Internet-delivered CBT efficacious, cost-effective for youths with social anxiety disorder

Cognitive behavioral therapy delivered over the internet was efficacious and cost-effective for children and adolescents with social anxiety disorder, according to results of a randomized clinical trial published in JAMA Psychiatry.

“To our knowledge, no study evaluating [internet-delivered CBT (ICBT)] for [social anxiety disorder] has yet used an active comparator, which is essential to distill the true effect of a behavioral intervention beyond the effects of practitioner attention and frequent monitoring and reporting of symptoms,” Martina Nordh, PhD, of the department of clinical neuroscience at Karolinska Institute and Stockholm Health Care Services in Sweden, and colleagues wrote. “Furthermore, no formal health economic evaluations of ICBT for [social anxiety disorder] in youths have previously been conducted. Cost-effectiveness analyses are important when evaluating new interventions to guide policy makers on how to best allocate resources.”

The researchers aimed to compare ICBT with internet-delivered supportive therapy (ISUPPORT), the active comparator, in terms of the efficacy and cost-effectiveness for youths with social anxiety disorder. They enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, between Sept. 1, 2017, and Oct. 31, 2018, with the final participant having reached the 3-month follow-up in May 2019. The researchers included 103 children and adolescents aged 10 to 17 years (mean age, 14.1 years; 77% female) who had a principal diagnosis of social anxiety disorder, as well as their parents. They randomly assigned 51 to therapist-guided ICBT and 52 to therapist-guided ISUPPORT for social anxiety disorder for 10 weeks. Both interventions consisted of 10 online modules, five separate parental modules and three video call sessions with a therapist. The Clinician Severity Rating (CSR), derived via the Anxiety Disorder Interview Schedule and rate by masked assessors 3 months following the end of treatment, served as the main outcome. Nordh and colleagues defined caseness as CSR scores of four or higher. Masked-assess-rated diagnostic status of social anxiety disorder and global functioning, child- and parent-reported social anxiety and depressive symptoms and health-related costs served as secondary outcomes.

Results showed significantly more efficaciousness in reducing the severity of social anxiety symptoms for ICBT vs. ISUPPORT, with mean CSR scores for ICBT at baseline and 3 months of follow-up of 5.06 and 3.96, respectively, vs. 4.94 and 4.48 for ISUPPORT. At the 3-month follow-up, Nordh and colleagues observed a significant between-group effect size of Cohen’s d = 0.67 (95% CI, 0.21-1.12). Moreover, all secondary outcome measures exhibited significant differences with small to large effect sizes, aside from child-rated quality of life. ICBT was associated with cost savings compared with ISUPPORT, according to results of cost-effectiveness analyses. Lower medication costs and increased school productivity accounted for most of the cost-savings in the ICBT group. The researchers reported one suicide attempt in the ISUPPORT group, which was the only serious adverse event that occurred in either group.

“Internet-delivered cognitive behavioral therapy has the potential to overcome common treatment barriers and increase availability of evidence-based psychological treatments for this patient group,” Nordh and colleagues wrote.