Humanistic counselling plus pastoral care as usual versus pastoral care as usual for the treatment of psychological distress in adolescents in UK state schools (ETHOS): a randomised controlled trial

Summary
Background
About one in seven adolescents have a mental health disorder in England, UK. School counselling is one
of the most common means of trying to address such a problem. We aimed to determine the effectiveness and cost-effectiveness
of school-based humanistic counselling (SBHC) for the treatment of psychological distress in young
people in England, UK.
Methods
We did a two-arm, individually randomised trial in 18 secondary state-funded schools across the Greater London
area of the UK. Participants were randomly assigned (1:1) using a centrally secure randomisation procedure with
random permuted blocks to either SBHC plus schools’ pastoral care as usual (PCAU), or PCAU alone. Participants
were pupils aged 13–16 years who had moderate-to-severe levels of emotional symptoms (measured by a score of ≥5 on
the Strengths and Difficulties Questionnaire Emotional Symptoms scale) and were assessed as competent to consent to
participate in the trial. Participants, providers, and assessors (who initially assessed and enrolled participants) were not
masked but testers (who measured outcomes) were masked to treatment allocation. The primary outcome was
psychological distress at 12 weeks (Young Person’s Clinical Outcomes in Routine Evaluation measure [YP-CORE];
range 0–40), analysed on an intention-to-treat basis (with missing data imputed). Costs were assessed at 24 weeks
(Client Service Receipt Inventory and service logs). The trial was registered with ISRCTN, number ISRCTN10460622.
Findings 329 participants were recruited between Sept 29, 2016, and Feb 8, 2018, with 167 (51%) randomly assigned to
SBHC plus PCAU and 162 (49%) to PCAU. 315 (96%) of 329 participants provided data at 12 weeks and scores were
imputed for 14 participants (4%). At baseline, the mean YP-CORE scores were 20·86 (SD 6·38) for the SBHC plus
PCAU group and 20·98 (6·41) for the PCAU group. Mean YP-CORE scores at 12 weeks were 16·41 (SD 7·59) for the
SBHC plus PCAU group and 18·34 (7·84) for the PCAU group (difference 1·87, 95% CI 0·37–3·36; p=0·015), with a
small effect size (0·25, 0·03–0·47). Overall costs at 24 weeks were £995·20 (SD 769·86) per pupil for the SBHC plus
PCAU group and £612·89 (1224·56) for the PCAU group (unadjusted difference £382·31, 95% CI £148·18–616·44;
p=0·0015). The probability of SBHC being more cost-effective reached 80% at a willingness to pay of £390 for a 1-point
improvement on the YP-CORE. Five serious adverse events occurred for four participants in the SBHC plus PCAU
group, all involving suicidal intent. Two serious adverse events occurred for two participants in the PCAU group, one
involving suicidal intent.
Interpretation
The addition of SBHC to PCAU leads to small reductions in psychological distress, but at an additional
economic cost. SBHC is a viable treatment option but there is a need for equally rigorous evaluation of alternative
interventions.