Towards an international expert consensus for defining treatment response, remission, recovery and relapse in obsessive-compulsive disorder

Stepped Care Internet-Delivered vs Face-to-Face Cognitive-Behavior Therapy for Pediatric Obsessive-Compulsive Disorder: A Trial Protocol for a Randomized Noninferiority Trial

Importance

Internet-delivered cognitive behavior therapy is an effective treatment for children and adolescents with obsessive-compulsive disorder and has the potential to markedly increase access to treatment for patients while being cost-effective for health care organizations.

Objective

To investigate whether internet-delivered cognitive behavior therapy implemented within a stepped care model is noninferior to, and cost-effective compared with, the gold standard of face-to-face cognitive behavior therapy for pediatric obsessive-compulsive disorder.

Design, Setting, and Participants

Multicenter, single-blind, randomized clinical noninferiority trial implemented at 2 specialist pediatric obsessive-compulsive disorder clinics in Stockholm and Gothenburg, Sweden. Participants are 152 children and adolescents aged 7 to 17 years with obsessive compulsive disorder, recruited through the 2 clinics and online self-referral. Patients will be randomized 1:1 to the stepped care intervention or face-to-face therapy. Blind evaluations will be conducted after treatment and at 3-month and 6-month follow-ups. At the 6-month follow-up (primary end point), noninferiority will be tested and resource use will be compared between the 2 treatment groups. Data will be analyzed according to intention-to-treat principles.

Intervention

Patients randomized to stepped care will first receive internet-delivered cognitive behavior therapy for 16 weeks; patients who are classified as nonresponders 3 months after treatment completion will receive additional face-to-face therapy. The control group will receive 16 weeks of face-to-face cognitive behavior therapy immediately following randomization and nonresponders at the 3-month follow-up will, as in the stepped care group, receive additional face-to-face therapy.

Main Outcomes and Measures

Noninferiority is defined as a 4-point difference on the primary outcome measure (Children's Yale-Brown Obsessive Compulsive Scale).

Discussion

Recruitment started October 6, 2017, and was completed May 24, 2019. Results from the primary end point will be available by May 2020. The naturalistic follow-ups (1, 2, and 5 years after the end of treatment) will continue to 2025. There are no interim analyses planned or stopping rules for the trial.

Trial Registration

ClinicalTrials.gov identifier: NCT03263546.

A Systematic Review of Evidence-based Treatment Strategies for Obsessive- compulsive Disorder Resistant to first-line Pharmacotherapy

BACKGROUND

Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). However, a significant proportion of patients do not respond satisfactorily to first-choice treatments. Several options have been investigated for the management of resistant patients.

OBJECTIVE

The aim of the present paper is to systematically review the available literature concerning the strategies for the treatment of resistant adult patients with OCD.

METHOD

We first reviewed studies concerning the definition of treatment-resistant OCD; we then analyzed results of studies evaluating several different strategies in resistant patients. We limited our review to double-blind, placebo-controlled studies performed in adult patients with OCD whose resistance to a first adequate (in terms of duration and dosage) SRI trial was documented and where outcome was clearly defined in terms of decrease in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores and/or response/ remission rates (according to the YBOCS).

RESULTS

We identified five strategies supported by positive results in placebo-controlled randomized studies: 1) antipsychotic addition to SRIs (16 RCTs, of them 10 positive; 4 head-to-head RCTs); among antipsychotics, available RCTs examined the addition of haloperidol (butyrophenone), pimozide (diphenyl-butylpiperidine), risperidone (SDA: serotonin- dopamine antagonist), paliperidone (SDA), olanzapine (MARTA: multi-acting receptor targeted antipsychotic), quetiapine (MARTA) and aripiprazole (partial dopamine agonist); 2) CBT addition to medication (2 positive RCTs); 3) switch to intravenous clomipramine (SRI) administration (2 positive RCTs); 4) switch to paroxetine (SSRI: selective serotonin reuptake inhibitor) or venlafaxine (SNRI: serotonin-norepinephrine reuptake inhibitor) when the first trial was negative (1 positive RCT); and 5) the addition of medications other than an antipsychotic to SRIs (18 RCTs performed with several different compounds, with only 4 positive studies).

CONCLUSION

Treatment-resistant OCD remains a significant challenge to psychiatrists. To date, the most effective strategy is the addition of antipsychotics (aripiprazole and risperidone) to SRIs; another effective strategy is CBT addition to medications. Other strategies, such as the switch to another first-line treatment or the switch to intravenous administration are promising but need further confirmation in double-blind studies. The addition of medications other than antipsychotics remains to be studied, as several negative studies exist and positive ones need confirmation (only 1 positive study).

Task-based fMRI predicts response and remission to exposure therapy in obsessive-compulsive disorder

Exposure and ritual prevention (EX/RP) is an effective first-line treatment for obsessive-compulsive disorder (OCD), but only some patients achieve minimal symptoms following EX/RP. Herein, we investigate whether task-based neural activity can predict who responds best to EX/RP. Unmedicated adult patients with OCD (n = 36) and healthy participants (n = 33) completed the Simon Spatial Incompatibility Task during high-resolution, multiband functional MRI (fMRI); patients were then offered twice-weekly EX/RP (17 sessions). Linear mixed-effects models were used to identify brain regions where conflict-related activity moderated the slope of change in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores across treatment. Conflict-related activity in the left pallidum and 35 cortical parcels/regions significantly predicted symptom improvement with EX/RP for patients with OCD (false discovery rate-corrected P < 0.05). Significant parcels/regions included cingulo-opercular and default mode network regions, specifically the anterior insula and anterior and posterior cingulate. Summarizing across these parcels/regions, greater conflict-related activity predicted greater EX/RP response and which patients achieved remission (Y-BOCS score ≤ 12; Cohen's d = 1.68) with >80% sensitivity and specificity. The association between brain activity and treatment response was partially mediated by patient EX/RP adherence (b = -2.99; 43.61% of total effect; P = 0.02). Brain activity and adherence together were highly predictive of remission. Together, these findings suggest that cingulo-opercular and default mode regions typically implicated in task control and introspective processes, respectively, may be targets for novel treatments that augment the ability of persons with OCD to resolve cognitive conflict and thereby facilitate adherence to EX/RP, increasing the likelihood of remission.

Predictors of acute outcomes for intensive residential treatment of obsessive-compulsive disorder

For those who suffer with chronic and disruptive obsessive-compulsive disorder (OCD), who have not been sufficiently helped by outpatient treatments or medications, intensive residential treatment (IRT) is often the next best treatment option. To date, research of the predictors of treatment outcome in IRT for OCD are mixed and sometimes contradictory. Additionally, although comorbidity is common for patients in this setting, the inclusion of comorbidity as a potential predictor of outcome has been mostly lacking in research to date. The current study aimed to address these issues by utilizing optimal indices of treatment outcomes, while incorporating comorbidity into our analyses, in order to identify the predictors of treatment outcomes in the IRT for OCD setting. To this end, we analysed outcome data from 379 patients receiving IRT for OCD at the Rogers Memorial OCD Center between August 2012, and December 2017. Results indicated that the most important predictor of treatment outcome was obsession severity at admission. Specifically, higher obsession severity at admission predicted poorer treatment outcomes at discharge. Clinical implications and suggestions for future research were discussed in the manuscript.

The course and clinical correlates of obsessive-compulsive disorder during the postpartum period: A naturalistic observational study

BACKGROUND

In this study, we aimed to investigate the course of obsessive-compulsive disorder (OCD) and the demographic and clinical correlates associated with significant changes in symptom severity in postpartum women.

METHODS

Data were collected form 37 consecutive postpartum women who were diagnosed with OCD during psychiatric interviews by means of the Structured Clinical Interview for DSM-IV (SCID-I). Psychiatric assessments were carried out on the first day after delivery and at 6 to 8 weeks in the postpartum period. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was administered at both assessments while the Hospital Anxiety and Depression Scale (HADS), Coping orientation to problems Experienced (COPE) and Multidimensional Scale of Perceived Social Support (MSPSS) and Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), were administered to the participants at the first assessment.

RESULTS

The mean score of Y-BOCS was significantly reduced from the baseline to the 6-8 week postpartum period. The proportion of patients with a decreaseof at least 35% in the total score of Y-BOCS during the postpartum period was 43.2%. When the patient groups with and without ≥35% decrease in the total score of Y-BOCS were compared, the group showing the decrease had a higher score of COPE-supression of competing activities, COPE-humor and TEMPS-A-hyperthymic affective temperament and more frequently reported a decrease in the severity of OCD symptoms after a previous childbirth. Logistic regression analysis indicated that the last two variables could accurately predict a ≥ 35 decrease in the severity of OCD symptoms during the postpartum period.

LIMITATIONS

The study has relatively small sample size.

CONCLUSIONS

The current results suggest that patients with OCD who exhibit hyperthymic affective temperament character and a decrease in symptoms following a previous childbirth may experience a significant alleviation in the severity of obsessive-compulsive symptoms during the postpartum period.

Adapted cognitive behavior therapy for obsessive-compulsive disorder with co-occurring autism spectrum disorder: A clinical effectiveness study

Obsessive-compulsive disorder and autism spectrum disorder commonly co-occur. Adapted cognitive behavior therapy for obsessive-compulsive disorder in adults with autism spectrum disorder has not previously been evaluated outside the United Kingdom. In this study, 19 adults with obsessive-compulsive disorder and autism spectrum disorder were treated using an adapted cognitive behavior therapy protocol that consisted of 20 sessions focused on exposure with response prevention. The primary outcome was the clinician-rated Yale-Brown Obsessive-Compulsive Scale. Participants were assessed up to 3 months after treatment. There were significant reductions on the Yale-Brown Obsessive-Compulsive Scale at post-treatment (d = 1.5), and improvements were sustained at follow-up (d = 1.2). Self-rated obsessive-compulsive disorder and depressive symptoms showed statistically significant reductions. Improvements in general functioning and quality of life were statistically non-significant. Three participants (16%) were responders at post-treatment and four (21%) were in remission from obsessive-compulsive disorder. At follow-up, three participants (16%) were responders and one (5%) was in full remission. Adapted cognitive behavior therapy for obsessive-compulsive disorder in adults with co-occurring autism spectrum disorder is associated with reductions in obsessive-compulsive symptoms and depressive symptoms. However, outcomes are modest; few patients were completely symptom free, and treatment engagement was low with few completed exposures and low adherence to homework assignments. We identify and discuss the need for further treatment refinement for this vulnerable group.

The Bergen 4-Day Treatment for Obsessive-Compulsive Disorder: Does It Work in a New Clinical Setting?

Sørlandet Hospital in Norway has a history of offering patients with obsessive-compulsive disorder (OCD) cognitive behavior group therapy using 12 weekly sessions of 2.5 h each. A previous evaluation of this treatment has shown that 51.9% did not respond at post-treatment. Recently, a highly concentrated group-treatment format, the Bergen 4-day treatment (B4DT), has been shown to help more than 90% of patients with OCD post-treatment. Based on these positive results, it was decided to explore whether the B4DT could be a feasible format for delivering ERP at another clinic. Thirty-five consecutively recruited patients were included in the current pilot study, and assessed at pre-treatment, post-treatment, and 3-month follow-up. Treatment response rate (35% reduction in OCD-symptom score) was 94% at post-treatment, and 80% at follow-up. Seventy-four percent were in remission at post-treatment and 68% at follow-up. Only one patient dropped out of treatment. The patients were highly satisfied with the treatment content and format. The results indicate that the 4-day treatment could successfully be implemented at a new clinic.

Dispositional resilience in treatment-seeking patients with obsessive-compulsive disorder and its association with treatment outcome

There is a lack of research on the relation between obsessive-compulsive disorder (OCD) and resilience. Dispositional resilience, as described and defined in literature on hardiness, consists of three facets, namely beliefs about having control in everyday living, having a sense of purpose or commitment, and a positive attitude toward challenges. This study explores associations between dispositional resilience (measured with the Dispositional Resilience Scale (DRS-15-R)), symptom severity, and treatment outcome in a sample of 89 patients treated with concentrated exposure therapy (cET), and compares the findings with scores from two reference groups (students and soldiers). The patient group had significantly lower resilience scores than the two reference groups. Weak correlations were observed between dispositional resilience and OCD symptoms. Differences in dispositional resilience were weakly related to remission status at follow-up (odds ratio of 1.11). Furthermore, resilience improved from pre- to post-treatment (Cohen's d of 0.65). Our results imply that patients' initial resilience score does not hinder nor facilitate treatment effects to a great extent in this format of ERP treatment.

Mindfulness-based Cognitive Therapy for Obsessive-Compulsive Disorder: A Pilot Study

BACKGROUND

Cognitive-behavioral therapy (CBT) is the first-choice intervention for obsessive-compulsive disorder (OCD); however, a notable proportion of patients either do not respond to treatment or relapse after CBT. Mindfulness-based treatment has been suggested as an alternative or complementary therapeutic strategy for OCD. However, only a few studies have focused on its application in clinical samples.

OBJECTIVE

To evaluate the impact of a new treatment, called "Mindfulness-based Cognitive Therapy for OCD." It is an 11-session manualized group intervention that integrates elements of CBT, mindfulness, compassion-focused therapy, and acceptance and commitment therapy.

METHODS

The program was delivered to 35 patients with a primary diagnosis of OCD.

RESULTS

Participants demonstrated good adherence to the intervention. There was a significant reduction in mean total score on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS-TS) (P<0.001; Cohen d=-0.72). One third of the participants (n=13) showed at least a 25% reduction on the Y-BOCS-TS, and 40% of the sample (n=14) were assigned to a lower Y-BOCS severity category after treatment. Significant changes were also found in depression (P<0.001; d=-0.80), worry (P<0.001; d=-0.79), alexithymia (P<0.01; d=-0.41), dissociation (P<0.05; d=-0.46), and general psychopathology (P<0.001; d=-0.58). Repeated measures linear mixed models showed that OCD symptom reduction was associated with an increase in mindfulness skills, in particular on the acting with awareness (P=0.006), nonjudging (P=0.001), and nonreactivity (P=0.001) facets.

CONCLUSIONS

Overall, these findings are promising and they suggest that randomized controlled studies be conducted to test the effectiveness of this new treatment program for this challenging and disabling mental disorder.

Mindfulness-based cognitive therapy (MBCT) in patients with obsessive-compulsive disorder (OCD) and residual symptoms after cognitive behavioral therapy (CBT): a randomized controlled trial

Up to one-third of individuals with obsessive-compulsive disorder (OCD) do not benefit from evidence-based psychotherapy. We examined the efficacy of mindfulness-based cognitive therapy (MBCT) as a complementary treatment option. In a prospective, bicentric, assessor-blinded, randomized, and actively controlled clinical trial, 125 patients with OCD and residual symptoms after cognitive behavioral therapy (CBT) were randomized to either an MBCT group (n = 61) or to a psychoeducational group (OCD-EP; n = 64) as an active control condition. At post-treatment, there was no significant benefit of MBCT over OCD-EP with the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) as the primary outcome measure, but with the Obsessive-Compulsive Inventory [OCI-R; F(1, 101) = 5.679, p = .036, effect size η²_partial = 0.053]. Moreover, the response rate and the improvement on secondary outcomes such as obsessive beliefs and quality of life was significantly larger in the MBCT group. Non-completion rates were below 10%. At the 6-month follow-up, OC symptoms were further improved in both groups; group differences were no longer significant. Our findings suggest that MBCT, compared to a psychoeducational program, leads to accelerated improvement of self-reported OC symptoms and secondary outcomes, but not of clinician-rated OC symptoms. In the midterm, both interventions yield similar and stable, but small improvements, suggesting that additional treatment options may be necessary.

Efficacy of pre-supplementary motor area transcranial direct current stimulation for treatment resistant obsessive compulsive disorder: A randomized, double blinded, sham controlled trial

BACKGROUND

A significant proportion of obsessive compulsive disorder (OCD) patients do not respond to specific serotonin reuptake inhibitors (SSRIs). There is a need to evaluate novel treatment options for OCD.

OBJECTIVE

In this double blinded, randomized, sham controlled study, we investigated the efficacy of add-on transcranial direct current stimulation (tDCS) in reducing the symptoms in SSRI-resistant OCD patients by employing anodal pre-supplementary motor area (pre-SMA) stimulation.

METHOD

Twenty-five patients with DSM-IV OCD having persistent symptoms despite adequate and stable treatment with at least one SSRI were randomly allocated to receive 20 min of verum (active) 2-mA tDCS or sham stimulation twice daily on 5 consecutive days [anode over Pre-SMA; cathode over right supra-orbital area]. Response to treatment was defined as at least 35% reduction in the Yale-Brown Obsessive-Compulsive Scale (YBOCS) total score along with a Clinical Global Impression - Improvement (CGI-I) score of 1 (very much improved) or 2 (much improved).

RESULTS

The response rate was significantly greater in the verum tDCS(4 out of 12) compared to sham-tDCS (0 out of 13) [Fisher's exact test, p = 0.04]. Repeated measures analysis of variance with tDCS type (verum vs. sham) as between subjects factor showed that there was a significant tDCS-type X time-point interaction with significantly greater reduction of YBOCS total score [F (1,22) = 4.95,p = 0.04,partial-η² = 0.18] in verum-tDCS group.

CONCLUSIONS

The results of this RCT suggest that tDCS may be effective in treating SSRI-resistant OCD. Future studies should examine the efficacy in larger samples of OCD and explore other potential target regions using randomized sham-controlled designs, in addition to examining the sustainability of the beneficial effects.

TRIAL REGISTRATION

Clinical Trials Registry India (http://ctri.nic.in/Clinicaltrials/login.php): Registration Number- CTRI/2016/04/006837).

Implementation of the Bergen 4-Day Treatment for Obsessive Compulsive Disorder in Iceland

OBJECTIVE

The purpose of this study was to evaluate the first implementation outside of Norway of the Bergen 4-day treatment for Obsessive Compulsive Disorder (OCD), an innovative and effective treatment format with high acceptance and basically no drop-out.

METHOD

Nineteen patients with OCD underwent the treatment at the Icelandic Anxiety Clinic (Kvíðameðferðarstöðin). Of these, 17 of the patients were classified pretreatment with severe to extreme symptoms and 2 were classified with moderate symptoms. 63% of the patients had previously received treatment for OCD (ERP or CBT).

RESULTS

Mean pretreatment score on Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was 28.79 (SD = 4.42). One week post-treatment mean Y-BOCS score was 9.95 (SD = 3.67). 94.7% of the patients had responded to treatment and 73.7 were in remission according to the international consensus criteria. At 3-month follow-up, the Y-BOCS score was 11.09 (SD = 5.89) where 78.9% of the patients had responded to treatment and 63.2% were in remission.

CONCLUSIONS

All patients expressed high satisfaction with the treatment format, and none of the patients would have preferred longer term treatment. The therapists also expressed satisfaction with the treatment format. The Bergen 4-day treatment for OCD is a very promising treatment for OCD, and can be successfully implemented outside Norway.

Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder

For more than half a century, stereotactic neurosurgical procedures have been available to treat patients with severe, debilitating symptoms of obsessive-compulsive disorder (OCD) that have proven refractory to extensive, appropriate pharmacological, and psychological treatment. Although reliable predictors of outcome remain elusive, the establishment of narrower selection criteria for neurosurgical candidacy, together with a better understanding of the functional neuroanatomy implicated in OCD, has resulted in improved clinical efficacy for an array of ablative and non-ablative intervention techniques targeting the cingulum, internal capsule, and other limbic regions. It was against this backdrop that gamma knife capsulotomy (GKC) for OCD was developed. In this paper, we review the history of this stereotactic radiosurgical procedure, from its inception to recent advances. We perform a systematic review of the existing literature and also provide a narrative account of the evolution of the procedure, detailing how the procedure has changed over time, and has been shaped by forces of evidence and innovation. As the procedure has evolved and adverse events have decreased considerably, favorable response rates have remained attainable for approximately one-half to two-thirds of individuals treated at experienced centers. A reduction in obsessive-compulsive symptom severity may result not only from direct modulation of OCD neural pathways but also from enhanced efficacy of pharmacological and psychological therapies working in a synergistic fashion with GKC. Possible complications include frontal lobe edema and even the rare formation of delayed radionecrotic cysts. These adverse events have become much less common with new radiation dose and targeting strategies. Detailed neuropsychological assessments from recent studies suggest that cognitive function is not impaired, and in some domains may even improve following treatment. We conclude this review with discussions covering topics essential for further progress of this therapy, including suggestions for future trial design given the unique features of GKC therapy, considerations for optimizing stereotactic targeting and dose planning using biophysical models, and the use of advanced imaging techniques to understand circuitry and predict response. GKC, and in particular its modern variant, gamma ventral capsulotomy, continues to be a reliable treatment option for selected cases of otherwise highly refractory OCD.

Insomnia in pediatric obsessive-compulsive disorder: prevalence and association with multimodal treatment outcomes in a naturalistic clinical setting

OBJECTIVE

Little is known about the prevalence and impact of insomnia on clinical outcomes in youth with obsessive-compulsive disorder (OCD). This study aimed to investigate this subject.

PATIENTS/METHODS

A total of 193 patients from a specialist pediatric OCD clinic completed a range of diagnostic and clinical measures, including the Insomnia Severity Index (ISI). Patients scoring above a previously validated cut-off on the ISI (score ≥9) were compared to the rest of the sample on sociodemographic and clinical characteristics. In a subsample of 143 (from the initial 193) patients who were treated at the clinic, a mixed-model analysis of variance (ANOVA) was used to compare the outcomes of multimodal OCD treatment in the insomnia (N = 60) vs no insomnia (N = 83) groups. The primary outcome measure was the clinician-administered Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at post-treatment and at three-month follow-up.

RESULTS

The psychometric properties of the ISI in our sample were excellent. At baseline, 42% (81/193) of the sample scored above the ISI cut-off for clinical insomnia. These participants had significantly higher OCD severity, higher rates of psychiatric comorbidities, more severe depressive symptoms, poorer general functioning, and were more likely to take sleep medications, compared to those who scored below the ISI cut-off. In the treated subsample, while the insomnia group remained more severely affected through the three time-points, both groups improved similarly on the CY-BOCS at post-treatment and at three-month follow-up.

CONCLUSION

Insomnia is relatively common in pediatric OCD and is associated with more severe psychopathology. However, with adequate multimodal, evidence-based treatment, these patients can improve as much as those without insomnia.

Indian guidelines on neurosurgical interventions in psychiatric disorders

Neurosurgery for psychiatric disorders (NPD) has been practiced for >80 years. However, the interests have waxed and waned, from 1000s of surgeries in 1940-1950s to handful of surgery in 60-80s. This changed with the application of deep brain stimulation surgery, a surgery, considered to be "reversible" there has been a resurgence in interest. The Indian society for stereotactic and functional neurosurgery (ISSFN) and the world society for stereotactic and functional neurosurgery took the note of the past experiences and decided to form the guidelines for NPD. In 2011, an international task force was formed to develop the guidelines, which got published in 2013. In 2018, eminent psychiatrists from India, functional neurosurgeon representing The Neuromodulation Society and ISSFN came-together to deliberate on the current status, need, and legal aspects of NPD. In May 2018, Mental Health Act also came in to force in India, which had laid down the requirements to be fulfilled for NPD. In light of this after taking inputs from all stakeholders and review of the literature, the group has proposed the guidelines for NPD that can help to steer these surgery and its progress in India.

Cost-effectiveness analysis of telephone cognitive-behaviour therapy for adolescents with obsessive-compulsive disorder

BACKGROUND

Telephone cognitive-behaviour therapy (TCBT) may be a cost-effective method for improving access to evidence-based treatment for obsessive-compulsive disorder (OCD) in young people.AimsEconomic evaluation of TCBT compared with face-to-face CBT for OCD in young people.

METHOD

Randomised non-inferiority trial comparing TCBT with face-to-face CBT for 72 young people (aged 11 to 18) with a diagnosis of OCD. Cost-effectiveness at 12-month follow-up was explored in terms of the primary clinical outcome (Children's Yale-Brown Obsessive-Compulsive Scale, CY-BOCS) and quality-adjusted life-years (QALYs) (trial registration: ISRCTN27070832).

RESULTS

Total health and social care costs were higher for face-to-face CBT (mean total cost £2965, s.d. = £1548) than TCBT (mean total cost £2475, s.d. = £1024) but this difference was non-significant (P = 0.118). There were no significant between-group differences in QALYs or the CY-BOCS and there was strong evidence to support the clinical non-inferiority of TCBT. Cost-effectiveness analysis suggests a 74% probability that face-to-face CBT is cost-effective compared with TCBT in terms of QALYs, but the result was less clear in terms of CY-BOCS, with TCBT being the preferred option at low levels of willingness to pay and the probability of either intervention being cost-effective at higher levels of willingness to pay being around 50%.

CONCLUSIONS

Although cost-effectiveness of TCBT was sensitive to the outcome measure used, TCBT should be considered a clinically non-inferior alternative when access to standard clinic-based CBT is limited, or when patient preference is expressed.Declaration of interestD.M.-C. reports research grants from the Swedish Research Council (Vetenskapsrådet), the Swedish Research Council for Health, working life and welfare (Forte), the US National Institute of Mental Health (NIMH), the UK National Institute of Health Research (NIHR), as well as royalties from Wolters Kluwer Health and Elsevier, all unrelated to the submitted work.

Course and outcome of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is generally believed to follow a chronic waxing and waning course. The onset of illness has a bimodal peak - in early adolescence and in early adulthood. Consultation and initiation of treatment are often delayed for several years. Studies over the past 2-3 decades have found that the long-term outcomes in OCD are not necessarily bleak and that at least half the treatment-seeking patients with OCD show symptomatic remission over long term. A short duration illness, of low severity that is treated early and intensively, with continued maintenance treatment over long term possibly has a good outcome. Recent studies have also identified neuroimaging and neuropsychological correlates of good outcome, but these need further replication. This paper presents an overview of conceptual issues and studies on long-term outcome of OCD and predictors of outcome.

Group Cognitive-Behavior Therapy or Group Metacognitive Therapy for Obsessive-Compulsive Disorder? Benchmarking and Comparative Effectiveness in a Routine Clinical Service

Cognitive-behavior therapy (CBT), delivered in an individual or group format, is the recommended treatment of choice for Obsessive-Compulsive Disorder (OCD), but no studies have benchmarked the outcomes for group CBT in real-world clinical settings. The first aim of this evaluation was to benchmark the outcomes for group CBT in a sample of 125 patients who attended a routine clinical service for OCD. The results showed that the outcomes for the group CBT were comparable to those reported in previous treatment studies. However, consistent with the CBT for OCD literature, 28% of patients receiving CBT reported minimal improvement. The second aim of this evaluation was to carry out a benchmarking analysis for group metacognitive therapy (MCT) to determine if this could provide any advantages in a sample of 95 patients who also attended this clinical service over a subsequent period. The clinically significant results obtained for group MCT improved upon or equaled those obtained for group CBT and those typically found in treatment studies. The group MCT cohort improved significantly more than the group CBT cohort even after controlling for important pre-treatment variables including age, gender, number of diagnoses, symptoms of depression, and psychotropic medication. MCT had significantly higher clinical response rates. Based on international expert consensus criteria, 86.3% of patients in the MCT cohort responded compared with 64% in CBT. The implications of these findings are discussed.

From Treatment Response to Recovery: A Realistic Goal in OCD

Despite longitudinal studies reporting symptomatic remission rates ranging from 32% to 70%, Obsessive-Compulsive Disorder is considered a persistent and very disabling disorder. However, these studies suggest that recovery can be a realistic goal for a subgroup of the Obsessive-Compulsive Disorder population and that a clear definition of recovery is timely in Obsessive-Compulsive Disorder. The aim of this paper is to discuss the dimensions of and propose an operational definition of recovery in Obsessive-Compulsive Disorder. Considering the impact generated by the definition of recovery for other mental disorders, this article discusses how this concept may shape the future of research and clinical practice in Obsessive-Compulsive Disorder. Ultimately, the hope is that the management of Obsessive-Compulsive Disorder may parallel, and expand upon, some of the current approaches implemented in the care of schizophrenia, so that early diagnosis, stepped-care techniques, and a personalized approach can be used to create recovery-oriented treatment programs and influence policy making for Obsessive-Compulsive Disorder.

Successfully treating 90 patients with obsessive compulsive disorder in eight days: the Bergen 4-day treatment

BACKGROUND

Oslo University Hospital, Norway, had by autumn 2016, accumulated a waiting list of 101 patients with obsessive-compulsive disorder (OCD) who had a legal right to receive treatment by a specialized OCD team. In this challenging situation, the Bergen OCD-team suggested to solve the problem by offering all patients an option for the rapid Bergen 4-day treatment (B4DT). The B4DT is an individual treatment delivered during four consecutive days in a group of six patients with the same number of therapists. The approach has previously shown a post-treatment response rate of 90% and a 3-month remission rate of 70%.

METHODS

Ninety-seven of the wait-list patients were available for the scheduled time slots, and 90 received the 4-day format during 8 days (45 patients each week). The therapists were recruited from 22 different specialized OCD-teams from all over Norway, and 44 (68%) had not previously delivered the 4-day format.

RESULTS

Post-treatment; 91.1% of the patients were classified as responders, and 72.2% were in remission. At 3-month follow-up; 84.4 were classified as responders and the remission rate was 67.7%. Oslo University Hospital now offers the 4-day treatment as standard treatment for OCD.

CONCLUSIONS

We conclude that the B4DT is an acceptable and potentially effective OCD-treatment.

Study protocol for a single-blind, randomised controlled, non-inferiority trial of internet-based versus face-to-face cognitive behaviour therapy for obsessive-compulsive disorder

INTRODUCTION

Expert guidelines recommend cognitive-behavioural therapy (CBT) as a first-line treatment for obsessive-compulsive disorder (OCD), but the majority of patients with OCD do not have access to CBT. Internet-delivered CBT (ICBT) has the potential to make this evidence-based treatment more accessible while requiring less therapist time than traditional face-to-face (f2f) CBT. Data from six clinical trials suggest that ICBT for OCD is both efficacious and cost-effective, but whether ICBT is non-inferior to traditional f2f CBT for OCD is yet unknown.

METHODS AND ANALYSIS

A single-blind, randomised, controlled, non-inferiority trial comparing therapist-guided ICBT, unguided ICBT and individual (f2f) CBT for adult OCD patients. The primary objective is to investigate whether ICBT is non-inferior to gold standard f2f CBT. Secondary objectives are to investigate if ICBT is equally effective when delivered unguided, to establish the cost-effectiveness of ICBT and to investigate if the treatment outcome differs between self-referred and clinically referred patients. Participants will be recruited at two specialist OCD clinics in Stockholm and also through online self-referral. Participants will be randomised to one of three treatment conditions: F2f CBT, ICBT with therapist support or unguided ICBT. The total number of participants will be 120, and masked assessments will be administered at baseline, biweekly during treatment, at post-treatment and at 3-month and 12-month follow-ups. The main outcome measure is the clinician-rated Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at 3-month follow-up. The margin of non-inferiority is set to 3 points on the Y-BOCS using a 90% CI.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethics Board of Stockholm (REPN 2015/1099-31/2) and registered at Clinicaltrials.gov (NCT02541968). The study will be reported in accordance with the Consolidated Standards of Reporting Trials statement for non-pharmacological trials. The results will be published in peer-reviewed academic journals and disseminated to patient organisations and media.

TRIAL REGISTRATION NUMBER

NCT02541968; Pre-results.

Ten-year follow-up study of Japanese patients with obsessive-compulsive disorder

AIM

Obsessive-compulsive disorder (OCD) is a well-known chronic illness. This study retrospectively investigated 10-year outcomes and associated clinical factors in Japanese OCD patients. We focused on the impact of several sociocultural factors, including medical expenses and insurance systems specific to each country, on the differences or biases in follow-up procedures of OCD.

METHODS

Seventy-nine patients diagnosed with OCD who received a standardized combination of treatments for 10 continuous years were divided into three groups according to their improvement rates on the Yale-Brown Obsessive-Compulsive Scale after 10 years of treatment.

RESULTS

A survival analysis revealed that the rate of patients achieving full remission increased every year. Following 10 years of treatment, 56% of OCD patients experienced 'full remission' for at least 1 year. Consequently, 48% exhibited full remission, and 37% exhibited partial remission at the end-point of this study. We identified several factors that were predictive of poorer outcomes, including lower Global Assessment of Functioning Scale scores and the presence of hoarding symptoms or involvement behaviors. In addition, improvement rates after 1 year significantly predicted better 10-year outcomes.

CONCLUSION

Our findings highlight the transcultural nature of long-term outcomes of OCD treatment, which appear to be independent of sociocultural differences.

The Bergen 4-Day Treatment for Panic Disorder: A Pilot Study

The current article reports on the findings from a pilot treatment study on panic disorder (PD) with or without agoraphobia. Consecutively referred patients were included and treated with the Bergen 4-day treatment format. Twenty-nine patients were included, primarily from unsuccessful treatment courses in the Norwegian specialist mental health care system, either ongoing or previously. Prior to treatment, only 34% were able to work but at 3-month follow-up 93% were able to do so. The proportion achieving reliable change on the panic severity measure was 76% post-treatment and 90% at follow-up. The remission rate was 72% at both assessments. These effects are significantly higher than those reported for six standard CBT studies in the literature using the same primary outcome measure (Panic Disorder Severity Scale). It is concluded that the Bergen 4-day treatment is a promising treatment approach for PD, and a randomized controlled trial is warranted.

The Bergen 4-Day OCD Treatment Delivered in a Group Setting: 12-Month Follow-Up

The Bergen 4-day concentrated exposure treatment (cET) for obsessive-compulsive disorder (OCD) has proven highly acceptable; with practically no drop-out and a 6 month remission rate of nearly 70%. The aim of the present study was to evaluate long term gains of the approach, and to compare the results to findings from our recent meta-analysis. Sixty-nine of 95 patients consecutively referred to an outpatient clinic in the specialist health care, were offered the Bergen 4-day treatment. Among the 65 who initiated treatment, 60.0% were classified with "severe" to "extreme" OCD. None of the patients dropped-out during treatment. Independent Yale-Brown Obsessive-Compulsive Scale interviews were conducted post-treatment, and at 3- and 12-month follow-up. Using the international consensus criteria, 83.1% responded to treatment at 12-month follow-up, and 67.7% of patients were classified as recovered. Significant changes were also seen in depression, as measured by Patient Health Questionnaire-9, and in generalized anxiety, as measured by Generalized Anxiety Disorder-7 scale. A total of 89% of the patients rated the treatment as very good and 100% would recommend the treatment to a friend. Compared to results in a recent meta-analysis, the Bergen 4-day treatment is favorable in respect to attrition, response and 12-month recovery. In sum the Bergen 4-day treatment is a feasible way to deliver treatment for OCD, and the effects are stable at 12-month follow-up. Implications for dissemination are discussed.

A study of novel bilateral thermal capsulotomy with focused ultrasound for treatment-refractory obsessive-compulsive disorder: 2-year follow-up

BACKGROUND

Recently, a new thermal lesioning approach using magnetic-resonance-guided focused ultrasound (MRgFUS) was introduced for the treatment of neurologic disorders. However, only 2 studies have used this approach for treatment-refractory obsessive-compulsive disorder (OCD), and follow-up was short-term. We investigated the efficacy and safety of bilateral thermal lesioning of the anterior limb of the internal capsule using MRgFUS in patients with treatment-refractory OCD and followed them for 2 years.

METHODS

Eleven patients with treatment-refractory OCD were included in the study. Clinical outcomes were evaluated using the Yale-Brown Obsessive Compulsive Scale, the Clinical Global Impression scale (including improvement and severity), the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A) at 1 week and 1, 3, 6, 12 and 24 months following MRgFUS. Neuropsychological functioning, Global Assessment of Functioning and adverse events were also assessed.

RESULTS

After MRgFUS, Yale-Brown Obsessive Compulsive Scale scores decreased significantly across the 24-month follow-up period (mean ± standard deviation, 34.4 ± 2.3 at baseline v. 21.3 ± 6.2 at 24 months, p < 0.001). Scores on the Hamilton rating scales for depression and anxiety also significantly decreased from baseline to 24 months (HAM-D, 19.0 ± 5.3 v. 7.6 ± 5.3, p < 0.001; HAM-A, 22.4 ± 5.9 v. 7.9 ± 3.9, p < 0.001). Global Assessment of Functioning scores improved significantly (35.8 ± 4.9 at baseline v. 56.0 ± 10.3 at 24 months, p < 0.001) and Memory Quotient significantly improved, but other neuropsychological functions were unchanged. The side effects of MRgFUS included headache and vestibular symptoms, but these were mild and transient.

LIMITATIONS

The main limitations of this study were the small sample size and the open-label design.

CONCLUSION

Bilateral thermal lesioning of the anterior limb of the internal capsule using MRgFUS may improve obsessive-compulsive, depressive and anxiety symptoms in patients with treatment-refractory OCD, without serious adverse effects.

Internet-delivered cognitive behavioural therapy for young children with obsessive-compulsive disorder: development and initial evaluation of the BIP OCD Junior programme

BACKGROUND

Internet-delivered cognitive behavioural therapy (ICBT) is a promising approach for increasing access to evidence-based treatments.

AIMS

To develop and evaluate the feasibility and preliminary efficacy of an ICBT programme for young children with obsessive-compulsive disorder (OCD), named BIP OCD Junior.

METHOD

Eleven children aged 7-11 years were enrolled in a 12-week open trial of parent- and therapist-guided ICBT for OCD. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).

RESULTS

There was a significant improvement in OCD symptoms post-treatment, with a large within-group effect size on the CY-BOCS (Cohen's d = 1.86, 95% CI 0.83 to 2.86). Results were maintained at 3-month follow-up. Both children and parents rated the treatment as credible and were highly satisfied with the intervention.

CONCLUSIONS

BIP OCD Junior is a feasible and credible treatment option for young children with OCD. Randomised controlled trials are needed to further establish its efficacy and cost-effectiveness relative to gold standard face-to-face CBT.

DECLARATION OF INTEREST

None.

"Association splitting" versus cognitive remediation in obsessive-compulsive disorder: A randomized controlled trial

Studies have confirmed the efficacy of the cognitive intervention Association Splitting (AS) in obsessive-compulsive disorder (OCD) when applied as a self-help technique. AS aims to alter symptom-provoking automated cognitive networks of OC-related stimuli by building new or strengthening established but weak neutral associations. The aim of this study was to investigate the acceptance and benefits of therapist-assisted AS as an add-on to cognitive behavioral therapy (CBT). One hundred and nine patients with OCD who were undergoing CBT were randomly assigned to either AS or cognitive remediation (CR). Both groups were assessed at baseline, 4 weeks and 6 months later. The primary measure was the Yale-Brown Obsessive Compulsive Scale. Although patients' acceptance of AS was good, AS was not better than CR regarding overall symptom severity. However, a larger decrease was found from baseline to 6 months follow-up in AS regarding avoidance. Moreover, subsidiary analyses excluding control patients who had obtained information about AS indicated its superiority. Because superiority of AS was found in post hoc analyses excluding control patients who had obtained information on AS, we suggest that contagion effects deserve consideration.

Three-Week Inpatient Treatment of Obsessive-Compulsive Disorder: A 6-Month Follow-Up Study

Background: Specialized inpatient or residential treatment might be an alternative treatment approach for patients with obsessive-compulsive disorder (OCD) that do not respond satisfactorily to the standard outpatient treatment formats.

Method: The aim of this open trial was to investigate the 6-month effectiveness of a 3-week inpatient treatment of OCD, where exposure with response prevention (ERP) was the main treatment intervention. The sample consisted of 187 adult patients with OCD, all with previous treatment attempts for OCD.

Results: The sample showed significant reductions in symptoms of OCD and depression. The effect sizes were large for obsessive-compulsive symptoms and moderate to large for depressive symptoms. At discharge, 79.7% of the intent-to-treat (ITT) group were classified as treatment responders (≥35% reduction in Y-BOCS scores). However, some participants experienced relapse, as 61.5% of the ITT group were classified as treatment responders at 6-month follow-up. Antidepressant use appeared not to influence the outcome. Only pre-treatment levels of obsessive-compulsive symptoms emerged as a significant predictor of relapse.

Conclusion: The 3-week inpatient programme produced similar treatment effects as previous inpatient and residential studies of longer duration (2 – 3 months). The results suggest that patients with severe OCD can be treated efficiently using this brief inpatient format. However, better relapse prevention interventions are needed.

Brain serotonin synthesis capacity in obsessive-compulsive disorder: effects of cognitive behavioral therapy and sertraline

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are both effective treatments for some patients with obsessive-compulsive disorder (OCD), yet little is known about the neurochemical changes related to these treatment modalities. Here, we used positron emission tomography and the α-[¹¹C]methyl-L-tryptophan tracer to examine the changes in brain regional serotonin synthesis capacity in OCD patients following treatment with CBT or SSRI treatment. Sixteen medication-free OCD patients were randomly assigned to 12 weeks of either CBT or sertraline treatment. Pre-to-post treatment changes in the α-[¹¹C]methyl-L-tryptophan brain trapping constant, K* (ml/g/min), were assessed as a function of symptom response, and correlations with symptom improvement were examined. Responders/partial responders to treatment did not show significant changes in relative regional tracer uptake; rather, in responders/partial responders, 12 weeks of treatment led to serotonin synthesis capacity increases that were brain-wide. Irrespective of treatment modality, baseline serotonin synthesis capacity in the raphe nuclei correlated positively with clinical improvement. These observations suggest that, for some patients, successful remediation of OCD symptoms might be associated with greater serotonergic tone.

Prediction of outcome in internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A machine learning approach

BACKGROUND

There are no consistent predictors of treatment outcome in paediatric obsessive-compulsive disorder (OCD). One reason for this might be the use of suboptimal statistical methodology. Machine learning is an approach to efficiently analyse complex data. Machine learning has been widely used within other fields, but has rarely been tested in the prediction of paediatric mental health treatment outcomes.

OBJECTIVE

To test four different machine learning methods in the prediction of treatment response in a sample of paediatric OCD patients who had received Internet-delivered cognitive behaviour therapy (ICBT).

METHODS

Participants were 61 adolescents (12-17 years) who enrolled in a randomized controlled trial and received ICBT. All clinical baseline variables were used to predict strictly defined treatment response status three months after ICBT. Four machine learning algorithms were implemented. For comparison, we also employed a traditional logistic regression approach.

RESULTS

Multivariate logistic regression could not detect any significant predictors. In contrast, all four machine learning algorithms performed well in the prediction of treatment response, with 75 to 83% accuracy.

CONCLUSIONS

The results suggest that machine learning algorithms can successfully be applied to predict paediatric OCD treatment outcome. Validation studies and studies in other disorders are warranted.

Clinical effectiveness, cost-effectiveness and acceptability of low-intensity interventions in the management of obsessive-compulsive disorder: the Obsessive-Compulsive Treatment Efficacy randomised controlled Trial (OCTET)

BACKGROUND

The Obsessive-Compulsive Treatment Efficacy randomised controlled Trial emerged from a research recommendation in National Institute for Health and Care Excellence obsessive-compulsive disorder (OCD) guidelines, which specified the need to evaluate cognitive-behavioural therapy (CBT) treatment intensity formats.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of two low-intensity CBT interventions [supported computerised cognitive-behavioural therapy (cCBT) and guided self-help]: (1) compared with waiting list for high-intensity CBT in adults with OCD at 3 months; and (2) plus high-intensity CBT compared with waiting list plus high-intensity CBT in adults with OCD at 12 months. To determine patient and professional acceptability of low-intensity CBT interventions.

DESIGN

A three-arm, multicentre, randomised controlled trial.

SETTING

Improving Access to Psychological Therapies services and primary/secondary care mental health services in 15 NHS trusts.

PARTICIPANTS

Patients aged ≥ 18 years meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for OCD, on a waiting list for high-intensity CBT and scoring ≥ 16 on the Yale-Brown Obsessive Compulsive Scale (indicative of at least moderate severity OCD) and able to read English.

INTERVENTIONS

Participants were randomised to (1) supported cCBT, (2) guided self-help or (3) a waiting list for high-intensity CBT.

MAIN OUTCOME MEASURES

The primary outcome was OCD symptoms using the Yale-Brown Obsessive Compulsive Scale - Observer Rated.

RESULTS

Patients were recruited from 14 NHS trusts between February 2011 and May 2014. Follow-up data collection was complete by May 2015. There were 475 patients randomised: supported cCBT (n = 158); guided self-help (n = 158) and waiting list for high-intensity CBT (n = 159). Two patients were excluded post randomisation (one supported cCBT and one waiting list for high-intensity CBT); therefore, data were analysed for 473 patients. In the short term, prior to accessing high-intensity CBT, guided self-help demonstrated statistically significant benefits over waiting list, but these benefits did not meet the prespecified criterion for clinical significance [adjusted mean difference -1.91, 95% confidence interval (CI) -3.27 to -0.55; p = 0.006]. Supported cCBT did not demonstrate any significant benefit (adjusted mean difference -0.71, 95% CI -2.12 to 0.70). In the longer term, access to guided self-help and supported cCBT, prior to high-intensity CBT, did not lead to differences in outcomes compared with access to high-intensity CBT alone. Access to guided self-help and supported cCBT led to significant reductions in the uptake of high-intensity CBT; this did not seem to compromise patient outcomes at 12 months. Taking a decision-making approach, which focuses on which decision has a higher probability of being cost-effective, rather than the statistical significance of the results, there was little evidence that supported cCBT and guided self-help are cost-effective at the 3-month follow-up compared with a waiting list. However, by the 12-month follow-up, data suggested a greater probability of guided self-help being cost-effective than a waiting list from the health- and social-care perspective (60%) and the societal perspective (80%), and of supported cCBT being cost-effective compared with a waiting list from both perspectives (70%). Qualitative interviews found that guided self-help was more acceptable to patients than supported cCBT. Professionals acknowledged the advantages of low intensity interventions at a population level. No adverse events occurred during the trial that were deemed to be suspected or unexpected serious events.

LIMITATIONS

A significant issue in the interpretation of the results concerns the high level of access to high-intensity CBT during the waiting list period.

CONCLUSIONS

Although low-intensity interventions are not associated with clinically significant improvements in OCD symptoms, economic analysis over 12 months suggests that low-intensity interventions are cost-effective and may have an important role in OCD care pathways. Further research to enhance the clinical effectiveness of these interventions may be warranted, alongside research on how best to incorporate them into care pathways.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN73535163.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 37. See the NIHR Journals Library website for further project information.

Multivariate resting-state functional connectivity predicts response to cognitive behavioral therapy in obsessive-compulsive disorder

Cognitive behavioral therapy (CBT) is an effective treatment for many with obsessive-compulsive disorder (OCD). However, response varies considerably among individuals. Attaining a means to predict an individual's potential response would permit clinicians to more prudently allocate resources for this often stressful and time-consuming treatment. We collected resting-state functional magnetic resonance imaging from adults with OCD before and after 4 weeks of intensive daily CBT. We leveraged machine learning with cross-validation to assess the power of functional connectivity (FC) patterns to predict individual posttreatment OCD symptom severity. Pretreatment FC patterns within the default mode network and visual network significantly predicted posttreatment OCD severity, explaining up to 67% of the variance. These networks were stronger predictors than pretreatment clinical scores. Results have clinical implications for developing personalized medicine approaches to identifying individual OCD patients who will maximally benefit from intensive CBT.

Unified protocol for the discontinuation of long-term serotonin reuptake inhibitors in obsessive compulsive disorder: Study protocol and methods

Obsessive-compulsive disorder (OCD) is chronic psychiatric disorder associated with high rates of functional impairment and decreased quality of life. Although serotonin reuptake inhibitors have demonstrated efficacy in the treatment of OCD, little data is available to guide clinicians on how to manage these medications long-term. Cognitive-behavioral approaches provide a promising avenue for helping OCD patients discontinue maintenance SRIs while minimizing the potential for symptom worsening. This manuscript describes the rationale and methods for pilot feasibility study designed to a unified, cognitive-behavioral strategy for discontinuing long-term SRIs in OCD. The aims of the study are (1) to evaluate the feasibility and acceptability of research procedures and interventions, (2) to test the efficacy of this treatment relative to an enhanced control condition and (3) to investigate the role of distress tolerance in both taper completion and clinical outcome. Our central aim is to investigate whether this approach improves discontinue outcomes relative to an enhanced control condition. Identifying optimal long-term treatment strategies for this population is needed to guide clinicians managing this often-chronic disorder.

A randomized controlled study of brief family-based intervention in obsessive compulsive disorder

BACKGROUND

Cognitive behaviour therapy (CBT) for Obsessive Compulsive Disorder (OCD) is therapist-intensive and prolonged making it less accessible to patients, particularly in resource-constrained situations. We examined the efficacy of a brief psychotherapeutic intervention as an adjunct to serotonin reuptake inhibitors (SRIs) in OCD.

METHOD

We randomized 64 adult OCD patients stabilized on SRIs to either the 6-session brief family-based intervention (BFBI; n = 30) that included psychoeducation, exposure and response prevention and family intervention or to a control arm of relaxation exercises (RE). Assessments were conducted at baseline and at 1- and 3- months post-intervention. Primary outcome measure was response to treatment defined as ≥ 35% reduction in the Yale-Brown Obsessive Compulsive Scale total score relative to baseline score plus a Clinical Global Impression- Improvement rating of very much improved or much improved. Family accommodation and expressed emotions were also assessed.

RESULTS

At 3- month follow-up, the BFBI group responded better than the RE group (53% vs. 12%, p < 0.001). Illness severity, family accommodation and expressed emotion declined significantly over time in the BFBI group compared to the RE group. The BFBI (OR = 13.17, p < 0.001) and baseline illness severity (OR = 0.746, p < 0.011) predicted treatment response.

LIMITATIONS

Sample size was small and follow-up duration was short. Control group had less time with the therapist although number of sessions was identical in both the groups.

CONCLUSION

Briefer intervention is effective in treating OCD. Briefer and inclusive format of intervention has important implications for clinical practice in resource-constrained circumstances.

The Dimensional Obsessive-Compulsive Scale: Development and Validation of a Short Form (DOCS-SF)

Accurately and reliably measuring the presence and severity of Obsessive-Compulsive Disorder (OCD) symptoms is essential for both routine clinical work and research. The current study investigated psychometric properties of the dimensional obsessive-compulsive scale-short form (DOCS-SF). DOCS-SF was developed and validated in Norwegian. DOCS-SF contains a checklist with four symptom categories and five severity items scored on a zero to eight scale yielding a total score of 0–40. Data were collected from adults with a current diagnosis of OCD (n = 204) and a community comparison group (n = 211). The results provided evidence of internal consistency and convergent validity, although evidence for discriminant validity was mixed. Evidence was also found for diagnostic sensitivity and specificity, and treatment sensitivity. The analyses suggested a cut-off score of 16. In summary, the data obtained proved similar to studies published on the original dimensional obsessive-compulsive scale. There is strong evidence for the reliability and validity of the DOCS-SF for assessing OCD symptoms in individuals with this condition and in non-clinical individuals.

Clinical features associated with increased severity of illness in tertiary clinic referred patients with obsessive compulsive disorder

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition. Specific patterns of psychiatric comorbidity, early age at onset, long duration of illness (DI) and untreated illness (DUI) have been associated with poor outcome in OCD. The present study was aimed to explore sociodemographic and clinical characteristics associated with increased severity of illness in a sample of OCD patients.

METHODS

A total of 124 OCD outpatients were recruited and divided into two groups on the basis of their severity of illness, as assessed through the Yale-Brown Obsessive Compulsive Scale (>24). Chi-squared test and t-test for independent samples were performed to compare sociodemographic and clinical variables between the two groups.

RESULTS

The group with increased severity of illness had a younger age, an earlier age at onset and age at first pharmacological treatment (p < .05). In addition, the same group showed a longer DI but a shorter DUI (p < .01). Moreover, significantly higher rates of psychiatric comorbidities (p < .01) were observed in the higher severity group.

CONCLUSIONS

Earlier age, age at onset and age at first pharmacological treatment, longer DI, shorter DUI and higher rate of psychiatric comorbidities were associated with increased severity of OCD. Further studies on larger samples are warranted to confirm the reported results.

Cost-effectiveness of therapist-guided internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: results from a randomised controlled trial

OBJECTIVES

To evaluate the cost-effectiveness of a therapist-guided internet-delivered cognitive behaviour therapy (ICBT) intervention for adolescents with obsessive-compulsive disorder (OCD) compared with untreated patients on a waitlist.

DESIGN

Single-blinded randomised controlled trial.

SETTING

A research clinic within the regular child and adolescent mental health service in Stockholm, Sweden.

PARTICIPANTS

Sixty-seven adolescents (12-17 years) with a Diagnostic and Statistical Manual of Mental Disorders Fifth Edition diagnosis of OCD.

INTERVENTIONS

Either a 12-week, therapist-guided ICBT intervention or a wait list condition of equal duration.

PRIMARY OUTCOME MEASURES

Cost data were collected at baseline and after treatment, including healthcare use, supportive resources, prescription drugs, prescription-free drugs, school absence and productivity loss, as well as the cost of ICBT. Health outcomes were defined as treatment responder rate and quality-adjusted life years gain. Bootstrapped mixed model analyses were conducted comparing incremental costs and health outcomes between the groups from the societal and healthcare perspectives.

RESULTS

Compared with waitlist control, ICBT generated substantial societal cost savings averaging US$-144.98 (95% CI -159.79 to -130.16) per patient. The cost reductions were mainly driven by reduced healthcare use in the ICBT group. From the societal perspective, the probability of ICBT being cost saving compared with waitlist control was approximately 60%. From the healthcare perspective, the cost per additional responder to ICBT compared with waitlist control was approximately US$78.

CONCLUSIONS

The results suggest that therapist-guided ICBT is a cost-effective treatment and results in societal cost savings, compared with patients who do not receive evidence-based treatment. Since, at present, most patients with OCD do not have access to evidence-based treatments, the results have important implications for the increasingly strained national and healthcare budgets. Future studies should compare the cost-effectiveness of ICBT with regular face-to-face CBT.

TRIAL REGISTRATION NUMBER

NCT02191631.

Aripiprazole augmentation in highly treatment-resistant obsessive-compulsive disorder - experience from a specialty clinic in India

OBJECTIVE

To study the effectiveness and tolerability of aripiprazole augmentation in patients with highly treatment-resistant obsessive-compulsive disorder (OCD) in a real-world scenario.

METHODS

We conducted a chart review of patients who were initiated on aripiprazole augmentation at a specialty OCD clinic in India between 2004 and 2014. Primary outcome measure was all-cause discontinuation.

RESULTS

23 patients were eligible for analysis. Patients had not achieved symptom remission despite a mean of over 3 prior SRI trials. Aripiprazole was continued to be used in seven patients (30%) at the time of last follow-up. Thirteen patients (57%) discontinued the drug due to side effects, and three patients (13%) discontinued aripiprazole citing no improvement. Six patients (26%) were noted to have ≥25% reduction on the Yale-Brown Obsessive-Compulsive Scale.

CONCLUSIONS

The study demonstrated, in a real-world setting, that aripiprazole may be a useful augmenting agent in a proportion of patients with highly treatment-resistant OCD. However, side effects may lead to premature discontinuation in many of them.

Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale

The objective of the study was to examine the optimal Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction and raw cutoffs for predicting cognitive-behavioral treatment (CBT) response among children and adolescents with obsessive-compulsive disorder (OCD). The sample consisted of children and adolescents with OCD (N = 241) participating in the first step of the Nordic long-term OCD treatment study and receiving 14 weekly sessions of CBT in the form of exposure and response prevention. Evaluations were conducted pre- and post-treatment, included the CY-BOCS, Clinical Global Impressions-severity/improvement. The results showed that the most efficient CY-BOCS cutoffs were 35 % reduction for treatment response, 55 % reduction for remission, and a post-treatment CY-BOCS raw total score of 11 for treatment remission. Overall, our results diverge from previous research on pediatric OCD with more conservative cutoffs (higher cutoff reduction for response and remission, and lower raw score for remission). Further research on optimal cutoffs is needed.

Therapist-Guided, Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Obsessive-Compulsive Disorder: A Randomized Controlled Trial

OBJECTIVE

Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD.

METHOD

Sixty-seven adolescents (12-17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention.

RESULTS

In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = -4.53, z = -3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19-1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00-2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week.

CONCLUSION

Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases. Clinical trial registration information-Internet-Delivered CBT for Adolescents With OCD: A Randomized Controlled Study (BiPOCD); http://clinicaltrials.gov; NCT02191631.

What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa

BACKGROUND

Relapse after treatment for anorexia nervosa (AN) is a significant clinical problem. Given the level of chronicity, morbidity, and mortality experienced by this population, it is imperative to understand the driving forces behind apparently high relapse rates. However, there is a lack of consensus in the field on an operational definition of relapse, which hinders precise and reliable estimates of the severity of this issue. The primary goal of this paper was to review prior studies of AN addressing definitions of relapse, as well as relapse rates.

METHODS

Data sources included PubMed and PsychINFO through March 19th, 2016. A systematic review was performed following the PRISMA guidelines. A total of (N = 27) peer-reviewed English language studies addressing relapse, remission, and recovery in AN were included.

RESULTS

Definitions of relapse in AN as well as definitions of remission or recovery, on which relapse is predicated, varied substantially in the literature. Reported relapse rates ranged between 9 and 52%, and tended to increase with increasing duration of follow-up. There was consensus that risk for relapse in persons with AN is especially high within the first year following treatment.

DISCUSSION

Standardized definitions of relapse, as well as remission and recovery, are needed in AN to accelerate clinical and research progress. This should improve the ability of future longitudinal studies to identify clinical, demographic, and biological characteristics in AN that predict relapse versus resilience, and to comparatively evaluate relapse prevention strategies. We propose standardized criteria for relapse, remission, and recovery, for further consideration.

Cognitive behavioral and pharmacological treatments of OCD in children: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) is ranked by the World Health Organization (WHO) among the 10 most debilitating disorders. The treatments which have been found effective are cognitive behavior therapy (CBT) and serotonin reuptake inhibitors (SRI). This meta-analysis includes all RCTs of CBT (25) and SRI (9) for OCD in youth using the Children's Yale-Brown Obsessive Compulsive Scale (C-YBOCS). CBT yielded significantly lower attrition (12.7%) than SRI (23.5%) and placebo (24.7%). The effect sizes for comparisons of CBT with waiting-list (1.53), placebo (0.93), and SRI with placebo (0.51) were significant, whereas CBT vs. SRI (0.22) and Combo (CBT+SRI) vs. CBT (0.14) were not. Regarding response rate CBT (70%) and Combo (66%) were significantly higher than SRI (49%), which was higher than placebo (29%) and WLC (13%). As for remission CBT (53%) and Combo (49%) were significantly higher than SRI (24%), placebo (15%), and WLC (10%), which did not differ from each other. Combo was not more effective than CBT alone irrespective of initial severity of the samples. The randomized controlled trials (RCTs) have a number of methodological problems and recommendations for improving research methodology are discussed as well as clinical implications of the findings.