Predictors and Moderators of Cognitive and Behavioral Therapy Outcomes for OCD: A Patient-Level Mega-Analysis of Eight Sites

doi:10.1016/j.beth.2018.04.004

Behavior Therapy

Volume 50, Issue 1, January 2019, Pages 165-176

https://doi.org/10.1016/j.beth.2018.04.004 Get rights and content

Highlights

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Behavior therapy, cognitive therapy and their combination showed benefits for OCD and depression
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Improvements in OCD symptoms were somewhat greater for treatments containing cognitive therapy
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Lower initial depression predicted more benefit, especially for behavior therapy
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Stronger beliefs about responsibility and harm and more education may influence cognitive therapy benefits
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Medication status and comorbidity did not predict treatment outcome.

Abstract

Cognitive (CT) and behavioral treatments (BT) for OCD are efficacious separately and in combination. Tailoring treatment to patient-level predictors and moderators of outcome has the potential to improve outcomes. The present study combined data from eight treatment clinics to examine the benefits of BT (n = 125), CT (n = 108), and CBT (n = 126), and study predictors across all treatments and moderators of outcome by treatment type. All three methods led to large benefits for OCD and depression symptoms. Residual gain scores for OCD symptoms were marginally smaller for BT compared to treatments containing CT. For depression, significantly more gains were evident for CBT than BT, and CT did not differ from either. Significantly fewer BT participants (36%) achieved clinically significant improvement compared to CT (56%), and this was marginally evident for CBT (48%). For all treatments combined, no predictors were identified in residual gain analyses, but clinically improved patients had lower baseline depression and stronger beliefs about responsibility/threat and importance/control of thoughts. Moderator analyses indicated that higher baseline scores on depression adversely affected outcomes for BT but not CT or CBT, and lower OCD severity and more education were associated with positive outcomes for CT only. A trend was evident for higher responsibility/threat beliefs to moderate clinical improvement outcomes for those receiving cognitive (CT and CBT), but not behavioral (BT) treatment. Medication status and comorbidity did not predict or moderate outcomes. Findings are discussed in light of models underlying behavioral and cognitive treatments for OCD.

Section snippets

Design and Sample

Pre- and posttreatment data were collected from eight participating research clinic centers that studied cognitive and behavioral treatments alone and/or in combination for outpatients diagnosed with OCD. Sites were chosen because they used similar manualized treatment procedures and identical outcome measures. Investigators could include data from participants treated in research trials and/or in outpatient clinic settings that employed comparable assessment and treatment protocols.

Sample Characteristics

Analyses included 359 participants of whom 125 received BT, 108 received CT, and 126 received CBT. Table 1 provides demographic information and descriptive statistics for the three treatment types and the eight different sites. Of 242 (67%) participants for whom race/ethnicity data were available, a large majority were Caucasian (91%, n = 221). Of the 324 (90%) participants whose marital status was known, 147 (45%) were married or cohabitating, 144 (44%) were single and never married, and 33

Discussion

The primary purpose of this study was to identify predictors of treatment response across interventions for OCD as well as moderators for BT, CT, and CBT using data from eight treatment clinics. Combining sites increased the sample size and appeared justified by the generally similar demographic features, with few exceptions. Baseline severity of OCD, depression and beliefs was also comparable across sites, with only one site (Cottraux) reporting higher Y-BOCS scores. Treatment outcomes were

Conflict of Interest Statement

The authors of the paper submit the following information about potential conflicts of interest:

Gail Steketee: Dr. Steketee was Co-PI on a grant funded by the International OCD Foundation (IOCDF) to Dr. Sabine Wilhelm to support this project. The funding enabled us to employ research assistants to gather and analyze the data. I am not aware of any specific bias with regard to outcomes due to the source of funding. She has received royalties from Elsevier Publications, Guilford Publications, New

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Feeling more confident to encounter negative emotions: The mediating role of distress tolerance on the relationship between self-efficacy and outcomes of exposure and response prevention for OCD
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While exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD), up to half of patients do not effectively respond. In an effort to better understand the mechanisms behind ERP, the inhibitory learning model emphasizes the roles of increasing perceived self-efficacy and distress tolerance. While self-efficacy and distress tolerance have separately been shown to predict OCD symptoms and treatment outcomes, no studies have assessed their joint effects in ERP. The current study examined distress tolerance as a mediator of the relationship between self-efficacy and ERP outcomes.
Patients in an intensive ERP-based treatment program (N = 116) completed weekly self-report measures.
Over the course of treatment, as OCD symptoms reduced, self-efficacy and distress tolerance both significantly increased. Importantly, increases in self-efficacy and distress tolerance mediated each other in explaining symptom reduction, suggesting a possible bi-directional effect.
The temporal relationship between changes in self-efficacy and distress tolerance is worthy of further investigation. In addition, the current sample had limited racial diversity and might not be representative of patients receiving lower levels of care. Findings merit replication to be ascertained of their reliability.
Findings suggest that during ERP, patients gain confidence in their abilities both to cope with general challenges and to withstand distress, potentially helping them engage with exposures and overcome initial fears. These findings provide support for the inhibitory learning model and highlight the mechanistic roles of self-efficacy and distress tolerance in ERP. Clinical implications to target both in treatment are discussed.
Anxiety during the long-term course of obsessive-compulsive disorder
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The study aimed to investigate anxiety and its relation with obsessive-compulsive symptoms during the long-term course of obsessive-compulsive disorder (OCD).
We used data from the Netherlands OCD Association (NOCDA) study, which included 419 participants with OCD (aged 18–79 years). Severity of obsessive-compulsive symptoms and anxiety at baseline and after two, four, and six years were entered into three models, which were analyzed using structural equation modeling: 1) the cross-lagged model, which assumes that anxiety and obsessive-compulsive symptoms are two distinct groups of symptoms interacting directly on the long-term; 2) the stable traits model, which assumes that anxiety and obsessive-compulsive symptoms result from two distinct latent factors, which are stable over the time and interact with each other; and 3) the common factor model, which assumes that anxiety and obsessive-compulsive symptoms are presentations of the same latent factor.
The cross-lagged model and the stable traits model both were valid models with a good model fit. The common factor model had a poor model fit and was rejected.
The duration of OCD varied widely between the participants (0–64 years). The majority experienced obsessive-compulsive symptoms since several years, which may have affected results on the course of anxiety and the interaction between anxiety and obsessive-compulsive symptoms.
Anxiety and obsessive-compulsive symptoms in OCD patients do not result from a shared underlying factor but are distinct, interacting symptom groups, probably interacting by distinct latent factors.
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Things that make you go Hmm: Myths and misconceptions within cognitive-behavioral treatment of obsessive-compulsive disorder
2023, Journal of Obsessive-Compulsive and Related Disorders
The past four decades have yielded a robust body of evidence supporting the efficacy and effectiveness of cognitive-behavioral therapy (CBT) as a gold-standard treatment for obsessive-compulsive disorder (OCD) across the lifespan. Exposure and response prevention (E/RP) has been identified as a key component of this approach. Despite robust research support for CBT with E/RP, several myths and misconceptions continue to proliferate in both research and practice settings. Such myths and misconceptions are concerning, as they lack empirical basis, may hinder widespread dissemination and implementation of CBT for OCD, and run contrary to the practice of evidence-based psychological medicine. Focusing on the importance of promoting evidence-based practice and generative clinical science, the present review article synthesizes relevant research within the field of treatments for OCD to address the following myths/misconceptions: (a) uncertainty exists concerning the evidence base supporting CBT for OCD, (b) E/RP attrition and dropout rates are unacceptably high due to excessive risk and perceived patient intolerability, and (c) alternative treatments for OCD need to be expeditiously developed due to major limitations of E/RP. Recommendations for future research and clinical dissemination and implementation to further advance a generative clinical science of OCD treatment are discussed.
Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore?
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Citation Excerpt :
As stated above, ERP, CBT and CT are all highly effective. Steketee et al.'s [19] mega-analysis of RCTs and clinical studies showed large effect sizes for CBT, CT and ERP for OCD and depression symptom reduction. However, OCD symptom severity decreases were slightly smaller for ERP in comparison to treatments that incorporated CT.
Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response.
Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response.
A number of ‘third wave’ therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more ‘personalised medicine informed’ treatment strategizing for OCD.
There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.

View all citing articles on Scopus

^☆: This study was supported by a grant from the International OCD Foundation awarded to Dr. Wilhelm. The authors are grateful to the following colleagues who provided data for this study: Dr. Jonathan Abramowitz, Dr. Jean Cottraux, Dr. Michael Kyrios, Dr. Kieron O’Connor, Dr. Neil Rector, Dr. David Tolin, Dr. Maureen Whittal, and Dr. Sabine Wilhelm.

^☆☆: Data statement. All data files were shared with permission of the investigators of the 8 research sites, following IRB regulations regarding protection of human subjects. We do not have permission to share these data files with other investigators.

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Predictors and Moderators of Cognitive and Behavioral Therapy Outcomes for OCD: A Patient-Level Mega-Analysis of Eight Sites☆,☆☆

Highlights

Abstract

Section snippets

Design and Sample

Sample Characteristics

Discussion

Conflict of Interest Statement

Behaviour Research and Therapy

The Lancet

Clinical Psychology Review

Clinical Psychology Review

Psychiatry Research

Behaviour Research and Therapy

Journal of Psychiatric Research

Journal of Anxiety Disorders

Clinical Psychology Review

Clinical Psychology Review

Clinical Psychology Review

Comprehensive Psychiatry

Behaviour Research and Therapy

Behaviour Research and Therapy

Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: A quantitative review

Journal of Consulting and Clinical Psychology

Diagnostic and statistical manual of mental disorders

Cognitive therapy of depression

Anxiety disorders interview Schedule for DSM-IV: Adult version

Obsessive-compulsive disorder: Prediction of outcome from behavioural psychotherapy

Acta Psychiatrica Scandinavica

A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder

Psychotherapy and Psychosomatics