Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder

Obsessive-Compulsive Disorder in Children and Adolescents

Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions.

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.

Secondary outcomes of enhanced cognitive behavioral therapy (eCBT) for children and adolescents with obsessive-compulsive disorder

Background

Obsessive-compulsive disorder (OCD) is a debilitating mental health condition usually presenting with a high degree of comorbid symptoms in the majority of cases. Although face-to-face cognitive-behavioral therapy (CBT) is considered the therapeutic golden standard for pediatric OCD, its accessibility, availability, and consistency in delivery are still limited. To address some of these challenges, an enhanced CBT (eCBT) package was created and introduced. This study explored eCBT's broad-based impact on OCD-related comorbid symptoms, functional impairment, quality of life and family accommodation among youth with OCD.

Methods

This open trial involved 25 pediatric patients with OCD (7-17 years), assessed between January 2018 to February 2020. All patients received eCBT for 14 weeks. Secondary outcomes were assessed at baseline, post-treatment, and 3-, 6-, and 12-month follow-up co-occurring symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ), Screen for Child Anxiety-Related Emotional Disorders (SCARED), and Mood and Feelings Questionnaire (MFQ). Quality of life was measured using the KINDL-R, functional impairment through the Child Obsessive-Compulsive Impact Scale Revised (COIS-R), and family accommodation by the Family Accommodation Scale (FAS). Linear mixed-effects models were applied to analyze treatment effects.

Results

Results indicated a significant decrease in OCD-related comorbid symptoms post-treatment, with SDQ mean reduce of 3.73 (SE = 1.10, child) and 4.14 (SE = 1.19, parent), SCARED mean reduce of 10.45 (SE = 2.52, child) and 8.40 (SE = 2.82, parent), MFQ mean reduce of 3.23 (SE = 1.11, child) and 2.69 (SE = 1.18, parent). Family accommodation declined with clinician scored FAS mean reduction of 13.25 (SE = 2.31). Quality-of-Life improved significantly post-treatment, with KINDL mean increase of 8.15 (SE = 2.87, children), and 10.54 (SE = 3.07, parents). These positive improvements were further amplified at the 3-month follow-up and remained consistent at the 12-month follow-up.

Conclusion

A significant reduction was observed in all secondary outcomes employed and OCD-related functional impairments from baseline to post-treatment, which was maintained through 12-month follow-up. These results imply that after receiving eCBT, children and adolescents experienced substantial decrease in the negative impacts of OCD-related symptoms on their daily life, including home, school, and social interactions.

Obsessive-compulsive disorder among individuals of Hispanic and Latin American ancestry: Cultural considerations for assessment and psychotherapy

Research specific to obsessive-compulsive disorder (OCD) among individuals of Hispanic and Latin American (H/L) ancestry is limited, as are culturally relevant assessment and treatment recommendations. This article discusses the implications of underrepresentation of H/L populations in OCD research and emphasizes the need to consider issues related to assessment, treatment, and structural barriers that hinder delivery of culturally appropriate first-line psychotherapy. Recommendations for assessment and treatment are provided to aid clinicians in distinguishing culturally normative thoughts and behaviors from OCD, as well as to inform the implementation of psychotherapeutic interventions with cultural humility. This manuscript offers recommendations for future research to tackle health equity concerns with respect to assessment and treatment and structural factors limiting access to culturally appropriate psychotherapy. Wide-scale efforts are needed to comprehensively understand how H/L cultures intersect with various OCD presentations and to further disseminate treatments to populations that have historically lacked access to mental health care.

eCBT Versus Standard Individual CBT for Paediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by recurring obsessions and compulsions often with severe impairment affecting 1-3% of children and adolescents. Cognitive behavioural therapy (CBT) is the therapeutic golden standard for paediatric OCD. However, face-to-face CBT is limited by accessibility, availability, and quality of delivery. Enhanced CBT (eCBT) a combination of face-to-face sessions at the clinic and treatment at home via webcam and a supportive app system aims to address some of these barriers. In this pilot study, we compared eCBT outcomes of 25 paediatric patients with OCD benchmarked against traditional face-to-face CBT (n = 269) from the Nordic Long-term OCD Treatment Study, the largest paediatric OCD CBT study to date. Pairwise comparisons showed no difference between eCBT and NordLOTS treatment outcomes. Mean estimate difference was 2.5 in favour of eCBT (95% CI - 0.3 to 5.3). eCBT compared to NordLOTS showed no significant differences between response and remission rates, suggesting similar effectiveness.

Effectiveness of videoconference-delivered psychotherapy for children, adolescents, and their parents: A meta-analysis of randomized controlled trials

INTRODUCTION

Over the last years, videoconference-delivered psychotherapy (VCP) has found its way into clinical practice. This meta-analysis is the first to evaluate the effectiveness of VCP for children and adolescents with a mental disorder and their parents.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) that compared the effectiveness of VCP for youths with a mental disorder to a control condition. Twelve studies were included. Two reviewers independently extracted data and rated study quality.

RESULTS

Effect size estimates for measures of children's symptoms of mental disorders were large for comparison between VCP and waitlist (posttreatment: Hedges's g = -1.26, k = 5) and negligible for comparisons between VCP and in-person treatment (posttreatment: g = 0.00, k = 6; follow-up: g = -0.05, k = 3). Similarly, effect size estimates for measures of children's functional impairments were large for comparison between VCP and waitlist (posttreatment: g = -1.10, k = 3) and negligible for comparisons between VCP and in-person treatment (posttreatment: g = -0.23, k = 3; follow-up: g = 0.04, k = 2). VCP more effectively reduced symptoms in children with an internalizing disorder (g = -0.88, k = 5) compared to externalizing disorders (g = 0.25, k = 2) or tic disorders (g = -0.08, k = 3).

DISCUSSION

The results provide preliminary evidence that VCP is an effective treatment for youths with a mental disorder and their parents. VCP was equally effective as in-person treatment in reducing children's symptoms and functional impairments. Limitations include the limited number of RCTs and incomplete reporting of methodological features.

Online versus in-person delivery of cognitive behaviour therapy for obsessive compulsive disorder: An examination of effectiveness

Cognitive behavioural therapy (CBT) including exposure and response prevention is the first-line psychological treatment for obsessive compulsive disorder (OCD). Given changes in the clinical landscape, there are increasing efforts to evaluate its effectiveness in online contexts. Mirroring the traditional in-person delivery, few studies have assessed the role of therapist-guided, manual-based CBT for OCD delivered in real-time via videoconferencing methods. The present study sought to fill this gap by comparing in-person and online delivery of group-based CBT for the treatment of OCD. A convenience sample of participants with moderate to severe OCD (n = 144) were recruited from a naturalistic database from two large OCD specialty assessment and treatment centres. Patients received group-based CBT that was provided in-person (pre-COVID-19 pandemic; March 2018 to March 2020) or online via videoconferencing (during the COVID-19 pandemic; March 2020 to April 2021). In both delivery methods, treatment consisted of 2-h weekly sessions led by trained clinicians. Analyses revealed that, regardless of treatment modality, both in-person and online groups demonstrated significant, reliable, and statistically equivalent improvements in OCD symptoms post-treatment. Videoconferenced, clinician-led CBT may be a promising alternative to in-person delivery for those with moderate to severe OCD symptoms.

The REThink Online Therapeutic Game: A Usability Study

BACKGROUND

Children and adolescents' help-seeking behaviors are often limited by fear, uncertainty, and stigma, as well as challenges with finding the right intervention, help, and a lack of familiarity with the process. A promising direction for the development of therapeutic interventions targeted at children is embedding them into gamified interventions, known as therapeutic or serious games. The aim of this paper is to describe the protocol of the beta REThink therapeutic game and to evaluate the usability of the game in a sample of children and adolescents.

METHODS

The study was delivered in schools, where 137 children and adolescents aged between 9 and 16 years old played the levels of the REThink game, followed by filling in the usability questionnaire.

FINDINGS

The results show above average evaluations for all levels of the game, for every dimension evaluated, namely presence/immersion, enjoyment, learning effectiveness, narratives, goal clarity, adequacy of learning material, and motivation. This study contributes to the literature on the usability of cognitive behavioral therapy-based therapeutic games for improvements in the emotion regulation abilities of children and adolescents, which can guide researchers interested in testing the REThink game in different protocols, as well to encourage its use by mental health specialists and parents.

Promoting OCD WEllness and resilience (POWER) study: Rationale, design, and methods

Obsessive-compulsive disorder (OCD) affects 1-2% of children and is associated with functional impairment and diminished quality of life. Several treatments are efficacious: cognitive behavioral therapy (CBT) with exposure and response prevention, serotonin reuptake inhibitor (SRI) monotherapy, and combined treatment (SRI + CBT). Expert clinician-informed practice parameters suggest that youth with mild to moderate OCD should be treated initially with CBT yet SRIs are frequently employed as the first-line intervention or in combination with psychotherapy in applied practice. Empirical data to guide SRI discontinuation in pediatric OCD are very limited. This study, Promoting OCD Wellness and Resiliency (POWER), aims to address this gap through a two phase, double-blinded, placebo-controlled, randomized controlled non-inferiority trial with the purpose of evaluating whether youth with OCD on an SRI can discontinue their medication after successful CBT augmentation and maintain wellness for a period of 24 weeks during which they receive maintenance CBT that models standard-of-care. In this paper we describe the rationale and methodological design of the POWER study.

To Proceed Via Telehealth or Not? Considerations for Pediatric Anxiety and Related Disorders Beyond COVID-19

The COVID-19 pandemic accelerated a widespread shift to telehealth among mental health professionals to prioritize both providers' and clients' safety. Telehealth is likely here to stay; however, there is limited practical guidance for clinicians about how to make decisions regarding who should proceed with care via telehealth versus in-person. There also is virtually no data on the effectiveness of hybrid approaches to care; yet this can be an attractive option with potential clinical benefit. This paper provides practice-informed guidance to support shared clinical decision-making between clinicians and families to decide whether to engage in therapy services in-person or via telehealth. We specifically focus on decision-making guidance relevant for youth with anxiety or related disorders, given the unique implications of telehealth for these youth. Guided by the three-legged stool of evidence-based practice, we discuss how clinicians can use principles of shared decision-making to inform clinical recommendations about treatment modality.

Clinical Considerations for an Evidence-Based Assessment for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an impairing mental health disease, generally beginning in childhood, affecting up to ∼3% of the population. Using evidence-based assessments (EBAs) is the starting point for the accurate diagnosis and treatment of OCD. EBAs consist of structured and semistructured clinician-administered interviews, parent-report and child-report, and self-report for adults. This article details the practical application, psychometric properties, and limitations of available assessments to determine the presence of OCD and evaluate OCD symptom severity. The following reviews measurement of constructs relevant to OCD (ie, insight, family accommodation, impairment) and details considerations for best clinical interview practices.

Development of a protocol for videoconferencing-based exposure and response prevention treatment of obsessive-compulsive disorder during the COVID-19 pandemic

BACKGROUND

The existing literature indicates that psychotherapeutic treatment, especially exposure and response prevention (ERP) is efficacious in treating obsessive-compulsive disorder (OCD). The coronavirus disease 2019 pandemic adversely impacted many patients with OCD and disrupted their usual treatment. Moreover, the pandemic forced a global switch to telemental health (TMH) services to maintain the standards and continuity of care. Consequently, clinicians are increasingly using TMH-based psychotherapeutic treatments to treat OCD. However, several challenges have made it difficult for them to implement these treatments in the changed circumstances imposed by the pandemic.

AIM

To describe the formulation, implementation, feasibility, and usefulness of videoconferencing-based ERP (VC-ERP) treatment for OCD during the coronavirus disease 2019 pandemic.

METHODS

This prospective, observational study was conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (July 2020-June 2021). All patients with OCD were assessed using the home-based TMH services of the department. The VC-ERP protocol for OCD was the outcome of weekly Zoom meetings with a group of clinicians involved in administering the treatment. After a systematic evaluation of the available treatment options, an initial protocol for delivering VC-ERP was developed. Guidelines for clinicians and educational materials for patients and their families were prepared. The protocol was implemented among patients with OCD attending the TMH services, and their progress was monitored. The weekly meetings were used to upgrade the protocol to meet the needs of all stakeholders. Feasibility and efficacy outcomes were examined.

RESULTS

All patients were diagnosed with OCD as a primary or a comorbid condition according to the International Classification of Diseases, 10^th version criteria. Out of 115 patients who attended the services during the study period, 37 were excluded from the final analysis. Of the remaining 78 patients, VC-ERP was initiated in 43 patients. Six patients dropped out, and three were hospitalized for inpatient ERP. Eleven patients have completed the full VC-ERP treatment. One patient completed the psychoeducation part of the protocol. VC-ERP is ongoing in 22 patients. The protocol for VC-ERP treatment was developed and upgraded online. A large proportion of the eligible patients (n = 34/43; 79%) actively engaged in the VC-ERP treatment. Drop-out rates were low (n = 6/43; 14%). Satisfaction with the treatment was adequate among patients, caregivers, and clinicians. Apart from hospitalization in 3 patients, there were no other adverse events. Hybrid care and stepped care approaches could be incorporated into the VC-ERP protocol. Therefore, the feasibility of VC-ERP treatment in terms of operational viability, service utilization, service engagement, need for additional in-person services, frequency of adverse events, and user satisfaction was adequate. The VC-ERP treatment was found to be efficacious in the 11 patients who had completed the full treatment. Significant reductions in symptoms and maintenance of treatment gains on follow-up were observed.

CONCLUSION

This study provided preliminary evidence for the feasibility and usefulness of VC-ERP in the treatment of OCD. The results suggest that VC-ERP can be a useful option in resource-constrained settings.

Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

Efficacy of remotely-delivered cognitive behavioural therapy for obsessive-compulsive disorder: An updated meta-analysis of randomised controlled trials

INTRODUCTION

Despite remotely-delivered cognitive behavioural therapy (CBT) being an emerging field, the evidence of its efficacy in obsessive-compulsive disorder (OCD) is limited. We aimed to estimate the efficacy of remotely-delivered CBT for OCD, compared to face-to-face CBT and non-CBT control conditions.

METHODS

Randomised clinical trials (RCTs) identified through a systematic literature search of PubMed, Ovid/PsychINFO and Web of Science until 21/06/2021. Eligible studies included individuals with OCD evaluating at least one form of remotely-delivered CBT versus a control condition. Random-effects meta-analyses, sub-analyses, meta-regressions, heterogeneity analyses, publication bias assessment and quality assessment.

RESULTS

Twenty-two RCTs were included (n = 1796, mean age = 27.7 years, females = 59.1 %). Remotely-delivered CBT was more efficacious than non-CBT control conditions for OCD symptoms (g = 0.936 95 % CI = 0.597-1.275, p < .001), depressive symptoms (g = 0.358, 95 % CI = 0.125-0.590, p = .003) and anxiety symptoms (g = 0.468, 95 % CI = 0.135-0.800, p = .006). There were no significant differences in efficacy between remotely-delivered CBT and face-to-face CBT for OCD symptoms (g = -0.104 95 % CI = -0.391-0.184, p = .479), depressive symptoms (g = 0.138, 95 % CI = -0.044-0.320, p = .138), anxiety symptoms (g = 0.166, 95 % CI = -0.456-0.780, p = .601) or quality of life (g = 0.057, 95 % CI = -0.178-0.292, p = .489). Higher baseline severity of OCD symptoms was associated with a lower efficacy of remotely-delivered CBT compared to face-to-face CBT (β = -0.092, p = .036). The quality of the included studies was mostly identified as "low risk of bias" (45.5 %) or "some concerns" (45.5 %).

LIMITATIONS

Heterogeneity and limited evidence for some outcomes.

CONCLUSIONS

Remotely-delivered CBT appears efficacious in reducing OCD symptoms and other relevant outcomes and is therefore a viable option for increasing treatment access. Preliminary evidence suggests some individuals with severe OCD may benefit more from face-to-face than remotely-delivered CBT.

Webcam-Based Online Coaching with Children and Adolescents with Obsessive-Compulsive Disorders – A Single-Case Study

Abstract. Objective: Although there is clear evidence-based knowledge regarding state-of-the-art treatment for pediatric obsessive-compulsive disorder (OCD), two main issues remain in clinical practice: (1) Exposure-based cognitive behavioral therapy (CBT) is limited in terms of availability and accessibility or is not adequately provided, and (2) despite large effect sizes of exposure-based CBT, the achieved recovery rates of 50–60 % still show room for improvement. These issues have prompted an increasing focus on delivering exposure-based CBT in new and innovative ways. This study aims to evaluate an intensive therapist-administered online coaching program consisting of exposure with response prevention via video teleconferencing (VTC) as an add-on to weekly outpatient CBT (blended therapy). Method: The blended therapy is examined in n = 5 children and adolescents with OCD using an AB design and multi-informant ratings. Results: This single-case study shows promising results, indicating that a decrease in OCD severity and related functional impairment can be attributed to blended therapy. Moreover, satisfaction with online coaching was high. Conclusions: Despite some principal limitations, the results support the effectiveness and feasibility of blended therapy.

Evidence of Phone vs Video-Conferencing for Mental Health Treatments: A Review of the Literature

PURPOSE OF REVIEW

The goal of this paper is to provide a comparative review of using phone (audio-only) or video for mental health treatments. Our review includes evidence of phone and video's effectiveness in terms of reduced symptomology, retention, satisfaction, therapeutic alliance, and other outcomes of interest. This review also discusses how patients and providers' experiences and attitudes differ between these two modalities. Finally, we present information on different usage rates of phone and video across patient populations and mental health provider types, and different implementation strategies.

RECENT FINDINGS

Treatments through phone and video are both able to reduce symptoms related to mental health conditions and have both been found to be non-inferior to in-person care. Both phone and video are more convenient to patients. Video offers important visual information that can be important to diagnosing mental health conditions. Phone, however, is more broadly accessible and may come with fewer technological issues. In the context of mental health care, where non-verbal cues are tied to symptomology and diagnosing, and a strong relationship between patient and provider can enhance treatment, we encourage the use of video, especially for psychotherapeutic services. However, as phone is more accessible, we ultimately recommend an accommodating approach, one that flexibly makes use of both phone and video. Future studies on telehealth should focus on direct, head-to-head comparisons between phone and video and conduct more rigorous testing on whether clinical differences exist.

Provider perceptions of telehealth and in-person exposure and response prevention for obsessive-compulsive disorder

Until recently, psychotherapies, including exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD), have primarily been delivered in-person. The COVID-19 pandemic required OCD providers delivering ERP to quickly transition to telehealth services. While evidence supports telehealth ERP delivery, limited research has examined OCD provider perceptions about patient characteristics that are most appropriate for this modality, as well as provider abilities to identify and address factors interfering with effective telehealth ERP. In the present study, OCD therapists (N = 113) rated the feasibility of delivering telehealth ERP relative to in-person for different (1) patient age-groups, (2) levels of OCD severity, and (3) provider ability to identify and address factors interfering with ERP during in-person and telehealth ERP (e.g., cognitive avoidance, reassurance seeking, etc.). Providers reported significantly greater feasibility of delivering telehealth ERP to individuals ages 13-to-65-years relative to other age groups assessed. Greater perceived feasibility for telehealth relative to in-person ERP was reported for lower versus higher symptom severity levels. Lastly, providers felt better able to identify and address problematic factors in-person. These findings suggest that providers should practice appropriate caution when offering telehealth ERP for certain patients with OCD. Future research may examine how to address these potential limitations of telehealth ERP delivery.

Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes.

METHOD

A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively.

RESULTS

The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8).

CONCLUSION

Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.

Obsessive compulsive disorder during the COVID-19 pandemic: A brief review of course, psychological assessment and treatment considerations

Obsessive-compulsive disorder (OCD) is an impairing mental health condition defined by intense distress in the presence of unwanted, recurrent thoughts, images, or impulses which are accompanied by compulsions and avoidance performed to reduce distress. During the COVID-19 pandemic, OCD has continued to be an impairing mental health condition regardless of symptom dimensionality (e.g., contamination, harm, etc.) with varying reports of the overall clinical course. However, changes in the assessment, treatment, and diagnosis of OCD have occurred to personalize care and be aligned with public health guidelines. Exposure and response prevention and pharmacotherapy remain the treatment of choice, even though the setting in which treatment is conducted may have shifted. Telehealth in particular has been a 'game-changer' for clinicians and patients alike. Given the continued health risk posed by the pandemic, treatment personalization should still be made to ensure safety for both patients and providers while balancing efficacy and patient preferences.

The impact of COVID-19 on the treatment of obsessive-compulsive disorder

The COVID-19 pandemic has led to challenges in providing cognitive-behavioral therapy for patients with obsessive-compulsive disorder (OCD). Despite the presence of the pandemic and the risk of contracting illness, therapists can continue to utilize exposure with response prevention (ERP), which is the gold standard psychotherapy treatment for OCD. Therapists can ethically implement ERP by focusing on core treatment tenets while incorporating guidelines recommended by the Centers for Disease Control and Prevention to mitigate risk for COVID-19 exposure. The pandemic has also provided an opportunity to more widely implement ERP through virtual telehealth appointments, which have notable benefits as well as some drawbacks.

Community Mental Health Clinicians' Perspectives on Telehealth During the COVID-19 Pandemic: Mixed Methods Study

BACKGROUND

In March 2020, a rapid shift to telehealth occurred in community mental health settings in response to the need for physical distancing to decrease transmission of the virus causing COVID-19. Whereas treatment delivered over telehealth was previously utilized sparingly in community settings, it quickly became the primary mode of treatment delivery for the vast majority of clinicians, many of whom had little time to prepare for this shift and limited to no experience using telehealth. Little is known about community mental health clinicians' experiences using telehealth. Although telehealth may make mental health treatment more accessible for some clients, it may create additional barriers for others given the high rates of poverty among individuals seeking treatment from community mental health centers.

OBJECTIVE

We examined community mental health clinicians' perspectives on using telehealth to deliver trauma-focused cognitive behavioral therapy to youth. We sought to better understand the acceptability of using telehealth, as well as barriers and facilitators to usage.

METHODS

We surveyed 45 clinicians across 15 community clinics in Philadelphia. Clinicians rated their satisfaction with telehealth using a quantitative scale and shared their perspectives on telehealth in response to open-ended questions. Therapists' responses were coded using an open-coding approach wherein coders generated domains, themes, and subthemes.

RESULTS

Clinicians rated telehealth relatively positively on the quantitative survey, expressing overall satisfaction with their current use of telehealth during the pandemic, and endorsing telehealth as a helpful mode of connecting with clients. Responses to open-ended questions fell into five domains. Clinicians noted that (1) telehealth affects the content (ie, what is discussed) and process (ie, how it is discussed) of therapy; (2) telehealth alters engagement, retention, and attendance; (3) technology is a crucial component of utilizing telehealth; (4) training, resources, and support are needed to facilitate telehealth usage; and (5) the barriers, facilitators, and level of acceptability of telehealth differ across individual clinicians and clients.

CONCLUSIONS

First, telehealth is likely a better fit for some clients and clinicians than others, and attention should be given to better understanding who is most likely to succeed using this modality. Second, although telehealth increased convenience and accessibility of treatment, clinicians noted that across the board, it was difficult to engage clients (eg, young clients were easily distracted), and further work is needed to identify better telehealth engagement strategies. Third, for many clients, the telehealth modality may actually create an additional barrier to care, as children from families living in poverty may not have the requisite devices or quality broadband connection to make telehealth workable. Better strategies to address disparities in access to and quality of digital technologies are needed to render telehealth an equitable option for all youth seeking mental health services.

Internet-based psychotherapy in children with obsessive-compulsive disorder (OCD): protocol of a randomized controlled trial

Background

Obsessive-compulsive disorder (OCD) in children can lead to a huge burden on the concerned patients and their family members. While successful state-of-the art cognitive behavioral interventions exist, there is still a lack of available experts for treatment at home, where most symptoms manifest. Internet-based cognitive behavioral therapy (iCBT) could overcome these restrictions; however, studies about iCBT in children with OCD are rare and mostly target computerized self-help resources and only email contact with the therapist. Therefore, we intended to build up and to evaluate an iCBT approach for children with OCD, replacing successful elements of traditional in-office face-to-face CBT, with face-to-face teleconferences, online materials, and apps.

Methods

With the help of a pilot feasibility study, we developed the iCBT consisting of 14 teleconference sessions with the child and parents. The sessions are supported by an app assessing daily and weekly symptoms and treatment course completed by children and parents. Additionally, we obtain heart rate and activity scores from the child via wristbands during several days and exposure sessions. Using a waiting list randomized control trial design, we aim to treat and analyze 20 children with OCD immediately after a diagnostic session whereas the control group of another set of 20 OCD patients will be treated after waiting period of 16 weeks. We will recruit 30 patients in each group to take account for potential dropouts. Outcomes for the treatment group are evaluated before randomization (baseline, t0), 16 weeks (end of treatment, t1), 32 weeks (follow-up 1, t2), and 48 weeks after randomization (follow-up 2, t3). For the waiting list group, outcomes are measured before the first randomization (baseline), at 16 weeks (waiting list period), 32 weeks (end of treatment), 48 weeks after the first randomization (follow-up I), and 64 weeks after the first randomization (follow-up II).

Discussion

Based on our experience of feasibility during the pilot study, we were able to develop the iCBT approach and the current study will investigate treatment effectiveness. Building up an iCBT approach, resembling traditional in-office face-to-face therapy, may ensure the achievement of well-known therapy effect factors, the acceptance in both patients and clinicians, and the wide distribution within the health system.

Trial registration

ClinicalTrials.govNCT05037344. Registered May 2019, last release August 13th, 2021.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model

BACKGROUND

While multiple treatments for pediatric anxiety and obsessive compulsive disorder (OCD) are efficacious, little is known about their cost-effectiveness. In response, we sought to provide relevant information through systematic review and cost-effectiveness simulation.

METHODS

We evaluated the cost-effectiveness of treatment for pediatric anxiety and OCD in two ways. First, we conducted a systematic review following PRISMA guidelines. Second, we evaluated cost-effectiveness for antidepressant medication, cognitive behavioral therapy, and their combination via a simulation that integrated information from the Truven MarketScan database and the NIMH National Database for Clinical Trials Related to Mental Illness.

RESULTS

Both systematic review and simulation found antidepressant medication and cognitive behavioral therapy to be cost-effective for pediatric anxiety and OCD. Antidepressant medication was the least costly approach, and cognitive behavioral therapy provided additional cost-effectiveness, especially for OCD.

LIMITATIONS

During systematic review, relatively few articles provided information about both costs and effectiveness. While there was a notable margin of error to support multiple interventions as cost-effective, limited prior research decreased precision of point estimates and comparisons between interventions.

CONCLUSIONS

Both antidepressant medication and cognitive behavioral therapy were found to be cost-effective for pediatric anxiety and OCD. Results supported investment from third party payers, who serve as critical gatekeepers that can increase treatment dissemination. However, more precise information would better inform the exact amount of investment needed, especially with regard to selection decisions between active interventions. Cost-effectiveness research would benefit from systematic collection of data on treatment costs and quality of life in future clinical trials.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder: A randomized controlled trial

OBJECTIVES

Obsessive-compulsive disorder (OCD) in childhood and adolescence often leads to significant impairment in various areas of life and has a high risk of becoming chronic. Cognitive behavioral therapy (CBT) is the recommended first-line treatment, but it is too rarely implemented in accordance with guidelines and is often not available close to the patient's home. Importantly, internet-based CBT could help to reduce this gap in care. Having previously successfully demonstrated the feasibility of an internet-based CBT approach, we aimed to assess its effectiveness in a waiting list controlled randomized trial.

METHODS

Children and adolescents aged 6-18 years with a principal diagnosis of OCD received 14 sessions of therapist-delivered CBT via videoconference distributed over 16 weeks. After inclusion, participants were randomly assigned to either the treatment or waiting list group. Participants in the treatment group began treatment immediately after baseline diagnostics, and participants in the waiting list group began treatment after a 16-week waiting period. The primary outcome was a pre-post comparison of OCD symptoms as measured with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Additionally, remission was an important outcome measure. Follow-up assessments were conducted for all measures 16 and 32 weeks after completion of treatment.

RESULTS

A total of 60 children and adolescents were included into the analyses. Over the course of the treatment, OCD symptoms according to the CY-BOCS significantly decreased in the treatment group compared to the waiting-list control group. Cohen's d between groups was 1.63. After the patients in the waiting list group also received the treatment, the OCD symptoms decreased significantly in this group as well. This improvement of symptoms increased over the course of the follow-up assessments. Remission rate peaked at the 32-week follow-up, with 68% in the treatment group and 79% in the waiting list group. Importantly, patient satisfaction with treatment was high to very high.

CONCLUSION

In our study, OCD symptoms decreased significantly and remission rate was high after internet-based CBT. Those effects were comparable to those found in studies of face-to-face treatment. Although further evidence is needed, these are early indications that our approach may be a viable way to provide access to adequate treatment for children and adolescents affected by OCD.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT05037344].

Efficacy of intensive CBT telehealth for obsessive-compulsive disorder during the COVID-19 pandemic

Despite evidence for the effectiveness of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD), many individuals with OCD lack access to needed behavioral health treatment. Although some literature suggests that virtual modes of treatment for OCD are effective, it remains unclear whether intensive programs like partial hospitalization and intensive outpatient programs (PHP and IOPs) can be delivered effectively over telehealth (TH) and within the context of a global pandemic. Limited extant research suggests that clinicians perceive attenuated treatment response during the pandemic. The trajectory and outcomes of two matched samples were compared using linear mixed modeling: a pre-COVID in-person (IP) sample (n = 239) and COVID TH sample (n = 239). Findings suggested that both modalities are effective at treating OCD and depressive symptoms, although the pandemic TH group required an additional 2.6 treatment days. The current study provides evidence that PHP and IOP treatment delivered via TH during the COVID-19 pandemic is approximately as effective as pre-pandemic IP treatment and provides promising findings for the future that individuals with complicated OCD who do not have access to IP treatment can still experience significant improvement in symptoms through TH PHP and IOP treatment during and potentially after the pandemic.

A qualitative exploration of adolescents’ experiences of digital Dialectical Behaviour Therapy during the COVID-19 pandemic

The UK government implemented national social-distancing measures in response to the global COVID19 pandemic. As a result, many appointments in the National Health Service (NHS) took place virtually, including psychological interventions in out-patient settings. This study explored the experiences of adolescents participating in a dialectical behaviour therapy (DBT-A) programme via teletherapy (i.e. via video or telephone call) in a Children and Adolescent Mental Health Service (CAMHS). Thirteen adolescents with emotion dysregulation and related problems completed an online qualitative survey about their experience and acceptance of DBT-A delivered virtually. Thematic analysis was conducted on the survey data and generated three over-arching themes: (1) sense of loss; (2) feeling uncontained; and (3) benefits of virtual DBT. These over-arching themes were composed of eight subthemes (‘loss of connection with group and therapist’; ‘loss of skills-building opportunities’; ‘limited privacy’; ‘lack of safe therapy space’; ‘difficult endings’; ‘home comforts’; ‘convenience and accessibility’; and ‘easier to participate with others’). This study suggests that adolescents doing virtual DBT-A need approaches that acknowledge and address the additional relational, emotional and practical challenges of online therapy while maintaining fidelity to the evidence-based treatment model. Suggestions for further research and preliminary practice guidelines are discussed.

Key learning aims

(1)

Implementation and Evaluation of Therapeutic Online Coaching Using Habit Reversal Training in Children With Tourette's Disorder - A Pilot Study

Cognitive-behavioral interventions can be difficult to implement in daily routine, which is often essential for generalizing treatment effects to natural settings. Furthermore, there is a lack of adequate care options concerning habit reversal training for children with Tourette’s disorder. The objective of this study is to evaluate therapeutic online coaching via videoconferencing in the natural environment of children with Tourette’s disorder in addition to face-to-face therapy (blended therapy). Online coaching took place twice a week for a maximum of 12 weeks. In a single-case study (n = 5; patients aged 8–11 years), the first results were obtained for exploratory purposes, especially with regard to the feasibility and reduction of symptoms and impairment. Various outcome measures were assessed (severity of symptoms, impairment, practical implementation, and satisfaction). Despite some principal limitations, the findings provide first hints that blended therapy is feasible and improves symptoms in some children with tics.

Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [DRKS00017199].

Acceptability and feasibility of enhanced cognitive behavioral therapy (eCBT) for children and adolescents with obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a disabling mental health disorder affecting 1-3% of children and adolescents. Cognitive behavioral therapy (CBT) is recommended as the first-line treatment, but is limited by accessibility, availability, and, in some cases, response to treatment. Enhancement with Internet technologies may mitigate these challenges.

METHODS

We developed an enhanced CBT (eCBT) treatment package for children and adolescents with OCD to improve treatment effect as well as user-friendliness. This study aims to explore the feasibility, acceptability, and preliminary effectiveness of the eCBT intervention. The eCBT protocol consists of 10 face-to-face and 12 webcam sessions delivered in 14 weeks. CBT is enhanced by a smartphone application (app) for children and parents to support and monitor treatment, psychoeducative videos, and therapist-guided webcam exposure exercises conducted at home. Assessments were performed at baseline, post-treatment, and at 3- and 6-month follow-up. Primary measures of outcomes were the the Client Satisfaction Questionnaire-8 (CSQ-8) (acceptability), treatment drop-out (feasibility) and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) (preliminary effectiveness).

RESULTS

This paper describes 25 patients with OCD (aged 8-17 years) treated with eCBT. Results indicated that children and parents were satisfied with eCBT, with CSQ-8 mean scores of 27.58 (SD 0.67) and 29.5 (SD 3.74), respectively (range 8-32). No patients dropped out from treatment. We found a mean of 63.8% symptom reduction on the CY-BOCS from baseline to post-treatment. CY-BOCS scores further decreased during 3-month and 6-month follow-up.

CONCLUSION

In this explorative study, eCBT for pediatric OCD was a feasible, acceptable intervention demonstrating positive treatment outcomes.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study

Cognitive behavioral therapy (CBT) is the first choice of treatment of obsessive–compulsive disorder (OCD) in children and adolescents. However, there is often a lack of access to appropriate treatment close to the home of the patients. An internet-based CBT via videoconferencing could facilitate access to state-of-the-art treatment even in remote areas. The aim of this study was to investigate feasibility and acceptability of this telemedical approach. A total of nine children received 14 sessions of CBT. The first session took place face-to-face, the remaining 13 sessions via videoconference. OCD symptoms were recorded with a smartphone app and therapy materials were made accessible in a data cloud. We assessed diagnostic data before and after treatment and obtained measures to feasibility, treatment satisfaction and acceptability. Outcomes showed high acceptance and satisfaction on the part of patients with online treatment (89%) and that face-to-face therapy was not preferred over an internet-based approach (67%). The majority of patients and their parents classified the quality of treatment as high. They emphasized the usefulness of exposures with response prevention (E/RP) in triggering situations at home. The app itself was rated as easy to operate and useful. In addition to feasibility, a significant decrease in obsessive–compulsive symptoms was also achieved. Internet-based CBT for pediatric OCD is feasible and well received by the patients and their parents. Furthermore, obsessive–compulsive symptomatology decreased in all patients. The results of this study are encouraging and suggest the significance of further research regarding this technology-supported approach, with a specific focus on efficacy.

Trial registration number: Clinical trials AZ53-5400.1-004/44.

The impact of COVID-19 on the treatment of obsessive-compulsive disorder

The COVID-19 pandemic has led to challenges in providing cognitive-behavioral therapy for patients with obsessive-compulsive disorder (OCD). Despite the presence of the pandemic and the risk of contracting illness, therapists can continue to utilize exposure with response prevention (ERP), which is the gold standard psychotherapy treatment for OCD. Therapists can ethically implement ERP by focusing on core treatment tenets while incorporating guidelines recommended by the Centers for Disease Control and Prevention to mitigate risk for COVID-19 exposure. The pandemic has also provided an opportunity to more widely implement ERP through virtual telehealth appointments, which have notable benefits as well as some drawbacks.

A Systematic Review on TeleMental Health in Youth Mental Health: Focus on Anxiety, Depression and Obsessive-Compulsive Disorder

Background and Objectives: The Internet is widely used and disseminated amongst youngsters and many web-based applications may serve to improve mental health care access, particularly in remote and distant sites or in settings where there is a shortage of mental health practitioners. However, in recent years, specific digital psychiatry interventions have been developed and implemented for special populations such as children and adolescents. Materials and Methods: Hereby, we describe the current state-of-the-art in the field of TMH application for young mental health, focusing on recent studies concerning anxiety, obsessive-compulsive disorder and affective disorders. Results: After screening and selection process, a total of 56 studies focusing on TMH applied to youth depression (n = 29), to only youth anxiety (n = 12) or mixed youth anxiety/depression (n = 7) and youth OCD (n = 8) were selected and retrieved. Conclusions: Telemental Health (TMH; i.e., the use of telecommunications and information technology to provide access to mental health assessment, diagnosis, intervention, consultation, supervision across distance) may offer an effective and efficacious tool to overcome many of the barriers encountering in the delivery of young mental health care.

Expert opinion in obsessive-compulsive disorder: Treating patients with obsessive-compulsive disorder during the COVID-19 pandemic

This commentary outlines assessment and treatment of patients with OCD during the era of COVID-19. The ongoing COVID-19 pandemic has required providers to make important considerations in treatment, including how usual risk is defined, as well as the use of personal protective equipment and telehealth services. These considerations have allowed providers to continue using both reliable and valid assessment procedures, as well as previously established and efficacious interventions. These adjustments create a context in which patient care for OCD remains fundamentally unchanged; however, important considerations should still be made because of the COVID-19 pandemic.

Defining and Addressing Gaps in Care for Obsessive-Compulsive Disorder in the United States

OBJECTIVE

Obsessive-compulsive disorder (OCD) can be a chronic and disabling illness with a lifetime prevalence of 2%, twice that of schizophrenia. Although effective treatments exist, OCD often remains underdetected and undertreated.

METHODS

The authors performed a scoping review of the literature (of articles in PubMed and PsycINFO published from January 1, 2000, to February 1, 2020) to define gaps in OCD diagnosis and treatment among U.S. adults. Interventions at the patient, clinician, and health care system levels used to address these gaps are described, and promising approaches from around the world are highlighted.

RESULTS

Of 102 potential studies identified in the search, 27 (including five non-U.S. studies) were included. The studies revealed that lack of clinician and patient knowledge about OCD and misdiagnosis contributes to its underdetection. Suboptimal prescribing of selective serotonin reuptake inhibitor medications and limited use of exposure and response prevention, as a first-line psychotherapy, contribute to OCD undertreatment. Digital health technologies show promise in increasing OCD detection and delivery of evidence-based care and in ensuring continuity of care (including during the COVID-19 pandemic).

CONCLUSIONS

Given the significant rates of disability, morbidity, and mortality associated with OCD, addressing gaps in OCD care will reduce the U.S. burden of mental illness. Further research is needed to determine how the use of digital health technologies can increase the detection and management of OCD.

Developmental Considerations in Obsessive Compulsive Disorder: Comparing Pediatric and Adult-Onset Cases

There appear to be two peaks of incidence of Obsessive Compulsive Disorder (OCD), one with a pre-adolescent onset and another in early adulthood. As new cases are added, the cumulative prevalence of OCD increases, but the great majority of cases have an onset in youth. The notion that early onset OCD represents a unique developmental subtype of the disorder has been considered by many researchers based on several specific age-related factors. Ascertainment and early intervention in affected youth is critical to abbreviate the functional impairments associated with untreated illness. In this paper we review the clinical, familial and translational biomarker correlates seen in early onset OCD that support the notion of a developmental subtype and discuss implications for research and treatment aimed at this cohort. The importance of cognitive, academic and social development tasks of childhood and adolescence, illness-specific and familial factors, and immune-mediated inflammatory factors are discussed, with their implications for management.

A review of evaluation approaches for telemental health programs

PURPOSE

Although studies have examined the effectiveness of telemental health programs, optimal approaches for their evaluation remain unclear. We sought to review the outcomes used to evaluate telemental health programs.

METHODS

We conducted a literature search in PubMed and Google Scholar for peer-reviewed studies published between January 2010 until October 2019, and we excluded review articles, opinion papers, presentations, abstracts, and program report without data.

RESULTS

1310 articles were identified, 34 of which were reviewed. Studies used a combination of non-clinical and clinical outcomes, most commonly engagement and impact rates, and standardised clinical measures. Very few studies examined technological feasibility, cost-effectiveness, and qualitative satisfaction reports.

CONCLUSIONS

This review is the first to summarise approaches to evaluate telemental health programs. Strengths and weaknesses of the evaluation outcomes are discussed in this review, highlighting essential factors that should be taken into consideration when developing a standardised framework for the evaluation of future telemental health programs.KEY POINTSThe methods used to evaluate telemental health programs are varied and no gold-standard for measurement of success exists.Clinical and non-clinical outcomes are being used to evaluate telemental health programs.More emphasis should be placed on feasibility measures such as cost-effectiveness.Therapeutic alliance should be a crucial part of evaluation of any telemental health program.Longer follow up times and larger sample sizes, as well as more diverse populations, are needed to generalise outcomes.Utilisation of clinical tools to assess success should be limited to standardised measures commonly used in clinical practice.

Knowledge and competency standards for specialized cognitive behavior therapy for pediatric obsessive-compulsive disorder

Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan.

Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment

In-person psychotherapy (IPP) has a long and storied past, but technology advances have ushered in a new era of video-delivered psychotherapy (VDP). In this meta-analysis, pre-post changes within VDP were evaluated as were outcome differences between VDP versus IPP or other comparison groups. A literature search identified k = 56 within-group studies (N = 1681 participants) and 47 between-group studies (N = 3564). The pre-post effect size of VDP was large and highly significant, g = +0.99 95% CI [0.67-0.31]. VDP was significantly better in outcome than wait list controls (g = 0.77) but negligible in difference from IPP. Within-groups heterogeneity of effect sizes was reduced after subgrouping studies by treatment target, of which anxiety, depression, and posttraumatic stress disorder (PTSD) (each with k > 5) had effect sizes nearing 1.00. Disaggregating within-groups studies by therapy type, the effect size was 1.34 for CBT and 0.66 for non-CBT. Adjusted for possible publication bias, the overall effect size of VDP within groups was g = 0.54. In conclusion, substantial and significant improvement occurs from pre- to post-phases of VDP, this in turn differing negligibly from IPP treatment outcome. The VDP improvement is most pronounced when CBT is used, and when anxiety, depression, or PTSD are targeted, and it remains strong though attenuated by publication bias. Clinically, therapy is no less efficacious when delivered via videoconferencing than in-person, with efficacy being most pronounced in CBT for affective disorders. Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta-analytic evidence.

Effect of Family and Patient Centered Empowerment Program on Depression, Anxiety and Stress in Patients with Obsessive-Compulsive Disorder and Their Caregivers' Burden

Background:

Considering the importance of family participation in patients' treatment and the positive effects of simultaneous patient and family education, this study was conducted to determine the effect of a family and patient-oriented empowerment program on depression, anxiety, and stress in patients with Obsessive-Compulsive Disorder (OCD) and their caregivers' burden.

Materials and Methods:

This quasi-experimental study was conducted on 50 OCD patients along with their primary caregivers. The intervention group participated in eight sessions of training, each lasting from 60 to 90 min (twice a week), and the control group received the usual treatment. The Depression, Anxiety and Stress Scale, Maudsley's Obsessive-Compulsive Inventory, Goldberg's General Health Questionnaire, and Zarit's Burden Inventory were used to collect the data before, immediately after and 1 month after the intervention, and then the gathered data were analyzed with t-test and analysis of variance using the Statistical Package for the Social Sciences software, version 21.

Results:

The changes in the mean scores of depression (F_2,48= 21.02, p < 0.001), anxiety (F_2,48= 29.72, p < 0.001), and stress (F_2,48= 16.52, p < 0.001) of the patients in the intervention group showed significant decrease over time; however, in the control group, there was no significant decrease in the mean scores of depression (F_2,48= 1.69, p = 0.19), anxiety (F_2,48= 0.47, p = 0.62), and stress (F_2,48= 1.09, p = 0.34) over time. The changes in the caregiver's burden score in both groups indicated a significant decrease over time in the intervention group (F_2,48= 24.70, p < 0.001) and the control group (F_2,48= 33. 30, p < 0.001).

Conclusions:

The findings of this study revealed that concurrently training the patients and caregivers could reduce the negative emotions of the patients and their caregivers' burden.

A Perspective on Client-Psychologist Relationships in Videoconferencing Psychotherapy: Literature Review

BACKGROUND

During the COVID-19 pandemic, people have been encouraged to maintain social distance. Technology helps people schedule meetings as remote videoconferencing sessions rather than face-to-face interactions. Psychologists are in high demand because of an increase in stress as a result of COVID-19, and videoconferencing provides an opportunity for mental health clinicians to treat current and new referrals. However, shifting treatment from face-to-face to videoconferencing is not simple: both psychologists and clients miss in-person information cues, including body language.

OBJECTIVE

This review proposes a new theoretical framework to guide the design of future studies examining the impact of a computer as a mediator of psychologist-client relationships and the influence of videoconferencing on the relationship process.

METHODS

We conducted a literature review including studies focused on communication and key concepts of the therapeutic relationship and therapeutic alliance.

RESULTS

Studies have reported that clients are generally satisfied with videoconference therapy in terms of the relationship with their therapists and the establishment of the therapeutic alliance. Conversely, studies indicate that psychologists continue to highlight difficulties in establishing the same quality of therapeutic relationship and therapeutic alliance. The contrasting experiences might underlie the differences in the type of emotional and cognitive work required by both actors in any therapy session; furthermore, the computer seems to take part in their interaction not only as a vehicle to transmit messages but also as an active part of the communication. A new model of interaction and relationship is proposed, taking into account the presence of the computer, along with further hypotheses.

CONCLUSIONS

It is important to consider the computer as having an active role in the client-psychologist relationship; thus, it is a third party to the communication that either assists or interferes with the interaction between psychologists and clients.

How technology can enhance treatment: A scoping review of clinical interventions for anxiety and obsessive-compulsive spectrum disorders

OBJECTIVES

Researchers are increasingly investigating how technology could be used to improve the efficacy of treatment for anxiety and obsessive-compulsive (OC) spectrum disorders. A broad range of technologies, disorders and therapeutic processes have been examined in the literature. This review summarizes the evidence for using technology in clinical interventions for anxiety and OC-spectrum disorders and highlights research gaps that should be addressed to improve the evidence base.

METHODS

A scoping review was conducted based on systematic searches of three databases. Broadly, the criteria included interventions that had integrated technology into clinical contexts to enhance treatment for anxiety and OC-spectrum disorders. All records were double-screened by two reviewers, and data were extracted on the characteristics of interventions, symptom outcomes, and implementation factors.

RESULTS

Searches returned 2,475 studies, of which 117 were eligible for inclusion in this review. Although almost all studies reported pre-post-symptom reductions, only one quarter of the controlled studies demonstrated additive effect of technology-based interventions in between-group analyses. We noted a trend in underreporting implementation factors.

CONCLUSIONS

Technology-based interventions can improve the efficacy of treatment for anxiety and OC-spectrum disorders, but there are challenges to achieving this goal. Based on a review of the included studies, we provide four specific recommendations to improve the quality and likelihood of success of future research projects.

PRACTITIONER POINTS

Technology-based adjuvants are unlikely to improve the efficacy of treatment for anxiety or OC-spectrum disorders based on their novelty or convenience alone. A subset of studies gives hope that specific innovations can improve treatment when targeting a therapeutic process that has been problematic. Clinicians seeking to improve the efficacy of their treatment should first define client-specific therapeutic factors (e.g., homework compliance) that could be leveraged, then apply a specific innovation to address this factor.

Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is an important cause of global health-related disability. In the last several decades, exposure and response prevention (EX/RP) has emerged as one of the most evidence-based treatments for adult and pediatric OCD. Recommended as a first-line treatment in practice guidelines for OCD, EX/RP, when expertly delivered, can be superior to serotonin reuptake inhibitor (SRI) medications alone and superior to adding antipsychotic medication to augment SRI treatment response. Despite a robust evidence base, EX/RP is not widely available. Moreover, although effective, only about half of patients who receive a standard course of EX/RP will achieve remission.This chapter will review innovations in delivering EX/RP, focusing on technology-based methods designed to increase access to EX/RP and translational neuroscience approaches to personalizing and optimizing EX/RP. Technology-based innovations to deliver EX/RP include video conferencing, internet-based treatment, and smartphone apps. Of these, internet-based, clinician-supported treatment has the most evidence base to date. Relevant to all technology-based innovations are the need for advances in the ethical, regulatory and financial aspects of understanding how access to EX/RP may be delivered to individuals of diverse socioeconomic backgrounds in accordance with professional standards and regulations and covered by healthcare.Advances in our understanding of the neural processes underlying learning and memory have led to new ways to combine EX/RP with medications, behavioral interventions, or neuromodulatory methods, with the goal of enhancing the functioning of brain circuits that subserve fear processing and cognitive control. Among the pharmacological approaches to enhancing EX/RP outcome, both ketamine and cannabinoids show promise in small open trials but are in need of further study. Studies to train cognitive control are at an early stage of development yet provide preliminary evidence that training neural processes may be a new path to personalize treatment. How best to combine EX/RP with different types of neuromodulation is being actively studied.Together these innovations in the delivery of EX/RP for OCD hold great promise for improving outcomes of care for individuals with OCD by increasing the availability and the individual treatment effects of this already effective treatment.

Pediatric behavioral telehealth in the age of COVID-19: Brief evidence review and practice considerations

Considerable efforts over the last decade have been placed on harnessing technology to improve access to behavioral health services. These efforts have exponentially risen since the outbreak of the Coronavirus disease 2019 (COVID-19), which has prompted a move to novel systems of care, largely based on telehealth delivery. This article aims to provide a broad review of evidence for telehealth assessment and treatment of externalizing disorders and internalizing disorders in children and discuss practice considerations and established guidelines for telehealth delivery. Existing literature supports the promise of behavioral health interventions including behavioral parent training and combination approaches for externalizing disorders as well as cognitive-behavioral based interventions for internalizing disorders. There is a scarcity of work on assessment via telehealth compared with the available treatment literature. While treatment may be most pressing given the COVID-19 circumstances to continue delivery of care, movement toward establishing evidence-based assessment via telehealth will be of increased importance. Lastly, practice guidelines have been set forth by national associations, professional societies, and supported by the development of national Telehealth Centers of Excellence. These guidelines and practice considerations are discussed within the context of COVID-19.

Adapting an emotional regulation and social communication skills group programme to teletherapy, in response to the COVID-19 pandemic

The COVID-19 pandemic created an unprecedented situation, whereby essential services within child and adolescent mental health services (CAMHS) were suspended. This created a need to modify regular methods of treatment at a rapid pace, to avoid cessation of clinical intervention and prevent potential regression in mental health. Eighteen children with moderate-to-severe mental health disorders and their parents were attending weekly group cognitive behaviour therapy-based sessions (‘The Secret Agent Society’ programme) when the Irish Department of Health suspended face-to-face intervention. This report describes how the group sessions were adapted to individualised, online therapeutic triads between each child, his/her parent and their clinician. Whilst internet technology has emerged as a promising solution to shortfalls in therapy services, in-depth exploration is needed to confirm the efficacy of telehealth for children attending CAMHS.

Effectiveness of ICT-based intimate partner violence interventions: a systematic review

BACKGROUND

Intimate Partner Violence is a "global pandemic". Meanwhile, information and communication technologies (ICT), such as the internet, mobile phones, and smartphones, are spreading worldwide, including in low- and middle-income countries. We reviewed the available evidence on the use of ICT-based interventions to address intimate partner violence (IPV), evaluating the effectiveness, acceptability, and suitability of ICT for addressing different aspects of the problem (e.g., awareness, screening, prevention, treatment, mental health).

METHODS

We conducted a systematic review, following PRISMA guidelines, using the following databases: PubMed, PsycINFO, and Web of Science. Key search terms included women, violence, domestic violence, intimate partner violence, information, communication technology, ICT, technology, email, mobile, phone, digital, ehealth, web, computer, online, and computerized. Only articles written in English were included.

RESULTS

Twenty-five studies addressing screening and disclosure, IPV prevention, ICT suitability, support and women's mental health were identified. The evidence reviewed suggests that ICT-based interventions were effective mainly in screening, disclosure, and prevention. However, there is a lack of homogeneity among the studies' outcome measurements and the sample sizes, the control groups used (if any), the type of interventions, and the study recruitment space. Questions addressing safety, equity, and the unintended consequences of the use of ICT in IPV programming are virtually non-existent.

CONCLUSIONS

There is a clear need to develop women-centered ICT design when programming for IPV. Our study showed only one study that formally addressed software usability. The need for more research to address safety, equity, and the unintended consequences of the use of ICT in IPV programming is paramount. Studies addressing long term effects are also needed.

Implementation of Home-Based Telemental Health in a Large Child Psychiatry Department During the COVID-19 Crisis

Objective: Telemental health (TMH) is not well described for mental health service delivery during crises. Most child and adolescent psychiatry training programs have not integrated TMH into their curricula and are ill equipped to respond during crises to their patients' needs. In this study, we present the implementation of a home-based TMH (HB-TMH) service during the COVID-19 pandemic. Methods: We describe the technological, administrative, training, and clinical implementation components involved in transitioning a comprehensive outpatient child and adolescent psychiatry program to a HB-TMH virtual clinic. Results: The transition was accomplished in 6 weeks. Most in-clinic services were rapidly moved off campus to the home. Owing to challenges encountered with each implementation component, phone sessions bridged the transition from in-clinic to reliable virtual appointments. Within 3 weeks (March 20, 2020) of planning for HB-TMH, 67% of all appointments were conducted at home, and within 4 weeks (March 27, 2020), 90% were conducted at home. By week 6 (April 3, 2020), reliable HB-TMH appointments were implemented. Conclusions: The COVID-19 pandemic crisis created the opportunity to innovate a solution to disrupted care for our established patients and to create a resource for youth who developed problems during the crisis. Our department was experienced in providing TMH services that facilitated the transition to HB-TMH, yet still had to overcome known and unanticipated challenges. Our experience provides a roadmap for establishing a HB-TMH service with focus on rapid implementation. It also demonstrates a role for TMH during (rather than after) future crises when usual community resources are not available.

Behavioral Assessment and Treatment of Selective Mutism in Identical Twins

Selective mutism (SM) is a childhood disorder characterized by persistent failure to speak in situations where speech is expected. There is evidence that behavioral interventions are effective for increasing speech in children with SM but studies have been limited by small, relatively homogeneous samples. Although twins appear to be disproportionately represented among children with SM, little is known about their specific treatment needs and barriers to effective treatment implementation in this population. This case study presents family-based behavioral therapy delivered to a set of 8-year-old, identical twins with SM. At posttreatment, both children displayed marked improvements in speaking and social engagement. Clinical considerations for working with twins with SM are discussed.