Systematic review of digital self-management therapeutics for irritable bowel syndrome; and, Exploring the feasibility of an Acceptance and Commitment Therapy smartphone app intervention for irritable bowel syndrome

BACKGROUND AND AIMS: Irritable Bowel Syndrome (IBS) is the most common gastrointestinal (GI) disorder; frequently associated with painful physical symptoms, psychological distress and impaired quality of life. While there is no existing ‘gold standard’ treatment for IBS; evidence highlighting the link between the gut and the brain has informed new treatment pathways: with a particular emphasis on psychological approaches in managing IBS. However, long waiting times and pressures on healthcare services often result in patients’ needs not being adequately met. Digital self-management therapeutics are increasingly applied in the management of health conditions, including IBS. The first chapter of this thesis systematically reviews Randomised Controlled Trials (RCTs) exploring the efficacy of digital self-management therapeutics for IBS. Specifically, this is examined in relation to physical symptomology and quality of life outcomes. In the second chapter, smartphone-delivered Acceptance and Commitment Therapy (ACT) is considered as a therapeutic approach for the management of IBS. While preliminary studies have demonstrated efficacy of ACT for IBS, digital delivery of ACT for IBS has not previously been explored. This study explores the feasibility, acceptability, and efficacy of trialling an ACT smartphone application for IBS patients. METHODS: In Chapter One, the evidence base for digital self-management therapeutics for IBS is systematically reviewed. Relevant databases were searched using inclusion and exclusion criteria to identify studies for review. In Chapter Two, recruitment methods, psychometric measures, app building and contents of the intervention are discussed. 83 eligible participants were identified by four GI Consultants across NHS Lothian, NHS Grampian and Imperial College Healthcare NHS Trust. 44 participants downloaded the app, with 29 participants providing data at two-month follow-up. RESULTS: In Chapter One, the systematic search identified 12 relevant RCTs for review. Their methodological quality was appraised by two reviewers, using the Cochrane Risk of Bias (RoB 2) tool. These studies demonstrated moderate-large effects in improving physical symptomology and moderate-large effects in improving quality of life, and generally these improvements were maintained at longer-term follow-up. Evidence comparing treatments to active controls, and longer-term comparison to control groups, were lacking. In Chapter Two, both feasibility and efficacy of the trial were explored. The trial was deemed feasible in terms of recruitment and retention. Paired-sample t-tests demonstrated that use of the ACT self-management application showed significant improvements in IBS acceptance, quality of life, and GI-related anxiety. Similar to a previous ACT self-help trial, improvements in IBSrelated avoidance behaviours were not found. Improvements in GI physical symptomology were noted; however contrary to hypothesis, these improvements were not significant. DISCUSSION: Results from Chapter One indicate the efficacy of digital self-management interventions for IBS; in terms of both physical symptoms and quality of life, with maintained improvements at longer-term follow-up. Large heterogeneity in level of guidance, samples, varying definitions of adherence with interventions, high levels of attrition and methodological quality limit confidence in the results’ generalisability. Suggestions are offered for both future systematic reviews and empirical work in the field based on these findings. Results in Chapter Two provide preliminary evidence of the feasibility and efficacy of a digital ACT smartphone intervention for management of IBS. Attrition and adherence with the intervention are discussed in the context of these results, alongside clinical implications for use of such an intervention as part of a stepped-care approach to IBS. This may be informed by screening GI symptomology at baseline to assess suitability of this lowintensity intervention going forward. A future larger-scale trial is warranted to further explore these preliminary findings