Effect of psychological therapy on disease activity, psychological comorbidity, and quality of life in inflammatory bowel disease: a systematic review and meta-analysis
Open accessAbstract
Background Inflammatory bowel disease is associated with psychological comorbidity and impaired quality of life. Psychological comorbidity could affect the natural history of inflammatory bowel disease. Psychological therapies might therefore have beneficial effects on disease activity, mood, and quality of life in patients with inflammatory bowel disease. We did a systematic review and meta-analysis examining these issues.Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials for articles published between 1947 and Sept 22, 2016. Randomised controlled trials (RCTs) recruiting patients with inflammatory bowel disease aged at least 16 years that compared psychological therapy with a control intervention or usual treatment were eligible. We pooled dichotomous data to obtain relative risks of induction of remission in active disease or prevention of relapse of quiescent disease, with 95% CIs. We pooled continuous data to estimate standardised mean differences in disease activity indices, anxiety, depression, perceived stress, and quality-of-life scores in patients dichotomised into those with clinically active or quiescent disease, with 95% CIs. We extracted data from published reports and contacted the original investigators of studies for which the required data were not available. We pooled all data using a random-effects model.Findings The search identified 1824 studies, with 14 RCTs of 1196 patients eligible for inclusion. The relative risk of relapse of quiescent inflammatory bowel disease with psychological therapy versus control was 0·98 (95% CI 0·77-1·24; p=0·87; I 2=50%; six trials; 518 patients). We observed a significant difference in depression scores (standardised mean difference -0·17 [-0·33 to -0·01]; p=0·04; I 2=0%; seven trials; 605 patients) and quality of life (0·30 [0·07-0·52]; p=0·01; I 2=42%; nine trials; 578 patients) with psychological therapy versus control at the end of therapy for patients with quiescent disease. However, these beneficial effects were lost at final point of follow-up (depression scores -0·11 [-0·27 to 0·05], p=0·17, I 2=0%, eight trials, 593 patients; quality of life 0·15 [-0·05 to 0·34], p=0·14, I 2=22%, ten trials, 577 patients). When we assessed the effect of individual physiological therapies on quality of life, only cognitive behavioural therapy had any significant beneficial effect (0·37 [0·02-0·72]). We noted no effect on disease activity indices or other psychological wellbeing scores when compared with control in patients with quiescent disease. Dichotomous data for induction of remission and continuous data for change in clinical disease activity indices, depression, anxiety, and perceived stress scores were only reported in one RCT of patients with active disease. Quality of life was assessed in two RCTs of patients with active disease, but was not significantly different between intervention and control groups (0·27 [-0·05 to 0·59]).Interpretation Psychological therapies, and cognitive behavioural therapy in particular, might have small short-term beneficial effects on depression scores and quality of life in patients with inflammatory bowel disease. Further RCTs of these interventions in patients with coexistent psychological distress are required.Funding None.
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CBT is demonstrated to be somewhat effective in improving HRQoL and depressive symptoms for those with IBD, but there remain mixed reviews on its long-term efficacy and its effectiveness, if any, in treating anxiety symptoms.
“CBT is demonstrated to be somewhat effective in improving HRQoL and depressive symptoms for those with IBD; however, there remain mixed reviews on its long-term efficacy and its effectiveness, if any, in treating anxiety symptoms (Ballou & Keefer, 2017; Bennebroek Evertsz et al., 2017; Gracie et al., 2017; Hanlon et al., 2018; Mikocka-Walus et al., 2017; Stapersma et al., 2020).”
From Moving Towards Acceptance and Values: A Qualitative Study of ACTforIBD Compared to IBD Psychoeducation (2024) · cites this paper as Gracie et al., 2017
The CBT analysis reports improved quality of life at the end of therapy, but the benefit was lost at final follow-up (Effect of Psychological Therapy on Quality of Life in IBD, p. 18). It found no significant CBT effect on depression or anxiety scores, although the overall psychological-therapy analysis found a short-term improvement in depression (Summary, p. 4). Thus, this source does not establish a CBT-specific improvement in depressive symptoms. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe focus on people without psychological comorbidities could have contributed to low efficacy of psychotherapy in IBD on psychological outcomes such as anxiety or coping.
“this could have contributed to low efficacy of psychotherapy in IBD on psychological outcomes such as anxiety or coping.”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Discussion (p. 19) suggests that the limited benefit on psychological outcomes may partly reflect most trials’ failure to recruit specifically patients with abnormal psychological health. The anxiety analysis (p. 15) found no significant benefit. The paper lists a coping measure in one trial (p. 37), but the passages found do not report an effect of psychotherapy on coping, so that example is not supported. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPsychotherapy is efficacious in improving QoL and depression in IBD.
“Our meta-analysis12 demonstrates the efficacy of psychotherapy in improving QoL and depression in IBD.”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Discussion (pp. 19, 22) reports limited, short-term improvements in depression and quality of life, particularly in patients with clinically quiescent IBD. The claim omits those limits: the paper says the effects appear to be lost over time, and the quality-of-life analysis (p. 17) found no benefit at final follow-up. (LLM, conf=0.88)
Experimental — accuracy not yet measuredMost studies of psychotherapy in IBD conducted to date have focused on people without psychological comorbidities.
“most studies conducted to date have focused on people without psychological comorbidities”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Discussion (p. 19) says most trials did not recruit specifically patients with abnormal psychological health; the Discussion (p. 21) says none studied patients with pre-existing depression or anxiety. This supports the point that studies generally did not focus on psychological comorbidity, but not the stronger implication that they focused on patients without it or excluded patients who had it. (LLM, conf=0.85)
Experimental — accuracy not yet measuredCBT has been found to be effective in reducing symptoms of depression and improving QoL in IBD.
“CBT has been found to be effective in reducing symptoms of depression and improving QoL in IBD.12”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The CBT-specific analysis (p. 18) found improved quality of life at the end of therapy, but the benefit was lost at final follow-up. It found no significant effect of CBT on depression scores compared with control therapy. The depression improvement reported for psychological therapies overall (Summary, p. 4) therefore does not establish the claim about CBT specifically. (LLM, conf=0.91)
Experimental — accuracy not yet measured
Psychological treatment to improve adaptation to IBD typically involves CBT, and there is some support for its efficacy on QOL and symptoms of depression.
“Psychological treatment to improve adaptation to IBD typically involves CBT, and there is some support for its efficacy on QOL and symptoms of depression.12”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Summary (p. 4) reports short-term improvements in quality of life and depression with psychological therapies overall. The CBT-specific analysis (p. 18) found improved quality of life but no significant effect on depression scores. The paper also does not establish that psychological treatment for IBD typically involves CBT. (LLM, conf=0.88)
Experimental — accuracy not yet measuredExisting CBT interventions for IBD offer only short-term benefits for mental health and QoL in IBD.
“existing CBT interventions for IBD offer only short-term benefits for mental health and QoL in IBD,12”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Discussion (p. 22) says CBT in particular may provide limited short-term improvements in depression and quality of life, with benefits lost over time (Discussion, p. 19). But the CBT-specific analysis found improved quality of life at the end of therapy and no significant effect on depression or anxiety (p. 18). The claim overstates both the certainty and the breadth of the mental-health benefit. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThere is a dearth of studies focused on psychological distress as the outcome in IBD.
“with a dearth of studies focused on psychological distress as the outcome, and little telemedicine used.”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Discussion (p. 20) describes a relatively small evidence base, and the Discussion (p. 21) says no included RCT studied psychological interventions specifically in patients with pre-existing depression or anxiety. But the paper does not establish a dearth of studies focused on psychological distress *as an outcome*: seven studies assessed depression scores (p. 16), and six assessed perceived stress (p. 16). Its clearest gap concerns the patients recruited, rather than whether distress was measured. (LLM, conf=0.83)
Experimental — accuracy not yet measuredMany studies of psychological interventions in IBD have poor methodological rigor and reporting.
“Many studies are observed to be non-randomized, devoid of inclusion and exclusion criteria, neglect to report salient participant data (e.g., IBD type), and neglect to report sufficient intervention program detail [18,19,20,21].”
From Brief and Telehealth Acceptance and Commitment Therapy (ACT) Interventions for Stress in Inflammatory Bowel Disease (IBD): A Series of Single Case Experimental Design (SCED) Studies (2022) · cites this paper as [18]
The Discussion (p. 20) says all included trials were at high risk of bias, chiefly because of inadequate blinding. It also notes that some studies considered for the review were excluded for lack of randomisation or separately reported patient data (p. 19). The paper does not establish that many studies omitted inclusion and exclusion criteria, IBD type, or sufficient intervention details. (LLM, conf=0.87)
Experimental — accuracy not yet measuredCBT changes do not continue long term (e.g., 18 months postintervention).
“these changes do not continue long term (eg, 18 months postintervention),5”
From Feasibility, Acceptability, and Preliminary Efficacy of Acceptance Commitment Therapy for Adults Living With Inflammatory Bowel Disease and Distress. (2024) · cites this paper as [5]
The Quality of Life results (p. 18) report that CBT improved quality of life at the end of therapy but that the benefit was lost at the final follow-up. The paper does not establish that this CBT benefit was lost specifically 18 months postintervention; its 18-month follow-up finding concerns psychological therapy in patients with active IBD (p. 13). (LLM, conf=0.86)
Experimental — accuracy not yet measuredCBT reduces symptoms of depression and improves IBD HRQoL.
“While cognitive behavioral therapy (CBT) has been found to reduce symptoms of depression and improve IBD HRQoL,5,6”
From Feasibility, Acceptability, and Preliminary Efficacy of Acceptance Commitment Therapy for Adults Living With Inflammatory Bowel Disease and Distress. (2024) · cites this paper as [5]
The CBT-specific analysis (Effect of Psychological Therapy on Quality of Life in IBD, p. 18) found improved quality of life at the end of therapy, but that benefit was lost at final follow-up. It found no significant effect of CBT on depression scores. The Summary (p. 4) reports a short-term depression benefit for psychological therapy overall, not specifically for CBT. (LLM, conf=0.90)
Experimental — accuracy not yet measuredCurrent evidence around the efficacy of different types of psychotherapy for IBD is mixed, and questions remain about what types of support might be most effective.
“Current evidence around the efficacy of different types of psychotherapy is mixed and there remain questions around what types of support might be most effective in improving patient outcomes for those with IBD (Ballou & Keefer, 2017; Gracie et al., 2017; Knowles et al., 2013).”
From Moving Towards Acceptance and Values: A Qualitative Study of ACTforIBD Compared to IBD Psychoeducation (2024) · cites this paper as Gracie et al., 2017
Psychological interventions for IBD tested to date offer only limited efficacy.
“Since psychological interventions for IBD tested to date have not been codesigned with consumers and offer only limited efficacy,12”
Little telemedicine is used in psychological interventions for IBD.
“with a dearth of studies focused on psychological distress as the outcome, and little telemedicine used.”
In IBD specifically, little research on low intensity or online psychotherapy is available.
“In IBD specifically, little research on low intensity or online psychotherapy is available.12”
Psychological interventions for IBD tested to date have not been codesigned with consumers.
“Since psychological interventions for IBD tested to date have not been codesigned with consumers and offer only limited efficacy,12”
From Acceptance commitment therapy (ACT) for psychological distress associated with inflammatory bowel disease (IBD): protocol for a feasibility trial of the ACTforIBD programme (2022) · cites this paper as [12]
The Discussion (pp. 19, 22) supports the citing sentence’s separate point about limited efficacy, but it does not address whether the interventions were codesigned with consumers. Searches for codesign, consumer involvement, and patient participation in intervention design found no passage establishing the quoted claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredThe evidence to date for any benefit of gut-brain neuromodulators or psychological therapies, including CBT, gut-directed hypnotherapy, and mindfulness as an adjunct to conventional treatment in IBD, is inconclusive, largely because these have been tested in unselected patients.
“Unfortunately, the evidence to date for any benefit of gut-brain neuromodulators[42] or psychological therapies[43], including cognitive behavioural therapy, gut-directed hypnotherapy, and mindfulness as an adjunct to conventional treatment in IBD is inconclusive, largely due to the fact that these have been tested in unselected patients.”
From Bidirectional brain-gut axis effects influence mood and prognosis in IBD: A systematic review and meta-analysis (2022) · cites this paper as [43]
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Self-citation
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Lamb, C. A., Kennedy, N. A., Raine, T., Hendy, P. A., Smith, P. J., Limdi, J. K., Hayee, B., Lomer, M. C. E., Parkes, G. C., Selinger, C., et al. (2019) · Gut · doi:10.1136/gutjnl-2019-318484 · Cited by 2,346 · see citing works
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Bisgaard, T. H., Allin, K. H., Keefer, L., Ananthakrishnan, A. N., & Jess, T. (2022) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/s41575-022-00634-6 · Cited by 572 · see citing works
The role of inflammation and the gut microbiome in depression and anxiety
Peirce, J. M., & Alviña, K. (2019) · Journal of Neuroscience Research · doi:10.1002/jnr.24476 · Cited by 466 · see citing works
Bi-directionality of brain–gut interactions in patients with inflammatory bowel disease
Gracie, D. J., Guthrie, E. A., Hamlin, P. J., & Ford, A. C. (2018) · Gastroenterology · doi:10.1053/j.gastro.2018.01.027 · Cited by 408 · see citing works
Self-citationFairbrass, K. M., Lovatt, J., Barberio, B., Yuan, Y., Gracie, D. J., & Ford, A. C. (2022) · Gut · doi:10.1136/gutjnl-2021-325985 · Cited by 225 · see citing works
Self-citationWynne, B., McHugh, L., Gao, W., Keegan, D., Byrne, K., Rowan, C., Hartery, K., Kirschbaum, C., Doherty, G., Cullen, G., et al. (2019) · Gastroenterology · doi:10.1053/j.gastro.2018.11.030 · Cited by 188 · see citing works
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Sweeney, L., Moss‐Morris, R., Czuber‐Dochan, W., Meade, L., Chumbley, G., & Norton, C. (2018) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.14493 · Cited by 112 · see citing works
Szigethy, E. M., Allen, J. I., Reiss, M., Cohen, W., Perera, L. P., Brillstein, L., Cross, R. K., Schwartz, D. A., Kosinski, L. R., Colton, J. B., et al. (2017) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2017.02.037 · Cited by 107 · see citing works
Antidepressants in inflammatory bowel disease
Mikocka-Walus, A., Ford, A. C., & Drossman, D. A. (2020) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/s41575-019-0259-y · Cited by 93 · see citing works
Self-citationRiggott, C., Mikocka-Walus, A., Gracie, D. J., & Ford, A. C. (2023) · The Lancet Gastroenterology & Hepatology · doi:10.1016/s2468-1253(23)00186-3 · Cited by 83 · see citing works
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The effect of psychotherapy on quality of life in IBD Patients: A systematic review
Paulides, E., Boukema, I., van der Woude, C. J., & de Boer, N. K. H. (2021) · Inflammatory Bowel Diseases · doi:10.1093/ibd/izaa144 · Cited by 47 · see citing works
Artom, M., Czuber-Dochan, W., Sturt, J., Proudfoot, H., Roberts, D., & Norton, C. (2019) · Pilot and Feasibility Studies · doi:10.1186/s40814-019-0538-y · Cited by 48 · see citing works
Stapersma, L., van den Brink, G., van der Ende, J., Szigethy, E. M., Beukers, R., Korpershoek, T. A., Theuns-Valks, S. D. M., Hillegers, M. H. J., Escher, J. C., & Utens, E. M. W. J. (2018) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsy029 · Cited by 46 · see citing works
Sceats, L. A., Dehghan, M. S., Rumer, K. K., Trickey, A., Morris, A. M., & Kin, C. (2020) · Colorectal Disease · doi:10.1111/codi.14905 · Cited by 33 · see citing works
Fairbrass, K. M., Gracie, D. J., & Ford, A. C. (2021) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.16454 · Cited by 31 · see citing works
Self-citationHinnant, L., Rios Villacorta, N., Chen, E., Bacchus, D., Dotson, J., Greywoode, R., Keefer, L., Lupe, S., Maggs, L., Meek, G., et al. (2025) · Inflammatory Bowel Diseases · doi:10.1093/ibd/izae151 · Cited by 31 · see citing works
Dober, M., Mikocka-Walus, A., Evans, S., Beswick, L., Emerson, C., & Olive, L. (2021) · Psychotherapy Research · doi:10.1080/10503307.2020.1813915 · Cited by 25 · see citing works
“Several review articles and meta-analyses have established that the efficacy of psychotherapy for IBD patients is mixed (Ballou & Keefer, 2017; Gracie et al., 2017; Knowles et al., 2013; McCombie et al., 2013; Tarricone et al., 2017; Timmer et al., 2011).”
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“For example, almost half of clients with depression and anxiety exhibit sudden large gains within the first two to four CBT treatment sessions [39,40].”
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Romano, D., Chesterman, S., Fuller-Tyszkiewicz, M., Evans, S., Dober, M., Gearry, R., Gibson, P. R., Knowles, S., McCombie, A., O, E., et al. (2024) · Inflammatory Bowel Diseases · doi:10.1093/ibd/izad122 · Cited by 19 · see citing works
“5 The rationale behind this approach is that improved psychological well-being may have flow-on effects to predict less frequent IBD flare-ups and improve HRQoL.”
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Burian, H., Böge, K., Burian, R., Burns, A., Nguyen, M. H., Ohse, L., Ta, T. M. T., Hahn, E., & Diefenbacher, A. (2021) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2021.110374 · Cited by 19 · see citing works
Naude, C., Skvarc, D., Maunick, B., Evans, S., Romano, D., Chesterman, S., Russell, L., Dober, M., Fuller-Tyszkiewicz, M., Gearry, R., et al. (2025) · American Journal of Gastroenterology · doi:10.14309/ajg.0000000000003032 · Cited by 15 · see citing works
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Wilkin, K., Evans, S., Van Niekerk, L., Romano, D., Fuller-Tyszkiewicz, M., Knowles, S., Chesterman, S., Raven, L., & Mikocka-Walus, A. (2024) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-023-09999-5 · Cited by 5 · see citing works
“Current evidence around the efficacy of different types of psychotherapy is mixed and there remain questions around what types of support might be most effective in improving patient outcomes for those with IBD (Ballou & Keefer, 2017; Gracie et al., 2017; Knowles et al., 2013).”
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“A recent meta-analysis has demonstrated usefulness of psychotherapy, particularly cognitive-behavioural therapy (CBT), in improving quality of life and symptoms of depression in IBD (Gracie et al., 2017).”
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Tse, C. S., Singh, S., & Sandborn, W. J. (2022) · Inflammatory Bowel Diseases · doi:10.1093/ibd/izab153 · Cited by 3 · see citing works
- Authors
- Gracie, D. J., Irvine, A. J., Sood, R., Mikocka-Walus, A., Hamlin, P. J., & Ford, A. C.
- Affiliations
- University of Leeds (GB)
- St James's University Hospital (GB)
- Corresponding author
- Gracie, David J
- Venue
- The Lancet Gastroenterology & Hepatology
- Publisher
- Elsevier BV
- Published
- 2017-03
- Volume
- 2
- Issue
- 3
- Pages
- 189-199
- ISSN
- 2468-1156 (ISSN-L)
- 2468-1253
- OpenAlex
- W2574509953
- Cited by
- 271
- References
- 54
- Citations by year
- 2026: 13 · 2025: 19 · 2024: 20 · 2023: 17 · 2022: 29 · 2021: 35 · 2020: 82 · 2019: 27 · 2018: 18 · 2017: 7
- FWCI
- 4.71
- Type
- journal article
- Language
- en
- Open access
- green
- figshare.com
- Licence
- Locations
- The Lancet. Gastroenterology & hepatology (publishedVersion)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Figshare (submittedVersion, cc-by)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Inflammatory Bowel Disease
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- inflammatory bowel disease, psychotherapy, disease activity, relapse prevention, remission induction, depression, anxiety, perceived stress, quality of life, psychological comorbidity, mood disorders, quiescent disease
- MeSH terms
- Affect, Anxiety, Depression, Humans, Psychotherapy, Quality of Life, Stress, Psychological, Inflammatory Bowel Diseases, Cognitive Behavioral Therapy
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