Improving access to talking therapies for IBS patients
Professor Hazel Everitt explains how her research into Cognitive Behavioural Therapy (CBT) delivered over the telephone or online can help benefit patients with Irritable Bowel Syndrome (IBS).
Many online treatments and Apps are released for a multitude of medical conditions every week. However, few of these are rigorously developed and tested for patient benefit against treatment as usual, and this is a concern. A large placebo response is frequently seen in chronic conditions and teasing this out from a true intervention effect is important if clinicians, patients and commissioners are to invest time and money in new technologies.
Our recently published NIHR-funded trial ACTIB (Assessing Cognitive Behavioural Therapy (CBT) in Irritable Bowel) evaluating the effectiveness of CBT delivered over the telephone or on a website, has received a flurry of activity and recognition including significant media interest from radio, television, newspaper and social media. This is very gratifying and follows many years of research by our wide multi-disciplinary research team. Background work included development and testing of the CBT for IBS theoretical model and a NIHR Research for Patient Benefit (RfPB) grant to develop and feasibility test the intervention which enabled our multicentre Randomised Controlled Trial (RCT) ACTIB to test clinical and cost effectiveness in response to an NIHR Health Technology Asssement (HTA) Programme research funding call to explore lower intensity options of CBT for IBS.
Harnessing telephone and online CBT
Irritable bowel syndrome (IBS) is a common long-term bowel condition causing symptoms such as abdominal pain, bloating, and a change in bowel habit (i.e. diarrhoea or constipation) which can vary over time. CBT is a talking therapy that can help manage IBS by identifying and managing thoughts and behaviours related to the condition.
NICE guidelines published in 2008 recommended CBT for people with ongoing IBS symptoms if they still had troublesome symptoms after first-line therapies such as diet, lifestyle, fibre and antispasmodics. The NICE guidance was based on limited research evidence of face-to-face CBT for IBS.
However, CBT as a treatment for IBS wasn’t, and in most areas still isn't available within the NHS. As a GP I see many patients whose IBS symptoms significantly impact their quality of life, but there are limited options to help. Cost and resource limitations mean that it’s unlikely that face-to-face CBT will be made widely available on the NHS. So how might one tackle this gap?
We assessed telephone and web-delivered CBT specifically developed for IBS, compared to usual GP or consultant lead care with no access to CBT (treatment as usual). Some telephone therapist support was offered to both the CBT groups, eight hours for the telephone group and two-and-a-half hours for the web-based group. The CBT therapists were co-located in one centre - South London and Maudsley NHS trust - allowing efficient training, support and supervision and were able to provide patient support across the country. We recruited 558 participants from London and the South Coast of England.
We believe ACTIB to be the largest trial of CBT for IBS worldwide. Our results showed that both telephone and online CBT had significant benefits on IBS at 12 months. Both in symptoms - abdominal pain, distention and bowel habit as measured by the IBS symptom severity score - and on impact on life - ability to work and manage at home, participate in social and private leisure activities and relationships as measured by the work and social adjustment scale.
Training the next generation of therapists
Improving access to CBT for IBS via telephone or web interventions could help many people with IBS. Harnessing these technologies has the potential to provide access for many patients at low cost and can be undertaken at a convenient time and place without additional travel time and costs.
We have already made our Therapy manuals available to the Improving Access to Psychological Therapy (IAPT) NHS services and have already trained more than 400 therapists in the delivery of IBS-specific CBT. We are also updating our web-based intervention (Regul8) for NHS compliance and are hoping that it will be included in the imminent NICE IAPT digital technology assessment exercise.
It is widely acknowledged that there is a balance between rapid access to potentially promising new technologies and ensuring clear patient benefit without harm. However, there is still a place for carefully developed, theoretically sound, patient focused interventions and rigorously conducted pragmatic RCTs to ensure effectiveness and credibility.
We are proud to have added to the evidence base in this area and are working hard to make sure that this research evidence is translated into clinical practice to make a difference to patients.
Professor Hazel Everitt, Chief Investigator of the ACTIB study; Professor of Primary Care Research, University of Southampton and General Practitioner
More information on the study, is available on the NIHR Journals Library website.
The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health and Social Care.