Clinical–Alimentary TractThe cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome☆
Abstract
Background & Aims: Psychotherapy and antidepressants are effective in patients with severe irritable bowel syndrome (IBS), but the cost-effectiveness of either treatment in routine practice has not been established. Methods: Patients with severe IBS were randomly allocated to receive 8 sessions of individual psychotherapy, 20 mg daily of the specific serotonin reuptake inhibitor (SSRI) antidepressant, paroxetine, or routine care by a gastroenterologist and general practitioner. Primary outcome measures of abdominal pain, health-related quality of life, and health care costs were determined after 3 months of treatment and 1 year later. Results: A total of 257 subjects (81% response rate) from 7 hospitals were recruited; 59 of 85 patients (69%) randomized to psychotherapy and 43 of 86 (50%) of the paroxetine group completed the full course of treatment. Both psychotherapy and paroxetine were superior to treatment as usual in improving the physical aspects of health-related quality of life (SF-36 physical component score improvement, 5.2 [SEM, 1.26], 5.8 [SEM, 1.0], and −0.3 [SEM, 1.17]; P < 0.001), but there was no difference in the psychological component. During the follow-up year, psychotherapy but not paroxetine was associated with a significant reduction in health care costs compared with treatment as usual (psychotherapy, $976 [SD, $984]; paroxetine, $1252 [SD, $1616]; and treatment as usual, $1663 [SD, $3177]). Conclusions: For patients with severe IBS, both psychotherapy and paroxetine improve health-related quality of life at no additional cost.
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Assessing the post-treatment therapeutic effect of tongxie in irritable bowel syndrome: A randomized controlled trial
2022, Complementary Therapies in MedicineDiarrhea predominant irritable bowel syndrome (IBS) is a highly relapsing gastrointestinal disorder decreasing the quality of life. Existing studies indicated that the therapeutic effects maintained for a period of time after the treatments were discontinued (post-treatment therapeutic effects or PTTE). In this study, we aim to assess the PTTE of tongxie. We performed a multiple center, controlled, double blind study of patients with IBS randomized to tongxie (n = 120) or placebo (n = 120) for 4 weeks and followed up for 57 weeks. The primary outcomes were abdominal pains and stool consistency. The secondary outcomes were pain frequency and stool frequency. Tertiary outcomes were adverse effects and global overall symptom. The outcome data were collected at days 1, 2, 3, weeks 1 and 4 during the treatment and at days 1, 2, 3, until week 57 during the post-treatment. Significantly more patients receiving tongxie were clinical responders to the primary and secondary endpoints from day 1 until the end of the treatment. The positive effects of tongxie were maintained until 17–25 weeks after tongxie was discontinued. The relapse-free probabilities in the tongxie group were significantly higher than those in the placebo group (P < .001). Twenty-five weeks after the therapies were discontinued could be considered as IBS natural history. During this period, an average of 53.8–56.3% of patients (pool tongxie and placebo data together) had IBS symptoms (pain scale ≥ 3, stool consistency ≥ 5). In particular, at the end of this study (week 61), 145 (54.2%) patients had IBS symptoms. Our results provide clinical insights into efficient and cost-effective management of refractory IBS, and lend support to the IBS management that the selection of a therapy should consider both its effectiveness during treatment and its PTTE after the treatment.
A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction
2022, GastroenterologyCitation Excerpt :Meta-analyses have shown effectiveness of psychodynamic-interpersonal therapy for functional somatic syndromes,43 as have RCTs in IBS and dyspepsia.44,45 Furthermore, there is evidence that psychodynamic-interpersonal therapy is superior to paroxetine and cost-effective.46 Psychodynamic-interpersonal therapy is particularly effective in cases of trauma or early life adversity.47
This Rome Foundation Working Team Report reflects the consensus of an international interdisciplinary team of experts regarding the use of behavioral interventions, specifically brain-gut behavior therapies (BGBTs), in patients with disorders of gut-brain interaction (DGBIs).
The committee members reviewed the extant scientific literature and, when possible, addressed gaps in this literature through the lens of their clinical and scientific expertise. The Delphi method was used to create consensus on the goals, structure, and framework before writing the report. The report is broken into 5 parts: 1) definition and evidence for BGBT, 2) the gut-brain axis as the mechanistic basis for BGBT, 3) targets of BGBTs, 4) common and unique therapeutic techniques seen in BGBT, and 5) who and how to refer for BGBT.
We chose to not only review for the reader the 5 existing classes of BGBT and their evidence, but to connect DGBI-specific behavioral targets and techniques as they relate directly, or in some cases indirectly, to the gut-brain axis. In doing so, we expect to increase gastrointestinal providers’ confidence in identifying and referring appropriate candidates for BGBT and to support clinical decision making for mental health professionals providing BGBT.
Both gastrointestinal medical providers and behavioral health providers have an opportunity to optimize care for DGBIs through a collaborative integrated approach that begins with an effective patient-provider relationship, thoughtful communication about the brain-gut axis and, when appropriate, a well communicated referral to BGBT.
The evaluation and the efficacy of psychoanalytical therapies and psychoanalysis
2021, Evolution PsychiatriqueCet article propose une revue de littérature concernant l’évaluation et l’efficacité des psychothérapies psychanalytiques et de la psychanalyse (PPP).
Après avoir proposé une vue d’ensemble de l’évaluation des psychothérapies, nous reprenons les travaux portant sur l’évaluation empirique et quantitative des PPP avant de nous centrer sur leur évaluation qualitative et processuelle.
Les résultats des études menées en ce domaine démontrent que les psychothérapies sont efficaces aussi bien sur le court terme que le long terme. Leur efficacité est le plus souvent indépendante de l’obédience théorique du clinicien. En revanche, les facteurs communs comme l’alliance thérapeutique ou les particularités du thérapeute sont des éléments prévalents de même que la durée et la fréquence des psychothérapies. Concernant plus précisément l’évaluation des PPP, celles-ci sont démontrées empiriquement comme étant efficaces pour la plupart des troubles psychiatriques. Plusieurs caractéristiques des PPP sont en outre corrélées de manière significative avec l’efficacité thérapeutique.
L’évaluation qualitative et processuelle des PPP apparaît complémentaire à ce premier niveau d’évaluation empirique qui présente plusieurs limites (biais d’allégeance, indistinction des processus, pratiques de recherches questionnables, etc.) mises notamment en évidence par la crise de la reproductibilité. La méthodologie des Essais Contrôlés Randomisés propose une évaluation de surface à laquelle doivent être associées des approches fondées davantage sur la pratique clinique. L’approche du groupe de Boston, l’analyse des processus psychothérapiques par le Psychotherapy Q-Sort (PQS) ainsi que la modélisation du processus de symbolisation par l’École de Lyon sont trois paradigmes de recherche qualitatifs particulièrement riches de ce point de vue.
Les PPP sont efficaces pour la plupart des troubles psychiatriques sur le court terme, en fin de thérapie et plusieurs années après celle-ci. Elles engendrent des transformations durables sur le plan des symptômes et de la personnalité. Elles apparaissent souvent plus efficaces que la pharmacothérapie et conduisent à des économies substantielles quand elles sont mises en œuvre dans des services de soin auprès de patients souffrant de pathologies variées.
This article proposes a review of the literature concerning the evaluation and the efficacy of psychoanalytic psychotherapy and psychoanalysis (PPP).
After proposing a global overview of the evaluation of psychotherapy, we sum up the empirical and quantitative evaluation of PPPs before focusing on their qualitative and process-based evaluation.
Psychotherapies are very effective both in the short and in the long term. Their effectiveness is largely independent of the clinician's theoretical affiliation. Common factors such as the therapeutic alliance or the particularities of the therapist are prevalent, as are the duration and the frequency of the session throughout the therapy. Concerning more specifically the evaluation of PPPs, they have been empirically demonstrated to be effective for most psychiatric conditions. Several characteristics of PPPs are also specifically correlated with therapeutic effectiveness. Moreover, they produce long-term therapeutic effects, particularly concerning personality and after the end of the therapy.
The qualitative and process-based evaluation of PPPs appears complementary to empirical evaluation, the latter suffering from several limitations (allegiance bias, indistinction of processes, questionable research practices, etc.) highlighted in particular by the recent crisis of reproducibility. The methodology of Randomized Controlled Trials should be associated with research based on clinical material. The approach of the Boston group, the analysis of psychotherapeutic processes with the Psychotherapy Q-Sort (PQS) and the modeling of the symbolization processes by the School of Lyon are three qualitative research paradigms that are particularly rich from this point of view.
PPPs are effective for most psychiatric disorders in the short term, at the end of the therapy, and for several years afterwards. They generate lasting transformations in terms of the reduction of symptoms and of personality evolution. They often appear to be more effective than pharmacotherapy and lead to substantial savings when they are implemented in health care facilities for patients suffering from a large variety of pathologies.
Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects
2021, Journal of Psychosomatic ResearchA recent meta-analysis of 17 randomized, controlled trials (RCTs) showed that Short-term Psychodynamic Psychotherapy (STPP) for functional somatic disorders (FSD) reduced somatic symptoms compared to wait list, minimal treatment, and treatment-as-usual controls. A clinically important yet unanswered question is how much improvement patients experience within STPP treatment.
Following a systematic search, we identified STPP trials presenting data at baseline and post-treatment/follow-up. Meta-analyses determined the magnitude of changes in somatic symptoms and other outcomes from before to after STPP, and analyses examined effect sizes as a function of study, therapy, and patient variables.
We identified 37 trials (22 pre-post studies and 15 RCTs) totaling 2094 patients treated an average of 13.34 sessions for a range of FSD. Across all studies, somatic symptoms improved significantly from pre-treatment to short-term follow-up with a large effect size (SMD = −1.07), which was maintained at long-term follow-up (SMD = −0.90). After excluding two outlier studies, effects at short- and medium-term follow-up remained significant but were somewhat reduced in magnitude (e.g., short-term SMD = −0.73). Secondary outcomes including anxiety, depression, disability, and interpersonal problems had medium to large effects. Effects were larger for studies of STPP that were longer than 12 sessions or used an emotion-focused type of STPP, and for chronic pain or gastrointestinal conditions than for functional neurological disorders.
STPP results in moderate to large improvements in multiple outcome domains that are sustained in long-term follow-up. STPP is an effective treatment option for FSD and should be included in treatment guidelines.
The role of serotonin and its pathways in gastrointestinal disorders
2021, The Complex Interplay Between Gut-Brain, Gut-Liver, and Liver-Brain AxesSerotonin (5-hydroxytryptamine or 5-HT) is a mediator with primary functions, both in the central nervous system and digestive system. At the digestive level, about 90% of 5-HT is localized in enterochromaffin cells, and about 10% in enteric neurons. In the gastrointestinal tract, 5-HT affects motor, secretory, and sensory functions via activation of seven subclasses of receptors, which differ on the basis of structure, function, and signaling mechanisms. The 5-HT transporter, deputed specifically to 5-HT reuptake, plays also an important role in the modulation of serotonergic pathways. There is increasing evidence that the serotonergic system is involved in the pathogenic mechanisms of gastrointestinal diseases, with particular regard for functional gastrointestinal disorders, and the pathophysiology of some frequently associated psychiatric and psychological comorbidities. The constant bidirectional interplay between brain and gut (brain–gut axis), in which 5-HT is deeply involved, can account for the multifaceted central and peripheral actions of this mediator. In this context, the role of the intestinal microbiota, with its ability of both producing 5-HT and being modulated by 5-HT, represents a field of high interest deserving preclinical and clinical investigations.
Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome
2021, GastroenterologyIrritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.
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Supported by the Medical Research Council of the United Kingdom and the North Western Region Health Authority (U.K.) R & D Directorate. SmithKlineBeecham provided the paroxetine but was not involved in the design, conduct, or analysis of the trial.