This study explored patient preferences toward the development of a psychological intervention to manage IBD fatigue. The main findings from the analysis indicate that patients with IBD preferred an online CBT intervention for as few weeks as possible. The analysis also determined that the type of intervention was the most important attribute to patients with IBD.

CBT was the most preferred intervention by respondents. It is possible that this is because CBT is so commonly used in psychotherapy [30] and more than half of our survey respondents had tried psychotherapy before, potentially making them familiar with CBT. ACT was the next preferred option demonstrating that respondents tended to select ACT when CBT was not offered. In contrast, participants demonstrated a significant negative preference for SFT and mindfulness meaning they were rarely chosen if either CBT or ACT was offered. It is unclear why respondents never seemed to preference mindfulness or SFT. When considering SFT, it is possible that respondents were unfamiliar with the description and therefore were more positively biased toward CBT. However, mindfulness is a type of psychological therapy that is increasing in its popularity for outcomes such as sleep and anxiety [31, 32]. As the description of mindfulness presented to the participants included ‘while acknowledging and accepting one’s thoughts, feelings and bodily sensations’, it is possible that this was unappealing to people with IBD as their condition can produce unpleasant sensations such as pain and urgency that respondents were not interested in focusing on [33]. However, a recent RCT of mindfulness in patients with Crohn’s disease reported a reduction in fatigue scores [18] making it worthwhile to explore why it was so unpopular in our sample and to develop strategies to promote it. Further, recent evidence has supported the use of yoga for people with IBD, which encompasses similarities to mindfulness through its use of breathing exercises and focus on posture. As evidence has demonstrated yoga has promising effects on improving QoL [34], exploring yoga as an alternative to mindfulness may offer insight into patient preferences in regard to psychological and mind–body interventions.

In regard to the modality of intervention, participants were most interested in participating in online interventions and rejected both the options of face-to-face and blended intervention designs in comparison to an online design. A RCT evaluating the use of online CBT for patients with IBD found that online CBT may be helpful for QoL but not in patients with depressive symptoms and it was prone to attrition [35]. However another RCT comparing face-to-face CBT with online CBT in IBD found no difference between the types of delivery. In this later RCT study, it was also noted that patients with greater need (such as those with fatigue) may respond more favorably to CBT [20]. While this evidence collectively does not directly demonstrate how beneficial online CBT in patients with IBD, it does indicate some promise for patients who would really benefit from an online intervention such as those with fatigue. Interestingly, these findings were collected at the beginning of the first global lockdown during the COVID-19 pandemic. It is unknown how the stay-at-home order may have influenced patient preference to online services. Regardless, it is worthwhile exploring how online psychological interventions may benefit patients with IBD fatigue levels.

Rather than comparing the duration of intervention dichotomously, duration was treated continuously in analysis. Findings indicate that when presented with each fixed-pair scenario, patients always preferred the shorter intervention regardless of the combination of durations presented. While informative, this may pose a challenge for clinicians in the development of an intervention as a meta-regression found a small significant association between number of psychotherapy sessions and efficacy [21] whereby the effect size was predicted to increase by a very small amount with each additional session. However, interestingly when examining the association between number of weeks of the intervention and effect size, longer duration resulted in a small decrease in effect size, potentially indicating that longer intervention duration can lower patient adherence. The authors also performed a sensitivity analysis using CBT only, and the negative significant relationship between number of weeks and efficacy remained [21]. Therefore, it may be that future interventions should aim for brief forms of psychotherapy with multiple sessions a week.

When weighting each of the attributes for relative importance, participants rated the type of intervention as the most important, followed by modality. In contrast, duration was awarded very little importance by participants, indicating that they are willing to be flexible when it comes to the duration of intervention but less so on the type and how it is delivered. Due to the amount of importance attributed to type of intervention, it may worth exploring why respondents preferenced CBT so strongly in comparison to the other descriptions.

The type of psychological intervention that people with IBD seem to preference most for managing their fatigue is a short online CBT intervention. A benefit of CBT is that it demonstrates efficacy in improving outcomes (such as depressive symptoms and quality of life) in a short number of weeks [21]. However, as only one eight-week CBT intervention has been trialled for IBD fatigue to date [11], it is unclear what minimum number of weeks is required to see a benefit in IBD fatigue. Additionally, the use of online CBT interventions in IBD is becoming more popular, with recent studies investigating its feasibility in improving pain in IBD [36]. This may be a beneficial avenue of further exploration given the strength of patient preference.

A limitation of the present study is the convenience sampling used which relied on a self-reported IBD diagnosis, with no objective measure to indicate disease activity. As such, it is unclear how present disease status may have impacted intervention preference. In line with this, there was no measure of sleep, which may have also contributed to the respondents’ present fatigue status. Further, there is a gender bias in our sampling as predominately females responded to the survey. As females are more likely to engage in psychotherapy than male patients [37], we are missing a significant proportion of the IBD population in this sample. Consequently, we cannot be certain of the preferences of males with IBD or explore how to increase their engagement in a psychological intervention for IBD fatigue. There is also likely a bias in the recruitment of this study as half of those who responded were already familiar with and therefore likely open to the use psychotherapy. Further, while the descriptions of each of the psychotherapies were approved by the registered psychologists on the research team, it is possible that the descriptions were written in a way to bias a preference toward CBT as most desirable because the description was familiar to the respondent. As a result, respondents may not have the familiarity to understand what the other interventions entail. As we did not ascertain what previous experience respondents had with psychotherapy, we are unsure how this may bias our results. As the description of each form of psychotherapy was kept brief and limited to the lay-person description, it is unclear whether respondents understood what sort of features are encompassed within each form of psychotherapy therefore we have no way to ascertain if these features influenced preference. Future studies should explore what feature of psychotherapy are most desirable to those with IBD to influence future intervention development. We also failed to ascertain potential preferences for group therapy versus individual therapy, as group therapies are effective in improving patient coping and adaptation while increasing social support and social integration in chronic illness populations [38].

It is also important to note that preference for a type of psychological intervention does not mean that intervention will be effective. The most important limitation of the study is that the conjoint analysis is run on combinations of attributes that we decided (based on experience and knowledge of past research). It cannot generalize to other treatment types that were not considered and therefore means a different pattern of response may emerge if different attributes were selected. Building on this, this study was also unable to run sub-analyses on how different patient features (such as demographic factors and IBD sub-type) to determine how these factors may be drivers of preference. It is important for future studies to explore these factors specifically to better inform intervention development.

To address the limitations of the present study, a replication study should be conducted with the additional element of psychoeducation to explain what each of the different types of psychotherapies involves and to determine whether CBT is the true preference of those with IBD. Additionally, qualitative interviews with a rich sample should be conducted to better understand patient preferences and how to best develop an intervention in line with patient preferences to which a future pilot RCT can be built upon.