EXPERT ANALYSIS At THE ECNP CONGRESS
VIENNA (FRONTLINE MEDICAL NEWS) – Christian Rück, MD, believes he has seen the future of treatment for obsessive-compulsive disorder, and it’s Internet-based cognitive-behavioral therapy.
The numbers tell the tale. Obsessive-compulsive disorder (OCD) affects 2% of the general population. It’s an often disabling condition marked by shame and stigma. Major practice guidelines recommend cognitive-behavioral therapy (CBT) as the evidence-based first-line nonpharmacologic therapy. Yet only 5%-10% of OCD patients ever receive conventional face-to-face CBT because of the severe shortage and geographic maldistribution of therapists trained in its use, the psychiatrist observed at the annual congress of the European College of Neuropsychopharmacology.
Thus, a huge unmet need exists for treatment access. And persuasive evidence now exists that Internet-based CBT (I-CBT) for OCD can be provided effectively, safely, and in an extremely cost-effective fashion. Indeed, it takes up very little therapist time – an average of 6-10 minutes per patient per week devoted to reading and answering participants’ emails. And since the therapist’s main role in this treatment approach is simply to encourage patient engagement in the structured online program, I-CBT readily lends itself to use by primary care physicians and other nonspecialists, according to Dr. Rück, a psychiatrist at the Karolinska Institute in Stockholm.
“The vast majority of OCD patients have access to nothing. To me, I-CBT provides us with a unique opportunity to sustain quality of care but still make it very widely available. It’s sort of like serving a top-notch lobster meal at McDonald’s prices,” he said.
Over the past 15 years, I-CBT programs have been developed and proven effective in more than 150 randomized controlled trials for a wide range of psychiatric and medical conditions, including depression, panic disorder, social phobia, severe health anxiety and other anxiety disorders, erectile dysfunction, atrial fibrillation, fibromyalgia, irritable bowel syndrome, and insomnia.
More recently, Dr. Rück and his coinvestigators have pioneered the development of I-CBT as an evidence-based treatment for OCD. They now are in the process of doing the same for body dysmorphic disorder, a related condition that’s often particularly challenging to treat successfully.
The investigators’ first large randomized controlled trial of I-CBT for OCD included 101 patients with a mean 18-year history of the disorder. They were assigned to 10 weeks of the online therapy or to an online supportive care control arm. Mean scores on the Yale-Brown Obsessive-Compulsive Scale ( Y-BOCS ) improved from 21.4 at baseline to 12.9 upon completion of the I-CBT program and 12.6 at follow-up 4 months post treatment. Sixty percent of the I-CBT group demonstrated clinically significant improvement, compared with 6% of controls ( Psychol Med. 2012 Oct;42:2193-203 ).
The benefit proved durable, as demonstrated in an extension study with periodic follow-up out to 24 months post completion of the I-CBT program. The incorporation of an Internet-based booster program in one arm of the follow-up protocol protected against relapses ( Psychol Med. 2014 Oct;442877-87 ).
Dr. Rück and his coinvestigators also have shown in a 128-patient, double-blind trial that d-cycloserine, a partial N-methyl-d-aspartate agonist that promotes fear extinction, augmented the response to I-CBT for OCD, but only in the subgroup not on concomitant antidepressant therapy. The remission rate was 60% at 3 months follow-up post I-CBT in antidepressant-free patients on d-cycloserine, compared with just 24% in d-cycloserine recipients taking antidepressants during I-CBT. Apparently, antidepressants blunt d-cycloserine’s fear-extinction effect ( JAMA Psychiatry. 2015 Jul;72:659-67 ).
The program content of I-CBT is the same as in conventional manualized CBT, but without the face-to-face contact. The I-CBT program consists of 10-15 weekly chapters or modules. There is homework, worksheets, and titrated exposures to fear-eliciting situations. Progress to the next module is contingent upon completion of the previous one, with the patient being required to successfully answer questions that show mastery of the material.
Most patients rate the program favorably. They like not having to show up in the therapist’s office week after week.
“One of the advantages of I-CBT is you can interact every day. If your exposure goes wrong you don’t have to wait 6 days until your next face-to-face appointment with your therapist; you can actually get treatment right away and in that way increase the speed of progress,” Dr. Rück observed.
Also, if the patient forgets a basic concept, he or she can go back and reread.
“Everything is saved. This makes it very easy to supervise. There’s nothing going on that can’t be seen. Isaac M. Marks , MD, an early OCD researcher at Imperial College London, once said that one of the greatest advantages of I-CBT is that the therapist can’t sleep with the patient,” Dr. Rück recalled.
His research group is now in the midst of a clinical trial designed to answer two key questions: Is I-CBT for OCD as effective as face-to-face CBT? And is the therapist really necessary in order to achieve optimal outcomes in I-CBT?
“It would be a kind of shock to us if all our therapist impact is for nothing, but we’ll find out soon,” he promised.
Dr. Rück and his coinvestigators recently developed a program for therapist-supervised I-CBT for patients with body dysmorphic disorder (BDD). In a single-blind pilot clinical trial involving 94 adults with BDD, the clinical response rate at 6 months of follow-up as defined by at least a 30% reduction from baseline in scores on the BDD–Y-BOCS was 56% in the I-CBT arm and 13% in controls assigned to online supportive care. The number needed to treat was impressively low, at 2.3. And those results were achieved by clinical psychology students having no prior experience with BDD, although they were closely supervised by an experienced clinician ( BMJ. 2016 Feb 2;352:i241 .
Dr. Rück has been disappointed to find that physicians, psychotherapists, and health care systems have been slow to embrace I-CBT for the conditions where there is solid supportive randomized trial evidence. I-CBT has been implemented within health care systems only in Australia and Stockholm County, the places where most of the research has been conducted.
“The literature has been around for about 15 years now, and we are noticing that the rollout of this is terribly slow. I’m starting to think that the health care system itself is one of the most problematic roadblocks, especially with regard to reimbursement issues. Maybe I-CBT should be offered outside of the health care system. Sometimes I think Google would do this better than a nationalized health care system,” the psychiatrist mused.
He reported having no financial conflicts of interest regarding his presentation.