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Lauri KO, Andersson E, Mataix-Cols D, Norlin L, Eriksson V, Melin K, Lenhard F, Serlachius E, Aspvall K. Long-term effect of stepped-care vs in-person cognitive behavioral therapy for pediatric obsessive-compulsive disorder. Internet Interv 2023; 32:100613. [PMID: 37033903 PMCID: PMC10073887 DOI: 10.1016/j.invent.2023.100613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
Long-term follow-up data from trials of digital mental health interventions are rare. This study reports 2-year follow-up data from a non-inferiority trial (N = 152) comparing stepped-care (internet-delivered cognitive behavioral therapy [CBT] followed by traditional in-person CBT if needed) vs in-person CBT for pediatric obsessive-compulsive disorder. Both treatment groups had comparable long-term effects, with the majority of participants being responders (stepped-care 66 %; in-person CBT 71 %) 2 years after the end of treatment.
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Lenhard F, Aspvall K, Andersson E, Ahlen J, Serlachius E, Lavner M, Brodin A, Mataix-Cols D. The Cost of Obsessive-Compulsive Disorder in Swedish Youth. Child Psychiatry Hum Dev 2023; 54:248-254. [PMID: 34585332 PMCID: PMC9867673 DOI: 10.1007/s10578-021-01261-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 01/26/2023]
Abstract
The economic impact of pediatric obsessive-compulsive disorder (OCD) on society is unknown. We compared a wide range of individual-level cost data of children 7-17 years with OCD (n = 152) with a control group from the general population in Sweden (n = 768). The total annual cost in the OCD group was M = 11941€ (95%CI [9915-13966]), compared to the control group M = 6380 € (95%CI [5461-7299]), corresponding to an estimated marginal mean cost of OCD of 5560 € per person and year (z = 4.99, p < .001). OCD was associated with significantly higher healthcare costs, parental absence from work and school productivity loss. OCD symptom severity was positively associated with higher costs. The total societal burden of pediatric OCD in Sweden was estimated to be 94.3 € million per year (95%CI [56.9-131.8]). These results have important implications for policy makers and for the allocation of healthcare resources. Similar studies are needed in other countries in order to estimate the global cost of the disorder.
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Affiliation(s)
- Fabian Lenhard
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Kristina Aspvall
- grid.425979.40000 0001 2326 2191Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Erik Andersson
- grid.4714.60000 0004 1937 0626Department of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Ahlen
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Eva Serlachius
- grid.425979.40000 0001 2326 2191Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Malin Lavner
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Anna Brodin
- grid.467087.a0000 0004 0442 1056Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - David Mataix-Cols
- grid.425979.40000 0001 2326 2191Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Aspvall K, Sampaio F, Lenhard F, Melin K, Norlin L, Serlachius E, Mataix-Cols D, Andersson E. Cost-effectiveness of Internet-Delivered vs In-Person Cognitive Behavioral Therapy for Children and Adolescents With Obsessive-Compulsive Disorder. JAMA Netw Open 2021; 4:e2118516. [PMID: 34328501 PMCID: PMC8325072 DOI: 10.1001/jamanetworkopen.2021.18516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Therapist-guided, internet-delivered cognitive behavioral therapy is an effective treatment option for children and adolescents with obsessive-compulsive disorder, but to our knowledge, its cost-effectiveness compared with traditional in-person treatment has not been established. OBJECTIVE To evaluate the cost-effectiveness of guided internet-delivered cognitive behavioral therapy implemented within a stepped-care model compared with in-person cognitive behavioral therapy for young people with obsessive-compulsive disorder. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation of a randomized noninferiority trial conducted at 2 specialist obsessive-compulsive disorder clinics in Sweden enrolled 152 children and adolescents aged 8 to 17 years with obsessive-compulsive disorder, mainly through clinician referrals (110 [72%]). Recruitment began October 6, 2017, and ended May 24, 2019. Follow-up ended April 14, 2020. INTERVENTIONS Participants were randomly assigned to receive either guided internet-delivered cognitive behavioral therapy or in-person cognitive behavioral therapy during a 16-week period. At the 3-month follow-up, nonresponders in both groups were offered additional in-person cognitive behavior therapy sessions. MAIN OUTCOMES AND MEASURES Health outcomes were treatment response rates (primary outcome), remission rates, and quality-adjusted life-years. Cost data were collected before treatment, after treatment, at 3-month follow-up, and at 6-month follow-up (primary end point) and are presented in 2020 US dollars. The differences in incremental costs and health outcomes were compared between the groups and presented from the health care professional, health care sector, and societal perspectives. RESULTS A total of 152 participants (94 girls [62%]; mean [SD] age, 13.4 [2.5] years) were randomized; 151 (99%) completed the trial. At the 6-month follow-up, 50 of 74 participants (68%) in the stepped-care group and 52 of 77 participants (68%) in the in-person cognitive behavioral therapy group were classified as treatment responders (odds ratio, 1.00 [95% CI, 0.51-1.98]; P = .99). Health economic analyses showed that the stepped-care group used fewer therapist resources than the in-person cognitive behavioral therapy group, resulting in a mean cost savings of $2104 (95% CI, $1202-$3006) per participant for the full study period of 10 months, corresponding to a relative savings of 39%. The cost savings remained largely comparable when taking wider health care sector and societal perspectives. CONCLUSIONS AND RELEVANCE This study suggests that, for young people with obsessive-compulsive disorder, a low-cost digital intervention followed by in-person treatment for nonresponders was cost-effective compared with in-person cognitive behavior therapy alone.
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Affiliation(s)
- Kristina Aspvall
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Filipa Sampaio
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Fabian Lenhard
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Karin Melin
- Institute Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Child and Adolescent Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lisa Norlin
- Region Västra Götaland, Department of Child and Adolescent Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Erik Andersson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Aspvall K, Andersson E, Melin K, Norlin L, Eriksson V, Vigerland S, Jolstedt M, Silverberg-Mörse M, Wallin L, Sampaio F, Feldman I, Bottai M, Lenhard F, Mataix-Cols D, Serlachius E. Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents: A Randomized Clinical Trial. JAMA 2021; 325:1863-1873. [PMID: 33974020 PMCID: PMC8114140 DOI: 10.1001/jama.2021.3839] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment. OBJECTIVE To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder. DESIGN, SETTING AND PARTICIPANTS A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020. INTERVENTIONS Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment. MAIN OUTCOMES AND MEASURES The primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS. RESULTS Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, -∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group). CONCLUSIONS AND RELEVANCE Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03263546.
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Affiliation(s)
- Kristina Aspvall
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Erik Andersson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Karin Melin
- Institute Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Child and Adolescent Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lisa Norlin
- Region Västra Götaland, Department of Child and Adolescent Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Viktor Eriksson
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Sarah Vigerland
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maral Jolstedt
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | | | - Lena Wallin
- Region Västra Götaland, Department of Child and Adolescent Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Filipa Sampaio
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Inna Feldman
- Department of Public Health and Caring Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Matteo Bottai
- Divison of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fabian Lenhard
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder. Curr Top Behav Neurosci 2021; 49:301-329. [PMID: 33590457 DOI: 10.1007/7854_2020_202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Obsessive-Compulsive Disorder is an important cause of global health-related disability. In the last several decades, exposure and response prevention (EX/RP) has emerged as one of the most evidence-based treatments for adult and pediatric OCD. Recommended as a first-line treatment in practice guidelines for OCD, EX/RP, when expertly delivered, can be superior to serotonin reuptake inhibitor (SRI) medications alone and superior to adding antipsychotic medication to augment SRI treatment response. Despite a robust evidence base, EX/RP is not widely available. Moreover, although effective, only about half of patients who receive a standard course of EX/RP will achieve remission.This chapter will review innovations in delivering EX/RP, focusing on technology-based methods designed to increase access to EX/RP and translational neuroscience approaches to personalizing and optimizing EX/RP. Technology-based innovations to deliver EX/RP include video conferencing, internet-based treatment, and smartphone apps. Of these, internet-based, clinician-supported treatment has the most evidence base to date. Relevant to all technology-based innovations are the need for advances in the ethical, regulatory and financial aspects of understanding how access to EX/RP may be delivered to individuals of diverse socioeconomic backgrounds in accordance with professional standards and regulations and covered by healthcare.Advances in our understanding of the neural processes underlying learning and memory have led to new ways to combine EX/RP with medications, behavioral interventions, or neuromodulatory methods, with the goal of enhancing the functioning of brain circuits that subserve fear processing and cognitive control. Among the pharmacological approaches to enhancing EX/RP outcome, both ketamine and cannabinoids show promise in small open trials but are in need of further study. Studies to train cognitive control are at an early stage of development yet provide preliminary evidence that training neural processes may be a new path to personalize treatment. How best to combine EX/RP with different types of neuromodulation is being actively studied.Together these innovations in the delivery of EX/RP for OCD hold great promise for improving outcomes of care for individuals with OCD by increasing the availability and the individual treatment effects of this already effective treatment.
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Aspvall K, Lenhard F, Melin K, Krebs G, Norlin L, Näsström K, Jassi A, Turner C, Knoetze E, Serlachius E, Andersson E, Mataix-Cols D. Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia. Internet Interv 2020; 20:100308. [PMID: 32082991 PMCID: PMC7019117 DOI: 10.1016/j.invent.2020.100308] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 02/07/2023] Open
Abstract
Obsessive-compulsive disorder (OCD) can be successfully treated with cognitive behaviour therapy (CBT). However, as few patients have access to CBT, there is a strong push to develop and evaluate scalable and cost-effective internet-delivered interventions. BIP OCD is a therapist-guided online CBT intervention for pediatric OCD that has shown promise in trials conducted at a single site in Stockholm, Sweden. In this study, we evaluated if BIP OCD is an acceptable, feasible, and effective treatment in other countries and clinical contexts. Thirty-one patients were recruited at three different sites; a specialist OCD clinic in Gothenburg (Sweden), a specialist OCD clinic in London (United Kingdom), and a university-based clinic in Brisbane (Australia). Acceptability and feasibility measures included treatment adherence and feedback from therapists. Clinician assessments were conducted at baseline, post-treatment, and 3-month follow-up. The average module completion for the participants was 8.1/12 (SD = 3.2) and the majority of patients completed the BIP OCD treatment (100% in Gothenburg, and 55.6% in both London and Brisbane). Pooling data from the three sites, the within-group effect sizes from baseline to post-treatment on the Children's Yale-Brown Obsessive-Compulsive Scale were in the expected range (bootstrapped Cohen's d = 1.78; 95% CI 1.18-2.39), with an additional symptom reduction to the 3-month follow-up (bootstrapped Cohen's d = 0.27; 95% CI 0.02-0.51). Participating therapists identified both advantages and difficulties supporting patients in this digital format. The results of this study suggest that the treatment effects obtained in the original BIP OCD trials can be generalized to other clinical contexts nationally and internationally. Lessons learned provide important information for successful implementation of BIP OCD in regular healthcare contexts.
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Affiliation(s)
- Kristina Aspvall
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Fabian Lenhard
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Karin Melin
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Child and Adolescent Psychiatry, CAP Specialized unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Georgina Krebs
- Institute of Psychiatry, Psychology & Neuroscience, MRC Social, Genetic and Developmental Psychiatry Centre King's College, London, United Kingdom
- National Specialist OCD, BDD and related disorders clinic, Maudsley Hospital, London, United Kingdom
| | - Lisa Norlin
- Department of Child and Adolescent Psychiatry, CAP Specialized unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Näsström
- Department of Child and Adolescent Psychiatry, CAP Specialized unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Amita Jassi
- National Specialist OCD, BDD and related disorders clinic, Maudsley Hospital, London, United Kingdom
| | - Cynthia Turner
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Elizabeth Knoetze
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Erik Andersson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
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