Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis

Abstract

<jats:sec><jats:title>Objectives</jats:title><jats:p>National guidelines for the management of irritable bowel syndrome (IBS) recommend that psychological therapies should be considered, but their relative efficacy is unknown, because there have been few head-to-head trials. We performed a systematic review and network meta-analysis to try to resolve this uncertainty.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>We searched the medical literature through January 2020 for randomised controlled trials (RCTs) assessing efficacy of psychological therapies for adults with IBS, compared with each other, or a control intervention. Trials reported a dichotomous assessment of symptom status after completion of therapy. We pooled data using a random effects model. Efficacy was reported as a pooled relative risk (RR) of remaining symptomatic, with a 95% CI to summarise efficacy of each comparison tested, and ranked by therapy according to P score.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We identified 41 eligible RCTs, containing 4072 participants. After completion of therapy, the psychological interventions with the largest numbers of trials, and patients recruited, demonstrating efficacy included self-administered or minimal contact cognitive behavioural therapy (CBT) (RR 0.61; 95% CI 0.45 to 0.83, P score 0.66), face-to-face CBT (RR 0.62; 95% CI 0.48 to 0.80, P score 0.65) and gut-directed hypnotherapy (RR 0.67; 95% CI 0.49 to 0.91, P score 0.57). After completion of therapy, among trials recruiting only patients with refractory symptoms, group CBT and gut-directed hypnotherapy were more efficacious than either education and/or support or routine care, and CBT via the telephone, contingency management, CBT via the internet and dynamic psychotherapy were all superior to routine care. Risk of bias of trials was high, with evidence of funnel plot asymmetry; the efficacy of psychological therapies is therefore likely to have been overestimated.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Several psychological therapies are efficacious for IBS, although none were superior to another. CBT-based interventions and gut-directed hypnotherapy had the largest evidence base and were the most efficacious long term.</jats:p></jats:sec><jats:sec><jats:title>Trial registration number</jats:title><jats:p>The study protocol was published on the PROSPERO international prospective register of systematic reviews (registration number CRD 42020163246).</jats:p></jats:sec>

Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta-analysis

“…85 In a recent meta-analysis based upon 11 European datasets, 14 containing over 2700 patients, the total annual cost related to IBS was estimated at almost €3000 per patient. Although therapies for IBS with proven efficacy exist, [86][87][88][89][90] none are curative, and their cost-effectiveness remain uncertain.…”

British Society of Gastroenterology guidelines on the management of irritable bowel syndrome

“…To inform this guideline, we updated a series of systematic reviews and trial-based or network meta-analyses conducted by some of the authors. [153][154][155][156][157][158][159][160][161][162][163] The aim was to assess the efficacy of dietary modifications and therapies, unlicensed, as well as licensed, pharmacological therapies, and psychological therapies in IBS. We considered RCTs comparing pharmacological therapies with placebo, psychological therapies with either no treatment or standard/usual care or dietary therapies with standard dietary advice, habitual diet or a sham dietary therapy.…”

“…We considered the following treatments: soluble or insoluble fibre, a diet low in fermentable oligosaccharides, disaccharides and monosaccharides and polyols (FODMAPs), a gluten-free diet, probiotics, antidiarrhoeals, antispasmodic drugs (including peppermint oil), laxatives, gut-brain neuromodulators (tricyclic antidepressants (TCAs) and SSRIs, previously termed antidepressant drugs), eluxadoline, 5-HT 3 receptor antagonists, antibiotics, secretagogues, 5-HT 4 receptor agonists or psychological therapies (including gut-directed hypnotherapy) (online supplemental table 1). As this was an update of prior meta-analyses, [153][154][155][156][157][158][159][160][161][162][163]…”

Potential Benefit With Complementary and Alternative Medicine in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

“…abdominal pain) were not assessed. Other carefully conducted reviews including network meta-analyses have reported benefit with psychological therapies in IBS, but the majority of included studies had no placebo or sham comparison leading to concerns for possible overestimation of treatment effects 7,8 . Meanwhile, a 2016 systematic review and meta-analysis 9 of randomized controlled trials (RCTs) of Chinese herbal medicine for diarrhea-predominant IBS found significant improvement in overall symptoms, diarrhea, and abdominal pain, but was restricted by small patient numbers and a limited bias assessment.…”