Virtual cognitive behavioral therapy noninferior to in-person CBT for health anxiety

Erland Axelsson

Cognitive behavioral therapy delivered online appeared noninferior to CBT delivered in person for health anxiety, according to results of a randomized noninferiority clinical trial published in JAMA Psychiatry.

A health economic analysis also showed a lower net societal cost with the online format.

“Clinically significant health anxiety, sometimes referred to as hypochondriasis, is a common and often debilitating problem with substantial economic consequences,” Erland Axelsson, PhD, of the department of clinical neuroscience at Karolinska Institutet in Stockholm, told Healio Psychiatry. “Conventional face-to-face CBT can be highly efficacious for individuals with clinically significant levels of health anxiety, but access to this type of treatment is poor. Previous studies have shown promising effects of internet-delivered cognitive behavior therapy (ICBT), which requires less therapist time."

Prior research showed ICBT was more effective than a rudimentary attention control and active comparator in the treatment of health anxiety. To test and compare the effectiveness of ICBT and face-to-face CBT, Axelsson and colleagues recruited 204 patients (mean age, 39 years; 70% women) with a principal diagnosis of health anxiety who were referred from routine care or self-referred to a primary care clinic. They randomly assigned patients 1:1 to 12 weeks of individual face-to-face CBT (n = 102) or to ICBT (n = 102). Change in health anxiety symptoms from baseline to week 12 served as the main outcome. The researchers conducted analyses from intention-to-treat and per-protocol perspectives and used the Health Anxiety Inventory’s noninferiority margin of 2.25 points.

Patients contributed with 2,386 data points on the Health Anxiety Inventory over the treatment period. Results showed the one-sided 95% CI upper limits for ICBT vs. face-to-face CBT difference in change were within the noninferiority margin in the intention-to-treat analysis and per-protocol analysis. The researchers observed that initial symptom level, recruitment path or patient treatment preference did not moderate the between-group effect. Further, they found that therapists spent 10 minutes per patient per week on ICBT vs. 45.6 minutes on face-to-face CBT. ICBT was associated with a lower net societal cost than face-to-face CBT, for a treatment period point difference of $3,845. Axelsson and colleagues reported no serious adverse events and no significant difference in the number of adverse events between groups.

“We were pleased to see that, as hypothesized, ICBT appeared to be noninferior to face-to-face CBT, at least in the short term," Axelsson told Healio Psychiatry. "Differences in effects on secondary outcomes were small, and most effects were sustained in the long term." – by Joe Gramigna

Disclosures: Axelsson reports grants from Karolinska Institutet and Stockholm County Council (ALF Medicine) during the conduct of the study. Please see the study for all other authors’ relevant financial disclosures.