Internet-delivered cognitive behavioral therapy (ICBT) outperformed an internet-based supportive therapy program for treating kids ages 10-17 years with social anxiety disorder (SAD), Swedish researchers found.
Cognitive behavioral therapy is considered first-line treatment for children and adolescents with SAD; however, a lack of trained therapists, high treatment costs, long distances to clinics, and the anxiety symptoms themselves prevent many kids from seeking help, Martina Nordh, PhD, of the Department of Clinical Neuroscience at Karolinska Institutet and Stockholm Health Care Services in Stockholm, Sweden, and colleagues explained in JAMA Psychiatry. ICBT, which has proven efficacy in adult patients with SAD, has the potential to overcome these barriers to access, but no study has evaluated the therapy against an active comparator among kids, and health economic evaluations for this population are lacking.
Nordh and colleagues conducted a study to evaluate the efficacy and cost-effectiveness of therapist-guided ICBT for kids with SAD against therapist-guided internet-delivered supportive therapy (ISUPPORT).
The study authors found that “therapist-guided ICBT was significantly more efficacious than ISUPPORT in reducing social anxiety symptoms, as well as depression, anxiety, and functional impairment, with between-group effect sizes in the moderate range,” they wrote. “From a societal perspective, ICBT was cost saving, with the main drivers of the savings being explained by a greater decrease in medication use and an increase in school productivity for youths receiving ICBT compared with those receiving ISUPPORT.”
Treatment with ICBT did not prove as cost-effective from the health care professional perspective—the therapy was more costly due to longer mean therapist support time—but it was still considered more effective than ISUPPORT, they added.
For their single-masked, superiority randomized clinical trial, Nordh and colleagues recruited patients ages 10-17 years with a principal diagnosis of SAD and their parents from Sept. 1, 2017 through Oct. 31, 2018 at a clinical research unit integrated with child and adolescent mental health services in Stockholm. Patients were excluded if they had diagnosed autism spectrum disorder, psychosis, bipolar disorder, or a severe eating disorder; high risk of suicide; ongoing alcohol or substance abuse; or had received CBT for any anxiety disorder within the last six months.
The study’s inclusion procedure consisted of an initial telephone screening and a face-to-face assessment at the clinic, at which a trained psychologist administered the Anxiety Disorders Interview Schedule, Child Version (ADIS-C) jointly with the patient and their parents. The ADIS-C interview and child- and parent-reported measures were administered prior to treatment, after treatment (10 weeks), and at three-months follow-up (22 weeks).
The trial interventions were ICBT and ISUPPORT, which each included 10 online modules, five separate parental modules, and three video call sessions with a therapist (20- to 30-minutes at weeks three, five, and seven). The primary components of the ICBT intervention were “psychoeducation about SAD, gradual exposure to social situations, social skills training, focus shifting (from internal to external attention), reduction of safety behaviors and avoidance, replacement of overly negative thinking with adaptive thoughts, and construction of a plan for relapse prevention,” the study authors explained. ISUPPORT consisted of psychoeducation about SAD and information about healthy habits and interpersonal relations.
“ISUPPORT also included encouragement from the therapists to generate and try strategies for handling challenging social situations and to continue to use strategies that the participant found helpful,” they noted. “Crucially, none of the key components thought to constitute the active elements of CBT for SAD (e.g., exposure) were included.”
The study’s primary outcome was the masked Clinician Severity Rating (CSR) score derived from ADIS-C interviews; secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs.
The final study cohort consisted of 103 patients (mean [SD] age, 14.1 [2.1] years; 79 [77%] female), of whom 51 were randomized to ICBT and 52 were assigned to ISUPPORT.
“Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms,” the study authors reported. “Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d=0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant).”
The cost-effectiveness analyses revealed that ICBT led to cost savings compared to ISUPPORT, “with the main drivers of the savings being lower medication costs (z=2.38, P=0.02) and increased school productivity (z=1.99, P=0.047) in the IBCT group,” they added.
One suicide attempt was reported in the ISUPPORT group; no other adverse events were reported.
Nordh and colleagues argued that further analyses into ICBT for this population should consider modifying treatment length and therapist support, noting that since “young persons with SAD seem to require more time to remit than those with other anxiety disorders, ICBT may require longer periods and/or intensified therapist support. Furthermore, parental involvement in ICBT may be particularly important for preadolescents and younger children to engage in the treatment. The optimal amount of therapist support and parental involvement in ICBT, in relation to child age, should be formally investigated.”
Also, they added, since SAD often occurs with comorbid anxiety disorders, future studies should compare disorder-specific forms of ICBT with transdiagnostic forms “with regard to their efficacy on comorbid conditions.”
Study limitations included that most participants were self-referred, suggesting they may have been more motivated to work through the mostly self-guided treatment. Also, ISUPPORT was seen as less credible than ICBT, possibly impacting treatment expectations.
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A Swedish study found that internet-delivered cognitive behavioral therapy (ICBT) outperformed an internet-based supportive therapy program for treating kids ages 10-17 years with social anxiety disorder (SAD)
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ICBT improved social anxiety symptoms, as well as depression, anxiety, and functional impairment in this population.
John McKenna, Associate Editor, BreakingMED™
Coauthor Mataix-Cols reported receiving personal fees from UpToDate, Wolters Kluwer Health, and Elsevier outside the study. Coauthor Serlachius reported receiving grants from the Swedish Research Council for Health, Working Life, and Welfare and Region Stockholm during the conduct of the study.
Cat ID: 52
Topic ID: 87,52,730,138,192,52,55,921
