Internet-based cognitive behavior therapy for obsessive compulsive disorder: a pilot study

Erik Andersson, Brjánn Ljótsson, Erik Hedman, Viktor Kaldo, Björn Paxling, Gerhard Andersson, Nils Lindefors, Christian Rück, Erik Andersson, Brjánn Ljótsson, Erik Hedman, Viktor Kaldo, Björn Paxling, Gerhard Andersson, Nils Lindefors, Christian Rück

Abstract

Background: Cognitive behavior therapy (CBT) is widely regarded as an effective treatment for obsessive compulsive disorder (OCD), but access to CBT therapists is limited. Internet-based CBT (ICBT) with therapist support is a way to increase access to CBT but has not been developed or tested for OCD. The aim of this study was to evaluate ICBT for OCD.

Method: An open trial where patients (N = 23) received a 15-week ICBT program with therapist support consisting of psychoeducation, cognitive restructuring and exposure with response prevention. The primary outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which was assessed by a psychiatrist before and immediately after treatment. Secondary outcomes were self-rated measures of OCD symptoms, depressive symptoms, general functioning, anxiety and quality of life. All assessments were made at baseline and post-treatment.

Results: All participants completed the primary outcome measure at all assessment points. There were reductions in OCD symptoms with a large within-group effect size (Cohen's d = 1.56). At post-treatment, 61% of participants had a clinically significant improvement and 43% no longer fulfilled the diagnostic criteria of OCD. The treatment also resulted in statistically significant improvements in self-rated OCD symptoms, general functioning and depression.

Conclusions: ICBT with therapist support reduces OCD symptoms, depressive symptoms and improves general functioning. Randomized trials are needed to confirm the effectiveness of this new treatment format.

Trial registration: ClinicalTrials.gov NCT01348529.

Figures

Figure 1
Figure 1
Flowchart.
Figure 2
Figure 2
Means and 95% confidence intervals of weekly OCD symptoms using OCI-R.
Figure 3
Figure 3
CGI improvements.

References

    1. Abramowitz JS. Understanding and treating obsessive-compulsive disorder: A cognitive-behavioral approach. NJ: Lawrence Erlbaum; 2006.
    1. Jacobi F. et al.Estimating the prevalence of mental and somatic disorders in the community: aims and methods of the German National Health Interview and Examination Survey. Int J Methods Psychiatr Res. 2002;11(1):1–18. doi: 10.1002/mpr.118.
    1. Fullana MA, Obsessive-compulsive symptom dimensions in the general population: Results from an epidemiological study in six European countries. J Affect Disord. 2009.
    1. Abramowitz J, Houts A. Concepts and controversies in obsessive-compulsive disorder. New York: Springer; 2005.
    1. Foa EB. Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues Clin Neurosci. 2010;12(2):199–207.
    1. Larsson BPM, Kaldo V, Broberg AG. Similarities and differences between practitioners of psychotherapy in Sweden: A comparison of attitudes between psychodynamic, cognitive, cognitive-behavioral, and integrative therapists. Journal of Psychotherapy Integration. 2009;19(1):34–66.
    1. Goisman RM. et al.Utilization of behavioral methods in a multicenter anxiety disorders study. J Clin Psychiatry. 1993;54(6):213–8.
    1. Mataix-Cols D, Marks IM. Self-help with minimal therapist contact for obsessive-compulsive disorder: a review. Eur Psychiatry. 2006;21(2):75–80. doi: 10.1016/j.eurpsy.2005.07.003.
    1. Cuijpers P. et guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine. 2010;40(12):1943–1957. doi: 10.1017/S0033291710000772.
    1. Cuijpers P, Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One. p. e21274.
    1. Fritzler BK, Hecker JE, Losee MC. Self-directed treatment with minimal therapist contact: preliminary findings for obsessive-compulsive disorder. Behav Res Ther. 1997;35(7):627–31. doi: 10.1016/S0005-7967(97)00024-7.
    1. Lovella K. et al.A pilot study of a self-help manual with minimal therapist contact in the treatment of obsessive-compulsive disorder. Clinical Effectiveness in Nursing. 2004;8(2):122–127. doi: 10.1016/j.cein.2004.05.004.
    1. Tolin DF. et al.A randomized controlled trial of self-directed versus therapist-directed cognitive-behavioral therapy for obsessive-compulsive disorder patients with prior medication trials. Behav Ther. 2007;38(2):179–91. doi: 10.1016/j.beth.2006.07.001.
    1. Moritz S. et al.How to treat the untreated: effectiveness of a self-help metacognitive training program (myMCT) for obsessive-compulsive disorder. Dialogues Clin Neurosci. 2010;12(2):209–20.
    1. Clark A. et al.A pilot study of computer-aided vicarious exposure for obsessive-compulsive disorder. Aust N Z J Psychiatry. 1998;32(2):268–75. doi: 10.3109/00048679809062738.
    1. Marks IM. et al.Home self-assessment of obsessive-compulsive disorder. Use of a manual and a computer-conducted telephone interview: two UK-US studies. Br J Psychiatry. 1998;172:406–12. doi: 10.1192/bjp.172.5.406.
    1. Bachofen M. et al.Home self-assessment and self-treatment of obsessive-compulsive disorder using a manual and a computer-conducted telephone interview: replication of a UK-US study. J Clin Psychiatry. 1999;60(8):545–9. doi: 10.4088/JCP.v60n0807.
    1. Greist JH. et al.Self-treatment for obsessive compulsive disorder using a manual and a computerized telephone interview: a U.S.-U.K. study. MD Comput. 1998;15(3):149–57.
    1. Greist JH. et al.Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry. 2002;63(2):138–45. doi: 10.4088/JCP.v63n0209.
    1. Kenwright M. et al.Brief scheduled phone support from a clinician to enhance computer-aided self-help for obsessive-compulsive disorder: randomized controlled trial. J Clin Psychol. 2005;61(12):1499–508. doi: 10.1002/jclp.20204.
    1. Palmqvist B, Carlbring P, Andersson G. Internet-delivered treatments with or without therapist input: does the therapist factor have implications for efficacy and cost? Expert Rev Pharmacoecon Outcomes Res. 2007;7(3):291–7. doi: 10.1586/14737167.7.3.291.
    1. Andersson G. Using the Internet to provide cognitive behaviour therapy. Behav Res Ther. 2009;47(3):175–80. doi: 10.1016/j.brat.2009.01.010.
    1. Hedman E. et al.Internet-Based Cognitive Behavior Therapy vs. Cognitive Behavioral Group Therapy for Social Anxiety Disorder: A Randomized Controlled Non-inferiority Trial. PLoS One. 2011;6(3):e18001. doi: 10.1371/journal.pone.0018001.
    1. Ljotsson B. et al.Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome--a randomized controlled trial. Behav Res Ther. 2010;48(6):531–9. doi: 10.1016/j.brat.2010.03.003.
    1. Hedman E. et al.Internet-based cognitive-behavioural therapy for severe health anxiety: randomised controlled trial. Br J Psychiatry. 2011;198(3):230–6. doi: 10.1192/bjp.bp.110.086843.
    1. Griffiths F. et al.Why are health care interventions delivered over the internet? A systematic review of the published literature. J Med Internet Res. 2006;8(2):e10. doi: 10.2196/jmir.8.2.e10.
    1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4. xxxvii. Washington, DC: American Psychiatric Association; 2000. p. 943.
    1. First MB, Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (Swedish Version) Danderyd: Pilgrim Press; 1999.
    1. Sheehan DV. et al.The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33.
    1. Goodman WK. et al.The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46(11):1006–11.
    1. Steketee G, Frost RO. Compulsive hoarding and acquiring: therapist guide. vii. New York; Oxford: Oxford University Press; 2007. p. 226.
    1. Mataix-Cols D. et al.Hoarding disorder: a new diagnosis for DSM-V? Depress Anxiety. 2010;27(6):556–72. doi: 10.1002/da.20693.
    1. Rosenfeld R. et al.A computer-administered version of the Yale-Brown Obsessive-Compulsive Scale. Psychological Assessment. 1992;4(3):329–332.
    1. Foa EB. et al.The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess. 2002;14(4):485–96.
    1. Svanborg P, Åsberg M. A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatr Scand. 1994;89(1):21–8. doi: 10.1111/j.1600-0447.1994.tb01480.x.
    1. Saunders JB. et al.Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Addiction. 1993;88(6):791–804. doi: 10.1111/j.1360-0443.1993.tb02093.x.
    1. Berman AH. et al.Evaluation of the Drug Use Disorders Identification Test (DUDIT) in criminal justice and detoxification settings and in a Swedish population sample. Eur Addict Res. 2005;11(1):22–31. doi: 10.1159/000081413.
    1. Sheehan DV. et al.The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33. quiz 34-57.
    1. Guy W, ed. Clinical Global Impressions. US Department of Health and Human services: Rockville; 1976.
    1. Zaider TI. et al.Evaluation of the clinical global impression scale among individuals with social anxiety disorder. Psychol Med. 2003;33(4):611–22. doi: 10.1017/S0033291703007414.
    1. Jones SH. et al.A brief mental health outcome scale-reliability and validity of the Global Assessment of Functioning (GAF) Br J Psychiatry. 1995;166(5):654–9. doi: 10.1192/bjp.166.5.654.
    1. Baer L, Blais MA. Current clinical psychiatry. xxi. New York: Humana Press; 2010. Handbook of clinical rating scales and assessment in psychiatry and mental health; p. 320.
    1. Federici A. et al.Consistency between self-report and clinician-administered versions of the Yale-Brown Obsessive-Compulsive Scale. J Anxiety Disord. 2010;24(7):729–33. doi: 10.1016/j.janxdis.2010.05.005.
    1. Abramowitz J, Tolin D, Diefenbach G. Measuring change in OCD: Sensitivity of the Obsessive Compulsive Inventory-Revised. Journal of Psychopathology and Behavioral Assessment. 2005;27:317–324. doi: 10.1007/s10862-005-2411-y.
    1. Svanborg P, Asberg M. A comparison between the Beck Depression Inventory (BDI) and the self-rating version of the Montgomery Asberg Depression Rating Scale (MADRS) J Affect Disord. 2001;64(2-3):203–16. doi: 10.1016/S0165-0327(00)00242-1.
    1. Hollandare F, Andersson G, Engstrom I. A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients. J Med Internet Res. 2010;12(5):e49.
    1. Meyer TJ. et al.Development and validation of the Penn State Worry Questionnaire. Behav Res Ther. 1990;28(6):487–95. doi: 10.1016/0005-7967(90)90135-6.
    1. Zlomke KR. Psychometric properties of internet administered versions of Penn State Worry Questionnaire (PSWQ) and Depression, Anxiety, and Stress Scale (DASS) Computers in Human Behavior. 2009;25(4):841–843. doi: 10.1016/j.chb.2008.06.003.
    1. EuroQol-Group. EuroQol - a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199–208.
    1. Rabin R, Charro Fd. EQ-SD: a measure of health status from the EuroQol Group. Annals of Medicine. 2001;33(5):337–343. doi: 10.3109/07853890109002087.
    1. Ravens-Sieberer U. et al.Feasibility, reliability, and validity of the EQ-5D-Y: results from a multinational study. Quality of Life Research. 2010;19(6):887–897. doi: 10.1007/s11136-010-9649-x.
    1. Shervin N, Comparison of paper and computer-based questionnaire modes for measuring health outcomes in patients undergoing total hip arthroplasty. J Bone Joint Surg Am. pp. 285–93.
    1. Frisch MB. et al.Clinical validation of the Quality of Life Inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment. 1992;4(1):92–101.
    1. Carlbring P. et al.Internet vs. paper and pencil administration of questionnaires commonly used in panic/agoraphobia research. Computers in Human Behavior. 2007;23(3):1421–1434. doi: 10.1016/j.chb.2005.05.002.
    1. Hedman E. et al.Internet administration of self-report measures commonly used in research on social anxiety disorder: A psychometric evaluation. Computers in Human Behavior. 2010;26(4):736–740. doi: 10.1016/j.chb.2010.01.010.
    1. Abramowitz JS. The Guilford self-help workbook series. x. New York: Guilford Press; 2009. Getting over OCD: a 10-step workbook for taking back your life; p. 307.
    1. Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59(1):12–9.
    1. Tolin DF, Abramowitz JS, Diefenbach GJ. Defining response in clinical trials for obsessive-compulsive disorder: a signal detection analysis of the Yale-Brown obsessive compulsive scale. J Clin Psychiatry. 2005;66(12):1549–57. doi: 10.4088/JCP.v66n1209.
    1. Andrews G. et al.Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One. 2010;5(10):e13196. doi: 10.1371/journal.pone.0013196.
    1. Oldfield VB, Salkovskis PM, Taylor T. Time-intensive cognitive behaviour therapy for obsessive-compulsive disorder: A case series and matched comparison group. Br J Clin Psychol. 2011;50(1):7–18. doi: 10.1348/014466510X490073.
    1. Andersson G. et al.Development of a New Approach to Guided Self-Help via the Internet: The Swedish Experience. Journal of Technology in Human Services. 2008;26(2-4):161–181. doi: 10.1080/15228830802094627.
    1. Lindsay M, Crino R, Andrews G. Controlled trial of exposure and response prevention in obsessive-compulsive disorder. Br J Psychiatry. 1997;171:135–9. doi: 10.1192/bjp.171.2.135.
    1. Twohig MP. et al.A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychol. 2010;78(5):705–16.
    1. Foa EB. et al.Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 2005;162(1):151–61. doi: 10.1176/appi.ajp.162.1.151.
    1. Mataix-Cols D. et al.Effect of referral source on outcome with cognitive-behavior therapy self-help. Compr Psychiatry. 2006;47(4):241–5. doi: 10.1016/j.comppsych.2005.11.007.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir