Psychological treatments of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that entails pain, discomfort, and disturbances in bowel movements. Treatment can involve symptomatic relief medication and advice on lifestyle changes, but various types of psychological treatment can also be considered.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Question

What systematic reviews have been published regarding the effects of cognitive behavioral therapy, acceptance and commitment therapy, mindfulness or hypnosis on irritable bowel syndrome in adults?

Method

A systematic literature search was performed using the following databases: Medline (via Ovid), Scopus and PsycInfo.
Two authors independently assessed the abstracts of all identified studies.
Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

Two relevant systematic reviews with moderate risk of bias were identified [1, 2]. The results and conclusions are presented in Table 1. In 26 relevant systematic reviews, the risk of bias was considered to be high, therefore the results and conclusions are not reported [3-28].

Table 1 Systematic reviews with moderate risk of bias.
Included studies Population, Intervention, Control Outcome and Results
Kim et al, 2022 [2]
Internet-Delivered Cognitive Behavioral Therapy in Patients with Irritable Bowel Syndrome: Systematic Review and Meta-Analysis
Relevant studies:
8 RCT 

Setting:
Sweden: 4 studies
USA: 3 studies
Taiwan: 1 study		 Population:
Adults with underlying IBS 

Intervention:
ICBT 

Control:
A group not receiving ICBT		 IBS symptom severity (ICBT-based exposure therapy)
(4 studies, 395 patients):
Positive effect compared to control
SMD: –0.68
(95% CI, –0.90 to –0.47) 

IBS symptom severity (short-term follow-up: 4 to 6 months)
(3 studies, 685 patients):
Positive effect compared to control
SMD: –0.39
(95% CI, –0.56 to –0.22) 

IBS symptom severity (long-term follow-up: 12 to 24 months
(2 studies, 576 patients):
Positive effect compared to control
SMD: –0.36
(95% CI, –0.54 to –0.17) 

Depression
(3 studies, 398 patients):
No effect compared to control
SMD: –0.16
(95% CI, –0.35 to 0.04) 

Note: This is a selection of meta-analyses where only adults (aged over 18 years). For more results, see [2] 
Authors' conclusion:
“In conclusion, this meta-analysis demonstrated that ICBT was superior to standard care or being on a waiting list with regard to improving IBS symptom severity […]. The effects on IBS symptom severity persisted for a long time after the intervention; […]. However, the number of RCTs concerning the provision of ICBT to patients with IBS is still limited, and the protocols for ICBT, including content, duration, and operators, are heterogeneous, requiring further research and standardization.”
Hanlon et al, 2018 [1]
Systematic review with meta-analysis: online psychological interventions for mental and physical health outcomes in gastrointestinal disorders including irritable bowel syndromeand inflammatory bowel disease
Relevant studies:
6 RCT 

Setting:
Sweden: 4 studies
USA: 1 study
Netherlands: 1 study		 Population:
Adults or children with gastrointestinal diagnoses diagnosed with well-established criteria 

Intervention:
Online psychological interventions 

Control:
Any comparison group		 IBS severity of symptoms at post intervention
Self-rated symptoms at post-intervention using GSRS-IBS
(3 studies, 341 patients):
Positive effect (statistically significant, p = 0.004) of online CBT compared to control
MD: –9.63
(95% CI, –16.18 to –3.08) 

IBS Level of depression at post intervention
(2 studies, 280 patients):
No statistically significant effect of online CBT compared to control
SMD: –0.18
(95% CI, –0.59 to 0.23) 

VSI at post-intervention assessment
GI symptom specific anxiety
(3 studies, 341 patients):
Positive effect (statistically significant, p = 0.0002) of online CBT compared to control
MD: –8.51
(95% CI, –12.99 to –4.04) 

Sheehan Disability Scales at post-intervention
Self-reported assessment of functional impairment
(2 studies, 146 patients):
Positive effect (statistically significant, p = 0.04) of online CBT compared to control
MD: –2.78(95% CI, –5.43 to –0.12) 

Note: This is a selection of meta-analyses where only adults (aged over 18 years) with IBS were included. For more results regarding adolescents and/or other gastrointestinal conditions, see [1] 
Authors' conclusion:
”The present systematic review suggests insufficient evidence of an association between online CBT and disease severity/activity, level of anxiety and depression, stress, maladaptive coping, HRQoL, and cost-effectiveness in patients with IBD and IBS. However, online psychotherapy was shown to improve gastrointestinal symptom-specific anxiety and lessen symptom induced disability.”

References

  1. Hanlon I, Hewitt C, Bell K, Phillips A, Mikocka-Walus A. Systematic review with meta-analysis: online psychological interventions for mental and physical health outcomes in gastrointestinal disorders including irritable bowel syndrome and inflammatory bowel disease. Alimentary pharmacology & therapeutics. 2018;48(3). Available from: https://doi.org/https://dx.doi.org/10.1111/apt.14840.
  2. Kim H, Oh Y, Chang SJ. Internet-Delivered Cognitive Behavioral Therapy in Patients With Irritable Bowel Syndrome: Systematic Review and Meta-Analysis. Journal of medical Internet research. 2022;24(6). Available from: https://doi.org/https://dx.doi.org/10.2196/35260.
  3. Aktaş S, Gülen M, Sevi OM. Mindfulness therapies for medically unexplained somatic symptoms: A systematic review. Sevi, Oya Mortan, Bahcesehir University, Faculty of Economics Administrative and Social Science, Department of Phychology, Istanbul, Turkey; 2019.
  4. Aucoin M, Lalonde-Parsi M-J, Cooley K. Mindfulness-based therapies in the treatment of functional gastrointestinal disorders: a meta-analysis; 2014. Available from: https://dx.doi.org/10.1155/2014/140724
  5. Axelsson E, Kern D, Hedman-Lagerlof E, Lindfors P, Palmgren J, Hesser H, et al. Psychological treatments for irritable bowel syndrome: a comprehensive systematic review and meta-analysis; 2023. Available from: https://dx.doi.org/10.1080/16506073.2023.2225745
  6. Babos C-I, Leucuta D-C, Dumitrascu DL. Meditation and Irritable Bowel Syndrome, a Systematic Review and Meta-Analysis. Journal of clinical medicine. 2022;11(21). Available from: https://doi.org/https://dx.doi.org/10.3390/jcm11216516.
  7. Black CJ, Thakur ER, Houghton LA, Quigley EMM, Moayyedi P, Ford AC. Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis; 2020. Available from: https://dx.doi.org/10.1136/gutjnl-2020-321191
  8. Chen LJ, Kamp K, Fang A, Heitkemper MM. Delivery Methods of Cognitive Behavior Therapy for Patients With Irritable Bowel Syndrome; 2022. Available from: https://dx.doi.org/10.1097/SGA.0000000000000671
  9. Ford AC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P. Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-Analysis; 2019. Available from: https://dx.doi.org/10.1038/s41395-018-0222-5
  10. Galvez-Sanchez CM, Montoro CI, Moreno-Padilla M, Reyes Del Paso GA, de la Coba P. Effectiveness of Acceptance and Commitment Therapy in Central Pain Sensitization Syndromes: A Systematic Review; 2021. Available from: https://dx.doi.org/10.3390/jcm10122706
  11. Gholamrezaei A, Ardestani SK, Emami MH. Where does hypnotherapy stand in the management of irritable bowel syndrome? A systematic review; 2006.
  12. Hedman E, Ljotsson B, Lindefors N. Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost-effectiveness; 2012. Available from: https://dx.doi.org/10.1586/erp.12.67
  13. Krouwel M, Farley A, Greenfield S, Ismail T, Jolly K. Systematic review, meta-analysis with subgroup analysis of hypnotherapy for irritable bowel syndrome, effect of intervention characteristics; 2021. Available from: https://dx.doi.org/10.1016/j.ctim.2021.102672
  14. Laird KT, Tanner-Smith EE, Russell AC, Hollon SD, Walker LS. Short-term and Long-term Efficacy of Psychological Therapies for Irritable Bowel Syndrome: A Systematic Review and Meta-analysis. Department of Psychology and Human Development, Peabody College, Vanderbilt University, Nashville, TN, United States Department of Human and Organizational Development, Peabody Research Institute, Vanderbilt University, Nashville, TN, United States Department of Pediatrics, Vanderbilt University, Nashville, TN, United States Department of Psychology, Vanderbilt University, Nashville, TN, United States; 2016. Available from: https://dx.doi.org/10.1016/j.cgh.2015.11.020
  15. Laird KT, Tanner-Smith EE, Russell AC, Hollon SD, Walker LS. Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis; 2017. Available from: https://dx.doi.org/10.1016/j.cpr.2016.11.001
  16. Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis; 2013. Available from: https://dx.doi.org/10.1371/journal.pone.0071834
  17. Lee HH, Choi YY, Choi M-G. The Efficacy of Hypnotherapy in the Treatment of Irritable Bowel Syndrome: A Systematic Review and Meta-analysis; 2014. Available from: https://dx.doi.org/10.5056/jnm.2014.20.2.152
  18. Li L, Xiong L, Zhang S, Yu Q, Chen M. Cognitive-behavioral therapy for irritable bowel syndrome: a meta-analysis; 2014. Available from: https://dx.doi.org/10.1016/j.jpsychores.2014.03.006
  19. Pajak R, Lackner J, Kamboj SK. A systematic review of minimal-contact psychological treatments for symptom management in irritable bowel syndrome; 2013. Available from: https://dx.doi.org/10.1016/j.jpsychores.2013.05.007
  20. Peters SL, Muir JG, Gibson PR. Review article: gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease; 2015. Available from: https://dx.doi.org/10.1111/apt.13202
  21. Radu M, Moldovan R, Pintea S, Baban A, Dumitrascu D. Predictors of outcome in cognitive and behavioural interventions for irritable bowel syndrome. A meta-analysis; 2018. Available from: https://dx.doi.org/10.15403/jgld.2014.1121.273.bab
  22. Schaefert R, Klose P, Moser G, Hauser W. Efficacy, tolerability, and safety of hypnosis in adult irritable bowel syndrome: systematic review and meta-analysis; 2014. Available from: https://dx.doi.org/10.1097/PSY.0000000000000039
  23. Spanier JA, Howden CW, Jones MP. A systematic review of alternative therapies in the irritable bowel syndrome; 2003.
  24. Tan G, Hammond DC, Gurrala J. Hypnosis and Irritable Bowel Syndrome: A Review of Efficacy and Mechanism of Action. Tan, Gabriel, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd. (116 MH CASE), Houston, TX, US, 77030; 2005. Available from: https://dx.doi.org/10.1080/00029157.2005.10401481
  25. Toivonen KI, Zernicke K, Carlson LE. Web-Based Mindfulness Interventions for People With Physical Health Conditions: Systematic Review; 2017. Available from: https://dx.doi.org/10.2196/jmir.7487
  26. Webb AN, Kukuruzovic RH, Catto-Smith AG, Sawyer SM. Hypnotherapy for treatment of irritable bowel syndrome; 2007.
  27. Wilson S, Maddison T, Roberts L, Greenfield S, Singh S. Systematic review: the effectiveness of hypnotherapy in the management of irritable bowel syndrome; 2006.
  28. Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO. Psychological treatments for the management of irritable bowel syndrome; 2009. Available from: https://dx.doi.org/10.1002/14651858.CD006442.pub2
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Published: Report no: ut202407 Registration no: SBU 2023/1223
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Search strategies

Medline via OvidSP 11 Jan 24

Title: Psychological treatments in IBS
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp= Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf.; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other.; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase

*Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity- and precision-maximizing version (2008 revision); Ovid format. The Cochrane Collaboration; 2008. Available from: https://training.cochrane.org/handbook/current/chapter-04-technical-supplement-searching-and-selecting-studies#section-3-6-1. with modifications: the following terms are added: clinical trial, phase iii.pt. ; randomised.ab. ; ("Phase 3" or "phase3" or "phase III" or P3 or "PIII").ti,ab,kw.
Search terms Items found
Population:
1. exp Irritable Bowel Syndrome/ or (ibs or irritab* bowel syndrom* or irritab* colon or colon irritab* or mucous coliti*).ab,bt,kf,ti 20 484
Intervention:
2. exp Cognitive Behavioral Therapy/ or exp Mindfulness/ or (cognitive behavio* or CBT or "acceptance and commitment" or mindfulness).ab,kf,bt,ti. 67 671
3. exp Hypnosis/ or Hypnos*.ab,bt,kf,ti. or Hypnot*.ab,bt,kf,ti. or Hypnotherap*.ab,bt,kf,ti. or Mesmer*.ab,bt,kf,ti. or trance.ab,bt,kf,ti. or hypnoanalys*.ab,bt,kf,ti. 31 160
Study types: systematic reviews and meta-analysis / randomized controlled trials*
4. ((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys*" or metaanalys*).ti,bt,ab.) not (editorial/ or letter/ or case reports/)) 464 520
Combined sets:
5.; 2 or 3 97 788
6. 1 and 5 661
Final result
7.  4 and 6 85

Scopus via scopus.com 11 Jan 24

Scopus via scopus.com 11 Jan 24
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other.; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words.; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range.; DOCTYPE = Publication type; "re" = review; “le" = letter; "ed" = editorial; "ch"= book chapter; "cp" = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. TITLE-ABS-KEY (ibs or "irritab* bowel syndrom*" or "irritab* bowel" or "irritab* colon" or "colon irritab*" or "mucous coliti*") 36 440
Intervention:
2. TITLE-ABS-KEY ("cognitive behavior*" OR "cognitive behaviour*" OR cbt OR "acceptance and commitment" OR mindfulness) 105 823
3.; TITLE-ABS-KEY (Hypnos* OR Hypnot* OR Mesmer* OR Hypnotherap* OR Trance OR Hypnoanalys*) 74 755
Study types: systematic reviews and meta-analysis / randomized controlled trials
4.          TITLE-ABS-KEY ( ( systematic  W/2  review )  OR  "meta analy*"  OR  metaanaly* ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”))   682 117
Combined sets:
5. 2 or 3 178 439
6. 1 and 5 1307
Final result
7. 4 and 6 191

PSYCINFO via EBSCO 11 Jan 24

Title: Psychological treatments in IBS
TI = Title; AB = Abstract; SU = Keyword, exact or part (including all other fields for indexed and author keywords); DE = Exact keyword; TX = All text; MR = Methodology; Nn = Near. Proximity operator retrieving terms within n words from each other.; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. TI (ibs or "irritab* bowel syndrom*" or "irritab* bowel" or "irritab* colon" or "colon irritab*" or "mucous coliti*") OR AB (ibs or "irritab* bowel syndrom*" or "irritab* bowel" or "irritab* colon" or "mucous coliti*") OR SU (ibs or "irritab* bowel syndrom*" or "irritab* bowel" or "irritab* colon" or "mucous coliti*") 2378
Intervention:
2. TI (cognitive behavio?r* or CBT or "acceptance and commitment" or mindfulness) OR AB (cognitive behavio?r* or CBT or "acceptance and commitment" or mindfulness) OR SU (cognitive behavio?r* or CBT or "acceptance and commitment" or mindfulness) 51 492
3. TI (hypnos* OR hypnotherapy OR hypnotism or hypnotherapies OR hypoanalys* mesmerism OR trance) OR AB (hypnos* OR hypnotherapy OR hypnotism or hypnotherapies OR hypoanalys* mesmerism OR trance) OR SU (hypnos* OR hypnotherapy OR hypnotism or hypnotherapies OR hypoanalys* mesmerism OR trance 19 523
Study types: systematic reviews and meta-analysis / randomized controlled trials
4. TI((systematic n3 review) OR "meta analys*" OR metaanalys*) OR AB((systematic n3 review) OR "meta analys*" OR metaanalys*) OR SU((systematic n3 review) OR "meta analys*" OR metaanalys*) OR (MR "Systematic Review" OR MR "meta analysis") 97 425
Combined sets:
5. 2 or 3 70 636
6. 1 and 5 266
Final result
7.; 4 and 6 22
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