Therapist-Assisted Internet-Based Cognitive Behavioral Therapy Versus Progressive Relaxation in Obsessive-Compulsive Disorder: Randomized Controlled Trial

Abstract

BackgroundObsessive-compulsive disorder (OCD) is a highly disabling psychological disorder with a chronic course if left untreated. Cognitive behavioral therapy (CBT) has been shown to be an effective treatment, but access to face-to-face CBT is not always possible. Internet-based CBT (iCBT) has become an increasingly viable option. However, no study has compared iCBT to an analogous control condition using a randomized controlled trial (RCT).ObjectiveA 2-armed RCT was used to compare a therapist-assisted 12-module iCBT to an analogous active attention control condition (therapist-assisted internet-based standard progressive relaxation training, iPRT) in adult OCD. This paper reports pre-post findings for OCD symptom severity.MethodIn total, 179 participants (117 females, 65.7%) were randomized (stratified by gender) into iCBT or iPRT. The iCBT intervention included psychoeducation, mood and behavioral management, exposure and response prevention (ERP), cognitive therapy, and relapse prevention; the iPRT intervention included psychoeducation and relaxation techniques as a way of managing OCD-related anxiety but did not incorporate ERP or other CBT elements. Both treatments included audiovisual content, case stories, demonstrations of techniques, downloadable audio content and worksheets, and expert commentary. All participants received 1 weekly email, with a maximum 15-minute preparation time per client from a remote therapist trained in e-therapy. Emails aimed to monitor progress, provide support and encouragement, and assist in individualizing the treatment. Participants were assessed for baseline and posttreatment OCD severity with the telephone-administered clinician-rated Yale-Brown Obsessive-Compulsive Scale and other measures by assessors who were blinded to treatment allocation.ResultsNo pretreatment differences were found between the 2 conditions. Intention-to-treat analysis revealed significant pre-post improvements in OCD symptom severity for both conditions (P<.001). However, relative to iPRT, iCBT showed significantly greater symptom severity improvement (P=.001); Cohen d for iCBT was 1.05 (95% CI 0.72-1.37), whereas for iPRT it was 0.48 (95% CI 0.22-0.73). The iCBT condition was superior in regard to reliable improvement (25/51, 49% vs 16/55, 29%; P=.04) and clinically significant pre-post-treatment changes (17/51, 33% vs 6/55, 11%; P=.005). Those undertaking iCBT post completion of iPRT showed further significant symptom amelioration (P<.001), although the sequential treatment was no more efficacious than iCBT alone (P=.63).ConclusionThis study is the first to compare a therapist-assisted iCBT program for OCD to an analogous active attention control condition using iPRT. Our findings demonstrate the large magnitude effect of iCBT for OCD; interestingly, iPRT was also moderately efficacious, albeit significantly less so than the iCBT intervention. The findings are compared to previous internet-based and face-to-face CBT treatment programs for OCD. Future directions for technology-enhanced programs f...

Cost-effectiveness of internet-based cognitive-behavioural therapy for obsessive-compulsive disorder

“…Data inputs for this study were sourced from a recent clinical trial that investigated the effectiveness of iCBT against iPRT as a control (Kyrios et al, 2018). To benchmark these treatments against current standard treatment (ffCBT) effectiveness data was sourced from recent academic literature.…”

“…The primary outcome measure for the analysis was the Yale-Brown Obsessive Compulsive Scale (YBOCS; Goodman et al, 1989). The pre-post effectiveness based upon intention to treat analysis (ITT) and reported as Cohen's d for the iCBT and iPRT interventions were 1.05 and 0.48 respectively (Kyrios et al, 2018). The effectiveness for the ffCBT was based upon a recent meta-analysis conducted by Olatunji et al (2013) which reported an effect size, for adults, of Hedges g = 1.08.…”

“…Reliable improvement was deemed to have occurred if the person's YBOCS score improved by >10 units. For the iCBT and iPRT interventions, 18% and 6% of participants, respectively, were classified as responders (Kyrios et al, 2018). For the benchmarking analysis, ffCBT the percentage of responders was sourced from two recent studies that used a similar approach (Fisher and Wells, 2005).…”

“…Time-based data for the iCBT and iPRT interventions were sourced from the recent clinical trial (Kyrios et al, 2018) using the YBOCS items which asked how much time was spent on obsessions (question 1) and compulsions (question 6) per day. Time lost per day was calculated based upon the time assumptions for each possible response listed in Table 2, and by summing the assumed times for both questions.…”

“…Internet-based CBT for people with OCD has been found to be comparable in effectiveness to face-to-face CBT (Andersson et al, 2012; Kyrios et al, 2018; Wootton et al, 2013). Internet-based CBT treatments for OCD are usually delivered in modules which present information through use of text, audio or video and which individuals can access and work through on their own (self-guided) or with an assistance of therapist (therapist-guided).…”