Therapist-Guided, Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Obsessive-Compulsive Disorder: A Randomized Controlled Trial

Effectiveness of internet-delivered cognitive behavioural therapy for anxiety and obsessive-compulsive disorders within routine clinical care in rural Sweden

Few studies have evaluated the implementation of ICBT in regular child and adolescent mental health services (CAMHS). This study aimed to explore the acceptability, feasibility, and effectiveness of ICBT for children and adolescents with anxiety disorders and obsessive-compulsive disorder (OCD) within a rural CAMHS. The study also explored outcome predictors and long-term outcomes. Eighty-three participants were consecutively recruited from a non-specialized CAMHS in Region Jämtland Härjedalen in northern Sweden. Therapist-guided ICBT was offered during 12 weeks to children aged 8-17 with an anxiety disorder or OCD. Acceptability and feasibility measures included treatment adherence, treatment satisfaction, and adverse events. The primary outcome measure was the Clinical Global Impression-Severity. Secondary measures of effectiveness included clinician-, self-, and parent-ratings of symptom severity and functional impairment. Assessments were completed at baseline, post-treatment, and three-month follow-up (primary endpoint). A two-year follow up was conducted using medical records. Potential predictors included both patient characteristics and treatment variables. Results indicated that ICBT was both acceptable and feasible according to study measures. Statistically significant improvements were found from baseline to the three-month follow-up on clinician rated severity (B [SE] = -0.92 [0.09]; p < .001), as well as on all secondary measures. Forty-three percent of participants no longer fulfilled criteria for their principal disorder at the three-month follow-up. No serious adverse events were reported. Clinical improvement was highest among children with higher functioning at baseline (B [SE] = -0.05 [0.02]; p < .05). Forty-six percent of participants had been in contact with CAMHS during the two-year follow-up period, mainly for reasons other than their initial diagnosis. Findings suggest that ICBT could be an acceptable and feasible treatment option for young people with anxiety disorders and OCD in rural non-specialized CAMHS settings. Further studies are needed to confirm treatment effectiveness in this setting. Trial registration: NCT02926365.

Efficacy and acceptability of cognitive-behavioral therapy and serotonin reuptake inhibitors for pediatric obsessive-compulsive disorder: a network meta-analysis

BACKGROUND

Cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) are recommended treatments for pediatric obsessive-compulsive disorder (OCD), but their relative efficacy and acceptability have not been comprehensively examined. Further, it remains unclear whether the efficacy of in-person CBT is conserved when delivered in other formats, such as over telephone/webcam or as Internet-delivered CBT (ICBT).

METHODS

PubMed, PsycINFO, trial registries, and previous systematic reviews were searched for randomized controlled trials (RCTs) comparing CBT (in-person, webcam/telephone-delivered, or ICBT) or SRIs with control conditions or each other. Network meta-analyses were conducted to examine efficacy (post-treatment Children's Yale-Brown Obsessive Compulsive Scale) and acceptability (treatment discontinuation). Confidence in effect estimates was evaluated with CINeMA (Confidence in Network Meta-Analysis).

RESULTS

Thirty eligible RCTs and 35 contrasts comprising 2,057 youth with OCD were identified. In-person CBT was significantly more efficacious than ICBT, waitlist, relaxation training, and pill placebo (MD range: 3.95-11.10; CINeMA estimate of confidence: moderate) but did not differ significantly from CBT delivered via webcam/telephone (MD: 0.85 [-2.51, 4.21]; moderate), SRIs (MD: 3.07 [-0.07, 6.20]; low), or the combination of in-person CBT and SRIs (MD: -1.20 [-5.29, 2.91]; low). SRIs were significantly more efficacious than pill placebo (MD: 4.59 [2.70, 6.48]; low) and waitlist (MD: 8.03 [4.24, 11.82]; moderate). No significant differences for acceptability emerged, but confidence in estimates was low.

CONCLUSIONS

In-person CBT and SRIs produce clear benefits compared to waitlist and pill placebo and should be integral parts of the clinical management of pediatric OCD, with in-person CBT overall having a stronger evidence base. The combination of in-person CBT and SRIs may be most efficacious, but few studies hinder firm conclusions. The efficacy of CBT appears conserved when delivered via webcam/telephone, while more trials evaluating ICBT are needed.

Cognitive Behavioral Digital Interventions are Effective in Reducing Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis

Anxiety disorders are the most prevalent mental health issues in childhood, yet most children do not receive treatment. With recent advances in technology, a growing number of digital anxiety interventions are becoming accessible. This study is the first meta-analysis to evaluate the effectiveness and usefulness of digital cognitive-behavioral anxiety interventions for individuals under the age of 18. Five electronic databases (PsycNET, Web of Science, Science Direct, Pub Med, SAGE Journals.) were systematically searched in 2021. Inclusion criteria were: randomized control trials with a wait list no treatment control, standalone to blended care with minimal therapist involvement, diagnosed anxiety disorder or elevated levels of anxiety, outcome anxiety levels had to be assessed by a clinician, or the patients themselves by a validated anxiety measure. We assessed and controlled for publication bias, and considered the risk of bias using the Cochrane risk-of-bias tool. Eighteen studies were found eligible, which examined 1290 participants in total. Pooled effect sizes using a random-effects model yielded low overall effect for self-ratings (g = 0.28, k = 18, p < 0.001, 95% CI [0.14; 0.41]), and medium effect for ratings of clinicians (g = 0.66, k = 13, p < 0.001, 95% CI [0.50; 0.80]) as well as for parental report (g = 0.49, k = 16, p < 0.001, 95% CI [0.29; 0.69]). We found that the effects were homogenous across studies. Further examining potential moderating factors of treatment efficacy is needed in future research, as well as conducting studies that compare traditional methods of care to their digital counterparts. Digital interventions could contribute to the well-being of children regardless of age, minimizing therapist involvement. We conclude that digital cognitive-behavioral interventions may provide an accessible, cost-effective, and scalable anxiety treatment option for children and adolescents.

Obsessive-compulsive disorder in treatment seeking children & adolescents during the COVID-19 pandemic

BACKGROUND

Few studies have investigated the COVID-19 pandemic's effect on children and adolescents with obsessive-compulsive disorder (OCD). This study aims to investigate whether the pandemic is associated with increased referral of young people with OCD, any changes in their symptom severity and treatment offered.

METHODS

Service data were used to investigate 58 young people (8-17 years) referred and assessed in the Central and Northwest London NHS Foundation Trust Child and Adolescent Mental Health Service (CAMHS), before and during the COVID-19 pandemic (months March-October 2018-2020). Changes in symptom severity were measured using the Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA). Patient records were reviewed to assess if COVID-19 had exacerbated symptoms. Type of treatment offered was compared.

RESULTS

26 (5.62%) assessments to CAMHS related to OCD in 2020, compared to 12 (1.30%) and 20 (2.27%) assessments pre-pandemic (2018 and 2019), showing a significant increase in the proportion of OCD cases (X2 (1, N = 58) = 20.3, p < 0.001). There was no significant difference in any HoNOSCA dimensions on initial assessment. However, 69.2% of patients in 2020 showed symptom worsening over the COVID-period, versus 46.7% of cases first assessed pre-pandemic. Significantly more patients were discharged without being offered treatment pre-pandemic (X2 (2, N = 58) = 12.7, p = 0.002). In 2020, there was an 8.5% increase in the frequency of medication offered.

DISCUSSION

The proportion of OCD cases in CAMHS increased in 2020 despite the overall number of CAMHS referrals falling. Furthermore, many cases reportedly worsened during the pandemic, and services will need to address the increased burden of more severe cases. Further larger investigation of this subject is warranted.

Secondary outcomes of enhanced cognitive behavioral therapy (eCBT) for children and adolescents with obsessive-compulsive disorder

Background

Obsessive-compulsive disorder (OCD) is a debilitating mental health condition usually presenting with a high degree of comorbid symptoms in the majority of cases. Although face-to-face cognitive-behavioral therapy (CBT) is considered the therapeutic golden standard for pediatric OCD, its accessibility, availability, and consistency in delivery are still limited. To address some of these challenges, an enhanced CBT (eCBT) package was created and introduced. This study explored eCBT's broad-based impact on OCD-related comorbid symptoms, functional impairment, quality of life and family accommodation among youth with OCD.

Methods

This open trial involved 25 pediatric patients with OCD (7-17 years), assessed between January 2018 to February 2020. All patients received eCBT for 14 weeks. Secondary outcomes were assessed at baseline, post-treatment, and 3-, 6-, and 12-month follow-up co-occurring symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ), Screen for Child Anxiety-Related Emotional Disorders (SCARED), and Mood and Feelings Questionnaire (MFQ). Quality of life was measured using the KINDL-R, functional impairment through the Child Obsessive-Compulsive Impact Scale Revised (COIS-R), and family accommodation by the Family Accommodation Scale (FAS). Linear mixed-effects models were applied to analyze treatment effects.

Results

Results indicated a significant decrease in OCD-related comorbid symptoms post-treatment, with SDQ mean reduce of 3.73 (SE = 1.10, child) and 4.14 (SE = 1.19, parent), SCARED mean reduce of 10.45 (SE = 2.52, child) and 8.40 (SE = 2.82, parent), MFQ mean reduce of 3.23 (SE = 1.11, child) and 2.69 (SE = 1.18, parent). Family accommodation declined with clinician scored FAS mean reduction of 13.25 (SE = 2.31). Quality-of-Life improved significantly post-treatment, with KINDL mean increase of 8.15 (SE = 2.87, children), and 10.54 (SE = 3.07, parents). These positive improvements were further amplified at the 3-month follow-up and remained consistent at the 12-month follow-up.

Conclusion

A significant reduction was observed in all secondary outcomes employed and OCD-related functional impairments from baseline to post-treatment, which was maintained through 12-month follow-up. These results imply that after receiving eCBT, children and adolescents experienced substantial decrease in the negative impacts of OCD-related symptoms on their daily life, including home, school, and social interactions.

Comparison of internet-based and face-to-face cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review and network meta-analysis

Cognitive behavioral therapy (CBT) is widely recognized as an effective treatment for obsessive-compulsive disorder (OCD). However, few patients are able to receive CBT. Internet-based CBT (ICBT) may be able to overcome this problem. In this study, we aimed to compare the efficacy of CBT, therapist-guided ICBT (TG-ICBT), unguided ICBT (UG-ICBT), and none therapist-guided ICBT (NTG-ICBT) by a network meta-analysis. The primary outcome was the mean change in OCD severity measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The secondary outcomes included the severity of depressive symptoms, side effects, and cost-effectiveness. A total of 25 trials with 1642 participants were included. We found that the efficacy of CBT was superior to that of TG-ICBT. The mean improvement in Y-BOCS/CY-BOCS scores was higher in CBT group than in UG-ICBT group, but this difference was not statistically significant. The efficacy did not differ significantly between TG-ICBT and UG-ICBT. CBT, TG-ICBT, and UG-ICBT were all more effective than the psychological placebo, waiting list, and pill placebo. In terms of efficacy, CBT combined with drug therapy was better than CBT, TG-ICBT, and UG-ICBT. Sensitivity analyses supported these findings. Based on the current evidence, we recommend TG-ICBT when CBT is not available. However, it is undeniable that UG-ICBT also has the potential to be an effective alternative to CBT. More evidence is needed to support this possibility.

Closing the Gap for Children with OCD: A Staged-Care Model of Cognitive Behavioural Therapy with Exposure and Response Prevention

Childhood obsessive-compulsive disorder (OCD) is among the most prevalent and disabling mental health conditions affecting children and adolescents. Although the distress and burden associated with childhood OCD are well documented and empirically supported treatments are available, there remains an unacceptable "treatment gap" and "quality gap" in the provision of services for youth suffering from OCD. The treatment gap represents the large number of children who never receive mental health services for OCD, while the quality gap refers to the children and young people who do access services, but do not receive evidence-based, cognitive behavioural therapy with exposure and response prevention (CBT-ERP). We propose a novel staged-care model of CBT-ERP that aims to improve the treatment access to high-quality CBT-ERP, as well as enhance the treatment outcomes for youth. In staged care, patients receive hierarchically arranged service packages that vary according to the intensity, duration, and mix of treatment options, with provision of care from prevention, early intervention, through to first and second-line treatments. Based on a comprehensive review of the literature on treatment outcomes and predictors of treatments response, we propose a preliminary staging algorithm to determine the level of clinical care, informed by three key determinants: severity of illness, comorbidity, and prior treatment history. The proposed clinical staging model for paediatric OCD prioritises high-quality care for children at all stages and levels of illness, utilising empirically supported CBT-ERP, across multiple modalities, combined with evidence-informed, clinical decision-making heuristics. While informed by evidence, the proposed staging model requires empirical validation before it is ready for prime time.

Self-help application for obsessive-compulsive disorder based on exposure and response prevention technique with prototype design and usability evaluation: A cross-sectional study

Background and Aims

Obsessive-compulsive disorder (OCD) is a relatively common disorder that, due to its debilitating nature, significantly affects personal abilities, job performance, social adjustment, and interpersonal relationships. There are significant barriers to accessing evidence-based cognitive-behavioral therapy as a first-line treatment for obsessive-compulsive disorder. Mobile health applications (Apps) offer a promising way to improve access to evidence-based therapies while overcoming these barriers. The present study was to design and evaluate a prototype of a self-help application for people with OCD (the most common pattern of OCD) based on the exposure and response prevention (ERP) technique.

Methods

This work was developed in four different phases. (1) Needs assessment: a thorough literature review, reviewing existing related programs and apps, and interviewing patients and psychiatrists; (2) Creating a paper prototype: considering the functional features identified in the previous phase using wireframe sketcher software. (3) Creating a digital prototype: developing an actual prototype using Axure RP software based on the information obtained from an expert panel's evaluation of the paper prototype. (4) Prototype usability evaluation: through a heuristic evaluation with experts and usability testing with patients using the SUS questionnaire.

Results

After requirement analysis, requirements were defined in the areas of information and educational elements, and functional capabilities. Prototypes designed based on identified requirements include capabilities such as in-app online self-help groups, assessing the severity of the symptoms of the disorder, psychological training, supportive treatment strategies, setting personalized treatment plans, tracking treatment progress through weekly reports provided, anxiety assessment, and setting reminders.

Conclusion

The results of the heuristic evaluation with experts made it possible to identify how to provide information and implement the capabilities in a way that is more appropriate and easier for the user.

Mobile Technologies for Supporting Mental Health in Youths: Scoping Review of Effectiveness, Limitations, and Inclusivity

BACKGROUND

Over the past decade, there has been growing support for the use of mobile health (mHealth) technologies to improve the availability of mental health interventions. While mHealth is a promising tool for improving access to interventions, research on the effectiveness and efficacy of mHealth apps for youths is limited, particularly for underrepresented populations, including youths of color and economically marginalized youths.

OBJECTIVE

This scoping review study sought to evaluate the following research questions: (1) What is the extent of the current literature on mHealth apps that provide intervention for mental health problems in children and adolescents? (2) What is known from the existing literature about the effectiveness or efficacy of delivering mental health services via mHealth apps? (3) What are the gaps in the knowledge base in the fields of technology and mental health? (4) Do the reviewed mHealth apps address issues of cultural sensitivity or have they been tested with underrepresented groups (ie, youths of color or economically marginalized groups)?

METHODS

An electronic database search was conducted using relevant search terms. Seven independent reviewers screened identified studies, including title and abstract review to determine if studies met the following inclusion criteria: (1) targeted samples with mental health symptomology or disorders, (2) studied youth participants aged 6-17 years, and (3) examined the use of a mobile app-based platform for intervention. Relevant studies were subjected to full-text review to extract and chart relevant data based on a priori research questions.

RESULTS

The initial database search yielded 304 papers published from 2010 to 2021. After screening and selection, the final review included 10 papers on the effectiveness and efficacy of mental health intervention apps for youths aged 8 to 17 years. Identified apps targeted a broad range of mental health challenges in youths (ie, depression, self-harm, autism spectrum disorder, anxiety, and obsessive-compulsive disorder). Results identified only a small number of studies suggesting that current effectiveness and efficacy research in this area are limited. While some studies provided general support for the effectiveness of mHealth apps in improving mental health outcomes in youths, several notable limitations were present across the literature, reducing the generalizability of findings. Additionally, considerations around racial, ethnic, and socioeconomic diversity were scarce across studies.

CONCLUSIONS

Although some studies cited in this scoping review provide support for the effectiveness and efficacy of mHealth apps targeting mental health concerns in youths, the overall body of literature remains quite limited. Moreover, mHealth apps expressly developed to be culturally responsive are almost nonexistent. Further efforts are needed to recruit youths who are typically underrepresented in research and invite stakeholder participation and collaborative input in the early stages of the mHealth app development process.

Adverse events in cognitive behavioral therapy and relaxation training for children and adolescents with obsessive-compulsive disorder: A mixed methods study and analysis plan for the TECTO trial

Background

Knowledge on adverse events in psychotherapy for youth with OCD is sparse. No official guidelines exist for defining or monitoring adverse events in psychotherapy. Recent recommendations call for more qualitative and quantitative assessment of adverse events in psychotherapy trials. This mixed methods study aims to expand knowledge on adverse events in psychotherapy for youth with OCD.

Methods

This is an analysis plan for a convergent mixed methods study within a randomized clinical trial (the TECTO trial). We include at least 128 youth aged 8-17 years with obsessive-compulsive disorder (OCD). Participants are randomized to either family-based cognitive behavioral therapy (FCBT) or family-based psychoeducation and relaxation training (FPRT). Adverse events are monitored quantitatively with the Negative Effects Questionnaire. Furthermore, we assess psychiatric symptoms, global functioning, quality of life, and family factors to investigate predictors for adverse events. We conduct semi-structured qualitative interviews with all youths and their parents on their experience of adverse events in FCBT or FPRT. For the mixed methods analysis, we will merge 1) a qualitative content analysis with descriptive statistics comparing the types, frequencies, and severity of adverse events; 2) a qualitative content analysis of the perceived causes for adverse events with prediction models for adverse events; and 3) a thematic analysis of the participants' treatment evaluation with a correlational analysis of adverse events and OCD severity.

Discussion

The in-depth mixed methods analysis can inform 1) safer and more effective psychotherapy for OCD; 2) instruments and guidelines for monitoring adverse events; and 3) patient information on potential adverse events. The main limitation is risk of missing data.

Trial registration

ClinicalTrials.gov identifier: NCT03595098. Registered on July 23, 2018.

Review: Adverse event monitoring and reporting in studies of pediatric psychosocial interventions: a systematic review

BACKGROUND

Adverse event monitoring in studies of psychotherapy is crucial to clinical decision-making, particularly for weighing of benefits and harms of treatment approaches. In this systematic review, we identified how adverse events are defined, measured, and reported in studies of psychosocial interventions for children with mental disorders.

METHOD

Medline, PsycINFO, Embase, ProQuest Dissertations and Theses Global, and the Cochrane Library were searched from January 2011-January 2023, and Google Scholar from January 2011-February 2023. English language experimental and quasi-experimental studies that evaluated the efficacy or effectiveness of psychosocial interventions for childhood mental disorders were included. Information on the definition, assessment, and report of adverse events was extracted using a checklist based on Good Clinical Practice guidelines.

RESULTS

In this review, 117 studies were included. Studies most commonly involved treating anxiety disorders or obsessive-compulsive disorder (32/117; 27%); 44% of the experimental interventions tested (52/117) were cognitive behavioral therapies. Adverse events were monitored in 36 studies (36/117; 31%) with a protocol used in 19 of these studies to guide monitoring (19/36; 53%). Twenty-seven different events were monitored across the studies with hospitalization the most frequently monitored (3/36; 8%). Event severity was fully assessed in 6 studies (17%) and partially assessed in 12 studies (33%). Only 4/36 studies (11%) included assessing events for cause.

CONCLUSIONS

To date, adverse events have been inconsistently defined, measured and reported in psychosocial intervention studies of childhood mental health disorders. Information on adverse events is an essential knowledge component for understanding the potential impacts and risks of therapeutic interventions.

Long-term effect of stepped-care vs in-person cognitive behavioral therapy for pediatric obsessive-compulsive disorder

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.

Efficacy of remotely-delivered cognitive behavioural therapy for obsessive-compulsive disorder: An updated meta-analysis of randomised controlled trials

INTRODUCTION

Despite remotely-delivered cognitive behavioural therapy (CBT) being an emerging field, the evidence of its efficacy in obsessive-compulsive disorder (OCD) is limited. We aimed to estimate the efficacy of remotely-delivered CBT for OCD, compared to face-to-face CBT and non-CBT control conditions.

METHODS

Randomised clinical trials (RCTs) identified through a systematic literature search of PubMed, Ovid/PsychINFO and Web of Science until 21/06/2021. Eligible studies included individuals with OCD evaluating at least one form of remotely-delivered CBT versus a control condition. Random-effects meta-analyses, sub-analyses, meta-regressions, heterogeneity analyses, publication bias assessment and quality assessment.

RESULTS

Twenty-two RCTs were included (n = 1796, mean age = 27.7 years, females = 59.1 %). Remotely-delivered CBT was more efficacious than non-CBT control conditions for OCD symptoms (g = 0.936 95 % CI = 0.597-1.275, p < .001), depressive symptoms (g = 0.358, 95 % CI = 0.125-0.590, p = .003) and anxiety symptoms (g = 0.468, 95 % CI = 0.135-0.800, p = .006). There were no significant differences in efficacy between remotely-delivered CBT and face-to-face CBT for OCD symptoms (g = -0.104 95 % CI = -0.391-0.184, p = .479), depressive symptoms (g = 0.138, 95 % CI = -0.044-0.320, p = .138), anxiety symptoms (g = 0.166, 95 % CI = -0.456-0.780, p = .601) or quality of life (g = 0.057, 95 % CI = -0.178-0.292, p = .489). Higher baseline severity of OCD symptoms was associated with a lower efficacy of remotely-delivered CBT compared to face-to-face CBT (β = -0.092, p = .036). The quality of the included studies was mostly identified as "low risk of bias" (45.5 %) or "some concerns" (45.5 %).

LIMITATIONS

Heterogeneity and limited evidence for some outcomes.

CONCLUSIONS

Remotely-delivered CBT appears efficacious in reducing OCD symptoms and other relevant outcomes and is therefore a viable option for increasing treatment access. Preliminary evidence suggests some individuals with severe OCD may benefit more from face-to-face than remotely-delivered CBT.

A randomized controlled trial evaluating the effect of an internet-based cognitive-behavioral program on anxiety symptoms in a community-based sample of adolescents

Adolescents' use of online resources to self-manage anxiety is growing. The objective of the current trial was to assess the effectiveness of an online, primarily self-led cognitive behavioral therapy (CBT) program in reducing anxiety symptoms compared to an active comparator, access to anxiety resources on a static website. A total of 563 adolescents (13-19 years) with self-identified anxiety concerns were enrolled. Self-reported anxiety symptoms were assessed pre- and post-intervention (6 weeks). Adolescents were further assessed 3 months post-intervention. Other outcomes assessed at the three time-points were quality of life (QOL) and healthcare utilization. Both interventions reduced anxiety symptoms after use. Group differences in symptom change were not significant post-intervention (p = 0.16), but were at 3 months (favouring online CBT; p = 0.04) with male participants reporting more symptom change (p = 0.03). Across time-points, as anxiety symptoms decreased, QOL increased (p < 0.001). Among participants that provided healthcare utilization before and after intervention use, the greatest changes in use were among online CBT users particularly for mental health provider visits (psychiatrist, -41.0 % vs. +18.5 %; social worker, -42.5 % vs. -22.1 %), hospital-based care (emergency department visits, -80.0 % vs. +79.4 %; hospital admissions, -76.1 % vs. +42.9 %), and use of self-help or alternative treatments (-60.0 % vs. +6.6 %). Results suggest that, over time, use of online CBT by adolescents can result in improved anxiety symptoms and fewer use of other healthcare resources compared to traditional online information seeking.

E-Mental-Health aftercare for children and adolescents after partial or full inpatient psychiatric hospitalization: study protocol of the randomized controlled DigiPuR trial

Background

During reintegration to daily school life following psychiatric hospitalization, children and adolescents are confronted with various challenges and are at risk for rehospitalization. Tailored post-discharge services could support a successful readjustment and accompany the high-risk transition period after discharge. The study DigiPuR (“Digital gestützte Psychotherapie und Reintegration,” digitally supported psychotherapy and reintegration) aims to establish and to evaluate an innovative digital aftercare program to alleviate challenges during reintegration and improve cross-sectoral care.

Methods

DigiPuR is a randomized controlled trial comparing a digital aftercare service with regular aftercare (TAU) (planned N = 150, 25 children/adolescents, 25 parents, and 25 teachers in each group). In the intervention group, direct communication via secure and regular video calls until 8 weeks after discharge and a secure messenger system between the hospital, family, and school, as well as, if needed, external support systems, are established. A longitudinal pre-post-follow-up assessment at admission, discharge, and 8, 24, and 36 weeks after discharge takes place supplemented by a daily smartphone-based ambulatory assessment from a triadic perspective of patients, parents, and teachers. Primary outcomes include whether participants in the intervention group have fewer readmissions and higher treatment satisfaction and health-related quality of life as well as lower symptom severity than participants in the control group.

Discussion

The present study is essential to address the cross-sectoral challenges associated with reintegration into daily (school) life following child and adolescent psychiatric hospitalization and to determine possible needed adaptations in partial or full inpatient settings. If applicability and efficacy of the aftercare service can be demonstrated, integration into regular care will be sought.

Trial registration

ClinicalTrials.govNCT04986228. Registered on August 2, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06508-1.

Appropriate Use and Operationalization of Adherence to Digital Cognitive Behavioral Therapy for Depression and Anxiety in Youth: Systematic Review

BACKGROUND

Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment.

OBJECTIVE

This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes.

METHODS

A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs.

RESULTS

There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this.

CONCLUSIONS

Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence.

TRIAL REGISTRATION

PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram.

Impact of Psychotherapy for Children and Adolescents with Anxiety Disorders on Global and Domain-Specific Functioning: A Systematic Review and Meta-analysis

A substantial empirical base supports the use of psychotherapy to alleviate anxiety symptoms and diagnoses in children and adolescents. However, focusing only on symptom or diagnostic reduction provides an incomplete picture of clinically meaningful efficacy given that anxiety disorders in this age group are integrally associated with problems in functioning. A systematic review and meta-analysis (N studies = 40, N participants = 3094) evaluating the impacts of psychotherapy for anxiety was conducted on the following outcomes: global functioning, social functioning, academic functioning, and school attendance. Randomised controlled trials with a passive control condition, a child and/or adolescent sample (7–17 years) with a primary anxiety diagnosis, and receiving anxiety-focused psychotherapy were eligible for inclusion if they reported suitable outcome data. Results from the meta-analysis indicated that from pre- to post-treatment, psychotherapy led to significant improvements in global functioning according to clinician (d = 1.55), parent (d = 0.67), and child (d = 0.31) reports and on social functioning according to parent (d = 0.51), but not child (d = 0.31) reports. The qualitative review provided preliminary support psychotherapy’s efficacy in increasing family functioning and school attendance, but not so much in enhancing academic performance. These results indicate that psychotherapy improves daily functioning in anxious children and adolescents. The study also highlighted the limited attention paid to measures of functioning in the empirical literature on treatment of childhood anxiety.

Trial Registry: This study is registered with PROSPERO under the identification number CRD42021246565.

Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review

BACKGROUND

Smartphone app-based therapies offer clear promise for reducing the gap in available mental health care for people at risk for or people with mental illness. To this end, as smartphone ownership has become widespread, app-based therapies have become increasingly common. However, the research on app-based therapies is lagging behind. In particular, although experts suggest that human support may be critical for increasing engagement and effectiveness, we have little systematic knowledge about the role that human support plays in app-based therapy. It is critical to address these open questions to optimally design and scale these interventions.

OBJECTIVE

The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach.

METHODS

We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded.

RESULTS

Of the 2940 titles returned by the searches, 64 (2.18%) were eligible for inclusion. This review found significant heterogeneity across all of the dimensions of coaching considered as well as considerable missing information in the published articles. Moreover, few studies had qualitatively or quantitatively evaluated how the level of coaching impacts treatment engagement or outcomes. Although users tend to self-report that coaching improves their engagement and outcomes, there is limited and mixed supporting quantitative evidence at present.

CONCLUSIONS

Digital mental health is a young but rapidly expanding field with great potential to improve the reach of evidence-based care. Researchers across the reviewed articles offered numerous approaches to encouraging and guiding users. However, with the relative infancy of these treatment approaches, this review found that the field has yet to develop standards or consensus for implementing coaching protocols, let alone those for measuring and reporting on the impact. We conclude that coaching remains a significant hole in the growing digital mental health literature and lay out recommendations for future data collection, reporting, experimentation, and analysis.

Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes.

METHOD

A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively.

RESULTS

The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8).

CONCLUSION

Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.

Feasibility of internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder in youth with autism spectrum disorder: A clinical benchmark study

Obsessive-compulsive disorder (OCD) is a treatable condition that often requires specialist care, particularly when comorbid with autism spectrum disorder (ASD). However, specialist clinics are few and typically located in large medical centers. To increase availability of evidence-based treatment for OCD in individuals with ASD, we adapted an internet-delivered cognitive behavior therapy (ICBT) protocol to suit the needs of these individuals and conducted a feasibility study (N = 22). The primary outcome was the clinician-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), administered at pre- and post-treatment as well as 3 months after treatment. ICBT was deemed acceptable and was associated with clinically significant improvements in CY-BOCS scores, corresponding to a large within-group effect size (Cohen's d = 1.33). Similarly, significant improvements were observed in most of the secondary parent- and self-rated measures. Approximately 60% of the participants were classed as treatment responders and 50% were in remission from their OCD at the 3-month follow-up. To provide a meaningful benchmark, we also analyzed data from a specialist clinic that regularly treats individuals with comorbid OCD and ASD (N = 52). These analyses indicated that specialized in-person CBT produced significantly larger effects (d = 2.69) while being markedly more resource demanding, compared to ICBT. To conclude, ICBT can be successfully adapted to treat OCD in youth with ASD and may be a viable alternative for those who do not have direct access to highly specialized treatment. Further improvements of the treatment protocol based on participant and therapist feedback are warranted, as is a formal test of its efficacy and cost-effectiveness in a randomized controlled trial.

Effect of Internet-Based vs Face-to-Face Cognitive Behavioral Therapy for Adults With Obsessive-Compulsive Disorder: A Randomized Clinical Trial

IMPORTANCE

Cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) is a highly specialized treatment that is in short supply worldwide.

OBJECTIVES

To investigate whether both therapist-guided and unguided internet-based CBT (ICBT) are noninferior to face-to-face CBT for adults with OCD, to conduct a health economic evaluation, and to determine whether treatment effects were moderated by source of participant referral.

DESIGN, SETTING, AND PARTICIPANTS

This study is a single-blinded, noninferiority, randomized clinical trial, with a full health economic evaluation, conducted between September 2015 and January 2020, comparing therapist-guided ICBT, unguided ICBT, and individual face-to-face CBT for adults with OCD. Follow-up data were collected up to 12 months after treatment. The study was conducted at 2 specialist outpatient OCD clinics in Stockholm, Sweden. Participants included a consecutive sample of adults with a primary diagnosis of OCD, either self-referred or referred by a clinician. Data analysis was performed from June 2019 to January 2022.

INTERVENTIONS

Guided ICBT, unguided ICBT, and face-to-face CBT delivered over 14 weeks.

MAIN OUTCOMES AND MEASURES

The primary end point was the change in OCD symptom severity from baseline to 3-month follow-up. The noninferiority margin was 3 points on the masked assessor-rated Yale-Brown Obsessive Compulsive Scale.

RESULTS

A total of 120 participants were enrolled (80 women [67%]; mean [SD] age, 32.24 [9.64] years); 38 were randomized to the face-to-face CBT group, 42 were randomized to the guided ICBT group, and 40 were randomized to the unguided ICBT group. The mean difference between therapist-guided ICBT and face-to-face CBT at the primary end point was 2.10 points on the Yale-Brown Obsessive Compulsive Scale (90% CI, -0.41 to 4.61 points; P = .17), favoring face-to-face CBT, meaning that the primary noninferiority results were inconclusive. The difference between unguided ICBT and face-to-face CBT was 5.35 points (90% CI, 2.76 to 7.94 points; P < .001), favoring face-to-face CBT. The health economic analysis showed that both guided and unguided ICBT were cost-effective compared with face-to-face CBT. Source of referral did not moderate treatment outcome. The most common adverse events were anxiety (30 participants [25%]), depressive symptoms (20 participants [17%]), and stress (11 participants [9%]).

CONCLUSIONS AND RELEVANCE

The findings of this randomized clinical trial of ICBT vs face-to-face CBT for adults with OCD do not conclusively demonstrate noninferiority. Therapist-guided ICBT could be a cost-effective alternative to in-clinic CBT for adults with OCD in scenarios where traditional CBT is not readily available; unguided ICBT is probably less efficacious but could be an alternative when providing remote clinician support is not feasible.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02541968.

Boosting exposure and response prevention with imagery-based techniques: a case study tackling sexual obsessions in an adolescent

Sexual obsessions are common in adolescents with obsessive compulsive disorder (OCD), but how to address these obsessions in a developmentally sensitive manner remains under-explored. This report presents the case of an adolescent who experienced unwanted sexual imagery, undergoing conventional exposure and response prevention, which was subsequently augmented with imagery-based techniques. This approach was associated with remission in symptoms of OCD and marked improvements in symptoms of anxiety and depression. The imagery-based approach was well received and valued as key to treatment success by the adolescent. This raises the tantalising possibility that working directly with images can fuel treatment innovation in tackling sexual (and non-sexual) obsessions in youth OCD.

Key learning aims

(1)

Potential Applications of Social Robots in Robot-Assisted Interventions for Social Anxiety

Social anxiety disorder or social phobia is a condition characterized by debilitating fear and avoidance of different social situations. We provide an overview of social anxiety and evidence-based behavioural and cognitive treatment approaches for this condition. However, treatment avoidance and attrition are high in this clinical population, which calls for innovative approaches, including computer-based interventions, that could minimize barriers to treatment and enhance treatment effectiveness. After reviewing existing assistive technologies for mental health interventions, we provide an overview of how social robots have been used in many clinical interventions. We then propose to integrate social robots in conventional behavioural and cognitive therapies for both children and adults who struggle with social anxiety. We categorize the different therapeutic roles that social robots can potentially play in activities rooted in conventional therapies for social anxiety and oriented towards symptom reduction, social skills development, and improvement in overall quality of life. We discuss possible applications of robots in this context through four scenarios. These scenarios are meant as ‘food for thought’ for the research community which we hope will inspire future research. We discuss risks and concerns for using social robots in clinical practice. This article concludes by highlighting the potential advantages as well as limitations of integrating social robots in conventional interventions to improve accessibility and standard of care as well as outlining future steps in relation to this research direction. Clearly recognizing the need for future empirical work in this area, we propose that social robots may be an effective component in robot-assisted interventions for social anxiety, not replacing, but complementing the work of clinicians. We hope that this article will spark new research, and research collaborations in the highly interdisciplinary field of robot-assisted interventions for social anxiety.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder: A randomized controlled trial

OBJECTIVES

Obsessive-compulsive disorder (OCD) in childhood and adolescence often leads to significant impairment in various areas of life and has a high risk of becoming chronic. Cognitive behavioral therapy (CBT) is the recommended first-line treatment, but it is too rarely implemented in accordance with guidelines and is often not available close to the patient's home. Importantly, internet-based CBT could help to reduce this gap in care. Having previously successfully demonstrated the feasibility of an internet-based CBT approach, we aimed to assess its effectiveness in a waiting list controlled randomized trial.

METHODS

Children and adolescents aged 6-18 years with a principal diagnosis of OCD received 14 sessions of therapist-delivered CBT via videoconference distributed over 16 weeks. After inclusion, participants were randomly assigned to either the treatment or waiting list group. Participants in the treatment group began treatment immediately after baseline diagnostics, and participants in the waiting list group began treatment after a 16-week waiting period. The primary outcome was a pre-post comparison of OCD symptoms as measured with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Additionally, remission was an important outcome measure. Follow-up assessments were conducted for all measures 16 and 32 weeks after completion of treatment.

RESULTS

A total of 60 children and adolescents were included into the analyses. Over the course of the treatment, OCD symptoms according to the CY-BOCS significantly decreased in the treatment group compared to the waiting-list control group. Cohen's d between groups was 1.63. After the patients in the waiting list group also received the treatment, the OCD symptoms decreased significantly in this group as well. This improvement of symptoms increased over the course of the follow-up assessments. Remission rate peaked at the 32-week follow-up, with 68% in the treatment group and 79% in the waiting list group. Importantly, patient satisfaction with treatment was high to very high.

CONCLUSION

In our study, OCD symptoms decreased significantly and remission rate was high after internet-based CBT. Those effects were comparable to those found in studies of face-to-face treatment. Although further evidence is needed, these are early indications that our approach may be a viable way to provide access to adequate treatment for children and adolescents affected by OCD.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT05037344].

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part II: psychological interventions

Part II of the European clinical guidelines for Tourette syndrome and other tic disorders (ECAP journal, 2011) provides updated information and recommendations for psychological interventions for individuals with tic disorders, created by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain original studies of psychological interventions for tic disorders, published since the initial European clinical guidelines were issued. Relevant studies were identified using computerized searches of the MEDLINE and PsycINFO databases for the years 2011-2019 and a manual search for the years 2019-2021. Based on clinical consensus, psychoeducation is recommended as an initial intervention regardless of symptom severity. According to a systematic literature search, most evidence was found for Habit Reversal Training (HRT), primarily the expanded package Comprehensive Behavioral Intervention for Tics (CBIT). Evidence was also found for Exposure and Response Prevention (ERP), but to a lesser degree of certainty than HRT/CBIT due to fewer studies. Currently, cognitive interventions and third-wave interventions are not recommended as stand-alone treatments for tic disorders. Several novel treatment delivery formats are currently being evaluated, of which videoconference delivery of HRT/CBIT has the most evidence to date. To summarize, when psychoeducation alone is insufficient, both HRT/CBIT and ERP are recommended as first-line interventions for tic disorders. As part of the development of the clinical guidelines, a survey is reported from ESSTS members and other tic disorder experts on preference, use and availability of psychological interventions for tic disorders.

Effect of Engagement With Digital Interventions on Mental Health Outcomes: A Systematic Review and Meta-Analysis

Digital mental health interventions (DMHIs) present a promising way to address gaps in mental health service provision. However, the relationship between user engagement and outcomes in the context of these interventions has not been established. This study addressed the current state of evidence on the relationship between engagement with DMHIs and mental health outcomes. MEDLINE, PsycINFO, and EmBASE databases were searched from inception to August 1, 2021. Original or secondary analyses of randomized controlled trials (RCTs) were included if they examined the relationship between DMHI engagement and post-intervention outcome(s). Thirty-five studies were eligible for inclusion in the narrative review and 25 studies had sufficient data for meta-analysis. Random-effects meta-analyses indicated that greater engagement was significantly associated with post-intervention mental health improvements, regardless of whether this relationship was explored using correlational [r = 0.24, 95% CI (0.17, 0.32), Z = 6.29, p < 0.001] or between-groups designs [Hedges' g = 0.40, 95% CI (0.097, 0.705), p = 0.010]. This association was also consistent regardless of intervention type (unguided/guided), diagnostic status, or mental health condition targeted. This is the first review providing empirical evidence that engagement with DMHIs is associated with therapeutic gains. Implications and future directions are discussed.

Systematic Review Registration: PROSPERO, identifier: CRD 42020184706.

Efficacy and cost-effectiveness of therapist-guided internet-delivered behaviour therapy for children and adolescents with Tourette syndrome: study protocol for a single-blind randomised controlled trial

Background

Treatment guidelines recommend behaviour therapy (BT) for patients with Tourette syndrome (TS) and chronic tic disorder (CTD). However, BT is rarely accessible due to limited availability of trained therapists and long travel distances to specialist clinics. Internet-delivered BT has the potential of overcoming these barriers through remote delivery of treatment with minimal therapist support. In the current protocol, we outline the design and methods of a randomised controlled trial (RCT) evaluating an internet-delivered BT programme referred to as BIP TIC. The trial’s primary objective is to determine the clinical efficacy of BIP TIC for reducing tic severity in young people with TS/CTD, compared with an active control intervention. Secondary objectives are to investigate the 12-month durability of the treatment effects and to perform a health economic evaluation of the intervention.

Methods

In this single-blind superiority RCT, 220 participants (9–17 years) with TS/CTD throughout Sweden will be randomised to 10–12 weeks of either therapist-supported internet-delivered BT based on exposure with response prevention (BIP TIC) or therapist-supported internet-delivered education. Data will be collected at baseline, 3 and 5 weeks into the treatment, at post-treatment, and 3, 6, and 12 months post-treatment. The primary endpoint is the 3-month follow-up. The primary outcome is tic severity as measured by the Yale Global Tic Severity Scale – Total Tic Severity Score. Treatment response is operationalised as scores of “Very much improved” or “Much improved” on the Clinical Global Impression – Improvement scale, administered at the primary endpoint. Outcome assessors will be blind to treatment condition at all assessment points. A health economic evaluation of BIP TIC will be performed, both in the short term (primary endpoint) and the long term (12-month follow-up). There are no planned interim analyses.

Discussion

Participant recruitment started on 26 April 2019 and finished on 9 April 2021. The total number of included participants was 221. The final participant is expected to reach the primary endpoint in September 2021 and the 12-month follow-up in June 2022. Data analysis for the primary objective will commence after the last participant reaches the primary endpoint.

Trial registration

ClinicalTrials.gov NCT03916055. Registered on 16 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05592-z.

Mobile-based interventions for common mental disorders in youth: a systematic evaluation of pediatric health apps

BACKGROUND

The access to empirically-supported treatments for common mental disorders in children and adolescents is often limited. Mental health apps might extend service supplies, as they are deemed to be cost-efficient, scalable and appealing for youth. However, little is known about the quality of available apps. Therefore, we aimed to systematically evaluate current mobile-based interventions for pediatric anxiety, depression and posttraumatic stress disorder (PTSD).

METHODS

Systematic searches were conducted in Google Play Store and Apple App Store to identify relevant apps. To be eligible for inclusion, apps needed to be: (1) designed to target either anxiety, depression or PTSD in youth (0-18 years); (2) developed for children, adolescents or caregivers; (3) provided in English or German; (4) operative after download. The quality of eligible apps was assessed with two standardized rating systems (i.e., Mobile App Rating Scale (MARS) and ENLIGHT) independently by two reviewers.

RESULTS

Overall, the searches revealed 3806 apps, with 15 mental health apps (0.39%) fulfilling our inclusion criteria. The mean overall scores suggested a moderate app quality (MARS: M = 3.59, SD = 0.50; ENLIGHT: M = 3.22, SD = 0.73). Moreover, only one app was evaluated in an RCT. The correlation of both rating scales was high (r = .936; p < .001), whereas no significant correlations were found between rating scales and user ratings (p > .05).

CONCLUSIONS

Our results point to a rather poor overall app quality, and indicate an absence of scientific-driven development and lack of methodologically sound evaluation of apps. Thus, future high-quality research is required, both in terms of theoretically informed intervention development and assessment of mental health apps in RCTs. Furthermore, institutionalized best-practices that provide central information on different aspects of apps (e.g., effectiveness, safety, and data security) for patients, caregivers, stakeholders and mental health professionals are urgently needed.

Acceptability and feasibility of enhanced cognitive behavioral therapy (eCBT) for children and adolescents with obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a disabling mental health disorder affecting 1-3% of children and adolescents. Cognitive behavioral therapy (CBT) is recommended as the first-line treatment, but is limited by accessibility, availability, and, in some cases, response to treatment. Enhancement with Internet technologies may mitigate these challenges.

METHODS

We developed an enhanced CBT (eCBT) treatment package for children and adolescents with OCD to improve treatment effect as well as user-friendliness. This study aims to explore the feasibility, acceptability, and preliminary effectiveness of the eCBT intervention. The eCBT protocol consists of 10 face-to-face and 12 webcam sessions delivered in 14 weeks. CBT is enhanced by a smartphone application (app) for children and parents to support and monitor treatment, psychoeducative videos, and therapist-guided webcam exposure exercises conducted at home. Assessments were performed at baseline, post-treatment, and at 3- and 6-month follow-up. Primary measures of outcomes were the the Client Satisfaction Questionnaire-8 (CSQ-8) (acceptability), treatment drop-out (feasibility) and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) (preliminary effectiveness).

RESULTS

This paper describes 25 patients with OCD (aged 8-17 years) treated with eCBT. Results indicated that children and parents were satisfied with eCBT, with CSQ-8 mean scores of 27.58 (SD 0.67) and 29.5 (SD 3.74), respectively (range 8-32). No patients dropped out from treatment. We found a mean of 63.8% symptom reduction on the CY-BOCS from baseline to post-treatment. CY-BOCS scores further decreased during 3-month and 6-month follow-up.

CONCLUSION

In this explorative study, eCBT for pediatric OCD was a feasible, acceptable intervention demonstrating positive treatment outcomes.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study

Cognitive behavioral therapy (CBT) is the first choice of treatment of obsessive–compulsive disorder (OCD) in children and adolescents. However, there is often a lack of access to appropriate treatment close to the home of the patients. An internet-based CBT via videoconferencing could facilitate access to state-of-the-art treatment even in remote areas. The aim of this study was to investigate feasibility and acceptability of this telemedical approach. A total of nine children received 14 sessions of CBT. The first session took place face-to-face, the remaining 13 sessions via videoconference. OCD symptoms were recorded with a smartphone app and therapy materials were made accessible in a data cloud. We assessed diagnostic data before and after treatment and obtained measures to feasibility, treatment satisfaction and acceptability. Outcomes showed high acceptance and satisfaction on the part of patients with online treatment (89%) and that face-to-face therapy was not preferred over an internet-based approach (67%). The majority of patients and their parents classified the quality of treatment as high. They emphasized the usefulness of exposures with response prevention (E/RP) in triggering situations at home. The app itself was rated as easy to operate and useful. In addition to feasibility, a significant decrease in obsessive–compulsive symptoms was also achieved. Internet-based CBT for pediatric OCD is feasible and well received by the patients and their parents. Furthermore, obsessive–compulsive symptomatology decreased in all patients. The results of this study are encouraging and suggest the significance of further research regarding this technology-supported approach, with a specific focus on efficacy.

Trial registration number: Clinical trials AZ53-5400.1-004/44.

Cost-effectiveness of Internet-Delivered vs In-Person Cognitive Behavioral Therapy for Children and Adolescents With Obsessive-Compulsive Disorder

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.

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder: A Randomized Clinical Trial

IMPORTANCE

Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited.

OBJECTIVE

To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).

DESIGN, SETTING, AND PARTICIPANTS

This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study.

INTERVENTIONS

ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist.

MAIN OUTCOMES AND MEASURES

The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs.

RESULTS

Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03247075.

Internet-delivered cognitive processing therapy for individuals with a history of bullying victimization: a randomized controlled trial

The purpose of this randomized controlled trial was to test an internet-delivered version of cognitive processing therapy (CPT) for the psychological distress associated with bullying victimization. The sample comprised 52 adults (i.e. 69.20% women; mean age = 43.37 (SD = 12.47); 3.85% ethnic minority) who self-identified as having a lifetime history of bullying victimization. Participants were randomized into three groups, which received 12 sessions of internet-delivered, therapist-guided, and content-modified version of CPT, 12 sessions of internet-delivered and therapist-guided stress management (SM), or a waitlist. Treatment outcomes included maladaptive trauma appraisals, symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety and stress, social anxiety, and anger. Hierarchical linear modeling was used to analyse the data. Findings indicated that CPT was effective in reducing the strength of maladaptive appraisals related to bullying victimization and symptoms of PTSD compared to the waitlist and SM. SM outperformed CPT and the waitlist in reducing symptoms of depression, general anxiety, and stress. In conclusion, the results of this trial suggest that internet-delivered CPT is effective for the psychological distress and maladaptive appraisals associated with bullying victimization but that adaptions might be needed to target more effectively symptoms of anxiety and depression.

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

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.

Evidence on Digital Mental Health Interventions for Adolescents and Young People: Systematic Overview

BACKGROUND

An estimated 1 in 5 adolescents experience a mental health disorder each year; yet because of barriers to accessing and seeking care, most remain undiagnosed and untreated. Furthermore, the early emergence of psychopathology contributes to a lifelong course of challenges across a broad set of functional domains, so addressing this early in the life course is essential. With increasing digital connectivity, including in low- and middle-income countries, digital health technologies are considered promising for addressing mental health among adolescents and young people. In recent years, a growing number of digital health interventions, including more than 2 million web-based mental health apps, have been developed to address a range of mental health issues.

OBJECTIVE

This review aims to synthesize the current evidence on digital health interventions targeting adolescents and young people with mental health conditions, aged between 10-24 years, with a focus on effectiveness, cost-effectiveness, and generalizability to low-resource settings (eg, low- and middle-income countries).

METHODS

We searched MEDLINE, PubMed, PsycINFO, and Cochrane databases between January 2010 and June 2020 for systematic reviews and meta-analyses on digital mental health interventions targeting adolescents and young people aged between 10-24 years. Two authors independently screened the studies, extracted data, and assessed the quality of the reviews.

RESULTS

In this systematic overview, we included 18 systematic reviews and meta-analyses. We found evidence on the effectiveness of computerized cognitive behavioral therapy on anxiety and depression, whereas the effectiveness of other digital mental health interventions remains inconclusive. Interventions with an in-person element with a professional, peer, or parent were associated with greater effectiveness, adherence, and lower dropout than fully automatized or self-administered interventions. Despite the proposed utility of digital interventions for increasing accessibility of treatment across settings, no study has reported sample-specific metrics of social context (eg, socioeconomic background) or focused on low-resource settings.

CONCLUSIONS

Although digital interventions for mental health can be effective for both supplementing and supplanting traditional mental health treatment, only a small proportion of existing digital platforms are evidence based. Furthermore, their cost-effectiveness and effectiveness, including in low- and middle-income countries, have been understudied. Widespread adoption and scale-up of digital mental health interventions, especially in settings with limited resources for health, will require more rigorous and consistent demonstrations of effectiveness and cost-effectiveness vis-à-vis the type of service provided, target population, and the current standard of care.

Efficacy of digital health interventions in youth with chronic medical conditions: A meta-analysis

BACKGROUND

Digital health interventions might extend service provisions for youth with chronic medical conditions (CC) and comorbid mental health symptoms. We aimed to comprehensively evaluate the efficacy of Internet- and mobile-based interventions (IMIs) for different psychological and disease-related outcomes in children and adolescents with CC.

METHOD

Studies were identified by systematic searches in CENTRAL, Embase, MEDLINE/PubMed and PsycINFO, complemented by searches in reference lists of eligible studies and other reviews. We included studies, when they were randomized controlled trials (RCTs) comparing the efficacy of an IMI to control conditions in improving psychological and disease-related outcomes in youth (mean age ≤ 18 years) with CC. Study selection, data extraction and risk of bias assessment were conducted independently by two reviewers. Meta-analyses were performed within a random-effects model, and Hedges' g (with 95% confidence intervals) was calculated as effect size measure. Primary outcomes were comorbid mental health symptoms (i.e., depression, anxiety and stress), as well as quality of life and self-efficacy.

RESULTS

A total of 19 randomized controlled trials (2410 patients) were included in this meta-analysis. IMIs were associated with improvements in self-efficacy (g = 0.38; 95% CI, 0.15 to 0.61; I 2 = 0) and combined disease-related outcomes (g = -0.13; 95% CI, -0.25 to -0.01; I 2 = 21). Meta-analyses on other outcomes were non-significant, and some pre-planned analyses were not feasible because of a shortage of studies.

CONCLUSION

The available evidence on IMIs for improving mental and health-related outcomes in youth with CC is limited. Our findings point to a rather small benefit and limited efficacy. Future research is needed, to comprehensively assess the potential of IMIs to extend collaborative care, and to identify factors contributing to improved user-centered interventions with better treatment outcomes.

Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Cognitive behavioural therapy (CBT), incorporating exposure and response prevention (ERP) is widely recognised as the psychological treatment of choice for obsessive-compulsive disorder (OCD). Uncertainty remains however about the magnitude of the effect of CBT with ERP and the impact of moderating factors in patients with OCD.

METHOD

This systematic review and meta-analysis assessed randomised-controlled trials of CBT with ERP in patients of all ages with OCD. The study was preregistered in PROSPERO (CRD42019122311). The primary outcome was end-of-trial OCD symptom scores. The moderating effects of patient-related and study-related factors including type of control intervention and risk of bias were examined. Additional exploratory analyses assessed the effects of treatment fidelity and impact of researcher allegiance.

RESULTS

Thirty-six studies were included, involving 2020 patients (537 children/adolescents and 1483 adults) with 1005 assigned to CBT with ERP and 1015 to control conditions. When compared against all control conditions, a large pooled effect size (ES) emerged in favour of CBT with ERP (g = 0.74: 95% CI = 0.51 to 0.97 k = 36), which appeared to diminish with increasing age. While CBT with ERP was more effective than psychological placebo (g = 1.13 95% CI 0.71 to 1.55, k = 10), it was no more effective than other active forms of psychological therapy (g = -0.05: 95% CI -0.27 to 0.16, k = 8). Similarly, whereas CBT with ERP was significantly superior when compared to all forms of pharmacological treatment (g = 0.36: 95% CI 0.7 to 0.64, k = 7), the effect became marginal when compared with adequate dosages of pharmacotherapy for OCD (g = 0.32: 95% CI -0.00 to 0.64, k = 6).A minority of studies (k = 8) were deemed to be at low risk of bias. Moreover, three quarters of studies (k = 28) demonstrated suspected researcher allegiance and these studies reported a large ES (g = 0.95: 95% CI 0.69 to 1.2), while those without suspected researcher allegiance (k = 8) indicated that CBT with ERP was not efficacious (g = 0.02: 95% CI -0.29 to 0.33).

CONCLUSIONS

A large effect size was found for CBT with ERP in reducing the symptoms of OCD, but depends upon the choice of comparator control. This meta-analysis also highlights concerns about the methodological rigor and reporting of published studies of CBT with ERP in OCD. In particular, efficacy was strongly linked to researcher allegiance and this requires further future investigation.

Use of EMDR-Derived Self-Help Intervention in Children in the Period of COVID-19: A Randomized-Controlled Study

Self-help treatments are an important intervention tool, with high accessibility and ease of application. To our knowledge, no research has previously been conducted on any self-help intervention derived from eye movement desensitization and reprocessing (EMDR) therapy. In this study, we evaluated the mental health status of children not directly affected by the pandemic and investigated the effects of using an EMDR-derived self-help intervention in children as a low-intensity treatment. The mental health status of 178 children was evaluated online via the State-Trait Anxiety Inventory for Children (STAIC) and Childhood Posttraumatic Stress Reaction Index (CPTS-RI). Then, children were randomly assigned to intervention and waitlist. A booklet containing EMDR-derived techniques was sent via the school online portal and the intervention was conducted. Posttests were administered 4 weeks later. The attrition rate was 45.5%, with 97 children completing the trial (intervention: 52; waitlist: 45). At baseline, 76.4% of children showed posttraumatic stress symptoms (PTSS) above threshold. Results showed a statistically significant decrease in the posttest PTSS scores for the intervention group compared to waitlist. The intervention group had significant pre–post improvement on all but one subscale, while the waitlist group showed a significant increase in state anxiety on the STAIC. In conclusion, posttraumatic stress was found to be high in children during the COVID-19 outbreak period, and EMDR-derived self-help intervention appeared to be an effective psychosocial intervention tool.

Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder

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.

Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis

BACKGROUND

Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited.

OBJECTIVE

The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects.

METHODS

We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome.

RESULTS

The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI -0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=-0.70, 95% CI -1.51 to 0.11, P=.09), but heterogeneity was very high (I²=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies.

CONCLUSIONS

cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population.

TRIAL REGISTRATION

PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9.

Long-term outcomes of therapist-guided Internet-delivered cognitive behavior therapy for pediatric obsessive-compulsive disorder

Cognitive behavior therapy (CBT) is the recommended first-line intervention for children and adolescents with obsessive-compulsive disorder (OCD), but is not broadly accessible. Internet-delivered CBT (ICBT) with minimal therapist support is efficacious and cost-effective, at least in the short term. Whether the therapeutic gains of ICBT for OCD are sustained in the long run is unknown. In this study, 61 adolescents with OCD who participated in a randomized trial of ICBT were followed-up 3 and 12 months after treatment. The proportion of treatment responders and remitters remained stable from post-treatment to 3-month follow-up and increased significantly from 3-month to 12-month follow-up. This study suggests that the gains of ICBT for youth with OCD are not only maintained long-term, but that further improvements continue to occur during follow-up.

OCD and COVID-19: a new frontier

People with obsessive compulsive disorder (OCD) are likely to be more susceptible to the mental health impact of COVID-19. This paper shares the perspectives of expert clinicians working with OCD considering how to identify OCD in the context of COVID-19, changes in the presentation, and importantly what to consider when undertaking cognitive behaviour therapy (CBT) for OCD in the current climate. The expert consensus is that although the presentation of OCD and treatment may have become more difficult, CBT should still continue remotely unless there are specific reasons for it not to, e.g. increase in risk, no access to computer, or exposure tasks or behavioural experiments cannot be undertaken. The authors highlight some of the considerations to take in CBT in light of our current understanding of COVID-19, including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. Special considerations for young people and perinatal women are discussed, as well as foreseeing what life may be like for those with OCD after the pandemic is over.

KEY LEARNING AIMS

(1)To learn how to identify OCD in the context of COVID-19 and consider the differences between following government guidelines and OCD.(2)To consider the presentation of OCD in context of COVID-19, with regard to cognitive and behavioural processes.(3)Review factors to be considered when embarking on CBT for OCD during the pandemic.(4)Considerations in CBT for OCD, including weighing up costs and benefits of behavioural experiments or exposure tasks in light of our current understanding of the risks associated with COVID-19.

Dr. Uhre et al. Reply

In a recent letter to the editor, a group of clinician-researchers posit that the conclusions in our published systematic review¹ on cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) are based on inappropriate methodology. In this reply, we address the concerns expressed by Storch et al.².

Engagement in technology-enhanced interventions for children and adolescents: Current status and recommendations for moving forward

Treatment engagement is a primary challenge to the effectiveness of evidence-based treatments for children and adolescents. One solution to this challenge is technology, which has been proposed as an enhancement to or replacement for standard clinic-based, therapist delivered services. This review summarizes the current state of the field regarding technology's promise to enhance engagement. A review of this literature suggests that although the focus of much theoretical consideration, as well as funding priorities, relatively little empirical research has been published on the role of technology as a vehicle to enhance engagement in particular. Moreover, lack of consistency in constructs, design, and measures make it difficult to draw useful comparisons across studies and, in turn, to determine if and what progress has been made toward more definitive conclusions. At this point in the literature, we can say only that we do not yet definitively know if technology does (or does not) enhance engagement in evidence-based treatments for children and adolescents. Recommendations are provided with the hope of more definitively assessing technology's capacity to improve engagement, including more studies explicitly designed to assess this research question, as well as greater consistency across studies in the measurement of and designs used to test engagement.

Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia

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.

Dyadic Psychosocial eHealth Interventions: Systematic Scoping Review

Background

Dyadic psychosocial interventions have been found beneficial both for people coping with mental or physical health conditions as well as their family members and friends who provide them with support. Delivering these interventions via electronic health (eHealth) may help increase their scalability.

Objective

This scoping review aimed to provide the first comprehensive overview of dyadic eHealth interventions for individuals of all ages affected by mental or physical illness and their family members or friends who support them. The goal was to understand how dyadic eHealth interventions have been used and to highlight areas of research needed to advance dyadic eHealth intervention development and dissemination.

Methods

A comprehensive electronic literature search of PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO was conducted for articles published in the English language through March 2019. Eligible records described a psychosocial eHealth intervention that intervened with both care recipients and their support person.

Results

A total of 7113 records were reviewed of which 101 met eligibility criteria. There were 52 unique dyadic eHealth interventions identified, which were tested across 73 different trials. Of the unique interventions, 33 were conducted among dyads of children and their supporting parent, 1 was conducted with an adolescent-young adult care recipient population, and the remaining 18 were conducted among adult dyads. Interventions targeting pediatric dyads most commonly addressed a mental health condition (n=10); interventions targeting adult dyads most commonly addressed cancer (n=9). More than three-fourths of interventions (n=40) required some human support from research staff or clinicians. Most studies (n=64) specified one or more primary outcomes for care recipients, whereas less than one-fourth (n=22) specified primary outcomes for support persons. Where specified, primary outcomes were most commonly self-reported psychosocial or health factors for both care recipients (n=43) and support persons (n=18). Results of the dyadic eHealth intervention tended to be positive for care recipients, but evidence of effects for support persons was limited because of few studies specifying primary outcomes for supporters. Trials of dyadic eHealth interventions were most commonly randomized controlled trials (RCTs; n=44), and RCTs most commonly compared the dyadic eHealth intervention to usual care alone (n=22).

Conclusions

This first comprehensive review of dyadic eHealth interventions demonstrates that there is substantial, diverse, and growing literature supporting this interventional approach. However, several significant gaps were identified. Few studies were designed to evaluate the unique effects of dyadic interventions relative to individual interventions. There was also limited assessment and reporting of outcomes for support persons, and there were no interventions meeting our eligibility criteria specifically targeting the needs of older adult dyads. Findings highlight areas of research opportunities for developing dyadic eHealth interventions for novel populations and for increasing access to dyadic care.

Systematic Review and Meta-Analysis: Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in Children and Adolescents

OBJECTIVE

To assess benefits and harms of cognitive-behavioral therapy (CBT) versus no intervention or versus other interventions for pediatric obsessive-compulsive disorder (OCD).

METHOD

We searched for randomized clinical trials of CBT for pediatric OCD. Primary outcomes were OCD severity, serious adverse events, and level of functioning. Secondary outcomes were quality of life and adverse events. Remission from OCD was included as an exploratory outcome. We assessed risk of bias and evaluated the certainty of the evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Nine trials (N = 645) were included comparing CBT with no intervention and 3 trials (N = 146) comparing CBT with selective serotonin reuptake inhibitors (SSRIs). Compared with no intervention, CBT decreased OCD severity (mean difference [MD] = -8.51, 95% CI = -10.84 to -6.18, p < .00001, low certainty), improved level of functioning (patient-rated: standardized MD [SMD] = -0.90, 95% CI = -1.19 to -0.62, p < .00001, very low certainty; parent-rated: SMD = -0.68, 95% CI = -1.12 to -0.23, p = .003, very low certainty), had similar proportions of participants with adverse events (risk ratio = 1.06, 95% CI = 0.93-1.22, p = .39, GRADE: low certainty), and was associated with reduced risk of still having OCD (risk ratio = 0.50, 95% CI = 0.37-0.67, p < .00001, very low certainty). We had insufficient data to assess the effect of CBT versus no intervention on serious adverse events and quality of life. Compared with SSRIs, CBT led to similar decreases in OCD severity (MD = -0.75, 95% CI = -3.79 to 2.29, p = .63, GRADE: very low certainty), and was associated with similar risk of still having OCD (risk ratio = 0.85, 95% CI = 0.66-1.09, p = .20, very low certainty). We had insufficient data to assess the effect of CBT versus SSRIs on serious adverse events, level of functioning, quality of life, and adverse events.

CONCLUSION

CBT may be more effective than no intervention and comparable to SSRIs for pediatric OCD, but we are very uncertain about the effect estimates.

How New Technologies Can Improve Prediction, Assessment, and Intervention in Obsessive-Compulsive Disorder (e-OCD): Review

BACKGROUND

New technologies are set to profoundly change the way we understand and manage psychiatric disorders, including obsessive-compulsive disorder (OCD). Developments in imaging and biomarkers, along with medical informatics, may well allow for better assessments and interventions in the future. Recent advances in the concept of digital phenotype, which involves using computerized measurement tools to capture the characteristics of a given psychiatric disorder, is one paradigmatic example.

OBJECTIVE

The impact of new technologies on health professionals' practice in OCD care remains to be determined. Recent developments could disrupt not just their clinical practices, but also their beliefs, ethics, and representations, even going so far as to question their professional culture. This study aimed to conduct an extensive review of new technologies in OCD.

METHODS

We conducted the review by looking for titles in the PubMed database up to December 2017 that contained the following terms: [Obsessive] AND [Smartphone] OR [phone] OR [Internet] OR [Device] OR [Wearable] OR [Mobile] OR [Machine learning] OR [Artificial] OR [Biofeedback] OR [Neurofeedback] OR [Momentary] OR [Computerized] OR [Heart rate variability] OR [actigraphy] OR [actimetry] OR [digital] OR [virtual reality] OR [Tele] OR [video].

RESULTS

We analyzed 364 articles, of which 62 were included. Our review was divided into 3 parts: prediction, assessment (including diagnosis, screening, and monitoring), and intervention.

CONCLUSIONS

The review showed that the place of connected objects, machine learning, and remote monitoring has yet to be defined in OCD. Smartphone assessment apps and the Web Screening Questionnaire demonstrated good sensitivity and adequate specificity for detecting OCD symptoms when compared with a full-length structured clinical interview. The ecological momentary assessment procedure may also represent a worthy addition to the current suite of assessment tools. In the field of intervention, CBT supported by smartphone, internet, or computer may not be more effective than that delivered by a qualified practitioner, but it is easy to use, well accepted by patients, reproducible, and cost-effective. Finally, new technologies are enabling the development of new therapies, including biofeedback and virtual reality, which focus on the learning of coping skills. For them to be used, these tools must be properly explained and tailored to individual physician and patient profiles.

Acceptability, feasibility, and efficacy of Internet cognitive behavioral therapy (iCBT) for pediatric obsessive-compulsive disorder: a systematic review

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic mental health disorder characterized by recurring obsessions and compulsions affecting 1-3% of children and adolescents. Current treatment options are limited by accessibility, availability, and quality of care. New technologies provide opportunities to address at least some of these challenges. This paper aims to investigate the acceptability, feasibility, and efficacy of traditional cognitive behavioral therapy with Internet cognitive behavioral therapy (iCBT) for pediatric OCD according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

METHOD

We searched EMBASE, Medline, PsycINFO, CENTRAL, LILACS, CINAHL, and Scopus. Results include articles from 1987 to March 2018. Main inclusion criteria were patients aged 4-18, primary diagnosis of OCD, and iCBT.

RESULTS

Of the 2323 unique articles identified during the initial search, six studies with a total of 96 participants met our inclusion criteria: three randomized controlled trials, one single-case multiple-baseline design, one open-label trial, and one case series. Four studies reported a significant decrease in OCD severity on the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) following iCBT, one study reported significant decrease in CY-BOCS scores for iCBT relative to waitlist, and the case series reported (some) symptom reduction in all participants. Six studies reported high rates of feasibility, and five studies reported good acceptability of iCBT.

CONCLUSION

At present, evidence regarding acceptability, feasibility, and efficacy of iCBT for pediatric OCD is limited. Results are promising but need to be confirmed and refined in further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD4201808587.