Transdiagnostic internet-delivered cognitive-behaviour therapy (CBT) for adults with functional gastrointestinal disorders (FGID): A feasibility open trial

https://doi.org/10.1016/j.jpsychores.2018.02.015Get rights and content

Highlights

  • An open trial of an Internet-delivered CBT (iCBT) program for people with functional gastrointestinal disorders (FGID).

  • A transdiagnostic program designed to treat anxiety, depression and disability in people with a range of chronic conditions.

  • High treatment completion rates and levels of satisfaction were observed with only modest clinician time per participant.

  • Improvements were observed in FGID, anxiety and depression symptoms, which remained or further improved at 3-month follow-up.

  • Results are encouraging and indicate large-scale controlled trials are warranted.

Abstract

Many people with functional gastrointestinal disorders (FGIDs) face significant barriers in accessing psychological treatments that are known to reduce symptoms and their psychological sequelae. This study examined the feasibility and initial outcomes of a transdiagnostic and internet-delivered cognitive behaviour therapy (iCBT) intervention, the Chronic Conditions Course, for adults with functional gastrointestinal disorders (FGIDs). A single-group feasibility open trial design was employed and administered to twenty seven participants. The course ran for 8 weeks and was provided with weekly contact from a Clinical Psychologist. Seventy percent of participants completed the course within the 8 weeks and 81.5% provided data at post-treatment. High levels of satisfaction were observed and relatively little clinician time (M = 42.70 min per participant; SD = 46.25 min) was required. Evidence of clinical improvements in FGID symptoms (ds ≥ 0.46; avg. improvement ≥21%), anxiety symptoms (ds ≥ 0.99; avg. improvement ≥42%), and depression symptoms (ds ≥ 0.75; avg. improvement ≥35%) were observed, which either maintained or continued to improve to 3-month follow-up. Evidence of improvement was also observed in pain catastrophising and mental-health related quality of life, but not physical-health related quality of life. These findings highlight the potential value of transdiagnostic internet-delivered programs for adults with FGIDs and support for the conduct of larger-scale controlled studies.

Introduction

Functional gastrointestinal disorders (FGIDs) are characterised by gastrointestinal symptoms such as pain, discomfort, bloating or altered bowel habits that are not explained by identifiable biochemical or structural abnormalities that are identified in the routine clinical settings [18]. Common FGIDs include irritable bowel syndrome (IBS), functional constipation, and functional dyspepsia. FGIDs are prevalent, with community estimates of prevalence of between 10 and 20% commonly reported [10]. FGIDs are associated with significant personal, societal, and economic cost. These include higher rates of work absenteeism and health care use [10], significantly lower quality of life [15,20], lower social functioning [15], and higher rates of psychological disorders such as depression and anxiety [15,33]. Current models of FGID pathology suggest that there is a bi-directional association between FGIDs and poorer psychological wellbeing [18,35]. This bidirectional relationship highlights the potential role of psychological treatments.

A range of psychological treatments have demonstrated efficacy in reducing the physical symptoms and psychological sequelae of FGIDs [40], especially those based on the principles of cognitive behaviour therapy (CBT) [11,25,26]. However, there are numerous barriers to psychological treatment for people with FGIDs, including the costs, stigma, distance from specialist services and a lack of availability of trained health practitioners [17,24,40]. One strategy for increasing access to CBT for FGIDs is the delivery of CBT treatment via the internet (iCBT) [21,2]. For example, Hunt et al. [17] developed an iCBT treatment that led to reduced IBS symptoms and improved quality of life, with outcomes being maintained for up to 3 months after treatment. Ljótsson and colleagues have since demonstrated the significant potential of iCBT for IBS in a concerted series of studies. These studies demonstrated that an iCBT program with mindfulness components helped reduce IBS symptoms, anxiety and depression, and increased quality of life [28] and compared favourably to a stress-management treatment [29]. Furthermore, these improvements were maintained at up to 18 months post treatment [30], and the treatment was shown to be cost-effective compared to treatment-as-usual, requiring only 165 min of clinician time per patient over the course of treatment [31]. This work has now been replicated in adolescents with FGIDs with similarly encouraging outcomes [3,32].

One important feature of the available iCBT literature is that it employed treatments specifically designed for patients with FGIDs, particularly IBS. Consequently, it is unclear whether the methodology associated with transdiagnostic treatment approaches, which have been demonstrated as effective for treating anxiety and depression [37,38,39], might have potential for adults with FGIDs. Transdiagnostic iCBT treatments are carefully designed to provide therapeutic information and teach psychological skills that are suitable for a broad range of psychological disorders and difficulties, rather than one specific disorder or difficulty. Potential advantages of transdiagnostic approaches include their utility in patient groups with comorbidity and the greater ease with which they can be disseminated relative to treatments that target one disorder [36]. While most of the published literature concerns transdiagnostic treatment approaches for anxiety and depression in physically healthy populations, several preliminary trials have explored the potential of transdiagnostic iCBT for improving symptoms in adults with physical health conditions, including various pain conditions ([5,6,7,12]), chronic kidney disease [9], recent cancer [1] and epilepsy [14]. For example, one recent feasibility trial (n = 27) examined the potential of a transdiagnostic iCBT intervention, the Chronic Conditions Course, at reducing a range of symptoms in adults with epilepsy [14]. This study found very high levels of engagement and acceptability, and evidence of clinically significant changes in depression, anxiety and disability. Importantly, the iCBT intervention was not specifically designed for adults with epilepsy and did not focus on one particular mental health disorder, such as depression; instead it was designed for adults with a broad range of chronic health conditions and mental health difficulties. These findings indicate the potential of transdiagnostic iCBT for adults with chronic physical health conditions, including adults with FGIDs.

The present study aimed to examine the feasibility of a transdiagnostic iCBT intervention, the Chronic Conditions Course, for adults with FGIDs. This course teaches core cognitive and behavioural skills for assisting adults with chronic health conditions to manage their mental health and functional abilities. The course comprises five core lessons delivered over 8 weeks and is provided with brief weekly contact from a clinical psychologist, which is provided via e-mail and telephone. The current study employed a single-group open-trial design to gain preliminary data about the feasibility, acceptability, and efficacy of the course to inform future randomized controlled trials. It was hypothesized that: (1) participants would rate the intervention as acceptable; (2) improvements on the primary outcomes of gastrointestinal symptoms, anxiety and depression would be observed at post-treatment and 3-month follow-up; and (3) evidence of improvements on the secondary outcomes of pain catastrophising and functional disability would also be observed.

Section snippets

Participants

Participants read about the trial and applied to participate via the eCentreClinic website (www.ecentreclinic.org). The eCentreClinic is a specialist research unit that provides information about common mental health and chronic health conditions and offers free psychological interventions via participation in clinical trials. The eCentreClinic website can be located via online searches and is promoted by various health professionals and websites within Australia. The present trial was also

Adherence and attrition

At post-treatment, 19 participants (70.4%) had read all five lessons, two (7.4%) four lessons only, one (3.7%) three lessons only, two (7.4%) two lessons only, and three (11.1%) one lesson only. Twenty participants (70%) provided mid-treatment data, 22 (81.5%) participants provided post-treatment data and 21 (77.8%) provided 3-month follow-up data. Participants who did not complete questionnaires at post-treatment were more likely not to have received a FGID diagnosis (Wald's χ2 = 6.38, =

Discussion

The present study explored the feasibility and preliminary efficacy of a new transdiagnostic iCBT course designed for a broad range of chronic physical health conditions. It was hypothesized that participants would find the course acceptable and that improvements in FGID, anxiety and depressive symptoms would be observed. These hypotheses were largely supported. The course was acceptable with high treatment completion rates and levels of satisfaction. These results were obtained with relatively

Conflicts of interest

B Dear and N Titov are authors and developers of the Chronic Conditions Course, but derive no personal or financial benefit from it. N Titov and B Dear are funded by the Australian Government to develop and provide a free national online assessment and treatment service, the MindSpot Clinic (www.mindspot.org.au), for people with anxiety and depression.

Acknowledgements

The authors gratefully acknowledge all of the participants for their involvement and helpful feedback throughout the research. The authors also gratefully acknowledge the reviewers for their helpful feedback on earlier versions of this manuscript. This research was enabled by funding from the National Health and Medical Research Council (NHMRC) (APP1052294) to BFD via an Australian Public Health Fellowship.

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