A Randomized Controlled Trial of Acceptance and Commitment Therapy (ACT) in Inflammatory Bowel Disease

The inflammatory bowel diseases (IBD), which include Crohn's disease and ulcerative colitis, are chronic conditions that often arise in young patients and may lead to a lifetime of physical disability. Psychological disabilities are also prevalent in patients with chronic diseases and epidemiological studies indicate that IBD patients are at increased risk of anxiety and mood disorders, with depression rates more than double that of matched community samples (27% versus 12%). IBD patients are also at increased risk of illness-related psychological difficulties including body image concerns, sexual problems and reduced self-esteem.

Therapeutic approaches to inflammatory bowel disease naturally focus on treatments that minimise disease activity and normalise physical function. Thus, there has been considerable research conducted on 5 ASA medications, steroids, immune modulators and biologic agents. In contrast, little attention has been paid to important, but 'low-technology', issues including quality of life and psychological comorbidities including depression, anxiety, stress, altered body image, sexuality, illness attitudes, self-esteem and other psychosocial IBD co-morbidities. Nevertheless, patient reported data and outcomes are increasingly being incorporated into research that informs strategic healthcare documents that, in turn, help formulate healthcare policy. Contemporary European and British guidelines now emphasise the benefits of a patient centred service that supplies psychological as well as medical support.

In addition to the burden that psychological disease places upon IBD patients, there is evidence that psychological morbidity and stress is also associated with disease activity. IBD patients with depression experience more disease flares than those with no diagnosable psychological condition and a Canadian study has also suggested that stress can be associated with disease flares. In contrast, a Spanish study on 163 patients concluded that stressful life events do not trigger exacerbations in IBD patients. Overall, it is likely that the relationship between stress and disease activity is bi-directional with each one influencing the other to some extent.

To date, interventions aimed at reducing psychological distress in IBD have tended to focus on either psychological education, stress management including relaxation techniques and autogenic training, psychodynamic psychotherapy, cognitive behavioral therapy and hypnosis. Studies have been variable with regard to psychological content and almost all had multiple methodological limitations, making it difficult to draw conclusions about the value of these interventions. Perhaps the most comprehensive review of psychological studies in IBD, which included 16 studies, concluded that while psychological interventions can make a positive contribution to best practice multidisciplinary IBD treatment, well designed studies are needed to determine the efficacy of different treatments.

We aim to conduct a multicenter randomised controlled trial to determine the efficacy of Acceptance and Commitment Therapy (ACT) on the psychological wellbeing of IBD patients.