Cognitive–behavioral therapy for irritable bowel syndrome: A meta-analysis

https://doi.org/10.1016/j.jpsychores.2014.03.006Get rights and content

Highlights

  • CBT was superior to waiting list, basic support or medical treatment for IBS.

  • CBT was not superior to other psychological treatments for IBS.

  • The efficacy of CBT for IBS may persist at long-term follow-up.

Abstract

Objective

To establish whether cognitive behavioral therapy (CBT) improves the bowel symptoms, quality of life (QOL) and psychological states of irritable bowel syndrome (IBS) patients.

Methods

Randomized controlled trials (RCTs) of CBT for adult patients with IBS were searched by using PubMed, Scopus and Web of Science. The standardized mean difference (SMD) with 95% confidence intervals (CIs) of the evidence-based outcome measures of the IBS bowel symptoms, QOL and psychological states at post-treatment and follow-up was calculated. Prespecified subgroup analysis was performed.

Results

Eighteen RCTs satisfied our inclusion criteria. In the subgroup analyses, CBT was more effective in reducing IBS bowel symptoms, QOL and psychological states than waiting list controls at the end of the intervention and short-term follow-up. When compared with controls of basic support and medical treatment, the effect sizes were found to favor CBT for the improvement of IBS bowel symptoms at post-treatment and short-term follow-up, but CBT was not superior to controls in improving QOL and psychological states. When comparing CBT with other psychological controls, the effect sizes were almost non-significant.

Conclusions

For IBS patients, CBT was superior to waiting list, basic support or medical treatment at the end of treatment but not superior to other psychological treatments. The meta-analysis might be limited by the heterogeneities and small sample sizes of the included studies.

Introduction

Irritable bowel syndrome (IBS) is a chronic, relapsing gastrointestinal symptom complex characterized by altered bowel habits and abdominal pain and discomfort, and it affects as many as 5%–20% of individuals in the population [1], [2]. The prevalence of IBS is modestly higher in women, and women are more likely to exhibit the constipation-predominant subtype and less likely to meet the criteria for the diarrhea-predominant subtype than men [3]. IBS represents an economic burden on society and decreases IBS patients' health-related quality of life [4], [5].

The current treatments for IBS are challenging and unsatisfactory [6]. The medical management tends to provide inadequate relief of IBS bowel symptoms [7], whereas the clinical trials of psychological therapies have demonstrated some improvements, especially cognitive behavior therapy (CBT). Notably, CBT has proven to be an effective therapy for both depression and anxiety disorders [8], [9]. In regard to the treatment for patients with somatization and symptom syndromes, CBT appears to be a promising treatment [10]. Although the etiology and pathogenesis of IBS remain elusive, it is recognized that patients with IBS are more likely to suffer from coexistent mood disorder, depression and anxiety than healthy controls [11], [12]. Thus, CBT might also be an effective and promising treatment strategy for IBS.

The cognitive behavioral model defines how events, thoughts, emotions, actions and physiological responses interact with each other. CBT as applied to IBS includes several main steps. The first step is to educate, which consists of the explanation of IBS symptoms and the CBT model. At the same time, the patients are encouraged to find the psychological factors that are interacting with their physical symptoms. Then, the patients and the therapist work together to identify the potential associations among their thoughts, emotions and actions with IBS symptoms. Lastly, behavioral therapy, such as stress management is applied [13].

There has been some CBT for IBS studies published, including several separate systematic reviews or meta-analyses, that address whether CBT improved the outcome in IBS [13], [14], [15], [16], [17]. These systematic reviews all held the view that CBT was superior to the waiting list controls. However, the evidence of CBT for IBS is controversial when compared with different types of active controls. Shen and Nahas [14] found that CBT was possibly not superior to education or psychoeducational support. In contrast, Kearney and Brown-Chang [15] concluded that CBT was possibly better than education and support. Hutton [13] stated that the effect of CBT was at least as great as the medical treatment for IBS. In recent meta-analyses, Ford et al. [16] concluded that CBT was superior to waiting list controls or physicians' “usual management” in IBS, and Zijdenbos et al. [17] also found that CBT was better than usual care or waiting list in improving symptoms and quality of life but was not superior to placebo. The evidence for the efficacy of CBT might be positive in treating IBS in these reviews [13], [14], [15], [16], [17]. However, these recent systematic reviews arrived at disparate conclusions, especially regarding the evidence of CBT for IBS being controversial when compared with active controls other than waiting list controls, and the validity of CBT follow-up has not been established. Finally, several important RCTs published after 2009 were not included in these previous meta-analyses. In this meta-analysis, we attempt to address these discrepancies and provide an up-to-date conclusion to establish the efficacy of CBT for IBS.

Section snippets

Study selection

To identify the relevant studies, we conducted a search of PubMed, Scopus, the Cochrane Library and Web of Science up to December 31, 2013. The keywords used for IBS and CBT are presented in Appendix A. Randomized controlled trials (RCTs) examining the effects of CBT in adult patients with IBS were eligible for inclusion (see inclusion criteria below).

For the full-text reading and final evaluation, we only included studies published in English. Conference abstracts were not included in our

Study characteristics

A total of 1008 citations were identified, of which 18 were finally selected for analysis (see Fig. 1). We handsearched the references of the previous reviews and found no additional studies. As methods for assessing three-arm trials were introduced in our study, the total number of analyzed circumstances was greater than 18. Treatment durations varied from five to 14 weeks, and the follow-up periods varied from two months to one year. The proportion of female patients recruited by all trials

Discussion

This study conducted a meta-analysis to establish the efficacy of CBT for IBS and highlighted some important findings. First, the pooled effect sizes of CBT for IBS appeared to favor the use of CBT for the improvement of IBS bowel symptoms, QOL and psychological states at post-treatment evaluations. At follow-up, our study found that CBT prevailed over controls in improvement of IBS bowel symptoms and QOL at short-term follow-ups, whereas the effect size displayed no significant difference in

Authorship

Guarantor of the article: Lishou Xiong

Author contributions: LSX contributed to the study concept, design, supervision and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version of the manuscript. LL and SHZ both contributed to the trial selection and data extraction. LL, SHZ and QY performed the analysis and interpretation of data, and LL wrote the article. MHC contributed to the supervision of the manuscript.

Funding

This study was funded by the Planned Science and Technology Project of Guangdong Province (2009B030801138).

Conflict of interest

The authors have no conflict of interests to report.

Acknowledgments

Declaration of personal interests: We are grateful to Professor Roger Jones and Tom Kennedy for answering our data queries and, where applicable, providing us with their original datasets for analysis.

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