February 11, 2019
Antidepressants and psychological therapies can reduce irritable bowel syndrome (IBS) symptoms, according to a new study.
“For patients with persistent IBS symptoms who may have failed initial dietary therapy or initial medication therapy, tricyclic antidepressants can be very useful as can psychological therapies,” Brian Lacy, MD, PhD, a gastroenterologist at Mayo Clinic in Jacksonville, Florida, told Gastroenterology Consultant. “Healthcare providers should feel comfortable and confident employing these therapies [and] tell their patients that to improve not just their IBS symptoms but global health, a holistic approach has to be taken which means addressing psychological issues as well as medical issues involving the GI tract.”
IBS is a heterogeneous disorder, with no validated treatment algorithm available. Thus, every patient has a unique set of symptoms that requires individualized therapy. However, it has been recognized that a majority of patients with IBS have a disorder of visceral sensitivity.
“Tricyclic antidepressants have been demonstrated to have a good analgesic effect in many pain syndromes such as diabetic neuropathy and fibromyalgia,” Lacy said. “Although their analgesic mechanism of action is not completely understood, they likely act by inhibiting both norepinephrine and serotonin in different pain pathways.”
For this meta-analysis, Dr Lacy, Dr Andrew Ford from Leeds Gastroenterology Institute in the UK, and colleagues sought to demonstrate that tricyclic antidepressants —amitriptyline, desipramine, imipramine, doxepine—can relieve symptoms of pain in patients with IBS.
By searching MEDLINE, EMBASE, PsychINFO, and the Cochrane Controlled Trials Register (up to July 2017), the researchers identified 53 randomized controlled trials that compared either the use of antidepressants with placebo (n=17), or psychological therapies with control therapy or conventional management (n=35) among adult participants with IBS. One trial compared both psychological therapy and antidepressants with placebo.
Overall, results indicated a relative risk (RR) of 0.66 for IBS symptoms not improving with antidepressants versus placebo with similar treatment effects for both tricyclic antidepressants and selective serotonin reuptake inhibitors. Although, there was heterogeneity apparent between randomized controlled trials of the latter.
The RR of symptoms not improving with psychological therapies was 0.69. The therapies determined as beneficial included cognitive behavioral therapy, relaxation therapy, multi-component psychological therapy, hypnotherapy, and dynamic psychotherapy.
Dr Lacy said the study findings were not bewildering to him.
“I was not personally surprised by the findings as I have used tricyclic antidepressants for years to improve patients with IBS symptoms,” Lacy said, adding that he frequently refers his patients with persistent IBS symptoms to a psychologist. However, he said other providers may be surprised.
“I suspect that many healthcare providers will be somewhat surprised by these findings as, although there is good data to support both the use of tricyclic antidepressants and psychological therapies, they are still not yet main stream,” Lacy said.
Although psychological therapy can be effective, it served as the main limitation of the study.
“Psychological therapies are a broad term that encompasses many different types of therapies,” Lacy said. “The best study [is in] cognitive behavioral therapy [CBT] and clearly the data supports the use of CBT for IBS symptoms.”
Other psychological therapies that appear to help are relaxation therapy, dynamic psychotherapy, and guided meditation, according to Lacy, but they have not been well-studied.
“We do not have large randomized placebo-controlled studies to report on,” he said.
Better research is still needed.
“I hope that larger studies will be performed to address some of the shortcomings we have discussed about psychological therapies,” Lacy said. “In addition, it would be very interesting to see prospective studies combined dietary therapies and psychological therapies or dietary therapies and tricyclic antidepressants.”
Ford A, Lacy B, Harris L, Quigley E, Moayyedi P. Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol. 2019;114(1):21-29.https://journals.lww.com/ajg/Fulltext/2019/01000/Effect_of_Antidepressants_and_Psychological.11.aspx.