Treatment Outcome and Predictors of Internet Guided Self-Help for Obsessive-Compulsive Disorder

doi:10.1016/j.beth.2015.06.001

Behavior Therapy

Volume 46, Issue 6, November 2015, Pages 764-774

https://doi.org/10.1016/j.beth.2015.06.001 Get rights and content

Highlights

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Obsessive-compulsive symptoms improved following Internet-guided self-help (iGSH).
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Depression, functioning, and quality of life also improved following iGSH.
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Higher motivation and attendance were associated with better treatment response.

Abstract

Internet-guided self-help (iGSH) has amassed significant empirical support for a variety of psychiatric conditions; however, it is not known who responds best to these treatments. This open trial examined the clinical outcomes and predictors of a 17-week iGSH program for obsessive-compulsive disorder (OCD). Therapist support was provided either in person or by phone 9 times for an average of 13 minutes per session. Twenty-four patients initiated treatment, and 17 of these (70.8%) completed. Results of the intent-to-treat sample indicated statistically significant improvements at posttreatment with large treatment effects for OCD symptoms as assessed by the Yale Brown Obsessive-Compulsive Scale (d = 0.87), and small to moderate improvements in depression (d = 0.19), functioning (d = 0.53), and quality of life (d = -0.18). These outcomes were largely maintained over a 6-month follow-up. Readiness to reduce avoidance of OCD triggers and attendance to therapist sessions were moderately associated with posttreatment response, and correctly classified the responder status (defined as clinically significant change) of nearly 9 out of 10 patients at posttreatment. These same variables did not predict responder status at 6-month follow-up. These results lend further empirical support to iGSH as a treatment for OCD and provide direction on the development of predictor models to identify patients who are and are not likely to acutely respond to iGSH.

Section snippets

Participants

Participants were 26 adult outpatients diagnosed with OCD (M age = 37.08, SD = 12.57, % women = 65.4, % Caucasian = 87.5%, % non-Hispanic = 95.8%), recruited primarily through the website/waiting list of an outpatient clinic specializing in CBT for anxiety and related disorders (n = 20, 76.9%). Inclusion criteria were (a) age 18–69, (b) at least mild OCD symptoms [clinician Yale-Brown Obsessive-Compulsive Scale (YBOCS; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989) ≥ 8 and clinician global

Recruitment and Retention

Participant flow and reasons for exclusion/discontinuation are outlined in Figure 1.

Program Use and Adverse Events

On average, participants completed 7 OCFighter steps (M = 7.00, SD = 2.49). Only 4 of 24 participants (16.7%) completed the highest step (step 9) and only 1 of 24 participants (4.2%) completed through step 6 within the first 2 weeks. Participants logged into OCFighter an average of 27.67 times (SD = 16.81) and for 236.67 minutes (SD = 84.23, range 60–340) total. On average, participants completed 6 sessions (M = 6.46, SD =

Discussion

This study lends further support to the efficacy of iGSH for OCD. Patients experienced mostly large pre-to-post treatment improvements in OCD, and small to moderate improvements in depression and quality of life, which were mostly maintained over 6-month follow-up. These results are generally consistent with the efficacy of other published reports of iGSH for OCD (Andersson et al., 2012, Andersson et al., 2011, Herbst et al., 2014, Wootton, Dear, Johnston, Terides and Titov, 2013, Wootton,

Conflict of Interest Statement

Dr. Diefenbach receives material support from Neuronetics. Dr. Tolin receives research support from Palo Alto Health Sciences. Dr. Wootton, Ms. Bragdon, and Ms. Moshier have no financial interests or conflicts of interest to disclose.

Acknowledgements

Funding for this study was provided by a grant (#126259) from Hartford Hospital to the first author. The funding source had no role in the study design; collection, analysis, interpretation of data; writing the report; or in making the decision to submit the article for publication. Data from this study were presented at the 2014 annual meeting of the Association for Behavioral and Cognitive Therapies, Philadelphia, PA.

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Citation Excerpt :
However, the presence of a guiding clinician was not associated with greater reductions in OCD symptom severity at post-treatment (controlling for pre-treatment severity). Our results appear consistent with previous studies that have highlighted the importance of the therapeutic relationship for treatment engagement; with strength of the working alliance (Andersson et al., 2015) and attending concurrent therapist sessions (Diefenbach et al., 2015) being associated with higher adherence. Also of note was that participants living in regional, rural and remote areas were more likely to complete treatment; and unlike in our previous research (Mahoney et al., 2014), age did not correlate with completion rates.
A growing evidence base supports the efficacy of Internet-based cognitive behavior therapy (iCBT) for obsessive compulsive disorder (OCD). However, very few studies have evaluated the effectiveness of iCBT for OCD in routine care settings which service the bulk of a population's health needs. This study evaluated the treatment outcomes of 309 adults who enrolled in an online CBT course for their symptoms of OCD. Most patients (62.8%) enrolled in a self-help or unguided iCBT course, and the remainder were supported by a routine care, community clinician. The entire iCBT course was completed by 39.3% of participants, with 61.2% completing the majority of iCBT lessons. Higher baseline depression symptom severity predicted poorer adherence, while the presence of a supervising clinician was associated with greater adherence. Medium effect size reductions in OCD symptom severity (g = 0.61), depression symptom severity (g = 0.56), and psychological distress (g = 0.69) were observed from pre-to post-treatment. Pre-treatment OCD and depression symptom severity predicted post-treatment OCD symptom severity. Current results support the use of iCBT for OCD in routine care settings, and as health care resources are finite, iCBT for OCD may serve as a useful, low-intensity, and scalable addition to the existing healthcare infrastructure.

View all citing articles on Scopus

¹: Bethany M. Wootton is now at University of Tasmania.

²: Laura B. Bragdon is now at State University of New York at Binghamton.

View full text

Treatment Outcome and Predictors of Internet Guided Self-Help for Obsessive-Compulsive Disorder

Highlights

Abstract

Section snippets

Participants

Recruitment and Retention

Program Use and Adverse Events

Discussion

Conflict of Interest Statement

Acknowledgements

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Biomedical Informatics

Behaviour Research and Therapy

Clinical Psychology Review

Behaviour Research and Therapy

European Psychiatry

Journal of Psychiatric Research

Behaviour Research and Therapy

Behaviour Research and Therapy

Journal of Obsessive-Compulsive and Related Disorders

Journal of Anxiety Disorders

Diagnostic and statistical manual of mental disorders

Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: A randomized controlled trial

Psychological Medicine

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

BMC Psychiatry

Long-term efficacy of Internet-based cognitive behavior therapy for obsessive-compulsive disorder with or without booster: A randomized controlled trial

Psychological Medicine

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

Journal of Clinical Psychiatry

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

Journal of Clinical Psychiatry

Experiences of guided internet-based cognitive-behavioural treatment for depression: A qualitative study

BMC Psychiatry

Patient expectations in internet-based self-help for social anxiety

Cognitive Behaviour Therapy

Cognitive function and treatment response in a randomized clinical trial of computer-based training in cognitive-behavioral therapy

Substance Use and Misuse

Statistical power analysis for the behavioral sciences

Is 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

Validity of a novel computerized cognitive battery for mild cognitive impairment

BMC Geriatrics

Quality of life assessment/intervention and the Quality of Life Inventory (QOLI)

Clinical validation of the Quality of Life Inventory: A measure of life satisfaction for use in treatment planning and outcome assessment

Psychological Assessment: A Journal of Consulting and Clinical Psychology

The Yale-Brown Obsessive Compulsive Scale. II. Validity

Archives of General Psychiatry