Nancy A. Melville

April 09, 2013

LA JOLLA, California — Internet-based cognitive-behavioral therapy (ICBT) is effective and more accessible than face-to-face CBT in patients suffering from hypochondriasis, new research suggests.

In a randomized, controlled trial, investigators at the Karolinska University Hospital Huddinge, in Stockholm, Sweden, found that ICBT was an effective and cost-effective treatment that can produce "large and enduring effects" in this patient population.

With severe health anxiety affecting about 2% to 4% of the population, the findings offer encouraging evidence of a potentially effective alternative treatment, said lead author Erik Hedman, PhD.

"The implications are that this new form of treatment can be just as effective as face-to-face CBT and that it could be used to dramatically increase accessibility to effective psychological treatment for the many persons suffering from severe health anxiety," Dr. Hedman told Medscape Medical News.

The findings were presented here at the Anxiety and Depression Association of America (ADAA) 33rd Annual Conference.

Large, Superior Benefit

One important drawback of traditional CBT is the simple matter of accessibility.

"Cognitive-behavior therapy has been shown to be effective when conducted face to face, but there is still a low accessibility to the treatment for several reasons, such as a lack of therapists with proper training," said Dr. Hedman.

"We thought that Internet-delivered CBT could be a way to increase accessibility with maintained large treatment effects," he added.

For the study, 81 patients with severe health anxiety were randomly assigned to a group who received an Internet-based CBT program (n = 40) or to a wait-listed group who only had access to an online discussion forum (n = 41).

The Internet program, based on CBT principles, consisted of 10 modules, or chapters, delivered during a 12-week period. Patients were provided with specific assignments in the program, and they then reported back to their online therapist via email.

The therapist provided written feedback, also via email, representing generally about 10 minutes of therapist time weekly per patient.

"Patients are exposed to the same interventions as in face-to-face CBT, but they learn about it through extensive self-help texts," Dr. Hedman said.

The results showed that patients receiving the Internet-based CBT showed "large and superior" benefits over the control participants in measures of health anxiety (between-group Cohen's d range = 1.52 - 1.62).

Furthermore, the main incremental cost-effectiveness ratio, calculated using bootstrap sampling, was -£1244, demonstrating "the societal economic gain for each additional case of remission when administering Internet-based CBT."

Providing Perspective

Although 10 minutes of therapist time per week may sound scant, the patient's treatment in the program is much more extensive, Dr. Hedman said.

"It is important to underscore that while the therapist spends 10 minutes weekly, the patient usually puts much more time into the treatment, often at least 1 hour per day. Internet-based CBT is in fact just as demanding, if not more, as conventional CBT," he added.

A typical assignment in the program would be to refrain from immediately calling a general practitioner when detecting a new bodily sensation that triggers illness thoughts, or to refrain from performing an Internet search of one's symptoms, he said.

For some patients with health anxiety, treatment can come down to being educated on some basic concepts of their condition, and it makes sense that those concepts might be effectively communicated through a program such as Dr. Hedman's, said New York–based clinical psychologist Martin Seif, MD.

"A large component of any treatment with CBT is psychoeducation, and there are several different psychoeducational components that can do well over the Web," he told Medscape Medical News.

"A patient, for instance, has some symptom and thinks, 'Oh my God, this is cancer,' and they feel they need to be reassured and can in fact become what we sometimes call 'reassurance junkies' — they feel the need to go to the doctor, or they repeatedly go online," he explained.

"But if just 15 or 20 minutes in CBT can be spent explaining that cycle — even if it's not in person — and how the attempt to reassure themselves in fact may be increasing their suffering, people can get some perspective of what's going on."

Not for Everybody

Researchers at the University of Regina, in Saskatchewan, Canada, have been working on a similar program exploring the effectiveness of Internet-based CBT programs for the treatment of patients with depression and anxiety disorders in Saskatchewan.

The program, called the Online Therapy Unit for Service, Education, and Research (, implements online therapy approaches initially developed at Swinburne University and MacQuarie University in Australia. It currently has 4 sections: the Wellbeing Course; Maternal Depression Online; GAD for Older Adults; and Wellbeing After Cancer.

According to researcher Nicole Alberts, who is involved in the program and who works with patients with health anxiety, among other conditions, the program has so far been shown to benefit many patients. However, she notes that there are some caveats.

"I think that ICBT can be a very useful mode of treatment for many patients," she told Medscape Medical News.

"At the same time, it is not recommended for all patients. Particularly if patients have severe depression and/or elevated suicide risk, then in-person services are often recommended. Also, if patients are experiencing several comorbid conditions, then in-person may sometimes be a better fit," she said.

For others, however, the Internet is proving to be a valuable tool for delivering effective treatment to patients, she added.

"I think, and I believe many would agree, that ICBT for health anxiety, other anxiety disorders, and depression is a convenient, cost-effective, and acceptable form of treatment that is very beneficial," Alberts said.

"Based on the research we have so far, the effectiveness also appears similar to in-person treatment for many of these conditions."

Dr. Hedman, Dr. Seif, and Ms. Alberts report no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) 33rd Annual Conference. Abstract 451R. Presented April 5, 2013.


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