People with irritable bowel syndrome may find cognitive behavioural therapy (a talking therapy) delivered via telephone or internet improves their symptoms. Compared with usual care alone, both interventions were shown to be more effective, with telephone delivery resulting in greater symptom reduction and web-based therapy being more cost-effective.
Irritable bowel symptoms can persist long-term and have a major impact on the quality of life. Stress is one of the known triggers. Cognitive behavioural therapy is known to help people identify and manage negative thought patterns. However, the availability of face-to-face talking therapy on the NHS is limited, especially for people without mental health symptoms.
This NIHR-funded trial involved 558 people with symptoms that were not responding to usual treatment such as medication.
The reductions in symptoms were thought to be clinically important, suggesting that they are worth exploring as a cost-effective and accessible way to help people manage their condition.
Why was this 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, have the potential to 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 this study do?
This randomised controlled trial involved 558 people with irritable bowel syndrome that had not responded to usual treatment. They were recruited from 74 GP surgeries and three gastroenterology outpatient clinics.
People were randomised to receive treatment as usual or, in addition, either 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 8 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 (CBT) group fell 61.6 points lower than the usual treatment group, (95% confidence interval [CI] 33.8 to 89.5) and the web CBT group 35.2 points lower than the usual treatment group, (95% CI 12.6 to 57.8). Authors previously determined a 35-point change between the groups was clinically significant.
- The primary outcome was also measured by the work and social adjustment scale (WSAS), 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 CBT group improved to 3.5 points lower than treatment as usual, (95% CI 1.9 to 5.1) and the web CBT group 3.0 points lower than the usual treatment group, (95% CI 1.3 to 4.6).
- Telephone CBT had greater adherence rates, with 84% of patients meeting the threshold for adherence, compared with 70% in the web CBT arm.
- More adverse events were seen in the CBT groups, 77 in the telephone CBT arm, 61 in the web CBT 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 (ICER) was £22,824 for telephone CBT and £7,724 for web CBT.
What does current guidance say on this issue?
The NICE 2008 guideline 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 CBT.
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.
Citation and Funding
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 RCT. Health Technol Assess. 2019;23(17).
This project was funded by the NIHR Health Technology Assessment Programme (project number 11/69/02).
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; Apr 10. doi: 10.1136/gutjnl-2018-317805. [Epub ahead of print].
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;11:395-402.
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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