A Randomized Controlled Trial of Self-Directed Versus Therapist-Directed Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder Patients With Prior Medication Trials

Tolin, David F.; Hannan, Scott; Maltby, Nicholas; Diefenbach, Gretchen J.; Worhunsky, Patrick D.; Brady, Robert E.

doi:10.1016/j.beth.2006.07.001

Cited by 97 publications

(67 citation statements)

References 46 publications

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“…A limited number of small open/uncontrolled trials [22][23][24][25][26] of self-help materials, with guidance from a therapist have demonstrated promising results. One RCT 25 randomised 41 patients with OCD to a self-help book with two contacts with a therapist or to 15 sessions of face-to-face therapist-delivered CBT including self-administered or therapist-administered ERP.…”

Section: Guided Self-helpmentioning

confidence: 99%

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

Lovell

Bower

Gellatly

et al. 2017

Health Technol Assess

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BackgroundThe Obsessive–Compulsive Treatment Efficacy randomised controlled Trial emerged from a research recommendation in National Institute for Health and Care Excellence obsessive–compulsive disorder (OCD) guidelines, which specified the need to evaluate cognitive–behavioural therapy (CBT) treatment intensity formats.ObjectivesTo determine the clinical effectiveness and cost-effectiveness of two low-intensity CBT interventions [supported computerised cognitive–behavioural therapy (cCBT) and guided self-help]: (1) compared with waiting list for high-intensity CBT in adults with OCD at 3 months; and (2) plus high-intensity CBT compared with waiting list plus high-intensity CBT in adults with OCD at 12 months. To determine patient and professional acceptability of low-intensity CBT interventions.DesignA three-arm, multicentre, randomised controlled trial.SettingImproving Access to Psychological Therapies services and primary/secondary care mental health services in 15 NHS trusts.ParticipantsPatients aged ≥ 18 years meetingDiagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for OCD, on a waiting list for high-intensity CBT and scoring ≥ 16 on the Yale–Brown Obsessive Compulsive Scale (indicative of at least moderate severity OCD) and able to read English.InterventionsParticipants were randomised to (1) supported cCBT, (2) guided self-help or (3) a waiting list for high-intensity CBT.Main outcome measuresThe primary outcome was OCD symptoms using the Yale–Brown Obsessive Compulsive Scale – Observer Rated.ResultsPatients were recruited from 14 NHS trusts between February 2011 and May 2014. Follow-up data collection was complete by May 2015. There were 475 patients randomised: supported cCBT (n = 158); guided self-help (n = 158) and waiting list for high-intensity CBT (n = 159). Two patients were excluded post randomisation (one supported cCBT and one waiting list for high-intensity CBT); therefore, data were analysed for 473 patients. In the short term, prior to accessing high-intensity CBT, guided self-help demonstrated statistically significant benefits over waiting list, but these benefits did not meet the prespecified criterion for clinical significance [adjusted mean difference –1.91, 95% confidence interval (CI) –3.27 to –0.55;p = 0.006]. Supported cCBT did not demonstrate any significant benefit (adjusted mean difference –0.71, 95% CI –2.12 to 0.70). In the longer term, access to guided self-help and supported cCBT, prior to high-intensity CBT, did not lead to differences in outcomes compared with access to high-intensity CBT alone. Access to guided self-help and supported cCBT led to significant reductions in the uptake of high-intensity CBT; this did not seem to compromise patient outcomes at 12 months. Taking a decision-making approach, which focuses on which decision has a higher probability of being cost-effective, rather than the statistical significance of the results, there was little evidence that supported cCBT and guided self-help are cost-effective at the 3-month follow-up compared with a waiting list. However, by the 12-month follow-up, data suggested a greater probability of guided self-help being cost-effective than a waiting list from the health- and social-care perspective (60%) and the societal perspective (80%), and of supported cCBT being cost-effective compared with a waiting list from both perspectives (70%). Qualitative interviews found that guided self-help was more acceptable to patients than supported cCBT. Professionals acknowledged the advantages of low intensity interventions at a population level. No adverse events occurred during the trial that were deemed to be suspected or unexpected serious events.LimitationsA significant issue in the interpretation of the results concerns the high level of access to high-intensity CBT during the waiting list period.ConclusionsAlthough low-intensity interventions are not associated with clinically significant improvements in OCD symptoms, economic analysis over 12 months suggests that low-intensity interventions are cost-effective and may have an important role in OCD care pathways. Further research to enhance the clinical effectiveness of these interventions may be warranted, alongside research on how best to incorporate them into care pathways.Trial registrationCurrent Controlled Trials ISRCTN73535163.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 37. See the NIHR Journals Library website for further project information.

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Section: Guided Self-helpmentioning

confidence: 99%

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

Lovell

Bower

Gellatly

et al. 2017

Health Technol Assess

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“…Given fi ndings of relative effi cacy for bibliotherapy [50], self-help with minimal therapist contact [51,52], and computerguided CBT [53], others have investigated a stepped care model of intervention among adults with OCD. Most recently, Tolin et al [54] randomly assigned 41 adults to self-or therapist-administered CBT; although both treatments were effective, therapist-administered CBT yielded a superior response. Studies examining stepped care in pediatric populations are needed, as are dissemination studies that target community clinicians.…”

Section: Disseminationmentioning

confidence: 97%

“…However, when tested empirically, no signifi cant effi cacy differences emerged between treatment administered in the home or the offi ce environment [30]. Another recent study investigated the therapist's role in treatment, fi nding that individuals who received CBT from a professional benefi ted more than those who used a self-directed CBT protocol [31]. Moreover, researchers have questioned whether administering CBT in a group format would provide benefi ts that are comparable to those of individual therapy.…”

Section: Alternative Treatment Delivery Settingsmentioning

confidence: 97%

Psychotherapy for obsessive-compulsive disorder

Storch

Mariaskin²,

Murphy

2009

Curr Psychiatry Rep

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Cognitive-behavioral therapy (CBT) with exposure and response prevention is a first-line intervention for adult and childhood obsessive-compulsive disorder. Methodologically rigorous controlled trials have suggested that benefits from CBT exceed those from placebo and attention-control conditions and have similar or greater efficacy than serotonergic monotherapy. This article reviews the nature of CBT and associated outcome data, highlighting recent empiric findings in the treatment literature.

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“…The evidence base for such advice is remarkably thin. The common practice of switching from SRIs to ERP after nonresponse in OCD appeared to be effective in two studies [6,7]. At present, no systematic studies of patients with OCD who are nonresponsive to ERP have been published.…”

Section: Introductionmentioning

confidence: 99%

Cognitive Therapy versus Fluvoxamine as a Second-Step Treatment in Obsessive-Compulsive Disorder Nonresponsive to First-Step Behavior Therapy

Balkom¹,

Emmelkamp

Eikelenboom³

et al. 2012

Psychother Psychosom

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Background: To compare the effectiveness of second-step treatment with cognitive therapy (CT) versus fluvoxamine in patients with obsessive-compulsive disorder (OCD) who are nonresponsive to exposure in vivo with response prevention (ERP). Methods: A 12-week randomized controlled trial at an outpatient clinic in the Netherlands comparing CT with fluvoxamine in OCD. Of 118 subjects with OCD treated with 12 weeks of ERP, 48 appeared to be nonresponders (Y-BOCS improvement score of less than one third). These nonresponders were randomized to CT (n = 22) or fluvoxamine (n = 26). The main outcome measure was the Y-BOCS severity scale. Statistical analyses were conducted in the intention-to-treat sample (n = 45) on an ‘as randomized basis’ and in the per-protocol sample (n = 30). Due to selective dropout in the fluvoxamine group, two additional sensitivity analyses were performed. Results: Complete data could be obtained from 45 subjects (94%) after 12 weeks. Fifty percent of the patients refused fluvoxamine after randomization compared to 13% who refused CT [χ²(1) = 7.10; p = 0.01]. CT as a second-step treatment did not appear to be effective in this sample of nonresponders. Fluvoxamine was significantly superior to CT in the intention-to-treat sample, in the per-protocol sample and in the two separately defined samples in which the sensitivity analyses were performed. Conclusions: OCD patients who are nonresponsive to ERP may benefit more from a switch to treatment with an antidepressant instead of switching to CT. In clinical practice, it may be important to motivate this subgroup of patients to undergo psychopharmacological treatment, as this may improve their outcome considerably.

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A Randomized Controlled Trial of Self-Directed Versus Therapist-Directed Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder Patients With Prior Medication Trials

Cited by 97 publications

References 46 publications

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

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

Psychotherapy for obsessive-compulsive disorder

Cognitive Therapy versus Fluvoxamine as a Second-Step Treatment in Obsessive-Compulsive Disorder Nonresponsive to First-Step Behavior Therapy

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