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Group and individual cognitive behavioral therapy (CBT) for children & adolescents with anxiety

Children's Mental Health: Anxiety
Benefit-cost methods last updated December 2018.  Literature review updated May 2018.
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Cognitive behavioral therapy (CBT) uses cognitive restructuring and self-talk, exposure to feared stimuli, and other strategies to treat mental health conditions, including anxiety. CBT interventions are typically delivered by therapists in individual or group format in an outpatient setting; well-known examples include the Coping Cat and Coping Koala programs. Programs in this analysis served typically or atypically developing children with anxiety disorders. This analysis includes both traditional CBT interventions, which on average provided an estimated 15 hours of therapy over 12 weeks, and brief, intensive CBT interventions, which on average provided an estimated 30 hours of therapy over two weeks.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2017). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $3,636 Benefits minus costs $10,313
Participants $5,634 Benefit to cost ratio $24.18
Others $1,113 Chance the program will produce
Indirect $374 benefits greater than the costs 95 %
Total benefits $10,758
Net program cost ($445)
Benefits minus cost $10,313
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $58 $0 $140 $29 $227
K-12 grade repetition $27 $0 $0 $13 $40
K-12 special education $171 $0 $0 $85 $256
Labor market earnings associated with anxiety disorder $2,437 $5,367 $0 $0 $7,804
Health care associated with internalizing symptoms $943 $267 $974 $469 $2,652
Mortality associated with depression $0 $0 $0 $0 $0
Adjustment for deadweight cost of program $0 $0 $0 ($221) ($221)
Totals $3,636 $5,634 $1,113 $374 $10,758
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,431 2015 Present value of net program costs (in 2017 dollars) ($445)
Comparison costs $927 2010 Cost range (+ or -) 30 %
In studies included in this analysis, participants received an average of 15 hours of therapist time. Per-participant cost estimates are based on weighted average therapist time, as reported in the treatment studies. Hourly therapist cost is based on the actuarial estimates of reimbursement by modality (Mercer. (2016). Mental health and substance use disorder services data book for the state of Washington). For comparison group costs, we use 2010 Washington State DSHS data to estimate the average reimbursement rate for anxiety treatment for children and adolescents.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

*The effect size for this outcome indicates percentage change, not a standardized mean difference effect size.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Anxiety disorder 10 39 1342 -0.681 0.059 10 -0.269 0.190 11 -0.914 0.001
Attention-deficit/hyperactivity disorder symptoms 10 1 42 -0.683 0.219 10 0.000 0.141 11 -0.683 0.002
Emergency department visits^^ 10 1 19 0.000 0.457 10 n/a n/a n/a 0.000 1.000
Externalizing behavior symptoms 10 9 495 -0.258 0.073 10 -0.142 0.075 13 -0.292 0.001
Global functioning^ 10 3 173 0.775 0.307 10 n/a n/a n/a 0.775 0.011
Health care costs*^^ 10 1 24 0.046 79.057 10 n/a n/a n/a 0.046 1.000
Hospitalization^^ 10 1 140 -0.082 0.168 10 n/a n/a n/a -0.082 0.627
Hospitalization (psychiatric)^^ 10 2 182 0.000 0.145 10 n/a n/a n/a 0.000 1.000
Internalizing symptoms 10 12 600 -0.338 0.065 10 -0.338 0.065 12 -0.379 0.001
Major depressive disorder 10 14 605 -0.187 0.068 10 0.000 0.310 12 -0.224 0.001
School attendance^ 10 1 24 0.019 0.286 10 n/a n/a n/a 0.019 0.948
Suicidal ideation^ 10 2 182 0.186 0.145 10 n/a n/a n/a 0.186 0.199
Suicide attempts^ 10 2 182 0.000 0.115 10 n/a n/a n/a 0.000 1.000

Citations Used in the Meta-Analysis

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