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Cited by 79Obsessive-Compulsive Spectrum DisordersDigital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Effect of Internet-Based vs Face-to-Face Cognitive Behavioral Therapy for Adults With Obsessive-Compulsive Disorder: A Randomized Clinical Trial

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Lundström, Lina, Flygare, Oskar, Andersson, Erik, Enander, Jesper, Bottai, Matteo, Ivanov, Volen Z., Boberg, Julia, Pascal, Diana +2 more·2022·JAMA Network Open
DOI 10.1001/jamanetworkopen.2022.1967PMC PMC9907343
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Abstract

Importance: Cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) is a highly specialized treatment that is in short supply worldwide. Objectives: To investigate whether both therapist-guided and unguided internet-based CBT (ICBT) are noninferior to face-to-face CBT for adults with OCD, to conduct a health economic evaluation, and to determine whether treatment effects were moderated by source of participant referral. Design, Setting, and Participants: This study is a single-blinded, noninferiority, randomized clinical trial, with a full health economic evaluation, conducted between September 2015 and January 2020, comparing therapist-guided ICBT, unguided ICBT, and individual face-to-face CBT for adults with OCD. Follow-up data were collected up to 12 months after treatment. The study was conducted at 2 specialist outpatient OCD clinics in Stockholm, Sweden. Participants included a consecutive sample of adults with a primary diagnosis of OCD, either self-referred or referred by a clinician. Data analysis was performed from June 2019 to January 2022. Interventions: Guided ICBT, unguided ICBT, and face-to-face CBT delivered over 14 weeks. Main Outcomes and Measures: The primary end point was the change in OCD symptom severity from baseline to 3-month follow-up. The noninferiority margin was 3 points on the masked assessor-rated Yale-Brown Obsessive Compulsive Scale. Results: A total of 120 participants were enrolled (80 women [67%]; mean [SD] age, 32.24 [9.64] years); 38 were randomized to the face-to-face CBT group, 42 were randomized to the guided ICBT group, and 40 were randomized to the unguided ICBT group. The mean difference between therapist-guided ICBT and face-to-face CBT at the primary end point was 2.10 points on the Yale-Brown Obsessive Compulsive Scale (90% CI, −0.41 to 4.61 points; P = .17), favoring face-to-face CBT, meaning that the primary noninferiority results were inconclusive. The difference between unguided ICBT and face-to-face CBT was 5.35 points (90% CI, 2.76 to 7.94 points; P < .001), favoring face-to-face CBT. The health economic analysis showed that both guided and unguided ICBT were cost-effective compared with face-to-face CBT. Source of referral did not moderate treatment outcome. The most common adverse events were anxiety (30 participants [25%]), depressive symptoms (20 participants [17%]), and stress (11 participants [9%]). Conclusions and Relevance: The findings of this randomized clinical trial of ICBT vs face-to-face CBT for adults with OCD do not conclusively demonstrate noninferiority. Therapist-guided ICBT could be a cost-effective alternative to in-clinic CBT for adults with OCD in scenarios where traditional CBT is not readily available; unguided ICBT is probably less efficacious but could be an alternative when providing remote clinician support is not feasible. Trial Registration: ClinicalTrials.gov Identifier: NCT02541968

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  • Access to CBT may be facilitated by therapist-supported remote delivery, which is less costly than and likely similarly effective to in-person CBT.

    “Access to cognitive behavioural therapy (CBT) may be facilitated by therapist-supported remote delivery, which is less costly than and likely similarly effective to in-person CBT 38 39 44”

    From Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline (2023) · cites this paper as [44]

    The Introduction says therapist-guided internet CBT can improve access, and the Cost-effectiveness Analysis reports substantially lower costs than face-to-face CBT. But the Results (Primary Outcome; page not provided) say noninferiority at three months was inconclusive, so the claim of likely similar effectiveness is stronger than this trial establishes. The findings concern adults with OCD. (LLM, conf=0.86)

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Research works printed but not linked: 2

  1. [1]National Collaborating Centre for Mental Health (UK). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. British Psychological Society; 2006. Accessed September 30, 2021. https://www.ncbi.nlm.nih.gov/books/NBK56458/ 21834191
  2. [29]van Roijen L, van Straten A, Tiemens B, Donker MCH. Manual Trimbos/iMTA Questionnaire for Costs Associated with Psychiatric Illness (TIC-P) (in Dutch). January 2002. Accessed February 4, 2022. https://www.researchgate.net/publication/254758194_Manual_TrimbosiMTA_Questionnaire_for_Costs_Associated_with_Psychiatric_Illness_TIC-P_in_Dutch

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Authors
Lundström, L., Flygare, O., Andersson, E., Enander, J., Bottai, M., Ivanov, V. Z., Boberg, J., Pascal, D., Mataix-Cols, D., & Rück, C.
Affiliations
  • Karolinska University Hospital (SE)
  • Karolinska Institutet (SE)
  • Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
  • Child and Adolescent Psychiatry Research Center, Department of Clinical Neuroscience, Stockholm Health Care Services, Region Stockholm, Karolinska Institutet Stockholm, Sweden
Corresponding author
Lundström, Lina
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2022-03-14
Volume
5
Issue
3
Pages
e221967
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2022.1967
PMC
PMC9907343
OpenAlex
W4220883978
Cited by
78
References
33
Citations by year
2026: 14 · 2025: 19 · 2024: 18 · 2023: 21 · 2022: 6
FWCI
14.61
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Karolinska Institutet
  • Stockholms Läns Landsting
  • Vetenskapsrådet
  • Forskningsrådet om Hälsa, Arbetsliv och Välfärd
  • Sveriges Läkarförbund
Topics
  • Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
obsessive-compulsive disorder, internet-based cognitive behavioral therapy, non-inferiority, health economic evaluation, treatment costs, OCD severity, Yale-Brown Obsessive Compulsive Scale, self-referral, clinician referral, mental health service utilization
MeSH terms
Adult, Anxiety, Anxiety Disorders, Female, Humans, Male, Obsessive-Compulsive Disorder, Cognitive Behavioral Therapy, Internet

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