Adopting our ‘wise man/in my personal experience’ mode we counsel our students and trainees on the critical value of time spent with the irritable bowel syndrome (IBS) sufferer, emphasising the importance of explaining to them the nature of their illness, and how stress and other environmental factors may influence their symptomatology.
This approach seems to make sense and to be consistent with the traditional role of the wholistic, caring physician; but then so did blood-letting to the Victorians! Demonstrating that this strategy is clinically valid is not easy. Although a number of strands of evidence had suggested that time allocated to the IBS patient was well spent, the randomised clinical trial from Labus and colleagues is, to my knowledge, the first attempt to subject what they describe as a psychoeducational intervention to the rigours of modern clinical research methodology.
In this study, those randomised to the active group received 5 weekly 2 hour sessions with a gastroenterologist and a therapist, which included education about IBS and its pathophysiology, instruction on the connection between mood, stress and gastrointestinal symptoms, relaxation training, and homework assignments. Subjects were then evaluated at the end of the programme, and at follow-up 3 months later. Symptom severity, depression and visceral sensitivity were reduced, and quality of life and coping skills enhanced at the end of the study, and at the 3-month follow-up assessment in the group that received the psychoeducation intervention.
These findings support prior observations, such as those of Owens and colleagues who noted that a positive physician-patient interaction was associated, in the long term, with fewer return visits to the clinic for IBS and an uncontrolled study, also from the Mayo clinic, that demonstrated, over a 6-month follow-up period, that an education class reduced symptoms and enhanced some health-promoting behaviours.
Apart from such shortcomings as the location of the study in a tertiary referral centre and relatively brief nature of the follow-up, what the Labus study cannot tell us is why their approach worked and, specifically, which of the elements of the programme was most beneficial. Given that psychological approaches have been shown to work in IBS and that one such approach, hypnotherapy, has been shown to exert sustained effects, one could postulate that it was the relaxation therapy that did the trick.
Determining the operative element(s) of the strategy employed by Labus and colleagues is of practical, as well as academic, interest; this information will be critical when one attempts to find support for such a programme, be it from a hospital, an academic institution or a payor.