認知行為治療或許可以緩解許多病患的大腸激躁症

作者：Nancy Fowler Larson  
出處：WebMD醫學新聞

　　May 5, 2010 — 根據發表於4月臨床腸胃病學與肝臟病學(Clinical Gastroenterology and Hepatology)期刊的研究，將近30%的大腸激躁症(IBS)病患指出，在4週的認知行為治療(cognitive behavioral therapy，CBT)之後，有相當程度的緩解，且多數人的改善持續達3個月。
　　
　　紐約州立大學醫學系胃腸科Jeffrey Lackner博士等人寫道，在經驗上，認為CBT可有效治療IBS，但是並不清楚哪些人在怎樣的情況下最有效。
　　
　　研究目標是確認對CBT有早期正面反應的研究對象是否可以持續，研究者隨機指派75名診斷為IBS的成人(年紀18-70歲)到以下三組之一：每週接受1小時的CBT、為期10週(標準CBT組[簡稱為S-CBT組])、在10週內接受4小時的課程(CBT接觸程度最小組[簡稱為MC-CBT組])，以及等候名單控制組。第4週定義為S-CBT組的第4次臨床課程，MC-CBT組的第2次臨床課程，總共有71名研究對象有資料可供分析。
　　
　　研究對象以「是或否」回答問題來評估他們的腹瀉、便秘和腹脹的嚴重度，他們也完成「大腸激躁症嚴重度量表(Irritable Bowel Syndrome Severity Scale，IBSSS)」和其他檢測。
　　
　　在研究中，治療有反應者定義為那些有達到適當疼痛與腸道症狀緩解者，以及IBSSS分數比開始時減少至少50分者。快速反應者(RRs)定義為那些在第4週即符合規範者，非快速反應者(NRRs)在第12週尚未達到那兩種目標。
　　
　　主要研究發現如下：
　　* 第4週時，29.6% (n = 21人)的研究對象為快速反應者，S-CBT組和MC-CBT組之間並無顯著差異(兩組分別是31% vs 27%)。
　　* 第12週時，52.1% (n = 37人)的研究對象屬於治療有反應者；根據IBSSS，快速反應者的症狀比非快速反應者不嚴重(127.2 vs 215.2；P < .001)，即便他們的症狀在研究開始時比較顯著(IBSSS分數：RR，330.3；NRR，274.6)。
　　* 第3個月時，47.9% (n = 34人)治療有反應者持續維持有反應的狀態；95.2% (20/21)的快速反應者維持其改善情況，非快速反應者只有28% (14/50)(Χ2；P < .001)。
　　
　　研究作者預期他們的研究可以獲致個人化、更有經濟效益的治療。
　　
　　Lackner博士在記者會中表示，迅速達到治療目標的病患—例如IBS症狀緩解—可以節省治療花費和減少治療價值有限之追蹤照護的不便，反之，在初期的一定課程之內未達反應的病患，可以被立即分辨並啟動或加強更強力的治療，而不會影響花費、避免治療失敗引起的挫折。
　　
　　研究作者提出兩個研究限制，其一，研究對象都是自願者，可能更可以接受心理介入方式，其二，研究發現無法一般化到更多人，因為該研究的強度不足以分辨S-CBT、和MC-CBT其他治療之間的差異。
　　
　　作者們寫道，應該以更大型的隨機控制試驗確認，是以簡短、居家的CBT方式，還是以密集的臨床CBT方式可以較快達到反應，還是只要是CBT就可以(相較於藥物治療等其他療法)。
　　
　　國家糖尿病暨消化、腎臟疾病研究所支持該研究，研究作者皆宣告沒有相關財務關係。


Cognitive Behavioral Therapy May Bring Relief to a Significant Number of Patients With Irritable Bowel Syndrome

By Nancy Fowler Larson
Medscape Medical News

May 5, 2010 — Nearly 30% of patients with irritable bowel syndrome (IBS) reported considerable relief after 4 weeks of cognitive behavioral therapy (CBT), and the vast majority sustained these improvements for 3 months, according to a study published in the April issue of Clinical Gastroenterology and Hepatology.

"[CBT] is an empirically validated treatment for [IBS], yet it is unclear for whom and under what circumstances it is most effective," write Jeffrey Lackner, PsyD, Division of Gastroenterology, Department of Medicine, State University of New York at Buffalo, and colleagues.

The goal of the study was to determine whether participants who reported an early, positive response to CBT would maintain that level of wellness. To that end, the researchers randomly assigned 75 adults (age, 18 - 70 years) diagnosed with IBS into 3 groups: those who received an hour of CBT once a week for 10 weeks (standard CBT [S-CBT]), those who underwent 4 hour-long sessions during a 10-week period (minimal-contact CBT [MC-CBT]), and wait-list control patients. Week 4 was defined as clinic session 4 for those in the S-CBT faction and clinic session 2 for the MC-CBT unit. Data were available for 71 of the participants.

The subjects answered yes-no questionnaires gauging the severity of their diarrhea, constipation, and bloating. They also completed the Irritable Bowel Syndrome Severity Scale (IBSSS) and other tests.

During the study, treatment responders were designated as those who achieved adequate relief of pain and bowel symptoms and whose IBSSS scores dropped by at least 50 points from their baseline. Rapid responders (RRs) were those who met the criteria during week 4. Nonrapid responders (NRRs) had not reached both goals by week 12.

Key findings of the research are as follows:

At week 4, 29.6% (n = 21) of participants were RRs, with no significant variation among those receiving S-CBT and those receiving MC-CBT (31% vs 27%, respectively).
At week 12, 52.1% (n = 37) of participants were treatment responders; RRs had much less severe symptoms, according to the IBSSS, than NRRs (127.2 vs 215.2; P < .001), even though their symptoms were more significant at the study's onset (IBSSS scores: RR, 330.3; NRR, 274.6).
At 3 months, 47.9% (n = 34) treatment responders continued to maintain their status; 95.2% (20/21) RRs sustained their gains compared with 28% (14/50) of NRRs (Χ2; P < .001).
The study authors predicted that their work could lead to individualized, more economical treatment.

"Patients who quickly achieve treatment gains — for example, IBS symptom relief — may be spared the cost and inconvenience of follow-up care of little therapeutic value," Dr. Lackner said in a press release. "Conversely, patients who do not respond within a set number of sessions early on could be immediately identified and triaged or 'stepped up' to potentially more powerful treatment(s) rather than bearing the cost, demoralization and frustration that comes with treatment failure."

There were 2 stated limitations to the study. First, the subjects were all volunteers, who may be more open to psychological intervention. Second, the findings may not generalize to a wider population because the study was not powered to discern differences among S-CBT, MC-CBT, and other therapies.

"Whether rapid response is more likely to occur in a brief, home-based or more intensive, clinic-based form of CBT and is unique to CBT (vs common ingredients of therapies including pharmacologic ones) is an important task of a larger randomized controlled trial," the authors write.

The National Institute of Diabetes and Digestive and Kidney Diseases supported the study. The study authors have disclosed no relevant financial relationships.

Clin Gastroenterol Hepatol. 2010;8:426-432.