Huanguang Jia

Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders

BACKGROUND & AIMS Studies of antidepressants and psychological treatments in functional bowel disorders (FBD) are methodologically limited. The aim of this study was to assess the clinical efficacy and safety of cognitive-behavioral therapy (CBT) against education (EDU) and desipramine (DES) against placebo (PLA) in female patients with moderate to severe FBD (irritable bowel syndrome, functional abdominal pain, painful constipation, and unspecified FBD). We also evaluated the amenability of clinically meaningful subgroups to these treatments. METHODS This randomized, comparator-controlled, multicenter trial enrolled 431 adults from the University of North Carolina and the University of Toronto with moderate to severe symptoms of FBD. Participants received psychological (CBT vs. EDU) or antidepressant (DES vs. PLA) treatment for 12 weeks. Clinical, physiologic, and psychosocial assessments were performed before and at the end of treatment. RESULTS The intention-to-treat analysis showed CBT as significantly more effective than EDU (P = 0.0001; responder rate, 70% CBT vs. 37% EDU; number needed to treat [NNT ], 3.1). DES did not show significant benefit over PLA in the intention-to-treat analysis (P = 0.16; responder rate, 60% DES vs. 47% PLA; NNT, 8.1) but did show a statistically significant benefit in the per-protocol analysis (P = 0.01; responder rate, 73% DES vs. 49% PLA; NNT, 5.2), especially when participants with nondetectable blood levels of DES were excluded (P = 0.002). Improvement was best gauged by satisfaction with treatment. Subgroup analyses showed that DES was beneficial over PLA for moderate more than severe symptoms, abuse history, no depression, and diarrhea-predominant symptoms; CBT was beneficial over EDU for all subgroups except for depression. CONCLUSIONS For female patients with moderate to severe FBD, CBT is effective and DES may be effective when taken adequately. Certain clinical subgroups are more or less amenable to these treatments.

Further validation of the IBS-QOL: a disease-specific quality-of-life questionnaire

Abstract OBJECTIVE: There has been growing interest in the investigation of health-related quality of life (HRQOL) among patients with gastrointestinal (GI) disorders. We recently reported on the development and preliminary validation of the IBS-QOL, a specific quality-of-life measure for irritable bowel syndrome (IBS). The aim of this study was to determine the longitudinal construct validity (responsiveness) of the IBS-QOL. METHODS: Female patients enrolled in a multicenter treatment trial for functional bowel disorders were studied pre- and posttreatment with the IBS-QOL and other health status measures. Based on the response to treatment for several variables (pain/14-day score, daily function, and days in bed/3 months), patients were stratified into Responders, Partial Responders, and Nonresponders. Change scores in the IBS-QOL were then statistically compared with changes in the other variables to determine their correlation and whether Responders were significantly different from non- and Partial Responders on the IBS-QOL. RESULTS: There was a significant correlation between change scores on the IBS-QOL and the other measures of treatment effect (Pain/14 days, r = 0.25, p CONCLUSION: The IBS-QOL is responsive to treatment in a referral-based clinical population of patients with functional bowel disorders.

What determines severity among patients with painful functional bowel disorders

OBJECTIVE: For patients with painful functional bowel disorders (FBD), physicians frequently make diagnostic and treatment decisions based on the severity of the pain reported; patients with severe painful complaints may receive extensive diagnostic tests and treatments. Therefore, it would be important to determine what clinical factors contribute to the judgment of severity among patients with FBD. The aim of this study was to identify the psychosocial, behavioral, and physiological (visceral sensitivity) factors that predicted severity in patients with moderate to severe FBD. METHODS: Two hundred eleven female patients with moderate or severe FBD, as determined by the Functional Bowel Disorder Severity Index, entered a multicenter treatment trial at the University of North Carolina and the University of Toronto. Patients filled out diary cards and were given questionnaires and physiological testing (rectal sensitivity using barostat). Analysis of covariance and logistic regression adjusting for demographic factors were performed to determine which factors distinguished patients at study entry with moderate from those with severe FBD. RESULTS: Patients with severe FBD were characterized by greater depression and psychological distress, poorer physical functioning and health-related quality of life, more maladaptive coping strategies, and greater health care utilization. There was a trend for patients with severe FBD to have lower rectal sensation thresholds. Regression analysis indicated that severity was best predicted by behavioral features: poorer daily physical function, difficulties related to eating, more phone calls to the physician, and more days in bed for GI symptoms. CONCLUSIONS: We conclude that patient illness behaviors are best correlated with severity in FBD. The use of psychopharmacological agents (e.g., antidepressants) and psychological treatments to treat psychiatric comorbidity and to improve behavioral coping styles is recommended. Training to help medical physicians identify and respond to psychosocial and behavioral features of these conditions is likely to improve patient satisfaction with their care and the clinical outcome.

Sexual and physical abuse are not associated with rectal hypersensitivity in patients with irritable bowel syndrome

Background: Patients with irritable bowel syndrome (IBS) have reduced pain thresholds for rectal distension. In addition, the prevalence of sexual/physical abuse in referred IBS patients is high and is associated with greater pain reporting, poorer health status, and poorer outcome. This lead to a hypothesis that abuse history may sensitise patients to report pain at a lower threshold. Aim: To compare rectal pain thresholds in women with IBS who had a history of severe abuse to IBS women with no history of abuse. Methods: We studied 74 IBS patients with a history of severe physical and/or sexual abuse and 85 patients with no history of abuse. Abuse history was assessed by a previously validated self-report abuse screening questionnaire. Rectal sensory thresholds were assessed using an electronic barostat and determined by the ascending method of limit (AML) and by the tracking technique. Results: IBS patients with a history of severe abuse had significantly higher rectal pain thresholds, as measured by AML (F (1, 111) = 6.06; p = 0.015) and the tracking technique (F (1, 109) = 5.21; p = 0.024). Patients with a history of severe abuse also reported a significantly higher threshold for urgency to defecate (F (1, 113) = 11.23; p = .001). Conclusion: Severe sexual/physical abuse is associated with higher urge and pain thresholds for rectal distension in IBS patients. This suggests that the greater pain reporting and poorer health status in IBS patients with abuse history are not related to increased rectal pain sensitivity. Further studies are needed to determine the causes of these findings.

Relationship of abuse history and other risk factors with obesity among female gastrointestinal patients

Little is know about the relationship of abuse history and other risk factors with being overweight and obese among gastrointestinal patients. The purpose of this study was to assess the relative risk of abuse history on being overweight and obese among 239 female gastrointestinal patients. Forty-one percent of the patients were found to be overweight or obese, 49% reported a history of physical abuse, and 42% had a sexual abuse history. A history of physical abuse (odds ratio = 1.34, P<0.03), being nonwhite (odds ratio = 2.66, P<0.01), being older (odds ratio = 1.03 for each year older, P<0.02), and having fewer years of schooling (odds ratio = 1.11, P<0.05) were found to be strongly associated with being overweight and/or obese. Among the female patients referred for gastrointestinal disorders at a university-based gastrointestinal clinic, a high proportion was overweight or obese. Physical abuse history and several demographic factors were significantly related to being overweight and obese in this clinical population.