BACKGROUND/RATIONALE:
Irritable bowel syndrome (IBS) is a prevalent and costly gastrointestinal (GI) disorder characterized by recurrent abdominal pain and changes in bowel habit. The lack of adequate medical interventions has led to interest in psychological treatments for IBS. Cognitive Behavioral Therapy (CBT) has shown promise in treating IBS and can be delivered efficaciously in a minimal contact (MC; 4 sessions) format, reducing cost and time constraints. Treatment of IBS is not well-researched in the Veteran population despite the relatively high prevalence of the syndrome (IBS is one of the four most common syndromes associated with service in the Gulf War) and increasing rates among returning OEF/OIF Veterans. Research is needed to explore whether MC-CBT treatment is effective for Veterans and how it can be implemented in the VA to maximize accessibility and satisfaction.

OBJECTIVE(S):
This study had three phases: 1) chart review of Veterans with IBS to understand population characteristics; 2) questionnaire assessing Veterans' characteristics and understanding of/ opinions about the MC-CBT treatment; 3) MC-CBT feasibility trial to understand whether Veterans would complete the treatment and derive benefit from it.

METHODS:
Administrative data identifed Veterans enrolled for care in VA Connecticut Healthcare System (VACHS) with a diagnosis of IBS and extracted data from Veterans' electronic medical records.These same Veterans were invited by letter to complete a questionnaire packet that included questions about IBS symptoms (IBS Symptom Severity Scale - IBS SSS, abdominal pain ratings), comorbidities (medical and psychiatric), quality of life (IBS-QOL), and opinions about our proposed treatment approach. Veterans received the MC-CBT intervention, as described in Lackner, 2008. Eligibility criteria were: IBS diagnosis and absence of a life threatening, acute medical or psychiatric condition that could negatively impact participation. Major variables studied (self-report and chart review) included: 1) psychiatric and medical diagnoses (i.e. PTSD, anxiety disorders, mood disorders, pain disorders), demographics, VA health care utilization; 2) ratings of perception of treatment credibility; 3) gastrointestinal symptoms, IBS-QOL, and treatment satisfaction (Client Satisfaction Questionnaire- CSQ).

FINDINGS/RESULTS:
Phase one included 537 Veterans (81% male, Mage= 62 (SD = 17.97)). Females were significantly younger (Mage = 51) than males [t (535) = 6.50, p < .000]. The majority (40%) were from Vietnam and Post-Vietnam war eras, 24% Persian Gulf era. Approximately 34% of the sample was diagnosed with depression, 28% with at least one anxiety disorder (e.g. general anxiety disorder, social phobia, panic disorder, or posttraumatic stress disorder (PTSD)), 24% with unspecified anxiety disorder, and 23% with PTSD. Fifty-four percent of the sample was diagnosed with hypertension, 45% gastroesophageal reflux disease (GERD), 35% back pain, 32% arthritis and 23% with abdominal pain. Mean BMI for males (28.60, SD=15.43) and females (27.88, SD=6.92) were within the overweight range. The mean number of outpatient mental health visits occurring over a period of 3.5 years was 8.9 (SD = 26) as compared to 1.3 (SD = 3.66), 8.1 (SD = 8.29) and 11 (SD = 15.57) visits to gastroenterology, primary care and other specialty clinics respectively.
In phase two, 24% (n = 128) of those surveyed responded; 83% were male; mean age was 62. Approximately 73% of those surveyed answered at least 4 of the 5 treatment comprehension questions correctly. Fifty-seven percent answered all questions correct. Responses to credibility questions were categorized into three levels: low (not logical, important or not likely), medium (somewhat) and high (very logical, important or likely). While 52% of the sample felt that the treatment was very logical and 80% felt it was very important to make the described treatment available to individuals with IBS, only 45% reported that the treatment was very likely to reduce future IBS problems. Higher pain ratings were associated with being less likely to recommend the treatment to a friend (r(106) = .-24, p < .01).
Of the 24 Veterans in phase three (81% male, Mage = 57.32, SD= 17.46), 11 completed treatment, 10 discontinued, 2 never started and 1 was disqualified due to mis-diagnosis of IBS. Reasons participants gave for discontinuing included: Too much time required (n=4), illness (n=2), too far to facility for treatment (n=1), and unknown (n=3). Pre-post treatment comparisons revealed no significant changes in the IBS-SSS (t(28)=.61,p=0.54), average pain scores (t(26)=0.92,p=.28), and IBS-QOL (t(26)=0.28,p=.78). Completers reported high levels of satisfaction on the CSQ (M=28.88, SD=4.09). To explore reasons for the high drop-out rate in this study (42%), we performed a logistic regression using demographic (age, gender), IBS symptom (pain, IBS-SSS), and QOL variables to predict treatment status (complete vs. drop-out) using a forced-entry method. None of these variables were significant predictors of treatment status.

IMPACT:
Our data suggest that Veterans diagnosed with IBS may differ in several ways from civilians. They appear to be older, predominantly male, have more chronic disease conditions (such as cardiovascular disease and obesity), and higher rates of PTSD versus other anxiety disorders. The unique characteristics of Veterans with IBS may need to be factored into evidenced based treatment for IBS.
While Veterans in our sample endorsed that treatment should be made available, fewer than half expected any benefit in the form of a reduction in future IBS problems. As credibility and expectancy are strong factors in predicting treatment outcomes, MC interventions for IBS should focus on strengthening patients' expectancy of improvement and understanding of likely benefits.
We were not able to produce significant treatment effects of MC-CBT. Possible factors influencing our results include small sample size, high drop-out rates, and lack of therapeutic alliance to engage patients adequately in the MC treatment. Demographic, symptom and QOL variables were not related to treatment status. Further analyses should focus on other factors related to outcome, such as number of sessions attended, additional methods for examining relative benefit of the treatment (use of age-matched VA comparison group, calculating percent improvement), and other potential influential variables (mental/physical health burden).

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External Links for this Project

NIH Reporter

Grant Number: I01HX000232-01
Link: https://reporter.nih.gov/project-details/7867682

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PUBLICATIONS:

Conference Presentations

1. Abel E, Kirlin J, Sanders KA, Lackner JM. Irritable Bowel Syndrome in Veterans: Treatment Credibility and Expectations. Poster session presented at: American Psychological Association Annual Convention; 2012 Aug 2; Orlando, FL. [view]
2. Abel E, Kirlin J, Sanders KA, Lackner JM. Physical and Psychiatric Comorbidities and Health Care Use in Veterans with Irritable Bowel Syndrome. Poster session presented at: American Psychological Association Annual Convention; 2012 Aug 2; Orlando, FL. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: none
MeSH Terms: none