Social Anxiety Disorder: Internet-based CBT is Effective and Economical for Treating Adolescents

The Research

Children and adolescents with social anxiety disorder (SAD) who received therapist-guided Internet-based cognitive behavioral therapy (ICBT) showed a significant reduction in the severity of social anxiety symptoms compared with Internet-based supportive therapy (ISUPPORT), according to a study by Nordh et al conducted in Sweden. Participants included 103 youth aged 10 to 14 who were diagnosed with SAD. Both the ICBT (n=51) and ISUPPORT (n=52) interventions comprised 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist. The authors noted that this study of ICBT for SAD was unique in that it used an active comparator as well as looked at the cost-effectiveness of the intervention.

Why it’s noteworthy – Barriers to treatment for SAD in youth include high costs and difficulty in accessing trained therapists in the patients’ areas, the authors wrote in the JAMA Psychiatry article. Their findings give hope that ICBT can be an effective and economical treatment for more children and adolescents, especially given that only about 10% of patients with SAD have contacted a professional about their social fears.

Reports & Perspectives

  • A social network, therapist moderation, and graphic medicine in the form of comics that delivered evidence-based therapeutic content were the core elements of a digital intervention, Entourage, designed for young people with social anxiety. A pilot study of Entourage by Rice et al found that it was highly engaging and potentially effective in reducing SAD symptoms and improving social connection among young people.
  • A qualitative study interviewed 10 adults who participated in an ICBT program for anxiety disorders to investigate what factors were important to the patients for the intervention to be perceived as useful. Participants were satisfied with the program’s system quality and information quality but suggested that more support and follow up from the therapist would improve its effectiveness.
  • Motivational interviewing (MI) before ICBT for anxiety and depression increased motivational statements and days in treatment, but no group differences in primary symptom or motivation changes were observed over time in a randomized controlled trial by Soucy et al. The authors wrote that future studies may examine whether certain populations benefit more from MI or if different timelines of offering MI could improve outcomes.
  • @LorenaFdelaC (OCD and related disorders researcher Lorena Fernández de la Cruz) tweets: “New RCT by @NordhMartina et al published today in @JAMAPsych showing that internet-delivered #CBT is an efficacious and cost-effective intervention for children and adolescents with social anxiety disorder.”
  • @SocialWorkCEU (Continued Social Work, a provider of continuing education courses) also tweets about the Swedish study, “The research could pave the way for easier and cheaper access to an effective treatment for a common adolescent condition known as social anxiety disorder.”
  • @SBMDigitalHlth (Society of Behavioral Medicine’s Behavioral Informatics & Technology special interest group) tweets: “RCT finds internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with social anxiety disorder #digitalhealth #ehealth” about the Swedish study.

In Practice

Psy-Q Challenge

What are the benefits of ICBT in treating social anxiety disorder in youth? Martina Nordh, PhD, answers.

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Depression Linked to Inflammation in Large UK Study

The Research

A large case-control study using data of 85,895 people from the UK Biobank database found a link between inflammation and major depressive disorder (MDD). Researchers at King’s College London found that even after adjusting for genetic, environmental, lifestyle, and medical factors of inflammation, the association between it and depression remained. The study compared 26,894 participants with MDD and 59,001 control subjects who reported no mental disorder, and it looked at levels of C-reactive protein (CRP, an inflammation marker) along with genetic and phenotypic data.

Depressed participants had higher levels of CRP in their blood and were more likely to have low-grade inflammation. Increased inflammation in depression was due to smoking habits and body mass index rather than to an “autoimmune” genetic predisposition, wrote the authors, who also suggested that an as yet undiscovered “core biological association” between inflammation and depression may one day explain the link.

Why it’s complicated – The association between inflammation and depression has been studied and debated for some time. Cambridge University psychiatry professor Edward Bullmore’s 2018 book, The Inflamed Mind, presented a case for a link between inflammation and depression, but researchers continue to seek a causal relationship.

Reports & Perspectives

  • Forbes et al examined inflammation and MDD in the geriatric population and wrote that more research must be done before treating depression with anti-inflammatories in this population.
  • A narrative review by Saccaro et al looks at the role of inflammation, anxiety, and stress in bipolar disorder and borderline personality disorder.
  • @newscientist tweets: “People with depression have higher levels of inflammation in their bodies than those without, but it is unclear whether this link is purely genetic or also influenced by people’s behavior,” and linked to its article about the King’s College study.
  • @DrUmaNaidoo (Harvard nutritional psychiatrist and director of nutritional and lifestyle psychiatry at Massachusetts General Hospital) tweeted about the King’s College study, “A new study suggests that the ‘genetic’ cause of #inflammation in #depression may actually be due to lifestyle factors, such as diet and nutrition. Is what we eat more influential on mental health than our genes?”

In Practice

New Digital Mental Health Interventions Aim to Treat Depression, OCD, ADHD

The Research

Several recent studies examined the effectiveness of digital interventions for mental health, including which mental health apps show potential for expanding access to care. Noteworthy studies in this rapidly evolving field include:

  • Depressive symptoms were improved in adults with diabetes and hypertension in Peru and Brazil with the use of a smartphone app developed by a team of researchers from the Northwestern University Feinberg School of Medicine. In two trials, held in São Paulo (n=880) and Lima (n=432), the intervention groups used a smartphone app that delivered a 6-week, 18-session digital intervention with support from nurse assistants, which was compared to groups receiving enhanced usual care. In both trials, the digital intervention significantly improved depressive symptoms at 3 months compared with enhanced usual care, but this was not sustained at 6 months.
  • Children and adolescents aged 8 to 17 years with obsessive-compulsive disorder (OCD) received either Internet-delivered CBT (ICBT, n=74) or in-person CBT (n=78) for 16 weeks in a study by Aspvall et al. After 3 months, nonresponders in the ICBT group were offered a course of in-person treatment, and nonresponders in the in-person CBT group were offered additional face-to-face treatment. The team found that ICBT delivered in a stepped care model was noninferior to in-person CBT at 6-month follow-up.
  • Researchers studied the effectiveness of a digital therapeutic for attention-deficit/hyperactivity disorder (ADHD) in children aged 8 to 14 years who were taking stimulant medication (n = 130) or no ADHD medication (n = 76). The intervention was AKL-T01, also called EndeavorRx, and is the first FDA-cleared prescription video game for inattention in children with ADHD, intended for use as part of a therapeutic program. Participants used the intervention for about 25 minutes per day, 5 days per week, for 4 weeks, followed by a 4-week pause and another 4-week treatment. ADHD-related impairment was improved in both groups.
  • A qualitative study asked 26 medical students about their attitudes toward internet- and mobile-based interventions, as they “show a relatively high prevalence for common mental disorders,” the authors wrote. The students had positive views of digital interventions as a first step toward in-person therapy, for stress reduction, and early interventions. They also preferred to use digital tools that were approved and provided by their university.
  • A systematic overview by Lehtimaki et al explored the evidence on digital mental health interventions for adolescents and young adults focusing on the efficacy, cost-effectiveness, and generalizability to low-resource settings. The team found that a small portion of the digital interventions studied were evidence based, and that more research must be done to evaluate their efficacy and cost-effectiveness in low- and middle-income countries.

Reports & Perspectives

  • The American Psychiatric Association created “Ask an App Advisor – a panel in which members of its App Advisor team answer questions about mental health apps.
  • A report on mental health apps offers a Practitioner’s Guide to integrating this technology into your practice.
  • @NUFeinbergMed (Northwestern Feinberg School of Medicine) tweets: “A mental health smartphone app developed by a team of Northwestern Medicine investigators helped improve depressive symptoms in patients with diabetes and hypertension, according to a clinical trial in @JAMA_current.”
  • @karolinskainst (Sweden’s Karolinska Institute) tweets: “Study from KI published in JAMA today shows that online cognitive behavioral therapy can be as effective as conventional CBT for children and adolescents with obsessive-compulsive disorder.”
  • @nschwalbe (Nina Schwalbe, last author on the Lehtimaki et al study) tweets: “While digital mental apps can increase access for teens, there is a need to test effectiveness in a range of settings and diverse groups of youth.”

In Practice

 

Last Updated: Aug 26, 2021