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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
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.


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

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Article Information

Accepted for Publication: February 22, 2021.

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

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Nordh M et al. JAMA Psychiatry.

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.

Data Sharing Statement: See Supplement 3.

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.

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