Therapies cut symptoms, though publication bias limits confidence, new research has found.
Behavioural therapies deliver meaningful symptom improvement for many patients with irritable bowel syndrome, according to a new systematic review and network meta-analysis that compared 67 randomised trials involving more than 7400 participants.
The analysis found that several brain–gut behaviour therapies, including minimal contact cognitive behavioural therapy, telephone-based disease self-management, dynamic psychotherapy, standard CBT, internet-delivered CBT and gut-directed hypnotherapy, consistently outperformed waiting list control for global IBS symptoms immediately after treatment.
However, the researchers noted that larger, more rigorous RCTs were needed to improve evidence for the treatment and stressed the findings should be viewed with caution.
“Several behavioural therapies are efficacious for global symptoms in IBS, although the most evidence exists for those classed as brain–gut behaviour therapies,” they wrote.
“However, certainty in the evidence for all direct and indirect comparisons across the network were rated as either low or very low confidence, due in part to publication bias and the risk of bias of the included trials.”
Findings have been published this month in The Lancet Gastroenterology and Hepatology.
The interventions, many rooted in brain–gut behavioural principles, demonstrated relative risk reductions in persistent global IBS symptoms compared with waiting list control ranging from 21% to 45%. Notably, minimal contact CBT and telephone disease self-management ranked among the highest-performing modalities, supported by large trials and strong P scores.
The researchers also examined patients with refractory IBS, and in this tougher-to-treat group, none of the behavioural therapies did better than waiting list control. However, telephone disease self-management, contingency management, group CBT, internet-based disease self-management and dynamic psychotherapy all surpassed attention placebo or routine care.
The analysis also updated longer-term data, which remain scarce. Only 14 RCTs reported outcomes at six months or later, yet within this limited evidence base, stress management, minimal contact disease self-management and telephone disease self-management outperformed routine care.
Forms of CBT showed sustained advantages over relaxation therapies, education and routine care, indicating some durability of effect beyond treatment cessation, the researchers reported.
Despite generally positive findings, the authors emphasised substantial caution. No study met low-risk criteria across all Cochrane domains, and publication bias was evident in several analyses. Lack of blinding remained a major methodological barrier, the researchers noted.
They said the research highlighted a growing acknowledgement that traditional pharmacotherapy trial standards inadequately captured the rigour of behavioural trials and that new evaluative frameworks were needed.
The review also underscored gaps in digital therapy research. While digital gut-directed hypnotherapy yielded encouraging results in two large trials, no other digital modalities demonstrated superiority to waiting list control.
For gastroenterologists seeking scalable, accessible behavioural options, this finding tempered enthusiasm for app-based or fully automated tools and reinforced the central role of clinician-supported interventions, the researchers wrote.
As IBS care increasingly shifted toward integrated models, they said effective behavioural therapies should be implemented earlier in the treatment pathway rather than reserved solely for refractory cases.
Related
Several promising delivery formats, including group-based, internet-supported and minimal-contact variants, could help overcome access barriers, reduce patient burden and lower healthcare costs, they said.
Evidence from one integrated outpatient program for disorders of gut–brain interaction suggested that embedding behavioural therapies within routine gastroenterology care improved symptoms, mood and quality of life while reducing management costs.
Key questions remain unanswered however, the researchers wrote. Few trials have examined predictors of response, although preliminary analyses suggest that anxiety levels, baseline symptom severity and non-GI somatic symptoms may influence outcomes.
Larger, rigorously controlled RCTs were needed to define patient subgroups most likely to benefit, optimise treatment dosing and strengthen long-term efficacy data. Standardised adverse event reporting was also urgently needed.
“In summary, we found numerous behavioural therapies to be efficacious for global symptoms in IBS. Most of these were treatments considered to be brain–gut behaviour therapies, with evidence for other types of therapy restricted to results from single trials or pooling several small RCTs,” the researchers concluded.
“Despite the promise of digital approaches, in terms of improving access, only digital gut-directed hypnotherapy had any evidence for efficacy. Nevertheless, our analysis provides support for alternative methods of delivery of behavioural therapies that could improve access.
“There was evidence for longer-term efficacy, beyond treatment cessation, for some therapies. However, the high risk of bias of all included RCTs, as well as possible publication bias, means that efficacy might have been overestimated and confidence in the results of the network meta-analysis was low or very low.
“Forms of CBT and gut-directed hypnotherapy had the largest evidence base, and forms of CBT, stress management, and disease self-management had some evidence for longer-term efficacy.
“Moving forward, RCTs should use appropriate control conditions, report adverse effects in full, and examine the influence of patient factors that predict response, and assess efficacy of behavioural therapies earlier in the disease course, before patients are refractory to medical management.”
