Sylvia Cooper

Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial

BACKGROUND Health anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics. METHODS We undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16-75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten sessions of adapted cognitive behaviour therapy (CBT-HA group) delivered by hospital-based therapists or to standard care in the clinics. The primary outcome was change in health anxiety symptoms measured by the Health Anxiety Inventory at 1 year and the main secondary hypothesis was equivalence of total health and social care costs over 2 years, with an equivalence margin of £150. Analysis was by intention to treat. The study is registered with controlled-trials.com, ISRCTN14565822. FINDINGS Of 28,991 patients screened, 444 were randomly assigned to receive either adapted cognitive behaviour therapy (CBT-HA group, 219 participants) or standard care (standard care group, 225), with 205 participants in the CBT-HA group and 212 in the standard care group included in the analyses of the primary endpoints. At 1 year, improvement in health anxiety in the patients in the CBT-HA group was 2·98 points greater than in those in the standard care group (95% CI 1·64-4·33, p<0·0001), and twice as many patients receiving cognitive behaviour therapy achieved normal levels of health anxiety compared with those in the control group (13·9% vs 7·3%; odds ratio 2·15, 95% CI 1·09-4·23, p=0·0273). Similar differences were observed at 6 months and 2 years, and there were concomitant reductions in generalised anxiety and, to a lesser extent, depression. Of nine deaths, six were in the control group; all were due to pre-existing illness. Social functioning or health-related quality of life did not differ significantly between groups. Equivalence in total 2-year costs was not achieved, but the difference was not significant (adjusted mean difference £156, 95% CI -1446 to 1758, p=0·848). INTERPRETATION This form of adapted cognitive behaviour therapy for health anxiety led to sustained symptomatic benefit over 2 years, with no significant effect on total costs. It deserves wider application in medical care. FUNDING National Institute for Health Research Health Technology Assessment Programme.

Prevalence of health anxiety problems in medical clinics

OBJECTIVES To determine the prevalence of significant health anxiety (hypochondriasis) in patients aged 16-75 in cardiology, respiratory medicine, neurological, endocrine and gastrointestinal clinics in general hospitals in London, Middlesex and North Nottinghamshire. METHOD The Health Anxiety Inventory (HAI) (short form) was administered to patients attending the five clinics over a 21 month period and all those who scored 20 or more invited to take part in a further assessment for a randomised controlled trial. RESULTS Of 43,205 patients attending the clinics 28,991 (67.1%) were assessed and of these, after exclusion of ineligible patients 5747 (19.8%) had significant health anxiety. 444 subsequently agreed to take part in a randomised controlled trial of treatment. The prevalence levels varied by clinic with neurology (24.7%) having the highest prevalence followed by respiratory medicine (20.9%), gastroenterology (19.5%), cardiology (19.1%), and endocrinology (17.5%). CONCLUSION Abnormal health anxiety is common and a significant problem in those attending medical clinics and deserves greater awareness.

The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams

BackgroundPersonality status is seldom assessed in community mental health teams except at a rudimentary level. This study challenges the assumption that this policy is either prudent or wise.AimsTo measure the prevalence of personality disorder within community mental health teams and to investigate its relationship to mental state disorders and overall pathology.MethodA cross-sectional survey of 2,528 of 2,567 psychiatric patients (98.5%) managed by community mental health teams in four urban settings in the UK in which diagnoses of personality and mental state pathology were assessed separately. Of these, a sample of 400 was interviewed, with a 70.5% completion rate for more in depth information.ResultsIn total, 40% of all patients in secondary care suffered from at least one personality disorder. Regression modelling showed personality pathology accounted for a greater degree of global psychopathology than psychosis, alcohol or drug dependence, but was associated with anxiety disorders.ConclusionComorbid personality pathology contributes greatly to overall psychopathology in secondary psychiatric care. It should be both recognised and managed.

The successes and failures of the DSPD experiment: the assessment and management of severe personality disorder

In the last 10 years a sum in excess of £200 million has been spent in developing a new programme of treatment for those deemed to have dangerous and severe personality disorder (DSPD) in England. This proto-diagnosis is a new concept in forensic psychiatric practice and, although its conception was bold, it carried considerable risks in implementation as so little was known about the effective management of this group of disorders. We review the successes and failures of this pioneering programme a decade after its introduction and conclude that although much has been gained from the experiment – particularly in developing services for those with personality disorder in general – it has been less effective in managing those whom it was primarily targeting and may not have been cost-effective.

The assessment of dangerous and severe personality disorder: lessons from a randomised controlled trial linked to qualitative analysis

Randomised controlled trials are difficult to carry out in high security prisons and very few have succeeded. We describe here a randomised controlled trial of early versus late assessment for the pilot phase of the new DSPD programme for dangerous and severe personality disorder, which assessed prisoners (n = 75) at baseline, then six months, and then one year after randomisation. The trial enjoyed 100% success in getting records and obtained useful qualitative data that helped to explain the findings, but the trial was compromised by repeated protocol violations on grounds that were seldom acknowledged openly but which we conclude were primarily due to ignorance of the purpose of such trials. This led to such contamination of the two arms of the trial that no clear conclusions could be drawn from the trial itself, except that relative costs showed expected differences. However, the trial also showed that the assessment programme was associated with better quality of life in terms of social relationships (p = .03), with an increase in aggression (p = .01), and with worse social functioning in those with less severe personality disorder (p < .01), with the qualitative data suggesting that frustration and unfulfilled expectations lay behind these findings. Suggestions are made about revisions to the assessment process and the changes necessary for successful trials to be mounted in the future.

The assessment of dangerous and severe personality disorder: service use, cost, and consequences

The dangerous severe personality disorder (DSPD) programme in England provides high security services for offenders with a personality disorder who have a high risk of re-offending. The cost and economic value of the programme is unknown. The aims of this study were to examine patterns in the service use of prisoners in assessment, to evaluate the cost and outcomes of prisoners in DSPD assessment compared to controls, and to identify the clinical and personal characteristics of prisoners with high costs. Individual-level service use data were collected from prisoner files and individual total costs estimated. Prisoners in DSPD assessment had contact with a variety of professionals and group activities. The DSPD group cost £3,500 more on average than those in the control prisons over six months (£25,150 vs. £21,963; p = .094). There were no significant differences in outcome, although there was a consistent trend for the DSPD assessment group to have worse outcomes than controls. In a cost-function analysis, social functioning had a positive impact on cost and psychopathy had a negative impact on cost. Given the substantially higher costs and observed deterioration in outcome among those in assessment compared to those who remain in a high security prison, the additional benefit of assessment is unclear and needs further exploration.

A descriptive evaluation of patients and prisoners assessed for dangerous and severe personality disorder

The Dangerous and Severe Personality Disorder (DSPD) programme was introduced to assess, manage and treat severely personality disordered individuals who present a high risk of serious offending. We describe the clinical and risk characteristics of the first 241 patients admitted to the high-security DSPD service for assessment. Eighty-four percent of patients were regarded as meeting the DSPD criteria. Clinically, the DSPD patients demonstrated high levels of psychopathy, with 78% scoring 25 or more on the Psychopathy Checklist. The most commonly diagnosed personality disorders were antisocial, borderline and paranoid. The risk assessments indicated the DSPD patients exhibited a broad range of risk factors for future offending, suggesting that these patients had extensive treatment needs. The DSPD service had been relatively successful in retaining patients, with 82% of those admitted to treatment remaining within the high-security DSPD service. The clinical mix of the patients may have implications for treatment outcome, and future challenges for the service are highlighted.

Preliminary studies of the ICD-11 classification of personality disorder in practice

OBJECTIVE This study aims to compare ICD-10 and putative ICD-11 classifications of personality disorder in different clinical populations. DESIGN Prospective recording of ICD-10 and ICD-11 personality disorder classifications was carried out in (1) an anxious medical population, (2) an acute psychiatric in-patient population and (3) a retrospective recording of a mixed anxiety depression cohort in which all baseline data were scored from baseline information using the ICD-11 classification and compared with the original ICD-10 assessments. METHOD Comparison of ICD-10 and ICD-11 prevalence of personality disorder in each population was carried out. RESULTS Data from 722 patients were recorded. Using the ICD-10 criteria, the prevalence of generic personality disorder was 33.8% compared with 40.4% using the ICD-11 ones (χ2  = 6.7; P < 0.01), with 103 (14.3%) discordant assessments. Using the severity definitions in ICD-11, 34.3% of patients had personality difficulty. Severity level varied greatly by population; severe personality disorder was five times more common in the inpatient group. The four domain traits originally denoted as qualifying severity in ICD-11, negative affective, dissocial, anankastic and detached, were linked to anxious, borderline, dissocial, anankastic and schizoid personality disorders in ICD-10. Many patients had pathology in two or more domains. CONCLUSIONS The ICD-11 classification of personality disorder yields somewhat higher levels of personality dysfunction than ICD-10, possibly because the age range for the onset of diagnosis is now flexible. The range of severity levels make the classification more useful than ICD-10 in clinical practice as it identifies the greater pathology necessary for intervention.

CHAMP: Cognitive behaviour therapy for health anxiety in medical patients, a randomised controlled trial

BackgroundAbnormal health anxiety, also called hypochondriasis, has been successfully treated by cognitive behaviour therapy (CBT) in patients recruited from primary care, but only one pilot trial has been carried out among those attending secondary medical clinics where health anxiety is likely to be more common and have a greater impact on services. The CHAMP study extends this work to examine both the clinical and cost effectiveness of CBT in this population.Method/DesignThe study is a randomized controlled trial with two parallel arms and equal randomization of 466 eligible patients (assuming a 20% drop-out) to an active treatment group of 5-10 sessions of cognitive behaviour therapy and to a control group. The aim at baseline, after completion of all assessments but before randomization, was to give a standard simple explanation of the nature of health anxiety for all participants. Subsequently the control group was to receive whatever care might usually be available in the clinics, which is normally a combination of clinical assessment, appropriate tests and reassurance. Those allocated to the active treatment group were planned to receive between 5 and 10 sessions of an adapted form of cognitive behaviour therapy based on the Salkovskis/Warwick model, in which a set of treatment strategies are chosen aimed at helping patients understand the factors that drive and maintain health anxiety. The therapy was planned to be given by graduate research workers, nurses or other health professionals trained for this intervention whom would also have their competence assessed independently during the course of treatment. The primary outcome is reduction in health anxiety symptoms after one year and the main secondary outcome is the cost of care after two years.DiscussionThis represents the first trial of adapted cognitive behaviour therapy in health anxiety that is large enough to test not only the clinical benefits of treatment but also whether the cost of treatment is offset by savings from reduced use of other health services in comparison to the control group.Cognitive behaviour therapy for Health Anxiety in Medical Patients (CHAMP)Trial registrationCurrent Controlled Trials ISRCTN14565822

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

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 3m, 6m, 12m and 24m. 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.