Treatment of childhood anxiety disorder in the context of maternal anxiety disorder PDF
Preview Treatment of childhood anxiety disorder in the context of maternal anxiety disorder
HEALTH TECHNOLOGY ASSESSMENT VOLUME 19 ISSUE 38 MAY 2015 ISSN 1366-5278 Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis Cathy Creswell, Susan Cruddace, Stephen Gerry, Rachel Gitau, Emma McIntosh, Jill Mollison, Lynne Murray, Rosamund Shafran, Alan Stein, Mara Violato, Merryn Voysey, Lucy Willetts, Nicola Williams, Ly-Mee Yu and Peter J Cooper DOI 10.3310/hta19380 Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis Cathy Creswell,1* Susan Cruddace,1 Stephen Gerry,2 Rachel Gitau,1 Emma McIntosh,3 Jill Mollison,4 Lynne Murray,1,5 Rosamund Shafran,6 Alan Stein,7,8 Mara Violato,9,10 Merryn Voysey,4 Lucy Willetts,11 Nicola Williams,2 Ly-Mee Yu4 and Peter J Cooper1,5 1School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK 2Centre for Statistics in Medicine, University of Oxford, Oxford, UK 3Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK 4Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK 5Department of Psychology, Stellenbosch University, Stellenbosch, South Africa 6Institute of Child Health, University College London, London, UK 7Department of Psychiatry, University of Oxford, Oxford, UK 8School of Public Health, University of Witwatersrand, Witwatersrand, South Africa 9Health Economics Research Centre, University of Oxford, Oxford, UK 10National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Oxford, Oxford, UK 11Berkshire Healthcare NHS Foundation Trust, Reading, UK *Corresponding author Declared competing interests of authors: Cathy Creswell was supported by aMedical Research Council Clinician Scientist Fellowship (G0601874). Published May 2015 DOI: 10.3310/hta19380 This reportshould be referenced as follows: Creswell C, Cruddace S, Gerry S, Gitau R, McIntosh E, Mollison J,et al. Treatment of childhood anxiety disorder in thecontext of maternal anxiety disorder: arandomised controlled trial and economic analysis. Health Technol Assess2015;19(38). HealthTechnology Assessment isindexed and abstracted in IndexMedicus/MEDLINE, Excerpta Medica/EMBASE, ScienceCitation Index Expanded (SciSearch®) andCurrent Contents®/ Clinical Medicine. Health Technology Assessment HTAEME ISSN1366-5278(Print) ISSN2046-4924(Online) Impactfactor:5.116 HealthTechnologyAssessmentisindexedinMEDLINE,CINAHL,EMBASE,TheCochraneLibraryandtheISIScienceCitationIndexandis assessedforinclusionintheDatabaseofAbstractsofReviewsofEffects. ThisjournalisamemberofandsubscribestotheprinciplesoftheCommitteeonPublicationEthics(COPE)(www.publicationethics.org/). 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ThisreportpresentsindependentresearchfundedbytheNationalInstituteforHealthResearch(NIHR).Theviewsandopinionsexpressedby authorsinthispublicationarethoseoftheauthorsanddonotnecessarilyreflectthoseoftheNHS,theNIHR,theMRC,NETSCC,theHTA programme,theEMEprogrammeortheDepartmentofHealth.Ifthereareverbatimquotationsincludedinthispublicationtheviewsand opinionsexpressedbytheintervieweesarethoseoftheintervieweesanddonotnecessarilyreflectthoseoftheauthors,thoseoftheNHS,the NIHR,NETSCC,theHTAprogramme,theEMEprogrammeortheDepartmentofHealth. ©Queen’sPrinterandControllerofHMSO2015.ThisworkwasproducedbyCreswelletal.underthetermsofacommissioning contractissuedbytheSecretaryofStateforHealth.Thisissuemaybefreelyreproducedforthepurposesofprivateresearchand studyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournalsprovidedthatsuitableacknowledgement ismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbe addressedto:NIHRJournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre, AlphaHouse,UniversityofSouthamptonSciencePark,SouthamptonSO167NS,UK. PublishedbytheNIHRJournalsLibrary(www.journalslibrary.nihr.ac.uk),producedbyPrepressProjectsLtd,Perth,Scotland (www.prepress-projects.co.uk). Editor-in-Chief of Health Technology Assessment and NIHR Journals Library Professor Tom Walley Director, NIHR Evaluation, Trials and Studies and Director of the HTA Programme, UK NIHR Journals Library Editors Professor Ken Stein Chair of HTA Editorial Board and Professor of Public Health, University of Exeter Medical School, UK Professor Andree Le May Chair of NIHR Journals Library Editorial Group (EME, HS&DR, PGfAR, PHR journals) Dr Martin Ashton-Key Consultant in Public Health Medicine/Consultant Advisor, NETSCC, UK Professor Matthias Beck Chair in Public Sector Management and Subject Leader (Management Group), Queen’s University Management School, Queen’s University Belfast, UK Professor Aileen Clarke Professor of Public Health and Health Services Research, Warwick Medical School, University of Warwick, UK Dr Tessa Crilly Director, Crystal Blue Consulting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Elaine McColl Director, Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, UK Professor William McGuire Professor of Child Health, Hull York Medical School, University of York, UK Professor Geoffrey Meads Professor of Health Sciences Research, Faculty of Education, University of Winchester, UK Professor John Powell Consultant Clinical Adviser, National Institute for Health and Care Excellence (NICE), UK Professor James Raftery Professor of Health Technology Assessment, Wessex Institute, Faculty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Kleijnen Systematic Reviews Ltd, UK Professor Helen Roberts Professor of Child Health Research, UCL Institute of Child Health, UK Professor Helen Snooks Professor of Health Services Research, Institute of Life Science, College of Medicine, Swansea University, UK Please visit the website for a list of members of the NIHR Journals Library Board: www.journalslibrary.nihr.ac.uk/about/editors Editorial contact: [email protected] NIHRJournalsLibrary www.journalslibrary.nihr.ac.uk DOI:10.3310/hta19380 HEALTHTECHNOLOGYASSESSMENT2015 VOL.19 NO.38 Abstract Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis Cathy Creswell,1* Susan Cruddace,1 Stephen Gerry,2 Rachel Gitau,1 Emma McIntosh,3 Jill Mollison,4 Lynne Murray,1,5 Rosamund Shafran,6 Alan Stein,7,8 Mara Violato,9,10 Merryn Voysey,4 Lucy Willetts,11 Nicola Williams,2 Ly-Mee Yu4 and Peter J Cooper1,5 1School of Psychology andClinical LanguageSciences, University ofReading, Reading, UK 2Centre for Statistics in Medicine, University of Oxford, Oxford, UK 3Health Economics and Health TechnologyAssessment, Institute of Healthand Wellbeing, University ofGlasgow, Glasgow, UK 4Nuffield Department of PrimaryHealth Care Sciences, University of Oxford, Oxford, UK 5Department ofPsychology, StellenboschUniversity, Stellenbosch, South Africa 6Institute of Child Health, University College London, London,UK 7Department ofPsychiatry, University ofOxford, Oxford, UK 8School of Public Health, University ofWitwatersrand, Witwatersrand, South Africa 9Health Economics Research Centre,University ofOxford, Oxford, UK 10National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Oxford, Oxford, UK 11Berkshire Healthcare NHS FoundationTrust, Reading, UK *Corresponding author [email protected] Background: Cognitive–behavioural therapy (CBT) for childhood anxiety disorders isassociated with modest outcomes in thecontext of parental anxiety disorder. Objectives: This study evaluated whether or notthe outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders isimproved by theaddition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused onmaternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated. Design: Participants were randomised to receive (i) child cognitive–behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT+maternal cognitive–behavioural therapy (MCBT)]; or (iii) CCBTwith an intervention to target mother–child interactions (MCIs) (CCBT+MCI). Setting: A NHS university clinic in Berkshire, UK. Participants: Twohundred and eleven children with aprimary anxiety disorder, whose mothers also had an anxiety disorder. Interventions: All families received eight sessions of individual CCBT. Mothers in theCCBT+MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in theMCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact. ©Queen’sPrinterandControllerofHMSO2015.ThisworkwasproducedbyCreswelletal.underthetermsofacommissioningcontractissuedbytheSecretaryofStatefor Health.Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournals vii providedthatsuitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbe addressedto:NIHRJournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonScience Park,SouthamptonSO167NS,UK. ABSTRACT Main outcome measures: Primaryclinicaloutcomeswerethechild’sprimaryanxietydisorderstatusand degreeofimprovementattheendoftreatment.Follow-upassessmentswereconductedat6and12months. Outcomesintheeconomicanalyseswereidentifiedandmeasuredusingestimatedquality-adjustedlife-years (QALYs).QALYSwerecombinedwithtreatment,healthandsocialcarecostsandpresentedwithinan incrementalcost–utilityanalysisframeworkwithassociateduncertainty. Results: MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had receivedCCBT, groupdifferences were no longer apparent. CCBT+MCI was associated with areduction in maternal overinvolvement and moreconfident expectations of the child. However, neither CCBT+MCBT nor CCBT+MCI conferred asignificant post-treatment benefit overCCBT in terms of child anxiety disorder diagnoses [adjusted riskratio (RR) 1.18,95% confidence interval (CI) 0.87to 1.62, p=0.29;adjusted RR CCBT+MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67,p=0.20, respectively] or globalimprovement ratings (adjusted RR1.25, 95% CI 1.00 to 1.59, p=0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53,p=0.13). CCBT+MCI outperformed CCBT on somesecondary outcome measures. Furthermore, primary economic analyses suggestedthat, at commonly acceptedthresholds of cost-effectiveness, the probability that CCBT+MCI willbe cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%. Conclusions: Good outcomes were achieved for children and their mothers acrosstreatment conditions. There was no evidence of abenefit to child outcome of supplementing CCBT witheither intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented acost-effective useof resources, although thehigh percentage of missing data onsome economic variables is ashortcoming. Future work should consider whether or noteffects of theadjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the useof abroad range of services when evaluating interventions with this clientgroup. Trial registration: Current Controlled Trials ISRCTN19762288. Funding: ThistrialwasfundedbytheMedicalResearchCouncil(MRC)andBerkshireHealthcareFoundation TrustandmanagedbytheNationalInstituteforHealthResearch(NIHR)onbehalfoftheMRC–NIHR partnership(09/800/17)andwillbepublishedinfullinHealthTechnologyAssessment;Vol.19,No.38. viii NIHRJournalsLibrary www.journalslibrary.nihr.ac.uk
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