Health Technology Assessment (Oct 2022)
One-session treatment compared with multisession CBT in children aged 7–16 years with specific phobias: the ASPECT non-inferiority RCT
Abstract
Background: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive–behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive–behavioural therapy principles but has a shorter treatment period. Objective: This research investigated the non-inferiority of one-session treatment to cognitive–behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined. Design: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations. Settings: There were 26 sites, including 12 NHS trusts. Participants: Participants were aged 7–16 years and had a specific phobia defined in accordance with established international clinical criteria. Interventions: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive–behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation. Main outcome measures: The primary outcome measure was the Behavioural Avoidance Task at 6 months’ follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children’s Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale. Results: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive–behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive–behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive–behavioural therapy compared with one-session treatment –0.123, 95% confidence interval –0.449 to 0.202 (intention to treat), mean difference –0.204, 95% confidence interval –0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive–behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive–behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment. Limitations: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up. Conclusions: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive–behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways. Trial registration: This trial is registered as ISRCTN19883421. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information.
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