Telephone or internet delivered talking therapy can alleviate irritable bowel symptoms

Why was the 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, can help 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 the study do?

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

People were randomised to receive treatment as usual or in addition to 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 eight 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 group fell 61.6 points lower than the usual treatment group (95% confidence interval 33.8 to 89.5), and the web cognitive behavioural therapy group 35.2 points lower than the usual treatment group (95% confidence interval 12.6 to 57.8). Authors previously determined that a 35 point change between the groups was clinically significant.

• The primary outcome was also measured by the work and social adjustment scale, 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 cognitive behavioural therapy group improved to 3.5 points lower than treatment as usual (95% confidence interval 1.9 to 5.1) and the web cognitive behavioural therapy group 3.0 points lower than the usual treatment group (95% confidence interval 1.3 to 4.6).

• Telephone cognitive behavioural therapy had greater adherence rates, with 84% of patients meeting the threshold for adherence, compared with 70% in the web cognitive behavioural therapy arm.

• More adverse events were seen in the cognitive behavioural therapy groups: 77 in the telephone arm, 61 in the web 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 was £22 824 for telephone cognitive behavioural therapy and £7724 for web cognitive behavioural therapy.

What does current guidance say on this issue?

The 2008 guideline from the National Institute for Health and Care Excellence 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 cognitive behavioural therapy.

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.