Efficacy of behavioural therapies for irritable bowel syndrome: a systematic review and network meta-analysis

Background

Irritable bowel syndrome (IBS) management guidelines recommend that behavioural therapies, particularly brain–gut behaviour therapies, should be considered as a treatment. Some, such as IBS-specific cognitive behavioural therapy (CBT) or gut-directed hypnotherapy, have specific techniques and, therefore, are in their own class of brain–gut behaviour therapy, while others, such as stress management or relaxation training, are common or universal techniques that are present in most classes of brain–gut behaviour therapy. In addition, there are other behavioural therapies or treatment options, including digital therapies, which are not classed as brain–gut behaviour therapies. We aimed to evaluate relative efficacy of the available behavioural therapies in IBS.

Methods

For this systematic review and network meta-analysis we searched MEDLINE, EMBASE, EMBASE Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials from inception to April 23, 2025, to identify randomised controlled trials (RCTs) comparing the efficacy of behavioural therapies for adults with IBS with each other, or a control intervention. We judged efficacy using dichotomous assessments of improvement in global IBS symptoms. We pooled data with a random effects model, with efficacy of each intervention reported as pooled relative risks (RRs) with 95% CIs. We ranked behavioural therapies according to their P score, which is the mean extent of certainty that one treatment is better than another, averaged over all competing behavioural therapies.

Findings

We identified 67 eligible RCTs, comprising 7441 participants. After completion of treatment, and compared with waiting list control, behavioural therapies with the largest numbers of trials, and patients recruited, that showed efficacy were: minimal contact CBT (RR for global IBS symptoms not improving at first point of follow-up post-treatment 0·55 [95% CI 0·39–0·76], P score 0·78; two RCTs, 511 patients), telephone disease self-management (0·57 [0·41–0·80], P score 0·75; two trials, 746 patients), dynamic psychotherapy (0·59 [0·43–0·80], P score 0·72; three RCTs, 303 patients), CBT (0·65 [0·53–0·80], P score 0·64; nine trials, 1150 patients), disease self-management (0·68 [0·50–0·92], P score 0·58; three RCTs, 375 patients), internet-based minimal contact CBT (0·77 [0·61–0·96], P score 0·43; five RCTs, 705 patients), and gut-directed hypnotherapy (0·79 [0·66–0·95], P score 0·39; 12 trials, 1507 patients). After completion of treatment, among trials recruiting only patients with refractory symptoms, telephone disease self-management and contingency management were both superior to attention placebo control (0·52 [0·28–0·94] and 0·50 [0·26–0·96], respectively) and routine care (0·46 [0·31–0·69] and 0·45 [0·24–0·85], respectively), and group CBT (0·50 [0·29–0·86]), internet-based minimal contact disease self-management (0·58 [0·40–0·86]), and dynamic psychotherapy (0·61 [0·44–0·86]) were all superior to routine care. Analyses for global IBS symptoms at first point of follow-up post-treatment, and for global IBS symptoms at first point of follow-up post-treatment when behavioural therapies were studied according to treatment class, showed evidence of publication bias when compared with waiting list control. The Cochrane risk of bias tool indicated that no RCT was at low risk of bias across all domains.

Interpretation

Several behavioural therapies are efficacious for global symptoms in IBS, although the most evidence exists for those classed as brain–gut behaviour therapies. However, certainty in the evidence for all direct and indirect comparisons across the network were rated as either low or very low confidence, due in part to publication bias and the risk of bias of the included trials.

Funding

None.