Cost-Effectiveness Analysis of School-Based Treatments for Anxiety Disorders

Background: School-based treatments for anxiety disorders are needed to address barriers to accessing community-based services. A key question for school administers are the costs related to these treatments. Aims of the Study: This study examined the cost-effectiveness of a school-based modular cognitive behavioral therapy (M-CBT) for pediatric anxiety disorders compared to school-based treatment as usual (TAU). Methods: Sixty-two school-based clinicians in Maryland and Connecticut were randomized (37 in CBT; 25 in TAU), trained, and enrolled at least one anxious student (148 students in CBT; 68 in TAU). Students (N = 216) were ages 6-18 (mean age 10.9); 63.9% were non-Hispanic White race-ethnicity; and 48.6% were female. Independent evaluators (IEs) assessed outcomes at post treatment and at a one-year follow up. Anxiety related costs included mental health care expenses and the opportunity costs of added caregiver time and missed school days. Results: The overall M-CBT ICER value of $6917/QALY reflected both lower costs for days absent from school (mean difference: $-117 per youth; p = 0.045) but also lower QALY ratings (mean difference: -0.024; p = 0.900) compared with usual school counseling. Among youth with more severe anxiety at baseline, M-CBT had a more favorable ICER ($-22,846/QALY). Other mental health care costs were similar between groups (mean difference: $-90 per youth; p = 0.328). Discussion: Although training school clinicians in M-CBT resulted in lower costs for school absences, evidence for the cost effectiveness of a modular CBT relative to existing school treatment for pediatric anxiety disorders was not robustly supported. Findings suggest school-based M-CBT is most cost effective for youth with the highest levels of anxiety severity and that M-CBT could help reduce the costs of missed school. Interpretations are limited due to use of retrospective recall, lack of data on medication use, and small sample size. Implications for Health Care Provision and Use: Schools may benefit from providing specialized school-based services such as M-CBT for students with the highest levels of anxiety. Implications for Health Policies: Investment decisions by schools should take into account lower costs (related to school absences), the costs of training clinicians, and student access to CBT in the community. Implications for Further Research: Replication with a larger sample, service use diaries, and objective school and medical records over a longer period of time is warranted.