Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients

a multicentre randomised controlled trial

Peter Tyrer, Sylvia Cooper, Paul Salkovskis, Helen Tyrer, Michael Crawford, Sarah Byford, Simon Dupont, Sarah Finnis, John Green, Elenor McLaren, David Murphy, Steven Reid, Georgina Smith, Duolao Wang, Hilary Warwick, Hristina Petkova, Barbara Barrett

Research output: Contribution to journalArticle

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Abstract

Background

Health anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics.

Methods

We undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16–75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten sessions of adapted cognitive behaviour therapy (CBT-HA group) delivered by hospital-based therapists or to standard care in the clinics. The primary outcome was change in health anxiety symptoms measured by the Health Anxiety Inventory at 1 year and the main secondary hypothesis was equivalence of total health and social care costs over 2 years, with an equivalence margin of £150. Analysis was by intention to treat. The study is registered with controlled-trials.com, ISRCTN14565822.

Findings

Of 28 991 patients screened, 444 were randomly assigned to receive either adapted cognitive behaviour therapy (CBT-HA group, 219 participants) or standard care (standard care group, 225), with 205 participants in the CBT-HA group and 212 in the standard care group included in the analyses of the primary endpoints. At 1 year, improvement in health anxiety in the patients in the CBT-HA group was 2·98 points greater than in those in the standard care group (95% CI 1·64–4·33, p<0·0001), and twice as many patients receiving cognitive behaviour therapy achieved normal levels of health anxiety compared with those in the control group (13·9% vs 7·3%; odds ratio 2·15, 95% CI 1·09–4·23, p=0·0273). Similar differences were observed at 6 months and 2 years, and there were concomitant reductions in generalised anxiety and, to a lesser extent, depression. Of nine deaths, six were in the control group; all were due to pre-existing illness. Social functioning or health-related quality of life did not differ significantly between groups. Equivalence in total 2-year costs was not achieved, but the difference was not significant (adjusted mean difference £156, 95% CI −1446 to 1758, p=0·848).

Interpretation

This form of adapted cognitive behaviour therapy for health anxiety led to sustained symptomatic benefit over 2 years, with no significant effect on total costs. It deserves wider application in medical care.

Original languageEnglish
Pages (from-to)219-225
Number of pages7
JournalLancet
Volume383
Issue number9913
Early online date18 Oct 2013
DOIs
Publication statusPublished - 18 Jan 2014

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Cognitive Therapy
Cost-Benefit Analysis
Anxiety
Randomized Controlled Trials
Health
Color
Costs and Cost Analysis
Secondary Care
Pulmonary Medicine
Control Groups
Preexisting Condition Coverage
Intention to Treat Analysis
Standard of Care
Health Care Costs
Health Status
Multicenter Studies
Odds Ratio
Quality of Life
Depression
Pathology

Cite this

Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients : a multicentre randomised controlled trial. / Tyrer, Peter; Cooper, Sylvia; Salkovskis, Paul; Tyrer, Helen; Crawford, Michael; Byford, Sarah; Dupont, Simon; Finnis, Sarah; Green, John; McLaren, Elenor; Murphy, David; Reid, Steven; Smith, Georgina; Wang, Duolao; Warwick, Hilary; Petkova, Hristina; Barrett, Barbara.

In: Lancet, Vol. 383, No. 9913, 18.01.2014, p. 219-225.

Research output: Contribution to journalArticle

Tyrer, P, Cooper, S, Salkovskis, P, Tyrer, H, Crawford, M, Byford, S, Dupont, S, Finnis, S, Green, J, McLaren, E, Murphy, D, Reid, S, Smith, G, Wang, D, Warwick, H, Petkova, H & Barrett, B 2014, 'Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial', Lancet, vol. 383, no. 9913, pp. 219-225. https://doi.org/10.1016/S0140-6736(13)61905-4
Tyrer, Peter ; Cooper, Sylvia ; Salkovskis, Paul ; Tyrer, Helen ; Crawford, Michael ; Byford, Sarah ; Dupont, Simon ; Finnis, Sarah ; Green, John ; McLaren, Elenor ; Murphy, David ; Reid, Steven ; Smith, Georgina ; Wang, Duolao ; Warwick, Hilary ; Petkova, Hristina ; Barrett, Barbara. / Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients : a multicentre randomised controlled trial. In: Lancet. 2014 ; Vol. 383, No. 9913. pp. 219-225.
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T1 - Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients

T2 - a multicentre randomised controlled trial

AU - Tyrer, Peter

AU - Cooper, Sylvia

AU - Salkovskis, Paul

AU - Tyrer, Helen

AU - Crawford, Michael

AU - Byford, Sarah

AU - Dupont, Simon

AU - Finnis, Sarah

AU - Green, John

AU - McLaren, Elenor

AU - Murphy, David

AU - Reid, Steven

AU - Smith, Georgina

AU - Wang, Duolao

AU - Warwick, Hilary

AU - Petkova, Hristina

AU - Barrett, Barbara

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N2 - BackgroundHealth anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics.MethodsWe undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16–75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten sessions of adapted cognitive behaviour therapy (CBT-HA group) delivered by hospital-based therapists or to standard care in the clinics. The primary outcome was change in health anxiety symptoms measured by the Health Anxiety Inventory at 1 year and the main secondary hypothesis was equivalence of total health and social care costs over 2 years, with an equivalence margin of £150. Analysis was by intention to treat. The study is registered with controlled-trials.com, ISRCTN14565822.FindingsOf 28 991 patients screened, 444 were randomly assigned to receive either adapted cognitive behaviour therapy (CBT-HA group, 219 participants) or standard care (standard care group, 225), with 205 participants in the CBT-HA group and 212 in the standard care group included in the analyses of the primary endpoints. At 1 year, improvement in health anxiety in the patients in the CBT-HA group was 2·98 points greater than in those in the standard care group (95% CI 1·64–4·33, p<0·0001), and twice as many patients receiving cognitive behaviour therapy achieved normal levels of health anxiety compared with those in the control group (13·9% vs 7·3%; odds ratio 2·15, 95% CI 1·09–4·23, p=0·0273). Similar differences were observed at 6 months and 2 years, and there were concomitant reductions in generalised anxiety and, to a lesser extent, depression. Of nine deaths, six were in the control group; all were due to pre-existing illness. Social functioning or health-related quality of life did not differ significantly between groups. Equivalence in total 2-year costs was not achieved, but the difference was not significant (adjusted mean difference £156, 95% CI −1446 to 1758, p=0·848).InterpretationThis form of adapted cognitive behaviour therapy for health anxiety led to sustained symptomatic benefit over 2 years, with no significant effect on total costs. It deserves wider application in medical care.

AB - BackgroundHealth anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics.MethodsWe undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16–75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten sessions of adapted cognitive behaviour therapy (CBT-HA group) delivered by hospital-based therapists or to standard care in the clinics. The primary outcome was change in health anxiety symptoms measured by the Health Anxiety Inventory at 1 year and the main secondary hypothesis was equivalence of total health and social care costs over 2 years, with an equivalence margin of £150. Analysis was by intention to treat. The study is registered with controlled-trials.com, ISRCTN14565822.FindingsOf 28 991 patients screened, 444 were randomly assigned to receive either adapted cognitive behaviour therapy (CBT-HA group, 219 participants) or standard care (standard care group, 225), with 205 participants in the CBT-HA group and 212 in the standard care group included in the analyses of the primary endpoints. At 1 year, improvement in health anxiety in the patients in the CBT-HA group was 2·98 points greater than in those in the standard care group (95% CI 1·64–4·33, p<0·0001), and twice as many patients receiving cognitive behaviour therapy achieved normal levels of health anxiety compared with those in the control group (13·9% vs 7·3%; odds ratio 2·15, 95% CI 1·09–4·23, p=0·0273). Similar differences were observed at 6 months and 2 years, and there were concomitant reductions in generalised anxiety and, to a lesser extent, depression. Of nine deaths, six were in the control group; all were due to pre-existing illness. Social functioning or health-related quality of life did not differ significantly between groups. Equivalence in total 2-year costs was not achieved, but the difference was not significant (adjusted mean difference £156, 95% CI −1446 to 1758, p=0·848).InterpretationThis form of adapted cognitive behaviour therapy for health anxiety led to sustained symptomatic benefit over 2 years, with no significant effect on total costs. It deserves wider application in medical care.

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