Cognitive Behavior Therapy for Social Activation in Schizophrenia Not Cost-Effective

man in therapy
man in therapy
Although treatment as usual for psychosis is guideline-congruent and well implemented, there appears to be no added value for adjunct cognitive behavioral therapy for social activation, according to the results of a study from the Netherlands.

Treatment as usual (TAU) augmented with adjunct cognitive behavioral therapy (CBT) for social activation (CBTsa) was not found to be cost-effective when compared with TAU alone in patients with schizophrenia spectrum disorder, according to study findings published in PLoS One.

Individuals with schizophrenia often suffer from cognitive deficits and negative symptoms that impair their social functioning. Social skills training can be effective in treating negative symptoms, and CBT has shown promise, as well.

A  team of researchers from the Netherlands Institute of Mental Health and Addiction conducted a health-economic evaluation in conjunction with a single-blind, randomized, controlled, parallel-group trial of CBTsa plus TAU compared with TAU alone in patients with recent-onset schizophrenia spectrum disorder ( Identifier: NCT03217955). They performed measurements at baseline, 3 months, and 3 and 6 months post-treatment. The Positive and Negative Syndrome Scale for Schizophrenia (PANSS) was used to determine clinical effectiveness. Covered costs included intervention, healthcare, patient and family, and productivity costs.

The study included 99 participants with an 81.6% participation rate in the CBTsa-plus-TAU group and a 78% participation rate in the TAU group at 3-month follow-up.  At 6-month follow-up, 79.6% of the participants in the CBTsa-plus-TAU group and 70% in the TAU group remained in the study.

Response rates were 34.7% in the CBTsa-plus-TAU group and 22% in the TAU group, while at 6-month follow-up the response rates were 36.7% and 24%, respectively. Patients in the CBTsa-plus-TAU group saw a mean Quality Adjusted Life Year (QALY) gain of 0.40 by 6-month follow-up, while patients in the TAU group gained 0.37, resulting in a significant 0.034 QALY difference favoring the CBTsa-plus-TAU group (P =.018).

Costs, however, favored the TAU group: the CBTsa-plus-TAU group had 6-month follow-up costs of 45,894 vs 34,977 in the TAU group. The mean incremental cost-effectiveness ratio was estimated at 87,886 per treatment responder.

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The investigators noted a number of study limitations. The small number of patients recruited resulted in the study being underpowered. In addition, the 6-month follow-up may not have been long enough to detect the efficacy of the CBTsa-plus-TAU regimen. Furthermore, the patients could not be blinded to the intervention and the use of healthcare resources, which figured into the cost analysis, relied on self-report, which is subject to recall bias.

The researchers suggested that the failure to find cost-effectiveness for the intervention may stem from the excellent quality of care that patients with schizophrenia receive in the Netherlands. They argued that cost-effectiveness may differ from one medical system to another and called for larger studies to determine to what extent CBTsa affects functional status and health-related quality of life.


Wijnen BFM, Pos K, Velthorst E, et al. Economic evaluation of brief cognitive behavioural therapy for social activation in recent-onset psychosis. PLoS One. 2018;13(11):e0206236.