Data trends are alarmingly clear; rates of depression and anxiety in young people have grown exponentially and have been further exacerbated by the pandemic. Funding for research in pediatrics is dwarfed by investments made in studying many adult-based health issues. The advent of digital health and the fact that young people are digital natives may open up more opportunities to address mental health issues earlier in the lifespan. Cognitive Behavioral Therapy (CBT) as a therapeutic approach effectively treats depression and anxiety in adults and children, regardless of the modality implemented. Less clear, for children, is how to deploy tools optimally as part of a stepped care model that blends face-to-face CBT with internet CBT (iCBT) and what works best for whom.
A new paper by Maral Jolstedt and colleagues from the Karolinska Institutet in Sweden focuses on long-term outcomes of a stepped care model leveraging iCBT in children recently published in European Child and Adolescent Psychiatry. The study included 123 children aged 8-12 years old with anxiety who received a twelve-week course of iCBT with limited therapist support. Participants were assessed at three and twelve months post iCBT. Those who did not see significant improvement in symptoms at three months received a course of face-to-face therapy. The intervention was structured to mirror a stepped care model; if someone didn’t improve, they were “stepped up” to a more intensive care level.
The authors were interested in exploring whether iCBT had enduring positive benefits. Anxiety was assessed using the Clinician Severity Rating (CSR), which is derived from the Diagnostic and Statistic Manual-IV (DMS-IV) and consists of a nine-point Likert scale ranging from zero, the absence of symptoms and impairment to eight, very severe symptoms and impairment. The iCBT tool was a web-based therapist-guided CBT program adapted for children and their caregivers. Children completed 12 modules with one or both of their parents; additionally, parents had 12 modules tailored for their use. Participants also had access to a therapist weekly via asynchronous messages on the treatment platform.
Findings indicate that 59% of the participants using iCBT remitted (n = 73), and they continued to improve over the study period. At the study conclusion, 89% of them remained free of symptoms. Those who did not remit were offered face-to-face therapy, and 48.6% of them accepted this modality of care. At the study’s end, 83% with free of their main symptoms. These findings endured at twelve months follow-up.
While children were not randomized into this stepped care approach, this study shows the benefit of having iCBT as part of a stepped care approach. Given the enormous challenges globally in access to mental health care, having a digital modality to offer as part of a comprehensive care model seems prudent. Many children can be supported towards symptom remission, which leaves more access to face-to-face care for those experiencing higher impairment levels.
Children, being digital natives, are harder to engage and retain in digital solutions, so the user experience for iCBT must be age-appropriate and attractive for children to want to engage in the course of care. iCBT offers additional ways to reduce the burden of suffering from depression and anxiety in youth.
Thanks for reading – Trina
(Opinions are my own)
Jolstedt, M., Vigerland, S., Mataix-Cols, D. et al. Long-term outcomes of internet-delivered cognitive behaviour therapy for paediatric anxiety disorders: towards a stepped care model of health care delivery. Eur Child Adolesc Psychiatry (2020). https://doi.org/10.1007/s00787-020-01645-x