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Psychological therapy

TL;DR — Brain–gut behavioural therapies have the largest evidence base of any non-dietary treatment in IBS and the worst access. The 2025 network meta-analysis (67 RCTs, 7,441 participants, search to April 2025) ranks minimal-contact CBT first (RR of global symptoms not improving 0.55, 95% CI 0.39–0.76, P-score 0.78; two RCTs, 511 patients), telephone disease self-management second (0.57, 0.41–0.80; two trials, 746 patients), and places gut-directed hypnotherapy — the intervention with the most trials (12) and patients (1,507) — seventh at 0.79 (0.66–0.95) (Thakur 2025, PMID 41077057). No RCT in that network was at low risk of bias across all domains, publication bias was evident, and every direct and indirect comparison was rated low or very low confidence. The predecessor network reached the same structural verdict: several therapies work, "none were superior to another," and efficacy "is likely to have been overestimated" (Black 2020, PMID 32276950). The best single trial is ACTIB (ISRCTN44427879): in 558 patients with refractory IBS, IBS-SSS at 12 months was 61.6 points lower with telephone CBT (95% CI 33.8–89.5, p<0.001) and 35.2 points lower with web CBT (12.6–57.8, p=0.002) than treatment as usual — effect sizes roughly two-fold larger than amitriptyline's 27-point difference in ATLANTIS (gut-brain-neuromodulators). Durability is the class's distinguishing feature: nurse-delivered gut-directed hypnotherapy held 61.8% responders at two years (Lövdahl 2025, PMID 40491242). Delivery mode appears not to matter much — face-to-face, digital, self-help and telephone CBT were statistically indistinguishable, though effective sample sizes were inadequate for most comparisons (Tao 2026, PMID 41505702) — which is the strongest available argument that the access problem is soluble.

The comparative ranking

Thakur 2025 (PMID 41077057) — 67 RCTs, 7,441 participants, versus waiting-list control, global IBS symptoms not improving at first post-treatment follow-up:

Therapy RR (95% CI) P-score Trials / patients
Minimal-contact CBT 0.55 (0.39–0.76) 0.78 2 / 511
Telephone disease self-management 0.57 (0.41–0.80) 0.75 2 / 746
Dynamic psychotherapy 0.59 (0.43–0.80) 0.72 3 / 303
CBT 0.65 (0.53–0.80) 0.64 9 / 1,150
Disease self-management 0.68 (0.50–0.92) 0.58 3 / 375
Internet-based minimal-contact CBT 0.77 (0.61–0.96) 0.43 5 / 705
Gut-directed hypnotherapy 0.79 (0.66–0.95) 0.39 12 / 1,507

In refractory-symptom trials only, telephone disease self-management and contingency management beat both attention-placebo control (RR 0.52, 0.28–0.94 and 0.50, 0.26–0.96) and routine care (0.46, 0.31–0.69 and 0.45, 0.24–0.85); 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) all beat routine care.

The earlier network (41 RCTs, 4,072 participants; Black 2020, PMID 32276950) put self-administered/minimal-contact CBT at RR 0.61 (0.45–0.83), face-to-face CBT at 0.62 (0.48–0.80) and gut-directed hypnotherapy at 0.67 (0.49–0.91) — a very similar ordering with a smaller evidence base. Both reviews reach the same three conclusions: several therapies work; none is demonstrably better than another; the effect sizes are probably inflated by bias and publication asymmetry.

For abdominal pain specifically

US guidelines suggest brain–gut behavioural therapy for persistent abdominal pain, so a pain-specific network was built (42 RCTs, 5,220 participants; Goodoory 2024, PMID 38777133):

Therapy RR of abdominal pain not improving P-score
Self-guided/minimal-contact CBT 0.71 (0.54–0.95) 0.58
Face-to-face multicomponent behavioural therapy 0.72 (0.54–0.97) 0.56
Face-to-face gut-directed hypnotherapy 0.77 (0.61–0.96) 0.49

Again none was superior to another, no trial was at low risk of bias across all domains, and funnel-plot asymmetry was present.

ACTIB: the trial that made CBT deliverable

Feature Detail
Design Three-arm RCT: telephone-delivered CBT (TCBT), web-based CBT with minimal therapist support (WCBT), treatment as usual (TAU); participants and therapists unblinded, investigators and statisticians blinded
Setting 74 general practices and 3 gastroenterology centres, London and South of England, May 2014 – March 2016
Participants 558 of 1,452 screened (38.4%) randomised; refractory IBS (clinically significant symptoms ≥12 months despite first-line therapy); 76% female, 91% white, mean age 43; 70.1% completed 12-month follow-up
Co-primary outcomes IBS-SSS and Work and Social Adjustment Scale (WSAS) at 12 months
IBS-SSS at 12 months TAU 205.6; TCBT −61.6 (33.8 to 89.5) points, p<0.001; WCBT −35.2 (12.6 to 57.8) points, p=0.002
WSAS at 12 months TAU 10.8; TCBT −3.5 (1.9–5.1), p<0.001; WCBT −3.0 (1.3–4.6), p=0.001
Secondary outcomes All significantly better in both CBT arms (p≤0.002)
Harms No serious adverse reactions to treatment

Source: Everitt 2019, PMID 30971419.

Two comparisons make ACTIB important. First, its effect on IBS-SSS is roughly double ATLANTIS's amitriptyline effect (−61.6 and −35.2 vs −27.0) and exceeds ATLANTIS's own 35-point minimum clinically important difference in the telephone arm (Ford 2023, PMID 37858323). Second, it improved function (WSAS), which amitriptyline did not (Wright-Hughes 2024, PMID 39397570). The trial's design was explicitly about access: both interventions were remote, and the web arm used minimal therapist time.

Gut-directed hypnotherapy

The intervention with the most trials, the smallest ranked effect and the best durability data.

Study Design Result
Lövdahl 2022, PMID 35505463 (NCT03432078) 119 patients randomised to individual (61) or group (58) nurse-administered hypnotherapy, 8 sessions over 12 weeks IBS-SSS fell in both arms (individual 332 → 216; group 315 → 217; both p<0.0001) with no difference between arms (p=0.16). Responders (≥50-point IBS-SSS fall) 69% individual vs 57% group (p=0.25). Extracolonic symptoms, psychological symptoms and quality of life all improved
Lövdahl 2025, PMID 40491242 (NCT06167018, NCT03432078) 2-year follow-up of 289 completers; 207 completed 2 years Responders 64.3% post-treatment, 62.8% at 6 months, 64.7% at 1 year, 61.8% at 2 years. IBS, extracolonic and psychological symptom severity all reduced and sustained (p<0.001). Predictors of response: younger age, individual (vs group) delivery, more severe baseline symptoms (R²=0.16)
Berry 2023, PMID 37391055 (NCT04133519) 378 randomised, 362 treated; 12 weeks of digital gut-directed hypnotherapy (Regulora) vs digital muscle relaxation, delivered by smartphone app Primary endpoint not met: abdominal-pain response 30.4% vs 27.1% (p=0.5352). More responders with hypnotherapy during the last 4 weeks of treatment (30.9% vs 21.5%, p=0.0232) and over the whole treatment period (29.3% vs 18.8%, p=0.0254). No serious adverse events
Devenney 2024, PMID 37927144 Post-hoc analysis of predictive factors for response in refractory IBS Predictive-factor analysis
Häuser 2024, PMID 38887623 Mini-review Overview of gut-directed hypnosis and hypnotherapy

Note the nurse-administered result carefully: a 12-week programme delivered by nurses, individually or in groups, kept ~62% of patients responding at two years. Nothing else in this knowledge base has comparable durability data. The comparison is not fair to drugs — hypnotherapy trials are unblinded, and the two-year data are a single-arm follow-up rather than a randomised comparison — but the magnitude and persistence are still striking.

Delivery, access and the scalability question

Study Question Finding
Tao 2026, PMID 41505702 Is face-to-face CBT better than remote modalities? 22 studies, 3,161 participants. Face-to-face vs digital MD −0.89 (95% CrI −20.78 to 18.73); vs self-help −1.73 (−21.03 to 17.80); vs telephone −0.76 (−20.86 to 19.38) on IBS-SSS — no differences. Effective sample size adequate only for the face-to-face-vs-self-help comparison (375/140); inadequate for digital (347/729) and telephone (140/627). Certainty moderate to low
Kim 2022, PMID 35687389 Internet-delivered CBT Systematic review and meta-analysis
Wallén 2025, PMID 39194012 Does internet CBT work outside trials? 309 consecutive routine-care patients at a Stockholm internet psychiatry clinic received 12 weeks of exposure-based CBT. GSRS-IBS fell from 48.06 (SD 11.26) to 33.06 (SD 10.81) at 6 months post-treatment (p<0.001), Cohen's d = 1.30 (1.08–1.51). Cross-lagged modelling showed reduction in avoidance behaviour preceded symptom reduction, not the reverse (p<0.001)
Lövdahl 2022, PMID 35505463 Can nurses deliver hypnotherapy, and in groups? Yes to both; group delivery was not significantly inferior

The mechanistic finding in the Stockholm effectiveness study — that reduction in avoidance behaviour drives symptom reduction rather than the other way round (Wallén 2025, PMID 39194012) — is one of the few mediation analyses in the IBS treatment literature and points to what the active ingredient may be.

Adjacent behavioural interventions: mindfulness and physical activity

These sit outside the brain–gut behaviour therapy class but are commonly recommended, and their evidence is weaker in a specific and instructive way.

Mindfulness. A randomised wait-list-controlled trial of mindfulness-based stress reduction in IBS found benefit on symptom severity (Zernicke 2013, PMID 22618308), and a secondary analysis of a 75-woman randomised pilot (Rome II criteria; eight weekly two-hour sessions plus a half-day) reported that the improvements in symptom severity, health-related quality of life and psychological symptoms seen at 3 months were sustained at 6 and 12 months (Gaylord 2024, PMID 42453561). Head-to-head comparisons of mindfulness-based stress reduction against dialectical behaviour therapy and acceptance and commitment therapy have been attempted in a pilot randomised trial (Taghvaeinia 2024, PMID 37976011). Mindfulness- and acceptance-based cognitive-behavioural therapies have been meta-analysed for bodily distress more broadly (Maas Genannt Bermpohl 2023, PMID 37151971).

Physical activity. The Cochrane review is the cleanest statement of what is and is not known: 11 RCTs, 622 participants, and no trial at low risk of bias. Meta-analysis of five studies comparing physical activity with usual care found improvement in global IBS symptoms (SMD −0.93, 95% CI −1.44 to −0.42; 185 participants) but at very low certainty because of unclear and high risk of bias, inconsistency and imprecision. Physical activity did not improve quality of life (SMD 1.17, −0.30 to 2.64; 134 participants) or abdominal pain (SMD 0.01, −0.48 to 0.50; 64 participants). Yoga versus walking was inconclusive (SMD −1.16, −3.93 to 1.62; 124 participants). Adverse-effect reporting was insufficient to assess harms at all (Nunan 2022, PMID 35766861). An earlier systematic review of exercise therapy reached a compatible conclusion (Zhou 2019, PMID 30232834).

The instructive point is the dissociation: physical activity may improve symptoms while doing nothing measurable for quality of life or pain — the opposite pattern to CBT in ACTIB, which improved both symptoms and the Work and Social Adjustment Scale (Everitt 2019, PMID 30971419).

Why this class is under-used

The evidence assembled here supports four statements simultaneously: 1. Psychological therapy produces clinically important and sometimes durable symptom improvements in IBS; its estimates should not be ranked directly against drug trials with different populations, controls and endpoints (Everitt 2019, PMID 30971419; Lövdahl 2025, PMID 40491242). 2. Its trials are the most bias-prone in the condition — no low-risk-of-bias RCT in a 67-trial network, plus publication bias (Thakur 2025, PMID 41077057). 3. Remote and minimal-contact delivery appears as effective as face-to-face (Tao 2026, PMID 41505702), and nurses can deliver it (Lövdahl 2022, PMID 35505463). 4. Guidelines recommend it, and it remains rationed by access (guidelines).

The most consequential evidence gap is a pragmatic head-to-head against a cheap drug in primary care — the setting where ATLANTIS showed amitriptyline works. Targeted PubMed and registry searches on 2026-09-02 retrieved no amitriptyline-versus-CBT trial; see OPEN-QUESTIONS.md.

Open questions

  • Neuromodulator or behavioural therapy first in primary care? Targeted PubMed and registry searches on 2026-09-02 retrieved no head-to-head trial (Ford 2023, PMID 37858323; Everitt 2019, PMID 30971419).
  • How much of the measured effect survives adequate blinding? Every network reports high risk of bias and funnel-plot asymmetry (Black 2020, PMID 32276950; Thakur 2025, PMID 41077057).
  • Why is minimal-contact CBT ranked first on two trials while hypnotherapy ranks seventh on twelve (Thakur 2025, PMID 41077057)? Ranking by P-score with wildly unequal evidence volumes is not a hierarchy of confidence.
  • Does digital hypnotherapy work? It missed its primary endpoint but beat the comparator on secondary pain-response windows (Berry 2023, PMID 37391055).
  • Is avoidance behaviour the mechanism (Wallén 2025, PMID 39194012)? A single replicated mediation finding, never tested experimentally.
  • Do the two-year hypnotherapy response rates hold in a randomised comparison, or is regression to the mean doing part of the work (Lövdahl 2025, PMID 40491242)?
  • Does physical activity do anything for quality of life or pain? Cochrane finds a symptom signal at very low certainty and null results for both (Nunan 2022, PMID 35766861).
  • Are mindfulness-based approaches a distinct class or a component of CBT? The 12-month durability signal is from a 75-woman pilot's secondary analysis (Gaylord 2024, PMID 42453561).
  • What is the cost per responder relative to amitriptyline, and would commissioning behavioural therapy at scale be affordable? ACTIB collected health-economic data (Everitt 2019, PMID 30971419); targeted PubMed and registry searches on 2026-09-02 retrieved no comparative analysis against drugs.

References

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  2. Black CJ, Thakur ER, Houghton LA, Quigley EMM, Moayyedi P, Ford AC. Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis. Gut. 2020;69(8):1441-1451. PMID 32276950
  3. Goodoory VC, et al. Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis. Gastroenterology. 2024;167(5):934-943.e5. PMID 38777133
  4. Everitt HA, et al. Assessing telephone-delivered cognitive-behavioural therapy (CBT) and web-delivered CBT versus treatment as usual in irritable bowel syndrome (ACTIB): a multicentre randomised trial. Gut. 2019;68(9):1613-1623. PMID 30971419
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