-MR and IMT-CBT alone also resulted in significantly better improvement of the primary outcome parameters (P all < 0.025 vs. SMT). HRQoL significantly improved in all groups with intensive medical therapy but not standard medical therapy. Differences between intensive medical therapy-all and standard medical therapy were not significant. Concomitant anxiety and depression was improved significantly by IMT-CBT (vs. SMT) but not other treatments.

CONCLUSIONS

In FD patients with refractory symptoms, intensified medical management involving function testing and psychological intervention yields superior long-term-outcomes. Additional CBT may be effective for the control of concomitant anxiety and depression.

Systematic review: the efficacy of treatments for irritable bowel syndrome--a European perspective

BACKGROUND

Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit.

AIM

To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe. The safety and tolerability of these therapies are the subject of an accompanying review.

METHODS

A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome.

RESULTS

There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised.

CONCLUSIONS

There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.

A meta-analysis of the effects of psychological interventions in pediatric oncology on outcomes of psychological distress and adjustment

OBJECTIVE

To estimate the effectiveness of psychological interventions in pediatric oncology on decreasing psychological distress and increasing psychological adjustment using meta-analytic methods.

METHODS

A meta-analysis was conducted on 12 psychological intervention studies in pediatric oncology using a weighted least squares (WLS) approach and random effect models.

RESULTS

Effect sizes significantly different from zero were found for parent distress (mean = 0.35, 95% CI = 0.20-0.49, n = 7) and parent adjustment (mean = 0.23, 95% CI = 0.07-0.40, n = 5). Effect sizes for child distress, child adjustment, parent-reported child distress, and parent-reported child adjustment were not significantly different from zero.

CONCLUSIONS

Psychological interventions in pediatric oncology show promise in decreasing distress and improving the adjustment of parents of children with cancer but may have minimal effects for child outcomes. Methodological issues of intervention research are discussed.

Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy

Using a sample of over 125 patients with irritable bowel syndrome (IBS) who were treated with cognitive therapy administered in small groups, we sought to predict end of treatment and 3-month follow-up improvement in two changes indices of gastrointestinal (GI) symptoms (Pain/Discomfort Index which assessed change in abdominal pain, abdominal tenderness and bloating and Bowel Regularity Index which assessed change in diarrhea and constipation). We also sought to predict scores on IBS specific quality of life (QOL) and overall level of psychological distress using the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant, but modest, levels of prediction were found for prediction of improvement in GI symptoms (4-15% of variance). Stronger significant prediction was obtained for the QOL and global psychological distress measure with R(2)'s ranging from 0.36 to 0.50. A wide variety of demographic, GI symptom, psychological status and psychiatric status variables entered the final prediction equations.

Psychosocial assessment of functional gastrointestinal disorders in clinical practice

Functional gastrointestinal disorders are the most common conditions encountered in gastroenterology practice and are also commonly encountered in primary care. Psychosocial factors play an important role in these disorders (along with any chronic digestive disorder) by influencing healthcare seeking, illness behavior, symptom severity, quality of life, and digestive motility and sensation. Identification of relevant psychosocial factors in patients with chronic digestive disorders influences care and is a critical determinant of outcomes. This article provides a review of relevant psychosocial variables, assessment techniques, and therapeutic suggestions that can be of value in assessing patients with functional gastrointestinal disorders.

Cognitive-behavioral treatment of irritable bowel syndrome

There is increasing evidence that supports the view that irritable bowel disorder (IBS) is a disorder of brain-gut function. Cognitive-behavioral therapy (CBT) has received increased attention in light of this recent shift in the conceptualization of IBS. This review has two main aims. The first is to provide a critical review of controlled trials on CBT for IBS. The second is to discuss ways of further developing CBT interventions that are more clinically relevant and meaningful to health care providers and individuals with a diagnosis of IBS. A theme from a CBT intervention will be presented to illustrate how CBT interventions can be incorporated within a larger social context. A review of CBT for IBS lends some limited support for improvement in some IBS symptoms and associated psychosocial distress. This conclusion needs to be expressed with some caution, however, in light of many methodological shortcomings including small sample sizes, inadequate control conditions and failure to identify primary versus secondary outcome measures. In addition, future studies will need to further develop more relevant CBT protocols that more fully integrate the patient's perspective and challenge social cognitions about this stigmatized disorder.

Towards A Better Understanding of Anxiety in Irritable Bowel Syndrome: A Preliminary Look at Worry and Intolerance of Uncertainty

Although it has been fairly well established that symptoms of anxiety are often present in patients with irritable bowel syndrome (IBS), less is known about the role of worry and intolerance of uncertainty in this population. This study investigates the relations among these variables in a sample of treatment-seeking IBS patients. Although the results are preliminary, worry does seem to predict gastrointestinal symptom severity and, when combined with a measure of current anxiety, accounts for almost 30% of the variance. Intolerance of uncertainty differentiated diarrhea-predominant IBS patients from constipation-predominant IBS patients. Earlier research has taken a psychiatric perspective on anxiety in IBS patients—the current study may provide some support for shifting our focus to the cognitive biases that may be operating in IBS patients, regardless of the presence of an anxiety disorder. Implications for a cognitive therapy approach to IBS treatment are discussed.

Potential future therapies for irritable bowel syndrome: will disease modifying therapy as opposed to symptomatic control become a reality?

Irritable bowel syndrome can remit spontaneously, implying cure is possible. Predictors of good prognosis include a short history, acute onset(possibly postinfective origin), absence of psychological disorders, and resolution of chronic life stressors. Possible-disease modifying treatments with long-lasting effects include diet and anti-inflammatory and psychological treatments. Dietary modifications, which often involve excluding dairy and wheat products, are successful in some patients. Anti-inflammatory treatments have been subjected to one RCT in postinfective IBS without benefit. Probiotics may have benefit in altering bacterial flora and as anti-inflammatory agents, but further trials are needed before they can be recommended. Psychological treatments may produce long-lasting responses. Relaxation therapy appears to have a nonspecific benefit. Psychotherapy has been shown to have long-term benefit and is particularly acceptable to, and effective for, those with overt psychological distress. Hypnotherapy has been shown to be effective in randomized placebo controlled trials and has a sustained effect.

A Critical Review of Cognitive, Behavioral, and Cognitive-Behavioral Therapies for Irritable Bowel Syndrome

Research on controlled evaluations of psychological treatments for IBS is summarized with regards to methodology and outcome, with special attention to differential outcome. There is ample evidence to support the efficacy of various combinations of cognitive and behavioral therapy techniques as well as brief psychodynamic psychotherapy, and hypnotherapy. There has also recently appeared some evidence that is not supportive of each approach. Long-term follow-up, although relatively rare, generally finds the maintenance of initial improvement in IBS symptoms. There is some growing evidence on changes in the putative cognitive mechanisms targeted by the cognitive therapy techniques. More research is needed on these process variables. The field may be ripe for direct comparisons of 2 or more psychological approaches to the IBS treatment.

Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis

This study conducted a systematic review to assess the quality of existing literature on psychological treatments for irritable bowel syndrome and to quantify the evidence for their efficacy. Three independent reviewers (2 from England, 1 from the United States) coded the quality of 32 studies, 17 of which provided data suitable for meta-analysis. Meta-analysis of efficacy data (50% reduction of symptoms) gave an odds ratio of 12 (95% confidence interval = 5.56-25.96) and a number needed to treat of 2. Psychological treatments are, as a class of interventions, effective in reducing symptoms compared with a pooled group of control conditions. Questions regarding the relative superiority of specific psychological treatments and influence of active versus nonspecific treatment effects remain unanswered.

Cognitive behaviour therapy for irritable bowel syndrome

The UK Department of Health states that there is suggestive, although not conclusive, evidence for the efficacy of cognitive behavioural therapy (CBT) in irritable bowel syndrome (IBS) and that CBT should be considered as a treatment option for the syndrome. This paper provides a general introduction to CBT, the principles which underlie it and how they can be applied to IBS. The components of CBT for IBS are described in some detail. Guidelines for gastroenterologists are provided on how these principles can be used to inform their practice and the existing outcome data are reviewed.