Trial Review

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Trial registered on ANZCTR


Registration number
ACTRN12620000422921
Ethics application status
Approved
Date submitted
18/02/2020
Date registered
30/03/2020
Date last updated
21/04/2022
Date data sharing statement initially provided
30/03/2020
Date results provided
21/04/2022
Type of registration
Prospectively registered

Titles & IDs
Public title
LIFE FLeX: An Adaptive Treatment Randomised Controlled Trial for Reducing Anxiety and Depression for Adults.
Scientific title
An Evaluation of Low Intensity Digital Mental Health Treatment Models for Reducing Anxiety and Depression in Adults: An Adaptive Treatment Randomised Controlled Trial
Secondary ID [1] 299197 0
Nil known.
Universal Trial Number (UTN)
U1111-1239-7297
Trial acronym
Nil.
Linked study record
Nil known.

Health condition
Health condition(s) or problem(s) studied:
Anxiety 316311 0
Depression 316312 0
Condition category
Condition code
Mental Health 314577 314577 0 0
Anxiety
Mental Health 314578 314578 0 0
Depression

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
A self-help, transdiagnostic digital mental health treatment program for reducing symptoms of anxiety and depression (called LIFE FLeX) delivered through the My Digital Health Platform will be evaluated in an adaptive randomised control design. Participants who consent and meet the study criteria will be given access to the LIFE FLeX digital health program immediately, however will be monitored for symptom improvement between two to three weeks post trial commencement. If a participant is not making progress (i.e., no change in anxiety and depression symptoms) they will be offered to augment their program with a therapist and randomly assigned to one of two treatment conditions Arm One; meet weekly with a therapist online via video-chat technology for up to 10 minutes or Arm Two; meet weekly with a therapist online via video-chat for up to 50 minutes. Video-chat support duration will be dependent upon the stage of module completion at which the participant is allocated a therapist. The maximum duration of therapist support delivered by video-chat will be up to 7 weeks.

The LIFE FLeX program is designed to provide people with information and strategies to address their anxiety and depressive symptoms and contains six ‘core’ modules, plus an Introduction module delivered over 8 weeks (participants are provided two weeks to complete module 4). There will also be a short two page ‘Booster’ module three weeks following the post-intervention assessment. The booster module will release at that time and participants will be notified by email that it has been released.

The six core LIFE FLeX digital health program modules are:

1. Increasing Biological Flexibility: Looks at the biology of the stress response, understanding what biological flexibility is and what techniques to use to increase biological flexibility (e.g., increasing physical activity, breathing control).
2. Increasing Emotional Flexibility: Looks at what emotions are, increasing emotional awareness, and use of emotional regulation strategies.
3. Increasing Thinking Flexibility: Looks at the role of thoughts in depression and anxiety and how to increase thinking flexibility (e.g., identifying and challenging unhelpful thoughts).
4. Increasing Behavioural Flexibility: Looks at how what we do influences how we think and feel and how to increase behavioural flexibility through reducing avoidance through gradual exposure (for anxiety) and increasing activity through behavioural activation (for depression).
5. Increasing Wellness (positive affect) Flexibility: Looks at wellness and positive affect and how to increase wellness through various strategies (e.g., acts of kindness, openness to experience, social connectedness).
6. Increasing Life FLeX-ability: Recap’s the entire program, reflects over progress and discusses relapse prevention.

Each module of the LIFE FLeX program will take approximately 25 minutes to complete. In order to reinforce the module-based information, there are 20-30 minutes of offline activities each week, which include applying the concepts / techniques discussed such as self-monitoring symptoms, undertaking one of the increasing biological and wellness flexibility intervention strategies, monitoring emotions and thoughts and undertaking the gradual exposure or behavioural activation activity. Participants will also receive automated emails (e.g., to remind them to log on, when to complete ‘during’, post/follow-up intervention questionnaires) and will be asked several questions at the beginning and of each module to help gauge their progress. Modules include text, graphics, audio, video, editable forms, interactive games (e.g., brain training) and downloads. Modules can be accessible via web, mobile or tablet devices.

Provisionally registered psychologists with Australian Health Practitioner Regulation Agency (AHPRA) who are in their 5th and 6th year of training within psychology will deliver the intervention in the two therapist assisted conditions.

The therapists of the study delivering the intervention will receive a training package on diagnostic assessment (the MINI), semi-structured interviewing techniques, digital mental health interventions; specifically ethical and legal aspects of service provision for the use of video-chat technology to deliver treatment. The therapists of the study will be required to complete a mixture of online modules and workshops to ensure knowledge and competency with all therapists required to pass competency checks prior to commencing interaction with participants.

Arm 1: Minimal support condition (supportive role)- Therapist support will be delivered weekly via video-chat technology, for up 10 minutes. The role of the therapist in the ‘minimal’ support treatment condition is to support the participant’s engagement with the LIFE FLeX program by specifically checking on participant progress with modules, participant understanding of program material, provide clarification where required and ensure that participants are clear on their between session module tasks assigned for completion. It will be important to ensure that fidelity of therapists’ role is maintained, that is, the therapists of the study remain in their ‘supporter’ role and do not to drift into therapy mode.
Arm 2: High support condition (therapist role) - Treatment will be delivered weekly via video-chat technology, for up to 50 minutes. The role of the therapist in the ‘high’ support treatment condition is to deliver the content of the transdiagnostic program LIFE FLeX to participants in the role of therapist and then to redirect participants to the online program LIFE FLeX for revision and consolidation of material in between scheduled sessions.
In order to ensure treatment fidelity and standardised treatment, the therapists will be provided with treatment manuals with random spot checks of their recorded video-chat sessions reviewed by two independent raters to determine adherence to study protocol. The provisional psychologists will receive regular opportunities for individual and group supervision from a registered clinical psychologist and AHPRA registered supervisor where any remedial strategies to improve fidelity will be implemented. Remedial strategies will include the provision of constructive feedback, a review of the components of treatment in sequence, further practice of skills where drift may have occurred, additional training (if necessary), review of initial fidelity training materials, and extra coaching/ supervision.

Several semi-structured interview schedules designed to assess attrition, participant and therapist experiences of receiving and delivering treatment via video-chat technology, along with assisting implementation efforts post -trial have also been created for the study. The interview schedules are estimated to take approximately 10-15 minutes and will be offered to participants via telephone, instant messaging or video-chat.
Intervention code [1] 316889 0
Treatment: Other
Comparator / control treatment
If participants fail to improve within the ‘no human support’ program within the first two to three weeks (i.e., no change in anxiety and depression symptoms), then they will be randomised to augment their program with either ‘minimal’ human support (i.e., up to 10 minute of a support session per week) or ‘high’ human support (i.e., up to 50 minutes of a therapy session per week), delivered by video-chat technology).
Control group
Active

Outcomes
Primary outcome [1] 322913 0
Primary Outcome- Anxiety
Change in anxiety scores as measured by the Generalised Anxiety Disorder Questionnaire (GAD-7).
Timepoint [1] 322913 0
Baseline, 3, 6, 9 and 21 weeks after intervention commencement.
Primary outcome [2] 322914 0
Primary Outcome- Depression
Change in depression scores as measured by the Patient Health Questionnaire (PHQ-9).
Timepoint [2] 322914 0
Baseline, 3, 6, 9 and 21 weeks after intervention commencement.
Secondary outcome [1] 380228 0
Secondary Outcome 1 – Motivation
Change in client motivation scores as measured by the Client Motivation for Therapy Scale (CMOTS).
Timepoint [1] 380228 0
Baseline and 9 weeks after intervention commencement.
Secondary outcome [2] 380229 0
Secondary Outcome 2- Self-Efficacy
Change in self-efficacy scores as measured by the Modified- Bipolar Self-Efficacy Scale (M-BPSES).
Timepoint [2] 380229 0
Baseline and 9 weeks after intervention commencement.
Secondary outcome [3] 380230 0
Secondary Outcome 3- Quality of Life
Change in quality of life scores as measured by the Assessment of Quality of Life (AQol-4D).
Timepoint [3] 380230 0
Baseline, 9 and 21 weeks after intervention commencement.
Secondary outcome [4] 380231 0
Secondary Outcome 4- Therapeutic Alliance
Change in therapeutic alliance scores as measured by the Modified Working Alliance Inventory- Short (Three versions; Technological Alliance, Participant Version and Therapist Version).
Timepoint [4] 380231 0
Week 3, 6 and 9 weeks after intervention commencement.
Secondary outcome [5] 380232 0
Secondary Outcome 5- System Usability Scale
Self developed questions to assess participants’ ease of program usability
Timepoint [5] 380232 0
3 weeks after intervention commencement
Secondary outcome [6] 380233 0
Secondary Outcome 6- Record of Health Services Utilisation
Participants will be required to maintain a record of their use of services during the trial (self-developed questions)
Timepoint [6] 380233 0
To be maintained by participants’ throughout trial
Secondary outcome [7] 380234 0
Secondary Outcome 7- Participant Satisfaction Questionnaire
Intervention satisfaction assessed by self-developed satisfaction questionnaire
Timepoint [7] 380234 0
9 weeks after program commencement
Secondary outcome [8] 380235 0
Secondary Outcome 8- Participant Preferences Questionnaire
Participants’ preferences for treatment assessed by self-developed preferences questionnaire
Timepoint [8] 380235 0
Pre-program commencement

Eligibility
Key inclusion criteria
Inclusion criteria – participants
a) Australian residents
b) 18 years or older
c) Have access to the internet
d) Able to read in English
e) Be able to register online, using an email address
f) Provide their informed consent
g) Medication stability
h) Primary diagnosis of anxiety or depression, or mixed anxiety and depression or sub-clinical symptoms of anxiety/ and or depression confirmed by the MINI diagnostic assessment

Inclusion criteria- therapists
a) At a minimum, the therapists of the study must have provisional registration as a psychologist with Australian Health Practitioner Regulation Agency (AHPRA).

Inclusion criteria- other
Local providers who offer mental health treatment services in the community (e.g., private practice, government funded or mental community health, and other NGOs) will be eligible to participate.
Minimum age
18 Years
Maximum age
No limit
Sex
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
a) Participants who have active psychosis
b) Suicidal ideation/ behaviours
c) Problematic alcohol or drug use
d) Concurrent psychotherapy
e) No internet access
f) Participants who do not provide a valid email address
g) Participants who do not consent to the conditions of the study

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)
sealed opaque envelopes
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Simple randomisation using a randomisation table from a statistic book
Masking / blinding
Open (masking not used)
Who is / are masked / blinded?



Intervention assignment
Parallel
Other design features
Phase
Not Applicable
Type of endpoint/s
Efficacy
Statistical methods / analysis
Only aggregate data will be used for main analysis. Assuming a conservative medium
effect (i.e. GPower f(v) test = 0.40), significance set at 5% (p = .05), power at 80%, 32 participants per condition is required to demonstrate statistical significance on the primary outcome measure. However, allowing for a 50% attrition rate, we will be required to recruit 64 participants per condition (total 192 participants).

Pre-, during, post- and follow-up variables will be subjected to mixed methods and repeated measures analyses to determine significant changes over group and time. Correlational, multiple regression, mediation and moderation analyses will be used to determine any potential predictors and discriminators of attrition and adherence. Open ended data obtained from intervention satisfaction questionnaires and interview questions will be analysed using protocols of content analysis to identify common themes.

Recruitment
Recruitment status
Completed
Date of first participant enrolment
Anticipated
29/04/2020
Actual
28/01/2021
Date of last participant enrolment
Anticipated
31/03/2021
Actual
30/09/2021
Date of last data collection
Anticipated
26/08/2021
Actual
30/03/2022
Sample size
Target
192
Accrual to date
Final
240
Recruitment in Australia
Recruitment state(s)
ACT,NSW,NT,QLD,SA,TAS,WA,VIC

Funding & Sponsors
Funding source category [1] 303737 0
University
Name [1] 303737 0
Federation University
Country [1] 303737 0
Australia
Primary sponsor type
University
Name
Federation University
Address
PO Box 663
Ballarat Vic 3353
Australia
Country
Australia
Secondary sponsor category [1] 305362 0
None
Name [1] 305362 0
Address [1] 305362 0
Country [1] 305362 0

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 304262 0
Human Research Ethics Committee (HREC), Federation University Australia
Ethics committee address [1] 304262 0
Ethics committee country [1] 304262 0
Australia
Date submitted for ethics approval [1] 304262 0
26/07/2019
Approval date [1] 304262 0
08/08/2019
Ethics approval number [1] 304262 0
A19-095

Summary
Brief summary
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 96326 0
Prof Britt Klein
Address 96326 0
DVC-RI Portfolio and BeRI
Federation University
107 Lydiard Street South
Ballarat Central VIC 3353
PO Box 663
Ballarat, Vic 3353
Country 96326 0
Australia
Phone 96326 0
+61 3 5327 6716
Fax 96326 0
Email 96326 0
[email protected]
Contact person for public queries
Name 96327 0
Brooke Andrews
Address 96327 0
Biopsychosocial and eHealth Research & Innovation (BeRI) Hub
Federation University
107 Lydiard Street South
Ballarat Central VIC 3353
PO Box 663
Ballarat VIC 3353
Country 96327 0
Australia
Phone 96327 0
+61 3 5327 9623
Fax 96327 0
Email 96327 0
[email protected]
Contact person for scientific queries
Name 96328 0
Brooke Andrews
Address 96328 0
Biopsychosocial and eHealth Research & Innovation (BeRI) Hub
Federation University
107 Lydiard Street South
Ballarat Central VIC 3353
PO Box 663
Ballarat VIC 3353
Country 96328 0
Australia
Phone 96328 0
+61 3 5327 9623
Fax 96328 0
Email 96328 0
[email protected]

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
What data in particular will be shared?
Individual participant data of published results only, after de-identification.
When will data be available (start and end dates)?
No start or end date as yet determined.
Available to whom?
Case-by-case basis at the discretion of the Principal Investigator
Available for what types of analyses?
Case-by-case basis at the discretion of the Principal Investigator
How or where can data be obtained?
Access subject to approval by Principal Investigator, followed by submission to the Ethical Review Committee to access the de-identified data and approval granted. The Principal Investigator, Professor Britt Klein can be contacted via the below details:

Professor Britt Klein
DVC-RI Portfolio and BeRI
Federation University
107 Lydiard Street South
Ballarat Central VIC 3353
PO Box 663
Ballarat


What supporting documents are/will be available?

No Supporting Document Provided



Results publications and other study-related documents

Documents added manually
No documents have been uploaded by study researchers.

Documents added automatically
SourceTitleYear of PublicationDOI
EmbaseEfficacy of a Digital Mental Health Biopsychosocial Transdiagnostic Intervention With or Without Therapist Assistance for Adults With Anxiety and Depression: Adaptive Randomized Controlled Trial.2023https://dx.doi.org/10.2196/45135
N.B. These documents automatically identified may not have been verified by the study sponsor.