Therapist differences in a randomised trial of the outcome of cognitive behaviour therapy for health anxiety in medical patients

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Abstract

Background

Health anxiety is common in medical settings and can be treated successfully by cognitive behaviour therapy. However it is not clear who might be best placed to deliver this therapy.

Objectives

In a planned secondary analysis of data from a randomised trial of adapted cognitive behaviour therapy for health anxiety we compared outcomes of therapy delivered by nurses and other professional groups.

Design

A randomised controlled trial with two treatment arms, 5–10 sessions of cognitive behaviour therapy adapted health anxiety or standard care.

Setting

Cardiology, endocrine, gastroenterology, neurological and respiratory clinics in six general hospitals in the UK covering urban, suburban and rural areas.

Participants

Medical patients attending the clinics who had pathological health anxiety and also scored for a diagnosis of hypochondriasis.

Methods

Patients were randomised to one of two treatment arms, 5–10 sessions of cognitive behaviour therapy adapted health anxiety or standard care delivered by naive therapists (not randomised) who were trained in advance before delivering the treatment. Independent assessment of outcomes by researchers masked to allocation status at 3 m, 6 m, 12 m and 24 m.

Results

444 patients were randomised in the trial, 219 to cognitive behaviour therapy adapted health anxiety and 225 to standard care. 373 (84%) completed assessments after two years. Those treated by nurses (n = 66) had improvement in health anxiety, generalised anxiety and depression outcomes that were significantly better and twice as great as those of the professional groups of assistant psychologists (n = 87) and graduate workers (n = 66) (P < 0.01 over all time points). The number needed to treat to show superiority of nurse-delivered treatment over other treatment delivery was 4 at 6 months and 6 at one year.

Conclusion

General nurses, after suitable training, are very effective therapists for patients with health anxiety in medical clinics and should be the therapists of choice for patients in these settings.

Introduction

Health anxiety is a relatively new diagnosis in psychiatry that has partly replaced the previous one of hypochondriasis, now abandoned in the latest US classification, DSM-5 (American Psychiatric Association, 2013, Tyrer and Tyrer, 2014). Because of this change there are limited data on its prevalence but it does appear to be a common condition in the community (3.5%) (Sunderland et al., 2013) and in secondary medical care (20%) (Tyrer et al., 2011a). These figures for health anxiety are much greater than those for hypochondriasis, which is a confusing diagnosis of limited acceptability (Bleichhardt and Hiller, 2007, Creed and Barsky, 2004). Health anxiety leads to unnecessary use of health services (Barsky et al., 1990) because of additional medical consultations and investigations. Following a pilot study showing the effectiveness of cognitive behaviour therapy (CBT) delivered by trained therapists (Seivewright et al., 2008) we set up the CHAMP (Cognitive behaviour therapy for Health Anxiety in Medical Patients) trial to examine the effectiveness and cost-effectiveness of a modified cognitive behavioural treatment for health anxiety (CBT-HA) with assessment of outcomes over a two-year period. At the time the study was formulated we planned to have all therapy delivered by nurses working in or close to the clinics concerned, in order to test a model that could be used to deliver therapy more widely if it were found to be successful. Unfortunately this was not possible (for mainly financial reasons) and so other therapists generally naive to the specific form of cognitive therapy to be given, including assistant psychologists and other graduate professionals were also included in the staff to deliver the therapy in our final protocol (Tyrer et al., 2011b).

This paper is not concerned with the overall effectiveness of the treatment, as this has been demonstrated previously; there was greater benefit in the symptomatic improvement of health anxiety and generalised anxiety over the two year period (Tyrer et al., 2014). This paper examines the outcome separated by therapist type, with a particular emphasis on the effectiveness of the therapy given by nurses and possible reasons given for this.

Section snippets

Methods

The CHAMP trial involved two parallel arms with randomisation of eligible patients to 5–10 sessions of CBT-HA or to standard care in the clinics. Assessments of health anxiety, generalised anxiety, depression, social function, quality of life and costs were made over a two-year period after randomisation. The primary outcome was change in the score of health anxiety using a standard instrument Salkovskis et al., 2002). Secondary hypotheses were that health anxiety at other time points,

Participants

All patients over a 20 month period attending medical out-patient clinics in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine in 6 general hospitals, King's Mill Hospital (North Nottinghamshire), St. Mary's Hospital (London), Charing Cross Hospital (London), Hammersmith Hospital (London), Chelsea and Westminster Hospital (London), and Hillingdon Hospital (Middlesex), were approached by research assistants by agreement with the staff concerned and offered the

CBT-HA arm

Cognitive therapy adapted for health anxiety (CBT-HA) was given to patients allocated to the active treatment group. This was based on the model first described by Salkovskis et al. (2003) and, although based on standard cognitive therapy principles, differed in focusing especially on the need for reassurance, hypervigilance, and fear of (rather than actual) disease that are core to the condition. The plan outlined at the beginning was to offer between 5 and 10 sessions of one hour each but

Results

445 patients were randomised to the trial and 376 (76%) completed the follow-up after two years (Fig. 1). One patient was randomised twice in error, both times to standard care; only the first of the assessments was used. Proportions followed up at other time points are shown elsewhere (Tyrer et al., 2014). The 219 patients randomised to CBT-HA were seen by a total of 17 therapists. In patients allocated to CBT-HA there was a significantly greater reduction in both health anxiety and

Discussion

The results of this trial should be seen in the general context of the employment of nurses in the delivery of psychological treatments. It has been well demonstrated that naïve nurses, including both those who are generally and mental health trained, are competent at delivering behavioural and cognitive behaviour therapies in a range of medical settings, mostly for depressive symptoms (Ekers et al., 2013a, Ekers et al., 2013b, Feng et al., 2012, Gega et al., 2007, Hendriks et al., 2014,

Conflicts of interest

PC developed CBT-HA, and HT is the author of a book describing CBT-HA in practice.

Funding

This research was funded by the National Coordinating Centre for Health Technology Assessment (NCCHTA) programme (project number 07/01/26). The views expressed in this publication are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS, or the Department of Health.

Ethical approval

North Nottingham Ethics Committee (08/H0403/56).

Acknowledgements

This research was funded by the National Coordinating Centre for Health Technology Assessment (NCCHTA) programme (project number 07/01/26), and was supported by the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre. The views expressed in this publication are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS, or the Department of Health. We particularly thank the North London and East Midlands hubs of the Mental Health

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