Systematic review, meta-analysis with subgroup analysis of hypnotherapy for irritable bowel syndrome, effect of intervention characteristics

Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a common, debilitating disorder characterized by abdominal pain and disordered bowel habits. Current pharmacologic treatments often provide incomplete symptom relief and may be poorly tolerated. Furthermore, alleviation of gastrointestinal symptoms does not always translate into improved quality of life for IBS patients. Current treatment guidelines recommend brain-gut behavior therapy (BGBT) in conjunction with other IBS therapies, and, in randomized controlled trials, BGBT has been shown to improve symptoms, patient satisfaction, functioning, and quality of life. Access to BGBT is limited by lack of adequately trained gastrointestinal psychologists, patient time constraints, and cost. Furthermore, clinician knowledge that BGBT is specific, and different from psychotherapy approaches for common mental health disorders, may limit referrals even where available. This review provides an overview of the pathophysiology of IBS, disease burden, unmet therapeutic needs, evidence base of novel digital therapeutics for IBS, and guidance on the introduction and appropriateness of these interventions for patients.

METHODS

We searched the literature for available published data relating to the use of novel digital therapeutics to provide cognitive behavioral therapy and gut-directed hypnotherapy in the treatment of irritable bowel syndrome.

RESULTS

Clinical trial data support the development and utility of digital therapeutics designed to deliver self-guided cognitive behavioral therapy and hypnotherapy for the treatment of IBS.

CONCLUSIONS

BGBTs are effective, guideline-recommended treatments for IBS. Digital therapeutic devices offer accessible, cost-effective treatment options for delivery of adjunctive BGBT for the treatment of IBS. The decision to recommend digital BGBTs should be guided by careful patient assessment that includes mental health screening and risk assessment.

Meta-analytic evidence on the efficacy of hypnosis for mental and somatic health issues: a 20-year perspective

Introduction

Documented use and investigation of hypnosis spans centuries and its therapeutic use has received endorsement by multiple medical associations. We conducted a comprehensive overview of meta-analyses examining the efficacy of hypnosis to provide a foundational understanding of hypnosis in evidence-based healthcare, insight into the safety of hypnosis interventions, and identification of gaps in the current research literature.

Methods

In our systematic review, meta-analyses of randomized controlled trials on the efficacy of hypnosis in patients with mental or somatic health problems compared to any control condition published after the year 2000 were included. A comprehensive literature search using Medline, Scopus, PsycINFO, The Cochrane Library, HTA Database, Web of Science and a manual search was conducted to identify eligible reviews. Methodological quality of the included meta-analyses was rated using the AMSTAR 2 tool. Effect estimates on various outcomes including at least three comparisons (k ≥ 3) were extracted and transformed into a common effect size metric (Cohen's d). If available, information on the certainty of evidence for these outcomes (GRADE assessment) was obtained.

Results

We included 49 meta-analyses with 261 distinct primary studies. Most robust evidence was reported for hypnosis in patients undergoing medical procedures (12 reviews, 79 distinct primary studies) and in patients with pain (4 reviews, 65 primary studies). There was a considerable overlap of the primary studies across the meta-analyses. Only nine meta-analyses were rated to have high methodological quality. Reported effect sizes comparing hypnosis against control conditions ranged from d = -0.04 to d = 2.72. Of the reported effects, 25.4% were medium (d ≥ 0.5), and 28.8% were large (d ≥ 0.8).

Discussion

Our findings underline the potential of hypnosis to positively impact various mental and somatic treatment outcomes, with the largest effects found in patients experiencing pain, patients undergoing medical procedures, and in populations of children/adolescents. Future research should focus on the investigation of moderators of efficacy, on comparing hypnosis to established interventions, on the efficacy of hypnosis for children and adolescents, and on identifying patients who do not benefit from hypnosis.

Clinical Trial Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023395514, identifier CRD42023395514.

Nerva, a mobile application of gut-directed hypnotherapy for irritable bowel syndrome: User characteristics, patterns of use, and predictors of persistence

Background

Hypnotic intervention for irritable bowel syndrome (IBS), or gut-directed hypnotherapy (GDH), is an effective treatment for improving IBS symptoms with minimal burden and risk in delivery to patients. The Nerva app, developed by Mindset Health, shows promise for dissemination and implementation of evidence-based GDH intervention for IBS.

Objectives

This study aimed to describe the demographic and clinical characteristics of Nerva app users, examine usage patterns, and explore potential factors associated with Nerva app usage.

Methods

A retrospective analysis of data was conducted of 14,898 individuals who downloaded and used the Nerva app between January 2022 and September 2022. Descriptive statistics and Chi-square tests of independence were calculated to examine demographic/clinical characteristics, usage patterns, and their associations to program persistence. Simple linear regression models were used for correlations of GI symptoms severity scores to user persistence.

Results

Users predominantly identified as female (77.2%; n = 11,503) and had a mean age of 38.59 years old (SD = 13.38). Thirty-one percent of users persisted with the program, and a small statistically significant association was found between Nerva app program persistence and age, χ2 (6, N = 6745) = 164.82, p < 0.001, V = .16.

Conclusions

The present study found promising adherence rates for the Nerva app program within the first six weeks of use. Statistics in prevalence estimates of IBS agree with previous literature and significant associations were found between user/clinical characteristics and Nerva app program persistence.

Psychological treatments for irritable bowel syndrome: a comprehensive systematic review and meta-analysis

A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a.

Irritable bowel syndrome - controversies in diagnosis and management

INTRODUCTION

The irritable bowel syndrome (IBS) is the best-recognized disorder of gut brain interactions (DGBI). However, it is controversial if the Rome IV criteria iteration for IBS diagnosis is fit for purpose.

AREAS COVERED

This review critically evaluates Rome IV criteria for diagnosis of IBS and addresses clinical considerations in IBS treatment and management, including dietary factors, biomarkers, disease mimics, symptom severity, and subtypes. The role of diet in IBS is critically reviewed along with the influence of the microbiota, including small intestinal bacterial overgrowth.

EXPERT OPINION

Emerging data suggest the Rome IV criteria are more suitable for identifying severe IBS and least useful for sub-diagnostic patients who are still likely to benefit from IBS treatment. Despite convincing evidence that IBS symptoms are diet-driven and often postprandial, a relationship to eating is not a Rome IV diagnostic criterion. Few IBS biomarkers have been identified, suggesting the syndrome is too heterogeneous to be measured by a single marker, and combined biomarker, clinical, dietary, and microbial profiling may be needed for objective characterization. With many organic diseases mimicking and overlapping with IBS, it's important clinicians are knowledgable about this to mitigate the risk of missing comorbid organic intestinal disease and to optimally treat IBS symptoms.

[Hypnotherapy for Irritable Bowel Syndrome]

Irritable bowel syndrome (IBS) is a functional disorder of the lower digestive tract. Based on the biopsychosocial model, there is a wide range of therapeutic interventions to deal with the symptoms of IBS and to improve the quality of life of those who are affected. In this context, hypnotherapy and in particular gut-directed hypnosis represents a psychotherapeutic intervention with great empirical evidence for its efficacy.

Current perspectives on irritable bowel syndrome: a narrative review

The pathophysiology of irritable bowel syndrome (IBS) has not yet been fully elucidated. We reviewed articles addressing IBS that have been published in the last 2 years and selected papers related to IBS pathophysiology and treatment. Studies of intestinal bacteria, low-grade mucosal inflammation, and increased mucosal permeability—factors involved in the pathophysiology of IBS—have been conducted. In addition, the involvement of intestinal bacteria in IBS pathology has been clarified; many studies of treatments related to intestinal bacteria have been reported. Moreover, several studies address the effect on IBS of antidepressants and psychotherapy through the brain–gut axis. The contents of these papers are described in this narrative review.

The clinical value of psycho-gastroenterological interventions for functional esophageal symptoms

BACKGROUND

Disorders of gut-brain interaction (DGBI) are associated with high symptom burden and poor quality of life. We evaluated the clinical value of multimodal therapy with psycho-gastroenterological interventions in patients with refractory functional symptoms.

METHODS

Of 80 DGBI patients managed over a 12-month period, 26 patients undergoing multimodal therapy (median age 60.0 years, 73.1%F) were compared to 54 patients (median age 56.0 years, 68.5%F) managed using conventional approaches. Psycho-gastroenterological multimodal therapy was individualized and included relaxation training (diaphragmatic breathing, passive muscle relaxation) and gut-direct hypnotherapy/guided imagery. All patients completed documentation of symptom frequency and severity using a 100 mm visual analog scale (VAS) and assessment of health-related quality of life (BEST score) before and following therapy. Data were analyzed to determine comparative change in symptom burden between the two cohorts.

KEY RESULTS

Baseline demographics and symptom burden were similar between the two treatment subgroups. While patients improved with both multimodal and conventional therapies, BEST score demonstrated greater improvement with multimodal therapy (p = 0.03). Physician perception of symptom burden at baseline and on follow-up did not correspond to self-reported questionnaire data. On multivariable analysis, multimodal therapy (OR 7.9, 95% CI 1.8-34.6, p = 0.006) and functional esophageal disorders (OR 17.6, 95% CI 2.6-121.1, p = 0.004) predicted >50% improvement in BEST score, while the presence of psychiatric disease was a negative predictor (OR 0.22, CI 0.05-0.94, p = 0.04).

CONCLUSIONS & INFERENCES

Psychological intervention using multimodal therapy provides clinical value to the management of functional esophageal symptoms among patients refractory to conventional therapy.

Hypnotherapy for persons with Irritable Bowel Syndrome: A three-arm randomized controlled trial

The current study sought to (1) compare the efficacies of Ericksonian hypnotherapy, traditional hypnotherapy, and educational talk in treating irritable bowel syndrome (IBS), and to (2) evaluate the impacts of hypnotic susceptibility on participants' responses to hypnotherapy. The study adopted a three-arm randomized controlled trial design and achieved an effective sample size of 144. Self-reported psychological questionnaires were used to assess participants' IBS symptom severity, health-related quality of life, and coping patterns at baseline, immediately post-intervention, and 3 months after intervention. The evaluation focused primarily on IBS symptom severity and health-related quality of life, as well as on the illness coping patterns of symptom catastrophizing and symptoms-related social hypervigilance.The findings showed that significant improvements in IBS symptom severity occurred in all three types of study groups immediately after completion of the intervention (p < .05, η_ρ² = .20). However, only the traditional hypnotherapy groups and the Ericksonian hypnotherapy groups still had a notably significant decrease in symptoms 3 months after the intervention, whereas the educational talk groups had dropped back to pre-treatment symptom levels at the 3-month follow-up. The amplitude of change of symptom catastrophizing in the traditional hypnotherapy groups was stronger than that in the Ericksonian hypnotherapy groups after completion of the intervention, and the two types of hypnotherapy groups were significantly lower in symptom catastrophizing both immediately after the intervention and also 3 months post-intervention (p < .001, η_ρ² = .17). The other coping mechanism studied, symptoms-related social hypervigilance, showed a significant decline only in the Ericksonian hypnotherapy groups (ps < .001, η_ρ² = .45). Interestingly, in the traditional hypnotherapy groups, persons with higher hypnotic susceptibility showed significant improvement in symptom severity, health-related quality of life, and coping patterns following treatment. Notably, the effects from Ericksonian hypnotherapy for IBS diverged from the effects from traditional hypnotherapy. Finally, both Ericksonian hypnotherapy and traditional hypnotherapy appeared to have greater positive effects than educational talk did, but at different levels.

Review article: the effectiveness of group and self-help hypnotherapy for irritable bowel syndrome and the implications for improving patients' choice and access to treatment

BACKGROUND

Individual hypnotherapy (IH) is a recognised treatment for irritable bowel syndrome (IBS). However, it is not widely available to patients due to its resource-intensive nature, lack of adequately trained therapists, and scepticism about hypnosis. Non-individualised hypnotherapy approaches, such as group and self-help hypnotherapy, could maximise existing therapist resources by treating more patients at the same time, thus widening patient access to treatment without incurring additional expenditure.

AIMS

To investigate the research literature for non-individualised approaches to hypnotherapy for IBS and to determine their effectiveness for reducing symptom severity and/or providing adequate relief.

METHODS

A literature review of published peer-reviewed studies was conducted. Quantitative research was selected to determine the effectiveness of the interventions.

RESULTS

Ten studies were eligible for inclusion. Three delivered group hypnotherapy, three integrated hypnosis within a group concept, and four utilised a self-help home hypnotherapy treatment using audio recordings. Both group hypnotherapy for adults and the self-help home hypnotherapy treatment for children were effective interventions that may be non-inferior to IH for patients with mild-to-moderate symptoms. Treatment benefits were long-lasting. The evidence for the integrative group concept and home treatment for adults was less compelling.

CONCLUSIONS

Group hypnotherapy for adults, and self-help hypnotherapy for children, may be cost-effective treatments that can widen access for patients with milder IBS in primary care settings. Further research is needed to determine the effectiveness of group hypnotherapy for patients with severe, refractory IBS.