Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: Results from a randomized controlled trial

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Abstract

Social anxiety disorder (SAD) is highly prevalent and associated with a substantial societal economic burden, primarily due to high costs of productivity loss. Cognitive behavior group therapy (CBGT) is an effective treatment for SAD and the most established in clinical practice. Internet-based cognitive behavior therapy (ICBT) has demonstrated efficacy in several trials in recent years. No study has however investigated the cost-effectiveness of ICBT compared to CBGT from a societal perspective, i.e. an analysis where both direct and indirect costs are included. The aim of the present study was to investigate the cost-effectiveness of ICBT compared to CBGT from a societal perspective using a prospective design. We conducted a randomized controlled trial where participants with SAD were randomized to ICBT (n = 64) or CBGT (n = 62). Economic data were assessed at pre-treatment, immediately following treatment and six months after treatment. Results showed that the gross total costs were significantly reduced at six-month follow-up, compared to pre-treatment in both treatment conditions. As both treatments were equivalent in reducing social anxiety and gross total costs, ICBT was more cost-effective due to lower intervention costs. We conclude that ICBT can be more cost-effective than CBGT in the treatment of SAD and that both treatments reduce societal costs for SAD.

Highlights

► Cost-effectiveness analysis of Internet-based CBT vs. group CBT for social anxiety. ► Both forms of CBT reduce societal costs of social anxiety disorder. ► Internet-based CBT is more cost-effective due to lower intervention costs. ► Internet-based CBT might be the most promising mean of disseminating CBT.

Introduction

Several features of social anxiety disorder (SAD) contribute to making it an economic burden from a societal perspective. It is highly prevalent (Furmark et al., 1999), has an onset in early adolescence (Kessler et al., 2005), and is associated with academic underachievement and an increased risk of unemployment (Magee et al., 1996, Wittchen et al., 2000). Furthermore, if untreated SAD is a chronic condition for a majority of the affected (Chartier et al., 1998, Reich et al., 1994) and has a profoundly negative impact on quality of life (Fehm, Pelissolo, Furmark, & Wittchen, 2005). The total annual societal costs for SAD have been estimated to $385 million per 1 million inhabitants when controlling for comorbidity (Acarturk et al., 2009). The main costs of SAD pertains indirect non-medical costs, i.e. loss of work and domestic productivity (Acarturk et al., 2009).

Cognitive behavioral group therapy (CBGT) has been shown to be effective in the treatment of SAD, producing improvements in about two thirds of treated patients (Heimberg et al., 1990, Heimberg et al., 1998). One study investigated the cost-effectiveness of treatments for SAD and found that CBGT seemed to be the least costly intervention compared to individual cognitive behavior therapy (CBT) and pharmacotherapy with SSRIs over a two year period (Gould, Buckminster, Pollack, Otto, & Massachusetts, 1997). However, CBGT is not widely disseminated due to a lack of trained therapists and high costs of treatment (Shapiro, Cavanagh, & Lomas, 2003). These costs do not, however, take societal economic impact into account, meaning that CBGT might be advantageous from an economic point of view in comparison to no treatment for society as a whole. Taking a societal perspective means including not only the costs of the administered treatment such as CBGT in the analysis, but also indirect costs, e.g. unemployment and sick leave. In addition, costs related to health care uptake are included, e.g. visits to primary care physicians.

In recent years, Internet-based CBT (ICBT) for SAD has been demonstrated to be efficacious in several randomized controlled trials (Andersson et al., 2006, Berger et al., 2009, Carlbring et al., 2007, Furmark et al., 2009, Titov et al., 2008). As ICBT requires a limited amount of therapist resources, often less than 10 min weekly per patient (Andersson, 2009, Barak et al., 2009), it has the potential of being a more cost-effectiveness treatment than CBGT, which in turn, could enable increased accessibility to CBT.

In one study, ICBT has been estimated to be less costly than CBGT and probably equally effective in reducing symptoms (Titov, Andrews, Johnston, Schwencke, & Choi, 2009). However, although pioneering work, Titov and colleagues used estimates partly based on previously published data from an independent study and differences between treatments were indirectly estimated. In addition, the analysis was based on the cost of the intervention only, not considering other medical and non-medical costs which constitute the major part of the societal economic burden of SAD. To date, no study has prospectively investigated the economic impact and cost-effectiveness of ICBT or CBGT for SAD from a societal perspective.

The aim of the present study was to investigate the economic impact of ICBT compared to CBGT for SAD from a societal perspective within the context of a randomized controlled trial. We hypothesized that the treatments would generate significant and equivalent societal cost reductions. In addition, we expected ICBT to be more cost-effectiveness due to lower costs of treatment.

Section snippets

Trial design

This was a prospective cost-effectiveness analysis adopting a societal perspective. We conducted a non-inferiority trial within the context of a parallel group study with unrestricted randomization in 1:1 ratio (ICBT or CBGT). Outcome assessors were blind to treatment status. The trial was registered at clinicaltrials.gov (identifier NCT00564967). The main outcome study has been reported elsewhere (Hedman et al., 2011).

Sample

Characteristics of the participants are presented in Table 1. Participants

Attrition, assessment of other treatments and pre-treatment equivalence

Loss of data is presented in Fig. 1. No participant reported having received another concurrent psychological treatment during the treatment period. One participant reported having commenced pharmacological treatment for social anxiety while receiving CBT within the context of the present study. There were no significant differences between the two treatment groups on any of the outcome measures at baseline nor in terms of costs (t(1, 124) = 0.02–1.38, p = .17–.98). In addition, there were no

Discussion

The aim of this study was to investigate the economic impact of ICBT compared to CBGT for SAD from a societal perspective. As expected, both treatments generated a substantial reduction of societal costs. Our second hypothesis, that ICBT can be a cost-effective treatment alternative in comparison to CBGT, was also supported. This was a result of equivalent effects of the treatments in terms of reducing societal costs, social anxiety and improving quality of life, but significantly lower

Conclusions

ICBT can be more cost-effective than CBGT in the treatment of SAD. Both treatments generated savings that exceeded the intervention cost of respective treatment within one year. As the primary source of cost difference was that ICBT required less therapist resources, the results indicate that ICBT is a highly promising treatment option to increase accessibility to CBT. More research is needed regarding long-term follow-up and direct comparisons between different forms of CBT and other

Financial disclosure

None reported.

Funding

This study was supported by research grants from Stockholm County Council and the Bror Gadelius Fund.

Role of the sponsor

The main funding organization (Stockholm County Council) is a public institution and neither of the funding organizations had any role in the design and conduct of the study; in the collection or interpretation of the data; nor in the writing of the report or in the decision to submit it.

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