Clinical effectiveness and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK

June Brown; Kirsty James; Stephen Lisk; James Shearer; Sarah Byford; Paul Stallard; Jessica Deighton; David Saunders; Jynna Yarrum; Peter Fonagy; Timothy Weaver; Irene Sclare; Crispin Day; Claire Evans; Ben Carter

doi:10.1016/S2215-0366(24)00101-9

Clinical effectiveness and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK

Lancet Psychiatry. 2024 May 13:S2215-0366(24)00101-9. doi: 10.1016/S2215-0366(24)00101-9. Online ahead of print.

Authors

June Brown¹, Kirsty James², Stephen Lisk³, James Shearer⁴, Sarah Byford⁴, Paul Stallard⁵, Jessica Deighton⁶, David Saunders⁷, Jynna Yarrum⁷, Peter Fonagy⁸, Timothy Weaver⁹, Irene Sclare¹⁰, Crispin Day³, Claire Evans⁶, Ben Carter²

Affiliations

¹ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. Electronic address: june.brown@kcl.ac.uk.
² Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; King's Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
³ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
⁴ Health Service & Population Research Department, King's College London, London, UK.
⁵ Department for Health, University of Bath, Bath, UK.
⁶ Anna Freud National Centre for Children and Families, London, UK.
⁷ Faculty of Health and Society, University of Northampton, Northampton, UK.
⁸ Anna Freud National Centre for Children and Families, London, UK; Department of Clinical Educational and Health Psychology, University College London, London, UK.
⁹ Faculty of Health, Social Care & Education, Middlesex University, London, UK.
¹⁰ Southwark CAMHS Clinical Academic Group, South London & Maudsley NHS Foundation Trust, London, UK.

PMID: 38759665
DOI: 10.1016/S2215-0366(24)00101-9

Abstract

Background: Depression and anxiety are increasingly prevalent in adolescents. The Brief Educational Workshops in Secondary Schools Trial investigated the effectiveness of a brief accessible stress workshop programme for 16-18-year-olds. We aimed to investigate the clinical effectiveness and cost-effectiveness of the DISCOVER cognitive behavioural therapy (CBT) workshop on symptoms of depression in 16-18-year-olds at 6 months compared with treatment-as-usual.

Methods: We conducted a multicentre, cluster randomised controlled trial in UK schools or colleges with sixth forms to evaluate clinical effectiveness and cost-effectiveness of a brief CBT workshop (DISCOVER) compared with treatment-as-usual. We planned to enrol 60 schools and 900 adolescents, using a self-referral system to recruit participants. Schools were randomised in a 1:1 ratio for participants to receive either the DISCOVER workshop or treatment-as-usual, stratified by site and balanced on school size and index of multiple deprivation. Participants were included if they were 16-18 years old, attending for the full school year, seeking help for stress, and fluent in English and able to provide written informed consent. The outcome assessors, senior health economist, senior statistician, and chief investigator were masked. People with lived experience were involved in the study. The primary outcome was depression symptoms measured with the Mood and Feelings Questionnaire (MFQ) at 6-month follow-up, in the intention-to-treat population of all participants with full covariate data. The trial was registered with the ISRCTN registry (ISRCTN90912799).

Findings: 111 schools were invited to participate in the study, seven were deemed ineligible, and 47 did not provide consent. Between Oct 4, 2021, and Nov 10, 2022, 933 students at 57 schools were screened for eligibility, seven were not eligible for inclusion, and 26 did not attend the baseline meeting and assessment, resulting in 900 adolescents participating in the study. The DISCOVER group included 443 participants (295 [67%] female and 136 [31%] male) and the treatment-as-usual group included 457 participants (346 [76%] female and 92 [20%] male). 468 (52%) of the 900 participants were White, and the overall age of the participants was 17·2 years (SD 0·6). 873 (97%) adolescents were followed up in the intention-to-treat population. The primary intention-to-treat analysis (n=854) found an adjusted mean difference in MFQ of -2·06 (95% CI -3·35 to -0·76; Cohen's d=-0·17; p=0·0019) at the 6-month follow-up, indicating a clinical improvement in the DISCOVER group. The probability that DISCOVER is cost- effective compared with treatment-as-usual ranged from 61% to 78% at a £20 000 to £30 000 per quality-adjusted life-year threshold. Nine adverse events (two of which were classified as serious) were reported in the DISCOVER group and 14 (two of which were classified as serious) were reported in the treatment-as-usual group.

Interpretation: Our findings indicate that the DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools. Given the importance of addressing mental health needs early in this adolescent population, additional research is warranted to explore this intervention.

Funding: National Institute for Health and Care Research Health Technology Assessment Programme.