Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents

Abstract

In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.OBJECTIVE To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder. DESIGN, SETTING AND PARTICIPANTSA randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020. INTERVENTIONS Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment. MAIN OUTCOMES AND MEASURESThe primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS. RESULTS Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, −ϱ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).CONCLUSIONS AND RELEVANCE Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.

Cost-effectiveness of Internet-Delivered vs In-Person Cognitive Behavioral Therapy for Children and Adolescents With Obsessive-Compulsive Disorder

“…Most participants (110 [72%]) were referred to the study by clinicians. More detailed information about the study participants can be found in the main outcome trial 22 and in Table 1 .…”

“…Blinded clinician assessments were conducted before treatment, after treatment, at 3-month follow-up, and at 6-month follow-up (primary end point). The study protocol 21 and primary efficacy results 22 have been published elsewhere. The study participant flow is presented in eFigure 1 in the Supplement .…”

“…A more detailed description of the treatment can be found elsewhere. 21 , 22 Participants who were assessed as being nonresponders at the 3-month follow-up 26 were offered up to 12 sessions of in-person CBT between the 3-month follow-up and the 6-month follow-up. The additional in-person sessions focused on exposure with response prevention according to a validated in-person CBT protocol for youths with OCD, 27 with individually tailored adaptations regarding the degree of parental involvement, session length, and need for home visits.…”

Feasibility of internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder in youth with autism spectrum disorder: A clinical benchmark study

“…The safety, efficacy, durability and cost-effectiveness of ICBT for children and adolescents for OCD have been well established ( Aspvall et al, 2018 ; Lenhard and Andersson, 2017 ; Lenhard et al, 2014 ; Aspvall et al, 2021 ; Lenhard et al, 2020 ; Lenhard et al, 2017 ). A recent study demonstrated non-inferiority of ICBT compared to in-person CBT for OCD when delivered in a stepped-care fashion ( Aspvall and Andersson, 2021 ). However, all previous studies systematically excluded young people with ASD, rendering the generalization of the results to this particular population uncertain.…”

Viewpoint: digital paediatrics—so close yet so far away

“…Synopsis of key digital health technologies -benefits, limitations, and illustrative examples of utilization in paediatric healthcare Yale-Brown Obsessive-Compulsive Scale score 11.57 vs. 10.57)9 .…”