Modified CBT Eases Hypochondria

Megan Brooks

October 22, 2013

Hospital patients who are excessively anxious about their health may benefit from brief, modified cognitive behavioral therapy (CBT), new research suggests.

In a clinical trial, adapted CBT for health anxiety (CBT-HA) delivered by nonspecialists with minimal training proved substantially more effective than standard care at reducing symptoms of health anxiety, the researchers report.

The study was published online October 18 in the Lancet.

About 10% to 20% of hospital patients excessively worry that they have a serious, undiagnosed illness, investigators note.

"Health anxiety or hypochondria is costly for healthcare providers, and an effective treatment could potentially save money by reducing the need for unnecessary tests and emergency hospital admissions," first author and study leader Peter Tyrer, MD, from Imperial College London, in the United Kingdom, said in a statement.

"Until now, we had no evidence that health anxiety in medical settings could be successfully treated. Our results indicate that CBT-HA is relatively cheap, can be delivered by general nurses with minimal training, and could be easily rolled out in hospital settings," he added.

Durable Effect

The Cognitive Behaviour Therapy for Health Anxiety in Medical Patients (CHAMP) study is a multicenter, randomized trial of 444 adult patients who were attending cardiac, endocrinologic, gastroenterologic, neurologic, or respiratory medicine clinics in secondary care and met criteria for excessive health anxiety.

Patients were randomly allocated to CBT-HA (n = 219) or standard care (n = 225), consisting of reassurance and support in secondary and primary care. Nonspecialist hospital-based therapists completed 2 workshops on CBT-HA and were then supervised by more experienced CBT therapists beforehand. The primary analysis was based on 205 patients in the CBT-HA group and 212 in the standard care group.

At 1 year, improvement in health anxiety as measured by the Health Anxiety Inventory was 2.98 points greater in patients in the CBT-HA group than in those in the standard care group (95% confidence interval [CI], 1.64 - 4.33; P < .0001).

Twice as many patients receiving CBT-HA achieved normal levels of health anxiety at 1 year (13.9% vs 7.3%; odds ratio, 2.15; 95% CI, 1.09 - 4.23; P = .0273). The CBT-HA group also showed concomitant reductions in generalized anxiety and, to a lesser extent, depression. The researchers note that the benefits achieved with CBT-HA were sustained at 2 years.

CBT-HA did not appear to cost more than standard care, but the authors caution that full economic data were only available for 73% of the required sample, so the study might have been underpowered for the cost hypothesis.

Nonetheless, Dr. Tyrer and colleagues believe that adapted CBT for health anxiety "deserves wider application in medical care."

Not Ready for Prime Time?

The CHAMP study results are "intriguing," but translating them into services is "problematic," write Chris Williams, MD, from the University of Glasgow, and Allan House, MD, from the University of Leeds in the United Kingdom in a linked comment.

On the issue of cost, they note that the study did not account for the cost of screening patients. This combined with the absence of effect on quality of life "raises a question about cost- effectiveness," they write.

Dr. Williams and Dr. House note that another unknown is what happens to false positives and false negatives and to more severe cases (beyond the capacity of the therapists in the trial) that would be identified in a screening program in routine practice.

Health anxiety is "only one of the problems noted in medical outpatients ― depression, hazardous alcohol use, poor treatment adherence, and other forms of medically unexplained presentation all press for recognition and intervention. To develop multiple parallel services makes no sense, especially since the common emotional disorders overlap substantially," they write.

Treatment "should be available in general hospital settings, in multidisciplinary liaison psychiatry or clinical health psychology clinics that can deal with the full range of problems that present," the editorialists conclude.

The study was funded by the National Institute for Health Research Health Technology Assessment Programme. Two of the investigators developed CBT-HA, and one is the author of a book describing CBT-HA in practice. Dr. Williams is author of a range of CBT-based books and online self-help resources addressing mental and physical health issues; he is director and shareholder in Five Areas Limited, which licenses these resources. Dr. House has disclosed no relevant financial relationships.

Lancet. Published online October 18, 2013. Abstract, Comment

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