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Rapid Responses: Rapid Responses published:
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Gut feelings
- Chris L. Manning (20 August 2005)
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C.B.T and Hypnotherapy to treat refractory Irritable bowel syndrome
- James Paul Pandarakalam (24 August 2005)
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Premature conclusion?
- Bart van Pinxteren (6 September 2005)
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Primary care cognitive behavioural therapy for irritable bowel syndrome: a placebo response only?
- Mark E McAlindon, D. Paul Hurlstone and David S. Sanders (13 September 2005)
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Chris L. Manning, CEO Primhe Twickenham
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Dear Sir An interesting paper that adds to the evidence-base for the effectiveness of CBT across many areas of practice. Evidence from use of CORE-PC shows that the intervener effect may be as important as the intervention and results from CBT may not be generalisable from one unit to another, dependent on levels of clinical expertise and unit specialisation. This issue heavily underlines the importance of the placebo effect, especially in the treatment of those with conditions that respond to psychological interventions (and it would be hard to find many that don't?), as has also been clearly debated recently in the issues concerning RCTs and SSRI antidepressants. Alongside other studies that show limitation of effect duration, those who strongly advocate CBT as the "only fruit" psychological intervention in the NHS need to bear in mind that topping up "boosters" may be required and that NHS (and other)units and that provider units and professionals differ in their levels of ability to engage and competence. This may be increasingly important as primary care becomes open-ground for competition amongst providers, especially the voluntary and private sectors. The other reminder in this paper, aside from the fact that we are all "hard wired", is that of the need for the more wholistic assessment of patients, and that the HAD, and other measurements, do not pick up all intervention effects because they are not designed to do so - and that other instruments are. This should serve as a timely reminder for NICE to be considering all aspects of quality of life and values, especially social ones, in the thorough assessment of any intervention. This is further re-iterated in the current issue in Minerva: "Sick leave for people with chronic lung conditions relates more to psychosocial and work issues than the state of their lungs, according to a Dutch study ( Respiratory Medicine 2005;99: 1022-31[CrossRef][Medline]). The authors asked 189 people with asthma or chronic obstructive pulmonary disease about their sick leave during the previous 12 months—along with other questions about their health, work, and psychosocial issues—and measured their lung function. Sick leave was associated with low job satisfaction, low job control, and having a new employer but not with lung function". Yours Faithfully Dr Chris Manning CEO Primhe (Primary care mental health and education) Mental Health Taskforce (England) Competing interests: None declared |
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James Paul Pandarakalam, consultant psychiatrist, 5 Boroughs Partnership NHS Trust St Helens North CMHT, Peasley Cross Resource Centre, St Helens, Merseyside WA 9 3DA
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C.B.T. to treat irritable bowel syndrome along with antispasmodics is found to be helpful 1.This is understandable as digestive system mirrors the mind. A recent meta-analysis has established that hypnosis enhances the efficacy of both psychodynamic and cognitive behavioural therapies.2 A cmbination of hypnotherapy and C.B.T along with drug treatment might accelerate the symptom controll of refractory irritable bowel syndrome. Five published randomised controlled trials have examined the effects of hypnotherapy in people with refractory irritable bowel syndrome.3-7 In one such trial involving 30 patients who had been unsuccessfully treated to any therapy, and having severe irritable bowel syndrome, it was found that after three months of treatment ( seven 30 minute sessions at increasing intervals over 3 months along with a tape for daily self hypnosis), the reductions in mean weekly overall symptom scores and improvement in well-being were greater in the hypnotherapy group than in the control group. A follow up study of the 15 patients in the hypnotherapy group over a mean of 18 months found that all patients had remained in remission. 8 Irvin Kirsch considers hypnotherapy an empirically validated, non- deceptive placebo and the effects are mediated by response expectancies 9. This is probably one of the several psychological mechanisms that explain the working of hypnosis. Mainstream psychiatry is still highly sceptical about the efficacy of hypnosis in clinical psychiatry 10.If cognitive therapy is useful in deprogramming the cognitive distortions, hypnotherapy can be effective in reprogramming the cognition. Self-hypnosis is to be discouraged until cognitive reprogramming has been achieved, as this can reinforce the existing cognitive disturbances. Cognitive therapy has to be revised to accommodate the hypnotic techniques. It is analogous to the shift from Newtonian to Quantum mechanics, as Newtonian laws were only good approximations. In its early days the cognitive science laboratory began to provide a new range of experimentally based assessment techniques 11, which may yet provide new insights into psychopathology. Just as there was a detectable ‘psychoanalytic drift’ in the practice of cognitive therapy in the eighties 12, now there is a ‘hypnotherapeutic drift’ in the educational circles of cognitive science. But hypnosis is not a penacea or a substitute for physical and various other psychotherapeutic treatment methods. 1.Tonny Kennedy, Roger Jones, Simon Darnley, Paul Seed, Simon Wessely, Trudie Chalder. Cognitive behavioural therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial. BMJ 2005: 435, DOI;10.1136/BMJ.38545.505764.06 2.Kirsch, I. & Lynn, S.J. The altered state of hypnosis: Changes in the theoretical landscape. American Psychologist 1995; 50, 846-858. 3.Whorwell PJ et al. Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet 1984; 2 (8414):1232-4 4.Forbes A et al. Hypnotherapy and therapeutic audiotape: effective in previously unsuccessfully treated irritable bowel syndrome?. Int J Colorectal Dis 2000; 15:328-34 5.Galovski TE, Blanchard EB. The treatment of irritable bowel syndrome with hypnotherapy. App Psychophysical Biofeedback 1998; 23.219-32 6. Palsson OS et al. Hypnosis treatment for severe irritable bowel syndrome. Investigation of mechanism and effect on symptoms. Dig Dis Sci 2002; 47: 2605-14. 7.Harvey RF et al. Individual and group hypnotherapy in treatment of refractory irritable bowel syndrome. Lancet 1989; 1 (8635):424-5. 8.Whorwell PJ et al. Hypnotherapy in severe irritable bowel syndrome: further experience. Gut 1987; 28:423-5. 9.Kirsch, Irvine. Hypnosis in Psychotherapy: Efficacy and mechanisms. Contemporary hypnosis 1996;13. 109-114. 10. Gelder Michael, Dennis Gath and Richard Mayor (1990). Oxford Textbook of Psychiatry. Oxford Medical Publications - Oxford 11.William J.M.G, Watts F.N., Macleod C and Mathews A (1988). Cognitive Psychology and Emotional Disorder, Chichester. John Wiley & Sons. 12.Power M.J. Cognitive therapy an outline of theory,practice and problems. British Journal of Psychotherapy 1989; 5, 544-556. Competing interests: None declared |
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Bart van Pinxteren, general practitioner Utrecht, The Netherlands
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Dear Sir, In their study Kennedy and colleagues demonstrate that in patients with irritable bowel syndrome a six week course of cognitive behaviour therapy (CBT) shows a significant benefit on symptom severity in comparison with ‘no treatment’. Figure 2 in their article suggests that the relative benefit of CBT reaches a maximum shortly after the intervention has ended at 3 months. The effect of CBT however wears off, leaving no significant benefit in comparison with ‘no treatment’ during follow-up at 6 and 12 months. Both the ‘wearing off’ and the fact that no control for CBT was included makes me wonder if not all I am looking at is a placebo-effect. I would suggest the study to be repeated with a control group receiving re- assurance in combination with some kind of psychological intervention with the same frequency and duration as the CBT that is given. At this moment I believe your report that ‘cognitive behaviour therapy reduces symptom severity of irritable bowel syndrome’ in a headline of ‘This week in the BMJ’ is premature, as is the suggestion that ‘cognitive behaviour therapy seems a useful addition to drugs treatment’ in ‘What this study adds’. Yours faithfully Bart van Pinxteren b.vanpinxteren@nhg-nl.org Competing interests: None declared |
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Mark E McAlindon, Consultant Gastroenterologist Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, D. Paul Hurlstone and David S. Sanders
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The idea of accessible community based treatment of a common disorder such as irritable bowel syndrome (IBS) is one with great appeal. IBS is not only common, but it causes much morbidity and cost in terms of resource utilisation in health services and lost revenue to employers and employees due to work absences. So it was with great interest that we read the study by Kennedy et al. But we question whether this study really demonstrates a beneficial role for cognitive behavioural therapy (CBT) in the treatment of IBS in the community. Patients randomised to mebeverine alone were known non-responders to the drug. So any response shown to CBT over and above mebeverine is as likely to have been a placebo as a real response. Furthermore, the apparent benefit of CBT over mebeverine alone lasts only for the duration of the intervention (three months): there is no difference in symptom score between the two groups thereafter. If so, the cost-effectiveness of training four nurses for 12 weeks to deliver up to six weekly 50 minute CBT sessions to provide a temporary placebo response seems likely to be minimal. The study does, however, provide reassuring data for future patients who can expect a substantial improvement in their symptom score over the next 12 months even if they are initially unresponsive to conventional treatment followed by a two week trial of mebeverine. Are these nurses going to continue to offer CBT for IBS in their general practices? Competing interests: None declared |
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