A meta-analysis of dropout rates from exposure with response prevention and pharmacological treatment for youth with obsessive compulsive disorder

High intensity approaches to exposure and response prevention for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with multidetermined etiological and maintaining mechanisms. Cognitive behavioral therapy (CBT), specifically exposure and response prevention (ERP), is the first line behavioral intervention to treat OCD. ERP directly targets threat learning that characterizes OCD through processes of habituation (fear extinction) and inhibitory learning, in addition to eliciting neuronal changes implicated in OCD. Although ERP has a strong evidence base, not all OCD patients respond fully to standard, weekly or twice-weekly outpatient ERP. High intensity ERP-treatment delivered through more and/or longer sessions in a condensed manner-is a potential alternative approach that has also demonstrated efficacy for adults and youth with OCD. The goal of this review article is to describe the nature, rationale, and evidence for high intensity ERP for OCD treatment. We describe the foundations of ERP for OCD, various formats of intensive ERP, clinical research on the efficacy of this approach including neuronal changes, and potential pharmacological and neurosurgical augmentation strategies. We conclude with limitations of the current literature on intensive approaches and recommendations for future directions. While additional research is needed, high intensity ERP may be a promising approach for patients who have not responded to standard ERP or for patients requiring rapid symptom improvement.

Intensive treatments for children and adolescents with anxiety or obsessive-compulsive disorders: A systematic review and meta-analysis

Anxiety and obsessive-compulsive disorders have a significant negative impact on youth. Cognitive behavioural therapy (CBT) is recommended and established as effective first-step treatment, but persistent symptoms and non-response are common. Intensive psychological treatments deliver more or longer sessions over a shorter time span, with fewer session gaps. However, an understanding of their effectiveness, characteristics, acceptability, and feasibility is lacking. Systematically searching five databases yielded four controlled and 36 uncontrolled studies (N=2707) involving youth with primary anxiety or obsessive-compulsive disorders, many of whom received prior treatments. Intensive treatments were acceptable and feasible, with low drop-out rates. Between-group analyses compared intensive treatment with standard treatment (k = 2) or waitlist (k = 2), revealing no significant post-treatment differences in symptom severity or remission. Uncontrolled within-group analyses of intensive treatments showed large improvements from pre- to post-treatment in symptoms (k = 47), remission (k = 17), impairment (k = 22), functioning (k = 5), and quality of life (k = 2), with larger effects at follow-ups. Intensive treatments show promise for youth with anxiety or obsessive-compulsive disorders by potentially offering high treatment completion rates and comparable outcomes to standard CBT, aiding earlier recovery and reducing overall suffering. This systematic review/meta-analysis provides a comprehensive overview of intensive treatments, their theoretical considerations, and empirical findings. Future RCTs should compare the effectiveness of standard and intensive treatments and identify optimal populations for their use.

Potential for Harm in the Treatment of Pediatric Obsessive-Compulsive Disorder: Pitfalls and Best Practices

Pediatric obsessive-compulsive disorder (OCD) can be debilitating and chronic unless treated early with efficacious intervention. The past several decades of intervention research have identified cognitive-behavioral therapy (CBT) with exposure and response/ritual prevention (ERP) as the first-line, evidence-based psychological intervention for pediatric OCD. Yet, many youths with OCD unfortunately remain inadequately treated. In well-meaning but misguided efforts to treat this complex disorder, clinicians holding misconceptions about ERP may fail to apply evidence-based treatments, misapply generic CBT techniques and ERP principles, or turn to non-evidence-based interventions. Potentially harmful treatments may worsen symptoms, while ineffective treatments can waste resources, impede patient access to efficacious treatment, and weaken public confidence in psychotherapy. The overarching goals of this review paper are to describe potentially harmful and ineffective practices in the treatment of pediatric OCD and to offer recommendations aligned with evidence-based practice. First, we dispel common misconceptions about ERP that may underlie its underuse among clinicians. We then describe potentially harmful and ineffective interventions for pediatric OCD, starting with misapplication of generic CBT techniques and ERP principles. We also identify non-evidence-based treatments for pediatric OCD that have limited conceptual or empirical foundations. Finally, we conclude with recommendations for clinicians who treat pediatric OCD, intervention researchers, training programs across mental health-related disciplines, and policymakers.

Efficacy and acceptability of cognitive-behavioral therapy and serotonin reuptake inhibitors for pediatric obsessive-compulsive disorder: a network meta-analysis

BACKGROUND

Cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) are recommended treatments for pediatric obsessive-compulsive disorder (OCD), but their relative efficacy and acceptability have not been comprehensively examined. Further, it remains unclear whether the efficacy of in-person CBT is conserved when delivered in other formats, such as over telephone/webcam or as Internet-delivered CBT (ICBT).

METHODS

PubMed, PsycINFO, trial registries, and previous systematic reviews were searched for randomized controlled trials (RCTs) comparing CBT (in-person, webcam/telephone-delivered, or ICBT) or SRIs with control conditions or each other. Network meta-analyses were conducted to examine efficacy (post-treatment Children's Yale-Brown Obsessive Compulsive Scale) and acceptability (treatment discontinuation). Confidence in effect estimates was evaluated with CINeMA (Confidence in Network Meta-Analysis).

RESULTS

Thirty eligible RCTs and 35 contrasts comprising 2,057 youth with OCD were identified. In-person CBT was significantly more efficacious than ICBT, waitlist, relaxation training, and pill placebo (MD range: 3.95-11.10; CINeMA estimate of confidence: moderate) but did not differ significantly from CBT delivered via webcam/telephone (MD: 0.85 [-2.51, 4.21]; moderate), SRIs (MD: 3.07 [-0.07, 6.20]; low), or the combination of in-person CBT and SRIs (MD: -1.20 [-5.29, 2.91]; low). SRIs were significantly more efficacious than pill placebo (MD: 4.59 [2.70, 6.48]; low) and waitlist (MD: 8.03 [4.24, 11.82]; moderate). No significant differences for acceptability emerged, but confidence in estimates was low.

CONCLUSIONS

In-person CBT and SRIs produce clear benefits compared to waitlist and pill placebo and should be integral parts of the clinical management of pediatric OCD, with in-person CBT overall having a stronger evidence base. The combination of in-person CBT and SRIs may be most efficacious, but few studies hinder firm conclusions. The efficacy of CBT appears conserved when delivered via webcam/telephone, while more trials evaluating ICBT are needed.

Unwanted outcomes in cognitive behavior therapy for pathological health anxiety: a systematic review and a secondary original study of two randomized controlled trials

INTRODUCTION

Cognitive behavior therapy (CBT) is effective for pathological health anxiety, but little is known about unwanted outcomes.

AREAS COVERED

We investigated unwanted outcomes in the form of adverse events, overall symptom deterioration, and dropouts in CBT for pathological health anxiety based on a systematic review of 19 randomized controlled trials (PubMed, PsycInfo, and OATD; last updated 2 June 2023; pooled N = 2188), and then a secondary original study of two randomized controlled trials (pooled N = 336). In the systematic review, 10% of participants in CBT reported at least one adverse event and 17% dropped out. Heterogeneity was substantial. In the original investigation, 17% reported at least one adverse event, 0-10% met criteria for overall symptom deterioration, and 10-19% dropped out. In guided Internet-delivered CBT, dropouts were more common with lower education and lower credibility/expectancy ratings. Higher adherence was associated with a larger reduction in health anxiety.

EXPERT OPINION

Unwanted effects are routinely seen in CBT for pathological health anxiety, but, under typical circumstances, appear to be acceptable in light of the treatment's efficacy. There is a need for more consistent methods to improve our understanding adverse events, dropouts, and overall symptom deterioration, and how these outcomes can be prevented.

Parent Management Training Augmentation to Address Coercive and Disruptive Behavior in Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder

Coercive and disruptive behaviors commonly interfere with cognitive-behavioral therapy (CBT) trials among youths with obsessive-compulsive disorder (OCD). Although evidence supports parent management training (PMT) for reducing disruptive behavior, no group-based PMT interventions exist for OCD-related disruptive behaviors. We studied feasibility and effectiveness of group-based adjunctive PMT among non-randomized, OCD-affected families receiving family-based group CBT. Linear mixed models estimated treatment effects across OCD-related and parenting outcomes at post-treatment and 1-month follow-up. Treatment response for 37 families receiving CBT + PMT (M_age = 13.90) was compared to 80 families receiving only CBT (M_age = 13.93). CBT + PMT was highly accepted by families. Families who received CBT + PMT had improved disruptive behaviors, parental distress tolerance, and other OCD-related outcomes. OCD-related outcomes did not significantly differ between groups. Results support CBT + PMT as effective treatment for pediatric OCD that may not provide incremental benefits beyond CBT alone. Future research should determine feasible and effective ways to incorporate key PMT components into CBT-based interventions.

Efficacy of exposure and response prevention therapy in mixed reality for patients with obsessive-compulsive disorder: study protocol for a randomized controlled trial

Many patients with obsessive-compulsive disorder (OCD) do not receive cognitive behavioral therapy with exposure and response prevention (first line treatment for OCD), for example, due to patients' fear of the exposure and reservations of the therapists. Technology-supported exposure (e.g., exposure therapy with response prevention in mixed reality [MERP]) for patients with OCD may help to overcome this obstacle. Building upon findings of our pilot study objectives of this study are to evaluate the efficacy, expectations of treatment success, feasibility, and acceptance of MERP as well as to identify possible limitations. In total, 64 outpatients with contamination-related OCD will be recruited and randomized to one of two conditions: MERP (six sessions in six weeks) and self-guided exposure therapy (six exercises in six weeks). Participants will be assessed before (baseline), after the six-week intervention period (post), as well as three months after post assessment (follow-up) regarding symptomatology (Yale-Brown Obsessive Compulsive Scale; Y-BOCS), their subjective evaluation of MERP (acceptance) and sense of presence. The planned study is the first to investigate MERP in patients with OCD.

Things that make you go Hmm: Myths and misconceptions within cognitive-behavioral treatment of obsessive-compulsive disorder

The past four decades have yielded a robust body of evidence supporting the efficacy and effectiveness of cognitive-behavioral therapy (CBT) as a gold-standard treatment for obsessive-compulsive disorder (OCD) across the lifespan. Exposure and response prevention (E/RP) has been identified as a key component of this approach. Despite robust research support for CBT with E/RP, several myths and misconceptions continue to proliferate in both research and practice settings. Such myths and misconceptions are concerning, as they lack empirical basis, may hinder widespread dissemination and implementation of CBT for OCD, and run contrary to the practice of evidence-based psychological medicine. Focusing on the importance of promoting evidence-based practice and generative clinical science, the present review article synthesizes relevant research within the field of treatments for OCD to address the following myths / misconceptions: (a) uncertainty exists concerning the evidence base supporting CBT for OCD, (b) E/RP attrition and dropout rates are unacceptably high due to excessive risk and perceived patient intolerability, and (c) alternative treatments for OCD need to be expeditiously developed due to major limitations of E/RP. Recommendations for future research and clinical dissemination and implementation to further advance a generative clinical science of OCD treatment are discussed.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by the presence of debilitating obsessions and compulsions. Cognitive and behavioral models of OCD provide a strong theoretic and empirical foundation for informing effective psychotherapeutic treatment. Cognitive-behavioral therapy (CBT) for OCD, which includes a deliberate emphasis on exposure and response/ritual prevention, has consistently demonstrated robust efficacy for the treatment of pediatric and adult OCD and is the front-line psychotherapeutic treatment for OCD. Two case vignettes describing CBT for OCD in practice as well as recommendations for clinicians are provided.

Comparative effectiveness of cognitive behavioral treatment, serotonin, and serotonin noradrenaline reuptake inhibitors for anxiety in children and adolescents: a network meta-analysis

AIM

Cognitive behavioral treatment (CBT) and selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for childhood anxiety disorders (ADs). The objective of this current analysis was to conduct a network meta-analysis to evaluate the comparative effectiveness of CBT, pharmacotherapy, and the combination of the two in treating pediatric ADs.

METHODS

The studies included consisted of randomized controlled trials evaluating non-selective serotonin reuptake inhibitors (e.g. clomipramine), SSRIs, selective noradrenaline reuptake inhibitors, CBT, or a combination of CBT and pharmacotherapy. Studies were eligible for inclusion if participants were 18 years or younger.

RESULTS

A total of 86 studies were included, with a total of 7594 participants, of which 41.51% were females. For remission, all three treatments were significantly more effective than both placebo (ORs ranging from 0.07 and 0.18) and wait-list (ORs ranging from 0.06 and 0.16). In terms of the severity of anxiety symptoms, all treatment forms were significantly more effective for reducing anxiety than wait-list (standardized mean differences (SMDs) ranging from 0.98 and 2.91). Only pharmacotherapy was significantly more effective in reducing anxiety symptoms than placebo (SMD = 2.01, 95% confidence interval, 1.02 to 3.01). Overall, the results demonstrate that CBT, pharmacotherapy, and their combination are effective treatments for childhood ADs. There was no significant difference between the three treatment forms. However, CBT was associated with lower attrition rates.

CONCLUSION

CBT, pharmacotherapy, and the combination of the two should all be considered to treat youths with ADs. However, potential risks and benefits should be considered before devising a treatment plan.

The effect of exposure and response prevention therapy on obsessive-compulsive disorder: A systematic review and meta-analysis

This meta-analysis mainly examined the effect size of exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) when compared with different control conditions, and the difference in the efficacy of different variants of ERP in the treatment of OCD. Thirty studies were included, involving 39 randomized controlled trials with 1793 participants, from 30 studies up to January 18, 2022. Hedge's g was calculated using random-effects models. The results showed that ERP had a definite effect on OCD (g = 0.37), and its effect was significant when the control condition was placebo (g = 0.97) or drug (g = 0.59). However, ERP did not show statistical differences with other therapies in improving OCD (g = -0.07). In addition, we found that both therapist and self-controlled exposure (at the same time as the therapist controls, self-control is exercised after the therapy session) and total response prevention can better improve OCD symptoms. In addition, compared with the control group, ERP reduced depression (g = 0.15) and anxiety symptoms (g = 0.23) in patients with OCD. Meta-regression results showed that the longer the length of sessions, the better the treatment effect (t = 2.41, p = 0.022).

Mindfulness-based psychotherapy in patients with obsessive-compulsive disorder: A meta-analytical Study

Background/Objective

Obsessive compulsive disorder is a disorder of special relevance in mental health, however, not all patients respond adequately to traditional intervention systems. The present work aims to study the usefulness of mindfulness-based interventions in patients with obsessive compulsive disorder.

Method

An exhaustive search of the literature between 1996 and 2021 allowed us to locate 11 published articles. The effect size was the pretest-posttest standardized mean change calculated for obsession-compulsion, as well as depression symptoms and conscious coping.

Results

he results showed mean effect sizes for mindfulness in the reduction of obsessive-compulsive symptoms (d + = 0.648) and, to a lesser extent, depression (d + = 0.417) and the improvement in Mindfull coping (d + = 0.509). There was no significant decrease in effect size when mindfulness was applied in patients with residual symptoms from previous treatments.

Conclusions

These results are promising regarding the usefulness of the application of intervention programs based on mindfulness in people with obsessive compulsive disorder, both as an alternative option and as a complementary treatment to more traditional intervention formats.

A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people

Background

Cognitive Behavioural Therapy (CBT) is the gold standard intervention for anxiety and related mental health disorders among young people; however, the efficacy of individual elements of CBT (e.g., exposure to feared stimuli) have received little scrutiny.

Aims

This scoping review, informed by three stakeholder groups and a scientific advisory group, aimed to identify the nature and extent of the available research literature on the efficacy of exposure to feared stimuli, moderators of effectiveness in young people aged 14-24 years.

Method

Three international stakeholder groups composed of clinicians (N = 8), parents/carers (N = 5) and youth with lived experience of anxiety (N = 7) provided input into study design and results. Using the PRISMA extension for scoping reviews, a search of MEDLINE/Ovid, PsycINFO, PubMed, CINAHL, SCOPUS, EMBASE, ERIC, and Health Collection (informit) was conducted using terms related to anxiety, ages 14-24, and exposure.

Results

From 3508 unique abstracts, 64 papers were included for the review. While there was evidence for the efficacy of exposure as a treatment for youth anxiety disorders, fundamental gaps in knowledge of exposure in this age group were identified. Most studies examined post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias with no randomised clinical trials uniquely evaluating exposure for the treatment of DSM-5 anxiety disorders. Exposure was typically delivered accompanied by other anxiety management techniques. A multitude of optimisation strategies have been tested, yet only one of these effects (timing relative to sleep) showed preliminary evidence of replication.

Conclusions

A systematic and theoretically driven program of research investigating the efficacy of exposure in young people and factors that moderate its efficacy, along with methods to overcome barriers for delivery, is urgently needed.

Co-occurring OCD and Panic Disorder: A Review of Their Etiology and Treatment

Estimated rates of co-occurrence between obsessive and compulsive disorder (OCD) and panic disorder (PD) are notable, but vary considerably, with rates from epidemiological and clinical studies ranging from 1.8% to 22% (Rector et al., 2017). We reviewed the current empirical literature on the etiology, treatment, diagnostic assessment, and differential diagnosis of co-occurring OCD/PD. Best practices for cognitive-behavioral treatment, including identifying and addressing treatment barriers are also addressed. Although it is acknowledged in current literature that co-occurring OCD and PD levels may be clinically significant, there remains a need to thoroughly examine the possible consequences and future research directions of this overlap. Future research must continue to elucidate the biological and environmental causes of OCD/PD co-occurrence.

Fear conditioning and extinction in obsessive-compulsive disorder: A systematic review

Laboratory experiments using fear conditioning and extinction protocols help lay the groundwork for designing, testing, and optimizing innovative treatments for anxiety-related disorders. Yet, there is limited basic research on fear conditioning and extinction in obsessive-compulsive disorder (OCD). This is surprising because exposure-based treatments based on associative learning principles are among the most popular and effective treatment options for OCD. Here, we systematically review and critically assess existing aversive conditioning and extinction studies of OCD. Across 12 studies, there was moderate evidence that OCD is associated with abnormal acquisition of conditioned responses that differ from comparison groups. There was relatively stronger evidence of OCD's association with impaired extinction processes. This included multiple studies finding elevated conditioned responses during extinction learning and poorer threat/safety discrimination during recall, although a minority of studies yielded results inconsistent with this conclusion. Overall, the conditioning model holds value for OCD research, but more work is necessary to clarify emerging patterns of results and increase clinical translational utility to the level seen in other anxiety-related disorders. We detail limitations in the literature and suggest next steps, including modeling OCD with more complex conditioning methodology (e.g., semantic/conceptual generalization, avoidance) and improving individual-differences assessment with dimensional techniques.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

Impact of the COVID-19 pandemic on exposure and response prevention outcomes in adults and youth with obsessive-compulsive disorder

The COVID-19 pandemic has created novel mental health challenges for those with pre-existing problems including obsessive-compulsive disorder (OCD). Our study reports on clinician perceptions regarding the effect of the COVID-19 pandemic on patients with OCD receiving exposure and response prevention treatment (ERP) prior to and during the pandemic. Participating clinicians completed a survey which included questions adapted from National Institute of Mental Health-Global Obsessive-Compulsive Scale (NIMH-GOCS) and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Clinicians rated clinical features at treatment initiation, just prior to the pandemic, and mid-pandemic (July/August, 2020). Findings suggest that the COVID-19 pandemic was associated with attenuation of ERP progress from expected rates in most patients during first several months of the pandemic; clinicians estimated that 38% of their patients had symptoms worsen during the pandemic and 47% estimated that symptoms remained unchanged despite participating in ERP. Those who endured financial distress or were medically at-risk for severe COVID-19 disease had worse ERP course. Adults also had a worse ERP course during than pandemic than youth. Further research is needed to better understand the effect of the COVID-19 pandemic on OCD symptomatology and treatment trajectory post-pandemic.

Effects of Treatment Setting on Outcomes of Flexibly-Dosed Intensive Cognitive Behavioral Therapy for Pediatric OCD: A Randomized Controlled Pilot Trial

Introduction: Optimizing individual outcomes of cognitive-behavioral therapy (CBT) remains a priority. Methods: Youth were randomized to receive intensive CBT at a hospital clinic (n = 14) or within their home (n = 12). Youth completed 3 × 3 h sessions (Phase I) and up to four additional 3-h sessions as desired/needed (Phase II). An independent evaluator assessed youth after Phase I, Phase II (when applicable), and at 1- and 6-months post-treatment. A range of OCD-related (e.g., severity, impairment) and secondary (e.g., quality of life, comorbid symptoms) outcomes were assessed. Results: Families' satisfaction with the treatment program was high. Of study completers (n = 22), five youth (23%) utilized no Phase II sessions and 9 (41%) utilized all four (Median Phase II sessions: 2.5). Large improvements in OCD-related outcomes and small-to-moderate benefits across secondary domains were observed. Statistically-significant differences in primary outcomes were not observed between settings; however, minor benefits for home-based treatment were observed (e.g., maintenance of gains, youth comfort with treatment). Discussion: Intensive CBT is an efficacious treatment for pediatric OCD. Families opted for differing doses based on their needs. Home-based treatment, while not substantially superior to hospital care, may offer some value, particularly when desired/relevant. Clinical Trial Registration: www.ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03672565, identifier: NCT03672565.

Little Doubt That CBT Works for Pediatric OCD

We write with great concern in response to the recent systematic review and meta-analysis of cognitive-behavioral therapy (CBT) in pediatric obsessive-compulsive disorder (OCD) by Uhre et al.¹ Although the authors' results consistently support the clinical efficacy of CBT for pediatric OCD, we expect that, much like ourselves, readers will be confused by the discordant and inappropriate conclusions that they put forward. These conclusions stem from the authors' application and interpretation of their particular qualitative methods, which could lead important stakeholders (eg, parents, patients, clinicians, and payers) to wrongly discount clear evidence for what is known to be the best evidence-based therapy for pediatric OCD.