Review of: Fallon BA et al, Am J Psychiatry 2017;174(8):756–764

Somatic symptom disorder (formerly known as hypochondriasis) is pretty common, with a prevalence of 5%–7%, and is much more likely to afflict women than men, with a gender ratio of about 10:1. While both psychotherapy and SSRI treatment are helpful, there is limited evidence about the efficacy of combining therapy with medication. A new study sought to remedy this gap.

Researchers recruited 195 people with hypochondriasis (the study occurred before DSM-5) and randomly assigned them to one of four groups: placebo, cognitive behavioral therapy (CBT), fluoxetine, or combination treatment with both CBT and fluoxetine. CBT sessions were delivered from a scripted manual to participants in six 60-minute sessions on a weekly basis, followed by 2 biweekly and then 3 monthly boosters by experienced therapists. Fluoxetine and placebo groups were both given 20- to 30-minute medication management appointments with psychiatrists. Fluoxetine was started at 10 mg QD and gradually increased up to 80 mg QD as tolerated. Patients in the combination group met with both a therapist and psychiatrist. Response was defined as a 25% improvement in symptom severity.

Hypochondriasis symptoms were evaluated at weeks 6, 12, and 24. Based on primary outcome measures at week 24, patients assigned to combination treatment had the highest response rate (47.2%)—higher than the therapy group (39.6%) or the placebo group (29.5%), but not statistically significantly higher than the fluoxetine group (44.4%). However, on a variety of secondary measures, the advantage of combination treatment over fluoxetine alone was less pronounced, and in some cases fluoxetine alone seemed more effective. Interestingly, patients in the fluoxetine-alone group ended up with a mean dose of 40 mg/day; this was higher than patients in the combination group, who took a mean dose of 30.9 mg/day. Adverse events were mild, and were similar in all four treatment groups.

TCPR’s Take
Fluoxetine was effective for symptoms of hypochondriasis. Adding CBT provided only a small additional benefit over fluoxetine alone, although this benefit might have been greater if the dose of fluoxetine in the combination group had been higher. Bottom line, you should consider fluoxetine treatment for your patients with somatic symptom disorder, with or without added CBT.