Both psychotherapy and paroxetine appear to improve health-related quality of life for patients with irritable bowel syndrome (IBS), and at no additional cost.
"Improvement in overall health-related quality of life is possible even if the pain does not greatly improve," said Francis Creed, M.D., a professor of psychological medicine at the university department of psychiatry at Manchester Royal Infirmary in Manchester, England.
"If patients with severe IBS do not respond to usual treatment, an SSRI antidepressant or referral to psychotherapy is worth trying," Creed told Psychiatric News. "Exploration of psychological problems, even if they are not very severe, may well lead to improvement in health-related quality of life."
Creed and colleagues published results comparing psychotherapy and paroxetine for IBS in the February issue of Gastroenterology.
In the study, 257 subjects treated at seven British hospitals for IBS were randomized to receive either psychotherapy, 20 mg of paroxetine for a period of three months, or treatment as usual—defined as whatever treatment was deemed appropriate by the patient’s treating physician.
Psychotherapy consisted of one two-hour and seven 45-minute sessions of "psychodynamic interpersonal therapy" delivered over three months.
Creed and colleagues found at one-year follow-up that abdominal pain was similar in all three groups. But both psychotherapy and paroxetine were superior to treatment as usual in improving the physical aspects of health-related quality of life, as measured by the SF36 Health Survey.
Importantly, psychotherapy—but not paroxetine—was associated with a significant reduction of health care costs compared with treatment as usual. Psychotherapy was associated with a total cost of $976 (U.S. dollars) compared with paroxetine at a cost of $1,252.
Treatment as usual was associated with a cost of $1,663, according to the study.
Creed says that many patients with irritable bowel syndrome typically don’t seek treatment at all or use over-the-counter products that may not be helpful. Most patients who do seek help from a gastroenterologist achieve some success with dietary modifications and antispasmodic or other medical therapies.
Yet a sizable cohort remains that is not helped, Creed says. And it is among this treatment-refractory group that the highest prevalence of psychiatric illness is found.
Creed and others say IBS is a condition that highlights the mental and emotional component of much medical illness, refuting the traditional dichotomy of mind and body. Among clinic patients with IBS, approximately 50 percent have significant anxiety and depression, Creed said.
"For some patients there is primarily an infective, dietary, or other cause," she told Psychiatric News. "For a small number of people it is primarily anxiety and depression. For the majority, however, there is a physical component together with a psychological component."
Constantine Lyketsos, M.D., a professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, called the study "extremely important," noting that there have been few controlled cost-effectiveness studies of the best way to treat IBS.
"This study is showing not only that treatment works and which treatments work, but also the effect on cost," Lyketsos told Psychiatric News. "In this particular case, it appears that it actually reduces health care costs to treat IBS in a particular way."
Lyketsos, who is chair of APA’s Committee on Consultation-Liaison Psychiatry and Primary Care Education, emphasized that the study demonstrates the value of psychiatric treatment of a condition typically thought of as medical illness. "Those of us in psychosomatic medicine have known this, and this study provides controlled-trial evidence to drive it home," he said.
Lyketsos said that while in most cases there is no known organic cause for the condition, the suffering and distress experienced by patients are real. "The issue is the functioning of the gut, which is affected by the patient’s perceptions," he said. "The problem isn’t in the gut necessarily, but how the brain interacts with the gut."
At press time, Lyketsos said that the American Board of Medical Specialties is expected to endorse psychosomatic medicine as a new psychiatric subspecialty (Psychiatric News, September 6, 2002).
"This study is an example of what this new field is going to do for psychiatry," he said. "There is going to be more of this kind of work at the research and clinical levels to show how psychiatric care of medically ill patients makes a difference."
An abstract of the study, "The Cost-Effectiveness of Psychotherapy and Paroxetine for Severe Irritable Bowel Syndrome," is posted on the Web at www2.gastrojournal.org under the February issue. ▪