Efficacy of Internet-Based Cognitive-Behavioral Therapy for OCD: Systematic Review & Meta-Analysis

Internet-based cognitive behavioral therapy (iCBT) is a form of psychotherapy delivered via the internet, allowing patients to access treatment remotely. It applies principles of cognitive behavioral therapy (CBT), like identifying unhelpful thoughts and gradually facing fears, through online modules, assignments, and sometimes contact with a therapist via email or messaging.

For example, an iCBT program could guide a patient with obsessive-compulsive disorder through learning about their condition and thought patterns, tracking compulsions, and doing exposure exercises at their own pace by signing in online.

Machado-Sousa, M., Moreira, P. S., Costa, A. D., Soriano-Mas, C., & Morgado, P. (2023). Efficacy of internet-based cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Clinical Psychology: Science and Practice, 30(2), 150–162. https://doi.org/10.1037/cps0000133

Key Points

1. Internet-based cognitive behavioral therapy (iCBT) is an effective treatment approach for reducing obsessive-compulsive disorder (OCD) symptoms in adults, with a large pooled pre-post effect size (g = 1.14).
2. Treatment gains were maintained at follow-up assessments, suggesting lasting OCD symptom improvement after iCBT.
3. No statistically significant differences were found between therapist-guided and self-guided iCBT in symptom improvement.
4. The study had some limitations including substantial heterogeneity across trials and a small number of RCTs available for analysis.
5. iCBT could be a valuable first step in a stepped-care model for OCD treatment to improve access and cost-effectiveness. Further research into real-world feasibility is warranted.

Rationale

Obsessive-compulsive disorder (OCD) is a disabling condition affecting 2-3% of the population, causing significant distress and impairment (Ruscio et al., 2010).

Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) is the gold standard psychological treatment, but barriers like accessibility and cost limit its reach (Andersson & Titov, 2014).

Internet-delivered CBT (iCBT) can increase access and be cost-effective, with demonstrated efficacy for OCD in previous studies (Dèttore et al., 2015; Pozza et al., 2016; Wootton, 2016).

However, prior meta-analyses are 5+ years old or lacked focus on iCBT specifically. This study provided an updated meta-analysis focused solely on iCBT for adult OCD patients to characterize its efficacy in ameliorating obsessive-compulsive symptoms.

Method

The systematic review and meta-analysis followed PRISMA guidelines for meta-analyses. 15 studies (6 RCTs, 9 open trials) with 552 OCD patients receiving iCBT were included.

Treatments were 8-17 weeks long and could be therapist-guided or self-guided. The Yale-Brown Obsessive Compulsive Scale (YBOCS) was the primary outcome measure of OCD severity.

According to the paper, the inclusion criteria for the studies in the meta-analysis were:

1. OCD had to be the primary diagnosis
2. The study sample must be adult patients (>18 years old)
3. A form of iCBT had to be the main treatment approach (regardless of treatment intensity)
4. Studies must have used the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) as the outcome measure
5. Studies must be published in English and in peer-reviewed journals
6. Qualitative studies, commentaries, editorial letters, and single-case studies were excluded

Initially, the authors also established a control group as an inclusion criterion. However, due to the limited number of available studies, they opted to include studies without a comparison group as well.

Sample

552 OCD patients over 15 studies; 68% female; mean age range 29-41 years; mean baseline YBOCS range 20-25.8.

Statistical Analysis

Random effects meta-analysis models calculated pooled effect sizes and confidence intervals. Heterogeneity was assessed using I2 values. Moderator effects were analyzed using subgroup analyses and meta-regressions. Publication bias was evaluated through funnel plots, Egger’s tests, and trim-and-fill analysis.

Effect sizes (Cohen’s d converted to Hedge’s g) were calculated for pre-post (k = 15), pre-follow-up (k = 11), and between-group (iCBT vs. control condition; k = 6) comparisons. Moderator effects and publication bias were assessed.

Results

The meta-analysis found that internet-based CBT (iCBT) had a large effect (g = 1.14) in reducing OCD symptoms from pre- to post-treatment. This means iCBT was effective in decreasing OCD symptoms.

The gains from iCBT were also large (g = 1.16) when measured from pre-treatment to follow-up assessments, meaning the OCD symptom improvement was maintained over time after treatment.

However, there was significant variability (heterogeneity) in the results across the different studies analyzed. When two outlier studies with unusually low effect sizes were removed, this heterogeneity decreased considerably.

There were no significant differences found between iCBT programs that were self-guided by the patient versus those with guidance from a therapist. Both formats had similar effectiveness for OCD symptom reduction.

Insight

This meta-analysis demonstrates iCBT is an effective treatment approach for ameliorating OCD, with large improvements maintained over time.

Accessibility, cost-effectiveness, and other advantages make iCBT a promising avenue for OCD care.

Therapist guidance did not appear to affect efficacy significantly. However, dropout rates were lower with guidance, highlighting its potential value for adherence.

Strengths

• The study benefited from an exclusive focus on iCBT for adult OCD patients, providing an updated synthesis.
• It assessed longer-term outcomes, included some real-world effectiveness data, and evaluated the impact of guidance level.

Limitations

• Substantial heterogeneity and a small pool of RCTs limited analysis comprehensiveness.
• Lack of consensus definitions for dropout and adherence also restricted these evaluations.
• Most treatments were 8-10 weeks, restricting insight into duration effects. Follow-up periods were also consistently short.

Implications

With demonstrated efficacy and advantages over face-to-face approaches, iCBT shows promise as a low-intensity first-line treatment in a stepped care model, before progressing to traditional CBT if needed.

This could greatly expand OCD treatment access. More research should examine real-world feasibility and long-term outcomes. Predictors of dropout and adherence also warrant attention to optimize implementation.

References

Primary reference

Machado-Sousa, M., Moreira, P. S., Costa, A. D., Soriano-Mas, C., & Morgado, P. (2023). Efficacy of internet-based cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Clinical Psychology: Science and Practice, 30(2), 150–162. https://doi.org/10.1037/cps0000133

Other references

Andersson, G., & Titov, N. (2014). Advantages and limitations of Internet-based interventions for common mental disorders. World Psychiatry, 13(1), 4-11. https://doi.org/10.1002/wps.20083

Dèttore, D., Pozza, A., & Andersson, G. (2015). Efficacy of technology-delivered cognitive behavioural therapy for OCD versus control conditions, and in comparison with therapist-administered CBT: Meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 44(3), 190-211. https://doi.org/10.1080/16506073.2015.1005660

Pozza, A., Andersson, G., & Dèttore, D. (2016). Therapist-guided internet-based cognitive-behavioural therapy for adult obsessive-compulsive disorder: A meta-analysis. European Psychiatry, 33(S1), s276-s277. https://doi.org/10.1016/j.eurpsy.2016.01.737

Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15(1), 53–63. https://doi.org/10.1038/mp.2008.94

Wootton, B. M. (2016). Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis. Clinical Psychology Review, 43, 103-113. https://doi.org/10.1016/j.cpr.2015.10.001

Keep Learning

1. How might factors like age, gender, OCD symptom dimensions, or comorbidities moderate iCBT efficacy? What demographic or clinical variables should future research prioritize?
2. What specific mechanisms make in-person and internet-delivered CBT differentially effective? Could insights here optimize technology-based approaches?
3. How can providers and health systems best integrate iCBT into OCD treatment pathways? What stepped-care models demonstrate the most clinical utility and cost-savings?
4. If therapist guidance does not improve symptom outcomes significantly, how should role, involvement level, and cost be weighted in implementation decisions? What guidance approaches optimize adherence?

Commentary

Adamis, A. M., & Olatunji, B. O. (2023). The promise and potential pitfalls of iCBT for obsessive–compulsive disorder. Clinical Psychology: Science and Practice, 30(2), 163–166. https://doi.org/10.1037/cps0000137

Promise: iCBT is Efficacious and Accessible

• The meta-analysis by Machado-Sousa et al. found that internet-based CBT (iCBT) has a large effect size in reducing OCD symptoms from pre- to post-treatment (g = 1.14) that is sustained at follow-up (g = 1.16).
• iCBT is more affordable, accessible, convenient, and less stigmatizing than traditional in-person CBT. It has potential to address barriers to mental health treatment.
• iCBT could be highly scalable and cost-effective way to meet rising need for OCD treatment, especially given increased OCD prevalence during the COVID-19 pandemic (Guzick et al., 2021).

Potential Pitfalls: Methodology Matters

• There is a lack of randomized controlled trials comparing iCBT to active treatment controls like in-person CBT, limiting conclusions about efficacy.
• Included studies have limited follow-up durations, non-representative samples, and lack reporting on indicators of study quality.
• More rigorous comparative effectiveness trials with long-term follow-up are needed before definitive clinical recommendations can be made.

For Whom is iCBT Recommended?

• It is unknown whether certain patient factors like OCD severity or phenotype predict better outcomes with iCBT versus in-person CBT.
• Future comparative studies should examine these as moderators (E. Andersson et al., 2015; Wheaton et al., 2021).

Directions on Dissemination

• More research is needed on whether therapist-guided iCBT yields better outcomes than self-guided to inform its role as a standalone or adjunct treatment (Lundström et al., 2022).
• Stepped care models utilizing self-guided or therapist-guided iCBT as a low-intensity first stage intervention are promising but require additional research before dissemination.