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Trial registered on ANZCTR


Registration number
ACTRN12618001418268
Ethics application status
Approved
Date submitted
20/08/2018
Date registered
24/08/2018
Date last updated
21/10/2022
Date data sharing statement initially provided
9/02/2022
Date results information initially provided
9/02/2022
Type of registration
Prospectively registered

Titles & IDs
Public title
Improving efficiency of online Cognitive Behaviour Therapy for childhood anxiety through videoconferencing and stepped care
Scientific title
Improving efficiency of online Cognitive Behaviour Therapy for childhood anxiety through videoconferencing and stepped care
Secondary ID [1] 293878 0
None
Universal Trial Number (UTN)
U1111-1208-4743
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Anxiety disorder 306344 0
Condition category
Condition code
Mental Health 305432 305432 0 0
Anxiety

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Both conditions will receive the BRAVE-ONLINE program, which includes 10 online sessions of approximately 45-minute duration, completed once per week. BRAVE includes evidence-based anxiety management strategies such as recognition of physiological symptoms, relaxation, coping self-talk, cognitive restructuring, graded exposure, and self-reinforcement. Sessions comprise visually appealing pages, reading material, question/answer exercises, games, quizzes and homework. There are different versions of the program for children (aged 8-12 years) and adolescents (aged 13-17 years). Participants receive automated email reminders of session availability, reminding of overdue sessions and reinforcing progress.

Intervention Arm 1- Stepped-Care Internet-Cognitive Behavioural Therapy (SC-iCBT) with therapist assistance.

Participants in this intervention arm will receive BRAVE-ONLINE as above, using a stepped-care version of the program. SC-iCBT will include all BRAVE-ONLINE components but incorporates 2 steps, namely (i) self-help iCBT and (ii) therapist guided iCBT. Step 1 (self-help) will be delivered to all SC participants and will include 5 sessions of low-intensity, self-directed iCBT (low intensity = no therapist support, participants complete program on their own).

‘Non-responders’ after Step 1 will progress to step 2, therapist-guided iCBT. Therapist support will include a brief videoconferencing call to introduce the therapist (10 minutes) after session 5, and one 30-minute videoconference call after session 5 (children) and session 6 (adolescents) where the therapist assists the participant to refine their exposure hierarchy (developed in the previous session) and assist in planning the implementation of this exposure hierarchy.

It will also include weekly 15-minute videoconference calls from the therapist to the participant after completion of each of the remaining 4 sessions. In these videoconference calls, the therapist will review participant responses, provide reinforcement of effort and correct misdirected responses. During this call, the therapist will be able to demonstrate treatment components and help the participant correct responses in the program by sharing their computer screen. The therapist is able to bring up the participant's responses and show them how to correct their understanding of key concepts and work through activities together.

Therapists are provided with guidelines for the videoconferencing calls and lists of the core activities in each session that need to be targeted. These are generated by the lead investigator. Therapists are asked to spend a maximum of 15 minutes on videoconference calls. In this study, therapists will hold a minimum of 4-years training in Psychology.

In terms of treatment fidelity, therapists are required to keep a record of the number of minutes spent each week on viewing responses and making videoconferencing calls, to provide a check of the treatment provided. Further, a random sample of 10% of videoconference calls will be recorded and examined by the lead investigator to check fidelity against lists of the core activities in each session that need to be targeted.

Step 1 ‘responders’ will continue to receive the remaining five sessions of the self-help program (no therapist support provided) until the post-intervention assessment.
‘Responders’ will continue to be monitored, receiving automatic email alerts with referral recommendations if they demonstrate a return to clinical levels of anxiety, but will not receive additional therapist contact. ‘Non-responders’ will be defined as any participant who has not demonstrated a reduction into the non-elevated range, based on sex-standardised means and percentiles (based on a large normative youth sample; and our previous large self-help trial) on the CAS-8 at mid-intervention. ‘Responders’ will be identified as participants who have demonstrated a reduction in anxiety by mid-intervention, to within the non-elevated range. This ‘step-up’ point was determined based on empirical evidence from our trial of BRAVE Self-Help which indicated that changes of this nature on the CAS-8 by Session 5 are representative of a positive response to the program and achieved by a significant proportion of the participants.

Participants will be able to access the online program beyond post-treatment, although no therapist support will be provided beyond this point.
Intervention code [1] 300142 0
Treatment: Other
Intervention code [2] 312209 0
Behaviour
Comparator / control treatment
Intervention Arm 2- Standard, therapist-guided internet-based cognitive-behavior therapy (TG-iCBT).

TG-iCBT will include all BRAVE-ONLINE components, delivered with videoconferencing therapist support including; an introductory video meeting prior to treatment (10 minutes), 15-minute therapist video contact at a set time following completion of each session (reinforcing effort and correcting misdirected responses), and an additional 15 minutes of video therapist support at mid-point (total 30-minute contact at session 5 (child) or 6 (teen) in total) to discuss exposure hierarchy development and implementation.

In this study, therapists will hold a minimum of 4-years training in Psychology. Participants will be able to access the online program beyond post-treatment, although no therapist support will be provided beyond this point.

Therapists are provided with guidelines for the videoconferencing calls and lists of the core activities in each session that need to be targeted. These are generated by the lead investigator. Therapists are asked to spend a maximum of 15 minutes on videoconference calls (except for the exposure call). In this study, therapists will hold a minimum of 4-years training in Psychology.

In terms of treatment fidelity, therapists are required to keep a record of the number of minutes spent each week on viewing responses and making videoconferencing calls, to provide a check of the treatment provided. Further, a random sample of 10% of videoconference calls will be recorded and examined by the lead investigator to check fidelity against lists of the core activities in each session that need to be targeted.
Control group
Active

Outcomes
Primary outcome [1] 304560 0
The primary outcome measure is clinician severity rating relating to the primary anxiety disorder.
Clinician rating of symptom severity for the primary anxiety diagnosis is determined from information obtained in the diagnostic interview, and rated on a 0-8-point scale. Diagnostic status and severity will be determined via a "blind", independent clinical diagnostic interview for anxiety disorders and clinician severity rating of diagnosis using Anxiety Disorders Interview Schedule: Child version (ADIS-C).
Timepoint [1] 304560 0
Pre-treatment
Post-treatment (primary-point)
6-month follow-up
Primary outcome [2] 304561 0
A second primary outcome will be diagnostic status: free of primary anxiety diagnosis.
Diagnostic status will be defined as whether or not the participant is free of their primary anxiety disorder.

Diagnostic status will be determined via a "blind", independent clinical diagnostic interview for anxiety disorders and clinician severity rating of diagnosis using Anxiety Disorders Interview Schedule: Child version (ADIS-C)
Timepoint [2] 304561 0
Pre-treatment
Post-treatment (primary endpoint)
6-month follow-up
Primary outcome [3] 307178 0
Diagnostic status: Free of all anxiety disorders
Diagnostic status will be defined as whether or not the participant is free of all anxiety disorders.
Timepoint [3] 307178 0
Pre-treatment
Post-treatment (primary endpoint)
6-month follow-up
Secondary outcome [1] 342402 0
Spence Children's Anxiety Scale- Child and Parent Version (SCAS-C&P)

This measure will be completed by parents and children and provides a comprehensive anxiety symptom assessment. The total anxiety score will be used as a secondary outcome measure and to corroborate ‘step-up’ decisions at mid-intervention (five weeks after commencing program).
Timepoint [1] 342402 0
Pre-treatment
Mid-point (five weeks after commencing program)
Post-treatment
6 month follow-up
Secondary outcome [2] 342403 0
Child Health Utility 9 Index (CHU9-D)

This measure assesses nine domains of general health in children, including: Worried, Sad, Pain, Tired, Annoyed, School Work, Sleep, Daily Routine, and Activities and will be used to inform the economic evaluation.
Timepoint [2] 342403 0
Pre-treatment
mid-intervention (five weeks after commencing program)
Post-Intervention
6 month follow-up
Secondary outcome [3] 342405 0
Children's Anxiety Scale-8 (CAS-8)

This is a brief 8-item anxiety scale to assess total anxiety severity. Participants with elevated pre-treatment scores (completed at program registration) will be invited to complete the diagnostic interview.
Timepoint [3] 342405 0
Completed at program registration, and as a standard part of the online program, at the beginning of each session.
Secondary outcome [4] 342406 0
Therapy adherence.
This data will be automatically generated through the program and will include the number of prescribed sessions and activities completed throughout the program.
Timepoint [4] 342406 0
Post-treatment
6-month follow-up
Secondary outcome [5] 342407 0
Treatment expectancy
Treatment expectancy will be assessed after the participant is allocated, at the completion of session 1, through a 5-item questionnaire developed by the team in earlier studies (March et al. 2009; Spence et al. 2006).
Timepoint [5] 342407 0
After completion of session 1
Secondary outcome [6] 342408 0
Treatment satisfaction/acceptability of children will be assessed at post-treatment with an, 8-item questionnaire developed by the team in earlier studies (March et al. 2009; Spence et al. 2006).
Timepoint [6] 342408 0
Post-treatment
Secondary outcome [7] 342409 0
Overall adaptive functioning as assessed via the Children's Global Assessment Scale. (CGAS: Schaffer et al., 1983).
The CGAS provides a single global rating of functioning, assigned to the youth by the independent, interviewing clinician, on a scale of 0 to 100, where lower scores indicate poorer functioning. A rating is given based on the child or adolescent's most impaired level of general functioning for the specified time period by selecting the lowest level which describes his/her functioning on a hypothetical continuum of health-illness, benchmarked against anchor points in a descriptive glossary. This assessment will be based on information obtained in the diagnostic interview.
Timepoint [7] 342409 0
Pre-treatment
Post-treatment
6-month follow-up
Secondary outcome [8] 350983 0
Therapist satisfaction will be measured using an amended version of the program satisfaction scale, amended for use by therapists to assess therapist acceptability
Timepoint [8] 350983 0
post-intervention
Secondary outcome [9] 350984 0
Economic evaluation:

The economic evaluation will assess the relative Cost Effectiveness (CEA) of TG-iCBT compared to SC-iCBT using cost data based on program development costs, maintenance of web-based infrastructure, videoconferencing software and facilities, and therapist delivery time. Any other program provision costs (including non market costs) will be captured and any additional incurred healthcare costs will be calculated using social values (Medicare rebate values). Calculation of mean values of both arms of the study will occur for comparison purposes with 95% confidence intervals obtained.

The patient net benefits from both treatment arms will be measured by obtaining their Health Related Quality of Life (HRQoL) over the same time period, collected via the CHU9. The Australian value set for adolescents will be used to score the CHU9 to convert HRQoL into Quality Adjusted Life Years (QALYs). All costs and QALYs will be converted to present values and the Incremental Cost-Effectiveness Ratio estimated. Sensitivity analysis will be undertaken where necessary, most likely in changes to treatment costs.
Timepoint [9] 350984 0
Post-intervention
6-month follow-up

Eligibility
Key inclusion criteria
Children and adolescents will be included in the study if they meet diagnostic criteria for a primary diagnosis of anxiety (social anxiety disorder, specific phobia, separation anxiety disorder, generalised anxiety disorder) with a clinical severity rating (CSR) of at least 4 (on a 0-8 scale). Comorbidity with other disorders will be permissible as long as the anxiety disorder is considered primary. Participants with comorbid depression will be excluded if the depression is severe (rated 6 or higher on an 8-point scale). Families must have access to a suitable computer and the internet, and be willing to participate in the study.
Minimum age
8 Years
Maximum age
17 Years
Sex
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
As the internet program requires a minimum reading age of 8 years, children with an identified intellectual handicap or learning disability will not be included. Children with a pervasive developmental disorder will also be excluded. For ethical reasons pertaining to the danger of potential self-harm, youngsters with clinical levels of depression (Clinician Severity Rating of 6 or higher on a 0-8 scale on the ADIS-C/P) will not be included in the program and will be referred elsewhere for assistance.

Study design
Purpose of the study
Treatment
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Allocation will concealed by using sealed opaque envelopes. The randomisation sequence will be determined by the first investigator who will provide the sealed envelopes to the assessors.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Stratified random assignment will be used controlling for participant age (child/teen) and using an allocation ratio of 1:1 to treatment conditions.
Simple randomisation will be employed using a randomisation table created by computer sequence generation.
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?


The people assessing the outcomes
Intervention assignment
Parallel
Other design features
This is a non-inferiority randomised controlled trial. The margin of non-inferiority was set at d=.20 (raw effect size). The lower bound of the confidence interval would not exceed d=-.40
Phase
Not Applicable
Type of endpoint/s
Efficacy
Statistical methods / analysis
We will aim to recruit between 50-75 participants per condition, which will provide sufficient power for a feasibility test of the primary outcome variable.

All analyses will be performed using SPSS. Per recommendations for non-inferiority trials (Scott, 2009; Piaggio et al. 2006), analyses will be conducted both using an intent-to-treat (ITT) and per-protocol (PP) approach. The latter is desirable in non-inferiority trials as protection from an increase in type I error risk; ITT analysis is more likely to narrow the difference between treatments and yield a non-inferior result. The continuous primary and secondary outcome data will be analysed using mixed model, hierarchical linear modelling, nested within treatment groups, taking time as a within subjects and group as a between subjects effect. Sensitivity analysis will assess the effects of attrition.

A one-sided 97.5% confidence interval will be applied as recommended for non-inferiority trials (Scott, 2009; Piaggio et al. 2006). Presence of anxiety diagnosis will be examined and reported using chi-square analyses. Effect sizes will be calculated for each measure and within each intervention condition to evaluate the level of clinically significant change at post-intervention and 6-month follow-up.

For the economic evaluation, this study will assess the relative Cost Effectiveness (CEA) of TG-iCBT compared to SC-iCBT using cost data. The patient net benefits from both treatment arms will be measured by obtaining their Health Related Quality of Life (HRQoL) over the same time period, collected via the CHU9. The Australian value set for adolescents will be used to score the CHU9 to convert HRQoL into Quality Adjusted Life Years (QALYs). All costs and QALYs will be converted to present values and the Incremental Cost-Effectiveness Ratio estimated. Sensitivity analysis will be undertaken where necessary, most likely in changes to treatment costs. The CEA will allow determination of whether the SC-iCBT intervention leads to a decrease in treatment costs compared to the TG-iCBT intervention.

Recruitment
Recruitment status
Completed
Date of first participant enrolment
Anticipated
27/08/2018
Actual
30/08/2018
Date of last participant enrolment
Anticipated
13/12/2019
Actual
26/08/2019
Date of last data collection
Anticipated
29/08/2020
Actual
28/05/2020
Sample size
Target
130
Accrual to date
Final
137
Recruitment in Australia
Recruitment state(s)
ACT,NSW,NT,QLD,SA,TAS,WA,VIC

Funding & Sponsors
Funding source category [1] 298500 0
Charities/Societies/Foundations
Name [1] 298500 0
Australian Rotary Health
Country [1] 298500 0
Australia
Primary sponsor type
University
Name
University of Southern Queensland
Address
USQ Springfield
37 Sinnathamby Blvd,
Springfield Central
QLD 4300
Country
Australia
Secondary sponsor category [1] 297640 0
University
Name [1] 297640 0
Griffith University
Address [1] 297640 0
Griffith University
Nathan campus
Kessels Rd., Nathan
QLD 4111
Country [1] 297640 0
Australia

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 299482 0
University of Southern Queensland Human Research Ethics Comittee
Ethics committee address [1] 299482 0
University of Southern Queensland
Education City
Sinnathamby Blvd
Springfield Central
QLD 4300
Ethics committee country [1] 299482 0
Australia
Date submitted for ethics approval [1] 299482 0
05/12/2017
Approval date [1] 299482 0
01/02/2018
Ethics approval number [1] 299482 0
H17REA271

Summary
Brief summary
Anxiety affects 7% of young people & only 50% receive help. This project aims to test the feasibility of a new, stepped care, internet based Cognitive behavioural treatment (iCBT) model for youth anxiety utilising the BRAVE Program. Therapist supported iCBT demonstrates equivalent efficacy with face to face CBT, but cost and insufficient numbers of clinicians means therapist guided iCBT is often not available or unsuitable to reach large numbers of anxious youth. Self help iCBT (no therapist) offers one solution.

A national trial of BRAVE Self Help (>16,000 registrations in 2 years) showed meaningful anxiety reductions for youth completing the program. Many children failed to complete the treatment without support and not all were successfully treated. There is a need to identify models of care that can reach large numbers and provide appropriate support; such as a Stepped Care Model (SCM). Within a SCM, all young people would first receive the less intensive treatment. Those who have not responded well to the first step then receive a more intensive intervention.

In this project, all participants would first receive 5 sessions of self help iCBT (step 1; psychoeducation, skills acquisition). Those who respond will receive 5 more self help sessions (skill rehearsal & maintenance). Those who fail to respond after step 1 would `step up' to receive their remaining 5 iCBT sessions with therapist guidance (step 2). Pilot evidence supports the use of a SCM in high intensity face to face CBT for childhood anxiety. To date, no studies of SCMs for iCBT exist. If a SCM approach, using self help plus therapist guided iCBT is as effective as therapist guided iCBT alone, we will have identified a scalable, easily disseminated model that can produce clinical outcomes similar to standard clinical therapy.

This particular project utilises small doses of 'high intensity' (e.g. face-to-face) contact to supplement an evidence based treatment. Thus it provides a potential model of care that can first capitalize on the benefits of online interventions, and subsequently provide high intensity care, only when needed. This may have the capacity to effectively personalize the treatment to the young person. The study will also provide insights into the acceptability of face-to-face contact via videoconferencing in such contexts.
Trial website
https://brave4you.psy.uq.edu.au/
Trial related presentations / publications
Public notes
Participants can register for the research trial at: https://brave4you.psy.uq.edu.au/
Participants who register for the program and meet eligibility criteria will be invited to participate.

Contacts
Principal investigator
Name 80558 0
A/Prof Sonja March
Address 80558 0
School of Psychology and Counselling, & Institute for Resilient Regions
University of Southern Queensland
Springfield Campus
37 Sinnathamby Blvd,
Springfield Central
QLD 4300
Country 80558 0
Australia
Phone 80558 0
+61 7 3470 4434
Fax 80558 0
Email 80558 0
sonja.march@usq.edu.au
Contact person for public queries
Name 80559 0
A/Prof Sonja March
Address 80559 0
School of Psychology and Counselling & Institute for Resilient Regions
University of Southern Queensland
Springfield Campus
37 Sinnathamby Blvd,
Springfield Central
QLD 4300
Country 80559 0
Australia
Phone 80559 0
+61 7 3470 4434
Fax 80559 0
Email 80559 0
sonja.march@usq.edu.au
Contact person for scientific queries
Name 80560 0
A/Prof Sonja March
Address 80560 0
School of Psychology and Counselling, & Institute for Resilient Regions
University of Southern Queensland
Springfield Campus
37 Sinnathamby Blvd,
Springfield Central
QLD 4300
Country 80560 0
Australia
Phone 80560 0
+61 7 3470 4434
Fax 80560 0
Email 80560 0
sonja.march@usq.edu.au

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
What data in particular will be shared?
De-identified data pertaining to primary and secondary outcomes may be shared. De-identified data will be shared with researchers under circumstances where the researchers have appropriate ethics approvals and appropriate research questions.
When will data be available (start and end dates)?
Data will only become available after all data has been analysed and results published from the trial. This includes both primary research questions, secondary research questions and those arising from the study later. These dates are to be determined.
Available to whom?
This de-identified data may be available to other researchers who hold suitable ethical clearance and wish to collaborate with the investigator team.
Available for what types of analyses?
The de-identified data may be available for review and meta-analytic purposes or other anlayses on request.
How or where can data be obtained?
The data can be obtained from the primary investigator at sonja.march@usq.edu.au


What supporting documents are/will be available?

Doc. No.TypeCitationLinkEmailOther DetailsAttachment
15004Informed consent form  sonja.march@usq.edu.au
15005Ethical approval  sonja.march@usq.edu.au



Results publications and other study-related documents

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