The relationship between the gut and the brain in IBS is an evolving and exciting area of research. Psychological therapies, including behavioural based techniques, as well as antidepressants have been proposed as treatment options for individuals with IBS. What do we know about these treatment options and how effective are they?
Psychological Therapies
Earlier this year, a systematic review and meta-analysis used data from 41 studies around the globe and included a total of 4072 participants that utilised different psychological treatments to treat IBS (1). Cognitive based-therapy (CBT) and gut directed hypnotherapy came out as the most effective treatment options (1).
- Cognitive based therapy
Cognitive based therapy is a common psychological therapy that is used to treat a number of health problems – from depression and anxiety, to weight management. In a session of CBT for IBS, therapists work with individuals to better understand how their emotions and thoughts impact their symptoms (2). Relaxation, self-regulation, stress/worry control, information about the gut-brain connection and relapse prevention training have been used in studies involving CBT (2).
There are a number of types of CBT, and the review found the two best for IBS include face-to-face, as well as minimal contact CBT. Minimal contact CBT involves less face-to-face sessions, and more study material at home, but the same principles of self-monitoring and muscle relaxation (3).
- Gut directed hypnotherapy
One of the earliest studies utilising gut-directed hypnotherapy was in the 1980s, where 30 IBS participants received either hypnotherapy or standard care over a 3-month period (4). At the end of the 3-month period, participants who received hypnotherapy found their symptoms to be mild or absent (4). The practice involves using sub-conscious mind, to enter a hypnotic state and focus attention on control over gastrointestinal function (4). Since this first study on gut-directed hypnotherapy in the 1980s, with increasing interest on the gut-brain axis, a number of clinical trials have emerged, including one from our team (5). Compared to a low FODMAP diet, gut-directed hypnotherapy was found to be equally as successful in improving symptoms for individuals in IBS.
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the main antidepressants that are prescribed for people with IBS (6). Generally, the doses used are lower than what would be used for individuals with depression. These drugs are effective because they block certain pathways in the central nervous system and gut that would lead to symptoms such as pain, diarrhoea and abdominal pain (7). The NICE guidelines for IBS recommend considering TCAs after other first line pharmacological therapies, and then SSRIs if TCAs are ineffective (8).
A 2019 systematic review found 18 randomised clinical trials that compared an antidepressant with placebo, and included 1127 individuals with IBS(6). Overall, those who took either TCAs or SSRIs were more likely to have improved IBS symptoms compared to a placebo (6). Interestingly, the review found that improvements in abdominal pain were seen in those taking TCAs, and not in those taking SSRIs. Side effects can be experienced with antidepressants, more commonly TCAs than SSRIS, where drowsiness and dry mouth has been reported (6).
Summary:
Alterations in the gut-brain axis play an important role in IBS, and targeting this axis through psychological therapies provides additional treatment options. While we still have a lot to learn about the bidirectional relationship of the gut and the brain in IBS, other effective treatment options include dietary (including low FODMAP), lifestyle and other pharmacological agents (i.e. laxatives). It may take you a few trial and errors of different ways to manage your IBS – work with your health professional to find a treatment that works best for you.
References:
1. 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. Gut. 2020;69(8):1441.
2. Lackner JM, Jaccard J, Keefer L, Brenner DM, Firth RS, Gudleski GD, et al. Improvement in Gastrointestinal Symptoms After Cognitive Behavior Therapy for Refractory Irritable Bowel Syndrome. Gastroenterology. 2018;155(1):47-57.
3. Lackner JM, Jaccard J, Krasner SS, Katz LA, Gudleski GD, Holroyd K. Self-administered cognitive behavior therapy for moderate to severe irritable bowel syndrome: clinical efficacy, tolerability, feasibility. Clin Gastroenterol Hepatol. 2008;6(8):899-906.
4. Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet. 1984;2(8414):1232-4.
5. Peters SL, Yao CK, Philpott H, Yelland GW, Muir JG, Gibson PR. Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(5):447-59.
6. Ford CA, Lacy EB, Harris AL, Quigley MME, Moayyedi MMP. Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-Analysis. The American Journal of Gastroenterology. 2019;114(1):21-39.
7. Rahimi R, Nikfar S, Rezaie A, Abdollahi M. Efficacy of tricyclic antidepressants in irritable bowel syndrome: a meta-analysis. World J Gastroenterol. 2009;15(13):1548-53.
8. National Institute for Health and Care Excellence. Irritable bowel syndrome in adults: diagnosis and management. UK: NICE; 2008.
