Commentary on: Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients (Tyrer et al THE LANCET-D-13-04564R2

Allan House

Chris Williams

Ruddy

Shapiro

Sunderland

Thomson

Tyrer

English

Williams, C.

House, A.

Enlighten

,          Williams, C., and House, A. (2013) Cognitive behaviour therapy for health anxiety. Lancet . ISSN 0140-6736  Copyright © 2013 The Lancet Publishing Group   A copy can be downloaded for personal non-commercial research or study, without prior permission or charge  Content must not be changed in any way or reproduced in any format or medium without the formal permission of the copyright holder(s)   When referring to this work, full bibliographic details must be given    http://eprints.gla.ac.uk/87216/     Deposited on: 31 October 2013                 Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk Commentary on: Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients (Tyrer et al THELANCET-D-13-04564R2) Chris Williams and Allan House Professor of Psychosocial Psychiatry, University of Glasgow Professor of Liaison Psychiatry, University of Leeds Pre-publication submitted article. The final article contains changes from this text  Unsurprisingly, anxiety and other emotional problems are common in general medical practice.  Not infrequently anxiety focuses on the possibility of serious disease that is not in fact present; there are fashions in terminology and the current terms in vogue are health anxiety or hypochondriasis1. As with much of the DSM lexicon, the diagnostic threshold is low and prevalences in the order of 15-20% are reported across clinical settings2. In spite of the absence of underlying disease, affected patients may be badly troubled by symptoms and they use significant resources in terms of investigation and inappropriate treatment.  No surprise again that cognitive behavioural therapy (CBT) is the most widely recommended intervention3, although the evidence is not strong. Access is typically limited, with a lack of accredited practitioners and long waiting lists in traditional mental health service settings4. There is therefore significant interest in modified shortened versions. For primary depression and anxiety approaches such as CBT self-help resources are now the recommended first step5 but similar developments have not generalised to physical healthcare.  In this issue, Tyrer et al report their finding that low intensity, shorter and more easily delivered interventions may be effective for health anxiety seen in general medical clinics. Treatment was by non-CBT experts who were trained in just two workshops to deliver 5-10 sessions of a manualised CBT-based treatment. The intervention improved scores on a health anxiety symptom inventory and the costs were no different from usual care. This result is intriguing and the authors suggest that the approach could be implemented in medical clinics with benefit, albeit that staff and patient attitudes would have to change before it could be widely adopted. Translation of these findings into services is problematic.  First, there is the issue of cost. Case finding for the intervention depends upon a two-stage screening. At 12 month follow up in the current trial 13.9% (n=30) CBT and 7.3% (N=16) controls no longer met case criteria for health anxiety, so screening of more than 28,000 patients attending hospital-based medical clinics led to the recovery of 14 people who wouldn’t have got better with routine care. The cost of screening wasn’t included in the analysis: combined with the lack of effect on quality of life that raises a question about cost-effectiveness.  There are other unknowns - what happened to false positives or false negatives or to the more severe cases (beyond the capacity of the therapists in the trial) that would be identified in a screening programme in routine practice. The current study interestingly seemed to lack high users of the health service; average health costs were just over GBP 8000. A challenge arises when we move from considering stand-alone therapies to thinking about service configuration, in that health anxiety is only one of the non-physical problems found in medical patients – depression, hazardous alcohol use, poor treatment adherence, and other forms of medically-unexplained presentation all press for recognition and intervention. It makes no sense to develop multiple parallel services especially as there is considerable overlap between the common emotional disorders - and CBT offers a generic treatment framework which is not fundamentally different across disorders. The intervention in the present study is unlikely to have been highly condition-specific, as indicated for example by the finding that general anxiety and depression levels also responded. So, where do we go next in developing a comprehensive and effective response to the problem of psychological morbidity in physical healthcare settings? We need research to evaluate interventions that can be practically and affordably integrated into service provision6; economic evaluation should include all costs of service provision; we need to find ways to track longer-term outcomes in conditions that are notoriously prone to relapse. In the meantime in clinical practice it seems more efficient and achievable to focus on identifying and treating severe cases rather than screening for common but relatively mild problems where we lack strong evidence of cost-effectiveness. Such treatment should be available in general hospital settings, in multi-disciplinary liaison psychiatry or clinical health psychology clinics that can deal with the full range of problems that present.  References 1. Sunderland M, Newby J, Andrews G  Health anxiety in Australia: prevalence, co-morbidity and service use  British Journal of Psychiatry; 2013: 202: 56-61  2. Thomson A, Page L. Psychotherapies for hypochondriasis. Cochrane Depression, Anxiety and Neurosis Group. 2009. (DOI: 10.1002/14651858.CD006520.pub2) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006520.pub2/abstract 3. Tyrer P, Cooper S, Crawford M, Dupont S, Green J, et al.  Prevalence of health anxiety problems in medical clinics. J Psychosom Res, 2011, 71(6): 392-4. (doi: 10.1016/j.jpsychores.2011.07.004. Epub 2011 Sep 13.) 4. Shapiro D, Cavanagh K. Lomas H. Geographic inequity in the availability of cognitive behavioural therapy in England and Wales. Behavioural and Cognitive Psychotherapy, 2003, 31: 185-192. 5. National Institute for Clinical Health and Excellence. (NICE) Depression: the treatment and management of depression in adults. National Clinical Practice Guideline 90. 2009 NICE Published online 6. Ruddy R House A. Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry. 2005; BJPsych Aug;187: 109-20.   *Chris Williams, Allan House Institute of Health and Wellbeing, University of Glasgow, Administration Building, Gartnavel Royal Hospital, Glasgow G12 0XH, UK (CW); and Leeds Institute of Health Sciences, University of Leeds, Leeds, UK (AH)  chris.williams@glasgow.ac.uk  Conflict of interest statement: CW is author of a range of cognitive behaviour therapy-based book and online self-help resources addressing mental and physical health issues including issues such as medically unexplained symptoms; he is director and shareholder in Five Areas Limited, which licenses these resources. AH declares that he has no conflicts of interest. 

Cognitive behaviour therapy for health anxiety

Enlighten: Publications

, 
 
 
 
 
 
 
 
 
 
Williams, C., and House, A. (2013) Cognitive behaviour therapy for health 
anxiety. Lancet . ISSN 0140-6736 
 
Copyright © 2013 The Lancet Publishing Group 
 
 
A copy can be downloaded for personal non-commercial research or 
study, without prior permission or charge 
 
Content must not be changed in any way or reproduced in any format 
or medium without the formal permission of the copyright holder(s) 
 
 
When referring to this work, full bibliographic details must be given 
 
 
 
http://eprints.gla.ac.uk/87216/ 
 
 
 
 Deposited on: 31 October 2013 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enlighten – Research publications by members of the University of Glasgow 
http://eprints.gla.ac.uk 
Commentary on: Clinical and cost-effectiveness of cognitive behaviour therapy for 
health anxiety in medical patients (Tyrer et al THELANCET-D-13-04564R2) 
Chris Williams and Allan House 
Professor of Psychosocial Psychiatry, University of Glasgow 
Professor of Liaison Psychiatry, University of Leeds 
Pre-publication submitted article. The final article contains changes from this text 
 
Unsurprisingly, anxiety and other emotional problems are common in general 
medical practice.  Not infrequently anxiety focuses on the possibility of serious 
disease that is not in fact present; there are fashions in terminology and the current 
terms in vogue are health anxiety or hypochondriasis1. As with much of the DSM 
lexicon, the diagnostic threshold is low and prevalences in the order of 15-20% are 
reported across clinical settings2. In spite of the absence of underlying disease, 
affected patients may be badly troubled by symptoms and they use significant 
resources in terms of investigation and inappropriate treatment.  
No surprise again that cognitive behavioural therapy (CBT) is the most widely 
recommended intervention3, although the evidence is not strong. Access is typically 
limited, with a lack of accredited practitioners and long waiting lists in traditional 
mental health service settings4. There is therefore significant interest in modified 
shortened versions. For primary depression and anxiety approaches such as CBT 
self-help resources are now the recommended first step5 but similar developments 
have not generalised to physical healthcare.  
In this issue, Tyrer et al report their finding that low intensity, shorter and more easily 
delivered interventions may be effective for health anxiety seen in general medical 
clinics. Treatment was by non-CBT experts who were trained in just two workshops 
to deliver 5-10 sessions of a manualised CBT-based treatment. The intervention 
improved scores on a health anxiety symptom inventory and the costs were no 
different from usual care. This result is intriguing and the authors suggest that the 
approach could be implemented in medical clinics with benefit, albeit that staff and 
patient attitudes would have to change before it could be widely adopted. 
Translation of these findings into services is problematic.  
First, there is the issue of cost. Case finding for the intervention depends upon a two-
stage screening. At 12 month follow up in the current trial 13.9% (n=30) CBT and 
7.3% (N=16) controls no longer met case criteria for health anxiety, so screening of 
more than 28,000 patients attending hospital-based medical clinics led to the 
recovery of 14 people who wouldn’t have got better with routine care. The cost of 
screening wasn’t included in the analysis: combined with the lack of effect on quality 
of life that raises a question about cost-effectiveness.  
There are other unknowns - what happened to false positives or false negatives or to 
the more severe cases (beyond the capacity of the therapists in the trial) that would 
be identified in a screening programme in routine practice. The current study 
interestingly seemed to lack high users of the health service; average health costs 
were just over GBP 8000. 
A challenge arises when we move from considering stand-alone therapies to thinking 
about service configuration, in that health anxiety is only one of the non-physical 
problems found in medical patients – depression, hazardous alcohol use, poor 
treatment adherence, and other forms of medically-unexplained presentation all 
press for recognition and intervention. It makes no sense to develop multiple parallel 
services especially as there is considerable overlap between the common emotional 
disorders - and CBT offers a generic treatment framework which is not fundamentally 
different across disorders. The intervention in the present study is unlikely to have 
been highly condition-specific, as indicated for example by the finding that general 
anxiety and depression levels also responded. 
So, where do we go next in developing a comprehensive and effective response to 
the problem of psychological morbidity in physical healthcare settings? We need 
research to evaluate interventions that can be practically and affordably integrated 
into service provision6; economic evaluation should include all costs of service 
provision; we need to find ways to track longer-term outcomes in conditions that are 
notoriously prone to relapse. In the meantime in clinical practice it seems more 
efficient and achievable to focus on identifying and treating severe cases rather than 
screening for common but relatively mild problems where we lack strong evidence of 
cost-effectiveness. Such treatment should be available in general hospital settings, 
in multi-disciplinary liaison psychiatry or clinical health psychology clinics that can 
deal with the full range of problems that present. 
 
References 
1. Sunderland M, Newby J, Andrews G  Health anxiety in Australia: 
prevalence, co-morbidity and service use  British Journal of Psychiatry; 
2013: 202: 56-61 
 
2. Thomson A, Page L. Psychotherapies for hypochondriasis. Cochrane 
Depression, Anxiety and Neurosis Group. 2009. (DOI: 
10.1002/14651858.CD006520.pub2) 
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006520.pub2/abst
ract 
3. Tyrer P, Cooper S, Crawford M, Dupont S, Green J, et al.  Prevalence of 
health anxiety problems in medical clinics. J Psychosom Res, 2011, 71(6): 
392-4. (doi: 10.1016/j.jpsychores.2011.07.004. Epub 2011 Sep 13.) 
4. Shapiro D, Cavanagh K. Lomas H. Geographic inequity in the availability of 
cognitive behavioural therapy in England and Wales. Behavioural and 
Cognitive Psychotherapy, 2003, 31: 185-192. 
5. National Institute for Clinical Health and Excellence. (NICE) Depression: the 
treatment and management of depression in adults. National Clinical Practice 
Guideline 90. 2009 NICE Published online 
6. Ruddy R House A. Meta-review of high-quality systematic reviews of 
interventions in key areas of liaison psychiatry. 2005; BJPsych Aug;187: 109-
20.  
 
*Chris Williams, Allan House 
Institute of Health and Wellbeing, University of Glasgow, Administration Building, Gartnavel 
Royal Hospital, Glasgow G12 0XH, UK (CW); and Leeds Institute of Health Sciences, 
University of Leeds, Leeds, UK (AH)  
chris.williams@glasgow.ac.uk 
 
Conflict of interest statement: CW is author of a range of cognitive behaviour therapy-
based book and online self-help resources addressing mental and physical health issues 
including issues such as medically unexplained symptoms; he is director and shareholder in 
Five Areas Limited, which licenses these resources. 
AH declares that he has no conflicts of interest. 


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