Cost-Effectiveness Analysis of School-Based Treatments for Anxiety Disorders.

BACKGROUND: School-based treatments for anxiety disorders are needed to address barriers to accessing community-based services. A key question for school administers are the costs related to these treatments. AIMS OF THE STUDY: This study examined the cost-effectiveness of a school-based modular cognitive behavioral therapy (M-CBT) for pediatric anxiety disorders compared to school-based treatment as usual (TAU). METHODS: Sixty-two school-based clinicians in Maryland and Connecticut were randomized (37 in CBT; 25 in TAU), trained, and enrolled at least one anxious student (148 students in CBT; 68 in TAU). Students (N = 216) were ages 6-18 (mean age 10.9); 63.9% were non-Hispanic White race-ethnicity; and 48.6% were female. Independent evaluators (IEs) assessed outcomes at post treatment and at a one-year follow up. Anxiety related costs included mental health care expenses and the opportunity costs of added caregiver time and missed school days. RESULTS: The overall M-CBT ICER value of $6917/QALY reflected both lower costs for days absent from school (mean difference: $--117 per youth; p = 0.045) but also lower QALY ratings (mean difference: -0.024; p = 0.900) compared with usual school counseling. Among youth with more severe anxiety at baseline, M-CBT had a more favorable ICER ($-22,846/QALY). Other mental health care costs were similar between groups (mean difference: $-90 per youth; p = 0.328). DISCUSSION: Although training school clinicians in M-CBT resulted in lower costs for school absences, evidence for the cost effectiveness of a modular CBT relative to existing school treatment for pediatric anxiety disorders was not robustly supported. Findings suggest school-based M-CBT is most cost effective for youth with the highest levels of anxiety severity and that M-CBT could help reduce the costs of missed school. Interpretations are limited due to use of retrospective recall, lack of data on medication use, and small sample size. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Schools may benefit from providing specialized school-based services such as M-CBT for students with the highest levels of anxiety. IMPLICATIONS FOR HEALTH POLICIES: Investment decisions by schools should take into account lower costs (related to school absences), the costs of training clinicians, and student access to CBT in the community. IMPLICATIONS FOR FURTHER RESEARCH: Replication with a larger sample, service use diaries, and objective school and medical records over a longer period of time is warranted.

Pediatric Anxiety Disorders: A Cost of Illness Analysis.

Few studies provide information about the clinical correlates of economic costs in pediatric anxiety disorders. This study uses baseline data from a randomized trial involving 209 children and adolescents with clinical anxiety to examine clinical and demographic correlates of direct and indirect costs. Measured costs included the direct costs of mental health services and the indirect costs resulting from children's missed school and parents' missed work. Validated measures of anxiety and depression severity and of internalizing and externalizing behaviors were reported by youth, their parents, and independent evaluators. Seventy-two percent of youth (n = 150) had positive costs. Among these youth, the mean annual total cost was $6405 (sd = $11,674), of which $5890 represented direct cost and $4658 represented indirect cost. Higher average costs were correlated with greater child anxiety and depression severity (p < 0.001). Most pediatric anxiety disorders result in substantial individual and family costs, and costs may increase rapidly with elevated anxiety severity and depressed mood.

Concordance between clinician, supervisor and observer ratings of therapeutic competence in CBT and treatment as usual: does clinician competence or supervisor session observation improve agreement?

BACKGROUND: Lowering the cost of assessing clinicians' competence could promote the scalability of evidence-based treatments such as cognitive behavioral therapy (CBT). AIMS: This study examined the concordance between clinicians', supervisors' and independent observers' session-specific ratings of clinician competence in school-based CBT and treatment as usual (TAU). It also investigated the association between clinician competence and supervisory session observation and rater agreement. METHOD: Fifty-nine school-based clinicians (90% female, 73% Caucasian) were randomly assigned to implement TAU or modular CBT for youth anxiety. Clinicians rated their confidence after each therapy session (n = 1898), and supervisors rated clinicians' competence after each supervision session (n = 613). Independent observers rated clinicians' competence from audio recordings (n = 395). RESULTS: Patterns of rater discrepancies differed between the TAU and CBT groups. Correlations with independent raters were low across groups. Clinician competence and session observation were associated with higher agreement among TAU, but not CBT, supervisors and clinicians. CONCLUSIONS: These results support the gold standard practice of obtaining independent ratings of adherence and competence in implementation contexts. Further development of measures and/or rater training methods for clinicians and supervisors is needed.

School-Based Treatment for Anxiety Research Study (STARS): a Randomized Controlled Effectiveness Trial.

The current study compared the effectiveness of a school-clinician administered cognitive behavioral treatment (CBT) to treatment as usual (TAU) at post-treatment (i.e., after 12 weeks) and at a 1 year follow-up. Sixty-two school-based clinicians (37 in CBT; 25 in TAU) and 216 students (148 students in CBT; 68 in TAU) participated. Students were ages 6-18 (mean age 10.87; 64% Caucasian & 29% African American; 48.6% female) and all met DSM-IV diagnostic criteria for a primary anxiety disorder. Independent evaluators (IEs) assessed clinical improvement, global functioning, and loss of anxiety diagnoses; children and parents completed measures of anxiety symptoms. At post-treatment, no significant treatment main effects emerged on the primary outcome; 42% and 37% of youth were classified as treatment responders in CBT and TAU respectively. However, parent-report of child anxiety showed greater improvements in CBT relative to TAU (d = .29). Moderation analyses at post-treatment indicated that older youth, those with social phobia and more severe anxiety at baseline were more likely to be treatment responders in CBT compared to TAU. At the 1 year follow-up, treatment gains were maintained but no treatment group differences or moderators emerged. CBT and TAU for pediatric anxiety disorders, when delivered by school clinicians were generally similar in effectiveness for lowering anxiety and improving functioning at both post-treatment (on all but the parent measure and for specific subgroups) and 1 year follow-up. Implications for disseminating CBT in the school setting are discussed.

Teacher Anxiety Program for Elementary Students (TAPES): intervention development and proposed randomized controlled trial.

BACKGROUND: Excessive student anxiety is a common problem that severely impairs short- and long-term academic functioning and increases teacher burden. Reducing student anxiety has been associated with improvement in educational functioning. Because anxiety manifests daily in the classroom, teachers are in an ideal position to identify and help students manage their anxiety. Unfortunately, teachers lack the knowledge and skills to support the learning of students with excessive anxiety. The Teacher Anxiety Program for Elementary Students (TAPES), a novel teacher-administered school-home collaborative intervention, was designed to address this gap. METHODS: This manuscript describes the protocol for developing and evaluating TAPES. Specifically, we present a description of: (1) the intervention and theoretical model; and (2) methods for the proposed randomized controlled trial comparing TAPES to a standard professional development seminar focused on reducing student anxiety. DISCUSSION: Primary aims examine the impact of the TAPES training on teacher knowledge and skill. Secondary aims examine the impact of TAPES on student outcomes. Exploratory aims will examine mediators based on our proposed theory of change. If effective, TAPES has the potential to directly benefit teachers (improving skills) and students (reducing anxiety and improving functioning). TRIAL REGISTRATION: ClinicalTrials.gov, NCT03899948. Registered on 28 March 2019.

Child Anxiety Prevention Study: Impact on Functional Outcomes.

This study examined the impact of a selective anxiety prevention program for offspring of clinically anxious parents on three domains of child functioning: (1) social, (2) familial, and (3) emotional/behavioral. Dyads were randomized into either the Coping and Promoting Strength program (CAPS; n = 70) or Information Monitoring (IM; n = 66) comparison group. Multi-informant assessments were conducted at baseline, post intervention, and 6 and 12 months follow-ups. Random effects mixed models under the linear growth modeling (LGM) framework was used to assess the impact of CAPS on growth trajectories. Over time, children in the CAPS group had significantly lower anxiety, anxious/depressed symptoms, and lower total behavior problems (parent report), compared to children in IM group. The intervention did not impact other domains assessed (e.g., social functioning), which may be due to "floor effects" on these measures. Longitudinal follow-up data is needed to provide valuable information about this high risk population.