The Cost Effectiveness of Psychological and Pharmacological Interventions for Social Anxiety Disorder:A Model-Based Economic Analysis

Background Social anxiety disorder is one of the most persistent and common anxiety disorders. Individually delivered psychological therapies are the most effective treatment options for adults with social anxiety disorder, but they are associated with high intervention costs. Therefore, the objective of this study was to assess the relative cost effectiveness of a variety of psychological and pharmacological interventions for adults with social anxiety disorder. Methods A decision-analytic model was constructed to compare costs and quality adjusted life years (QALYs) of 28 interventions for social anxiety disorder from the perspective of the British National Health Service and personal social services. Efficacy data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published literature and national sources, supplemented by expert opinion. Results Individual cognitive therapy was the most cost-effective intervention for adults with social anxiety disorder, followed by generic individual cognitive behavioural therapy (CBT), phenelzine and book-based self-help without support. Other drugs, group-based psychological interventions and other individually delivered psychological interventions were less cost-effective. Results were influenced by limited evidence suggesting superiority of psychological interventions over drugs in retaining long-term effects. The analysis did not take into account side effects of drugs. Conclusion Various forms of individually delivered CBT appear to be the most cost-effective options for the treatment of adults with social anxiety disorder. Consideration of side effects of drugs would only strengthen this conclusion, as it would improve even further the cost effectiveness of individually delivered CBT relative to phenelzine, which was the next most cost-effective option, due to the serious side effects associated with phenelzine. Further research needs to determine more accurately the long-term comparative benefits and harms of psychological and pharmacological interventions for social anxiety disorder and establish their relative cost effectiveness with greater certainty

Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis

SummaryBackgroundSocial anxiety disorder—a chronic and naturally unremitting disease that causes substantial impairment—can be treated with pharmacological, psychological, and self-help interventions. We aimed to compare these interventions and to identify which are most effective for the acute treatment of social anxiety disorder in adults.MethodsWe did a systematic review and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013. We analysed interventions by class and individually. Outcomes were validated measures of social anxiety, reported as standardised mean differences (SMDs) compared with a waitlist reference. This study is registered with PROSPERO, number CRD42012003146.FindingsWe included 101 trials (13 164 participants) of 41 interventions or control conditions (17 classes) in the analyses. Classes of pharmacological interventions that had greater effects on outcomes compared with waitlist were monoamine oxidase inhibitors (SMD −1·01, 95% credible interval [CrI] −1·56 to −0·45), benzodiazepines (−0·96, −1·56 to −0·36), selective serotonin-reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors (SSRIs and SNRIs; −0·91, −1·23 to −0·60), and anticonvulsants (−0·81, −1·36 to −0·28). Compared with waitlist, efficacious classes of psychological interventions were individual cognitive–behavioural therapy (CBT; SMD −1·19, 95% CrI −1·56 to −0·81), group CBT (−0·92, −1·33 to −0·51), exposure and social skills (−0·86, −1·42 to −0·29), self-help with support (−0·86, −1·36 to −0·36), self-help without support (−0·75, −1·25 to −0·26), and psychodynamic psychotherapy (−0·62, −0·93 to −0·31). Individual CBT compared with psychological placebo (SMD −0·56, 95% CrI −1·00 to −0·11), and SSRIs and SNRIs compared with pill placebo (−0·44, −0·67 to −0·22) were the only classes of interventions that had greater effects on outcomes than appropriate placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy (SMD −0·56, 95% CrI −1·03 to −0·11) and interpersonal psychotherapy, mindfulness, and supportive therapy (−0·82, −1·41 to −0·24).InterpretationIndividual CBT (which other studies have shown to have a lower risk of side-effects than pharmacotherapy) is associated with large effect sizes. Thus, it should be regarded as the best intervention for the initial treatment of social anxiety disorder. For individuals who decline psychological intervention, SSRIs show the most consistent evidence of benefit.FundingNational Institute for Health and Care Excellence

Health psychology interventions to improve adherence to maintenance therapies in asthma

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Main objectives To determine the effectiveness of theory-based and non-theory based health psychology interventions for improving adherence to maintenance therapy in adults with asthma Secondary objectives To compare the effectiveness of adherence interventions which are based on theory, as defined by the Theory Coding Scheme (TCS), to interventions which are not theory-based To identify and describe, using the TSC and Theoretical Domain Framework (TDF), the different health psychology theories which have been used in interventions to improve adherence to maintenance therapy in adults with asthma To evaluate the extent to which health psychology theory has been applied to the development of adherence interventions in asthm

Cost-effectiveness plane showing the incremental costs and QALYs of all interventions versus wait list.

<p>Wait list is placed at the origin; results are for 1,000 adults with social anxiety disorder at 5 years after treatment. The continuous line shows the cost-effectiveness efficiency frontier, while the slope of the dotted line indicates the NICE lower cost effectiveness threshold (£20,000/QALY). The data used to construct Fig 2 are provided in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.t005" target="_blank">Table 5</a>.</p

Schematic diagram of the economic model constructed to assess the cost-effectiveness of interventions for social anxiety disorder.

<p>Schematic diagram of the economic model constructed to assess the cost-effectiveness of interventions for social anxiety disorder.</p

Results of network meta-analysis that were utilised in the economic model: probability of recovery at end of treatment.

<p>The log-odds of recovery on wait list was assumed to follow a normal distribution with mean -2.629 and variance 1.235 (estimated using all the wait list arms of RCTs included in the NMA); this translates into a probability of recovery for wait list (mean, 95% credible intervals) as shown above.</p><p>C&W: Clark and Wells model; GCBT: group cognitive behavioural therapy; ICBT: individually delivered cognitive behavioural therapy; IPT: interpersonal therapy; NMA: network meta-analysis; PDPT: psychodynamic psychotherapy; SHNS: self-help no support; SHWS: self-help with support</p><p>Interventions ranked according to probability of recovery (highest to lowest).</p

Cost-effectiveness acceptability frontier of pharmacological and psychological interventions for adults with social anxiety disorder.

<p>The values used to construct Fig 3 are provided in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.s005" target="_blank">S2 Table</a>.</p

Intervention costs of psychological treatments (2015 prices).

<p>^aCost of therapists was estimated using the unit cost of Band 7 qualified clinical psychologists (NHS Agenda for Change for qualified Allied Health Professionals), which includes salary, on-costs and overheads [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.ref039" target="_blank">39</a>]; additional qualification costs estimated as a proportion of this unit cost, after examining unit costs without/with qualification costs for other mental health professionals (consultant psychiatrists and mental health nurses); estimated unit cost for Band 7 therapist equals £110 per hour; total cost per person includes a GP visit for referral to the psychological service; GP unit cost taken from [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.ref038" target="_blank">38</a>].</p><p>C&W: Clark and Wells model; GCBT: group cognitive behavioural therapy; ICBT: individually delivered cognitive behavioural therapy; IPT: interpersonal therapy; PDPT: psychodynamic psychotherapy; SHNS: self-help no support; SHWS: self-help with support</p><p>Intervention costs of psychological treatments (2015 prices).</p

Intervention costs of pharmacological treatments considered in the economic analysis (2015 prices).

<p>^a Drug acquisition costs were taken from the Electronic Drug Tariff for England and Wales [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.ref037" target="_blank">37</a>]; lowest reported price for each drug was used, including prices of generic forms, where available.</p><p>^b GP cost includes 4 GP visits during 12 weeks of initial treatment and 3 visits during the 26-week maintenance period, at £46.75 per visit = £327.25; GP unit cost, including qualification and direct care staff costs, was taken from [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.ref038" target="_blank">38</a>] and inflated to 2015 price.</p><p>Intervention costs of pharmacological treatments considered in the economic analysis (2015 prices).</p