Internet-Delivered CBT Effective Treating Health Anxiety

Erland Axelsson, PhD

While health anxiety can lead to excessive medical investigations and substantial societal costs, internet-based therapy could be effective and beneficial alternative for both the patient and the therapist.

A team based in Sweden, led by Erland Axelsson, PhD, Division of Psychology, Department of Clinical Neuroscience, Karolinska Institute, examined whether treatment of health anxiety is as effective through internet-delivered cognitive behavioral therapy as it is through face-to-face cognitive behavior therapy while using less resources.

In the randomized, noninferiority clinical trial, the investigators examined 204 adults with a principal diagnosis of health anxiety in a primary care setting. Each patient was either self-referred or referred from routine care.

The mean age of the 204 patients was 39 years old, with 143 women in the study contributing 2386 data points on the Health Anxiety Inventory over the treatment period.

Recruitment began in December 2014 and concluded July 2017. The investigators collected follow-up data up to 12 months following treatment.

The main outcomes sought were changes in health anxiety symptoms from baseline to week 12.

Each patient was randomized to 12 weeks of internet-delivered CBT or individual face-to-face CBT. The participants in the online treatment group each spent 10 minutes per week with a therapist, while the face-to-face group spent an average of 45.6 minutes per week with the therapist.

The net societal cost was much lower in the online treatment group, with a $3854 treatment period point difference.

There was no significant group difference in the number of adverse events, with no serious adverse event reported in either group.

The 1-sided 95% CI upper limits for the internet-delivered CBT compared face-to-face CBT difference in change were within the noninferiority margin in the intention-to-treat analysis (B = 0.00; upper limit: 1.98; Cohen d = 0.00; upper limit: 0.23) and per-protocol analysis (B = 0.01; upper limit: 2.17; Cohen d = 0.00; upper limit: 0.25).

The between-group effect was not moderated by initial symptom level, recruitment path, or patient treatment preference.

“In this trial, internet-delivered CBT appeared to be noninferior to face-to-face CBT for health anxiety, while incurring lower net societal costs,” the authors wrote. “The online treatment format has potential to increase access to evidence-based treatment for health anxiety.”

Health anxiety or hypochondriasis is considered a common and chronic mental health condition associated with distress, substantial healthcare costs, and frequent attendance throughout the healthcare system. While face-to-face CBT is considered standard treatment, access can be limited.

There is some evidence showing antidepressants can help treat health anxiety, along with CBT. In the current standard of care, patients will meet with a therapist once a week over the course of 3 months. About 66% of patients will respond to this method of treatment.

Internet-delivered CBT is a text-based online treatment where each patients works with conventional CBT strategies and communicates regularly with a therapist through an email-like system. Each patient has the ability to access treatment at any time of the day with little time required from the therapist.

Prior to the comparison with face-to-face CBT, internet-delivered CBT was found to be more effective than a rudimentary attention control (d = 1.62; 95% CI, 1.10-2.10)¹³ and active comparator (pooled d = 0.81; 95% CI, −0.30-1.92).

The study, “Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety,” was published online in JAMA Psychiatry.