Guided self-help digital cognitive behavioural therapy for children and young people with mild to moderate symptoms of anxiety or low mood: early value assessment

Mental health services are in high demand and access varies widely across the country. The availability of effective mental health treatments is limited, with a shortage of qualified staff and long waiting times. Access to treatment can depend on the severity of symptoms. Children and young people who are referred for treatment with a mental health professional may be offered education, advice, support and signposting while waiting for treatment. Early research suggests that the COVID‑19 pandemic has had a substantial effect on the mental health of children and young people and has intensified the issues related to accessing effective mental health treatments.

There is a need to improve access to effective mental health treatments, especially given the increase in mental health conditions seen during the pandemic. The patient experts noted that it can be difficult to get access to mental health care but that it was important for children and young people to have access to treatment as soon as possible. They also noted that in their experience there were no options available to them while waiting for treatment. The clinical experts agreed that many children and young people are not getting access to treatment when they need it. The committee concluded that there is an unmet clinical need and access to effective mental health treatments needs to be improved.

Further evidence will be generated while the technologies are in use to address the immediate unmet need, with appropriate risk management processes in place. The clinical experts stressed the importance of clinical risk management. The companies advised that they have risk management and safeguarding systems in place. Also, all these technologies are supported by healthcare professionals that check in with users on a weekly basis. The clinical experts noted that even though risk management is important, many children and young people do not currently get access to any treatment while they are waiting. These guided self-help digital cognitive behavioural therapy (CBT) technologies are a way to increase access to treatment with support from a healthcare professional. The committee concluded that these technologies can be used as an initial option if used with appropriate safeguarding and risk management processes in place while evidence is generated.

The evidence shows that digital CBT technologies have a potential benefit for children and young people with mild to moderate symptoms of anxiety or low mood. The evidence base consists of 5 published studies, 2 unpublished studies and 2 conference abstracts. Of these, 7 were single arm designs with no direct comparator, 1 was a randomised controlled trial design and 1 was a 2‑arm non-randomised design. The external assessment group (EAG) noted that there is weak evidence to suggest an improvement in anxiety symptom severity for these technologies. The EAG noted that the sample sizes across the studies were small so presented a risk of false chance findings and underpowered analyses. The committee concluded that the evidence base is very limited for all 5 technologies. One technology had some higher-level evidence that showed an improvement in symptoms of anxiety compared with treatment as usual, but none of them were considered to have a stronger evidence base than the others. See the assessment report for further details.

Some neurodivergent children and young people may benefit from these guided self-help digital CBT technologies. The patient experts noted that neurodivergent children and young people are more likely to have significant mental health needs. They may look at digital technologies differently and it is important that the technologies meet their needs. Some patient experts liked the online interaction in place of face-to-face interaction because they can be used without having to meet in person. The committee concluded that some neurodivergent children and young people may benefit from this more remote method of delivering therapy.

Children and young people with limited access to equipment, internet connection or the privacy needed to complete the intervention are unlikely to benefit from the guided self-help digital CBT technologies. They may also lack experience with computers or electronic devices. These digital technologies are unlikely to improve treatment options for these children and young people so other treatment options including face-to-face CBT may be more appropriate.

The duration of the intervention and the licence cost per user may affect costs. The committee noted that the parameter values in the model were based on very limited data sources, so the results are uncertain. Also, the value of information analysis confirmed that further research is needed on the effectiveness of the 5 digital CBT technologies and the health state utilities. Based on the analysis, the key parameters affecting the cost effectiveness are the length of treatment and the licence cost per user. It is unknown if the shorter duration of treatment with 4 out of 5 technologies will lead to poorer outcomes, or whether the longer duration of treatment simply increases costs. The model seemed relatively insensitive to the use of a mental health support worker compared with a clinical psychologist. The committee concluded that more data on these parameters is needed.

The key evidence gaps relate to the population and key outcomes. The committee concluded that the evidence is very limited, so evidence generation is needed to address these key evidence gaps for all 5 technologies:

• There is no evidence for use of these technologies by children and young people with low mood only. The clinical experts noted that often children and young people will have symptoms of both anxiety and low mood. Most of the technologies are intended to treat symptoms of anxiety, but the companies confirmed that they can be used for children and young people with symptoms of low mood, if they are primarily presenting with symptoms of anxiety. Silvercloud has 1 technology that is specifically designed for young people with low mood only.

• There is no evidence for use of these technologies by neurodivergent children and young people. The clinical experts noted that the population these technologies are aimed at has a high rate of neurodivergent children and young people, but the evidence implicitly or explicitly excluded them.

• There is some heterogeneity in reporting symptoms of severity and impairment. Most studies reported symptom severity using the revised child anxiety and depression scale and impairment measures using the child anxiety impact scale and the strength and difficulties questionnaire. The clinical experts confirmed that these are appropriate measures. But self-reporting of these measures for young people would be preferable, whereas for children this can be parent-reported.

• There is limited evidence on levels of engagement and reasons and rates of drop out from studies. The clinical experts noted that if children and young people stop using the technologies early without any improvement it may make further re-engagement and treatment effectiveness less likely.

• There is no evidence on health-related quality of life. The clinical experts noted the importance of measuring quality of life and stated that different measures may be needed for children and young people. The EAG clarified that the EQ‑5D‑Y does not have a UK value set, but that the CHU‑9D is specifically for children and young people.

• There is limited evidence available for the decision modelling. The EAG noted that evidence on outcomes related to the effectiveness of the digital CBT technologies compared with treatment as usual, should be generated to improve the certainty of the results of the model. These should include health-related quality of life, withdrawals from treatment and level of psychological support.