September 27, 2022
10 min read
Basnayake C, et al. Lancet Gastroenterol Hepatol. 2020;doi:10.1016/S2468-1253(20)30215-6.
Keefer L, et al. Gastroenterology. 2018;doi:10.1053/j.gastro.2018.01.045.
Craven reports no relevant financial disclosures. Lupe reports serving on the board of advisers for Agora Health. Riehl reports serving as the director of behavioral health for GI OnDEMAND. Taft reports ownership of Oak Park Behavioral Medicine LLC, consulting for Takeda and serving on the board of advisers for Agora Health.
As research evolves on the pivotal role the brain-gut connection plays in digestive diseases, so too has knowledge of how best to treat patients.
While the exact pathogenesis of many digestive diseases remains largely unknown, scientific evidence points to disturbances in gut, brain and nervous system interaction that may cause changes to normal gastrointestinal tract function, producing symptoms that range from mildly inconvenient to severely debilitating. The traditional focus of abnormalities in motility and visceral sensation has shifted to include psychosocial distress as one of the most important triggers of worsening symptoms.
“The brain-gut axis is a bidirectional communication pathway, meaning the brain and the gut are in constant communication through nerves and chemical signals, including those from the microbiome,” Meredith R. Craven, PhD, MPH, clinical assistant professor and director of GI health psychology at Stanford Medicine, told Healio Gastroenterology. “When brain-gut communication becomes dysregulated, the brain has a difficult time dampening down signals from the gut, so normal gut functioning may be experienced as intense or painful. At the same time, the brain may also send inappropriate messages to the gut which can change intestinal functioning.
“Because of the brain-gut axis, cognitive, affective and behavioral processes can perpetuate and maintain bothersome GI symptoms,” she continued. “Our emotions and thoughts can worsen gut symptoms, and our gut symptoms can inflame our emotions and thoughts.”
According to the 2018 clinical practice update on incorporating gastrointestinal psychology – also known as gastropsychology – into management of digestive disorders, brain-gut psychotherapies like cognitive-behavior therapy and gut-directed hypnotherapy have the capacity to reduce health care utilization and symptom burden. As such, the authors recommended that gastroenterologists routinely assess a patient’s health-related quality of life, refer them to a health psychologist or medical social worker, and keep an ongoing, open line of communication regarding the importance of behavioral modification on symptom relief.
“Health psychology is the study of the interplay of psychological, biological, social and cultural factors affecting physical health and illness,” Emily Edlynn, PhD, licensed clinical psychologist at Oak Park Behavioral Medicine in Illinois, previously told Healio Gastroenterology. “An important way to distinguish health psychology from clinical psychology is that health psychologists are not primarily treating psychiatric disorders and mental illness.
“Although those of us who identify as GI psychologists often find ourselves explaining what that means to our colleagues, it is exactly what it sounds like: We are psychologists specializing in working with people who have GI conditions. We alternate between the academic descriptors ‘psychogastroenterology’ and ‘gastropsych,’ representing the natural marriage of the worlds of psychology and gastroenterology.”
To better understand GI psychology, Healio Gastroenterology spoke with experts about its place in a patient’s care plan, how to implement it into practice and how emerging digital therapeutics could help provide a stopgap for at-risk patients already on the waitlist for mental health services.
Although psychological, behavioral and dietary therapies are often effective in an integrated approach, they have not routinely been provided to patients with functional GI disorders.
Megan E. Riehl
“Research has shown the benefits of tailoring a patient’s treatment team to include a GI psychologist, registered GI dietitian, pelvic floor therapist and more,” Megan E. Riehl, PsyD, a GI psychologist and clinical assistant professor at the University of Michigan, wrote in an installment of Healio’s gastropsychology blog. “A multidisciplinary, integrative team adds value to the patient experience and improves outcomes. While the field and patients are eager to incorporate behavioral therapy into their treatment plan, access to this type of integrative care is still quite difficult in many parts of the world.”
The MANTRA study, an open-label, single-center trial, found that an integrative care model of GI dietitians, gut-focused hypnotherapists, psychiatrists and behavioral physiotherapists improved symptom severity, psychological state and quality of life among 188 patients with functional GI disorders compared with standard care alone (84% responders vs. 57% responders; P = .001). Among patients with IBS and functional dyspepsia, integrated care correlated with a greater reduction in IBS symptom severity score (50-point reduction: 66% vs. 38%; P = .017) and Nepean Dyspepsia Index (46% vs. 11%; P = 0.47), as well as a lower cost per successful outcome.
When implementing behavioral support in this type of care model, experts cite two distinct approaches: fully/co-located integrated care or complete referral.
“At Cleveland Clinic, we developed a fully integrated clinic model where I am right in the hallway with the physician — if you came in to see a physician, you may also end up seeing a psychologist and a dietitian as part of your visit,” Stephen Lupe, PsyD, director of behavioral medicine at Cleveland Clinic, said. “Then, we all come together and determine what we need to do to provide this person with the best chance of improving GI functioning. In my opinion, that is the most comprehensive way to do it. But a ‘medical home’ is not available everywhere.”
A variation of the fully integrated care model is the co-located model, in which all members of a care team have access to the same medical records, but rather than each member seeing the patient during one visit, provider sessions are scheduled separately to maximize one-on-one attention.
The second approach to integrating gastropsychology into multidisciplinary care is the complete referral model, in which a hospital or practice establishes a relationship with an outside provider. Most often this occurs when an organization either cannot afford to keep an expert on site or there is not one available.
“The reality is there are not enough mental health clinicians trained in GI psych,” Tiffany H. Taft, PsyD, research associate professor of medicine and psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine, said. “There are entire states in the U.S. that might only have two experts listed.”
She added, “With COVID-19, the one silver lining was telemedicine and the rapid expansion of access. The problem is, we were all overbooked before COVID — now it’s even worse.”
Specifics of Patient Care
The overarching goal of care is to help patients understand their body’s response to chronic digestive disease and encourage them to thrive. However, although many conditions are lifelong, intensive behavioral therapy does not necessarily need to be.
“Therapy is typically short-term, goal-oriented, skills-based and focused on the impact the digestive symptoms are having on the person’s life and well-being,” Craven said. “We use evidence-based, brain-gut behavior therapies, such as cognitive-behavior therapy or gut-directed hypnotherapy. These therapies can improve symptoms, decrease health care utilization, and improve coping, resilience and well-being.
“Even better, brain-gut behavior therapies are durable, with patients experiencing long-term benefits even after completing therapy.”
Because each patient’s disease course is different, treatment plans should be as well. While prescribed sessions usually range from six to eight, Lupe advised providers to “adjust as needed.”
“Someone may get scheduled for seven visits with me right off the bat, where we work on using different therapeutic methods and on various lifelong coping skills,” he said. “A lot of times at that point, patients begin to feel much better and more confident continuing on their own. I can sit back and continue my involvement from the background and, if something comes up, jump back in and help support them.”
On the opposite end of the spectrum, when access is limited and providers have waitlisted patients, emerging technological tools like digital therapeutics, or app-based care, may assist patients with important skills in the interim.
“Our future is focused on access and individualization of care,” Craven said. “We are seeing a swell of digital tools like online programs and mobile apps that provide evidence-based programs or tools for tracking symptoms. I think the digital space, including digitally-connected devices that can provide biofeedback style interventions, are exciting.”
Lupe noted that these digital aids could help alleviate pressures on patients who are waiting to see an appropriate mental health provider. “What I’m trying to implement right now is app-based care for the patients who are on the waitlist,” he said. “There are several kinds of apps out there that are developing in this space that may be useful to teach patients skills during the waitlist period to help patients while they are waiting for us.”
Riehl noted that available digital therapeutic resources are an “ever-evolving, non-exhaustive list,” with several notable programs that deliver behavioral treatment and symptom tracking including Nerva, Zemedy, Mahana IBS, Regulora, Dieta, mySymptoms and Cara Care.
“The value of gastropsych is it simultaneously helps patients to live better lives and relieves the stress physicians face when trying to do it all,” Taft said. “When it comes to social-emotional quality of life, every patient is affected in some way when living with a chronic digestive condition. By aiding patients with their behavioral care, we are not just helping the patient but are also taking pressure off the team. Let us do that for you and help people live better lives, despite these chronic conditions that are not going to go away.”
Put Gastropsychology Into Practice
Before adding a gastropsychology expert into an organization or setting up a line of referral, health care providers should check the Rome Foundation directory for a GI psychologist or medical social worker in their state or region. In areas where that is not an option, telehealth opportunities may be available through the Psychology Interjurisdictional Compact (PSYPACT), an interstate agreement that allows psychologists registered in one state to see a patient who resides in another state.
Physicians should read experts’ profiles, reach out for vetting and build personal relationships. Taft recommends asking about their training, background and areas of expertise. Additionally, having a few backups, including GI psychologists, medical social workers or general mental health providers, is helpful for finding a patient’s perfect fit.
“In an ideal world, providers would hire a full-time gastropsychologist who would be co-located with the gastroenterologists. However, this is not always possible,” Craven said. “Other good options include hiring a part-time GI health psychologist, creating referral pathways with community mental health providers or providing trainings for clinicians already in your practice.”
Become a Licensed GI Psychologist
As mentioned, one of the greatest barriers facing GI psychology today is lack of access and available experts.
“Graduate students in clinical psychology programs generally don’t know about GI psychology as an area in which they can be trained,” Taft said. “We are trying to push that out through various awareness strategies, but it’s been really slow. Unfortunately, in 17 years, having only 500 people globally is not good.”
For those interested in pursuing education to become a gastropsychologist, experts advise obtaining a doctorate in clinical or counseling psychology and specializing in health psychology or behavioral medicine that meets the American Psychological Association criteria. Opportunities exist for those interested in pursuing a master’s degree in medical social work, and internships or continuing education courses in brain-gut behavior therapy are also available.
Similarly, for established psychologists and licensed clinical social workers with a newfound interest in GI psychology, specialized training and CME opportunities can be found through organizations such as the Rome Foundation.
Barriers to Integrated Behavioral Care
Aside from access and availability, another barrier to both integrated care and its implementation in practice is the stigma surrounding mental health. The longstanding assumption from patients is that referral to a mental health provider means their symptoms are not real, but rather something they have imagined. It is important to emphasize the brain-gut connection early so patients do not view behavioral support as a last resort or think of their symptoms as merely psychologically based.
When caring for a patient concerned that their symptoms are not entirely physical, and therefore somehow less legitimate, Taft recommended spinning the notion of “it’s all in your head” to give it a new meaning.
“Technically this is true, because your brain is your body’s control system and it’s controlling your digestive tract,” she said. “In theory, what we feel in our bodies is in our head but not in the sense that illness or symptoms aren’t there or aren’t real. Rather, much of our current medical technology is not advanced enough to visualize what is going on at the neurological level of the gut.”
Encouraging a patient to buy-in to gastropsychology begins with the gastroenterologist speaking confidently about the brain-gut axis and how treatments can be integrated into an overall care plan. Craven recommended providers ask early and often about stress, symptom-specific anxiety and the impact a patient’s symptoms have on their quality of life.
The Future of Gastropsychology Care
While the ideal future for GI psychology features improved access to one-on-one care, the emergence of digital therapeutics offers a bevy of behavioral resources patients can use in the comfort of their homes. The digital therapeutic space is an ever-evolving market in which one size does not fit all – but it does give providers a wider array of therapy options to match individual patient needs.
“Just as important as it is to understand which patients should be prioritized to a GI psychologist or to a general mental health provider, it’s helpful to understand which patients may benefit from utilizing some of the digital therapeutics available,” Riehl said.
Riehl explained that patients with more severe psychiatric symptoms and those who need more comprehensive mental health treatment should be prioritized to a general mental health practitioner. Patients benefit most from brain-gut behavior therapies when their mental health comorbidities have already been addressed or treated before working with a specialized GI psychologist.
“It is difficult for patients to engage in brain-gut behavior therapies if they have significant depression, anxiety or trauma,” Craven noted. “We can also work with patients who are already engaged in therapy to address their general mental health and can even collaborate with their community therapist.”
For patients with milder symptoms and an interest in self-guided care, an evidence-based program delivered via telemedicine may be a good fit.
Riehl suggested providers scan the market often, read literature on study outcomes and use them in practice to determine patient experience. Understanding how patients feel and how digital therapy may fit into their treatment plan are key factors for a successful outcome.
“As we create innovative solutions to improve access to GI behavioral health resources and interventions, we must be open to discussing how they fit into patients’ treatment plans and follow up on their user experience,” Riehl said. “Exciting research in the delivery of treatment for a variety of GI conditions is needed and will certainly improve the lives of people interested in these invaluable services.”
- Basnayake C, et al. Lancet Gastroenterol Hepatol. 2020;doi:10.1016/S2468-1253(20)30215-6.
- Keefer L, et al. Gastroenterology. 2018;doi:10.1053/j.gastro.2018.01.045.