Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Psychotherapy plus standard medical treatment improved symptoms of the irritable bowel syndrome

ACP J Club. 1991 July-Aug;115:9. doi:10.7326/ACPJC-1991-115-1-009


Source Citation

Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology. 1991 Feb;100:450-7.


Abstract

Objective

To assess the effectiveness of adjunctive psychological treatment for patients with the irritable bowel syndrome refractory to standard medical treatment.

Design

Randomized controlled trial of 3 months duration.

Setting

Gastroenterology clinic at an English teaching hospital.

Patients

115 consecutive patients with symptoms of abdominal pain and distention, an abnormal bowel habit without discoverable organic pathology, symptoms for > 1 year that had not improved after 6 months of antispasmodic therapy or bulking agents, or both, were considered for the study. 13 patients refused or were excluded. 87% completed the trial. Patients were aged 20 to 75 years.

Intervention

53 patients were randomized to psychotherapy and 49 to continued medical treatment alone. All patients continued medical treatment. Psychological treatment included 7 interviews during which the patient's symptoms, feelings, and emotional problems were explored. Patients in the control group attended baseline and 3-month assessment sessions and discussed their bowel-symptom charts on 3 other occasions.

Main outcome measures

Severity of symptoms was assessed by the gastroenterologist (using a 9-point scale) and the patient, who also kept a daily symptom chart.

Main results

There were 8 men and 45 women in the treatment group compared with 17 men and 32 women in the control group (P < 0.05 for excess of men in the control group), but men and women showed similar trends toward symptom improvement. 30% of patients had major depression and 18% had anxiety states. After 3 months, the median severity score assigned by the gastroenterologist was improved for patients receiving psychotherapy (median, 2; range, 0 to 8) but was unchanged for control patients (median, 5; range, 0 to 8, P < 0.01). Abdominal discomfort and diarrhea improved more in the treatment group than in the control group based on the gastroenterologists' ratings (P < 0.01 and P < 0.05, respectively). Patients' biweekly ratings and daily charts showed similar improvement, but also showed more improvement for distension in the treatment group (P < 0.01). There was no improvement in constipation for either group. Patients receiving psychotherapy showed a lessening of depression (P < 0.001) and anxiety (P < 0.01). Covariate analysis showed that improvement in psychological status led to improvement in bowel symptoms rather than the reverse.

Conclusion

Psychotherapy in addition to medical treatment improved symptoms of the irritable bowel syndrome in patients with refractory disease.

Sources of funding: North West Regional Health Authority and Reckitt and Colman.

Address for article reprint: Dr. E. Guthrie, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, England, UK.


Commentary

The irritable bowel syndrome has an estimated prevalence in the general Western population of approximately 17% (1). Most of these people do not consult a physician. Many patients with the irritable bowel syndrome who do visit their doctors may only want reassurance and some suggestions as to how to manage their symptoms. Those patients who repeatedly see their doctors and have no satisfaction may represent a subgroup with psychological problems that determine how they perceive and react to the disorder (2, 3).

The study by Guthrie and colleagues suggests that this group with overt psychiatric symptoms may benefit from the addition of psychological treatment to their regimen. This conclusion is undermined somewhat by the number of men in the study. There was a 25% higher proportion of men than would be expected according to studies in North American clinical settings (2, 3). Also, the credibility of the randomization procedure is brought into question by the significantly higher proportion of men assigned to the control group. If the randomization was done correctly, then the results are useful clinically.

Martin H. Poleski, MD
McGill UniversityMontreal, Quebec, Canada


References

1. Drossman DA, Sandler RS, McKee DC, Lovitz AJ. Bowel patterns among subjects not seeking health care. Gastroenterology. 1982;83:529-34.

2. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. Gastroenterology. 1988;95:701-8.

3. Whitehead WE, Bosmajian L, Zonderman AB, Costa PT, Schuster MM. Symptoms of psychologic distress associated with irritable bowel syndrome. Gastroenterology. 1988;95:709-14.


Author's Response

Random allocation was done correctly and initially did not produce significantly different numbers of men in the two groups. The difference became significant when 2 patients were withdrawn because underlying organic gastrointestinal illness was discovered.

Elspeth Guthrie, MD