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Including exposure therapy during internet-based cognitive behavioral therapy (ICBT) was associated with reduced treatment costs in irritable bowel syndrome (IBS), a Swedish randomized trial found.

While use of ICBT with exposure initially increased direct patient costs by 20% ($213.50 per participant) versus ICBT without exposure, the added therapy led to greater reductions in societal costs over 6 months ($2,020.10 vs $602.60, respectively), reported Hugo Wallen, a PhD student from the Karolinska Institutet in Stockholm, and colleagues.

At 6 months after treatment, a return-on-investment analysis showed a return of $5.64 for every $1 invested in ICBT with exposure therapy, according to the findings in .

"Exposure exercises are demanding for patients, possibly making the treatment more time consuming for both patients and therapists and hence more expensive," the group wrote in their introduction. "On the other hand, a more efficacious treatment that reduces both IBS symptoms and IBS-related avoidance behavior can potentially reduce societal costs."

The therapy led to non-significant increases in time spent on ICBT for both patients (36.1 vs 29.9 hours) and therapists (1.6 vs 1.4 hours) alike.

ICBT with exposure led to a 12.97-point reduction in Gastrointestinal Symptom Rating Scale (GSRS)-IBS score, as compared to a 9.09-point reduction in the group that did not receive exposure therapy. According to a relative incremental cost effectiveness ratio, each 1-point reduction on GSRS-IBS score was associated with societal savings of approximately $301.69.

Significant clinical improvement (a 30% decrease or more on GSRS-IBS) was seen in 66% of participants who received exposure compared to 52% of those who did not.

"The hypothesis was that exposure -- by providing patients with better strategies to handle symptoms and/or by reducing the severity of symptoms -- would reduce the need for health care and sick leave more than the same treatment without exposure and thereby make up for its potentially higher direct treatment costs," the group wrote.

In the U.S., direct IBS healthcare costs -- medical exams, medications, and other treatment options -- have been estimated to cost $2 billion per year. Adding indirect IBS costs increases that number to roughly $30 billion per year.

Based on their showing that adding exposure therapy to was effective for treating IBS, Wallen and colleagues wanted to assess the economic effects of the approach with ICBT.

"Our research group has developed a CBT protocol for IBS that is based on the role of gastrointestinal symptom-specific anxiety (GSA) in the maintenance and exacerbation of symptom severity and disability in IBS," Wallen and colleagues explained.

High GSA levels are associated with a reduced quality of life, and patients tend to avoid behaviors that would provoke symptoms, they noted. For example, a person may avoid eating a specific food due to fear of not being close to a bathroom, and become embarrassed.

Their GSA-CBT protocol combines four treatment areas: mindfulness training, systematic exposure to IBS stimuli, psychoeducation, and values-based behavioral change. The goal of systematic exposure is to reduce anxiety and IBS severity.

"The study showed that inclusion of exposure had an incremental treatment effect and that the effects of exposure were mediated through reduced GSA (i.e., avoidance behavior and symptom-worry)," the authors stated.

The current study included 309 Swedish adults with IBS who were randomized 1:1 to ICBT with or without exposure therapy. Average participant age was 42, and almost 80% were women. On average, most participants were diagnosed with IBS about 8.4 years prior to study enrollment.

Patients were included if they met the ROME III requirements for an IBS diagnosis, but excluded if they had alarming or severe psychiatric symptoms. Patients endured 10 weeks of internet-provided education and were guided to "expose themselves to IBS-related situations and stimuli that elicited fear and distress." Internet treatments ended with a text message on IBS relapse prevention by a psychologist who followed up with participants in a messaging system.

Direct and indirect costs were compared at baseline and after treatment, with the primary endpoint being costs after 6 months of ICBT. Outcomes, as measured by GSRS score, were examined before treatment, at 6 months of treatment, and after treatment.

Limitations of the study included the possibility for non-IBS-related medical costs to be included, thus overestimating costs in the analyses. Healthcare costs also vary between Sweden and the U.S., where the estimates were calculated. Furthermore, some participants did not complete treatment, and statistical modeling filled in missing data.

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