Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study

Abstract

Background Social anxiety disorder (SAD) is common, typically starts in adolescence and has a low natural recovery rate. Existing psychological treatments for adolescent SAD are only moderately effective. It is possible that recovery rates for adolescents could be substantially improved by adapting a psychological therapy that is highly effective among adults with SAD. Objectives To train child and adolescent mental health services (CAMHS) therapists to deliver cognitive therapy for SAD in adolescents (CT-SAD-A) and assess therapist competence. To estimate the costs to the NHS of training therapists to deliver CT-SAD-A and the mean cost per adolescent treated. To examine the feasibility of a randomised controlled trial (RCT) to compare CT-SAD-A with the general form of cognitive–behavioural therapy that is more commonly used. Design During the training phase of the study, it became clear that the RCT would not be feasible because of high staff turnover and unfilled posts within CAMHS and changes in the nature of referrals, which meant that few young people with primary SAD were accessing some of the participating services. The study design was altered to comprise the following: a training case series of CT-SAD-A delivered in routine CAMHS, an estimate of the cost to the NHS of training therapists to deliver CT-SAD-A and of the mean cost per adolescent treated, and qualitative interviews with participating young people, parents, therapists and service managers/leads. Setting Five CAMHS teams within Berkshire Healthcare and Oxford Health NHS Foundation Trusts. Participants Eight therapists received training in CT-SAD-A. Twelve young people received CT-SAD-A, delivered by six therapists. Six young people, six parents, seven therapists and three managers participated in qualitative interviews. Interventions Cognitive therapy for social anxiety disorder in adolescents (CT-SAD-A). Main outcome measures Measured outcomes included social anxiety symptoms and diagnostic status, comorbid symptoms of anxiety and depression, social and general functioning, concentration in class and treatment acceptability. Patient level utilisation of the intervention was collected using clinicians’ logs. Results Nine out of 12 participants achieved good outcomes across measures (r ≥ 0.60 across social anxiety measures). The estimated cost of delivering CT-SAD-A was £1861 (standard deviation £358) per person. Qualitative interviews indicated that the treatment was acceptable to young people, parents and therapists, but therapists and managers experienced challenges when implementing the training and treatment within the current CAMHS context. Limitations Findings were based on a small, homogeneous sample and there was no comparison arm. Conclusions CT-SAD-A is a promising treatment for young people with SAD, but the current CAMHS context presents challenges for its implementation. Future work Further work is needed to ensure that CAMHS can incorporate and test CT-SAD-A. Alternatively, CT-SAD-A should be delivered and tested in other settings that are better configured to treat young people whose lives are held back by SAD. The new schools Mental Health Support Teams envisaged in the 2017 Children’s Mental Health Green Paper may provide such an opportunity. Funding The National Institute for Health Research (NIHR) Health Technology Assessment programme. Individual funding was also provided for Cathy Creswell, David M Clark and Eleanor Leigh as follows: NIHR Research Professorship (Cathy Creswell); Wellcome Senior Investigator Award (Anke Ehlers and David M Clark); and the Wellcome Clinical Research Training Fellowship (Eleanor Leigh).

Exploring young people's perspectives on mental health support: A qualitative study across three geographical areas in England, UK

“…Our findings echo previous research into deficits in mental health support within healthcare services and school settings (e.g. Care Quality Commission, 2017 , Creswell et al, 2021 , see below). However, a significant finding is that YP were acutely aware of how poverty impacted mental health and how funding cuts impacted on the availability of support within their local areas.…”

“…YP were aware of how funding cuts and gaps in provision directly impacted on their everyday lives, with long waiting times and high thresholds for mental health support (Care Quality Commission, 2017 ), high turnover of therapists due to stress levels, (Creswell et al, 2021 ; Owens & Charles, 2016 ) early discharge from care (Owens & Charles, 2016 ), poor resources and low pay for youth organisations/youth workers, and the need for more capacity, staff training and support within schools and health service settings. Such findings are significant given the push to deliver the ‘levelling up’ agenda in the United Kingdom which calls to reduce inequalities in health between the richest and the poorest (Department for Levelling Up, Housing and Communities, 2022 ).…”

“…YP were aware of how funding cuts and gaps in provision directly impacted on their everyday lives, with long waiting times and high thresholds for mental health support (Care Quality Commission, 2017), high turnover of therapists due to stress levels, (Creswell et al, 2021;Owens & Charles, 2016) early discharge from care (Owens & Charles, 2016), poor resources and low pay for youth organisations/youth workers, and the need for more capacity, staff training and support within schools and health service settings.…”

“…"More money needs to be provided because like they need to get paid for actually -I know they do it apparently to just help kids and stuff like that, but it's like they're taking it out of their free time and they're choosing to do that instead of spending time with their family. I just feel like there needs to be more money provided for both the workers but also for the YP were aware of how funding cuts and gaps in provision directly impacted on their everyday lives, with long waiting times and high thresholds for mental health support (Care Quality Commission, 2017), high turnover of therapists due to stress levels, (Creswell et al, 2021;Owens & Charles, 2016) early discharge from care (Owens & Charles, 2016), poor resources and low pay for youth organisations/youth workers, and the need for more capacity, staff training and support within schools and health service settings.…”

The Management of Social Anxiety: More Than 25 Years Later, Where are we?

“…In France, the study by Camart et al (2006) shows the effectiveness of CBTs in 60 patients conducted in group therapy settings. Most behavioral and cognitive therapy protocols are built on the following pillars: exposure to avoided situations, cognitive restructuring, assertiveness, and social skills training, decentration including getting out of self-observation and out of cognitive fusion (Creswell et al, 2021).…”