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Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis

The American Journal of Gastroenterology (2018) | Download Citation

Subjects

Abstract

Objectives

Irritable bowel syndrome (IBS) is a chronic functional bowel disorder that is thought to be due to a disorder of brain–gut function. Drugs acting centrally, such as antidepressants, and psychological therapies may, therefore, be effective.

Methods

We updated a previous systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, PsychINFO, and the Cochrane Controlled Trials Register were searched (up to July 2017). Trials recruiting adults with IBS, which compared antidepressants versus placebo, or psychological therapies versus control therapy or “usual management” were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI).

Results

The search strategy identified 5316 citations. Fifty-three RCTs, reported in 51 separate articles, were eligible for inclusion: 17 compared antidepressants with placebo, 35 compared psychological therapies with control therapy or “usual management”, and one compared both psychological therapy and antidepressants with placebo. Four of the trials of psychological therapies, and one of the RCTs of antidepressants, were identified since our previous meta-analysis. The RR of IBS symptoms not improving with antidepressants versus placebo was 0.66 (95% CI 0.57–0.76), with similar treatment effects for both tricyclic antidepressants and SSRIs, although with heterogeneity between RCTs of the latter (I2 = 49%, P = 0.07). The RR of symptoms not improving with psychological therapies was 0.69 (95% CI 0.62–0.76). Cognitive behavioral therapy, relaxation therapy, multi-component psychological therapy, hypnotherapy, and dynamic psychotherapy were all beneficial when data from two or more RCTs were pooled. There was significant heterogeneity between studies (I2 = 69%, P < 0.001) and significant funnel plot asymmetry. There were also issues regarding trial design, including lack of blinding.

Conclusions

Antidepressants are efficacious in reducing symptoms in IBS patients. Psychological therapies also appear to be effective treatments for IBS, although there are limitations in the quality of the evidence, and treatment effects may be overestimated as a result.

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Acknowledgements

This study was performed to inform the American College of Gastroenterology Monograph on IBS. We would like to thank Dr. Johanne Agger, Dr. Doron Boltin, Professor Ram Dickman, and Dr. Elyse Thakur for responding to our queries about their papers and, in some instances, providing us with extra data. The work was supported by the American College of Gastroenterology Institute and the Canadian Institute for Health Research. Paul Moayyedi is the Principal Investigator for the Inflammation, microbiome, and alimentation: gastro-intestinal and neuropsychiatric effects (IMAGINE) - a Strategy for Patient Oriented Research (SPOR) chronic disease network that evaluates the impact of psychological interventions in GI disease.

Author information

Affiliations

  1. Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK

    • Alexander C Ford MBChB, MD, FRCP
  2. Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK

    • Alexander C Ford MBChB, MD, FRCP
  3. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA

    • Brian E Lacy PhD, MD, FACG
  4. Division of Gastroenterology and Hepatology, Mayo School of Medicine, Scottsdale, AZ, USA

    • Lucinda A. Harris MS, MD, FACG
  5. Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX, USA

    • Eamonn MM Quigley MD, FRCP, FACP, MACG, FRCPI
  6. Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, ON, Canada

    • Paul Moayyedi MBChB, PhD, FACG

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Guarantor of the article

Alexander C Ford, MBChB, MD, FRCP.

Specific author contributions

ACF, BEL, LAH, EMMQ, and PM conceived the study. ACF and PM collected all data. ACF and PM analyzed and interpreted the data. ACF drafted the manuscript. All authors commented on drafts of the paper. All authors have approved the final draft of the manuscript.

Financial support

American College of Gastroenterology.

Potential competing interests

None.

Corresponding author

Correspondence to Alexander C Ford MBChB, MD, FRCP.

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https://doi.org/10.1038/s41395-018-0222-5