Healio Hot Topic

GI psychologists bring value to IBS patient care

The benefits of incorporating GI-specific psychological care for patients with irritable bowel syndrome are becoming increasingly recognized. Hence, integrating a GI psychologist can be an asset to a GI practice. Recently, we spoke with Megan E. Riehl, PsyD, a GI psychologist and clinical assistant professor of internal medicine at Michigan Medicine, about the emerging field of psychogastroenterology, the benefits of brain-gut therapies for patients and the value a GI psychologist can bring to a GI practice.

Healio: How does a GI psychologist bring value to a GI practice?

Riehl: Value is currently being assessed from an economic perspective in psychogastroenterology research. However, gastroenterology practices with fully integrated psychologists report value in patient symptom and quality of life improvements, patient satisfaction and decreased health care utilization. There is also value from a physician burnout perspective as a GI psychologist can aid in decreasing health care utilization with some refractory patients who place numerous phone calls, portal messages in the EMR or request frequent clinic visits.

Megan E. Riehl

Healio: Which GI conditions most benefit from brain-gut therapies?

Riehl: Brain-gut therapies delivered by a trained mental health professional who has specialized training in psychogastroenterology are most beneficial for patients with disorders of gut-brain interactions, such as irritable bowel syndrome (IBS) and patients with inflammatory bowel diseases. Psychogastroenterology is an emerging subspecialty in the field of gastroenterology and addresses the complexities of the physiological and psychological interplay (brain-gut axis) that perpetuates gastrointestinal conditions. Brain-gut therapies include cognitive behavioral therapy (CBT) and gut-directed hypnotherapy.

Healio: Can you provide a very simple explanation of the goals and rational behind the incorporation of psychogastroenterology?

Riehl: Given that the brain and gut are constantly communicating, behavioral therapy in GI settings is tailored to address the miscommunication that takes place for patients with GI conditions from a psychological perspective. Treatment focuses on providing patients with tools to improve coping, resilience and stress management. Additionally, brain-gut therapies are evidence-based treatments that target abdominal pain, GI motility and visceral hypersensitivity that can be difficult to treat in traditional medical settings. Psychogastroenterology accounts for the importance of multidisciplinary care for IBS patients.

Healio: Can you describe the ideal candidate for GI focused behavioral therapy? Any predictors of positive response?

Riehl: Gastroenterologists are encouraged to refer patients with moderate to severe IBS to a GI psychologist early in treatment planning and present the referral as an opportunity for collaboration. Patients who have insight into the role of stress on their symptoms and are interested in learning adaptive coping strategies are ideal. Predictors have been difficult to ascertain, but this is an area of focus in my current clinical research.

Healio: Can you describe the type of IBS patient who is not appropriate for referral for GI focused behavioral therapy? Any predictors of a poor response?

Riehl: Patients with untreated psychopathology (eg, suicidal ideation, severe depression or anxiety, personality disorder, substance abuse, disordered eating) are not ideal candidates for brain-gut therapies. It is recommended that patients achieve stable mood by working with a general mental health professional before consultation with a GI psychologist.

Healio: What is a typical course of therapy in your practice?

Riehl: Treatment is short-term, typically 5 to 7 sessions.

Healio: How do you decide when treatment has been completed? How do you decide to stop therapy?

Riehl: Patients may complete the 7 sessions of the gut-directed hypnotherapy protocol or provide feedback pertaining to achieving a desirable symptom and quality of life improvement, which is reason to complete treatment. Patients may return for additional sessions in the future as needed.

Healio: How would you choose between CBT and hypnosis?

Riehl: Patients are referred for an initial consultation to assess whether they are an appropriate candidate for brain-gut therapies and then to discuss treatment planning. Patients that recognize that stress impacts their symptoms and have interest in learning coping strategies to better manage physiological arousal and visceral hypervigilance are candidates for gut-directed hypnotherapy. If a patient has difficulty with negative thoughts and maladaptive coping skills to manage the complexities of their bowel symptoms, CBT may be implemented into the treatment plan. CBT teaches patients to observe their negative thought patterns and challenge those thoughts with cognitive restructuring. Avoidance behaviors, safety behaviors and inflexible coping are also targeted in CBT.

Healio: Are your services reimbursed?

Riehl: Services are reimbursed using insurance. I bill with health and behavior codes that use the patient’s medical diagnosis.

Healio: What about internet or booked based therapy? Does it work as well as face to face therapy? If not internet or book-based therapy, how about telemedicine?

Riehl: For patients with IBS who may be symptomatic, the ability to engage in treatment using the internet or a book-based therapy from the comfort of their own home can certainly be beneficial and preferred by some. Research evaluating short-term internet-based CBT is emerging. Preliminary and anecdotal results look favorable, but more research is needed in this area. In my clinical opinion, the use of telemedicine should be personalized, and a combination of in-clinic and telemedicine sessions will likely be effective. Additional work is needed at this time to address reimbursement and insurance coverage.

Healio: Any insights from DDW on this topic that you would care to discuss?

Riehl: The Rome Foundation introduced psychogastroenterology in a meeting at DDW 2018 that highlighted the evolution and current state of this working group. At present, there are about 140 members on 6 continents and this is the first dedicated organization for psychosocial aspects of gastrointestinal treatment and research. The meeting discussed important redefinitions of certain language such as “disorders of gut-brain interactions instead of “functional gastrointestinal disorders (FGIDs)” and “central neuromodulators” instead of antidepressants. This subspecialty will aid in the development of clinical core competencies for mental health professionals who want to participate in the care of GI patients. This will allow for our field to grow, allowing better access to care for patients in need.

Disclosure: Riehl reports no relevant financial disclosures.

The benefits of incorporating GI-specific psychological care for patients with irritable bowel syndrome are becoming increasingly recognized. Hence, integrating a GI psychologist can be an asset to a GI practice. Recently, we spoke with Megan E. Riehl, PsyD, a GI psychologist and clinical assistant professor of internal medicine at Michigan Medicine, about the emerging field of psychogastroenterology, the benefits of brain-gut therapies for patients and the value a GI psychologist can bring to a GI practice.

Healio: How does a GI psychologist bring value to a GI practice?

Riehl: Value is currently being assessed from an economic perspective in psychogastroenterology research. However, gastroenterology practices with fully integrated psychologists report value in patient symptom and quality of life improvements, patient satisfaction and decreased health care utilization. There is also value from a physician burnout perspective as a GI psychologist can aid in decreasing health care utilization with some refractory patients who place numerous phone calls, portal messages in the EMR or request frequent clinic visits.

Megan E. Riehl

Healio: Which GI conditions most benefit from brain-gut therapies?

Riehl: Brain-gut therapies delivered by a trained mental health professional who has specialized training in psychogastroenterology are most beneficial for patients with disorders of gut-brain interactions, such as irritable bowel syndrome (IBS) and patients with inflammatory bowel diseases. Psychogastroenterology is an emerging subspecialty in the field of gastroenterology and addresses the complexities of the physiological and psychological interplay (brain-gut axis) that perpetuates gastrointestinal conditions. Brain-gut therapies include cognitive behavioral therapy (CBT) and gut-directed hypnotherapy.

Healio: Can you provide a very simple explanation of the goals and rational behind the incorporation of psychogastroenterology?

Riehl: Given that the brain and gut are constantly communicating, behavioral therapy in GI settings is tailored to address the miscommunication that takes place for patients with GI conditions from a psychological perspective. Treatment focuses on providing patients with tools to improve coping, resilience and stress management. Additionally, brain-gut therapies are evidence-based treatments that target abdominal pain, GI motility and visceral hypersensitivity that can be difficult to treat in traditional medical settings. Psychogastroenterology accounts for the importance of multidisciplinary care for IBS patients.

Healio: Can you describe the ideal candidate for GI focused behavioral therapy? Any predictors of positive response?

Riehl: Gastroenterologists are encouraged to refer patients with moderate to severe IBS to a GI psychologist early in treatment planning and present the referral as an opportunity for collaboration. Patients who have insight into the role of stress on their symptoms and are interested in learning adaptive coping strategies are ideal. Predictors have been difficult to ascertain, but this is an area of focus in my current clinical research.

PAGE BREAK

Healio: Can you describe the type of IBS patient who is not appropriate for referral for GI focused behavioral therapy? Any predictors of a poor response?

Riehl: Patients with untreated psychopathology (eg, suicidal ideation, severe depression or anxiety, personality disorder, substance abuse, disordered eating) are not ideal candidates for brain-gut therapies. It is recommended that patients achieve stable mood by working with a general mental health professional before consultation with a GI psychologist.

Healio: What is a typical course of therapy in your practice?

Riehl: Treatment is short-term, typically 5 to 7 sessions.

Healio: How do you decide when treatment has been completed? How do you decide to stop therapy?

Riehl: Patients may complete the 7 sessions of the gut-directed hypnotherapy protocol or provide feedback pertaining to achieving a desirable symptom and quality of life improvement, which is reason to complete treatment. Patients may return for additional sessions in the future as needed.

Healio: How would you choose between CBT and hypnosis?

Riehl: Patients are referred for an initial consultation to assess whether they are an appropriate candidate for brain-gut therapies and then to discuss treatment planning. Patients that recognize that stress impacts their symptoms and have interest in learning coping strategies to better manage physiological arousal and visceral hypervigilance are candidates for gut-directed hypnotherapy. If a patient has difficulty with negative thoughts and maladaptive coping skills to manage the complexities of their bowel symptoms, CBT may be implemented into the treatment plan. CBT teaches patients to observe their negative thought patterns and challenge those thoughts with cognitive restructuring. Avoidance behaviors, safety behaviors and inflexible coping are also targeted in CBT.

Healio: Are your services reimbursed?

Riehl: Services are reimbursed using insurance. I bill with health and behavior codes that use the patient’s medical diagnosis.

Healio: What about internet or booked based therapy? Does it work as well as face to face therapy? If not internet or book-based therapy, how about telemedicine?

Riehl: For patients with IBS who may be symptomatic, the ability to engage in treatment using the internet or a book-based therapy from the comfort of their own home can certainly be beneficial and preferred by some. Research evaluating short-term internet-based CBT is emerging. Preliminary and anecdotal results look favorable, but more research is needed in this area. In my clinical opinion, the use of telemedicine should be personalized, and a combination of in-clinic and telemedicine sessions will likely be effective. Additional work is needed at this time to address reimbursement and insurance coverage.

PAGE BREAK

Healio: Any insights from DDW on this topic that you would care to discuss?

Riehl: The Rome Foundation introduced psychogastroenterology in a meeting at DDW 2018 that highlighted the evolution and current state of this working group. At present, there are about 140 members on 6 continents and this is the first dedicated organization for psychosocial aspects of gastrointestinal treatment and research. The meeting discussed important redefinitions of certain language such as “disorders of gut-brain interactions instead of “functional gastrointestinal disorders (FGIDs)” and “central neuromodulators” instead of antidepressants. This subspecialty will aid in the development of clinical core competencies for mental health professionals who want to participate in the care of GI patients. This will allow for our field to grow, allowing better access to care for patients in need.

Disclosure: Riehl reports no relevant financial disclosures.