Journal of Psychosomatic Research 64 (2008) 613 620

The relationship between somatisation and outcome in patients

with severe irritable bowel syndrome,
Francis Creed a,,1 , Barbara Tomenson a,1 , Elspeth Guthrie a,1 , Joy Ratcliffe a ,
Lakshmi Fernandes c,1 , Nicholas Read c,1 , Steve Palmer d , David G. Thompson b,1
a

Division of Psychiatry, University of Manchester

Section of Gastrointestinal Science, University of Manchester
c
Centre for Human Nutrition, Northern General Hospital, University of Sheffield
d
Centre for Health Economics, University of York
b

Received 5 September 2007; received in revised form 18 February 2008; accepted 18 February 2008

Abstract
Objective: This study aimed to assess the relationship between
somatisation and outcome in patients with severe irritable bowel
syndrome (IBS). Method: Two hundred fifty-seven patients with
severe IBS included in a randomised controlled trial were assessed
at baseline and divided into four quartiles on the basis of their
somatisation score. The patients were randomised to receive the
following over 3 months: brief interpersonal psychotherapy, 20 mg
daily of the SSRI antidepressant paroxetine, or treatment as usual.
Outcome 1 year after treatment was assessed using the Short Form36 physical component summary (PCS) score and total costs for
posttreatment year. Results: The patients in the quartile with the
highest baseline somatisation score had the most severe IBS, the
most concurrent psychiatric disorders, and the highest total costs
for the year prior to baseline. At 1 year after the end of treatment,

however, the patients with marked somatisation, who received

psychotherapy or antidepressant, had improved health status
compared to those who received usual care: mean (S.E.) PCS
scores at 15 months were 36.6 (2.2), 35.5 (1.9), and 26.4 (2.7) for
psychotherapy, antidepressant, and treatment-as-usual groups,
respectively (adjusted P=.014). Corresponding data for total costs
over the year following the trial, adjusted for baseline costs, were
1092 (487), 1394 (443), and 2949 (593) (adjusted P=.050).
Conclusions: Patients with severe IBS who have marked
somatisation improve with treatment like other IBS patients and
show a greater reduction of costs. Antidepressants and psychotherapy are cost-effective treatments in severe IBS accompanied by
marked somatisation.
2008 Elsevier Inc. All rights reserved.

Keywords: Irritable bowel syndrome; Outcome; Health-related quality of life; Somatisation; Antidepressants; Psychotherapy

Disclosure: F. Creed has consultancy links with Lilly. He has received

payment for sitting on an advisory panel. All other authors declare that they
have no competing interests.

Grant support: Medical Research Council (MRC) Grant No.

G9413613 and UK North West Regional Health Authority Research and
Development Directorate.
Corresponding author. Psychiatry Research Group, Medical School,
University of Manchester, Rawnsley Building, Oxford Road, M13 9WL
Manchester, UK. Tel.: +44 0161 276 5331/5395; fax: +44 0161 273 2135.
1
On behalf of the North of England IBS Research Group: Chris Babbs,
Joe Barlow, Chandu Bardhan, Francis Creed, David Dawson, Lakshmi
Fernandes, Elspeth Guthrie, Stephanie Howlett, Linda McGowan, Jane
Martin, Jim Moorey, Kierran Moriarty, Stephen Palmer, Joy Ratcliffe,
Nicholas Read, Christine Rigby, Irene Sadowski, David Thompson, and
Barbara Tomenson.
E-mail address: francis.creed@manchester.ac.uk (F. Creed).
0022-3999/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2008.02.016

Introduction
Irritable bowel syndrome (IBS) is a common disorder,
which forms the major reason for referral to gastroenterology clinics and often leads to impaired health-related
quality of life and high health care and societal costs [1,2].
Depressive and anxiety disorders commonly coexist with
IBS [2,3] and a history of sexual abuse is common [2];
these all contribute to poor outcomes [2,46]. In addition,
some IBS patients report numerous bodily symptoms,
known either as somatisation or as extraintestinal IBS
symptoms [3]. Nearly half of IBS patients attending a
tertiary referral clinic have somatisation disorder or border

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F. Creed et al. / Journal of Psychosomatic Research 64 (2008) 613620

on this diagnosis [7,8]. Such somatisation is associated

with other psychiatric disorders (e.g., anxiety and depressive disorders), marked impairment of functioning, and
high health care use [7,911].
Psychological treatment and antidepressants have been
used to treat IBS [1218], and when patients improve, there
may be a reduction in somatisation score [1923], especially
if there is a history of sexual abuse [4], but no previous study
has examined how IBS patients with somatisation respond to
treatment with psychotherapy or antidepressants.
In a recent randomised controlled trial, we found that both
psychodynamic interpersonal therapy and an SSRI antidepressant led to improved health status in patients who had
severe IBS [24]. This improvement was not obviously
related to concurrent anxiety or depressive disorder but was
related to somatisation score [25]. In view of this finding, we
report here a further analysis of our trial data to examine
whether patients with a high baseline somatisation score
improved in health status and total costs following treatment.
We tested the hypothesis that patients with a high
somatisation score would show less improvement in health
status than those with low somatisation scores when treated
with psychotherapy or an SSRI antidepressant. Since we did
not measure somatisation disorder, we divided our sample of
IBS patients into groups according to baseline SCL-90
somatisation score, as others have done previously [9,26],
and compared these groups in terms of other baseline
variables and response to treatment. In order to specify the
importance of somatisation, we controlled for the effect of
depression, anxiety, and sexual abuse history.
Method
Participants were recruited from patients attending seven
gastroenterology clinics in UK. All clinic patients who
fulfilled Rome I criteria for IBS [27] and whose symptoms
had not responded to usual medical treatment were invited
to join the trial. This involved random allocation to eight
sessions of individual psychotherapy, 3 months of treatment
with 20 mg daily of the SSRI antidepressant paroxetine, or
routine care by a gastroenterologist and a general practitioner
[24]. Patients were excluded if they had a psychotic disorder,
a severe personality disorder, or an active suicidal ideation or
if they had consumed more than 50 units of alcohol per
week, but patients with other psychiatric disorders were
included. Patients were recruited by gastroenterologists and
first assessed by researchers in the gastroenterology clinic.
Assessments reported here were made at baseline (entry
to the trial) and 12 months after treatment was completed
(i.e., 15 months after baseline). Full details of the trial have
been reported previously, including the CONSORT details,
and will not be repeated here [24].
The following self-administered questionnaires were
completed by each patient at baseline and at 15 months
follow-up. Severity of current abdominal pain was assessed
using a visual analogue scale (VAS) taken from the McGill

Pain Questionnaire [28]. Somatisation was measured using

the SCL-90 questionnaire, and the somatisation subscale was
used in this study [29]. A history of sexual abuse was
documented using the Drossman questionnaire [30]. In this
report, sexual abuse refers to being forced to have sexual
contact against one's will either as a child or as an adult.
Health status was measured using the Short Form-36 (SF-36)
[31], which corresponds closely to patients' rating of the
degree to which it disrupts their daily lives [32,33]. We used
the physical component summary (PCS) score as the main
outcome variable [34]. This is a composite score of the
following scales: physical function, role limitation physical,
bodily pain, and health perception; a low score indicates poor
health status.
A trained psychiatrist who worked independent of
treating clinicians and was blind to treatment group
assessed severity of depressive symptoms using the
Hamilton Rating Scale for Depression [35]. This psychiatrist also assessed psychiatric diagnosis at baseline only
using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) [36].
Total costs were calculated using the following: (a) Direct
health care costs derived by applying an appropriate unit cost
to each recorded contact or episode of care. These contacts
were taken directly from the patient's hospital and primary
care notes because all patients received professional health
care solely from the U.K. National Health Service [24]. This
included inpatient days, all other hospital attendances, all
primary care contacts, domiciliary care services, and
prescribed medications plus alternative therapies. (b) Direct
non-health care costs, namely, travel and additional patient
expenditure as a result of the illness including nonprescription medication. (c) Productivity costs measured by applying
the patient's wage rate to the number of days lost due to
either illness or clinic attendance. Data are presented for two
time periods: 12 months prior to baseline and 12 months after
the end of treatment.
The trial was designed with abdominal pain, SF-36
physical component scores (health status), and costs as
primary outcome variables as they measure different
domains [24]. The trial was powered (85 patients in each
group) on improvement in abdominal pain found in our
previous trial [37]. There was no prior power calculation for
the present study. Ethics committee approval was obtained
from each hospital taking part in the study, and all
participants signed written informed consent after full
explanation prior to entering the study.
Data analysis
All data were entered and analysed on SPSS, version
13.5. We divided the sample into four quartiles on the
basis of baseline somatisation score and compared these
in terms of sociodemographic variables and other baseline
variables using chi-square or one-way analysis of
variance tests for linear trend. We then compared the

F. Creed et al. / Journal of Psychosomatic Research 64 (2008) 613620

outcome scores by treatment group (psychotherapy,

antidepressant, and treatment as usual) for each quartile
to assess whether the beneficial effect of treatment
recorded for the whole trial was found in one quartile
or more. This was an intention-to-treat analysis and
included all patients, whether or not they had adhered to
the treatment to which they had been allocated. Analysis
of SF-36 physical component score at 15 months followup (i.e., 1 year after the end of treatment) used ANCOVA
with the following as covariates: age, sex, baseline
physical component score, years of education, Hamilton
depression score, panic and generalised anxiety disorders,
and abuse history. The analysis of costs used total costs
for the year following treatment as the outcome with the
same list of covariates except for the fact that total costs
for the year prior to trial baseline was used instead of
baseline PCS score.

615

Results
Two hundred fifty-seven participants (81% of eligible
patients) were recruited to the study. The 60 patients who
declined to enter the study were similar in baseline characteristics to the participants. The IBS was chronic (median duration,
8 years) and severe (mean typical pain score was 67.4 out of
100). Seventy (27%) participants were unemployed as a result of
illness, and 121 (47%) had a psychiatric disorder, principally
depressive disorder (29%), panic disorder (12%), generalised
anxiety disorder (14%), and neurasthenia (35%) [6]. Of the 257
patients, follow-up data 1 year after treatment were available for
225 patients (87.5%) and data on total costs were available for
249 patients (97%). The patients for whom there were no
follow-up data on SF-36 PCS were significantly younger than
the remainder but not significantly different in terms of sex,
SF-36 PCS score, and SCL-90 somatisation score.

Table 1
Comparison of the four quartiles according to baseline somatisation scores (1 being the lowest and 4 being the highest)
Quartile according to somatisation score a
1 (00.5),
n=57
Demographic data
Female
Marital status
Single
Married/Cohabiting
Separated/
Divorced/Widowed
White Caucasian
12 years of
education (or more)
Unemployed due
to ill-health
Sexual abuse
None
Forced touching
Rape
SCAN diagnosis
Depression
Panic disorder
Hypochondriasis
Neurasthenia
Generalised
anxiety disorder
Rome diagnosis
General
Diarrhea
Constipation

2 (0.510.99),
n=69

3 (1.01.49),
n=60

4 (1.54.0),
n=65

P value
b

43

75

62

90

48

80

47

72

1.0

8
40
9

14
70
16

18
40
11

26
58
16

13
41
6

22
68
10

11
42
12

17
65
18

5.1

.53

55
39

96
68

67
40

97
58

60
35

100
58

65
23

100
35

3.5 b
12.3 b

.061
b.001

13

23

10

14

11

18

34

52

14.8 b

b.001

48
5
4

84
9
7

53
7
9

77
10
13

47
7
6

78
12
10

44
9
12

68
14
18

4.0 b

.045

9
1
3
16
5

16
2
5
28
9

13
5
5
17
8

19
7
7
25
12

20
5
2
21
11

33
8
3
21
18

32
18
11
34
11

49
28
17
52
17

20.0 b
19.3 b
4.1 b
9.9 b
2.4

b.001
b.001
.042
.002
.12

20
21
16

35
37
28

40
16
12

58
25
17

32
12
16

53
20
27

30
22
13

46
34
20

9.8

.13

.32

Continuous variables at baseline

Mean

S.E.

Mean

S.E.

Mean

S.E.

Mean

S.E.

P value

Age (years)
Mean total costs
(UK ) for 1 year
prior to baseline

38.3
1027

1.6
164

39.1
1168

1.5
166

39.6
976

1.6
109

42.6
2058

1.3
329

.048
.001

a
b

Six subjects do not belong to any of the four somatisation groups because they did not complete the SCL-90 at baseline.
2 test for linear trend across the four somatisation groups.

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F. Creed et al. / Journal of Psychosomatic Research 64 (2008) 613620

In the 3-month treatment period, 59 of 85 (69%) patients

randomised to psychotherapy completed all eight sessions
whereas 43 of 86 (50%) patients randomised to paroxetine
completed the 12-week course (P=.013). At follow-up (15
months after baseline), there was no difference between
the three random allocation groups on abdominal pain
severity, but SF-36 physical component score had
improved for both psychotherapy and paroxetine groups
compared to the treatment-as-usual group, and this was
achieved at no additional cost [24]. The higher costs for 3
months of psychotherapy and paroxetine were offset by
lower costs in the subsequent year; hence, the mean health
care costs for the whole period from baseline to 1 year
after the end of treatment, adjusted for baseline costs, were
683 (S.E.=144), 789 (S.E.=138), and 970 (S.E.=141)
for psychotherapy, antidepressants, and treatment as usual,
respectively (P=.36) [24].
Baseline data four quartiles according to somatisation
Somatisation data were available at baseline for 251
patients; the mean SCL-90 somatisation score was 1.12
(S.D.=0.76, range=03.9). The 251 patients were divided
into four quartiles according to baseline SCL-90 somatisation scores: 00.5 (n=57), 0.510.99 (n=69), 1.01.49
(n=60), and 1.54.0 (n=65). The mean (S.D.) number of
somatic symptoms endorsed as moderately bothersome or
worse on the SCL-90 questionnaire (maximum of 12) was
0.7 (0.7), 2.4 (1.0), 4.1 (1.0), and 8.0 (2.2) for the four
quartiles, respectively. The most common symptoms were
the following: headaches, faintness or dizziness, pain in
lower back, soreness of muscles, trouble getting one's
breath, hot or cold spells, numbness or tingling in certain
parts of the body, feeling weak in certain parts of the body,
and heavy feeling in arms or legs.
The sociodemographic characteristics of the four quartiles
are shown in Table 1. The patients from the quartile with the
highest somatisation score were older, were more likely to be
unemployed due to ill-health, and had received fewer years
of education than the other groups. These patients with high
somatisation scores also had more marked IBS symptoms
(abdominal pain and severity score on a daily diary)
(Table 2), but there was no difference according to Rome
diagnosis. All psychiatric diagnoses, except generalised

Fig. 1. SF-36 PCS scores at 1 year after the end of treatment, by treatment
group for the four quartiles according to baseline somatisation score, are
shown. Follow-up PCS score was adjusted for age, sex, years of education,
depression, panic and generalised anxiety disorders, abuse history, and
baseline SF-36 physical component score.

anxiety disorder, were more common in the quartile with the

highest somatisation scores (Table 1).
The quartile with the highest somatisation score also had
the lowest SF-36 physical component scores, indicating
greatest impairment of health status (Table 2). The total costs
for 1 year before baseline were greatest in this quartile with a
high somatisation score (Table 1, bottom row).
Outcome at follow-up 1 year after the end of treatment by
somatisation quartile
There was no difference between the four somatisation
quartiles in the proportion who adhered to the course of
treatment to which they were randomised: 82.5%, 81.2%,
76.7%, and 73.8% of each quartile received four or more
sessions of psychotherapy or 6 weeks of antidepressant
treatment. At follow-up, 1 year after the end of treatment, the
mean SF-36 physical component scores (adjusted for
baseline score) were no longer significantly different across
the four somatisation quartiles. This occurred because the
SF-36 physical component score in the quartiles with a high
somatisation score had improved by 7 points (from 31.1 to
38.1, Table 2 bottom row). Abdominal pain scores and
symptom diary scores were also not significantly different
between the four quartiles at follow-up as the patients in the
quartile with the highest somatisation score had improved

Table 2
Scores for IBS symptoms, depression, and SF-36 (health status) at baseline and at follow-up 1 year after the end of treatment (in italics)
Baseline and follow-up values

Mean

S.E.

Mean

S.E.

Mean

S.E.

Mean

S.E.

VAS score for abdominal pain (maximum, 100)

VAS score for abdominal pain at 1 year follow-up
IBS symptom severity (composite diary score)
IBS symptom severity at 1 year follow-up
Hamilton Rating Scale of Depression score
Hamilton Rating Scale of Depression score at 1 year follow-up
SF-36 physical component score
SF-36 physical component score at 1 year follow-up

26.1
30.2
1.47
1.35
7.8
7.3
42.4
41.7

3.2
3.9
0.09
0.1
0.8
0.8
1.3
1.5

31.7
27.1
1.51
1.38
10.0
6.8
40.2
42.3

2.9
3.3
0.08
0.1
0.6
0.7
1.2
1.2

34.9
32.8
1.66
1.44
12.2
6.5
37.4
40.9

3.1
3.6
0.08
0.1
0.7
0.8
1.4
1.3

47.8
33.3
2.07
1.58
15.1
11.9
31.1
38.1

3.0
3.6
0.08
0.1
0.8
0.8
1.1
1.3

b.001
.58
b.001
.36
b.001
b.001
b.001
.13

F. Creed et al. / Journal of Psychosomatic Research 64 (2008) 613620

617

Table 3
Change in SF-36 physical component score (mean and S.E.) by treatment group according to somatisation quartile (1 being the lowest and 4 being the highest)
1 (00.5), n=39

2 (0.510.99), n=58

3 (1.01.49), n=46

4 (1.54.0), n=49

Somatisation group

Mean

S.E.

Mean

S.E.

Mean

S.E.

Mean

S.E.

Psychotherapy
Antidepressants
Treatment as usual
P value for comparison between treatment groups

3.8 (n=12)
3.3 (n=10)
2.4 (n=17)
.89

2.4
2.6
2.0

6.7 (n=20)
5.2 (n=20)
1.7 (n=18)
.14

1.7
1.7
1.8

3.7 (n=11)
6.7 (n=20)
0.79 (n=15)
.12

2.9
2.2
2.6

6.9 (n=16)
4.4 (n=22)
5.0 (n=11)
.009

2.2
1.9
2.8

Scores were adjusted for age, sex, years of education, depression, panic and generalised anxiety disorders, abuse history, and baseline PCS score.

considerably (Table 2). Depression scores had dropped but

were still significantly different across the groups.
Outcome by treatment group and by somatisation quartile
Health status
The differences according to treatment group are shown
in Fig. 1. In the quartile with the highest baseline
somatisation score, the psychotherapy and antidepressant
groups had higher (i.e., less impaired) SF-36 physical
component scores at follow-up than the treatment-as-usual
group (right-hand columns in Fig. 1). The change in SF-36
physical component score between baseline and 15 months
follow-up is shown in Table 3. It can be seen that the
improvement after treatment in the quartile with the highest
somatisation score is comparable with the other quartiles, but
in this quartile, the significant difference between treatment
groups is explained by the worsening of the treatment-asusual group.
Costs
The total costs for the year after treatment ended are
shown in Fig. 2. A difference between treatment groups is
apparent only in the quartile with the highest somatisation
score. In this quartile, the mean total costs were reduced in
the posttreatment year compared to the year before baseline
for the psychotherapy and antidepressant groups but
remained high in the treatment-as-usual group. Total costs
over the year following the end of treatment, adjusted for
baseline costs, were 1092 (487), 1394 (443), and 2949
(593) for the psychotherapy, antidepressant, and treatmentas-usual groups, respectively (adjusted P=.050).

somatisation score did poorly with treatment as usual

physical component scores deteriorated by a clinically
significant amount (5 points) in this group, and the total
costs incurred in this group remained very high. By contrast,
the patients with a high somatisation score who received
psychotherapy or paroxetine showed an improvement in
their physical component score by a clinically significant
amount and a reduction in total costs of ca. 50% compared to
pretrial levels. We had not expected this result as patients
with marked somatisation are generally considered to be the
least likely to improve.
In this study, we did not assess somatisation disorder
as such. It is notable, however, that the quartiles with a
low somatisation score reported only a few bodily
symptoms, indicating that these patients did not have
somatisation disorder, which is defined by multiple bodily
symptoms. By contrast, the quartile with the highest
somatisation score reported a mean of eight different
bothersome bodily symptoms, which is compatible with
the previous result that 25% of tertiary clinic IBS patients
had somatisation disorder. Patients from this top quartile
were more likely than those from the other quartiles to
have other psychiatric disorders (depressive disorder,
panic disorder, and neurasthenia) and to incur high health
care and total costs and were more impaired in line with
the previous findings.

Discussion
The main new finding in this study is the fact that our
hypothesis was not confirmed; patients with a high
somatisation score responded to psychotherapy or antidepressant treatment like other patients who had a lower
somatisation score. In fact, it was only in the quartile with the
highest somatisation score that the improvement in SF-36
physical component score was significantly different, with
greater improvement in the psychotherapy and paroxetine
groups than in the treatment-as-usual group. This result
could be explained by the fact that patients with a high

Fig. 2. Total costs for 1 year (geometric means) after treatment ended, by
treatment group for the four quartiles according to baseline somatisation
score, are shown. Total costs were adjusted for age, sex, years of education,
depression, panic and generalised anxiety disorders, abuse history, and
baseline costs (12 months before baseline).

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F. Creed et al. / Journal of Psychosomatic Research 64 (2008) 613620

Like Kroenke et al. [26], we found that dividing our

sample into four groups according to somatisation score
shows a doseresponse relationship with health status,
which was markedly impaired in our quartile with the
highest somatisation score [nearly two standard deviations
below the population norm (of 50, S.D.=10)]. The pattern
of costs differed from the dose response reported by
Spiegel et al. [9], which can be explained by the fact that
our inclusion criteria meant that all our participants had
rather high costs whereas Spiegel's sample included many
with very low costs. The high costs in our sample contrast
with the low costs for IBS patients in primary care [38]. It
is likely that patients with IBS and a high somatisation
score are mostly seen in secondary care clinics, and this
may be why psychological treatments for IBS have been
found to be more effective in secondary care than primary
care it is only in the more severe IBS that a significant
difference can be found between treated and comparison
groups [39]. In general medical patients, Barsky et al. [11]
found that health care costs were almost doubled in the
patients who had high somatisation scores compared to the
remainder even after adjusting for the effect of other
psychiatric diagnoses.
Since we adjusted for depression, anxiety, and panic
disorder, the effect we have observed can be attributed to
somatisation, not to other psychiatric disorders. Only one
previous study has adjusted for other psychiatric disorders
and found that in functional gastrointestinal disorders in a
population-based sample, SCL-90 somatisation score was
the sole predictor of health-related quality of life in a
multivariate analysis [40]. Two clinic studies found similar
results [41,42], although one referred to extraintestinal
symptoms of IBS, which also refers to number of bodily
symptoms [3]. This strong association between somatisation
and health status raises the possibility that the negative
outcomes associated with IBS (impaired health status and
high costs) are attributable to the minority of IBS patients
who show somatisation.
One other study has shown reduction of health care costs
when somatisation disorder is successfully treated with
psychological treatment [23]. It was limited to patients who
would attend a psychiatric clinic for stress management,
which is unlikely to be representative of patients with
marked somatisation. The reduction of health care costs in
that study might have been due, in part, to the letter sent to
the patients' primary care physician recommending limited
investigations. Our trial did not include any such recommendation; thus, the reduced costs presumably relate to the
patients feeling better (Table 2).
Ours was a pragmatic trial, not an explanatory one;
hence, we do not have data to explain the mechanisms
underlying the improvements in health-related quality of
life and reduced costs in the quartile with a high
somatisation score. We did find a reduction of IBS
symptoms and abdominal pain, but the reduction of
depression was less marked, which is compatible with the

findings in systematic reviews that improvement in

symptoms appears to be independent of change in mood
[12,14,19]. A reduction of somatisation score has been
reported to occur with treatment of IBS by hypnotherapy,
where it was accompanied by reduction of anxiety rather
than depression [20].
There are a number of limitations of this study. It is
based on a secondary analysis of data collected in a trial,
which was not designed specifically for this purpose, and
numbers in the main analysis are small. This was a
pragmatic trial designed to assess cost-effectiveness of
psychotherapy and an SSRI antidepressant compared to
usual treatment and did not, therefore, include a placebo
group. We did not measure coping or other measures that
might have helped explain how our active treatments acted
independent of depression and pain. Our sample included
only patients with severe IBS; hence, our results may not
be generalisable to a wider group of patients with IBS. On
the other hand, we were able to recruit a very high
proportion of eligible patients; thus, our sample would be
representative of severe IBS, which has not responded to
usual treatment; less severe IBS probably includes fewer
patients with marked somatisation. Furthermore, the
numerous assessments in our study meant that we could
adjust for numerous confounders, especially other psychiatric disorders and abuse history.
The main clinical implication of this study is the
importance of enabling patients with IBS and a high
somatisation score to reach antidepressant or psychological
treatment. Left untreated, such patients do poorly their
quality of life deteriorates and they continue to incur high
health care costs. This study has reinforced the finding of the
main trial that such treatment for these patients is costeffective [24]. The outstanding research tasks are to identify
the exact mechanisms through which these treatments work
and try and identify a somatisation score that most closely
defines patients who have poor outcome if left untreated and
would benefit from treatment this is the theoretical basis
of a somatisation disorder [43,44].
Acknowledgments
The research team is thankful to the following: the MRC
for financing the study, the Health Authorities for financing
the psychotherapists, the patients who consented to take
part in the trial, and the doctors who prescribed the
antidepressant medication.
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