Parent-Delivered CBT May Widen Access to Anxiety Treatment

Batya Swift Yasgur, MA, LSW

May 24, 2017

Children with anxiety disorders benefit as much from parent-delivered cognitive-behavioral therapy (CBT) as from solution-focused brief therapy delivered by mental health professionals, and parent-delivered CBT is more cost-effective, new research shows.

"We already knew that parent-delivered CBT worked and that it was quicker than most CBT approaches for childhood anxiety disorder. But we wanted to establish whether it was more cost-effective than other types of brief psychological treatments for these children," study investigators Cathy Creswell, PhD, professor of developmental clinical psychology and National Institute of Health Research research professor, School of Psychology and Clinical Language Sciences, University of Reading, Berkshire, United Kingdom, told Medscape Medical News.

"The take-home message is that if you are looking for increased access to effective treatment for child anxiety disorders, the clinical outcomes are good for both treatments. But the cost savings associated with parent-delivered CBT seems to be a good reason for offering parents this approach as first-line treatment," she said.

The study was published online in the May 17 issue of the Lancet Psychiatry.

Lack of Access to Quality Care

Less than one third of children with anxiety disorders have access to professionally delivered evidence-based treatments, the authors note.  Moreover, treatments are "typically lengthy," often involving 14 to16 hour-long sessions in specialty settings.

Previous studies of parent-delivered CBT showed outcomes similar to those of more traditionally delivered CBT. "However, whether this therapy would be superior to a credible, alternative, brief psychological treatment remains unclear," they note.

"In the UK and many other places around the world, it is just not possible for services to deliver intense CBT treatment to children with anxiety. Much briefer treatments are in use but have not yet been formally evaluated," said Dr Creswell.

To investigate the relative benefits of brief interventions, the researchers compared the effectiveness and cost-effectiveness of parent-delivered CBT to solution-focused brief therapy, which is widely used in National Health Service (NHS) mental health settings for treating children with anxiety.

They randomly assigned children with anxiety, aged 5 to 12 years, on a 1:1 basis to receive parent-delivered CBT or solution-focused brief therapy.

Families in both groups received approximately 5 hours of treatment. Before the trial, the therapists received a 2-day training in each treatment approach.

In the CBT group, parents received a self-help book and up to eight weekly sessions of therapist-supported brief guided parent-delivered CBT. Of these, four were conducted face-to-face and four were conducted via brief telephone interviews.

Solution-focused brief therapy consisted of an initial face-to-face session with the parent and child, four face-to-face sessions with the child, and a final session with the parent and child.

Assessment points took place at baseline (prior to randomization), after treatment (primary endpoint), and 6 months after treatment completion.

The primary outcome was an improvement of "much" or "very much," as measured by the Clinical Global Impression of Improvement (CGI-I) scale. The CGI-I score was based on parent and child report on the Anxiety Disorders Interview Schedule, child and parent version.

A variety of clinical scales were used to measure secondary outcomes related to clinical severity ratings. Quality-adjusted life-years (QALYs) that were used in cost-utility analysis were derived from the Child Health Utility 9D.

Increased Access, Reduced Cost

The researchers "adopted a societal perspective" to assess resource use and costs, including all health, social care, non-NHS cost-generating services, and lost leisure and productivity time estimates for parents.

Between March 23, 2012, and March 31, 2014, 136 children were randomly assigned to receive brief guided parent-delivered CBT (n = 68) or solution-focused brief therapy (n = 68).

At the primary endpoint assessment, 59% of children in the parent-delivered CBT group showed an improvement of "much" or "very much" in CGI-I score, compared with 69% of children in the solution-focused brief therapy group. At the 6-month follow-up assessment, 66% of children in the parent-delivered CBT group showed an improvement, compared with 72% in the solution-focused brief therapy group.

There were no significant differences between groups across both time points in clinical (CGI-I: relative risk, 1.01; 95% confidence interval [CI], 0.86 - 1.19; P = .95) or economic (QALY: mean difference, 0.006; 95% CI, –0.009 to 0.02; P = .42) outcome measures, the researchers reported.

However, brief guided parent-delivered CBT was associated with lower costs (mean difference, –£448; 95% CI, –£934 to £37; P = .070) than solution-focused brief therapy and was more likely to "represent a cost-effective use of resources," the researchers stated.

The lower cost of the parent-delivered CBT intervention was driven by treatment costs (mean difference, –£133; 95% CI, –£204 to –£63; P < .0001) and time off from school or work or leisure time for children and parents (£200; 95% CI, –£386 to –£13; P = .036).

Although the actual amount of time spent in treatment delivery was similar between the groups, the researchers attributed the lower cost of parent-delivered CBT to reductions in the therapists' travel expenses to the treatment site (ie, time that they could have spent in other activities and mileage cost) and time spent in administrative tasks.

"We did not anticipate the differences in costs because we deliberately made sure that the amount of treatment time was the same between the two groups," Dr Creswell noted.

"By taking costs and outcomes together, we looked at overall cost-effectiveness, and that is when we found that parent-led CBT can be highly cost-effective in comparison to other treatments, not only by keeping the therapists' costs down but also in terms of wider health and social costs," she said.

Doubling Access to Care

Commenting on the study for Medscape Medical News, Paul Stallard, PhD, professor of child and family mental health, University of Bath, United Kingdom, called the study "important" because it was "undertaken in a real-world setting" and also "includes an economic analysis."

"This therefore helps to determine not only whether an intervention works but also whether it can be delivered at lower costs than traditional care," said Dr Stallard, author of an accompanying editorial, who was not involved in the study.

The study "demonstrated that significant positive effects can be obtained by brief 5-hour low-intensity interventions requiring little training," he said.

He cautioned that the study "was not designed to compared brief vs standard psychological interventions, and further direct comparison are required to establish equivalence."

Nevertheless, the study shows that "brief interventions are effective, with 60% to 70% of children in this study demonstrating improvements at the end of treatment and at 6 months of follow-up," he observed.

"The study supports a stepped-care approach to the treatment of anxiety disorders, where brief, low-intensity interventions are provided as the first step for these children," he said.

He added that implementing this intervention would double the number of children with anxiety disorders being treated with brief interventions.

Dr Creswell agreed. "Over the past few years, we have been contacted by many NHS childhood and adolescent teams with long waiting lists for children with anxiety. They are very keen to have efficient ways of treating these children. Now, numerous teams are using this approach as first line. It is brief and although it is not effective in all children, it works well in most."

This study was funded by the National Institute of Health Research.Dr Creswell is the author of a published book for parents that was used in the brief guided parent-delivered CBT group of this trial and receives royalties from sales of this book. Dr Stallard had no direct involvement with this study but is involved with Dr Creswell on a National Institute for Health Research Health Technology Assessment trial investigating two cognitive interventions for the treatment of social anxiety in adolescents.

Lancet Psychiatry. Published online May 17, 2017. Abstract, Editorial

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