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The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2598 (Published 19 April 2012) Cite this as: BMJ 2012;344:e2598
  1. Sally N Merry, associate professor1,
  2. Karolina Stasiak, research fellow1,
  3. Matthew Shepherd, lecturer2,
  4. Chris Frampton, associate professor of biostatistics3,
  5. Theresa Fleming, research fellow1,
  6. Mathijs F G Lucassen, research fellow1
  1. 1Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
  2. 2School of Counselling, Human Services and Social Work, Faculty of Education, University of Auckland
  3. 3Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, New Zealand
  1. Correspondence to S N Merry s.merry{at}auckland.ac.nz
  • Accepted 9 March 2012

Abstract

Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual.

Design Multicentre randomised controlled non-inferiority trial.

Setting 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services).

Participants 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual.

Interventions Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists.

Outcomes The primary outcome was the change in score on the children’s depression rating scale-revised. Secondary outcomes included response and remission on the children’s depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children’s anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings.

Results 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n=85, treatment as usual n=85) were assessed after intervention and 168 (90%, SPARX n=83, treatment as usual n=85) were assessed at the three month follow-up point. Per protocol analyses (n=143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as “possibly” or “probably” related to the intervention did not differ between groups (SPARX n=11; treatment as usual n=11).

Conclusions SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment.

Trial registration Australian New Zealand Clinical Trials ACTRN12609000249257.

Footnotes

  • We thank Maru Nihoniho and staff from Metia Interactive for their invaluable work developing SPARX; the young people who helped to design SPARX; the young people who participated in the study and provided us with useful feedback on their experiences of SPARX; the clinicians and school guidance counsellors who recruited participants for the study; the research assistants who assisted with data collection across all the study sites; the local investigators who assisted with individual site coordination and data collection; the Cultural Advisory Group who provided valuable feedback and guidance to the research team in the course of the study; Kaumātua Rawiri Wharemate for his ongoing support for the Werry Centre and this study in particular; Candace Bagnall for all the work she has done to help people access effective mental health services in New Zealand; Tiki Taane for letting us use the track “Faded” in SPARX for the duration of the trial; and Iona Bailey, a general practitioner in Tauranga, who suggested computerising treatment for adolescent depression to associate SNM a decade ago. The trial protocol is available on www.sparx.org.nz.

  • Contributors: SNM conceived this study and is guarantor. SNM, KS, MS, CF, TF, and MFGL designed and initiated the study. SNM, KS, MS, and TF were responsible for participant recruitment, data gathering, and preparation of the database. MFGL assisted in data gathering. CF was responsible for statistical analysis. SNM monitored processes, with particular reference to managing adverse events. SNM wrote the first draft of the manuscript. KS, MS, CF, MFGL, and TF revised the manuscript. All authors contributed to and approved the final version of the paper. All authors had full access to all of the data and can take responsibility for its integrity. The research team has full access to all the data and the corresponding author had final responsibility for the decision to submit the paper.

  • Funding: The New Zealand Ministry of Health funded the study but had no direct involvement in the design or conduct of the study, analysis of the data, or writing up of the results.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that: SNM, KS, MS, CF, TF, and MFGL were supported by the University of Auckland for the submitted work; SNM, KS, MS, CF, TF and MFGL have no relationships with the University of Auckland that might have an interest in the submitted work in the previous three years; and SNM, KS, MS, CF, TF, and MFGL have no non-financial interests that may be relevant to the submitted work.

  • Ethical approval: This study was approved by the multiregion ethics committee (New Zealand Ministry of Health) MEC/08/12/159. Participants aged 16 years and older provided their own informed consent to participate in the study. For participants 15 years and younger, parental/guardian informed consent was obtained together with the informed consent of the participant.

  • Data sharing: The dataset is available on request from the corresponding author at s.merry{at}auckland.ac.nz.

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