Internet CBT Bests Internet-Based Supportive Therapy for Social Anxiety Disorder in Youth

By Marilynn Larkin

May 25, 2021

NEW YORK (Reuters Health) - Internet-delivered cognitive behavioral therapy (ICBT) was more efficacious and cost-effective than internet-based support therapy (ISUPPORT) for social-anxiety disorder (SAD) in young people, a randomized clinical trial from Sweden shows.

"Most youths rated ICBT as a credible treatment that they were satisfied with and, on average, they completed almost eight out of the 10 online modules and almost all of the video sessions," Dr. Martina Nordh of the Karolinska Institute told Reuters Health by email. "This indicates that the treatment not only seems effective, but also feasible, acceptable and sufficiently engaging for children and adolescents."

"It is well known that only a small proportion of youths with SAD seek and receive effective treatment, so we did not know how much interest in the study we could expect," she noted. "We were quite surprised to end up having more than 300 interested families during the enrollment period."

"Of those that were eventually included in the study, only a third had sought psychological treatment for SAD previously," she said. "This informed us that there is a clear need for more accessible treatment options for this patient group."

As reported in JAMA Psychiatry, the superiority study enrolled participants in Stockholm from 2017 to 2018. After assessment, 103 young people with SAD (mean age, 14; 77% female) and their parents were randomized to ICBT or ISUPPORT, both of which included 10 online modules, five separate parental modules, and three video call sessions with a therapist.

The main outcome was the Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors three months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating clinical "caseness."

ICBT was significantly more effective than ISUPPORT in reducing SAD symptom severity. Mean CSR scores for ICBT at baseline and at the three-month follow-up were 5.06 and 3.96, respectively, compared with 4.94 and 4.48 for ISUPPORT, with a significant time-group interaction.

Similarly, all secondary outcome measures - i.e., masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported SAD symptoms, and health-related costs - showed significant differences, except for child-rated quality of life.

Cost-effectiveness analyses indicated savings associated with ICBT compared with ISUPPORT; the main drivers of savings were lower medication costs and increased school productivity in the ICBT group.

There was one suicide attempt in the ISUPPORT group, and no other serious adverse events in either group.

Dr. Nordh said, "We are planning a joint project with the newly opened Internet treatment unit within the Child and Adolescent Mental Health Services in Stockholm to implement and disseminate the program via a Swedish national online platform."

"The treatment protocol is currently not available outside of Sweden," she noted, "but interested researchers from other countries can contact us to discuss possible collaborations if they have a digital platform that meets the highest safety standards for digital interventions and is in compliance with local policies, laws and regulations."

Dr. Maria Espinola, a clinical psychologist at the University of Cincinnati College of Medicine in Ohio, commented on the study for Reuters Health. "Given the association between untreated mental health disorders and poor health outcomes, educational underachievement, poverty, shortened life expectancy, and incarceration, youth mental illness constitutes a serious public-health concern," she said in an email.

"It's important to embrace cost-effective, technology-augmented, easily disseminated therapeutic interventions that can help us reach everyone in need of care," said Dr. Espinola.

Nonetheless, she added, "We have to remember that this is a low-intensity treatment that was developed as a first step and cannot substitute for face-to-face treatment."

Dr. Shannon Bennett, a clinical psychologist at Weill Cornell Medicine in New York City, also commented by email. "I agree that ICBT could be very useful for SAD in adolescents, with the caveat that it is crucial for adolescents with social anxiety to practice managing their anxiety in live social and performance situations," she said.

"Simply interacting with a program online will not adequately prepare someone for in person interactions," she told Reuters Health. "Thus, the planned live practice is essential for coping skill rehearsal and anxiety reduction."

Additional research is necessary to understand the value and limits of ICBT as a stand-alone treatment, she noted. "However, there is a lot of potential in utilizing the internet or app-based treatments as an adjunct to traditional therapy."

SOURCE: JAMA Psychiatry, online May 12, 2021.