Cognitive behaviour therapy for non-cardiac pain in the chest (COPIC): a multicentre randomized controlled trial with economic evaluation

Patients with depression symptoms are more likely to experience improvements of internet-based cognitive behavioral therapy: a secondary analysis of effect modifiers in patients with non-cardiac chest pain in a randomized controlled trial

BACKGROUND

Non-cardiac chest pain is common and associated with increased anxiety and reduced health-related quality of life. Randomized controlled trials on psychological interventions for patients with non-cardiac chest pain have reported mixed results. Patients with non-cardiac chest pain are a heterogeneous group. Identifying sub-groups that could potentially benefit more (or less) from an intervention would be valuable knowledge. We have conducted a randomized controlled trial where internet-based cognitive behavioural therapy (iCBT) had effect on reducing cardiac anxiety and increasing health-related quality of life at 12-month follow-up. The aim of the present study was to explore potential effect modifiers of iCBT in patients with non-cardiac chest pain on cardiac anxiety and/or health related quality of life at 12-month follow-up.

METHODS

We analysed data from our randomized, controlled trial where 161 patients with non-cardiac chest pain were included and randomized to either iCBT or a treatment as usual (control). Cardiac anxiety measured by the Cardiac Anxiety Questionnaire and health-related quality of life measured by the EuroQol Visual Analog Scale at 12 month follow-up were the primary outcomes. Four potential baseline characteristics where identified as potential effect modifiers by a theory-based approach: (1) depression measured by the Patient Health Questionnaire; (2) anxiety measured by the Body Sensations Questionnaire; (3) prior healthcare contacts measured by a self-developed question; and (4) chest pain frequency measured by a self-developed question. Each potential effect modifier was analysed in a linear regression model where cardiac anxiety and EQ-VAS scores at 12-month follow-up, separately, were used as dependent variables. The potential differential treatment effect for each effect modifier was assessed by the interaction term: effect modifier x treatment group.

RESULTS

Depression symptoms at baseline predicted a differential treatment effect at 12-month follow-up on health-related quality of life in favor of the iCBT group (regression coefficient of the interaction term: -1.85 (CI -3.28 to -0.41), p = 0.01), but not on cardiac anxiety at 12-month follow-up. Fear of bodily symptoms, chest pain frequency and prior health care contacts at baseline did not predict a treatment effect on either health-related quality of life or cardiac anxiety.

CONCLUSIONS

Depression symptoms at baseline predicted a positive treatment effect of iCBT on health-related quality of life in patients suffering from non-cardiac chest pain. This indicates that it is important to identify patients with non-cardiac chest pain and co-occurring depression symptoms given that they are particularly likely to benefit from iCBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03096925 .

Mindfulness-based intervention in patients with persistent pain in chest (MIPIC) of non-cardiac cause: a feasibility randomised control study

Objective

The study evaluated the feasibility of mindfulness-based cognitive therapy (MBCT) in patients with non-cardiac chest pain by assessing their willingness to participate and adhere to the programme, and for these data to help further refine the content of MBCT for chest pain.

Patients and methods

This prospective 2:1 randomised controlled trial compared the intervention of adapted MBCT as an addition to usual care with just usual care in controls. Among 573 patients who attended the rapid access chest pain clinic over the previous 12 months and were not diagnosed with a cardiac cause but had persistent chest pain were invited. The intervention was a 2-hour, weekly, online guided 8-week MBCT course. Compliance with attendance and the home practice was recorded. Enrolled patients completed the Seattle angina questionnaire (SAQ), Hospital Anxiety and Depression Scale, Cardiac Anxiety Questionnaire, Five-Facet Mindfulness Questionnaire, and Euro Quality of Life–5 Dimensions–5 Level at baseline assessment and after 8-week period.

Results

Persistent chest pain was reported by 114 patients. Of these, 33 (29%) patients with a mean age of 54.2 (±12.2) years and 68% women, consented to the study. Baseline questionnaires revealed mild physical limitation (mean SAQ, 76.8±25), high levels of anxiety (76%) and depression (53%), modest cardiac anxiety (CAQ,1.78±0.61) and mindfulness score (FFMQ, 45.5±7.3). Six patients subsequently withdrew due to bereavement, caring responsibilities and ill health. Of the remaining 27 participants, 18 in the intervention arm attended an average of 5 sessions with 61% attending ≥6 sessions. Although not statistically powered, the study revealed a significant reduction in general anxiety, improved mindfulness and a trend towards improvement in SAQ scores in the intervention arm.

Conclusion

One-third of patients with persistent non-cardiac chest pain were willing to participate in mindfulness-based therapy. An improvement in anxiety and mindfulness was detected in this feasibility study. A larger trial is required to demonstrate improvement in chest pain symptoms.

Hypnosis and Cognitive Behavioral Therapies for the Management of Gastrointestinal Disorders

PURPOSE OF REVIEW

To review the nature, current evidence of efficacy, recent developments, and future prospects for cognitive behavioral therapy (CBT) and gut-directed hypnotherapy, the two best established psychological interventions for managing gastrointestinal (GI) disorders.

RECENT FINDINGS

New large randomized controlled trials are showing that cost-effective therapy delivery formats (telephone-based, Internet-based, fewer therapist sessions, or group therapy) are effective for treating GI disorders. CBT and hypnotherapy can produce substantial improvement in the digestive tract symptoms, psychological well-being, and quality of life of GI patients. However, they have long been hampered by limited scalability and significant cost, and only been sufficiently tested for a few GI health problems. Through adoption of more cost-effective therapy formats and teletherapy, and by expanding the scope of efficacy testing to additional GI treatment targets, these interventions have the potential to become widely available options for improving clinical outcomes for patients with hard-to-treat GI disorders.

Recent Advances in the Understanding and Treatment of Health Anxiety

PURPOSE OF REVIEW

To examine the diagnosis of health anxiety, its prevalence in different settings, public health significance, treatment, and outcome.

RECENT FINDINGS

Health anxiety is similar to hypochondriasis but is characterized by fear of, rather than conviction of, illness. Lifetime prevalence rates are 6% in the population and as high as 20% in hospital out-patients, leading to greater costs to health services through unnecessary medical contacts. Its prevalence may be increasing because of excessive internet browsing (cyberchondria). Drug treatment with antidepressants has some efficacy but is not well-liked, but psychological treatments, including cognitive behavior therapy, stress management, mindfulness training, and acceptance and commitment therapy, given either individually, in groups, or over the Internet, have all proved efficacious in both the short and longer term. Untreated health anxiety leads to premature mortality. Health anxiety has become an increasing clinical and public health issue at a time when people are being formally asked to take more responsibility in monitoring their own health. More attention by health services is needed.

Study on the Therapeutic Effects of Drug and Cognitive-Behavioral Therapy on Non-Erosive Reflux Disease Patients With Emotional Disorders

OBJECTIVE

To assess the correlation between the incidence of non-erosive reflux disease (NERD) and mental and psychological factors, deepen the understanding of the pathogenesis of NERD and explore effective treatments.

METHODS

NERD patients with mood disorders who met the inclusion criteria were randomly divided into a drug treatment group, a psychotherapy group, and a psychotherapy combined with drug treatment group. Before and after treatment, the patients were retrospectively analyzed using the gastroesophageal reflux disease Questionnaire, Hamilton Depression Scale, Hamilton Anxiety Scale, and SF-36 Quality of Life Scale.

RESULTS

All three treatments were found to relieve patients' symptoms and improve their quality of life to some extent. The psychotherapy combined with drug treatment group showed the best overall curative effect. The Hamilton Depression and Anxiety Scale scores were significantly lower in the psychotherapy-alone group and psychotherapy combined with drug treatment group than in the drug treatment alone group at 4, 8, and 12 weeks (P < 0.05).

CONCLUSION

Medication, psychotherapy, and psychotherapy combined with medication can relieve clinical symptoms and improve quality of life to varying degrees in patients with NERD.

Proton pump inhibitor and selective serotonin reuptake inhibitor therapy for the management of noncardiac chest pain

INTRODUCTION

Although gastroesophageal reflux disease is the main cause of noncardiac chest pain (NCCP), proton pump inhibitors (PPIs) benefit a minority of patients. Our prospective study evaluated the effect of PPI and selective serotonin reuptake inhibitors on the different subtypes of NCCP characterized by impedance-pH monitoring.

METHODS

All NCCP patients underwent impedance-pH monitoring and on the basis of the results, those with abnormal distal esophageal acid exposure received PPIs twice daily (group A), those with a positive symptom index for chest pain received citalopram 20 mg and PPI once daily (group B), and those with a negative symptom index for chest pain received citalopram 20 mg once daily (group C). Therapy was administered for 12 weeks and treatment success was defined as complete disappearance of chest pain.

RESULTS

From March 2015 to March 2016, 63 patients were included (group A=9, group B=18, group C=36). After 12 weeks of therapy, complete resolution of chest pain was noted in 8/9 (88.9%) group A, 13/18 (72.2%) group B, and 24/36 (66.7%) group C patients.

CONCLUSION

Combined impedance-pH monitoring identifies different subtypes of NCCP patients who can receive tailored management. Targeted therapy with PPIs and/or citalopram offers complete symptom relief in the great majority of them.

Clinical and cost-effectiveness of adapted cognitive behaviour therapy for non-cardiac chest pain: a multicentre, randomised controlled trial

OBJECTIVE

To investigate the cost-effectiveness of a modified form of cognitive behavioural therapy (CBT) for recurrent non-cardiac chest pain.

METHODS

We tested the effectiveness and cost-effectiveness of a modified form of CBT for chest pain (CBT-CP)(4-10 sessions) in patients who attended cardiology clinics or emergency medical services repeatedly. Patients were randomised using a remote web-based system to CBT-CP or to standard care in the clinic. Assessments were made at baseline and at 6 months and 12 months. The primary outcome was the change in the Health Anxiety Inventory Score at 6 months. Other clinical measures, social functioning, quality of life and costs of services were also recorded.

RESULTS

Sixty-eight patients were randomised with low attrition rates at 6 months and 12 months with 81% of all possible assessments completed at 6 months and 12 months. Although there were no significant group differences between any of the outcome measures at either 6 months or 12 months, patients receiving CBT-CP had between two and three times fewer hospital bed days, outpatient appointments, and A&E attendances than those allocated to standard care and total costs per patient were £1496.49 lower, though the differences in costs were not significant. There was a small non-significant gain in quality adjusted life years in those allocated to CBT-CP compared with standard care (0.76 vs 0.74).

CONCLUSIONS

It is concluded that CBT-CP in the context of current hospital structures is not a viable treatment, but is worthy of further research as a potentially cost-effective treatment for non-cardiac chest pain.

TRIAL REGISTRATION NUMBER

ISRCTN 14711101.

Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain - a pilot randomized controlled study

BACKGROUND

Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care.

METHODS

A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22-76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention.

RESULTS

Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups.

CONCLUSIONS

The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02336880 . Registered on 8 January 2015.