Gut-directed hypnotherapy after 65: what the evidence really says | Dr. Stephanie Moleski

In this episode of Gut-Brain Therapy, the Nerva podcast, gastroenterologist Dr. Stephanie Moleski, MD, sits down with Nerva's Chloe Millar to answer a question clinicians face constantly: when a 70-year-old asks whether gut-directed hypnotherapy will help, what does the evidence actually let us say? Gut-brain disorders like constipation, reflux-type symptoms, and functional IBD symptoms all climb with age, yet almost every trial of gut-directed hypnotherapy has been run in younger adults.

Dr. Moleski, Associate Professor of Medicine at Sidney Kimmel Medical College at Thomas Jefferson University and Medical Director of the Jefferson Celiac Center, walks through the evidence across the full range of gut-brain disorders. She is candid about where it is strong (IBS), where it is only extrapolated (functional dyspepsia, heartburn, constipation, and IBD overlap), and where the proof runs out for US Medicare-age patients. Drawing on the 2025 Anderson randomized controlled trial of Nerva in IBS and a 1,000-patient audit of gut-directed hypnotherapy spanning ages 17 to 91, she covers how to counsel patients over 65, the practical barriers for older adults (device access, hearing, digital literacy, cost, and coverage), where gut-brain programs like Nerva fit as an adjunct rather than a replacement for diet, medication, or workup, and how to set condition-specific expectations while ruling out organic disease first, especially with new symptoms after 50.

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http://www.nervahealth.com?utm_source=ig&utm_medium=other&utm_campaign=pc

Gut-Brain Therapy podcasts are adapted from Nerva webinars, sign up for our next one here:
 www.crowdcast.io/@mindset-health

Transcript

SPEAKER_00 0:00

And the age range went from 17 to 91. So this is the widest age range that we have. They found that age was not a significant predictor of response. 67% achieved greater than 30% pain reduction, and it was unaffected by IBS subtype.

SPEAKER_01 0:16

You're listening to a NERVA podcast. Clinical conversations about the science of gut brain disorders and the real people we care for every day. These podcasts are created from our free webinars, which you can sign up for at the link in our bio. This week we have some news. NERVA's gut brain therapy program is now available at no out-of-pocket cost for eligible US patients with original Medicare through the new CMS Access Model.

SPEAKER_02 0:55

I'm so pleased to be hosting today's talk, Rewiring the Gut Brain Access After 65, which is presented by Dr. Stephanie Milleschi. Dr. Milleski is a gastroenterologist and associate professor of medicine at Thomas Jefferson University in Philadelphia. At Jefferson, she serves as a medical director of the Jefferson Celiac Centre, Medical Director of the Barla Ambulatory Surgery Centre, and Associate Programme Director of the Gastroenterology Fellowship Programme, where she helps train the next generation of GI physicians. A clinician and research interests span celiac disease, women's gastrointestinal health, and the broader landscape of GI disorders. Dr. Milleski brings more than two decades of experience caring for patients and a particular understanding of how challenging functional GI conditions can be to live with. So we're delighted to have her here with us today to talk about rewiring the gut brain access after 65. So without further ado, I will hand over to Dr. Milleski for her talk.

SPEAKER_00 2:00

Thanks for having me. I'm excited to talk to you all a little bit more about rewiring the gut brain access in our patients over 65. Today I will talk more about understanding the brain-gut access and mechanisms of gut-directed hypnotherapy across different disorders of gut-brain interactions. We'll review clinical evidence for gut-directed hypnotherapy in the NERVA app in IBS, functional dyspepsia, functional heartburn, GERD overlap, functional constipation, and the IBD symptom management. I will compare NERVA and look at current guidelines, recommendations. We'll examine what is known and what's not known about gut direct and hypnotherapy, specifically in our Medicare-aged patients across each different disorder of gut brain interaction. We'll talk about practical practical barriers and strategies for offering this therapy to our older patients and how I like to counsel patients on realistic condition-specific expectations. So we know that there's a gap. The burden of gut brain disorders is large. About 43% of adults meet the criteria for at least one disorder of gut brain interaction. Less than 1% have access to GI-focused behavioral therapy. And those who do, it's over a year wait to get in with a GI psychologist. We know this is a big problem. In the U.S., the annual healthcare cost for IBS alone is over $20 billion. And of note, the ACG and the AGA are two big GI organizations. Their guidelines endorse brain gut behavioral therapies, including gut-directed hypnotherapy for IBS with a level one evidence. So what is gut-directed hypnotherapy? It's a structured mind-body intervention that uses hypnotic suggestion to modulate gut sensation, motility, and pain perception. The key components are relaxation, induction, gut-focused imagery, such as soothing the gut, the esophagus, and the colon. There's positive suggestion and reinforcement, ego strengthening techniques, and the protocols are anatomically customized. So gastroduodenal for functional dyspepsia, esophageal directed for heart burner globus sensation, and colonic for IBS or constipation. Of note, I like to tell my patients that this is not like a stage hypnosis. The patient is always fully conscious and in control. The gut brain access targets different pathways. There's central sensitization, which it reduces cortical amplification and visceral pain signals. There's visceral hypersensitivity, it raises the gut pain threshold via descending modulation. It helps with autonomic dysregulation by shifting the system the sympathetic nervous system to more sympathetic nervous system balance, thus improving motility and secretion. It helps with psychologic comorbidity, so it reduces anxiety and depression that amplify GI symptoms. And it helps dampen the cortisol-driven gut reactivity. There's a large spectrum of disorders that we can apply to with functional disease. And for gut drugged hypnotherapy, there's evidence across many of the disorders of gut brain interactions. The ones we'll cover today include some esophageal disorders such as functional heartburn, globus, functional chest pain, and dysphagia, functional dyspepsia. For the bowel, we're going to cover some IBS, all subtypes, diarrhea, constipation, or mixed, functional constipation and diarrhea, anerectal disorders, including functional constipation and fecal incontinence, and the IBD functional overlap. So what is the NERVA app and how does it work? So it's a smart-free smartphone tablet app that delivers six-week sessions, 42 sessions of gut-directed hypnotherapy that are about 15 minutes each. It's delivered daily. It's developed from Monash University, which is really well known for IBS research, and is now been positioned for the broader gut brain program. The context is informed techniques studied across other disorders of gut brain interaction. So it's daily audio sessions, about 15 minutes each for 42 days total. It has symptom tracking, so built-in IBS symptom scale monitoring, visual progress. It has flare-up tools, so condition-targeted tools when patients have more pain, reflux, or constipation. And there's a maintenance library, so patients have continued access to the program after they're done a particular session. Of note, this is not FDA cleared for as a prescription digital therapeutic. It's listed as a recommended resource in AGA and ACG affiliated publications. Let's look at some of the evidence. IBS is where the strongest data exists. So there's a great study that was published out of the American Journal of Gastroenterology in 2025. It was by Anderson and his colleagues. And this is a randomized control trial, looked at 244 adults with IBS and compared NERVA to active control, so an identical program that did not have gut directed hypnotherapy. For the NERVA group, 81% versus 63% of controls achieved greater than 50 point decrease in their IBS symptom scale. For NERVA, 71% versus 35% in controls reported a greater than 30% reduction in abdominal pain. So of note, these are all statistically significant. Also of note is that the median age was 38 years old and 90% female. So of note, there was no subgroup analysis for patients over 65. What other data do we have? Well, Barry et al. looked at a digital gut-directed hypnotherapy versus muscle relaxation. This was published in clinical gastro and hepatology, and the primary endpoint was narrowly missed, but more pain responders during treatment, 30.9% versus 20.5%. So this was supportive of class evidence, but no, and also showed that there were no serious adverse events. The Manchester audit looked at a thousand refractory IBS patients. They found that face-to-face gut-directed hypnotherapy. They looked at that, the median age was 51.6, and the age range went from 17 to 91. So this is the widest age range that we have in this category of data. They found that age was not a significant predictor of response. 67% achieved greater than 30% pain reduction, and it was unaffected by IBS subtype. Thacker et al. did a meta-analysis that was published in Lancet Gastroenterology and Hepatology in 2025. And this was clinician-administered cognitive behavioral therapy and gut-directed hypnotherapy. Found that these had the highest, strongest evidence base. They also found that digital apps noted to not be administered by a clinician were not personalized, had a potential limitation. So this is an important caveat when we're counseling our patients on what NERVA can and cannot replace as NERVA is not administered by a clinician. What about our patients over 65? So there's no NERVA-specific randomized controlled trials for our patients over 65, but face-to-face gut-dredded hypnotherapy in the Manchester Otter over over a thousand patients, which is reassuring for the modality itself. What about other functional GI disorders? So functional dyspepsia affects 7% of adults globally, and it lacks FDA-approved medication. It does share IBS's brain-gut pathophysiology with visceral hypersensitivity, altered motility, and psychologic comorbidity. And now NERVA targets functional dyspepsia. About 70% of the NERVA patients report upper symptoms. So this is great that we can target this for our patients. What's the data here? Well, the Calvert et al. published a study in 2002, found that gut-directed hypnotherapy was superior to supportive care and standard medical therapy in refractory functional dyspepsia, with a 73% response rate versus 43% for medical therapy, and the improvement was sustained at 12 months. This is the first high-quality gut-directed hypnotherapy trial in functional dyspepsia. The Metame Health Functional Dyspepsia Protocol is the first fully standardized gut-directed hypnotherapy protocol for functional dyspepsia. It's licensed for digital delivery as a prescription digital therapeutic framework. And the Loyola Medicine Pilot is self-administered audio-based gut-directed hypnotherapy and functional dyspepsia with a 96% program completion. It demonstrates fully digital clinical, clinician-independent model, the closest analog to how NERVA is used. What about functional dyspepsia in older adults? Well, the prevalence falls from ages 18 to 35, which is about 9.5%, to less to 3.9% in our patients over 65. However, a meta-analysis using broader symptom criteria found a higher prevalence in patients over 65. So the diagnostic definitions matter. I do want to note that the new onset dyspepsia in older adults requires more extensive workup, so potentially an upper endoscopy to exclude malignancy, an ulcer or H. pylori, before we settle on the diagnosis of functional dyspepsia. And while there's no specific studies looking at our patients over 65, we have the Calvert study that and the Loyola pilot and enrolled primarily middle-aged adults that we can refer to. And what does this mean for us as clinicians? Once organic disease is excluded, gut-directed hypnotherapy is a reasonable evidence-informed option, framed by extrapolated, not proven, efficacy in our older adults' patient. Another advantage is polypharmacy. Gut-directed hypnotherapy carries zero drug interaction risks, meaning this is helpful for our patients who are on multiple medications, as we see in some of our older adults. What about the functional heartburn and reflux overlap symptoms? Functional heartburn presents as typical GERD symptoms, but it doesn't have that pathologic acid exposure on pH monitoring and doesn't respond to PPI. This prevalence does rise with age, and gut-directed hypnotherapy targets the esophageal hypersensitivity-driving symptoms, but not acid itself. Here we have some evidence. Manchester Esophageal Protocol is a standardized gut-directed hypnotherapy protocol for esophageal disorders of gut-brain interaction using tactile and imagery suggestions targeting esophageal sensory and perception and motility. And the mechanism rationale is that esophageal hypersensitivity shares the same central sensitization and descending pain modulation pathway as visceral hypersensitivity and IBS. In our patients over 65, I think this is really important because you know that reflux rises with age and PPI overuse is rampant. Studies have shown that up to 70% of long-term users on PPIs have no documented indication. And many of those who are on PPIs actually may have functional heartburn or hypersensitive esophagus. There is an evidence gap here. There's no gut-directed hypnotherapy trial that has examined functional heartburn specifically over 65 years old. No Medicare coverage exists for any app-based gut-directed hypnotherapy for esophageal symptoms. So consider gut-directed hypnotherapy in our older patients who have PPI refractory reflux after we've ruled out actual PPI or erosive esophagitis, whether that's with an endoscopy or pH testing. What about functional constipation? Well, this is important for Medicare patients because constipation rises significantly with age, with up to 30 to 40% of adults over 65. This might be slow transit, it might be polypharmacy, it might be reduced mobility, dehydration, pelvic floor dysfunction. And this is the one disorder of gut-brain interaction where Medicare age actually is more affected, yet the evidence in this population is completely absent. But we however we know that gut-directed hypnotherapy targets gut brain components. It doesn't replace evaluation of slow transit constipation, pelvic fluoride synergia, and medication review. IBD symptom overlap and the aging IBD population is important. Nerva is positioned as an adjunct for those seeking support alongside IBD care. So it's not a treatment for active inflammation, but it can target the functional gut brain symptoms such as pain, urgency, and bloating that persists in many of our IBD patients, even when they're in histologic remission. Why is this important in our Medicare patients? Well, about 10 to 15% of our newly diagnosed IBD patients are over 60. And as the population ages, this is rising. Again, the elderly with IBD might have polypharmacy, they have more comorbidities, worse hospitalization outcomes. So considering gut-directed hypnotherapy makes sense for them. While there's no gut-directed hypnotherapy study examining aging IBD patients, this is a gap in our knowledge. We do have some smaller studies. There's a small randomized control study looking at single session hypnosis found to reduce inflammatory markers and active ulcerative colitis. Another study by Mouseley et al. looked at gut-directed hypnotherapy and appeared to extend remission at 12 months in quiescent ulcerative colitis. A pilot study from 2023 looked at adjunctive virtual gut-directed hypnotherapy, feasible and acceptable in Crohn's disease. So the overall base is limited to small randomized controlled trials and case series, but it's mechanistically compelling. So this is a chart sort of reviewing everything. I'll just summarize up by saying in the different disorders of gut brain interaction, we have the strongest evidence for IBS in all subtypes with a great randomized control study looking specifically at NERVA. It's strong level one evidence according to the American College of Gastroenterology with some, and it includes some Medicare data with the Manchester audit. The other disorders of gut-brain interaction do not have specific randomized controlled trials, but they do have some studies which we reviewed looking at class evidence. So we love guidelines in academic medicine, and we do have some support for NERVA in the ACG, AGA, and in the British Medical Journal. In 2021, the ACG guidelines recommend gut-directed psychotherapies, including gut-directed hypnotherapy for moderate to severe IBS. And this guidance is IBS specific with level one evidence. In the AGA best practice, this endorses gut-directed hypnotherapy as well as a well-tested brain-gut behavioral therapy for digestive orders with a strong endorsement. The British Medical Journal in 2024 identifies digital gut-directed hypnotherapy apps as a practical solution for the access gap for gut-brain behavioral therapies. So let's talk about practical implementation and access. And our patients get NERVA. So the standard price for NERVA is $199 for the year. With a clinician referral, it's $149. So we have a referral code sent to our patients via NERVA, and that gives a 25% discount off the standard price. And there's also a patient assistant program, so financial support is available for either a reduced or a waived cost for patients in financial difficulty who could not otherwise access NERVA. But of note and new in July is the United States patients age 65 plus, many of them may have access to NERVA at no out-of-pocket cost. Eligibility that's required and confirmed at sign-up, but this is really an exciting opportunity for our Medicare patients. What are some things we want to think about in our older adult patients? We know that many of our patients younger aged 18 to 24, about 34% of those are reported, recommended to NERVA by their providers, and about 4% in our patients over 65. Yet older adults who engage show greater persistence than younger users from study on SIMRC from 2024. Some barriers we want to be aware of in our older patients is the smartphone or tablet they may not be as familiar with. They might not even have one. Of course, we worry about patients might have hearing difficulty because these are audio-based sessions. They may have issues with vision or find motor impairment that can affect their navigation. We want to make sure they have access to Wi-Fi or cellular access. Some of our older adults are on a fixed income, although hopefully they'll be able to get access through Medicare. And then we worry, some patients will worry about skepticism about an app based or non pharmaceutical therapy, and there could be some polypharmacy that may affect their compliance, that may cause. Complicate their results for gut directed hypnotherapy. So when I'm thinking about the NERVA for a patient, I ask them if they have access to a device. I make sure obviously they have good hearing and visual so it's not a burden for them. My nurse or my medical assistant can help with an in-office app demonstration. Will involve family members or caregivers when that's needed. I do like to frame that this is an evidence-based gut neuroscience. It's not just alternative medicine. I'll address the cost, make sure they're aware, and also note that patients over 65 may have no out-of-pocket cost. I like to set realistic expectations. So that this is something that's done for at least six weeks every day is when you get the best results, just 15 minutes a day. And I always am using this in conjunction with other existing GI care. And this is after I've done a required workout. So looking at the big picture, the American Geriatric Society, they're advocating for continued Medicare access to telehealth and digital health, recognizing that older adults benefit from these digital digital tools. I also um the digital divide in older adults is interesting and important to note. Willingness to use health apps decreases with age, but with structured onboarding caregiver involvement and clinician endorsement, patients can do quite well. So good candidates for NERVA are patients who are confirmed to have disorders of gut brain interaction. They might have moderate to severe symptoms after organic disease has been excluded. They have persistent functional GI symptoms. They are have an interest in non-pharmaceutical or adjuvant approaches. They have to have access to a smartphone or tablet, motivated to complete their six-week course. And particularly in our patients who who are recognized or we see that there's a history of anxiety or stress that's driving their GI symptoms, this can be particularly helpful. I would avoid recommending NERVA if these are new onset GI symptoms that have not yet been evaluated, particularly in our patients over 50 when we worry about things like malignancy. And we want to make sure that we've ruled out things like an ulcer, IBD, or celiac disease. We want to make sure our IBD patients are well controlled before we rely on NERVA to help with additional symptoms. The patients need their mental health needs to be in control with no active psychosis or severe psychiatric illness. If they don't have access to a device or family support, this may not be appropriate. And if there's severe hearing impairment as well, also if they're just not willing to commit to 15 minutes a day for six weeks. Some of the talking points I'll go through is validating the approach, say this isn't an alternative to medicine. This is gut-directed hypnotherapy, it has good evidence, and Nerva can help deliver it through your phone. I set expectations, saying that for IBS, about 80% of patients in the main trial improved significantly. And for dyspepsia and reflux symptoms, the evidence is an earlier stage, but the mechanism is the same. I address the costs like we talked about earlier. I explain that the patient is always in control. It's nothing like stage hypnosis. It's really more just a guided relaxation that retrains how your gut and brain communicate with each other. And then I make sure I'm following up and tracking outcomes. I try to follow up with the patient in six weeks to see how they're doing. Nerva, if if you opt in, can send you reports, which I find very helpful as a clinician. So, in summary, gut-directed hypnotherapy is level one evidence for IBS. It shows promise across all functional dyspepsia, functional heartburn, constipation, and IBD overlap, given that the fact that these share the same brain gut mechanisms. Functional dyspepsia, heartburn, and IBD evidence is real, but from the broader gut-directed hypnotherapy class, not nervous-specific randomized control trials. These I like to set condition-specific expectations. There's no FDA clearance for Medicare reimbursement pathway. In summary, the price is $199 a year with a clinician referral $149. But for our patients over 65, it may be available at no out-of-pocket costs. I want to just emphasize screening for Rome criteria with organic disease being excluded, especially any new or concerning symptoms over 50. I'd like to just review that Anderson study from 2025 that shows that 81% of NERVA users achieved clinically meaningful IBS symptom scale improvement versus 63% controls. This is a statistically significant improvement, and it was sustained at six months. So this is the strongest digital gut-directed hypnotherapy randomized trial to date. None of the trials have been looked at patients over 65, although the Manchester audit did include older patients, and that's the best proxy. And constipation, where gut-directed hypnotherapy is the thinnest, is where Medicare patients are most effective. And digital literacy, hearing, and device access is needed for individualized counseling. Thank you so much. I'll take any questions. Amazing.

SPEAKER_02 27:55

Thank you so much, Dr. Muleski. That was brilliant and just so interesting and helpful to have such a deep dive on the research and then real kind of uh helpful practical examples of how you bring this up with all the adults. Um so we do have some questions that have been submitted to us. Um so I will ask you a few of those now. Um so first question is uh a lot of older patients have been told for years that their symptoms are just stress or just aging. How do you validate them and introduce gut brain framing without landing it as another dismissal?

SPEAKER_00 28:38

So that's a really good point. And a lot of patients come to me with similar thoughts. And, you know, I really explained, I think getting an understanding of the pathophysiology of functional symptoms is really important, and discussing how there's a lot of serotonin receptors in the gut. So when we have more stress, we have more symptoms. Um, I also talk a lot about sort of the mechanisms of of relaxation and gut relaxation and how that can help um help improve symptoms. So I I acknowledge that their symptoms are real and significant, and then this is just this is a good way to help improve them.

SPEAKER_02 29:21

Brilliant, thank you. And we have one submitted can gut-directed hypnotherapy help with anxiety and depression.

SPEAKER_00 29:31

So, yes, it can help with anxiety and depression. Of course, like I mentioned in one of the slides, we want to make sure they're they're involving a mental health provider if that's deemed necessary. So the relaxation um that can be involved with the gut-directed hypnotherapy can can help with some of the anxiety and depression symptoms as well.

SPEAKER_02 29:56

Brilliant, thank you. This is quite a practical one from someone. So when one of my old when one of my older IBD patients is still getting pain and bloating, even though their disease is meant to be in remission, how do you tell whether it's a flare-up coming or coming on or more of a gut brain thing? And when is it safe to focus on diet and gut brain strategies rather than sending them back for stronger medication?

SPEAKER_00 30:25

So that's a really good question, and something we see in the clinic very frequently, you know, to especially, I think the this was in the context of inflammatory bowel disease. Um, we want to make sure that their disease is well controlled. So oftentimes we're getting a fecal calprotectin level stool study. We might be doing a colonoscopy if they have small bowel disease, checking uh an enterography, whether that's CT or MR enterography. Because we don't want to just try to ignore that they might have active disease. But once you've ruled out any active disease, if you have colonoscopy with biopsies showing mucosal healing and good imaging and good stool studies, then this is Nerva would be a good option there to help with some of their um persistent symptoms.

SPEAKER_02 31:14

Amazing, thank you. And how do I confidently diagnose a disorder of the gut-brain interaction rather than misorganic disease, malignancy, ischemia, diverticular disease, microscopic colitis, which all rise with age?

SPEAKER_00 31:32

Yeah, that's a really good question. And that is kind of like a whole month of GI in all wrapped up in one. Um, but you know, you would want to make sure you're including a gastroenterologist if if they haven't seen a gastroenterologist, because for it depends on the symptoms. If it's upper, they might need an endoscopy, they might need a pH study or a manometry. If it's lower, you know, they might need imaging or a colonoscopy. So I would say if there's any question, you know, referring to a gastroenterologist would be helpful, especially in our older adults, to make sure we're not missing any organic disease.

SPEAKER_02 32:08

Brilliant. Thank you. And then one last question. What happens to the microbiome after 65? And uh in terms of kind of reduced diversity, dysbiosis of aging, and does that alter how disorders of the gut brain interaction present or respond to treatments?

SPEAKER_00 32:28

So that's a really good question. We know that the gut microbiome is really important in much of disease, um, not just GI, but everywhere from cancers to obesity to mental health, but specifically certainly in in GI disorders. And the gut microbiome does change as we age. Um, interestingly, we don't know, we don't have any great data to know exactly how that changes. And while some of pain perception can increase as you get older, and some of it can decrease as it gets older, um, that would be a great thing to study to looking at the um gut microbiome and how that changes functional disorders. But at this point, we only have limited data on that.

SPEAKER_02 33:14

Brilliant. Well, thank you so much for this insightful talk and yeah, really detailed and helpful. And um as I mentioned at the beginning, um, and as Dr. Mileski mentioned in her talk, Nerva is now available at no cost for patients who are 65 and over in the US. All you have to do is refer them via the form or the facts, and um, they'll be sent a web assessment where uh we'll find out their eligibility there. Um, just make sure you include their date of birth in the referral. Um, so yeah, if you're interested in learning more about Nerva, feel free, feel free to book in a call with us um using the link. And thank you again, Dr. Muneschi, for such a brilliant talk. Um, it was really, really, really great. Thank you. Thanks, Chloe. Thanks for having me. It was nice chatting with you all.

SPEAKER_01 34:10

Thanks for listening to this NERVA podcast, where we explore the science behind gut brain disorders and share real clinical insights from the people we support every day. If you found this helpful, you can join our free webinars for more evidence based discussions and practical guidance. You'll find the registration link in our bio. We'll see you in the next episode.