"Answer to irritable bowel syndrome is the mind, study shows," states The Telegraph.
The headline is based on research conducted in the UK involving people with irritable bowel syndrome (IBS).
They were provided with different types of cognitive behavioural therapy (CBT) on top of usual treatment, compared with usual treatment alone, to help reduce their IBS symptoms.
The researchers found both web-based and telephone-based CBT reduced IBS symptoms more than usual treatment, which involved IBS medications and GP follow-up.
The CBT approach was based on a number of factors, such as tackling unhelpful thoughts related to IBS.
As IBS can be triggered by stress and anxiety, getting stressed or anxious about the condition in the first place could make symptoms worse.
These results are promising and provide additional support for the UK NICE guidelines for IBS, which also recommend CBT and talking therapies to help reduce IBS symptoms.
The fact that both telephone-based and web-based CBT were effective is also promising, as access to face-to-face CBT is often limited.
One issue is that quite a few people dropped out of this study before it finished, which reduces how reliable the results are.
Also, the research does not provide information on which parts of the CBT programme worked best for people affected by IBS.
This information may help prevent IBS symptoms getting worse for those who have recently been diagnosed with the condition.
Where did the story come from?
The study was carried out by researchers from the University of Southampton, King's College London and King's College Hospital.
It was funded by the National Institute for Health Research.
The headlines from the Mail Online and The Independent are slightly misleading, as they both imply that talking therapies are better than drugs for IBS.
But to be eligible for this trial, only people who did not have their IBS successfully treated with drugs for 12 or more months were included.
So the study group may not have been representative of people with IBS who did respond to drugs. And this means the 2 treatments cannot be directly compared.
What kind of research was this?
This study is a randomised controlled trial (RCT) with 3 different interventions being tested. RCTs are the most reliable way of assessing the effect of something.
In this study, the RCT aimed to find out whether people with IBS experienced fewer symptoms when they used web-based CBT, telephone-based CBT or usual treatment.
The more people included in an RCT the better, and this trial was fairly large, but only 558 out of 1,452 people (38.4%) were included. Only 70.1% of these completed 12 months of follow-up.
What did the research involve?
To get people involved in the RCT, the researchers sent letters to the GPs of 15,065 people who'd had IBS between May 2014 and March 2016.
Of those, 1,452 people were determined to be eligible for the trial.
People were eligible if they:
- were clinically assessed as having IBS
- had ongoing symptoms of IBS measured using an assessment tool called the IBS symptom severity score
- had been provided with some standard treatments for IBS
- had been suffering from IBS for more than or equal to 12 months
People were excluded if they had:
- unexplained bleeding from the bottom or weight loss
- inflammatory bowel disease
- coeliac disease
- peptic ulcer disease
- colorectal cancer
- were younger than 18 years old
- received CBT in the last 2 years
A final 558 people met the inclusion criteria and agreed to take part. Of those, 76% were female and 91% were white, with a mean age of 43 years.
They were then randomised to receive 1 of the following interventions for treating IBS:
- telephone-delivered CBT plus usual care
- web-based CBT plus usual care
- treatment as usual, which included taking IBS medications and usual GP or consultant follow-up with no psychological therapy
People in all 3 groups received an information sheet on lifestyle and diet in IBS. All therapists were qualified to deliver CBT.
To assess if the interventions were working, the primary outcomes were people's IBS symptoms and their ability to participate in usual life activities assessed at baseline, 3, 6 and 12 months.
The primary outcomes were tested using the change in 2 rating scales:
- the IBS symptom severity score (IBS-SSS), scale 0 (not affected) to 500 (most severely affected) – a 35-point change between the groups was determined to be a significant difference
- the work and social adjustment scale (WSAS), scored between 0 (not affected) and 40 (severely affected) – based on how disruptive IBS was to both a person's working and social life
The researchers also tested several secondary outcomes, including:
- mood, symptom relief and ability to cope with IBS symptoms at 3, 6 and 12 months
- people's ability to cope with their illness and life after treatment
- overall mood
The trial stopped after 12 months of starting the interventions, and 70.1% of people completed their allocated treatment group.
What were the basic results?
From baseline to 12 months, IBS-SSS scores were:
- slightly improved in the treatment-as-usual group, from 258 to 206
- moderately improved in the telephone CBT group, from 272 to 139 (adjusted comparison 61.6 points lower than the usual treatment group, 95% confidence interval [CI] 33.8 to 89.5)
- moderately improved in the web CBT group, from 264 to 163 (adjusted comparison 35.2 points lower than the usual treatment group, 95% CI 12.6 to 57.8)
From baseline to 12 months, WSAS scores were:
- slightly improved from 12.4 to 10.8 in the treatment-as-usual group
- moderately improved from 12.3 to 6 in the telephone CBT group (adjusted comparison 3.5 points lower than treatment as usual, 95% CI 1.9 to 5.1)
- moderately improved from 13 to 7.4 in the web CBT group (adjusted comparison 3 points lower than the usual treatment group, 95% CI 1.3 to 4.6)
All secondary outcomes showed significantly greater improvement for people who were receiving CBT over treatment as usual.
How did the researchers interpret the results?
The researchers stated that this is the first large RCT with long-term follow-up that compares web-based CBT for IBS with telephone-delivered CBT with treatment as usual.
They go on to say that both CBT interventions showed clinically and statistically significant improvements in IBS symptoms and impact on life and mood that were maintained at 12 months.
They concluded that good adherence to treatment and sustained improvements in IBS at 12 months can be achieved with telephone and web-based CBT for IBS.
This RCT uses a fairly large sample size of patients, and suggests both web-based and telephone-based CBT could help people who suffer from the symptoms of IBS.
While the results are promising, as ever there are limitations that may reduce the impact of these findings.
This trial may not be representative of everyone with IBS. People who are unwilling to try CBT for IBS are unlikely to have participated, for example, and a lot of people with IBS do not seek medical treatment.
Many people dropped out of the trial over 12 months, which reduces the reliability of the results.
Most people in the trial were white (91%). There are known ethnic differences in people affected by IBS as a result of dietary and cultural factors, but this trial could not assess this because of the small sample size of different ethnicities.
Despite these limitations, this trial does provide evidence that both web-based and telephone-delivered CBT are better than usual treatment.
But the results do not give us any practical information about what elements of the therapy helped control or reduce symptoms of IBS.
This could have been the result of changes in diet, reduction in stress, improved sleep or other factors.
Further detail on the lifestyle changes that really worked for people with IBS in this trial would help healthcare professionals target the right individuals for these treatments.
You can get psychological therapies, including CBT, on the NHS. You do not need a referral from your GP – you can refer yourself directly to a psychological therapies service.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
The Telegraph, 11 April 2019
Mail Online, 11 April 2019
The Independent, 11 April 2019
The Guardian, 11 April 2019
Links to the science
Gut. Published online April 10 2019