Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: a multicentre randomised controlled trial

Richard Morriss, Shireen Patel, Sam Malins, Boliang Guo, Fred Higton, Marilyn James, Mengjun Wu, Paula Brown, Naomi Boycott, Catherine Kaylor-Hughes, Martin Morris, Emma Rowley, Jayne Simpson, David Smart, Michelle Stubley, Joe Kai, Helen Tyrer, Richard Morriss, Shireen Patel, Sam Malins, Boliang Guo, Fred Higton, Marilyn James, Mengjun Wu, Paula Brown, Naomi Boycott, Catherine Kaylor-Hughes, Martin Morris, Emma Rowley, Jayne Simpson, David Smart, Michelle Stubley, Joe Kai, Helen Tyrer

Abstract

Background: It is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU).

Methods: A single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective.

Results: Of the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI -2.81; 95% CI -5.11 to -0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group.

Conclusions: RCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care.

Trial registration: The trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036.

Keywords: Cognitive behaviour therapy; Depression; Digital; Family care; High care costs; Hypochondriasis; Illness anxiety disorder; Remote therapy; Urgent care; Videoconferencing.

Conflict of interest statement

Ethics approval and consent to participate

Ethical approval was obtained from the National Research Ethics Service London – Riverside Committee (reference 14/LO/1102). All participants gave written informed and oral consent to the study, directly to a member of the research team.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Consort diagram: participant flow into randomised controlled trial. *There was one randomization protocol violation. One participant who was allocated into TAU by the randomisation system was accidentally sent the incorrect treatment allocation letter, resulting in them receiving the RCBT therapy. This error was identified following the completion of treatment. The participant completed outcome data only at three months. **There was an enrolment protocol violation. Two participants in the RCBT group did not meet the criteria of ≥18 on the SHAI. This error was not identified until final analysis and as such both participants were included in the analysis
Fig. 2
Fig. 2
Mean (95% CI) change in 14-item Short Health Anxiety Inventory over 12 months remote cognitive behaviour therapy versus treatment as usual
Fig. 3
Fig. 3
Plot of bootstrapped samples on the cost-effectiveness plan using EQ-5D-5L utilities

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