Cost-effectiveness of child-focused and parent-focused interventions in a child anxiety prevention program

Evidence for investing in parenting interventions aiming to improve child health: a systematic review of economic evaluations

A comprehensive review of the economic evidence on parenting interventions targeting different aspects of child health is lacking to support decision-making. The aim of this review is to provide an up to date synthesis of the available health economic evidence for parenting interventions aiming to improve child health. A systematic review was conducted with articles identified through Econlit, Medline, PsychINFO, and ERIC databases. Only full economic evaluations comparing two or more options, considering both costs and outcomes were included. We assessed the quality of the studies using the Drummond checklist. We identified 44 studies of varying quality that met inclusion criteria; 22 targeting externalizing behaviors, five targeting internalizing problems, and five targeting other mental health problems including autism and alcohol abuse. The remaining studies targeted child abuse (n = 5), obesity (n = 3), and general health (n = 4). Studies varied considerably and many suffered from methodological limitations, such as limited costing perspectives, challenges with outcome measurement and short-time horizons. Parenting interventions showed good value for money in particular for preventing child externalizing and internalizing behaviors. For the prevention of child abuse, some programs had the potential of being cost-saving over the longer-term. Interventions were not cost-effective for the treatment of autism and obesity. Future research should include a broader spectrum of societal costs and quality-of-life impacts on both children and their caregivers.

The multifaceted consequences and economic costs of child anxiety problems: A systematic review and meta-analysis

Background

Over a quarter of people have an anxiety disorder at some point in their life, with many first experiencing difficulties during childhood or adolescence. Despite this, gaps still exist in the current evidence base of the multiple consequences of childhood anxiety problems and their costs.

Methods

A systematic review of Medline, PsycINFO, EconLit and the National Health Service Economic Evaluation Database was conducted for longitudinal and economic studies reporting on the association between childhood anxiety problems and at least one individual-, family- or societal-level outcome or cost. All studies were synthesised narratively. For longitudinal studies, 'effect direction' was used as a common metric, with random effects meta-analysis undertaken where possible.

Results

Eighty-three studies met inclusion criteria and were synthesised narratively. We identified 788 separate analyses from the longitudinal studies, which we grouped into 15 overarching outcome domains. Thirteen of the studies were incorporated into 13 meta-analyses, which indicated that childhood anxiety disorders were associated with future anxiety, mood, behaviour and substance disorders. Narrative synthesis also suggested associations between anxiety problems and worse physical health, behaviour, self-harm, eating, relationship, educational, health care, employment, and financial outcomes. 'Effect direction' was conflicting in some domains due to a sparse evidence base. Higher economic costs were identified for the child, their families, healthcare providers and wider society, although evidence was limited and only covered short follow-up periods, up to a maximum of 2 years. Total annual societal costs per anxious child were up to £4040 (2021 GBP).

Conclusions

Childhood anxiety problems are associated with impaired outcomes in numerous domains, and considerable economic costs, which highlight the need for cost-effective interventions and policies to tackle them. More economic evidence is needed to inform models of the long-term, economic-related, consequences of childhood anxiety problems.

Review: Economic evidence of preventive interventions for anxiety disorders in children and adolescents - a systematic review

BACKGROUND

Anxiety disorders are common in children and youth. Also, in prevention, be it universal, selective or indicated, economic evaluation supports decision-making in the allocation of scarce resources. This review identified and summarised the existing evidence of economic evaluations for the prevention of anxiety disorders in children and adolescents.

METHODS

A systematic search was conducted on the EBSCO, Scopus, Web of Science, ProQuest, Cochrane and PubMed databases. We included studies that focused on children and adolescents under 18 years of age, aimed to prevent anxiety disorders and presented an incremental analysis of costs and effectiveness. A registered checklist was used that assessed the quality of the included articles.

RESULTS

The search yielded 1697 articles. Five articles were included in this review. Three were RCT-based, and two were model-based studies. Out of five included interventions, one was a universal school-based intervention, two selective interventions and two indicated interventions. Universal school-based prevention of anxiety was not cost-effective compared with usual teaching. Selective parent training and indicative child- and parent-focused CBT prevention were likely cost-effective compared with usual care or doing nothing.

CONCLUSION

Parent education and cognitive behaviour therapy interventions can be cautiously interpreted as being a cost-effective way of preventing anxiety in children and adolescents. However, the evidence is weakly related to cost-effectiveness as there are only a few studies, with relatively small sample sizes and short follow-ups.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model

BACKGROUND

While multiple treatments for pediatric anxiety and obsessive compulsive disorder (OCD) are efficacious, little is known about their cost-effectiveness. In response, we sought to provide relevant information through systematic review and cost-effectiveness simulation.

METHODS

We evaluated the cost-effectiveness of treatment for pediatric anxiety and OCD in two ways. First, we conducted a systematic review following PRISMA guidelines. Second, we evaluated cost-effectiveness for antidepressant medication, cognitive behavioral therapy, and their combination via a simulation that integrated information from the Truven MarketScan database and the NIMH National Database for Clinical Trials Related to Mental Illness.

RESULTS

Both systematic review and simulation found antidepressant medication and cognitive behavioral therapy to be cost-effective for pediatric anxiety and OCD. Antidepressant medication was the least costly approach, and cognitive behavioral therapy provided additional cost-effectiveness, especially for OCD.

LIMITATIONS

During systematic review, relatively few articles provided information about both costs and effectiveness. While there was a notable margin of error to support multiple interventions as cost-effective, limited prior research decreased precision of point estimates and comparisons between interventions.

CONCLUSIONS

Both antidepressant medication and cognitive behavioral therapy were found to be cost-effective for pediatric anxiety and OCD. Results supported investment from third party payers, who serve as critical gatekeepers that can increase treatment dissemination. However, more precise information would better inform the exact amount of investment needed, especially with regard to selection decisions between active interventions. Cost-effectiveness research would benefit from systematic collection of data on treatment costs and quality of life in future clinical trials.

Cost-benefit Analysis of the Coping and Promoting Strength Program

This study sought to estimate the net benefits and return on investment (ROI, %) of the Coping and Promoting Strength (CAPS) program to families and insurers, respectively, using data from a multi-year follow up of 136 US families who had participated in a randomized efficacy trial of CAPS. CAPS is a brief parent-focused psychosocial intervention that was compared to information monitoring in the trial. Of the 136 original participants, 113 (83%) completed follow-up interviews 7.1 years, on average, after the CAPS study baseline (mean follow-up age: 15.8 years; range: 13.1 to 20.8 years). Parent-reported willingness-to-pay values and estimates of behavioral healthcare cost savings from delayed onset of anxiety were used to simulate the average net benefits of CAPS to families and insurance plans, respectively, assuming patients pay 20% coinsurance. Psychologists in private offices were expected to charge an average of approximately $195 per CAPS session or $1417 in total in 2020 dollars. The estimated family share of the total CAPS session cost was $283 per youth, while the insurer share was $1134 per youth. Given these costs, the CAPS intervention was estimated to result in average overall net benefits of $1033 per youth (95% CI: -$546 to $2611). Families gained $344 (95% CI: $232 to $455 per family) for an ROI of 121%. Insurance plans on average gained a net savings of $689 per youth (95% CI: -$778 to $2156 per youth) for an average ROI of 61%. In this multiyear follow-up of offspring of anxious parents, exposure to the CAPS pediatric anxiety prevention program was found to be more economically efficient than was waiting for an anxiety disorder to be diagnosed. ClinicalTrials.gov Identifier: NCT00847561.

Do Costs in the Education Sector Matter? A Systematic Literature Review of the Economic Impact of Psychosocial Problems on the Education Sector

BACKGROUND

Psychosocial (e.g., anxiety or behavior) problems lead to costs not only in the healthcare sector but also in education and other sectors. As psychosocial problems develop during the critical period of establishing educational trajectories, education costs are particularly relevant in the context of psychosocial problems among children and adolescents.

OBJECTIVES

This study aimed to gain insights into the methods used for the inclusion of education costs in health economics studies and into the proportion of the education costs in relation to the total costs associated with a condition or an intervention.

METHODS

We systematically searched the PubMed, Embase, SSCI, CINAHL, PsycINFO, ERIC, and Econlit databases in August 2019 for economic evaluations of mental health, psychosocial and educational interventions, and cost-of-illness studies of mental, behavioral, and neurodevelopmental disorders conducted from a societal perspective in populations of children and adolescents. An additional search was conducted in February 2021 to update the review.

RESULTS

In total, 49 articles were included in the analysis. The most common cost items were special education, school absenteeism, and various educational professionals (educational psychologist). A variety of methods were employed for the identification, measurement, and/or valuation of education costs. The proportion of education costs to the total costs of condition/intervention ranged from 0 to 67%, with the mean being 18.5%.

DISCUSSION

Since education costs can constitute a significant proportion of the total costs of an intervention or condition, including them in health economics studies might be important in informing optimal resource allocation decisions. Although various methods are available for including education costs in health economics studies, further research is needed to develop evidence-based methods for producing comparable estimates.

Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations

BACKGROUND

The prevention of mental disorders and promotion of mental health and well-being are growing fields. Whether mental health promotion and prevention interventions provide value for money in children, adolescents, adults, and older adults is unclear. The aim of the current study is to update 2 existing reviews of cost-effectiveness studies in this field in order to determine whether such interventions are cost-effective.

METHODS AND FINDINGS

Electronic databases (including MEDLINE, PsycINFO, CINAHL, and EconLit through EBSCO and Embase) were searched for published cost-effectiveness studies of prevention of mental disorders and promotion of mental health and well-being from 2008 to 2020. The quality of studies was assessed using the Quality of Health Economic Studies Instrument (QHES). The protocol was registered with PROSPERO (# CRD42019127778). The primary outcomes were incremental cost-effectiveness ratio (ICER) or return on investment (ROI) ratio across all studies. A total of 65 studies met the inclusion criteria of a full economic evaluation, of which, 23 targeted children and adolescents, 35 targeted adults, while the remaining targeted older adults. A large number of studies focused on prevention of depression and/or anxiety disorders, followed by promotion of mental health and well-being and other mental disorders. Although there was high heterogeneity in terms of the design among included economic evaluations, most studies consistently found that interventions for mental health prevention and promotion were cost-effective or cost saving. The review found that targeted prevention was likely to be cost-effective compared to universal prevention. Screening plus psychological interventions (e.g., cognitive behavioural therapy [CBT]) at school were the most cost-effective interventions for prevention of mental disorders in children and adolescents, while parenting interventions and workplace interventions had good evidence in mental health promotion. There is inconclusive evidence for preventive interventions for mental disorders or mental health promotion in older adults. While studies were of general high quality, there was limited evidence available from low- and middle-income countries. The review was limited to studies where mental health was the primary outcome and may have missed general health promoting strategies that could also prevent mental disorder or promote mental health. Some ROI studies might not be included given that these studies are commonly published in grey literature rather than in the academic literature.

CONCLUSIONS

Our review found a significant growth of economic evaluations in prevention of mental disorders or promotion of mental health and well-being over the last 10 years. Although several interventions for mental health prevention and promotion provide good value for money, the varied quality as well as methodologies used in economic evaluations limit the generalisability of conclusions about cost-effectiveness. However, the finding that the majority of studies especially in children, adolescents, and adults demonstrated good value for money is promising. Research on cost-effectiveness in low-middle income settings is required.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019127778.

Universal Mental Health Interventions for Children and Adolescents: A Systematic Review of Health Economic Evaluations

BACKGROUND

Effective mental health interventions may reduce the impact that mental health problems have on young people's well-being. Nevertheless, little is known about the cost effectiveness of such interventions for children and adolescents.

OBJECTIVES

The objectives of this systematic review were to summarize and assess recent health economic evaluations of universal mental health interventions for children and adolescents aged 6-18 years.

METHODS

Four electronic databases were searched for relevant health economic studies, using a pre-developed search algorithm. Full health economic evaluations evaluating the cost effectiveness of universal mental health interventions were included, as well as evaluations of anti-bullying and suicide prevention interventions that used a universal approach. Studies on the prevention of substance abuse and those published before 2013 fell outside the scope of this review. Study results were summarised in evidence tables, and each study was subject to a systematic quality appraisal.

RESULTS

Nine studies were included in the review; in six, the economic evaluation was conducted alongside a clinical trial. All studies except one were carried out in the European Union, and all but one evaluated school-based interventions. All evaluated interventions led to positive incremental costs compared to their comparators and most were associated with small increases in quality-adjusted life-years. Almost half of the studies evaluated the cost effectiveness of cognitive behavioural therapy-based interventions aimed at the prevention of depression or anxiety, with mixed results. Cost-effectiveness estimates for a parenting programme, a school-based social and emotional well-being programme and anti-bullying interventions were promising, though the latter were only evaluated for the Swedish context. Drivers of cost effectiveness were implementation costs; intervention effectiveness, delivery mode and duration; baseline prevalence; and the perspective of the evaluation. The overall study quality was reasonable, though most studies only assessed short-term costs and effects.

CONCLUSION

Few studies were found, which limits the possibility of drawing strong conclusions about cost effectiveness. There is some evidence based on decision-analytic modelling that anti-bullying interventions represent value for money. Generally, there is a lack of studies that take into account long-term costs and effects.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42019115882.

Cost-effectiveness of preventing child internalising problems: Results from the translational trial of Cool Little Kids at school entry

OBJECTIVE

A translational trial evaluated the effectiveness of screening for inhibited childhood temperament, followed by a preventive parenting program -Cool Little Kids. This study determined the cost-effectiveness from societal and health sector perspectives using trial data.

METHOD

Resources to deliver the screening and parenting sessions were determined from study records. Parents completed a questionnaire reporting resources used at one-year follow-up. Standard Australian unit costs were applied. Clinical outcomes for children and parental quality adjusted life-years (QALYs) were used to calculate incremental cost-effectiveness ratios (ICERs).

RESULTS

Total societal costs were lower, but non-significant for the intervention compared to the control group (mean difference -$500 p = 0.937). Total health sector costs were significantly greater (mean difference $1,956; p = 0.015). The intervention led to significantly fewer internalising symptoms (Strengths and Difficulties Questionnaire (SDQ)-emotional difficulties adjusted mean difference -0.5; p = 0.006), fewer children with SDQ-emotional symptoms in the abnormal range (24.2 % vs. 33.0 % p = .014) and fewer with diagnosed anxiety (44.2 % vs. 50.2 % p = 0.427). From the societal perspective, the intervention would likely be cost-effective. Health sector ICERs were $1,171/SDQ-emotional symptom decrease, $51/abnormal SDQ avoided and $77/anxiety case avoided.

CONCLUSIONS

This economic analysis alongside an implementation study provides an early indication that Cool Little Kids may be cost-effective.

A randomised controlled trial of treatments of childhood anxiety disorder in the context of maternal anxiety disorder: clinical and cost-effectiveness outcomes

BACKGROUND

This study evaluated whether clinical and economic outcomes from CBT for child anxiety disorders in the context of maternal anxiety disorders are improved by adding treatment focused on (a) maternal anxiety disorders or (b) mother-child interactions.

METHODS

Two hundred and eleven children (7-12 years, 85% White British, 52% female) with a primary anxiety disorder, whose mothers also had a current anxiety disorder, were randomised to receive (a) child-focused CBT with nonspecific control interventions (CCBT+Con), (b) CCBT with CBT for the maternal anxiety disorder (CCBT+MCBT), or (c) CCBT with an intervention targeting the mother-child interaction (CCBT+MCI). A cost-utility analysis from a societal perspective was conducted using mother/child combined quality-adjusted life years (QALYs). [Trial registration: https://doi.org/10.1186/isrctn19762288].

RESULTS

MCBT was associated with immediate reductions in maternal anxiety compared to the nonspecific control; however, after children had also received CCBT, maternal outcomes in the CCBT+MCI and CCBT+Con arms improved and CCBT+MCBT was no longer superior. Neither CCBT+MCBT nor CCBT+MCI conferred a benefit over CCBT+Con in terms of child anxiety disorder diagnoses post-treatment [primary outcome] (adj RR: 1.22 (95% CI: 0.88, 1.67), p = .23; adj RR: 1.21 (95% CI: 0.88, 1.65), p = .24, respectively) or global improvement ratings (adj RR: 1.25 (95% CI: 0.99, 1.57), p = .06; adj RR: 1.18 (95% CI: 0.93, 1.50), p = .17) or six and 12 months later. No significant differences between the groups were found on the main economic outcome measures (child/mother combined QALY mean difference: CCBT+MCBT vs. CCBT+Con: -0.04 (95% CI: -0.12, 0.04), p = .29; CCBT+MCI vs. CCBT+Con: 0.02 (95% CI: -0.05, -0.09), p = .54). CCBT+MCI was associated with nonsignificantly higher costs than CCBT (mean difference: £154 (95% CI: -£1,239, £1,547), p = .83) but, when taking into account sampling uncertainty, it may be cost-effective compared with CCBT alone.

CONCLUSIONS

Good outcomes were achieved for children and their mothers across treatment arms. There was no evidence of significant clinical benefit from supplementing CCBT with either CBT for the maternal anxiety disorder or treatment focussed on mother-child interactions, but the addition of MCI (and not MCBT) may be cost-effective.

The ReThink study: a 3-arm parallel randomized trial of cognitive bias modification, with and without adherence promotion, for adolescent anxiety disorder: trial design and protocol

BACKGROUND

Anxiety disorders are the most common mental health problem among youth, contribute to reduced quality of daily life, and are associated with high rates of comorbidity. However, treatment rates for anxiety are very low, causing a sizeable treatment gap. There is an immediate need to identify treatment interventions that are effective, affordable, and can be delivered easily to the youth population. Cognitive Bias Modification (CBM) is one potentially effective intervention that could reach youth on a large scale, especially when self-administered at home. Thus, we aim to assess the benefit of CBM to treat youth anxiety. Further, we aim to test whether adding an adherence promotion (AP) component to the CBM intervention can improve outcomes, and whether CBM delivered both with and without the AP component is cost effective.

METHODS

This is a 12-month randomized controlled trial (RCT) conducted within an existing healthcare system. Potentially eligible youth (ages 12 to 17) will be identified by reviewing the electronic health record (EHR) for clinical anxiety diagnoses, which are then confirmed via research interview. We aim to enroll 498 participants and randomize them 1:1:1 to one of three arms: Arm 1 is a Low-Ratio version of the CBM program (nearly identical to the other CBM versions, but minimally effective); Arm 2 is a High-Ratio "active" CBM program; and Arm 3 is the High-Ratio CBM program with an added AP component. Participants will complete assessments at baseline, 1-, 3-, 6- and 12-months post-baseline. Youth in all three arms will self-administer the CBM program at home and will be asked to complete twelve intervention sessions over a four-week period. Arm 3 participants (High-Ratio CBM + AP) will also receive up to four telephone calls from phone coaches during the intervention period to provide technical assistance, encouragement, and motivational enhancement to increase adherence. The primary clinical outcome will be anxiety remission at 6-month follow-up.

DISCUSSION

This study protocol describes the method and design for an RCT to test whether self-administered CBM both with and without adherence promotion can be an effective at-home treatment for anxious youth.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02156531, First Posted June 5, 2014.

Review: The impact of pediatric mental health care provided outpatient, primary care, community and school settings on emergency department use - a systematic review

BACKGROUND

Increases in emergency department (ED) visits for pediatric mental health care point to a need to understand the impact of mental health services in relation to emergency-based care. This systematic review examined the impact of mental health services delivered in outpatient, primary care, community and/or school settings on ED use and costs for ED-based mental health care.

METHOD

Two electronic databases and gray literature were searched. Eligible studies consisted of randomized/controlled clinical trials or cohort studies examining the effects of mental health services on ED use and costs for this care. Two reviewers independently screened the studies for relevance and study quality. Relative risks (RR), risk differences (RD), or mean differences (MD) were calculated for each study's primary outcome with 95% confidence intervals (CI). Meta-analysis was deferred due to substantial heterogeneity.

RESULTS

Six studies were included. Overall risk of bias in the studies ranged from low, unclear, to high. The majority of programs had no effect on ED visits for mental health care. A school-based program was found to reduce the risk of ED visits for any reason during use (RD, -8.0%; 95% CI: -15.2%, -0.9%); however, these visits were not specific to mental health. Three studies examined costs. A wrap-around clinical management program was associated with higher average ED costs per patient per month ($20.07 US dollars) compared to usual outpatient care; other studies reported no cost differences.

CONCLUSIONS

At this time, there is limited evidence to suggest outpatient, primary care, community and/or school-based mental health services impact ED use and costs for mental health care. Additional studies are needed.

Effects of a parent training programme for the treatment of young children with separation anxiety disorder

Cognitive behavioural therapy (CBT) has been shown to be an effective treatment for anxiety disorders in children. However, the majority of studies conducted to date have included heterogeneous samples of children combining social anxiety disorder, generalized anxiety disorder and separation anxiety disorder (SAD) together. Few studies have examined the efficacy of CBT to specifically treat SAD. Moreover, research on the impact of CBT for SAD in children younger than 7 years old has been very limited. To address these issues, we examined the effects of a CBT parent training programme with six children with SAD aged between 4 and 7 years using a non-concurrent multiple baseline design. Parents completed semi-structured interviews, questionnaires and daily diaries to assess their child's anxiety symptoms, parental practices and parental stress. Results indicated that five of six children no longer met the criteria for SAD diagnosis after treatment and at 3-month follow-up. Moreover, the daily diaries showed that four of six children presented a systematic favourable change of the total weekly frequency of SAD symptoms. Finally, four mothers reported a decrease in overprotection, but we observed no changes in parental stress.

Effectiveness of Psychological and/or Educational Interventions in the Prevention of Anxiety: A Systematic Review, Meta-analysis, and Meta-regression

Importance

To our knowledge, no systematic reviews or meta-analyses have been conducted to assess the effectiveness of preventive psychological and/or educational interventions for anxiety in varied populations.

Objective

To evaluate the effectiveness of preventive psychological and/or educational interventions for anxiety in varied population types.

Data Sources

A systematic review and meta-analysis was conducted based on literature searches of MEDLINE, PsycINFO, Web of Science, EMBASE, OpenGrey, Cochrane Central Register of Controlled Trials, and other sources from inception to March 7, 2017.

Study Selection

A search was performed of randomized clinical trials assessing the effectiveness of preventive psychological and/or educational interventions for anxiety in varying populations free of anxiety at baseline as measured using validated instruments. There was no setting or language restriction. Eligibility criteria assessment was conducted by 2 of us.

Data Extraction and Synthesis

Data extraction and assessment of risk of bias (Cochrane Collaboration's tool) were performed by 2 of us. Pooled standardized mean differences (SMDs) were calculated using random-effect models. Heterogeneity was explored by random-effects meta-regression.

Main Outcomes and Measures

Incidence of new cases of anxiety disorders or reduction of anxiety symptoms as measured by validated instruments.

Results

Of the 3273 abstracts reviewed, 131 were selected for full-text review, and 29 met the inclusion criteria, representing 10 430 patients from 11 countries on 4 continents. Meta-analysis calculations were based on 36 comparisons. The pooled SMD was -0.31 (95% CI, -0.40 to -0.21; P < .001) and heterogeneity was substantial (I2 = 61.1%; 95% CI, 44% to 73%). There was evidence of publication bias, but the effect size barely varied after adjustment (SMD, -0.27; 95% CI, -0.37 to -0.17; P < .001). Sensitivity analyses confirmed the robustness of effect size results. A meta-regression including 5 variables explained 99.6% of between-study variability, revealing an association between higher SMD, waiting list (comparator) (β = -0.33 [95% CI, -0.55 to -0.11]; P = .005) and a lower sample size (lg) (β = 0.15 [95% CI, 0.06 to 0.23]; P = .001). No association was observed with risk of bias, family physician providing intervention, and use of standardized interviews as outcomes.

Conclusions and Relevance

Psychological and/or educational interventions had a small but statistically significant benefit for anxiety prevention in all populations evaluated. Although more studies with larger samples and active comparators are needed, these findings suggest that anxiety prevention programs should be further developed and implemented.

A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years

Background

Anxiety in children is common, impairs everyday functioning and increases the risk of severe mental health disorders in adulthood, yet few children with anxiety are identified and referred for treatment.

Objective

To investigate the clinical effectiveness and cost-effectiveness of a universal school-based preventative programme (FRIENDS) in reducing symptoms of anxiety and low mood.

Design

Cluster randomised controlled trial. Schools (n = 41) were randomly assigned after recruitment on a 1 : 1 : 1 basis to health-led FRIENDS, school-led FRIENDS and usual school provision.

Setting

Primary schools in three local education authorities in the south-west of England.

Participants

Children (n = 1362) aged 9–10 years attending school and participating in personal, social and health education (PSHE).

Interventions

The FRIENDS programme is a cognitive–behavioural therapy programme that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. The FRIENDS programme was led by either a trained member of the school or a health leader external to the school and was delivered over 9 consecutive weeks. The comparison group received usual school PSHE lessons. Interventions were delivered in the academic year September 2011–July 2012.

Main outcome measures

Clinical effectiveness assessed by child report of symptoms of anxiety (Revised Child Anxiety and Depression Scale, RCADS); cost-effectiveness based on RCADS and quality-adjusted life-years (Child Health Utility 9 Dimensions, CHU-9D) between baseline and 6 months; process evaluation, evaluation of reach and attrition and qualitative feedback from children, school staff and parents.

Results

At 12 months there was a difference in the adjusted mean RCADS scores for health-led FRIENDS compared with school-led FRIENDS [–3.91, 95% confidence interval (CI) –6.48 to –1.35] and for health-led FRIENDS compared with usual school provision (–2.66, 95% CI –5.22 to –0.09). At 24 months we were able to assess only 43.6% of our cohort. There were few differences in baseline characteristics between completers and non-completers. Child-reported anxiety in all three groups had reduced by 24 months and there were no longer any group effects. There were no between-group effects for any parent- or child-completed secondary outcomes at 12 or 24 months. The cost of the FRIENDS programme was £52–56 per child. We found no evidence that the FRIENDS programme was cost-effective over a 6-month period; however, our subgroup for the economic analysis differed significantly from our main trial cohort.

Conclusions

Although greater reductions in anxiety were noted at 12 months when the FRIENDS programme was delivered by health leaders, these additional benefits were not maintained at 24 months. Children’s anxiety levels improved irrespective of the intervention that they received. Our economic evaluation and 24-month assessment had significant shortcomings. However, the universal delivery of specific anxiety prevention programmes will result in additional costs that may be beyond the finances available to most schools. Future work should identify the active ingredients and potential moderators of universal anxiety programmes to determine whether programme length can be reduced, short-term effectiveness maintained and cost-effectiveness improved. At present, our results find limited evidence to support the universal provision of specific anxiety prevention programmes in UK primary schools.

Trial registration

Current Controlled Trials ISRCTN23563048.

Funding

The National Institute for Health Research Public Health Research programme.

The population cost-effectiveness of a parenting intervention designed to prevent anxiety disorders in children

BACKGROUND

Prevention and early intervention for anxiety disorders has lagged behind many other forms of mental disorder. Recent research has demonstrated the efficacy of a parent-focussed psycho-educational programme. The programme is directed at parents of inhibited preschool children and has been shown to reduce anxiety disorders at 1 and 3 years following intervention. The current study assesses the cost-effectiveness of this intervention to determine whether it could provide value-for-money across a population.

METHOD

A cost-utility economic framework, using Disability-Adjusted-Life-Years (DALYs) as the outcome, was adopted. Economic modelling techniques were used to assess the incremental cost-effectiveness ratio (ICER) of the intervention within the Australian population context, which was modelled as add-on to current practice. The perspective was the health sector. Uncertainty was measured using multivariate probabilistic testing and key assumptions were tested using univariate sensitivity analysis.

RESULTS

The median ICER for the intervention was AUD$8,000 per DALY averted with 99.8% of the uncertainty iterations falling below the threshold value-for-money criterion of AUD$50,000 per DALY averted. The results were robust to sensitivity testing.

CONCLUSIONS

Screening young children in a preschool setting for an inhibited temperament and providing a brief intervention to the parents of children with high levels of inhibition appears to provide very good value-for-money and worth considering in any package of preventive care. Further evaluation of this intervention under routine health service conditions will strengthen conclusions. Acceptability issues associated with this intervention, particularly to preschool staff and parents, need to be considered before wide-scale adoption is undertaken.

Cost and effects of a universal parenting programme delivered to parents of preschoolers

BACKGROUND

Parenting programmes are effective in improving child behaviour and parental well-being, but long follow-up studies of universally offered programmes are scarce.

METHODS

A cluster randomized controlled trial was conducted to assess the costs and effects of Triple P levels 2-3 on child externalizing behaviours and parental mental health. The programme was offered universally to parents of preschoolers (self-selection allowed). Preschools were randomized to Triple P or a waitlist control. Health outcomes were reduction in externalizing behaviours measured on the Eyberg Child Behaviour Inventory-22 and improvement in parental mental health measured on the Depression Anxiety Stress Scales collected at baseline, 6-, 12- and 18-month follow-up. Child outcomes were based on 355 children aged 3-5 years (child sample) and parental outcomes on 759 parents (parental sample) with baseline data. Costs were collected from a municipality perspective, including 312 children and 488 parents with baseline data in the intervention preschools.

RESULTS

Sixty-seven (29%) parents attended the intervention. Triple P showed no significant improvement in child externalizing behaviours or parental mental health at either of the follow-up points. Triple P had an average yearly total cost of 3007 Swedish Krona (SEK) (€323) per child or 1922 SEK (€207) per parent. Running Triple P cost 227 SEK (€24) per child or 145 SEK (€16) per parent yearly.

CONCLUSION

Offering low intensity levels of Triple P with 29% attendance may not be a reasonable use of public resources, as no evidence of improvement in child externalizing behaviours or parental mental health was found.

Economic evaluations of interventions designed to prevent mental disorders: a systematic review

AIM

The prevention of mental disorders is a growing field and there are interventions that have been demonstrated to prevent some disorders, particularly depression, from developing. The aim of the current study is to update two existing reviews of the cost-effectiveness studies of preventive interventions for mental disorders in order to determine whether such interventions are good value-for-money.

METHODS

A search was undertaken in Medline, PsycInfo and Econlit. The search was limited to articles published in English covering the period from 2010 to September 2013. Inclusion criteria for the review comprised comparative economic evaluations of interventions designed to prevent mental disorders.

RESULTS

Ten new economic evaluations have been published since 2010, more than doubling the numbers of economic evaluations of preventive interventions for mental disorders published prior to 2010. Using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, the majority of studies were of a good standard and used cost-utility frameworks.

CONCLUSIONS

Indicated types of interventions for the prevention of depression and anxiety appeared to be particularly good value-for-money and most of these studies were modelled evaluations. Unfortunately, many such interventions are still not routinely provided. Future trials of preventive interventions for mental disorders need to include robust economic evaluations so that the economic impact of such interventions from the individual study participant perspective can be determined.

Factors associated with the referral of anxious children to mental health care: the influence of family functioning, parenting, parental anxiety and child impairment

This study aims to identify factors that predict the mental health care referral of anxious children. In total, 249 children and families, aged 8-13 years, participated: 73 children were referred with anxiety disorders to mental health care [mean (M) age = 10.28, standard deviation (SD) = 1.35], 176 non-referred anxious children recruited in primary schools (M age = 9.94, SD = 1.22). Child anxiety and other disorders were assessed with semi-structured interviews. Child anxiety symptoms, behavioural problems, parental anxiety, the parenting styles overprotection, autonomy encouragement, rejection, and the family functioning dimensions control and relational functioning, were assessed with child, father and mother report on questionnaires. The summed interference rating of children's anxiety disorders was a predictor of referral, consistent over child and parent reports, but not comorbidity. Most family and parenting variables did not predict referral, nor differed between the referred and non-referred sample. Contrary to our hypothesis, maternal self-reported anxiety decreased the odds of referral and child reported parental autonomy granting increased, while child reported overprotection decreased the odds of referral. The impairment for the child due to the number and severity of their anxiety disorder(s) is, based on child, mother and father report associated with referral. This indicates that those who need it most, receive clinical treatment.

An explorative cost-effectiveness analysis of school-based screening for child anxiety using a decision analytic model

Anxiety in children is highly frequent and causes severe dysfunction. Various studies have used screening procedures to identify high-anxious children and offer them indicated prevention, but the cost-effectiveness of these screening procedures in combination with a preventive intervention has never been examined. This study compared four potential strategies in relation to the prevention of child anxiety: (1) a one-time school-based screening which offers a child-focused intervention, (2) the screening and offering of a parent-focused intervention, (3) the screening and differentially offering a child- or parent-focused intervention, depending on whether or not the parents are anxious themselves, and (4) or doing nothing. An economic evaluation from a societal perspective (i.e. including direct healthcare costs, direct non-healthcare costs, indirect costs, and out-of-pocket costs), using a decision-analytic model. The model was based on the real-world 2-year participation rates of screening and intervention, and real-world costs and effects of high- and median-anxious children (aged 8-12) from regular primary schools. Incremental cost-effectiveness ratios were calculated, and several secondary and one-way sensitivity analyses were performed. The strategy of doing nothing and the strategy of screening and differentially offering the child- or parent-focused intervention, depending on parental anxiety levels were both worthwhile, with the latter strategy costing relatively little extra money compared to doing nothing. In conclusion, some evidence for the cost-effectiveness of screening and intervening was found. Screening and offering a parent-focused intervention to children of anxious parents, and a child-focused intervention to children of non-anxious parents, were found to be the most cost-effective approach.