Quiz

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety DisorderA Randomized Clinical Trial

Educational Objective
To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for social anxiety disorder (SAD) in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).

1 Credit CME

JAMA Psychiatry

Published Online: May 12, 2021

Original Investigation

Article Information and Disclosures

Martina Nordh, PhD¹;

Tove Wahlund, PhD¹;

Maral Jolstedt, PhD¹;

et al

Hanna Sahlin, PhD¹;

Johan Bjureberg, PhD¹;

Johan Ahlen, PhD^1,2;

Maria Lalouni, PhD^1,3;

Sigrid Salomonsson, PhD¹;

Sarah Vigerland, PhD¹;

Malin Lavner, MSc¹;

Lars-Göran Öst, PhD⁴;

Fabian Lenhard, PhD¹;

Hugo Hesser, PhD^5,6;

David Mataix-Cols, PhD¹;

Jens Högström, PhD¹;

Eva Serlachius, MD, PhD¹

Author Affiliations

¹Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
²Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
³Division of Neuro, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
⁴Department of Psychology, Stockholm University, Stockholm, Sweden
⁵Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
⁶Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden

Read article on JAMA Network

Read Article Take Quiz

Key Points

Question Is internet-delivered cognitive behavioral therapy (ICBT) an efficacious and cost-effective treatment for youths with social anxiety disorder (SAD)?

Findings In this randomized clinical trial of 103 children and adolescents with a principal diagnosis of SAD and their parents, a 10-week course of ICBT was efficacious and cost-effective compared with an active comparator.

Meaning Internet-delivered cognitive behavioral therapy has the potential to overcome common treatment barriers and increase the availability of evidence-based psychological treatments for young people with SAD; policy makers could consider ICBT with minimal therapist support a promising, low-intensity treatment for children and adolescents with SAD.

Abstract

Importance Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited.

Objective To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).

Design, Setting, and Participants This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study.

Interventions ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist.

Main Outcomes and Measures The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. 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.

Results Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. 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 indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group.

Conclusions and Relevance In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD.

Trial Registration ClinicalTrials.gov Identifier: NCT03247075

Take Quiz

Buy This Activity

Article Information

Accepted for Publication: February 22, 2021.

Published Online: May 12, 2021. doi:10.1001/jamapsychiatry.2021.0469

Corresponding Author: Martina Nordh, PhD, Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Gävlegatan 22, SE-113 30, Stockholm, Sweden (martina.nord@ki.se).

Author Contributions: Drs Högström and Serlachius contributed equally to this work and share last authorship. Drs Nordh and Serlachius had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nordh, Salomonsson, Lenhard, Mataix-Cols, Högström, Serlachius.

Acquisition, analysis, or interpretation of data: Nordh, Wahlund, Jolstedt, Sahlin, Bjureberg, Ahlen, Lalouni, Vigerland, Lavner, Öst, Lenhard, Hesser, Mataix-Cols, Högström, Serlachius.

Drafting of the manuscript: Nordh, Jolstedt, Lenhard, Hesser, Högström.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Nordh, Lenhard, Hesser.

Obtained funding: Vigerland, Mataix-Cols, Serlachius.

Administrative, technical, or material support: Nordh, Wahlund, Jolstedt, Sahlin, Bjureberg, Ahlen, Lalouni, Salomonsson, Vigerland, Lavner, Högström, Serlachius.

Supervision: Nordh, Öst, Mataix-Cols, Högström, Serlachius.

Conflict of Interest Disclosures: Dr Mataix-Cols reported receiving personal fees from UpToDate, Wolters Kluwer Health, and Elsevier outside the submitted work. Dr Serlachius reported receiving grants from the Swedish Research Council for Health, Working Life, and Welfare and Region Stockholm during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was funded by grant Forte 2014-4052 from the Swedish Research Council for Health, Working Life, and Welfare and grant HNSV 14099 from Region Stockholm. Dr Högström was supported by grant K0173-2016 from Region Stockholm (clinical postdoctoral appointment: 2017-2020). Dr Serlachius was supported by Region Stockholm (clinical research appointment: 2017-0605).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Karin Sundström, MSc, and Viktor Eriksson, MSc, provided invaluable clinical work, Mathilde Annerstedt, MSc, assisted with participant assessments, and Malin Burman, BSc, provided administrative support. All were compensated with salaries funded by grant 2014-4052 from the Swedish Research Council for Health, Working Life, and Welfare and grant HNSV 14099 from Region Stockholm. We thank all participating families and Child and Adolescent Mental Health Services practitioners who made the study possible.

References

Stein DJ , Lim CCW , Roest AM , et al; WHO World Mental Health Survey Collaborators. The cross-national epidemiology of social anxiety disorder: data from the World Mental Health Survey Initiative. BMC Med. 2017;15(1):143. doi:10.1186/s12916-017-0889-2 PubMed Google Scholar Crossref

Patel A , Knapp M , Henderson J , Baldwin D . The economic consequences of social phobia. J Affect Disord. 2002;68(2-3):221-233. doi:10.1016/S0165-0327(00)00323-2 PubMed Google Scholar Crossref

Scaini S , Belotti R , Ogliari A , Battaglia M . A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents. J Anxiety Disord. 2016;42:105-112. doi:10.1016/j.janxdis.2016.05.008 PubMed Google Scholar Crossref

Pilling S , Mayo-Wilson E , Mavranezouli I , Kew K , Taylor C , Clark DM ; Guideline Development Group. Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance. BMJ. 2013;346:f2541. doi:10.1136/bmj.f2541 PubMed Google Scholar Crossref

Burstein M , He JP , Kattan G , Albano AM , Avenevoli S , Merikangas KR . Social phobia and subtypes in the National Comorbidity Survey-Adolescent Supplement: prevalence, correlates, and comorbidity. J Am Acad Child Adolesc Psychiatry. 2011;50(9):870-880. doi:10.1016/j.jaac.2011.06.005 PubMed Google Scholar Crossref

Merikangas KR , He JP , Burstein M , et al. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32-45. doi:10.1016/j.jaac.2010.10.006 PubMed Google Scholar Crossref

Dalrymple KL , Zimmerman M . Treatment-seeking for social anxiety disorder in a general outpatient psychiatry setting. Psychiatry Res. 2011;187(3):375-381. doi:10.1016/j.psychres.2011.01.004 PubMed Google Scholar Crossref

Holmes EA , Ghaderi A , Harmer CJ , et al. The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science. Lancet Psychiatry. 2018;5(3):237-286. doi:10.1016/S2215-0366(17)30513-8 PubMed Google Scholar Crossref

Podina IR , Podina IR , Mogoase C , et al. A meta-analysis on the efficacy of technology mediated CBT for anxious children and adolescents. J Ration Emot Cogn Behav Ther. 2016;34(1):31-50. doi:10.1007/s10942-015-0228-5 Google Scholar Crossref

10.

Rooksby M , Elouafkaoui P , Humphris G , Clarkson J , Freeman R . Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety: systematic review and meta-analysis. J Anxiety Disord. 2015;29:83-92. doi:10.1016/j.janxdis.2014.11.006 PubMed Google Scholar Crossref

11.

Kampmann IL , Emmelkamp PM , Morina N . Meta-analysis of technology-assisted interventions for social anxiety disorder. J Anxiety Disord. 2016;42:71-84. doi:10.1016/j.janxdis.2016.06.007 PubMed Google Scholar Crossref

12.

Spence SH , Donovan CL , March S , Kenardy JA , Hearn CS . Generic versus disorder specific cognitive behavior therapy for social anxiety disorder in youth: a randomized controlled trial using internet delivery. Behav Res Ther. 2017;90:41-57. doi:10.1016/j.brat.2016.12.003 PubMed Google Scholar Crossref

13.

Chambless DL , Hollon SD . Defining empirically supported therapies. J Consult Clin Psychol. 1998;66(1):7-18. doi:10.1037/0022-006X.66.1.7 PubMed Google Scholar Crossref

14.

Jolstedt M , Wahlund T , Lenhard F , et al. Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial. Lancet Child Adolesc Health. 2018;2(11):792-801. doi:10.1016/S2352-4642(18)30275-X PubMed Google Scholar Crossref

15.

Lenhard F , Andersson E , Mataix-Cols D , et al. Therapist-guided, internet-delivered cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2017;56(1):10-19.e2. doi:10.1016/j.jaac.2016.09.515 PubMed Google Scholar Crossref

16.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.

17.

Silverman WK , Albano AM . Anxiety Disorders Interview Schedule: ADIS-IV Child Interview Schedule. Vol 2. Graywind Publications; 1996.

18.

Nordh M , Vigerland S , Öst L-G , et al. Therapist-guided internet-delivered cognitive-behavioural therapy supplemented with group exposure sessions for adolescents with social anxiety disorder: a feasibility trial. BMJ Open. 2017;7(12):e018345. doi:10.1136/bmjopen-2017-018345 PubMed Google Scholar

19.

Faul F , Erdfelder E , Lang AG , Buchner A . G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175-191. doi:10.3758/BF03193146 PubMed Google Scholar Crossref

20.

Hudson JL , Rapee RM , Lyneham HJ , McLellan LF , Wuthrich VM , Schniering CA . Comparing outcomes for children with different anxiety disorders following cognitive behavioural therapy. Behav Res Ther. 2015;72:30-37. doi:10.1016/j.brat.2015.06.007 PubMed Google Scholar Crossref

21.

Hedeker D , Gibbons RD . Longitudinal Data Analysis. Vol 451. John Wiley & Sons; 2006.

22.

Bouwmans C, Jong KD, Timman R, et al. Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P). BMC Health Serv Res. 2013;13:217. doi:10.1186/1472-6963-13-217

23.

Assessing the performance of a new generic measure of health-related quality of life for children and refining it for use in health state valuation. Appl Health Econ Health Policy. 2011;9(3):157-169. doi:10.2165/11587350-000000000-00000

24.

Herbert JD , Gaudiano BA , Rheingold AA , et al. Cognitive behavior therapy for generalized social anxiety disorder in adolescents: a randomized controlled trial. J Anxiety Disord. 2009;23(2):167-177. doi:10.1016/j.janxdis.2008.06.004 PubMed Google Scholar Crossref

25.

Masia-Warner C , Klein RG , Dent HC , et al. School-based intervention for adolescents with social anxiety disorder: results of a controlled study. J Abnorm Child Psychol. 2005;33(6):707-722. doi:10.1007/s10802-005-7649-z PubMed Google Scholar Crossref

26.

Beidel DC , Turner SM , Sallee FR , Ammerman RT , Crosby LA , Pathak S . SET-C versus fluoxetine in the treatment of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1622-1632. doi:10.1097/chi.0b013e318154bb57 PubMed Google Scholar Crossref

27.

Spence SH , Donovan C , Brechman-Toussaint M . The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitive-behavioural intervention, with and without parental involvement. J Child Psychol Psychiatry. 2000;41(6):713-726. doi:10.1111/1469-7610.00659 PubMed Google Scholar Crossref

28.

Olivares J , García-López LJ , Beidel DC , Turner SM , Albano AM , Hidalgo MD . Results at long-term among three psychological treatments for adolescents with generalized social phobia (I): statistical significance. Psicología Conductual. 2002;10(1):147-166.Google Scholar

29.

Hedman E , Andersson G , Ljótsson B , et al. Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial. PLoS One. 2011;6(3):e18001. doi:10.1371/journal.pone.0018001 PubMed Google Scholar

30.

Öst LG , Cederlund R , Reuterskiöld L . Behavioral treatment of social phobia in youth: does parent education training improve the outcome? Behav Res Ther. 2015;67:19-29. doi:10.1016/j.brat.2015.02.001 PubMed Google Scholar Crossref

31.

Pennant ME , Loucas CE , Whittington C , et al; Expert Advisory Group. Computerised therapies for anxiety and depression in children and young people: a systematic review and meta-analysis. Behav Res Ther. 2015;67:1-18. doi:10.1016/j.brat.2015.01.009 PubMed Google Scholar Crossref

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety DisorderA Randomized Clinical Trial

Behavioral Therapy vs Supportive Therapy for Youths With Social Anxiety Disorder

See More About

Want full access to the AMA Ed Hub?

AMA Membership provides:

Sign in to access

Want full access to the AMA Ed Hub?

Sign in to customize your interests

With a personal account, you can:

Name Your Search

Sign in to save your search

With a personal account, you can:

Lookup An Activity

My Saved Searches

My Saved Courses

Purchase access