Treatment of childhood anxiety disorder in the context of maternal anxiety disorder

218 Pages·2015·2.97 MB·English

by  Creswell C

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).
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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
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