Increasing access to personalized care for pediatric anxiety disorders: a large-scale randomized controlled trial of stepped versus stratified care

Research problem and questionsAnxiety disorders (ADs) are the number one contributor to disability in Swedish youth.

Cognitive-behavioral therapy (CBT) is effective for ADs, delivered both in-person and by the Internet (ICBT), but child and adolescent mental health services (CAMHS) struggle to provide care in a timely and evidence-driven way. ICBT can increase access to treatment but risks and benefits in regular health care are unclear.

The purpose of this project is to increase the availability and precision of evidence-based treatment for youth with ADs by comparing two models of service delivery: stepped care, where all patients start with ICBT and stratified care, where patients are matched to ICBT or in-person CBT.

In both models, non-responders move up to a more intensive intervention: ICBT -> in-person CBT -> intensive CBT +/- medication.

A large-scale randomized controlled trial (RCT, see Fig 1) examining outcomes at 4, 8 and 12 months will address the following questions:1. Does stepped or stratified care yield best treatment response in pediatric ADs?2. Which model is most cost-effective?3. Which model yields most equity in outcomes across socioeconomic and clinical complexity groups?4.

Which patient and family characteristics predict outcomes across interventions?

Data and methodThe study will be conducted as part of regular health care in CAMHS Skåne and include a diverse patient group.

In collaboration with patients, parents, clinicians, and decision-makers, we will develop the research protocol and conduct a pilot study to improve feasibility, acceptability, and transferability.

A large-scale RCT (N=646) will be conducted to provide unprecedented knowledge about how to best organize care for pediatric ADs.Project realizationCAMHS Skåne receives >2,000 annual referrals about pediatric anxiety and is providing organizational and financial support. The project group is world-leading in eHealth/ICBT for pediatric ADs and has conducted several RCTs in CAMHS settings.

We seek funding for co-production, study personnel, PhD students, and postdocs.RelevanceEffective treatments only reach 10% of youth with ADs and existing resources are allocated without sufficient evidence.

This project will conduct the largest CAMHS RCT to date to identify how to best allocate resources for pediatric ADs with the long-term goal to improve access to and precision of high-quality care and reduce waiting-list time, patient burden, and overall healthcare costs.