Published: 13-05-2020 17:00 | Updated: 13-05-2020 18:15

Effects of Internet CBT for health anxiety on par with face-to-face treatment

Photo: Pixabay

Researchers at Karolinska Institutet have compared two ways of delivering cognitive behavioral therapy to treat people with health anxiety, a condition that may increase in the wake of COVID-19. Out of about 200 study participants, half received Internet-CBT and half received conventional face-to-face CBT. The results, published in JAMA Psychiatry, show that Internet-delivered treatment had comparable effects, and may serve as an alternative in helping people who are worried about their health.

Portrait of Erik Hedman.
Erik Hedman-Lagerlöf Photo: Ulf Sirborn

“The study is unique in that it is the first direct comparison of face-to-face CBT and Internet-delivered CBT for health anxiety,” says Erik Hedman-Lagerlöf, professor of psychology and researcher at the Department of Clinical Neuroscience, Karolinska Institutet. “The results show that a treatment delivered exclusively online is sufficient to achieve tough and required behavioral changes. This is especially relevant now when the coronavirus pandemic limits our opportunities for physical meetings, while the fear of being affected by a severe health condition is discussed more frequently.”

Health anxiety, also referred to as hypochondriasis, is characterized by an excessive and persistent fear or worry about serious illness. It often leads to significant suffering and functional impairment. About 3.5 percent of the general population and up to 20 percent of patients in medical clinics are estimated to suffer from the condition, which causes great strain on the health care system.

Demand for conventional CBT exceeds availability

In face-to-face CBT, which typically involves weekly sessions with a mental health clinician, about two thirds of patients respond to treatment. However, given the prevalence of health anxiety and scarcity of mental health professionals, the need for treatment far exceeds the availability of evidence-based face-to-face therapy. The researchers therefore wanted to examine the effect of an Internet-based treatment where the patient has access to information online and communicates regularly with a therapist through an email-like system. The patient also engages in behavioral changes in their day-to-day life, just as in the case of face-to-face CBT.

In the study, 204 adults with health anxiety were randomized to receive either face-to-face or Internet CBT for a period of 12 weeks. The participants were asked to rate their level of health anxiety each week using a standardized questionnaire commonly referred to as the Health Anxiety Inventory.

According to the researchers, Internet CBT had effects largely on par with the face-to-face treatment. This was despite the fact that the average Internet-therapist spent only 10 minutes per patient per week compared with about 45 minutes in the other group.

Internet CBT more time efficient

Erland Axelsson
Erland Axelsson Photo: Privat bild

”One significant advantage is that the therapist can help more patients in the same time, but also that the treatment can be delivered regardless of the patient’s geographical location, including to people living in rural areas,” says Erland Axelsson, psychologist and researcher at the Department of Clinical Neuroscience, Karolinska Institutet. “The fact that you can access the content and communicate with your therapist at any time of the day also means that people who struggle to take time off from work can take part in treatment.”

Another positive aspect of online CBT is that patients who are reluctant to seek psychological treatment due to perceived stigma may be more inclined to seek help, Erland Axelsson adds.

The study was conducted from 2014 to 2020 as a collaboration between Gustavsberg’s primary care clinic and Karolinska Institutet. This research was financed by Karolinska Institutet, Region Stockholm, and Psykiatrifonden. Some of the authors have reported conflicts of interest including the co-authorship of a self-help book for health anxiety and shareholdings in a company specializing in online psychiatric symptom assessment.


”Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial”. Erland Axelsson, Erik Andersson, Brjánn Ljótsson, Daniel Björkander, Maria Hedman-Lagerlöf och Erik Hedman-Lagerlöf. JAMA Psychiatry, online 13 maj 2020, doi: 10.1001/jamapsychiatry.2020.0940