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We are grateful for the opportunity to comment on the two items of correspondence. Our article presents the administrative incidence, prevalence and comorbidities, and care and cost of irritable bowel syndrome (IBS) in the billing data from the German Barmer health insurance (Barmer Ersatzkasse, 1). We agree with Dr. Spangenberg that food intolerances in many patients contribute to symptoms of IBS. In the general population and in clinical trials, up to 50% of IBS patients report food intolerances (2). We discuss several possible reasons why the prevalence of cases coded for food intolerances (e.g. lactose intolerance in 8% of IBS cases) was lower than that expected from epidemiological studies; these reasons include not having ICD-10 codes for some food intolerances as well as a lack of testing or coding for food intolerances by the practitioner (1).

Colonization of the colon with anaerobes is not an ICD-10 diagnosis and therefore could not be recorded in the billing data. A recent systematic review found a large heterogeneity of studies comparing the gut microbiota of IBS patients with healthy controls. A higher concentration of anaerobes in the stool of IBS patients was not found (3). As far as we know, no guideline for IBS recommends healing IBS with clindamycin, which Dr. Neussel describes as being able to “do wonders.” A controlled trial of clindamycin for IBS was not found in PubMed.

Both correspondences comment critically on the possible role of psychological factors and psychotherapy in IBS. There is a high degree of interindividual variability in the importance of mental factors in the development and course of IBS (2)—as with food intolerances. Our observational study confirms the high rate of association of IBS with anxiety and depressive disorders (2).

In the four quarters prior to as well as the quarter in which IBS was diagnosed, 58% of persons with IBS had received psychotherapy services according to the current German guidelines. Additionally, 26% received outpatient psychiatry or specialist psychosomatic treatment. Billing data from health insurance carriers cannot make any statement as to whether the psychiatric–psychotherapeutic services were “inappropriate and meaningless”—as claimed by Dr. Neussel. In contrast to the therapy recommended by Dr. Neussel with clindamycin, the efficacy and safety of various psychotherapeutic procedures, such as gut-directed hypnosis and cognitive behavioral therapy, are well documented for IBS (4). The German S3 guideline on IBS recommends performing psychological diagnostics to detect psychosocial stress and/or mental comorbidity. Psychotherapeutic procedures should be based on the manifestation of the mental symptom burden (with psychosomatic primary care from a practitioner or gastroenterologist for mild cases, and specialist psychotherapy in severe cases) and be integrated into a comprehensive medical approach that also includes nutritional advice and symptom-related drug therapy.

DOI: 10.3238/arztebl.2019.0755c

On behalf of the authors
Prof. Dr. med. Winfried Häuser
Klinik für Innere Medizin I, Klinikum Saarbrücken, Klinik für Psychosomatische Medizin und Psychotherapie, Technical University of Munich, Germany
whaeuser@klinikum-saarbruecken.de

Prof. Dr. med. Peter Layer
Israelitisches Krankenhaus, Hamburg, Germany

Conflict of interest statement
Prof. Häuser has received author royalties for a CD with medical hypnosis for persons with IBS from Hypnos Verlag.

Prof. Layer has received consultant honoraria from Allergan.

1.
Häuser W, Marschall U, Layer P, Grobe T: The prevalence, comorbidity, management and costs of irritable bowel syndrome—an observational study using routine health insurance data. Dtsch Arztebl Int 2019; 116: 463–70 VOLLTEXT
2.
Andresen V, Keller J, Pehl C, Schemann M, Preiss J, Layer P: Irritable bowel syndrome–the main recommendations. Dtsch Arztebl Int 2011;108:751–60 CrossRef MEDLINE PubMed Central
3.
Maharshak N, Ringel Y, Katibian D, et al.: Fecal and mucosa-associated intestinal microbiota in patients with diarrhea-predominant irritable bowel syndrome. Dig Dis Sci 2018; 63: 1890–9 CrossRef MEDLINE
4.
Ford AC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P: Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol 2019; 114: 21–39 CrossRefMEDLINE
1.Häuser W, Marschall U, Layer P, Grobe T: The prevalence, comorbidity, management and costs of irritable bowel syndrome—an observational study using routine health insurance data. Dtsch Arztebl Int 2019; 116: 463–70 VOLLTEXT
2.Andresen V, Keller J, Pehl C, Schemann M, Preiss J, Layer P: Irritable bowel syndrome–the main recommendations. Dtsch Arztebl Int 2011;108:751–60 CrossRef MEDLINE PubMed Central
3.Maharshak N, Ringel Y, Katibian D, et al.: Fecal and mucosa-associated intestinal microbiota in patients with diarrhea-predominant irritable bowel syndrome. Dig Dis Sci 2018; 63: 1890–9 CrossRef MEDLINE
4.Ford AC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P: Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol 2019; 114: 21–39 CrossRefMEDLINE

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