Cognitive behavioural therapy (CBT) is substantially more effective than standard care at reducing symptoms of health anxiety in medical patients, and can be delivered by non-specialist staff with minimal training at little extra cost, according to an RCT published by The Lancet today.

The CHAMP (Cognitive behaviour therapy for Health Anxiety in Medical Patients) trial (Tyrer, 2013) is the first large scale study to test the effectiveness of CBT for health anxiety in hospital patients.  It’s a widespread problem with 10-20% of inpatients said to worry excessively that they have a serious undiagnosed illness. Finding an effective treatment could provide significant cost savings and reduce the need for unnecessary tests and emergency admissions.

A 2007 Cochrane review (Thompson, 2007) concluded that CBT was one of five psychotherapies that were effective at reducing hypochondriasis, but all of the trials included in the review were small and there were no controlled studies of long-term outcome and no studies in hospital settings.

A number of positive trials have been published in the last few years that investigate CBT for patients with health anxiety and hypochondriasis, but none looked specifically at patients in the hospital setting.

Methods

The CHAMP study randomly assigned 444 people (aged 16–75 years) with abnormal health anxiety who were being treated in six general hospitals in the UK. Patients came from cardiac, endocrine, gastroenterological, neurological and respiratory medicine clinics in secondary care.

Participants received one of two treatments:

1. CBT-HA: 5–10 sessions of a modified cognitive behavioural treatment for health anxiety (219 participants)
2. Standard care: consisting of reassurance and support in secondary and primary care (225 participants)

Patients were treated at outpatient clinics by non-CBT experts who had been trained in just two workshops and then supervised by more experienced CBT therapists.

The research team compared the differences in health anxiety, generalised anxiety, depression, social function, quality of life, and costs between the groups over 2 years.

The intention to treat analysis included 205 participants from the CBT-HA group and 212 from the standard care group in the analysis of primary end points.

Results

• 

  The CBT was delivered by general nurses with minimal training

  After 12 months, twice as many patients given CBT-HA achieved normal levels of health anxiety as those receiving usual care (13.9% vs 7.3%; odds ratio 2.15, 95% CI 1.09 to 4.23 p=0.0273)

• CBT-HA also significantly improved generalised anxiety and depression compared with standard treatment
• These improvements were sustained at 2 years, with no significant differences in cost
• Nine people died during the trial (6 in the standard care group and all due to pre-existing illness)

Conclusions

The authors concluded:

Before this study we had no evidence that health anxiety in medical settings could be successfully treated. Our findings demonstrate that CBT-HA is relatively cheap with an average of 6 sessions of treatment, and is effective in reducing health anxiety both in the short-term and up to two years after treatment, and also reduces generalised anxiety and depression. As health professionals with no previous training in this treatment have been shown in this study to be successful practitioners, this treatment could be generalised easily to hospital settings.

Lead author Professor Peter Tyrer said:

Until now, we had no evidence that health anxiety in medically 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.

Some interesting comments were added by Chris Williams (University of Glasgow) and Allan House (University of Leeds):

Translation of these findings into services is problematic…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…treatment should be available in general hospital settings, in multi-disciplinary liaison psychiatry or clinical health psychology clinics that can deal with the full range of problems that present.

Links

Tyrer, P. et al Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. The Lancet Published online October 18, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61905-4 [Abstract]

Thomson A, Page L. Psychotherapies for hypochondriasis. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006520. DOI: 10.1002/14651858.CD006520.pub2.

Brunet, M. Hypochondria: a word desperately in need of a makeover. The Mental Elf, 14 Apr 2013.

Zucchelli, F. Mindfulness shows promise as treatment for health anxiety. The Mental Elf, 14 Mar 2013.