Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety

Summary & key facts

Researchers compared 12 weeks of internet-delivered cognitive behavior therapy (CBT) with the usual face-to-face CBT for people with health anxiety. In a trial of about 200 adults, the online therapy worked about as well as in-person therapy for reducing health anxiety symptoms. The online program used much less therapist time and cost society less during the treatment period, and there were no serious harms reported. These results suggest online CBT could be a more accessible option, but they come from one trial of 204 people and should be seen as promising rather than final.

Key facts:

• The study randomly assigned 204 adults with health anxiety to 12 weeks of either internet-delivered CBT or individual face-to-face CBT, with half of the people in each group.
• The researchers used a standard health-anxiety questionnaire that runs from 0 to 54 and set a small margin (about 2.25 points) to decide if online therapy was not meaningfully worse than face-to-face therapy.
• By the main analyses, the change in symptoms after 12 weeks for the online group was within that small margin, meaning the online treatment appeared not worse than face-to-face treatment.
• Therapists spent far less time per patient each week with the online program — about 10 minutes versus about 46 minutes for face-to-face therapy.
• The study estimated lower net societal costs for the online treatment during the treatment period, with a difference of roughly $3,900 in favor of the internet program.
• There was no clear difference between the groups in the number of adverse events, and no serious adverse events were reported.
• The result was consistent whether researchers looked only at people who completed treatment or at everyone assigned to a group, and it did not change based on how sick people were at the start, how they were recruited, or which treatment they preferred.
• Follow-up information was collected for up to 12 months after treatment, but the main outcome reported focused on the 12-week treatment change.

Abstract

Importance: Health anxiety is a common and often chronic mental health problem associated with distress, substantial costs, and frequent attendance throughout the health care system. Face-to-face cognitive behavior therapy (CBT) is the criterion standard treatment, but access is limited. Objective: To test the hypothesis that internet-delivered CBT, which requires relatively little resources, is noninferior to face-to-face CBT in the treatment of health anxiety. Design, Setting, and Participants: This randomized noninferiority clinical trial with health economic analysis was based at a primary care clinic and included patients with a principal diagnosis of health anxiety who were self-referred or referred from routine care. Recruitment began in December 10, 2014, and the last treatment ended on July 23, 2017. Follow-up data were collected up to 12 months after treatment. Analysis began October 2017 and ended March 2020. Interventions: Patients were randomized (1:1) to 12 weeks of internet-delivered CBT or to individual face-to-face CBT. Main Outcomes and Measures: Change in health anxiety symptoms from baseline to week 12. Analyses were conducted from intention-to-treat and per-protocol (completers only) perspectives, using the noninferiority margin of 2.25 points on the Health Anxiety Inventory, which has a theoretical range of 0 to 54. Results: Overall, 204 patients (mean [SD] age, 39 [12] years; 143 women [70%]) contributed with 2386 data points on the Health Anxiety Inventory over the treatment period. Of 204 patients, 102 (50%) were randomized to internet-delivered CBT, and 102 (50%) were randomized to face-to-face CBT. The 1-sided 95% CI upper limits for the internet-delivered CBT vs 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. Therapists spent 10.0 minutes per patient per week in the online treatment vs 45.6 minutes for face-to-face CBT. The net societal cost was lower in the online treatment (treatment period point difference: $3854). There was no significant group difference in the number of adverse events, and no serious adverse event was reported. Conclusions and Relevance: 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 online treatment format has potential to increase access to evidence-based treatment for health anxiety. Trial Registration: ClinicalTrials.gov Identifier: NCT02314065.

Topics

Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes Digital Mental Health Interventions Psychosomatic Disorders and Their Treatments

Categories

Health Sciences Medicine Psychiatry and Mental health

Tags

Anxiety Attendance Clinical psychology Cognitive behavioral therapy Distress Economic growth Economics Health care Internal medicine Medicine Mental health Physical therapy Psychiatry Psychological intervention Randomized controlled trial

Conditions & symptoms

Anxiety Anxiety or worry