Non-pharmacological treatments in the irritable bowel syndrome.

Abstract

Over the last two decades evidence has mounted to suggest that non-pharmacological therapies may be helpful in IBS. Like IBS trials of pharmacological therapies, the studies are often small and poorly controlled. The trials designed to account for a high placebo response rate have either compared non-pharmacological strategies with conventional treatment, or selected only patients who were placebo non-responders. There is broad agreement from the few adequately controlled trials that psychotherapy offers a clear additional therapeutic benefit over and above medical treatments[12]. Hypnotherapy appears to be particularly potent, and, in expert hands, produces consistently impressive therapeutic results even in patients refractory to conventional IBS treatment[17]. Most IBS patients respond to standard medical treatments. Psychological strategies are time consuming, labour intensive and generally unavailable to the relatively large numbers of patients who might benefit. Consequently, these therapies are best reserved for selected patients who fail to respond to reassurance and education, dietary manipulation, antispasmodics and low dose amitriptyline. Increasingly, patients are expressing a preference for non-pharmacological treatment strategies. Where resources allow, it is not unreasonable to offer these patients a psychodynamic approach as first-line therapy. Ideally, the gastroenterologist should have access to a range of treatment strategies including diet, drugs, psychotherapy, hypnotherapy, relaxation therapy and biofeedback. New approaches such as gut directed, computer-aided biofeedback are particularly attractive as, unlike the interpersonal therapies, this mode of biofeedback does not require highly trained therapists and can be self-administered[24]. Whatever the choice of non-pharmacological therapy, there is evidence that both the doctor and patient can expect symptom improvement, especially when conventional medical measures have failed.