Internet-delivered CBT shows promise for managing social anxiety disorder

Therapist-guided internet-delivered cognitive behavioural therapy (ICBT*) was an effective intervention for children and adolescents with social anxiety disorder (SAD) compared with internet-delivered supportive therapy (ISUPPORT**), a study has shown.

“SAD is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large,” said the researchers. However, only a small fraction of individuals with SAD report their symptoms. “Barriers to treatment access include low availability of trained therapists, high treatment costs, long distances to clinics, and the nature of [symptoms, making] it difficult for the individual to seek help,” the researchers explained.

“The therapist-guided ICBT programme is a revised version of the treatment previously developed and piloted by our research group … ICBT with minimal therapist support [may be] a promising, low-intensity treatment [in this setting],” they continued.

A total of 103 children and adolescents (mean age 14.1 years, 77 percent female) were randomized 1:1 to 10 weeks of therapist-guided ICBT or ISUPPORT. Both interventions included 10 online modules, three videocall sessions with a therapist, and five parental modules. [JAMA Psychiatry 2021;78:705-713]

Mean baseline CSR*** scores for the respective ICBT and ISUPPORT arms were 5.06 and 4.94. At 3 months, these dropped to 3.96 and 4.48, respectively, generating a significant interaction effect (β=−0.27; p=0.005) and between-group effect size of moderate strength (d=0.67), favouring ICBT.

“[These suggest that] ICBT was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms,” said the researchers.

Except for child-rated quality of life, all secondary endpoints also revealed significant interaction effects (d=0.64 and d=0.83 [child- and parent-reported SAD symptoms, respectively], d=0.47 and d=0.78 [child- and parent-reported anxiety/depressive symptoms, respectively], and d=0.39 and d=0.48 [masked assessor- and parent-reported global/general functioning, respectively]). “In all cases, results favoured ICBT, and most between-group effect sizes at 3 months were in the moderate range,” the researchers explained.

There were more SAD-free participants in the ICBT vs the ISUPPORT arm at 3 months (31 percent vs 18 percent); however, the difference was not significant (p=0.09).

Average societal cost was lower for ICBT vs ISUPPORT (€2,426 vs €3,502). “Incremental cost-effectiveness ratio regarding total societal cost differences and differences in remitter status was −€17,901 … indicating that ICBT was associated with cost savings while generating more participants free of SAD vs ISUPPORT,” the researchers explained.

From a societal perspective, ICBT was cost-saving, primarily owing to the greater reduction in medication use (z=2.38; p=0.02) and increase in school productivity (z=1.99; p=0.047) among those on ICBT vs ISUPPORT, they continued.

From a healthcare professional perspective however, ICBT was costlier due to longer mean therapist support times. “Because 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,” they explained. Nonetheless, ICBT still bested ISUPPORT efficacy-wise.

A low-intensity, first-step alternative

“ICBT has the potential to overcome common treatment barriers [and its] implementation in clinical practice could markedly increase the availability of effective evidence-based psychological interventions for this patient group,” said the researchers.

“[However,] ICBT should not be regarded as a substitute for standard face-to-face treatment,” they pointed out. “[It should be considered] a low-intensity treatment to be deployed as a first step, thus freeing resources for young people who require more intensive treatments.”

Future studies should evaluate other variables that might help improve adherence to SAD treatment (eg, treatment length, parental involvement). [Behav Res Ther 2015;67:1-18] Exploring disorder-specific and transdiagnostic forms of ICBT may also be valuable, as SAD frequently occurs with comorbid anxiety disorders.

Participants will be followed for a year after treatment to establish durability of the findings.