Low-intensity interventions for anxiety disorders
Authors: Paul Stallard
Journal: The Lancet Psychiatry (2017)

Anxiety disorders in children are common, impairing, and persistent,1Kessler RC Berglund P Demler O Jin R Merikangas KR Walters EE Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.Arch Gen Psychiatry. 2005; 62: 593-602Crossref PubMed Scopus (12916) Google Scholar and result in substantial costs to health, social care, and educational services.2Snell T Knapp M Healey A et al.Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data.J Child Psychol Psychiatry. 2013; 54: 977-985Crossref PubMed Scopus (93) Google Scholar Although effective interventions are available,3James AC James G Cowdrey FA Soler A Choke A Cognitive behavioural therapy for anxiety disorders in children and adolescents.Cochrane Database Syst Rev. 2015; 6 (CD004960)Google Scholar there are not enough suitably trained therapists to meet demand within child and adolescent mental health services (CAMHS),4Shafran R Fonagy P Pugh KA Myles P Transformation of mental health services for children and young people in England.in: Beidas RS Kendall PC Dissemination and implementation of evidence-based practices in child and adolescent mental health. Oxford University Press, New York, NY2014: 158-178Google Scholar resulting in fewer than a third of children with mental health needs accessing the help they require. The challenge facing CAMHS is to maintain service quality while maximising the impact and use of the resources available to deliver accessible, acceptable, effective, and cost-effective interventions. In The Lancet Psychiatry, Cathy Creswell and colleagues5Creswell C Violato M Fairbanks H et al.Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial.Lancet Psychiatry. 2017; (published online May 17)http://dx.doi.org/10.1016/S2215-0366(17)30149-9Summary Full Text Full Text PDF PubMed Scopus (60) Google Scholar report findings from their pragmatic randomised controlled trial comparing two brief psychological interventions—brief guided parent-delivered cognitive behaviour therapy (CBT) and solution-focused brief therapy—for children aged 5–12 years with anxiety disorders. Although solution-focused brief therapy might not be widely used as an intervention for childhood anxiety, there is tentative support that it could be effective, particularly as an early intervention for less severe presentations.6Bond C Woods K Humphrey N Symes W Green L Practitioner review: the effectiveness of solution focused brief therapy with children and families: a systematic and critical evaluation of the literature from 1990–2010.J Child Psychol Psychiatry. 2013; 54: 707-723Crossref PubMed Scopus (88) Google Scholar Primary mental health workers received 2 days of training in each intervention, followed by fortnightly supervision, and both interventions were delivered with 5 h of therapist contact. Results for the primary outcome of clinician-rated recovery, on the basis of Clinical Global Impressions of Improvement (CGI-I), showed that 40 (59%) of 68 children in the brief guided parent-delivered CBT group versus 47 (69%) of 68 children in the solution-focused brief therapy group had an improvement of much or very much in CGI-I score after treatment, and 45 (66%) versus 49 (72%) had an improvement at 6 months' follow-up, with no significant differences between groups (relative risk 1·01, 95% CI 0·86–1·19; p=0·95). The study included an economic analysis, which showed that, both interventions achieved similar outcomes. Further work is needed to assess the suggestion that brief guided parent-delivered CBT might be associated with lower costs, given that the difference in cost was not statistically significant; however, cost reductions might come from both intervention delivery and the wider societal costs arising from changes in service use and clinic attendance. Few economic evaluations of interventions for child mental health disorders have been reported.7Beecham J Annual research review: child and adolescent mental health interventions: a review of progress in economic studies across different disorders.J Child Psychol Psychiatry. 2014; 55: 714-732Crossref PubMed Scopus (79) Google Scholar In view of the current climate of financial austerity, Creswell and colleagues' findings are important and highlight how interventions of similar length delivered in different ways need to be compared not just for their clinical differences, but also for their cost differences. In this instance, use of brief telephone contacts reduced the need for face-to-face consultations and associated travel costs and time off work or school to attend clinic appointments. Although intervention acceptability was not reported, reviews have shown that technologically supported interventions are rated highly by children and parents.8Boydell KM Hodgins M Pignatiello A Teshima J Edwards H Willis D Using technology to deliver mental health services to children and youth: a scoping review.J Can Acad Child Adolesc Psychiatry. 2014; 23: 87-99PubMed Google Scholar The role of digital health in the delivery and support of child mental health interventions is receiving greater attention than previously9Department of HealthFuture in mind: promoting, protecting and improving our children and young people's mental health and wellbeing.http://www.thewellcentre.org/uploads/2/1/8/6/21862188/childrens_mental_health_report_march_2015.pdfDate: March, 2015Google Scholar because technological advances have resulted in the use of newer technologies, such as smartphone apps, video conferencing, and computerised interventions. However, clinicians are often cautious about adopting technology, with common barriers including a lack of technological competence, technical problems, and concerns about effectiveness. The present findings provide a way forward and offer a timely reminder that highly familiar low-technology telephone support can be a cost-effective way of using clinical resources. This study also highlights the value of low-intensity interventions for children with anxiety disorders. Typically, low-intensity interventions involve fewer sessions, often include self-help materials, and can be delivered by mental health workers with less specialist knowledge.10Bennett-Levy J Richards D Farrand P et al.Oxford guide to low intensity CBT interventions. Oxford University Press, New York, NY2010Crossref Google Scholar Although the study was not designed to directly compare brief and standard CAMHS interventions, the outcomes from these brief interventions at 6 months seem to be similar to those achieved with lengthier CAMHS interventions, such as CBT.3James AC James G Cowdrey FA Soler A Choke A Cognitive behavioural therapy for anxiety disorders in children and adolescents.Cochrane Database Syst Rev. 2015; 6 (CD004960)Google Scholar Further research is needed to directly establish equivalence between brief and traditional interventions, although if these results were replicated the implications for clinical services could be substantial. Twice as many children could be treated by brief guided parent-delivered CBT and solution-focused brief therapy than by traditional CAMHS interventions, which typically involve 12–16 sessions. The CAMHS workforce could be readily expanded because these interventions can be delivered by less specialist child mental health workers. Furthermore, the interventions require little training and could readily be incorporated into national training initiatives, such as the Children's and Young People Improving Access to Psychological Therapies programme in England.4Shafran R Fonagy P Pugh KA Myles P Transformation of mental health services for children and young people in England.in: Beidas RS Kendall PC Dissemination and implementation of evidence-based practices in child and adolescent mental health. Oxford University Press, New York, NY2014: 158-178Google Scholar Creswell and colleagues' results are a timely reminder of the value of brief low-intensity interventions for the treatment of child anxiety disorders. Incorporation of low-intensity interventions such as these as part of a stepped care pathway for the treatment of anxiety disorders could be a cost-effective way of maximising the impact of the CAMHS resources currently available. PS had no direct involvement with this study; he is however involved with Cathy Creswell and Mara Violato on a National Institute for Health Research Health Technology Assessment trial investigating two cognitive interventions for the treatment of social anxiety in adolescents. Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trialOur findings show no evidence of clinical superiority of brief guided parent-delivered CBT. However, guided parent-delivered CBT is likely to be a cost-effective alternative to solution-focused brief therapy and might be considered as a first-line treatment for children with anxiety problems. Full-Text PDF Open Access