AIM: To characterize the patients utilizing a gastroenterology behavioral medicine service and examine the effect of treatment on health care utilization.

METHODS: Patients were referred by their gastroenterologists for psychological treatment during a 15 mo period. Patients seen for an intake with a psychologist completed the Brief Symptom Inventory (BSI) and a checklist of psychosocial concerns. A subset of patients with functional bowel disorders also completed a disease specific quality of life measure. Chart review was conducted to obtain information on type and frequency of sessions with the psychologist, the number of outpatient gastroenterology visits, and number of gastroenterology-related medical procedures during the 6 mo following psychological intake.

RESULTS: Of 259 patients referred for treatment, 118 (46%) completed an intake with a psychologist. Diagnoses included: irritable bowel syndrome (42%), functional dyspepsia (20%), inflammatory bowel diseases (20%), esophageal symptoms (10%), and “other” (8%). Demographic variables and disease type did not differentiate between those who did and did not schedule an intake. Mean t-scores for the BSI global score index and the depression, anxiety, and somatization subscales fell below the cutoff for clinical significance (t = 63). Treatments were predominantly gut-directed hypnosis (48%) and cognitive behavioral therapy (44%). Average length of treatment was 4 sessions. Among functional gastrointestinal (GI) patients, those patients who initiated treatment received significantly fewer GI-related medical procedures during the 6 mo following the referral than patients who did not schedule an intake [t (197) = 2.69, P < 0.01].

CONCLUSION: Patients are receptive to psychological interventions for GI conditions and there is preliminary evidence that treatment can decrease health-care utilization among patients with functional GI conditions.

Chronic gastrointestinal (GI) problems account for a significant proportion of physician workload in outpatient gastroenterology practices. Inflammatory bowel diseases (IBD) and functional bowel disorders jointly account for more than half of the patients seen by gastroenterologists[1]. The cost of managing these conditions is high. The estimated direct cost of irritable bowel syndrome (IBS) alone is estimated to be 1.3 billion in the United States and is similar to other chronic medical conditions such as asthma, hypertension, and congestive heart failure[2,3]. In addition, the psychosocial impact of chronic digestive symptoms is significant. Patients with both functional (e.g., IBS) and organic GI conditions (e.g., IBD) experience impaired quality of life (QOL) and increased rates of psychological distress[4,5].

Traditional medical treatments are often inadequate for managing functional gastrointestinal conditions, particularly for patients with moderate to severe symptoms[6]. As a result these patients often pursue alternative treatment options. In fact more than 50% of patients with IBS and IBD turn to complementary and alternative medicine treatments and nearly 1/3 of patients with IBD express interest in psychological treatment[7-9].

Psychological interventions are now well-established, effective treatments that can complement usual medical care for many chronic GI conditions. Cognitive behavioral therapy and gut-directed hypnosis are empirically supported interventions for IBS and the American Gastroenterological Association recommends psychological treatments for moderate to severe patients[10-12]. In addition to IBS, gut-directed hypnotherapy has been demonstrated as an effective treatment for functional dyspepsia, non-cardiac chest pain, and acid reflux[13-15]. Less is known about the benefits of stress management and behavioral interventions for IBD. However, emerging evidence indicates that psychological interventions are beneficial for improving mood, QOL, and even prolonging remission in IBD patients[16,17].

Many of these positive outcomes can be attributed to patients’ increased self-efficacy to manage and cope with their digestive condition, thereby reducing burden on medical providers[18]. There is some empirical evidence that psychological treatments can decrease health care utilization. For example, relaxation training contributed to less frequent doctor visits among IBS patients and psychological treatment was associated with reduced health care costs in patients with IBS[19,20].

Despite the documented benefits of psychological interventions for GI conditions, these treatments have not been well integrated into gastroenterology practices and are not easily accessible to patients. Many barriers have been suggested, including concerns about reimbursement for behavioral services, referrals only being made for patients with significant psychological symptoms, and the misconception that patients are not receptive to psychological interventions[11]. Palsson and Whitehead recently published a primer for gastroenterologists, encouraging providers to consider referring patients with functional GI conditions for psychological treatment and recommendations on making a successful referral[6]. Their article is an important step in explaining how these treatments can become more integrated into the care of patients with chronic GI conditions. The purpose of the current study is to demonstrate how this integration can occur in a clinical context. This is the first study that we are aware of to evaluate the acceptability and feasibility of offering behavioral treatment as part of routine clinical practice within a gastroenterology clinic.

The goal of the current study was to characterize an integrated psychological gastroenterology service and examine impact of this service on health-care utilization. Specific aims were to: (1) examine the number of patients referred and proportion of patients that engaged in psychological treatment for their GI condition; (2) determine any demographic or disease related variables that might influence the likelihood of a patient pursuing treatment; (3) characterize the psychosocial functioning of patients pursuing behavioral treatment; and (4) among patients with functional GI conditions, evaluate the impact of receiving behavioral medicine services on health care utilization (i.e., physician office visits, medical procedures).

Chronic GI disorders cause significant quality of life impairment and account for a significant proportion of health care utilization[24]. There is strong empirical evidence that psychological treatments for functional GI disorders are beneficial; however, the implementation of these treatments in a clinical setting has lagged behind. The results of the present study indicate that it is feasible to implement these treatments in an outpatient GI clinic and that many of the barriers to treatment that have been suggested in the past can be overcome[11]. Table 3 provides a list of common myths about psychological treatments for GI patients and corresponding facts based on findings of this study and our experience running an integrated psychosocial GI service.

Our findings suggest that many patients are in fact receptive to and interested in psychological treatment. Over 200 patients were referred for psychological treatment within a 15-mo time span and nearly half of these patients met with a psychologist. Historically, referrals for psychological treatments are only considered for patients who are significantly distressed. Our experience has been that even patients who are functioning quite well emotionally can still benefit from these treatments. The majority of the patients in the current study identified stress as a contributing factor to their GI condition, but they were not suffering from a psychological disorder. These findings are contrary to the perception that only highly anxious or depressed patients will benefit or be interested in meeting with a psychologist.

It is notable that patients with a wide range of GI conditions utilized behavioral treatments. Traditionally, psychological referrals are only considered for patients with functional conditions. However, 20% of the referrals made in this study were for patients with inflammatory bowel disease and patients with various organic GI conditions are commonly seen by the health psychologist in our clinic (e.g., celiac sprue, pancreatitis, eosinophilic gastrointestinal diseases). Our experience has been that IBD patients in particular are eager to work with a GI health psychologist and this is consistent with research findings[9]. Furthermore, patient demographics did not influence whether or not patients pursued health psychology services. This should encourage gastroenterologists to consider referring a wide range of patients and not assume that certain demographic groups (e.g., elderly) would not be interested.

Our findings are consistent with past research indicating that psychological interventions can reduce healthcare burden. For example, Creed et al[19] found that psychological intervention, but not antidepressant medication, was associated with reduced health care costs, largely due to fewer gastroenterology follow-up visits. Similarly, our results indicate that functional GI patients who participate in psychological treatment are less likely to need further medical procedures for their GI condition. Although psychological treatments may require greater time investment from the patient initially, there is less long-term medical follow-up needed (outpatient visits, medical procedures, medications); thereby reducing burden on patients and providers. Given the effectiveness of psychological treatments for GI conditions, it is not surprising that patients engaged in these treatments were in less need of medical attention.

Another significant finding from this study is the short-term nature of treatment. The average length of treatment in our study was 4 sessions. These findings are consistent with past research indicating that a significant proportion of IBS patients treated with CBT respond to treatment within 4 wk (referred to as rapid responders) and maintain symptom improvement for at least 3 mo[10]. These findings are contrary to the misconception that psychological treatment requires a long-term time commitment. CBT is designed to be a short-term skills-based treatment that teaches the patient to self-manage their condition. Patients will be more likely to consider psychological treatment if they understand that this is a short-term investment. It is notable that the treating provider in this study is a health psychologist with specific training and experience in gastroenterology. Implementation of psychological treatments for GI conditions requires specialized knowledge and training and these same results might not be achieved by a “general” psychotherapist. Unfortunately there are a limited number of providers with this expertise, making it challenging for physicians to find psychological providers to refer to.

Our clinical experience has been that many of the suggested barriers to offering psychological treatments for gastrointestinal conditions can be addressed with appropriate integration of these services. By having a provider on-site, offering behavioral medicine services in conjunction with medical treatment, and streamlining referrals, patients are more receptive to health psychology services. Furthermore, effective communication of the referral by the gastroenterologist is important[6]. Concerns have also been raised about financial cost as a barrier to psychological treatment. It is worth noting that health psychologists have specialized billing codes (i.e., health and behavior codes) that allow for behavioral treatment to be billed under the patient’s medical insurance. All patients seen for treatment in this study received behavioral intervention through their medical insurance. These billing codes not only make treatments more accessible to patients, but also de-stigmatize treatment by differentiating it from mental health treatment.

Although this study contributes important findings, its limitations should be noted. Our sample was drawn from Northwestern’s outpatient gastroenterology clinic, located in downtown Chicago. This patient population is typically well-educated, affluent, and has adequate resources to benefit from psychological treatments. Additional barriers might be present for patients from different geographical areas with more diverse socioeconomic status. This study was also limited by small sample size of various disease groups. An important goal of future research will be to obtain chart review data on a larger portion of patients, collect additional measures of HCU (e.g., clinic phone calls, medication use), and examine barriers to participating in psychological services. Despite these limitations, this study provides insight into the role that psychologists can play in improving care and outcomes of patients with gastrointestinal conditions.