PRINCE Secondary Trial

    Not Recruiting
  • participants needed
  • sponsor
    King's College London
Updated on 22 January 2021


Brief Summary: Persistent Physical Symptoms (PPS; also known as medically unexplained symptoms - MUS) is a term used to describe a range of physical health difficulties that people can experience and for which the exact cause is unclear. Between 20 and 40% of patients in primary care, and about 50% in secondary care experience PPS. Not only are PPS common, but the overlap across different patient groups may indicate that these phenomena are transdiagnostic. PPS are associated with profound disability and high health care costs, and if left untreated the prognosis of these patients is poor. There is an accumulating body of evidence demonstrating that cognitive behavioural interventions can reduce levels of symptoms and improve functioning in patients with PPS. A pragmatic RCT was designed to evaluate the clinical and cost-effectiveness of cognitive behavioural therapy (CBT) + Standard Medical Care (SMC) versus Standard Medical Care alone, in the treatment of patients with PPS. The trial will focus on patients with a variety of symptoms (e.g., non-cardiac chest pain, fibromyalgia), across secondary care clinics (e.g., neurology, cardiology, and rheumatology). Patients who have been referred to secondary care in the past six months will also be recruited from General Practice (GP) surgeries.


Background and study aims In primary care between 20 and 40% of patients have medically unexplained physical symptoms. The term medically unexplained symptoms (MUS) is commonly used by health care professionals. However a survey of a healthy population and a separate survey of patients with chronic fatigue syndrome (CFS) suggested that the term persistent physical symptoms (PPS) was the preferred term. The term PPS may have its drawbacks, but it will used for the rest of this document to cover MUS as well as any other terms that may be used in the literature and clinical settings to refer to these symptoms. In secondary care, about 50% of patients have PPS, in many specialties. PPS are associated with profound disability and high health care costs. Around 50% of sufferers have co-morbid anxiety and depression and sleep anxiety. Left untreated, the prognosis of these patients is poor.

This study is a pragmatic RCT that will evaluate the clinical and cost-effectiveness of cognitive behavioural therapy + standard medical care (CBT+SMC) which involves 8 sessions of CBT versus standard medical care (SMC) in the treatment of patients with PPS.

Who can participate? Patients with various PPS, such as fibromyalgia, non-cardiac chest pain, postural orthostatic tachycardia syndrome, a range of neurological symptoms (e.g., weakness, abnormal movement) etc. will be recruited. Participants will be recruited from clinics in secondary care (e.g., neurology, cardiology, rheumatology) at various hospitals and GP practices in London and Greater London.

What does the study involve? Potential participants will be identified by clinical staff who will refer them to the research team. In primary care, the GP practice will send trial invitation letters to eligible patients in the post. Patients who give their consent to take part in the study will complete a number of questionnaires asking about their symptoms and use of health care services, and about their thoughts, feelings, and beliefs related to their PPS (i.e., baseline). This will take approximately 1.5 hours. After this research assessment, half of participants will be randomly assigned to the treatment arm (i.e., CBT+SMC), or to the control (i.e.,SMC) arm. Participants in the treatment arm will receive 8 individual sessions of CBT (weekly or fortnightly sessions). The therapy aims to help the patient develop an understanding of the relationship between cognitive, physiological and behavioural aspects of their problem; to understand factors that may be maintaining the problem and to learn how to modify their behavioural and cognitive responses in order to prevent ongoing symptoms and disruption to healthy living. Participants in the SMC group will receive usual care within the clinic/GP practice.

Participants in both arms will also be asked to complete questionnaires at baseline and at 9, 20, 40, and 52 weeks after randomisation. The assessment will be independent of the health care professionals delivering care.

Additionally, patients with PPS who do not meet all the inclusion criteria for the trial and patients who meet all the inclusion criteria but decline to take part, will be presented with the option of completing questionnaires about their PPS, medical services use, and thoughts/feelings/beliefs about their symptoms (at baseline, and 9, 20, 40, and 52 weeks post-consent). This is to gain a better understanding of care pathways within NHS for patients with PPS. Although these patients will not be randomised, their consent to being followed-up routinely will be obtained.

What are the possible benefits and risks of participating? By taking part in the study patients may get helpful information about their condition. If assigned to the CBT+SMC arm, patients will receive 8 sessions of CBT focused on helping them manage their symptoms, which may improve their symptoms and increase their psychosocial functioning. It is unclear whether CBT for patients with PPS is effective; this trial will assess whether there are benefits to receiving it. Patients may benefit from being followed up closely and completing measures. It is not expected that participation in the study is associated with risks. The therapists involved in the trial are highly qualified specialists with extensive experience in treating patients with PPS. The trial team also includes a psychiatrist who will further ensure patient safety in complex cases. Participants will be free to take a break at any point during the meetings and are free to withdraw from the study at any point. Participants will also be informed that they can raise any concerns they may have with the research team and will be provided with the Patient Advice & Liaison Service contact information.

Where is the study run from? The study has been set up by the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) at King's College London and the South London and Maudsley NHS Foundation Trust, and will be conducted at several hospitals in London/Greater London, including Guy's and St Thomas' Hospitals, King's College Hospital, Princess Royal University Hospital, Royal Free Hospital, and University Hospital Lewisham.

When is the study starting and how long is it expected to run for? The study has started in July 2015 and the end date for the project is October 2017.

Who is funding the study? The study is funded by the Guy's and St. Thomas' Charity.

Who is the main contact? Prof Trudie Chalder

Condition Persistent Physical Symptoms (PPS)
Treatment Cognitive Behavioural Therapy (CBT)
Clinical Study IdentifierNCT02426788
SponsorKing's College London
Last Modified on22 January 2021

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