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NIHR Signal Telephone or internet delivered talking therapy can alleviate irritable bowel symptoms

Published on 27 June 2019

doi: 10.3310/signal-000784

People with irritable bowel syndrome may find cognitive behavioural therapy (a talking therapy) delivered via telephone or internet improves their symptoms. Compared with usual care alone, both interventions were shown to be more effective, with telephone delivery resulting in greater symptom reduction and web-based therapy being more cost-effective.

Irritable bowel symptoms can persist long-term and have a major impact on the quality of life. Stress is one of the known triggers. Cognitive behavioural therapy is known to help people identify and manage negative thought patterns. However, the availability of face-to-face talking therapy on the NHS is limited, especially for people without mental health symptoms.

This NIHR-funded trial involved 558 people with symptoms that were not responding to usual treatment such as medication.

The reductions in symptoms were thought to be clinically important, suggesting that they are worth exploring as a cost-effective and accessible way to help people manage their condition.

Share your views on the research.

Why was this study needed?

Irritable bowel syndrome affects up to 10 to 20% of the population. Symptoms include bloating, constipation and diarrhoea. There is no cure, and people with the condition often experience recurrent flare-ups.

Usual treatment includes maintaining a healthy lifestyle, and medication such as laxatives and antispasmodics. Face-to-face cognitive behavioural therapy has been shown to help, but NHS availability is limited, and some people find it difficult to attend appointments. Remote delivery options, such as web and telephone therapy, have the potential to overcome these barriers, but their effectiveness has yet to be established for irritable bowel symptoms. This large study helps add to the evidence base.

What did this study do?

This randomised controlled trial involved 558 people with irritable bowel syndrome that had not responded to usual treatment. They were recruited from 74 GP surgeries and three gastroenterology outpatient clinics.

People were randomised to receive treatment as usual or, in addition, either telephone or web-based therapy. The content was aimed at fostering healthy eating patterns, managing stress, and reducing focus on symptoms. The telephone arm received a self-help manual and 8 hours of telephone therapist support. The web participants received online access to an interactive website and 2.5 hours of telephone therapist support. Assessments were undertaken at baseline, 3, 6 and 12 months.

Limitations of this trial include the higher than ideal dropout rate, which may mean that the true benefit is smaller than it appears. The low rates of participation from eligible people may mean that many people are unwilling to try, or stick with this talking therapy, limiting its feasibility to be used more widely.

What did it find?

  • According to the irritable bowel symptom severity score (IBS-SSS), a scale of 0 (not affected) to 500 (severe), all groups saw a sustained reduction in symptoms at 12 months. The telephone cognitive behavioural therapy (CBT) group fell 61.6 points lower than the usual treatment group, (95% confidence interval [CI] 33.8 to 89.5) and the web CBT group 35.2 points lower than the usual treatment group, (95% CI 12.6 to 57.8). Authors previously determined a 35-point change between the groups was clinically significant.
  • The primary outcome was also measured by the work and social adjustment scale (WSAS), scored between 0 (not affected) and 40 (severely affected). A slight improvement was seen in the treatment as usual group; scores improved from 12.4 to 10.8. Scores in the telephone CBT group improved to 3.5 points lower than treatment as usual, (95% CI 1.9 to 5.1) and the web CBT group 3.0 points lower than the usual treatment group, (95% CI 1.3 to 4.6).
  • Telephone CBT had greater adherence rates, with 84% of patients meeting the threshold for adherence, compared with 70% in the web CBT arm.
  • More adverse events were seen in the CBT groups, 77 in the telephone CBT arm, 61 in the web CBT arm and 55 in the treatment as usual arm. Authors attribute this to the therapist reporting protocol.
  • Compared with treatment as usual, the incremental cost-effectiveness ratio (ICER) was £22,824 for telephone CBT and £7,724 for web CBT.

What does current guidance say on this issue?

The NICE 2008 guideline on the management of irritable bowel syndrome recommends dietary and lifestyle changes, such as increasing physical activity.

Laxatives and other medications may also be prescribed, and if these do not work, antidepressants can be given as they can help reduce pain. If the above treatments do not improve symptoms after 12 months, people can be referred for psychological treatment such as CBT.

What are the implications?

Although a promising alternative to traditional face-to-face cognitive behavioural therapy, web and telephone delivered therapy still requires trained therapist input.

Therapists working in the Improving Access to Psychological Therapies services may already possess the required skills, but this does not address the additional therapist hours needed.

It may be that further research pinpointing the most effective cognitive behavioural therapy elements for these disabling symptoms is necessary to help focus resources further.

Citation and Funding

Everitt H, Landau G, Little P et al. Therapist telephone-delivered CBT and web-based CBT compared with treatment as usual in refractory irritable bowel syndrome: the ACTIB three-arm RCT. Health Technol Assess. 2019;23(17).

This project was funded by the NIHR Health Technology Assessment Programme (project number 11/69/02).

Bibliography

Everitt H, Landau S, O’Reilly G et al. Assessing telephone-delivered cognitive–behavioural therapy (CBT) and web-delivered CBT versus treatment as usual in irritable bowel syndrome (ACTIB): a multicentre randomised trial. Gut. 2019; Apr 10. doi: 10.1136/gutjnl-2018-317805. [Epub ahead of print].

Francis C, Morris J and Whorwell P. The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther. 1997;11:395-402.

NHS website. Irritable bowel syndrome (IBS). London: Department of Health and Social Care; updated 2017.

NICE. Irritable bowel syndrome in adults: diagnosis and management. CG61. London: National Institute for Health and Care Excellence; 2008.

Why was this study needed?

Irritable bowel syndrome affects up to 10 to 20% of the population. Symptoms include bloating, constipation and diarrhoea. There is no cure, and people with the condition often experience recurrent flare-ups.

Usual treatment includes maintaining a healthy lifestyle, and medication such as laxatives and antispasmodics. Face-to-face cognitive behavioural therapy has been shown to help, but NHS availability is limited, and some people find it difficult to attend appointments. Remote delivery options, such as web and telephone therapy, have the potential to overcome these barriers, but their effectiveness has yet to be established for irritable bowel symptoms. This large study helps add to the evidence base.

What did this study do?

This randomised controlled trial involved 558 people with irritable bowel syndrome that had not responded to usual treatment. They were recruited from 74 GP surgeries and three gastroenterology outpatient clinics.

People were randomised to receive treatment as usual or, in addition, either telephone or web-based therapy. The content was aimed at fostering healthy eating patterns, managing stress, and reducing focus on symptoms. The telephone arm received a self-help manual and 8 hours of telephone therapist support. The web participants received online access to an interactive website and 2.5 hours of telephone therapist support. Assessments were undertaken at baseline, 3, 6 and 12 months.

Limitations of this trial include the higher than ideal dropout rate, which may mean that the true benefit is smaller than it appears. The low rates of participation from eligible people may mean that many people are unwilling to try, or stick with this talking therapy, limiting its feasibility to be used more widely.

What did it find?

  • According to the irritable bowel symptom severity score (IBS-SSS), a scale of 0 (not affected) to 500 (severe), all groups saw a sustained reduction in symptoms at 12 months. The telephone cognitive behavioural therapy (CBT) group fell 61.6 points lower than the usual treatment group, (95% confidence interval [CI] 33.8 to 89.5) and the web CBT group 35.2 points lower than the usual treatment group, (95% CI 12.6 to 57.8). Authors previously determined a 35-point change between the groups was clinically significant.
  • The primary outcome was also measured by the work and social adjustment scale (WSAS), scored between 0 (not affected) and 40 (severely affected). A slight improvement was seen in the treatment as usual group; scores improved from 12.4 to 10.8. Scores in the telephone CBT group improved to 3.5 points lower than treatment as usual, (95% CI 1.9 to 5.1) and the web CBT group 3.0 points lower than the usual treatment group, (95% CI 1.3 to 4.6).
  • Telephone CBT had greater adherence rates, with 84% of patients meeting the threshold for adherence, compared with 70% in the web CBT arm.
  • More adverse events were seen in the CBT groups, 77 in the telephone CBT arm, 61 in the web CBT arm and 55 in the treatment as usual arm. Authors attribute this to the therapist reporting protocol.
  • Compared with treatment as usual, the incremental cost-effectiveness ratio (ICER) was £22,824 for telephone CBT and £7,724 for web CBT.

What does current guidance say on this issue?

The NICE 2008 guideline on the management of irritable bowel syndrome recommends dietary and lifestyle changes, such as increasing physical activity.

Laxatives and other medications may also be prescribed, and if these do not work, antidepressants can be given as they can help reduce pain. If the above treatments do not improve symptoms after 12 months, people can be referred for psychological treatment such as CBT.

What are the implications?

Although a promising alternative to traditional face-to-face cognitive behavioural therapy, web and telephone delivered therapy still requires trained therapist input.

Therapists working in the Improving Access to Psychological Therapies services may already possess the required skills, but this does not address the additional therapist hours needed.

It may be that further research pinpointing the most effective cognitive behavioural therapy elements for these disabling symptoms is necessary to help focus resources further.

Citation and Funding

Everitt H, Landau G, Little P et al. Therapist telephone-delivered CBT and web-based CBT compared with treatment as usual in refractory irritable bowel syndrome: the ACTIB three-arm RCT. Health Technol Assess. 2019;23(17).

This project was funded by the NIHR Health Technology Assessment Programme (project number 11/69/02).

Bibliography

Everitt H, Landau S, O’Reilly G et al. Assessing telephone-delivered cognitive–behavioural therapy (CBT) and web-delivered CBT versus treatment as usual in irritable bowel syndrome (ACTIB): a multicentre randomised trial. Gut. 2019; Apr 10. doi: 10.1136/gutjnl-2018-317805. [Epub ahead of print].

Francis C, Morris J and Whorwell P. The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther. 1997;11:395-402.

NHS website. Irritable bowel syndrome (IBS). London: Department of Health and Social Care; updated 2017.

NICE. Irritable bowel syndrome in adults: diagnosis and management. CG61. London: National Institute for Health and Care Excellence; 2008.

Therapist telephone-delivered CBT and web-based CBT compared with treatment as usual in refractory irritable bowel syndrome: the ACTIB three-arm RCT

Published on 1 May 2019

Everitt H, Landau S, Little P, Bishop FL, O'Reilly G, Sibelli A, Holland R, Hughes S, Windgassen S, McCrone P, Goldsmith K, Coleman N, Logan R, Chalder T & Moss-Morris R.

Health Technology Assessment Volume 23 Issue 17 , 2019

BACKGROUND: Irritable bowel syndrome (IBS) affects 10-22% of people in the UK. Abdominal pain, bloating and altered bowel habits affect quality of life and can lead to time off work. Current treatment relies on a positive diagnosis, reassurance, lifestyle advice and drug therapies, but many people suffer ongoing symptoms. Cognitive-behavioural therapy (CBT) is recommended in guidelines for patients with ongoing symptoms but its availability is limited. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of therapist telephone-delivered CBT (TCBT) and web-based CBT (WCBT) with minimal therapist support compared with treatment as usual (TAU) in refractory IBS. DESIGN: This was a three-arm randomised controlled trial. SETTING: This trial took place in UK primary and secondary care. PARTICIPANTS: Adults with refractory IBS (clinically significant symptoms for 12 months despite first-line therapies) were recruited from 74 general practices and three gastroenterology centres from May 2014 to March 2016. INTERVENTIONS: TCBT - patient CBT self-management manual, six 60-minute telephone sessions over 9 weeks and two 60-minute booster sessions at 4 and 8 months (8 hours' therapist time). WCBT - interactive, tailored web-based CBT, three 30-minute telephone sessions over 9 weeks and two 30-minute boosters at 4 and 8 months (2.5 hours' therapist time). MAIN OUTCOME MEASURES: Primary outcomes - IBS symptom severity score (IBS SSS) and Work and Social Adjustment Scale (WSAS) at 12 months. Cost-effectiveness [quality-adjusted life-years (QALYs) and health-care costs]. RESULTS: In total, 558 out of 1452 patients (38.4%) screened for eligibility were recruited - 186 were randomised to TCBT, 185 were randomised to WCBT and 187 were randomised to TAU. The mean baseline Irritable Bowel Syndrome Symptom Severity Score (IBS SSS) was 265.0. An intention-to-treat analysis with multiple imputation was carried out at 12 months; IBS SSS were 61.6 points lower in the TCBT arm [95% confidence interval (CI) 89.5 to 33.8; p < 0.001] and 35.2 points lower in the WCBT arm (95% CI 57.8 to 12.6; p = 0.002) than in the TAU arm (IBS SSS of 205.6). The mean WSAS score at 12 months was 10.8 in the TAU arm, 3.5 points lower in the TCBT arm (95% CI 5.1 to 1.9; p < 0.001) and 3.0 points lower in the WCBT arm (95% CI 4.6 to 1.3; p = 0.001). For the secondary outcomes, the Subject's Global Assessment showed an improvement in symptoms at 12 months (responders) in 84.8% of the TCBT arm compared with 41.7% of the TAU arm [odds ratio (OR) 6.1, 95% CI 2.5 to 15.0; p < 0.001] and 75.0% of the WCBT arm (OR 3.6, 95% CI 2.0 to 6.3; p < 0.001). Patient enablement was 78.3% (responders) for TCBT, 23.5% for TAU (OR 9.3, 95% CI 4.5 to 19.3; p < 0.001) and 54.8% for WCBT (OR 3.5, 95% CI 2.0 to 5.9; p < 0.001). Adverse events were similar between the trial arms. The incremental cost-effectiveness ratio (ICER) (QALY) for TCBT versus TAU was £22,284 and for WCBT versus TAU was £7724. Cost-effectiveness reduced after imputation for missing values. Qualitative findings highlighted that, in the CBT arms, there was increased capacity to cope with symptoms, negative emotions and challenges of daily life. Therapist input was important in supporting WCBT.CONCLUSIONS: In this large, rigorously conducted RCT, both CBT arms showed significant improvements in IBS outcomes compared with TAU. WCBT had lower costs per QALY than TCBT. Sustained improvements in IBS symptoms are possible at an acceptable cost. Suggested future research work is longer-term follow-up and research to translate these findings into usual clinical practice. FUTURE WORK: Longer-term follow-up and research to translate these findings into usual clinical practice is needed. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 23, No. 17. See the NIHR Journals Library website for further project information. The University of Southampton sponsored this study. Funding was received from the NIHR HTA Board and the NIHR Clinical Research Network and support was received from the NIHR Clinical Research Network.

Expert commentary

IBS affects a significant number of people, and the use of cognitive behavioural therapy has been long established. However, its availability can limit its use.

Accessing traditional face-to-face counselling can also be difficult for those with busy, complicated lifestyles. This study shows that accessing cognitive behavioural therapy remotely is effective, and is something that we should be recommending to patients in line with NICE guidelines. 

Kevin Barrett, GP, New Road Surgery, Croxley Green; Chair of the Primary Care Society for Gastroenterology; RCGP and Crohn's and Colitis UK Spotlight Project Lead Clinical Champion

The commentator declares no conflicting interests