A scoping literature review was conducted on psychological and stress reduction treatments of gastrointestinal conditions. Several PubMed searches were performed, all of which had filters of full-text English language primary and secondary articles published after 2010. The first PubMed search of “Irritable Bowel Syndrome/therapy” AND (“self-care” OR “hope”) yielded 44 results. A second PubMed search of “Stress, Psychological/prevention and control”[MAJR] AND “gastrointestinal” yielded 35 results. A final third search “Stress, Psychological/prevention and control” AND “gastrointestinal” contributed 66 results. 32 studies yielded in the three searches were duplicates. A total of 113 studies were included in the initial title and abstract screening. During full-text review, references were reviewed and seven articles were included in our review contributing to a final count of 120 publications for screening.

Title and abstract screening was performed and 32 articles were approved by three of the authors for further evaluation with a full-text review. Inclusion criteria was met by English literature articles written since 2000 that investigated the use of psychotherapies for the relief of gastrointestinal symptoms. During full-text screening, primary and secondary research studies that investigated the benefit of psychological therapies for patients with gastrointestinal condition’s symptom relief met inclusion criteria for the review. Articles that did not meet all elements of inclusion criteria were excluded from review. While some publications addressed self-management or patient education programs, if a predominant focus of these programs was on stress reduction and cognitive therapies met inclusion criteria if clinical gastrointestinal outcomes were primary measures. Authors independently conducted their own full-text review and met to achieve a consensus. Two additional studies were included following reference reviews of selected articles. At the conclusion of the literature review, 12 articles were included ( Figure 1 ). Because all 12 articles successfully addressed our research question through peer reviewed randomized control trials and met inclusion criteria, we determined that they were of appropriate quality for this review.

Information was extracted from the articles included in the review and organized into tables for comparison. Demographic information including study location, study design, mean patient age, gender breakdown, and reported statistically significant differences in demographics was extracted ( Table 1 ). Further information regarding the study methodology was extracted including the following: study sample sizes, duration of follow-up, percentage in control and intervention arms, treatment details, outcomes, and treatment delivery method ( Tables 2 , 3 ).

The initial search yielded 145 total results, 12 of which were included in the final review. 4 of these studies were systematic reviews of previous randomized control trials (RCTs) comparing psychological interventions to either a usual care or placebo group (18–21). Psychological interventions included cognitive behavioral therapy (CBT), intrapersonal psychotherapy, dynamic psychotherapy, and stress reduction or relaxation therapy. As one study investigating psychopharmacology (tricyclic antidepressants and SSRIs) did so relative to psychotherapy and care as usual, it was deemed to meet inclusion criteria (20). 4 studies compared psychological interventions to usual care provided by the physician (12, 13, 16, 17). Alternate controls employed in the reviewed studies include patients receiving symptom management treatment (11), on a wait-list (15), IBS symptom education (10), or mebeverine medical therapy (14). Of the 8 RCTs included in our review, 6 used CBT as the primary psychological intervention in comparison to a control (10, 11, 14–17). Two of the 6 RCTs using CBT studies compared minimal contact CBT or over the telephone CBT to in person CBT (10, 15). Meanwhile the other two RCTs performed by Jarrett 2009 and Heitkemper 2004 utilized comprehensive multicomponent therapy that included education, diet counseling, relaxation, stress management, and CBT (12, 13).

Most studies included in the review’s subjects were primarily female and white, belonging to the middle-upper socioeconomic status. While IBS has been noted predominantly in white women (31), these studies overlook the potential benefits for males, racial minorities, and lower socioeconomic classes. It has been noted that racial minority IBS patients receive less specialist consultations and are subjected to more aggressive and costly procedural workups than typically employed in routine care (32, 33). While studies included in this review commonly excluded comorbid conditions and disabilities to minimize confounding, this neglected the study of psychotherapies’ influence in these communities’ gastrointestinal complaints. The included studies did not report psychological comorbidities in their patients which could confound the relationship of the therapies to changes in actual outcomes or improvement in mental health.

Several studies did not account for patient income status, a demographic particularly salient when monitoring IBS symptoms, as low-income patients often experience increased stress which may aggravate symptoms. Heitkemper et al. took this into account and noted that patients lost to follow-up in their study were less likely to be married or partnered and less likely to have an annual family income greater than $40,000 (p values of 0.12 and 0.13 respectively) (12). This finding urges the scientific community to take these demographics into consideration more consistently when evaluating barriers to health maintenance.

While all studies evaluated gastrointestinal clinical outcomes, few measured the clinical utility and economic outcomes of psychological IBS treatment (10, 18). Ahl et al., 2013’s systematic review included one study that reported a 60% reduction in primary care visits relative to the control group after receiving psychotherapeutic treatment (18, 34). None of the papers reviewed in our study measured income differences, healthcare utilization, or costs to patients and the system. Furthermore, the different QOL metrics used across studies varied in their ability to account for economic stress, healthcare access, and social stressors. This made it difficult to compare QOL outcomes between studies as well as assess the holistic impact of psychological IBS treatments. Again, the absence of recording patient socioeconomic status in studies clouds analysis as worsened stress could inflame IBS symptoms leading to increased healthcare utilization and higher health costs.

Our study did have limitations due to the available literature on the subject and lack of standardization in evaluating interventions. The broad range of psychological interventions and metrics used to in the reviewed studies created difficulty in comparison and mislead interpretations. Although some reviewed studies included self-reported catastrophic thoughts, psychological distress questionnaires, and CS-FBD as measures of QOL (14, 17), these are the very thought patterns psychological interventions target to improve patient QOL. Therefore, their use as a metric for QOL indirectly assumes the association under inquiry, that psychological interventions improve the QOL and symptom burden that patients experience.

As only 12 publications met inclusion criteria, this topic demands more rigorous study. Future research into this area should focus on understudied populations, diversifying subjects involved in the studies and accounting for patients’ racial, disability, and economic status especially. While the use of psychological therapies has been associated with decreased primary care visits and overall symptom improvement, the cost of intensive psychological therapy programs is significant. Many of these programs required a long duration of treatment (> 2 months) with external requirements for symptom monitoring, dietary changes, and homework following sessions. This review suggests that greater patient choice in modality and regimen of psychotherapy does not compromise the symptomatic relief they may experience from their IBS treatment. By evaluating economic outcomes and clinical utility, research may guide interventions and policies that aim to expand healthcare access and improve IBS patients’ lives.