Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial

Axelsson, Erland; Andersson, Erik; Ljótsson, Brjánn; Björkander, Daniel; Hedman-Lagerlöf, Maria; Hedman-Lagerlöf, Erik

doi:10.1001/jamapsychiatry.2020.0940

Cited by 125Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesTelemedicine and Telehealth Implementation

Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial

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Axelsson, Erland, Andersson, Erik, Ljótsson, Brjánn, Björkander, Daniel, Hedman-Lagerlöf, Maria, Hedman-Lagerlöf, Erik·2020·JAMA Psychiatry

DOI 10.1001/jamapsychiatry.2020.0940PMC PMC7221860

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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.

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A non-inferiority trial found no difference in outcome between internet-delivered and face-to-face CBT for a health anxious sample with either IAD and SSD, but internet-delivered therapy resulted in lower net societal costs.
“For example, a non-inferiority trial compared internet-delivered to face-to-face CBT (including health anxious sample with either IAD and SSD) and found no difference in outcome, but with internet-delivered therapy resulting in lower net societal costs [80].”
From Illness Anxiety Disorder: A Review of the Current Research and Future Directions (2024) · cites this paper as [80]
The time spent by the psychotherapist per participant in guided i-CBT is 22% of the therapist's time for f-CBT.
“The time spent by the psychotherapist per participant in the guided i-CBT was estimated to be 22% of the therapist’s time for f-CBT [29].”
From Cost-effectiveness of internet-supported cognitive behavioral therapy for university students with anxiety symptoms: A Markov-model analysis (2022) · cites this paper as [29]
Internet-delivered CBT for health anxiety has effectiveness comparable to face-to-face CBT.
“Results from a recent randomised controlled trial (RCT) [24] and a systematic review and meta-analysis suggested that the effectiveness of internet-delivered CBT (iCBT) for health anxiety is comparable to that of face-to-face CBT [10, 24].”
From Cost Effectiveness of Internet-Delivered Acceptance and Commitment Therapy for Patients with Severe Health Anxiety: A Randomised Controlled Trial (2022) · cites this paper as [24]
The overhead cost for the i-CBT platform is US$19.
“The overhead cost for the i-CBT platform was estimated to be US $19 [29].”
From Cost-effectiveness of internet-supported cognitive behavioral therapy for university students with anxiety symptoms: A Markov-model analysis (2022) · cites this paper as [29]
The Health Economic Outcomes section reports lower therapist costs for ICBT and refers to supplementary cost tables, but the passages in our copy do not give an overhead cost for the platform. Searches for “$19,” “overhead,” and platform costs found no such estimate. (LLM, conf=0.75)
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Using the Internet to Provide Treatment for Health Anxiety
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Authors: Axelsson, E., Andersson, E., Ljótsson, B., Björkander, D., Hedman-Lagerlöf, M., & Hedman-Lagerlöf, E.
Affiliations: Karolinska Institutet (SE)
Gustavsberg Academic Primary Care Clinic, Gustavsberg, Sweden
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
ORCID: Axelsson, Erland
Andersson, Erik
Ljótsson, Brjánn
Venue: JAMA Psychiatry
Publisher: American Medical Association (AMA)
Published: 2020-09-01
Volume: 77
Issue: 9
Pages: 915
ISSN: 2168-622X (ISSN-L)
DOI: 10.1001/jamapsychiatry.2020.0940
PMC: PMC7221860
OpenAlex: W3024887656
Cited by: 125
References: 49
Citations by year: 2026: 19 · 2025: 17 · 2024: 13 · 2023: 26 · 2022: 29 · 2021: 9 · 2020: 10 · 2018: 1
FWCI: 16.72
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: JAMA Psychiatry (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: Karolinska Institutet
Topics: Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Keywords: health anxiety, internet-based cognitive behavioral therapy, non-inferiority, primary care, Health Anxiety Inventory, treatment access, health care costs, patient preferences, patient satisfaction, patient-reported outcomes
MeSH terms: Internet-Based Intervention, Adult, Anxiety Disorders, Attitude to Health, Female, Follow-Up Studies, Humans, Hypochondriasis, Male, Middle Aged, Outcome and Process Assessment, Health Care, Primary Health Care, Cognitive Behavioral Therapy, Cost of Illness

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Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial

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