Focusing on Accessibility of Evidence-Based Treatments for Obsessive-Compulsive Disorder

Worldwide, there are large gaps in the availability of psychotherapy, and this is particularly true for high-quality, evidence-based psychotherapeutic treatments such as cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD). CBT is the first-line treatment for OCD, and this lack of availability and accessibility is inherently problematic, because treatments that are inaccessible to the general population are unable to have a meaningful public mental health impact.

Lundström et al¹ examined key research questions to determine whether internet-based CBT (ICBT) should be recommended for implementation in health care settings. Although the authors were not able to conclusively demonstrate the noninferiority of ICBT to traditionally delivered CBT, they found that unguided ICBT and therapist-guided ICBT were cost-effective, and participants receiving all treatments experienced significant improvement in their symptoms.¹ Although the predefined noninferiority margin in this trial was 3 points on the Yale-Brown Obsessive Compulsive Scale–Self-Rated,¹ the authors note that this was a more conservative margin than previous noninferiority trials of OCD, which have used margins of 4 or 5 points. If a margin of 5 had been used, therapist-guided ICBT would have been deemed noninferior to traditionally delivered CBT.

The transparency of Lundström et al¹ around their predefined noninferiority margin is laudable; at the same time, the mental health community would be remiss to conclude that ICBT programs for OCD should not be recommended for implementation in health care settings. OCD remains significantly undertreated, with only 40% of patients with OCD receiving any type of OCD treatment, and only 5% receiving CBT.² Given these data and the limited access to mental health professionals who are well-trained and qualified to deliver CBT for OCD, there is an urgent need to expand the accessibility of CBT for OCD, with attention on internet-delivered modalities. Implementation of supported ICBT interventions for OCD appears key for meeting the mental health needs of the world’s population.

To guide efforts at implementing ICBT interventions for OCD, it would be wise to evaluate the comparative effectiveness and the payment models for having a therapist or clinician deliver support to the patient compared with having a trained layperson or coach deliver support to the patient. In the diverse health care payment systems found around the world, there may very well be different conclusions based on the type of health care insurance and reimbursement structures that exist in diverse settings. Layperson-supported or technician-supported ICBT interventions for depression and anxiety have demonstrated effects comparable to those of therapist-supported interventions.^3,4 In a small study of a computer-delivered CBT program for OCD, in which a self-guided intervention was compared with an intervention with layperson support and with therapist support, significant reductions in symptoms were observed in all groups with no significant differences between groups.⁵ However, these results are unlikely to be replicated outside the context of a clinical trial, in which participants are typically highly motivated, interested in engaging in digital mental health interventions, and receive some level of support and commitment to the structure of the clinical trial and contact with study staff for research assessments. Indeed, across different mental health conditions, the use of unguided ICBT programs typically results in improvements relative to no-treatment or waiting list control conditions, but are often hampered by high levels of dropout. To meet the needs of an increasingly distressed population,⁶ multipronged approaches to providing mental health resources and services are needed. A growing body of literature highlights the COVID-19 pandemic as a major stressor that has exacerbated symptoms of OCD, particularly among patients with contamination and washing symptoms⁷ and those experiencing financial distress.⁸ Clinician reports suggest that more than one-third of patients with OCD have experienced a worsening of symptoms during the pandemic⁸; however, there is evidence that patients under the care of an OCD specialist were less likely to self-report increases in symptoms during COVID-19.⁷ Without a doubt, we need to expand our mental health workforce and to prioritize training in evidence-based treatments such as CBT for OCD. However, given the vast number of people who need services, the barriers individuals experience to receiving traditionally delivered psychotherapy, and the indisputable benefits of ICBT, investments are needed to make these programs accessible in routine care settings.