Exposure CBT is Cost-Effective Alternative for Traditional CBT for People With Fibromyalgia

New research comparing cost-effectiveness of online exposure cognitive behavioral therapy (EXP-CBT) and online traditional CBT (T-CBT) for people with fibromyalgia (FM) has found that EXP-CBT be a cost-effective alternate but did not find any marked cost- or effect differences.1

“Besides being a cost-effective alternative to face-to-face-treatment2, online interventions have other important health economic benefits. Treatment is independent of geographical distance, which reduces salary loss due to time taken from work as well as travel expenses. Moreover, there is no risk of insufficient use of therapist time due to canceled appointments, which further enhances efficient use of limited health care resources,” lead investigator Maria Hedman-Lagerlöf, PhD, Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Stockholm, Region Stockholm, Sweden, and colleagues wrote.1

The research analyzed health economic data from a randomized controlled trial including 274 participants with FM assigned to either EXP-CBT or T-CBT. The analysis had a time horizon of 15 months and evaluated treatment effectiveness relative to both direct and indirect costs together and direct costs only. The investigators also performed bootstrapped net benefit regression analyses to compare cost and effect differences between EXP-CBT and T-CBT under different willingness-to-pay (WTP) scenarios.

The trial found that after 15 months of follow-up, mean Fibromyalgia Impact Questionnaire (FIQ) scores were 43.8 (standard deviation [SD], 19.8) in the EXP-CBT and 48.7 (SD, 18.8) in the T-CBT group and statistically similar. Likewise, mean EQ-5D scores at that time were 0.57 (SD, 0.29) in the EXP-CBT group and 0.48 (SD, 0. 33) in the T-CBT group.1

Hedman-Lagerlöf and colleagues found that EXP-CBT was cost-effective similarly to T-CBT over the 15 months study period (−1477; 95% CI, −7444 to 4490; z = −0.49; P = .628). The incremental cost-effectiveness ratio (ICER) considering direct and indirect costs of EXP-CBT was −1477/0.09 = –$16,884 per responder on FIQ (14% reduction). From a health care provider perspective of only direct costs, the corresponding ICER was −1162/0.09 = –$12,911.1

Looking at EQ-5D scores, ICER was −1477/0.05 = –$28,763 for EXP-CBT considering both direct and indirect costs and −1162/0.05 = –$23,240 considering only direct costs. Using quality-adjusted life years as an outcome, there was a 69% probability of EXP-CBT being cost-effective even at a WTP threshold of $0 considering direct and indirect costs and a 90% probability of being cost-effective with a WTP of $0 considering only direct costs.1

Importantly, the investigators noted that ICER estimates are always large when effect differences are small, as in this study. They also noted the use of self-reported data as a limitation of the study and encouraged future studies to evaluate EXP-CBT and T-CBT in a clinical context and compare the cost-effectiveness to treatment as usual, as well as in severe patients in specialized pain clinics.

“In conclusion, online exposure therapy for FM may be a cost-effective alternative compared to online traditional CBT. However, given the similarity in effects and costs between the two groups, neither EXP-CBT nor T-CBT could be said to be unambiguously cost-effective in comparison to the other,” Hedman-Lagerlöf and colleagues concluded.1

REFERENCES

1. Hedman-Lagerlöf M, Hedman-Lagerlöf E, Buhrman M, Axelsson E. Cost-effectiveness and cost-utility of exposure-based vs. traditional cognitive behavior therapy for fibromyalgia: Results from a randomized controlled trial. J Pain. 2025; 30 (105375)

2. Donker T, Blankers M, Hedman E, Ljótsson B, Petrie K, Christensen H. Economic evaluations of Internet interventions for mental health: a systematic review. Psychological Medicine. 2015;45(16):3357-3376. doi:10.1017/S0033291715001427