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NIHR Signal Telephone-delivered CBT can provide lasting benefits for people with IBS

Published on 21 November 2019

doi: 10.3310/signal-000842

People with irritable bowel syndrome (IBS) who receive cognitive behavioural therapy (CBT) continue to have lower levels of symptoms over the following two years. Telephone-delivered CBT is particularly effective, with 71% of study participants experiencing a clinically significant improvement in their IBS symptoms.

This NIHR-funded study is the 24-month follow-up to an earlier publication of 12-month outcomes for 558 people with IBS receiving usual care alone or additional telephone or web-based therapy. The former paper showed that both therapies helped people deal with their IBS.

This longer-term follow-up shows that CBT continues to benefit patients months after therapy sessions have stopped, with the greater therapist contact time appearing to give the best results.

IBS can be a very debilitating and difficult condition to treat. The present study helps strengthen the case for the provision of remote talking therapies, particularly telephone-based therapy, as a way to improve access and outcomes for patients.

Share your views on the research.

Why was this study needed?

As many as 10 to 20% of the population is affected by IBS. Symptoms include diarrhoea, bloating and constipation. Usual treatment includes maintaining a healthy lifestyle, and medication such as laxatives and antispasmodics. However, these only manage the condition and many people experience recurrent flare-ups.

Face-to-face CBT has been shown to help, but NHS availability is limited, and some people can struggle to attend appointments. Remote delivery options, such as web and telephone therapy, have been shown to help overcome these barriers, but their long-term effectiveness has yet to be established. This study aimed to demonstrate whether the effectiveness of CBT continues in the months after sessions have ceased.

What did this study do?

The original study involved 558 people with IBS that had not responded to the usual treatment. They were randomised to continue to receive usual care alone or to have either telephone-CBT or web-based CBT in addition.

The CBT content was aimed at fostering healthy eating patterns, managing stress and reducing symptoms. The telephone-CBT arm received a self-help manual and 8 hours of telephone therapist support, whereas web-CBT participants received access to an interactive website and 2.5 hours of telephone therapist support over eight months.

After the first 12 months of the trial, the treatment as usual group were given access to the website (web-CBT participants had ongoing access). Telephone-CBT participants were not given access to the website but could continue to use their CBT manuals.

A limitation of this study is the number of people lost to follow-up (42%). The researchers used the data they had to take this missing data into account and avoid bias in their analyses.

What did it find?

  • Symptoms were assessed by the IBS Symptom Severity Score (IBS-SSS), scale 0 (not affected) to 500 (most severely affected). More participants experienced a clinically significant IBS-SSS improvement (≥50 points) from baseline to 24 months with CBT: 84 (71%) of 119 participants in the telephone-CBT group, 62 (63%) of 99 in the web-CBT group, and in 48 (46%) of 105 in the usual care group.
  • At 24 months, telephone-CBT significantly reduced IBS symptoms compared with usual care (mean IBS-SSS difference -40.5 points, 95% CI -66.0 to -15.0).
  • While symptoms were slightly lower with web-CBT than with usual care, this difference was not statistically significant (mean IBS-SSS difference -12.9 points, 95% CI ‑38.8 to +12.9).
  • Both forms of CBT reduced the impact of IBS on participants’ lives, as measured by the Work and Social Adjustment Scale (WSAS), scored between 0 (not affected) and 40 (severely affected). The mean WSAS score was 3.1 points (95% CI 1.3 to 4.9) lower in the telephone-CBT group and 1.9 points (95% CI 0.1 to 3.7) lower in the web-CBT group than in the usual care group.
  • In total 41 adverse events were reported between 12 to 24 months, but none were thought to be due to the intervention. There were 11 events in the telephone-CBT group, 15 in the web-CBT group, and 15 in the usual care group. Of these, eight were reported as gastrointestinal-related, six as musculoskeletal, and five as psychological, and the nature of the remainder was not reported.

What does current guidance say on this issue?

The NICE 2008 guideline (updated in 2017) on the management of IBS recommends dietary and lifestyle changes, such as increasing physical activity. Dietary advice includes having regular meals, limiting high-fibre and “resistant starch” foods, caffeine and fizzy drinks. If these measures are unsuccessful, single food avoidance or exclusion diets such as the low FODMAP diet (see Definitions tab) may be suggested under professional guidance.

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?

The present study provides further evidence of the effectiveness of CBT for alleviating the symptoms of IBS. It is important to note the increased effectiveness of telephone-delivered therapy, even if not face-to-face, actual contact with a therapist is crucial and highlights the need for appropriately trained staff rather than predominantly web-based options.

Citation and Funding

Everitt H, Landau S, O’Reilly G et al. Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trial. Lancet Gastroenterol Hepatol. 2019;4(11).863-72.
 

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

Bibliography

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 R C T.  Health Technol Assess. 2019;23(17):1-154.

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;68(9):1613-23.

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(2):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?

As many as 10 to 20% of the population is affected by IBS. Symptoms include diarrhoea, bloating and constipation. Usual treatment includes maintaining a healthy lifestyle, and medication such as laxatives and antispasmodics. However, these only manage the condition and many people experience recurrent flare-ups.

Face-to-face CBT has been shown to help, but NHS availability is limited, and some people can struggle to attend appointments. Remote delivery options, such as web and telephone therapy, have been shown to help overcome these barriers, but their long-term effectiveness has yet to be established. This study aimed to demonstrate whether the effectiveness of CBT continues in the months after sessions have ceased.

What did this study do?

The original study involved 558 people with IBS that had not responded to the usual treatment. They were randomised to continue to receive usual care alone or to have either telephone-CBT or web-based CBT in addition.

The CBT content was aimed at fostering healthy eating patterns, managing stress and reducing symptoms. The telephone-CBT arm received a self-help manual and 8 hours of telephone therapist support, whereas web-CBT participants received access to an interactive website and 2.5 hours of telephone therapist support over eight months.

After the first 12 months of the trial, the treatment as usual group were given access to the website (web-CBT participants had ongoing access). Telephone-CBT participants were not given access to the website but could continue to use their CBT manuals.

A limitation of this study is the number of people lost to follow-up (42%). The researchers used the data they had to take this missing data into account and avoid bias in their analyses.

What did it find?

  • Symptoms were assessed by the IBS Symptom Severity Score (IBS-SSS), scale 0 (not affected) to 500 (most severely affected). More participants experienced a clinically significant IBS-SSS improvement (≥50 points) from baseline to 24 months with CBT: 84 (71%) of 119 participants in the telephone-CBT group, 62 (63%) of 99 in the web-CBT group, and in 48 (46%) of 105 in the usual care group.
  • At 24 months, telephone-CBT significantly reduced IBS symptoms compared with usual care (mean IBS-SSS difference -40.5 points, 95% CI -66.0 to -15.0).
  • While symptoms were slightly lower with web-CBT than with usual care, this difference was not statistically significant (mean IBS-SSS difference -12.9 points, 95% CI ‑38.8 to +12.9).
  • Both forms of CBT reduced the impact of IBS on participants’ lives, as measured by the Work and Social Adjustment Scale (WSAS), scored between 0 (not affected) and 40 (severely affected). The mean WSAS score was 3.1 points (95% CI 1.3 to 4.9) lower in the telephone-CBT group and 1.9 points (95% CI 0.1 to 3.7) lower in the web-CBT group than in the usual care group.
  • In total 41 adverse events were reported between 12 to 24 months, but none were thought to be due to the intervention. There were 11 events in the telephone-CBT group, 15 in the web-CBT group, and 15 in the usual care group. Of these, eight were reported as gastrointestinal-related, six as musculoskeletal, and five as psychological, and the nature of the remainder was not reported.

What does current guidance say on this issue?

The NICE 2008 guideline (updated in 2017) on the management of IBS recommends dietary and lifestyle changes, such as increasing physical activity. Dietary advice includes having regular meals, limiting high-fibre and “resistant starch” foods, caffeine and fizzy drinks. If these measures are unsuccessful, single food avoidance or exclusion diets such as the low FODMAP diet (see Definitions tab) may be suggested under professional guidance.

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?

The present study provides further evidence of the effectiveness of CBT for alleviating the symptoms of IBS. It is important to note the increased effectiveness of telephone-delivered therapy, even if not face-to-face, actual contact with a therapist is crucial and highlights the need for appropriately trained staff rather than predominantly web-based options.

Citation and Funding

Everitt H, Landau S, O’Reilly G et al. Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trial. Lancet Gastroenterol Hepatol. 2019;4(11).863-72.
 

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

Bibliography

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 R C T.  Health Technol Assess. 2019;23(17):1-154.

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;68(9):1613-23.

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(2):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.

Cognitive behavioural therapy for irritable bowel syndrome: 24-month follow-up of participants in the ACTIB randomised trial

Published on 21 November 2019

Everitt, HLandau, SO’Reilly, GSibelli8, AHughes, S Windgassen, SHolland, RLittle, PMcCrone, PBishop, FGoldsmith, KColeman, NLogan, R Chalder, T Moss-Morris8, R

The Lancet Gastroenterology & Hepatology , 2019

Background Irritable bowel syndrome (IBS) is common, affecting 10–20% of the adult population worldwide, with many people reporting ongoing symptoms despite first-line therapies. Cognitive behavioural therapy (CBT) is recommended in guidelines for refractory IBS but there is insufficient access to CBT for IBS and uncertainty about whether benefits last in the longer term. Assessing Cognitive behavioural Therapy for IBS (ACTIB) was a large, randomised, controlled trial of two forms of CBT for patients with refractory IBS. ACTIB results showed that, at 12 months, both forms of CBT for IBS were significantly more effective than treatment as usual at reducing IBS symptom severity in adults with refractory IBS. This follow-up study aimed to evaluate 24-month clinical outcomes of participants in the ACTIB trial. Methods In the ACTIB three-group, randomised, controlled trial, 558 adults with refractory IBS were randomly allocated to receive either therapist-delivered telephone CBT (telephone-CBT group), web-based CBT with minimal therapist support (web-CBT group), or treatment as usual (TAU group) and were followed up for 12 months. Participants were adults with refractory IBS (clinically significant symptoms for ≥12 months despite being offered first-line therapies), recruited by letter and opportunistically from 74 general practices and three gastroenterology centres in London and the south of England (UK) between May 1, 2014, and March 31, 2016. Primary outcome measures were IBS Symptom Severity Score (IBS-SSS) and Work and Social Adjustment Scale (WSAS), assessed in the intention-to-treat (ITT) population with multiple imputation. This study was a non-prespecified naturalistic follow-up and analysis of the participants of the ACTIB trial at 24 months assessing the same outcomes as the original trial. Outcome measures were completed online by participants or a paper questionnaire was posted, or telephone follow-up undertaken. The ACTIB trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISRCTN44427879. Findings 24-month follow-up of outcomes was achieved for 323 (58%) of 558 participants: 119 (64%) of 186 in the telephone-CBT group, 99 (54%) of 185 in the web-CBT group, and 105 (56%) of 187 in the TAU group. At 24 months, mean IBS-SSS was 40·5 points (95% CI 15·0 to 66·0; p=0·002) lower in the telephone-CBT group and 12·9 points (−12·9 to 38·8; p=0·33) lower in the web-CBT group than in the TAU group. The mean WSAS score was 3·1 points (1·3 to 4·9; p<0·001) lower in the telephone-CBT group and 1·9 points (0·1 to 3·7; p=0·036) lower in the web-CBT group than in the TAU group. A clinically significant IBS-SSS change (≥50 points) from baseline to 24 months was found in 84 (71%) of 119 participants in the telephone-CBT group, in 62 (63%) of 99 in the web-CBT group, and in 48 (46%) of 105 in the TAU group. In total 41 adverse events were reported between 12 to 24 months: 11 in the telephone-CBT group, 15 in the web-CBT group, and 15 in the TAU group. Of these, eight were reported as gastrointestinal related, five as psychological, and six as musculoskeletal. There were no adverse events related to treatment. Interpretation At 24-month follow-up, sustained improvements in IBS were seen in both CBT groups compared with TAU, although some previous gains were reduced compared with the 12-month outcomes. IBS-specific CBT has the potential to provide long-term improvement in IBS, achievable within a usual clinical setting. Increasing access to CBT for IBS could achieve long-term patient benefit.

FODMAP stands for “fermentable oligosaccharides, disaccharides, monosaccharides and polyols”. These are groups of carbohydrates that can be broken down by the process of fermentation by microorganisms such as bacteria. If the small bowel is not able to produce enough enzymes to break them down, then they enter the large bowel (colon) where they are fermented by these organisms. This process produces gas, and particles which retain water in the colon, causing diarrhoea. This is not an allergic reaction but is based on the quantity of each type of carbohydrate that can be tolerated depending on the enzyme response of each person.

                                                                                                    

Examples of foods high in specific FODMAPs include:

  • Oligosaccharides: galactose (beans and lentils) and fructans (wheat, onions and leeks)
  • Disaccharides: maltose (sweet potatoes) and lactose (milk, yoghurt and cheese)
  • Monosaccharides: fructose (sugar or some fruits such as apples)
  • Polyols: sugar-free sweeteners

Expert commentary

Irritable bowel syndrome affects 10-20% of the population and the symptoms can be significant for many. CBT is recommended by NICE and the benefits are proven. Accessing face-to-face therapy can be difficult for many, and remote therapies may be appropriate. This study shows that the initial benefits of telephone or web-based CBT do persist over time and this is a therapeutic option that we should be recommending alongside dietary and lifestyle modifications.

Dr Kevin Barrett, GP Partner in Hertfordshire; RCGP and Crohn's and Colitis UK Inflammatory Bowel Disease Spotlight Project Clinical Champion.

The commentator declares no conflicting interests

Expert commentary

This study demonstrates long-term efficacy of both telephone-delivered and web-based CBT in reducing IBS symptom severity and improving the quality of life in patients with refractory IBS and should support the future funding and dissemination of such programmes. The authors plan a cost-benefit assessment and it would be interesting to see an analysis which includes utilisation of other health resources, such as GP visits and a comparison of lost work days compared to "usual treatment”.

I might hypothesise technology-delivered CBT offers the hope not only to improve symptom severity but also to reduce health resource utilisation and work absenteeism over the long-term.

Dr Simon Smale, Clinical Director of GI Medicine and Surgery Manchester Royal Infirmary

The commentator is a trustee and acting Chair of the IBS Network, and CEO and a shareholder of More Than Just Medicine Ltd  ​