Psychological Therapies in Patients with Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Table 2

Baseline characteristics and description of interventions.

Author, year, country, and objective	Inclusion/exclusion criteria	Number of patients () and baseline characteristics	Length of follow-up	Interventions; number of patients (number of patients lost to follow-up); Description of intervention
Corney et al., 1991  [22]; Country: UK; Objective: to establish if stress management is superior to medical management in IBS and if psychosocial factors predict therapeutic response.	Inclusion: abdominal pain that fits no other disease pattern and/or nonbloody diarrhea and/or constipation with discomfort; 6 months of symptoms; normal sigmoidoscopy and rectal biopsy; and altered bowel habits.; Exclusion: presence of psychological disorders as rated by CIS (>13).	: 42; Age: range 19–73. Half were aged under 30.; Gender: 74% females.; Race: NR; Previous treatment: NR	9 months	BT; 22 (1); Behavioral therapy. 6–15 weekly one-hour sessions with nurse behavior therapist. Discussed symptoms and impact on life. Pain management techniques.; MT; 20 (0); Medical treatment. 1–4 outpatient appointments; treatment using explanation, reassurance, medications, antispasmodics, bulk laxatives, and dietary advice.
Greene and Blanchard, 1994 [25]; Country: USA; Objective: to investigate if a treatment designed to address anxiety related to GI symptoms can be advantageous to IBS patients.	Inclusion: Latimer criteria; age 18–70.; Exclusion: schizophrenia; bipolar disorder; organic mental disorder; or patients involved in cognitive therapy in the last 12 months.	: 20; Age: 38.2 (10.9)^*; Gender: 75% females.; Race: NR; Previous treatment: NR	10 weeks	CT; 10 (2); Cognitive therapy. Ten individual 1-hour sessions: biweekly for two weeks and then weekly for 6 more weeks. Education on IBS and increased subjects' awareness of association of stressors, thoughts, and appraisals of symptoms.; SM; 10 (0); Symptom monitoring condition. Monitored GI symptoms with diary for 10 weeks.
Fernandez et al., 1998 [24]; Country: Spain; Objective: to explore the superiority of behavioral approaches to IBS over other procedures.	Inclusion: Manning criteria; endoscopic workup; IBS for more than a year; at least two of the following: wrong ingestion of medicines prescribed by doctor and/or noncompliance, more than one visit not scheduled by gastroenterologist, worker absenteeism or difficulties with carrying out ordinary job tasks, previous psychiatric treatment, and entry into the emergency service without medical indication.; Exclusion: NR	: 90; Age: 44; Gender: 66% females.; Race: NR; Previous treatment: NR	12 weeks	CM; 23 (7); Contingency management. Aim to show the patient how to practice adaptive behaviors to IBS symptoms and to extinguish maladaptive behaviors in the presence of those symptoms. 10 weekly sessions.; SM; 21 (6); Stress management. Aim to provide the patient with effective techniques to mitigate the physiological effects of stress and tension and to modify his/her coping skills. Daily practice for about 20 minutes. 10 weekly sessions.; CG and PCG; 23 and 23 (4 and 6); Control group (conventional medical treatment) and placebo control group (some imaginative and active visualization of bowel function exercises and the prompting of their own capacity for self-regulation through thought, stimulating their concentration to the utmost. Daily practice at home and 10 weekly sessions of practice with therapist).
Vollmer and Blanchard, 1998 [36]; Country: USA; Objective: to investigate whether cognitive therapy in a small group setting could provide a cost-effective alternative to individual therapy.	Inclusion: Rome I criteria.; Exclusion: lab findings, physician examination, irritable bowel disease, intestinal parasites, organic pathology, or pregnancy. Diagnosis of serious psychiatric illness.	: 32; Age: 43.47 (12.58)^*; Gender: 78% females.; Race: NR; Previous treatment: NR	10 weeks	ICT; 11 (NR); Individual cognitive therapy. Increasing subjects' awareness of association of stressors, thoughts, and IBS symptoms. Training subjects to identify and modify cognitive appraisals of behaviors. Change depressive life scripts. Weekly 60-minute sessions for 10 weeks.; GCT; 11 (NR); Group cognitive therapy. Same as above but in weekly 90-minute group sessions for 10 weeks.; WC; 10 (NR); Waitlist control. 8-week symptom monitoring.
Heymann-M nnikes et al., 2000 [26]; Country: Germany; Objective: to investigate if behavioral therapy with medical treatment is more effective than medical treatment alone in a tertiary GI referral center.	Inclusion: Rome I criteria and medical assessment.; Exclusion: Mental disorders as detected by screening tests.	: 26; Age: 37.8 (14.57)^*; Gender: 81% females.; Race: NR; Previous treatment: NR	3 months	SMBT; 13 (1); Standardized multicomponent behavioral treatment. 10 sessions, 60 minutes each over 10 weeks with clinical psychologists in pilot tested behavioral program adapted for IBS. Included: information; shaping of a plausible illness model; progressive muscle relaxation; cognitive coping strategies; problem-solving; assertiveness; and social skills training.; SMT; 13 (1); Standard medical therapy. Supportive physician-patient relationship and symptom oriented pharmacotherapy. Met for 30–45 minutes every 2 weeks with GI doctor.
Boyce et al., 2003 [20]; Country: Australia; Objective: to compare the effects of CBT with relaxation versus clinical care alone in IBS patients.	Inclusion: Rome I criteria; no structural bowel pathology accounting for their symptoms; age ≥ 18; speaking sufficient English.; Exclusion: Any major medical or psychotic illness; history of alcoholism; current psychological treatment and use of antidepressants or antipsychotics; or current use of medications that could affect bowel function.	: 105; Age: 42.3 (11.8)^*; Gender: 81% females.; Race: NR; Previous treatment: 50% had previously had treatment for IBS at some point. Two-week washout before randomization for all subjects.	12 months	CBT + RCC; 35 (17); Cognitive behavioral therapy with routine clinical care. Psychological assessment followed weekly 1-hour CBT sessions over 8 weeks by clinical psychologist. Manual-based program based on hypochondriasis model and CBT approach used for anxiety with IBS modification. Homework included relaxation skills, restructuring cognition, enhanced coping strategies, and symptom appraisal, in addition to RCC.; RT + RCC; 36 (23); Relaxation training with routine clinical care. Psychological assessment followed by weekly 30 min face to face instructional sessions for 8 weeks on relaxation strategies. Also completed homework assessments of tension, in addition to RCC.; RCC; 34 (13); Routine clinical care. Three 15–30 min sessions with a gastroenterologist, including medical management, symptom discussion, and dietary fiber advice.
Creed et al., 2003; Hyphantis et al., 2009 [15, 27]; Country: UK; Objective: to assess the relationship between change in interpersonal difficulties and change in chronic pain, health status, and psychological state in IBS patients.	Inclusion: Rome I criteria; age 18–65; duration of symptoms more than 6 months; failure to respond to usual medical treatment for a minimum of 3 months; severe abdominal pain, more than 59 on a visual analogue scale; no contraindication to either psychotherapy or paroxetine; ability to complete the study questionnaires.; Exclusion: NR	: 257; Age: 39.97 (1.37)^*; Gender: 80% females.; Race: 98% white, 2% other.; Previous treatment: NR	15 months	Psychotherapy; 85 (13); Psychodynamic interpersonal therapy. One long (2 hours) and 7 short (45 minutes) individual sessions over 3 months. Patients encouraged to discuss their symptoms in depth; links between symptoms and emotional factors were identified. After the 3 months, patients returned to their general practitioner who then managed care.; SSRI; 86 (13); Selective serotonin reuptake inhibitor. Paroxetine 20 mg orally once a day for 3 months. After the 3 months, patients returned to their general practitioner for management of care.; TAU; 86 (9); Treatment as usual. Patients continued with routine management under physician supervision.
Tkachuk et al., 2003 [35]; Country: Canada and USA; Objective: to compare efficacy of 10 sessions of CBGT with a home-based symptom monitoring with weekly telephone contact treatment on refractory IBS patients.	Inclusion: Rome I criteria; negative for inflammatory bowel disease, parasites, organic pathology, and pregnancy.; Exclusion: severe mental disorders including schizophrenia, bipolar disorder, and severe major depression, current drug or alcohol abuse, or organic mental disorder.	: 28; Age: 39.5 (12.5)^*; Gender: 96% females.; Race: NR; Previous treatment: patients continued to receive medical treatment as usual but were asked to maintain their typical use patterns for the period of the study.	11 weeks	CBGT; 14 (NR); Cognitive-behavioral group therapy. Two cognitive-behavioral therapists cofacilitated groups of 3–8 IBS patients. Ten 90-minute sessions over 9 weeks (2 in the first week, 1 for the next 8 weeks). Focused on patient education and goals; relaxation training; cognitive therapy; assertion training; relapse prevention strategies.; SMTC; 14 (NR); Symptom monitoring with weekly telephone contact. Monitored GI symptoms for 13 weeks. Weekly 15-minute phone contact while the same 9 weeks CBGT took place. Patients encouraged to discuss symptoms.
McCrone et al., 2008; Kennedy et al., 2005; Kennedy et al., 2006 [17, 28, 29]; Country: UK; Objective: to assess the efficacy of cognitive behavior therapy delivered in primary care for treating IBS.	Inclusion: Rome I; age 16–50; moderate to severe IBS symptoms despite 2 weeks of usual treatment and 2 weeks of mebeverine therapy.; Exclusion: pregnancy or breast feeding; alarm symptoms suggestive of colorectal cancer; history of IBD or celiac disease; abdominal pain relieved by acid inhibiting drugs.	: 149; Age: 33.7 (9.15)^*; Gender: 85% females.; Race: NR; Previous treatment: NR	14 months	CBT + mebeverine; 72 (11); Cognitive behavioral therapy. Six 50-minute sessions delivered by face-to-face contact with a trained nurse, in addition to mebeverine 270 mg three times a day.; Mebeverine; 77 (6); Mebeverine 270 mg three times a day.
Blanchard et al., 2007; Lackner et al., 2007 [19, 32]; Country: USA; Objective: to assess the cost savings of group CBG versus individual as well as the efficacy of both treatments on GI symptoms of IBS.	Inclusion: Rome II diagnosis. Age greater than 18.; Exclusion: organic GI disease; very low baseline diary pain ratings; psychotic disorder; severe major depression with moderate to severe suicidal ideation; previous lifetime exposure to CBT.	: 210; Age: 49.2 (13.1)^*; Gender: 82% females.; Race: 95% white, 5% other.; Previous treatment: NR	5 months	CBT; 120 (11); Cognitive behavioral therapy. 3–6 participant group sessions. Ten weekly 90 min sessions. Explains the role of stress in IBS symptoms; teaches to become observers of cognitions through journaling. Attention directed to cognitive fallacies; attempts to change maladaptive core beliefs and problem-solving.; PS; 46 (6); Psychoeducational support. 3–6 participants, ten weekly 90 min sessions. Discussions on diet, food sensitivity, diagnostic test education, and physician experiences. Emphasis on sharing views and being supportive.; SSEM; 44 (5); Symptom and stressful event monitoring. Participants asked to monitor GI symptoms and stress events daily for 10 weeks. Seen once at midpoint for contact.
Lackner et al., 2010; Lackner et al., 2008 [31, 33]; Country: USA; Objective: to test the acute treatment effects of self-administered CBT compared to a waitlist control condition in IBS patients.	Inclusion: Rome II criteria; age 18–70; willingness to maintain a stable dose of IBS medications during the pretreatment baseline period; minimum 6th grade reading level.; Exclusion: presence of comorbid organic gastrointestinal disease or mental retardation; concomitant or lifetime participation in psychotherapy featuring cognitive-behavioral techniques; current or past diagnosis of schizophrenia or other psychotic disorders; current diagnosis of unipolar depression with suicidal ideation; and current diagnosis of psychoactive substance abuse.	: 75; Age: 46.6 (16.7)^*; Gender: 87% females.; Race: 95% white, 3% black, 1% Hispanic, and 1% Asian.; Previous treatment: NR	3 months	S-CBT; 23 (7); Standard CBT. Skills-based training program delivered to patients in 10 weekly, 1-hour sessions with weekly assignments. Six overlapping phases: (1) education of stress and IBS, (2) self-monitoring of stress associated with IBS, (3) muscle relaxation, (4) learning to identify, reevaluate, and change negatively skewed thoughts associated with IBS, (5) changing underlying “core” beliefs (e.g., perfectionism) that fuel threatening cognitions, and (6) formal training in problem-solving to strengthen the ability to cope with realistic stressors associated with IBS.; MC-CBT; 25 (5); Minimal contact CBT. Covers the same range of procedures featured in S-CBT but relies extensively on self-study materials. Meeting for only four 60-minute clinic visits during the same period. Two 10-minute phone contacts are scheduled at weeks 3 and 7 to troubleshoot any problems. Meetings introduced material.; WLC; 27 (0); Waiting list control. Subjects were placed on a 10-week delayed treatment waiting list, during which time they engaged in daily self-monitoring of gastrointestinal symptoms.
Chilcot and Moss-Morris, 2013; Moss-Morris et al., 2010 [21, 34]; Country: UK; Objective: to investigate the efficacy of a CBT-based self-management manual for the treatment of IBS.	Inclusion: Rome I modified or Rome II criteria; age 18 to 72; could read and write English; living within geographical proximity to the study center.; Exclusion: suffered from another medical condition that had potential to affect symptoms; had had bowel surgery; had a current serious mental disorder.	: 64; Age: 39.5 (16.8)^*; Gender: 72% females.; Race: 89% white, 11% other.; Previous treatment: NR.	8 months	CBT + TAU; 31 (1); Cognitive behavioral therapy and treatment as usual. IBS fact sheet in addition to a comprehensive self-management manual and weekly assignments. Also received a 1-hour face-to-face session with a health psychologist at the beginning of the program and two 1-hour therapy sessions by telephone scheduled midway and towards the end.; TAU; 33 (0); Treatment as usual. IBS fact sheet included an explanation of how IBS is diagnosed and reassurance that the complete range of tests had been conducted and that their history indicated no structural causes.
Craske et al., 2011; Wolitzky-Taylor et al., 2012 [23, 37]; Country: USA; Objective: to evaluate the efficacy of a treatment for IBS that directly targets hypervigilance and hypersensitivity to visceral sensations, modeled on the methods used for the treatment of panic disorder.	Inclusion: Rome II criteria.; Exclusion: presence of another chronic pain condition; major mental illness such as schizophrenia and bipolar disorder and substance abuse; or taking narcotic pain medication.	: 110; Age: 39.47 (13.50)^*; Gender: 75% females.; Race: 73% white, 9% black, 2 Hispanic, 10% Asian, and 6% other.; Previous treatment: subjects continued their usual care, 8.1% on benzodiazepines and 13.5% on antidepressant medication (SSRIs, SNRIs, or TCAs).	6 months	IE CBT; 47 (22); CBT focused on interoceptive cues. Goal of therapy to reduce anxious and avoidant responses to visceral sensations. Consists of IBS symptoms education; attention training; cognitive therapy against visceral sensations; interoceptive exposure to reduce fear of sensations; in vivo exposure to feared situations with IBS symptoms. 10 sessions over 10 weeks, each session lasting 50 minutes.; SM CBT; 41 (18); CBT focused on stress management. Goal of therapy to reduce cognitive and physical stressful reactions to daily life events. Consists of education about IBS symptoms and stress; self-monitoring symptoms; muscle relaxation training; cognitive therapy; in vivo exposure to personally stressful situations unrelated to IBS sensations. 10 sessions over 10 weeks, each session lasting 50 minutes.; AC; 22 (9); Attention control. Self-monitoring of IBS symptoms; educational material about IBS; and discussions with therapist. 10 fifty-minute sessions over 10 weeks.
Gaylord et al., 2011 [12]; Country: USA; Objective: to explore the feasibility and efficacy of a group program of mindfulness training for women with IBS.	Inclusion: Rome II criteria; female; age 18–75; ability to understand English; willingness to participate.; Exclusion: diagnosis of mental illness with psychosis; history or current diagnosis of IBD or GI malignancy; uncontrolled lactose intolerance; celiac disease; history of abdominal trauma or surgery involving gastrointestinal resection; or pregnancy.	: 75; Age: 42.73 (19.31)^*; Gender: 100% females.; Race: 72% white, 17% black, and 11% other.; Previous treatment: subjects continued with their usual care.	5 months	MG; 36 (2); Mindfulness training group. 8 weekly 2-hour sessions plus one half-day retreat. Mindfulness-based stress and pain management program taught by trained mindfulness instructors. Instruction and assignments related to the body scan, sitting and walking meditation, and mindful yoga. The basic course was adapted to an IBS population. Weekly assignments included readings from provided texts: “Full Catastrophe Living” and “IBS for Dummies.”; SG; 39 (7); Support group. 8 weekly 2-hour sessions plus one half-day retreat. A social-support group intervention led by master’s level social workers to control for expectations of benefit and amount of group contact. Focused on predesignated topics and open group discussions about subjects’ experiences and reactions to the topic. Weekly assignments included readings from the provided text: “IBS for Dummies.”
Labus et al., 2013 [30]; Country: USA; Objective: to investigate the efficacy of a CBT-based self-management manual for the treatment of IBS.	Inclusion: Rome II criteria; organic disease was excluded with appropriate testing, and a clinical diagnosis of IBS was made by an experienced gastroenterologist.; Exclusion: NR	: 69; Age: 46.8 (12.6)^*; Gender: 72% females.; Race: 84% white, 9% black, 3% Hispanic, 1% Asian, and 3% other.; Previous treatment: subjects were instructed to continue their IBS care.	3 months	Psychoeducational course; 34 (NR); A course led by a gastroenterologist (45%) with a therapist (55%) and consisting of 5 consecutive weekly 2-hour sessions in a group setting with 5–8 participants per group. Participants were also given reading and practical homework assignments related to the topics covered in each session. The course consisted of an educational component, psychological component, relaxation training, and homework assignments, in addition to chapters from “IBS and the Mind-Body Brain-Gut connection.”; Waitlist; 35 (NR); Chapters from “IBS and the Mind-Body Brain-Gut connection.”

^*Age is expressed in years and presented as mean (standard deviation).
Abbreviations in interventions column are explained directly under intervention; UK: United Kingdom; IBS: irritable bowel syndrome; CIS: the clinical interview schedule; : number of patients; NR: not reported; USA: United States of America; GI: gastrointestinal; CBT: cognitive behavioral therapy; CBG: cognitive-behavioral group therapy; IBD: inflammatory bowel disease; SSRI: selective serotonin reuptake inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor; TCA: tricyclic antidepressant.