In drug-refractory IBS, group CBT with interoceptive exposure improved symptoms and quality of life at 13 wk

A single-center, open-label trial randomized 114 patients with moderate to severe drug-refractory irritable bowel syndrome (IBS) to receive group cognitive behavioral therapy with interoceptive exposure (CBT-IE) or to be placed on a waiting list. Both arms practiced self-monitoring and received treatment as usual. At week 13, patients in the CBT-IE arm reported greater improvements in both IBS symptom severity and quality of life (QoL) compared with those on the waiting list, dropping 115.8 versus 29.7 points on the IBS Symptom Severity Score (difference, −86.1; 95% CI, −117.3 to −55.0) and gaining 20.1 versus −0.2 points on the IBS Quality of Life Measure (difference, 20.3; 95% CI, 15.2 to 25.3). Six unexpected serious adverse events were reported but were judged to be unrelated to the interventions.

The study was published in April by the American Journal of Gastroenterology. The following commentary by Daniel Oliver, MD, and Nicholas J. Talley, MD, PhD, FACP, was published in the ACP Journal Club section of the August Annals of Internal Medicine.

Although effective, individually provided multidisciplinary care with psychological, behavioral, and dietary interventions is not routinely available for patients with IBS. The benefit of group (vs. individual) CBT, which could improve accessibility for patients with IBS, is unclear. CBT-IE has been proposed to have some success, but data are limited. IE desensitizes responses to body sensations that may trigger symptoms; it aims to remove the “fear of fear” and has been successfully applied in panic disorder.

This Japanese, single-center randomized trial by Kikuchi and colleagues found that CBT-IE improved both IBS symptoms and QoL compared with a waitlist. Mode of delivery in the trial changed from face-to-face to internet-based delivery because of the COVID-19 pandemic, but post hoc subgroup analyses showed that this did not affect outcomes.

By 13 weeks, 67% of patients in the CBT-IE group responded on the Irritable Bowel Syndrome Global Improvement Scale, but only 5% of patients in the waitlist group responded—this remarkably low response rate may reflect a population of drug-refractory patients and/or dissatisfaction with standard care (although patients in both groups received education and self-monitoring). Time with a therapist was greater in the CBT-IE group, which may have biased success. There were too few patients with IBS-constipation to determine if this subgroup benefited (most had diarrhea, and few were receiving antidiarrheal drugs).

Group CBT has not been directly compared with individual CBT, and whether CBT-IE is superior to CBT alone cannot be disentangled, so the value of group CBT-IE remains uncertain. Moreover, the results from a single center may not be generalizable. A head-to-head comparison of multidisciplinary care vs. group CBT by internet delivery in patients with IBS is now warranted.