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.
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).
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.
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