Practical Approaches to Working with a Gastrointestinal Psychologist.

Integrated models of care for chronic digestive conditions, such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), are becoming the standard of care and require patients to have access to brain-gut behavior therapies. Further progress is needed to implement this approach across GI practice settings and will require gastroenterologists to build collaborative relationships with GI Psychologists. This review provides guidance on practical steps for integrating brain-gut behavior therapy into a GI practice, including guidance on assessing patients for their appropriateness for referral, effective communication strategies to recommend brain-gut behavior therapy, and tips on how to develop a referral pathway and successful collaboration with a GI Psychologist.

Pilot Study of a Self-Administered Hypnosis Intervention for Functional Dyspepsia.

BACKGROUND: Functional dyspepsia (FD) is a chronic disorder of the upper gastrointestinal tract that currently lacks substantially effective therapy options. AIMS: To evaluate the feasibility and potential impact on FD symptoms and well-being of a fully automated gut-directed hypnosis intervention delivered via audio recordings. METHODS: FD patients were enrolled at a single medical center and given access to a password-protected website where they completed 7 bi-weekly audio-recorded hypnosis sessions over a 3-month period. Study questionnaires including the Patient assessment of upper gastrointestinal symptom severity index, Short-Form Nepean Dyspepsia Index, the Visceral Sensitivity Index, and the Brief Symptom Inventory (BSI-18) were completed online pre-treatment, mid-treatment, post-treatment and at 3-month follow-up. RESULTS: Of 23 enrolled patients (18 females; mean age = 38 years), 96% completed the entire treatment program and 3-month follow-up. Intention-to-treat analyses showed significant improvement at both end of treatment and 3-month follow-up in dyspepsia severity and quality of life, as well as in gut-specific anxiety and psychological distress. 68% of treatment completers reported that their FD symptoms were improved. Improvement in FD severity was significantly positively correlated with baseline PAGI-SYM total scores and BSI Global Severity Index scores. CONCLUSIONS: The fully automated hypnosis audio treatment program, which requires no therapist or clinician involvement, demonstrated excellent feasibility and resulted in significant improvement in FD symptoms, quality of life and emotional well-being. The results indicate that the intervention has high potential as adjunctive therapy for FD and warrants further investigation in a randomized controlled trial.

Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights.

Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) condition associated with significant health care utilization and quality-of-life impairment. Latest research indicates that the brain-gut axis plays a key role in the disorder, and the presence of psychological factors and central processing deficits contribute to symptom severity and disability. Psychological therapies as a whole have demonstrated good efficacy in reducing the severity of IBS symptoms. Cognitive-behavioral therapy (CBT) has been tested most rigorously in multiple randomized controlled trials and consistently demonstrates significant and durable effects on IBS symptoms and quality of life. Various protocols for treating IBS have been developed, and most recent advances in the field include exposure-based treatments to target symptom-specific anxiety as well as modified delivery methods, including internet-based treatment models. Despite the well-documented advantages of CBT for IBS, it has been poorly disseminated and few patients have access to this treatment. The primary barrier to dissemination is the limited number of therapists with adequate training in GI psychology to provide this evidence-based intervention. Future developments in the field need to focus on training opportunities to equip more therapists to competently provide CBT for this population. Further efforts to develop telemedicine platforms for delivering this intervention will also improve accessibility for patients.

Snapshot of an integrated psychosocial gastroenterology service.

AIM: To characterize the patients utilizing a gastroenterology behavioral medicine service and examine the effect of treatment on health care utilization. METHODS: Patients were referred by their gastroenterologists for psychological treatment during a 15 mo period. Patients seen for an intake with a psychologist completed the Brief Symptom Inventory (BSI) and a checklist of psychosocial concerns. A subset of patients with functional bowel disorders also completed a disease specific quality of life measure. Chart review was conducted to obtain information on type and frequency of sessions with the psychologist, the number of outpatient gastroenterology visits, and number of gastroenterology-related medical procedures during the 6 mo following psychological intake. RESULTS: Of 259 patients referred for treatment, 118 (46%) completed an intake with a psychologist. Diagnoses included: irritable bowel syndrome (42%), functional dyspepsia (20%), inflammatory bowel diseases (20%), esophageal symptoms (10%), and "other" (8%). Demographic variables and disease type did not differentiate between those who did and did not schedule an intake. Mean t-scores for the BSI global score index and the depression, anxiety, and somatization subscales fell below the cutoff for clinical significance (t = 63). Treatments were predominantly gut-directed hypnosis (48%) and cognitive behavioral therapy (44%). Average length of treatment was 4 sessions. Among functional gastrointestinal (GI) patients, those patients who initiated treatment received significantly fewer GI-related medical procedures during the 6 mo following the referral than patients who did not schedule an intake [t (197) = 2.69, P < 0.01]. CONCLUSION: Patients are receptive to psychological interventions for GI conditions and there is preliminary evidence that treatment can decrease health-care utilization among patients with functional GI conditions.

Control condition design and implementation features in controlled trials: a meta-analysis of trials evaluating psychotherapy for depression.

ABSTRACT: Control conditions are the primary methodology used to reduce threats to internal validity in randomized controlled trials (RCTs). This meta-analysis examined the effects of control arm design and implementation on outcomes in RCTs examining psychological treatments for depression. A search of MEDLINE, PsycINFO, and EMBASE identified all RCTs evaluating psychological treatments for depression published through June 2009. Data were analyzed using mixed-effects models. One hundred twenty-five trials were identified yielding 188 comparisons. Outcomes varied significantly depending control condition design (p < 0.0001). Significantly smaller effect sizes were seen when control arms used manualization (p = 0.006), therapist training (p = 0.002), therapist supervision (p = 0.009), and treatment fidelity monitoring (p = 0.003). There were no significant effects for differences in therapist experience, level of expertise in the treatment delivered, or nesting vs. crossing therapists in treatment arms. These findings demonstrate the substantial effect that decisions regarding control arm definition and implementation can have on RCT outcomes.

Relationship between depression, fatigue, subjective cognitive impairment, and objective neuropsychological functioning in patients with multiple sclerosis.

OBJECTIVE: This study explored the influence of depression and fatigue on subjective cognitive complaints and objective neuropsychological impairment in patients with multiple sclerosis (MS). METHODS: Data for this study were taken from a randomized controlled trial, comparing 16 weeks of telephone-administered cognitive-behavioral therapy and telephone-administered supportive emotion focused therapy for the treatment of depression. The sample includes 127 patients with MS. The following self-report measures were collected pre- and posttreatment: Perceived Deficits Questionnaire, Beck Depression Inventory-II, and Modified Fatigue Impact Scale. Measures of objective cognitive functioning and the Hamilton Rating Scale for Depression were administered over the telephone. RESULTS: Our results showed that changes in depression and fatigue significantly predicted changes in subjective cognitive complaints from pre- to posttreatment, with patients perceiving fewer cognitive problems at posttreatment (beta = .36, p < .001 and beta = .61, p < .001, respectively). Changes in depression and fatigue were not significantly related to changes in objective neuropsychological performance. Improvements in depression and fatigue also predicted improved accuracy in perceiving cognitive abilities from pre- to posttreatment (OR = .77, p < .001 and OR = .90, p < .001, respectively). CONCLUSIONS: The results of this study suggest that improvements in depression and fatigue through treatment do not influence objective neuropsychological performance in MS patients, but do relate to changes in subjective impairment. Furthermore, these changes improve patients' abilities to accurately perceive their cognitive functioning.

Perceived breast cancer risk, social support, and distress among a community-based sample of women.

Four dimensions of perceived social support (emotional/informational, tangible, affectionate, positive social interaction) were examined as moderators of the effect of perceived breast cancer risk on distress in a cross-sectional sample of 1,366 women recruited from the general population. Heightened perceived breast cancer risk predicted higher levels of depression, but only among women who reported low levels of perceived emotional/informational, tangible, affectionate, and positive social interaction support. Tangible and positive social interaction support mitigated the negative effect of heightened risk perception on anxiety. Perceived breast cancer risk was associated with greater cancer worry, regardless of the degree of social support perception. However, this association was weaker for women who perceived greater positive social interaction support. The results suggest that women's perceptions of social support availability can protect them against some of the adverse emotional consequences of heightened breast cancer risk perceptions.