Improving access to gut-brain therapies for IBS.
Improving access to gut-brain therapies for IBS.
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改善 IBS 肠脑疗法的可及性。
DOI：
10.1016/s2468-1253(19)30291-2
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发表时间：
2019
期刊：
影响因子：
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通讯作者：
T. Taft
中科院分区：
文献类型：
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作者：
T. Taft
Hazel Everitt及其同事3提供了更多证据，支持通过电话或互联网提供IBS CBT的简短、最低限度接触策略的有效性。这些方法并不一定是新的，因为之前的研究已经显示了电话、4、5基于网络、6和最小接触模式的CBT对IBS的疗效。然而，Everitt和他的同事们对500多名IBS患者的研究比以前的努力更大，也是第一次包括两年评估。结果证实，这些策略是有效的，迫切需要为IBS提供无障碍CBT。将心理胃肠病学服务整合到临床实践中的一个相当大的障碍是成本。IBS是一种治疗和管理费用高昂的疾病，每年直接卫生保健支出为15-100亿美元，间接成本估计为200亿美元。9心理胃肠病服务不太可能占这些成本的一小部分。然而，传统的CBT通常涉及10次左右的办公室访问，这引发了对时间、成本和患者负担的担忧。上述缺乏训练有素的治疗师，特别是在以大学为基础的中心之外，这进一步加剧了这些问题。Everitt和他的同事3发现，通过电话或网络提供的CBT产生了大约60%-70%的治疗应答者(通过IBS症状严重程度评分至少降低50分来定义)，相比之下，只有略低于50%的患者通过常规治疗(没有行为疗法)取得应答。24个月时，电话CBT组IBS症状严重程度评分比常规治疗组低40·5分(95%CI 15·0~66·0)，网络CBT组比常规治疗组低12.9分(-12·9~38·8；p=0·33)，工作和社会适应量表评分比常规治疗组低3.1分(95%CI 1·3~4·9)，网络CBT组比常规治疗组低1.9分(0·1~3·7)。一个重要的问题是，在这些形式下为IBS提供CBT的成本是否证明治疗反应的收益是合理的。具体地说，通过这些途径提供的IBS CBT是否减少了诊所就诊、诊断程序和其他直接卫生保健支出？在英国国家医疗服务体系和美国以保险为基础的体系中，管理者经常提出成本效益问题，他们决定是否为心理胃肠病服务分配资金。未来CBT治疗IBS的临床试验的目标应该是具体表明，本研究强调的高效治疗不仅降低了与更典型的办公室心理治疗相关的成本，还降低了IBS过高的直接和间接成本。成本效益高的CBT治疗IBS可以显著减轻IBS的经济负担的手段有三倍。首先，针对IBS的CBT通过副交感神经系统参与放松策略(例如，横隔膜呼吸和引导成像)来靶向肠道-大脑通路，从而改善肠道动力，并改善大脑内侧前额叶皮质对痛觉的下调。10秒，针对IBS的CBT针对的是认知-情感过程，包括内脏疼痛过敏、症状特异性焦虑和疼痛灾难(即预测绝对最坏的情况，同时严重低估一个人的应对能力)。CBT通过重组认知和提高解决问题的技能来缓解这些过程，例如通过增加患者对IBS可能并不总是完全可以解决的问题的接受。…
Hazel Everitt and colleagues3 provide additional evidence to support the efficacy of brief, minimalcontact strategies to deliver CBT for IBS via telephone or internet. These approaches are not necessarily novel, as previous research has shown the efficacy of telephone, 4, 5 web-based, 6 and minimal-contact models of CBT for IBS. 7, 8 However, Everitt and colleagues’ study3 of over 500 patients with IBS is larger than previous efforts, and is also the first to include a 2-year assessment. The results confirm that these strategies are effective and that there is an imperative need for accessible CBT for IBS. One considerable barrier to the implementation of integrated psychogastroenterology services into clinical practice is cost. IBS is an expensive condition to treat and manage, with US $1· 5–10 billion spent in direct health-care expenditures and an estimated $20 billion in indirect costs per year. 9 Psychogastroenterology services are unlikely to account for more than a small percentage of these costs. However, traditionally delivered CBT, which typically involves around ten office visits, raises concerns about time, cost, and patient burden. The aforementioned scarcity of properly trained therapists, especially outside university-based centres, further compounds these issues. Everitt and colleagues3 found that CBT delivered via telephone or web yields approximately 60–70% treatment responders (defined by a reduction of at least 50 points on the IBS Symptom Severity Score), compared with just under 50% of patients achieving a response with treatment as usual (no behavioural therapy). At 24 months, mean IBS Symptom Severity Score was 40· 5 points (95% CI 15· 0 to 66· 0) lower in the telephone-CBT group and 12· 9 points (–12· 9 to 38· 8; p= 0· 33) lower in the web-CBT group than in the treatment as usual group, and the mean Work and Social Adjustment Scale score was 3· 1 points (95% CI 1· 3 to 4· 9) lower in the telephone-CBT group and 1· 9 points (0· 1 to 3· 7) lower in the web-CBT group than in the treatment as usual group. An important question is whether the costs of delivering CBT for IBS in these formats justifies the gains in treatment response. Specifically, does CBT for IBS delivered via these routes reduce clinic visits, diagnostic procedures, and other direct health-care expenditures? Both within the UK’s National Health Service and the US insurance-based system, cost–benefit questions are often raised by administrators who determine whether psychogastroenterology services are assigned funding. Future clinical trials for CBT for IBS should aim to concretely show that efficient delivery of treatment, highlighted in this study, not only reduces the costs associated with more typical, in-office psychotherapy but also reduces the exorbitant direct and indirect costs of IBS.The means by which cost-effective CBT for IBS could significantly reduce the economic burden of IBS are three-fold. First, CBT for IBS targets gut–brain pathways via engagement of the parasympathetic nervous system with relaxation strategies (eg, diaphragmatic breathing and guided imagery), which result in improved gut motility and improved downregulation of pain perception by the medial prefrontal cortex of the brain. 10 Second, CBT for IBS targets cognitive-affective processes including visceral pain hypersensitivity, symptom-specific anxiety, and pain catastrophising (ie, anticipating the absolute worst-case scenario while severely underestimating one’s ability to cope). CBT mitigates these processes via cognitive restructuring and improvement of problem-solving skills, for instance by increasing the patient’s acceptance that IBS might not always be a fully solvable problem …