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NIHR Signal Talking therapy may relieve high levels of anxiety about health conditions

Published on 24 October 2017

doi: 10.3310/signal-000495

A specific talking therapy called ‘cognitive behavioural therapy for health anxiety’ may help people who are excessively worried about their health. Health anxiety reduced by a small, but meaningful amount, among the medical outpatients who were identified and treated. 

Delivered in one-hour sessions every two weeks, therapy lasted about four months. It was provided by junior therapists and trained nurses with no previous experience of the therapy. Benefits lasted for about five years.

This UK-based NIHR trial is the largest so far to screen and treat people for health anxiety in the outpatient setting.

Therapy improved health anxiety, but quality of life benefits varied depending on the scale used to measure them. For this reason, the researchers suggest that it is too early to say if it might be cost-effective. In theory, it might help in reducing demand for outpatient services. 

Relief of the symptoms of this under-recognised condition is appealing, but less than one in ten patients took up the offer of treatment. So questions remain about how to increase participation and whether current services could ramp up to meet the need. 

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Why was this study needed?

Health anxiety is thought to be a common, but under-recognised condition. The current trial covering nearly 29,000 hospital outpatients found that it affected one in five of clinic attendees. Typical symptoms include excessive worry about an existing or possible future health condition and seeking reassurance or extra tests. Anxiety about health can produce physical symptoms, which may mask the underlying psychological problem. Often there is inappropriate or excessive use of health services.

Previous trials in primary care had suggested that cognitive behavioural therapy could be helpful for relieving health anxiety, for example by explaining that fear of a disease is different to having a disease.

This was the first large trial to address the clinical and cost-effectiveness of a cognitive behavioural therapy adapted for people with health anxiety among those attending medical outpatient clinics.

What did this study do?

The NIHR-funded Cognitive-behaviour therapy for Healthy Anxiety in Medical Patients (CHAMP) randomised controlled trial involved 444 adults attending five UK hospital medical clinics. Eligible participants showed high levels of anxiety as defined by a score of 20 or more on the 14-question short form of the Health Anxiety Inventory (HAI).

Relatively inexperienced therapists, such as nurses or student psychologists, were trained to provide 5 to 10 one-hour sessions of cognitive behavioural therapy for health anxiety over 2 to 4 months. Standard care was usual primary or clinic care, but clinicians were told that patients had excessive anxiety. Anxiety levels were reassessed after one and five years. A meaningful clinical difference was two points on the HAI scale.

Fewer than 10% of eligible patients with health anxiety agreed to take part, which may limit the applicability of the findings.

What did it find?

  • One year after treatment, HAI scores were 2.97 points lower in the cognitive behavioural therapy for health anxiety (CBT-HA) group (95% confidence interval [CI] 1.57 to 4.37). Scores had reduced by an average 6.44 points for CBT recipients compared with 3.20 for the standard care group. CBT-HA gave a maximal benefit at six months (7.11 score reduction vs 2.33 with standard care), but improvements were maintained to five years (between-group difference 2.20 points, 95% 0.70 to 3.70).
  • Subgroup analysis by condition showed that CBT-HA gave significant improvements among patients seen in cardiology clinics only (between-group difference 5.21, 95% CI 2.08 to 8.34). This was followed by in order of (non-significant) effectiveness by gastroenterology, endocrinology and neurology clinics, with least benefit in respiratory patients.
  • By therapist, greatest improvement was seen when CBT-HA was provided by nurses. Odds ratios for improvement at any follow-up time compared with standard care were 3.16 for nurses (95% CI 1.97 to 5.06), 2.05 for graduate workers (95% CI 1.25 to 3.36), while the odds ratio for trainee psychologists fell short of statistical significance.
  • There were 12 deaths in each (similar sized) group.
  • Using the EQ5D scale, there was no evidence that CBT-HA was cost-effective. There was also no difference in overall cost between the two groups, as improvements in anxiety and depression scores offset the cost of providing CBT. However, there was a change in the quality of life measured using a specific health anxiety scale. This led the researchers to conclude that it is possible that the intervention could be shown to be cost-effective in the future.

What does current guidance say on this issue?

The 2016 NICE guideline on multiple health conditions doesn’t specifically address health anxiety, although it does recommend being alert for anxiety or depression that may exist alongside medical conditions.

The NICE guideline from 2011 on common mental health problems recommends cognitive behavioural therapy in the management of depression and anxiety disorders but does not cover health anxiety.

What are the implications?

This study highlights a common but largely hidden problem that is not currently addressed by healthcare services. It demonstrates that it is feasible to train health professionals to provide cognitive behavioural therapy for health anxiety in the outpatient setting and that it may help.

However, the low participation rate is a problem. People with health concerns may have objected to being assessed or treated for health anxiety. The study excluded people in receipt of mental health services, and there may be some overlap with other anxiety conditions.

CHAMP’s continuing follow-up to eight years may address the characteristics of a health anxiety service that is acceptable to patients. It may also better inform resource needs.

Citation and Funding

Tyrer P, Salkovskis P, Tyrer H, et al. Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years. Health Technol Assess. 2017;21(50):1-58.

This project was funded by the National Institute for Health Research HTA programme (project number 07/01/26).

Bibliography

NHS Choices. Health anxiety (hypochondria). London: Department of Health; 2015

NICE. Common mental health problems: identification and pathways to care. CG123. London: National Institute for Health and Care Excellence; 2011.

NICE. Multimorbidity: clinical assessment and management. NG56. London: National Institute for Health and Care Excellence; 2016.

Why was this study needed?

Health anxiety is thought to be a common, but under-recognised condition. The current trial covering nearly 29,000 hospital outpatients found that it affected one in five of clinic attendees. Typical symptoms include excessive worry about an existing or possible future health condition and seeking reassurance or extra tests. Anxiety about health can produce physical symptoms, which may mask the underlying psychological problem. Often there is inappropriate or excessive use of health services.

Previous trials in primary care had suggested that cognitive behavioural therapy could be helpful for relieving health anxiety, for example by explaining that fear of a disease is different to having a disease.

This was the first large trial to address the clinical and cost-effectiveness of a cognitive behavioural therapy adapted for people with health anxiety among those attending medical outpatient clinics.

What did this study do?

The NIHR-funded Cognitive-behaviour therapy for Healthy Anxiety in Medical Patients (CHAMP) randomised controlled trial involved 444 adults attending five UK hospital medical clinics. Eligible participants showed high levels of anxiety as defined by a score of 20 or more on the 14-question short form of the Health Anxiety Inventory (HAI).

Relatively inexperienced therapists, such as nurses or student psychologists, were trained to provide 5 to 10 one-hour sessions of cognitive behavioural therapy for health anxiety over 2 to 4 months. Standard care was usual primary or clinic care, but clinicians were told that patients had excessive anxiety. Anxiety levels were reassessed after one and five years. A meaningful clinical difference was two points on the HAI scale.

Fewer than 10% of eligible patients with health anxiety agreed to take part, which may limit the applicability of the findings.

What did it find?

  • One year after treatment, HAI scores were 2.97 points lower in the cognitive behavioural therapy for health anxiety (CBT-HA) group (95% confidence interval [CI] 1.57 to 4.37). Scores had reduced by an average 6.44 points for CBT recipients compared with 3.20 for the standard care group. CBT-HA gave a maximal benefit at six months (7.11 score reduction vs 2.33 with standard care), but improvements were maintained to five years (between-group difference 2.20 points, 95% 0.70 to 3.70).
  • Subgroup analysis by condition showed that CBT-HA gave significant improvements among patients seen in cardiology clinics only (between-group difference 5.21, 95% CI 2.08 to 8.34). This was followed by in order of (non-significant) effectiveness by gastroenterology, endocrinology and neurology clinics, with least benefit in respiratory patients.
  • By therapist, greatest improvement was seen when CBT-HA was provided by nurses. Odds ratios for improvement at any follow-up time compared with standard care were 3.16 for nurses (95% CI 1.97 to 5.06), 2.05 for graduate workers (95% CI 1.25 to 3.36), while the odds ratio for trainee psychologists fell short of statistical significance.
  • There were 12 deaths in each (similar sized) group.
  • Using the EQ5D scale, there was no evidence that CBT-HA was cost-effective. There was also no difference in overall cost between the two groups, as improvements in anxiety and depression scores offset the cost of providing CBT. However, there was a change in the quality of life measured using a specific health anxiety scale. This led the researchers to conclude that it is possible that the intervention could be shown to be cost-effective in the future.

What does current guidance say on this issue?

The 2016 NICE guideline on multiple health conditions doesn’t specifically address health anxiety, although it does recommend being alert for anxiety or depression that may exist alongside medical conditions.

The NICE guideline from 2011 on common mental health problems recommends cognitive behavioural therapy in the management of depression and anxiety disorders but does not cover health anxiety.

What are the implications?

This study highlights a common but largely hidden problem that is not currently addressed by healthcare services. It demonstrates that it is feasible to train health professionals to provide cognitive behavioural therapy for health anxiety in the outpatient setting and that it may help.

However, the low participation rate is a problem. People with health concerns may have objected to being assessed or treated for health anxiety. The study excluded people in receipt of mental health services, and there may be some overlap with other anxiety conditions.

CHAMP’s continuing follow-up to eight years may address the characteristics of a health anxiety service that is acceptable to patients. It may also better inform resource needs.

Citation and Funding

Tyrer P, Salkovskis P, Tyrer H, et al. Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years. Health Technol Assess. 2017;21(50):1-58.

This project was funded by the National Institute for Health Research HTA programme (project number 07/01/26).

Bibliography

NHS Choices. Health anxiety (hypochondria). London: Department of Health; 2015

NICE. Common mental health problems: identification and pathways to care. CG123. London: National Institute for Health and Care Excellence; 2011.

NICE. Multimorbidity: clinical assessment and management. NG56. London: National Institute for Health and Care Excellence; 2016.

Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years

Published on 7 September 2017

Tyrer P, Salkovskis P, Tyrer H, Wang D, Crawford M J, Dupont S, Cooper S, Green J, Murphy D, Smith G, Bhogal S, Nourmand S, Lazarevic V, Loebenberg G, Evered R, Kings S, McNulty A, Lisseman-Stones Y, McAllister S, Kramo K, Nagar J, Reid S, Sanatinia R, Whittamore K, Walker G, Philip A, Warwick H, Byford S & Barrett B.

Health Technology Assessment Volume 21 Issue 50 , 2017

Background Health anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care. Objective To determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive–behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medical outpatients. Design Randomised controlled trial. Setting Five general hospitals in London, Middlesex and Nottinghamshire. Participants A total of 444 patients aged 16–75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics who scored ≥ 20 points on the Health Anxiety Inventory (HAI) and satisfied diagnostic requirements for hypochondriasis. Those with current psychiatric disorders were excluded, but those with concurrent medical illnesses were not. Interventions Cognitive–behaviour therapy for health anxiety – between 4 and 10 1-hour sessions of CBT-HA from a health professional or psychologist trained in the treatment. Standard care was normal practice in primary and secondary care. Main outcome measures Primary – researchers masked to allocation assessed patients at baseline, 3, 6, 12, 24 months and 5 years. The primary outcome was change in the HAI score between baseline and 12 months. Main secondary outcomes – costs of care in the two groups after 24 and 60 months, change in health anxiety (HAI), generalised anxiety and depression [Hospital Anxiety and Depression Scale (HADS)] scores, social functioning using the Social Functioning Questionnaire and quality of life using the EuroQol-5 Dimensions (EQ-5D), at 6, 12, 24 and 60 months, and deaths over 5 years. Results Of the 28,991 patients screened over 21 months, 5769 had HAI scores of ≥ 20 points. Improvement in HAI scores at 3 months was significantly greater in the CBT-HA group (mean number of sessions = 6) than in the standard care, and this was maintained over the 5-year period (overall p < 0.0001), with no loss of efficacy between 2 and 5 years. Differences in the generalised anxiety (p = 0.0018) and depression scores (p = 0.0065) on the HADS were similar in both groups over the 5-year period. Gastroenterology and cardiology patients showed the greatest CBT gains. The outcomes for nurses were superior to those of other therapists. Deaths (n = 24) were similar in both groups; those in standard care died earlier than those in CBT-HA. Patients with mild personality disturbance and higher dependence levels had the best outcome with CBT-HA. Total costs were similar in both groups over the 5-year period (£12,590.58 for CBT-HA; £13,334.94 for standard care). CBT-HA was not cost-effective in terms of quality-adjusted life-years, as measured using the EQ-5D, but was cost-effective in terms of HAI outcomes, and offset the cost of treatment. Limitations Many eligible patients were not randomised and the population treated may not be representative. Conclusions CBT-HA is a highly effective treatment for pathological health anxiety with lasting benefit over 5 years. It also improves generalised anxiety and depressive symptoms more than standard care. The presence of personality abnormality is not a bar to successful outcome. CBT-HA may also be cost-effective, but the high costs of concurrent medical illnesses obscure potential savings. This treatment deserves further research in medical settings. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 50. See the NIHR Journals Library website for further project information.

The core components of the cognitive behavioural therapy for health anxiety intervention included the following:

  • Recognising fear of disease rather than actual disease
  • Awareness of the dangers of internet browsing
  • Avoiding reassurance
  • Negative consequences of body monitoring and hypervigilance
  • Recognising that the awful possible explanations of symptoms are rare
  • Reading three booklets summarising health anxiety

Expert commentary

We all understand that patients in routine medical clinics can be anxious, but one in five have a clinically significant health anxiety. This means they suffer much more worry and consult more often than they need.

A relatively brief course of cognitive behavioural therapy adapted for this group reduced anxiety, and the benefits lasted for five years. There was no evidence that serious medical illnesses were neglected in anxious participants who had psychological treatment.

It makes sense to develop a cognitive behavioural therapy-health anxiety service linked to medical clinics; it means patients get appropriate treatment; it may even save money.

Dr David Kessler, Reader in Primary Care, University of Bristol