Search

ObjectivesThe aim was to describe sub-populations and examine cognitive-behavioral therapy (CBT) outcome from the Nordic Long-Term OCD Treatment Study (NordLOTS), based on health anxiety symptoms (HAS), body dysmorphic symptoms (BDS), tic symptoms (TS), hoarding symptoms (HS), autism spectrum disorder symptoms (ASDS), age and OCD symptom type.MethodsThe NordLOTS included 269 OCD patients aged 7-17 years with OCD (DSM-IV) who all received stepped-care treatment beginning with 14 weekly sessions of CBT and assessed 3 years after ended treatment.ResultsHAS were present in 31% of the participants (often with other anxiety symptoms), BDS in 7.8% of the sample and correlated with age and other anxiety symptoms, ASDS symptoms in 10% with higher rates of ADHD and tic disorders, lower insight, more indecisiveness and pervasive slowness. TS were found in 29.9% of participants, who were more likely to be male, have earlier OCD onset, more impairment and comorbidity. HS were seen in 26.8%, who also had more comorbid tic disorders and indecision. All subgroups (including age groups) presented with different OCD symptom profiles. Patients with higher levels of symmetry/hoarding related symptoms responded slightly more favorable to CBT than those with other types of OCD symptoms. Contamination symptoms may be important for a specific population of limited responders.ConclusionsAlthough subpopulations presented with different demographic and clinical profiles, most did not differ in their response to CBT. Symmetry/hoarding related OCD may show a slightly more favorable response to CBT compared with other types of OCD.

ObjectivesThe aim of the present study was to investigate long-term OCD symptom severity trajectories in the NordLOTS sample during and up to three years after stepped-care treatment and to detect predictors of trajectory group membership. Further, the aim was to investigate quality of life over three years in the trajectory groups.MethodsLong-term symptom severity trajectories were investigated using latent class growth analysis (LCGA) on data from all 269 patients from the NordLOTS who were assessed at seven time points over three years: Pre-CBT, mid-treatment, post-CBT and 6, 12, 24, and 36 months after treatment. Symptom severity was assessed using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Predictors of class membership were investigated using multivariate analysis. Patient and parent proxy ratings of quality of life were assessed at the same seven time points (n = 220).ResultsThree distinct long-term OCD symptom severity trajectory groups were identified: a) acute, sustained responders (54.6%); b) slow, continued responders (23.4%); and c) limited long-term responders (21.9%). Baseline predictors of group membership pertained to age, symptom severity, contamination/cleaning, and anxiety symptoms. Further, the groups showed differences in quality of life over the three years compared to norm levels.ConclusionsClinical attention is required for adolescent OCD patients showing less convincing response to first-line CBT as well as contamination/cleaning and anxiety symptoms. They may have reached the established clinician-rated cut-off for treatment response, yet patient-rated quality of life assessment after treatment could detect patients in need of further care.

The NordLOTS rationale for a stepped-care study was that patients who received serotonin re-uptake inhibitors (SRI) were mainly CBT non-responders while RCTs examining the outcome of SRI were treatment naive. We argued that CBT non-responders may have an attenuated SRI response, and that continued CBT would be the preferable control contingency as we had reason to believe that CBT (particularly focusing on exposure and response prevention (ERP)) may still show some efficacy. A 3-year follow-up of all patients was added to inform on treatment durability.In NordLOTS, 269 step-1 participants had a pre-ERP average CY-BOCS score of 24.6, and completers (n = 241) of ERP treatment had a response rate (post ERP CY-BOCS ≤ 15 points) of 72.6% with a mean symptom reduction of 52.9%. Out of 69 non- or partial responders to step 1 ERP, 54 patients accepted step 2 randomization to continued ERP or sertraline (mean CY-BOCS = 27.3 and 25.2, respectively). Due to attrition, the final intent-to-treat sample included 50 participants (48% males). Twenty-one of 28 participants (75 %) completed continued ERP while 15 of 22 participants (69.2%) completed sertraline. The CY-BOCS total score examination revealed no differences between treatments (mean = 21.3 and 21.1, respectively) and response rates were 50.0% and 45.4%, respectively.Good step-1 ERP response rates, and equal response to step-2 sertraline or continued ERP showed that extended treatment may be worthwhile in pediatric OCD, and following our 269 participants yearly for three years will demonstrate if treatment durability is acceptable as well.

ObjectivesSexual obsessions including thoughts about sexual acts with family members, sexually inappropriate behavior, or homosexual orientation may remain undiagnosed because of embarrassment to report thoughts that are perceived as unacceptable. This study investigated prevalence of sexual obsessions and treatment outcome.MethodsSexual obsessions and OCD severity were assessed with the Children’s Yale-Brown Obsessive- Compulsive Scale in all 269 participants of the Nordic Long-term OCD Treatment study (mean age 12.8 years, 48.7% boys) at baseline, after treatment and three years follow-up. Treatment consisted in individual manualized Cognitive Behavioral Therapy (CBT) with exposure and response prevention. Patients with and without sexual obsessions were compared on clinical characteristics and treatment outcomes.ResultsSexual obsessions were reported by 18% of the NordLOTS sample. Participants with sexual obsessions were slightly older than those without (13.5 versus 12.7 years). Both groups had no difference in treatment outcome.ConclusionOur results suggest that a considerable number of children with OCD experience sexual obsessions. If addressed and treated, the response to CBT is similar as in other obsessions. Sexual obsessions may add a significant load of distress and embarrassment to the burden of exaggerated worries present in OCD. CBT practitioners need to be aware that sexual obsessions might be disguised and not disclosed during assessment and the treatment course. Clinicians need to assist the child to identify these obsessions in a sensitive dialogue and to address them in treatment. Findings, including case examples, will be discussed and implications for clinical practice outlined.

ObjectivesThe aim of the present study (part of the NordLOTS) was to examine the long-term outcome of a stepwise treatment for childhood OCD with initial CBT and a comparison between extended treatment with either continued CBT or sertraline for non-responders to initial CBT. Further, the aim was to investigate whether duration of treatment is an important indicator of three-year outcome.MethodsThis long-term follow-up study included 269 participants (48% males) from the NordLOTS sample. All participants were followed over three years (6, 12, 24 and 36 months) after initial CBT, symptom severity was repeatedly assessed with the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Primary outcome measure was the CY-BOCS, treatment response and remission were defined as CY-BOCS total scores ≤15 and ≤10, respectively. Analyses were conducted according to intent-to-treat principles with linear mixed-effects (LME) model.ResultsAt three-year follow-up 73% (n = 196) were free from OCD or in clinical remission, and another 17% (n = 46) responders to treatment. The mean CY-BOCS total score at baseline of 24.7 decreased to 5.0 after three years with a mean decrease of 5.9 from after treatment to three-year follow-up. Duration of treatment did not influence the symptom level at three-year follow-up and no significant difference was found (p = .99) between the different extended treatments.ConclusionFindings suggest a long-term durability of gains made by manualized CBT, and if needed, extended treatment with CBT or augmentation with sertraline for pediatric OCD and symptoms decreased even further during the three-year period.

ObjectivesObsessive-Compulsive Disorder (OCD) affects 1-2% of the child and adolescent population, severely affecting their quality of life. Cognitive-behavioral therapy (CBT) and medication are efficacious, but a significant proportion of patients still fail to respond adequately to treatment. Few studies have systematically looked at the long-term outcomes, specific group outcome trajectories, and predictors of outcomes. The overall aim is to use the study results to guide practitioners with patients who do not respond to CBT.MethodsSix presentations are based on results from the Nordic Long-term OCD Treatment Study (NordLOTS) that included 269 OCD patients aged 7-17 years from Denmark, Norway and Sweden. All participants received stepped-care treatment starting with 14 weekly sessions of CBT. Non-responders were randomized to either prolonged CBT or SSRIs. All patients were monitored for three years after ended CBT.ResultsLong-term treatment effects for pediatric OCD were sustainable for the sample as a whole, but subgroups with less favorable outcome trajectories were identified based on both OCD severity and functional impairment. Relapse at some point during follow-up was not uncommon. Predictors of different outcomes are identified.ConclusionsOutcome data from the NordLOTS will be discussed with focus on long-term treatment outcomes, including different groups of outcome trajectories based on OCD type and severity, functional impairment and comorbidity. Various predictors of treatment outcomes will be discussed, including comorbidity and OCD symptom types. Findings will be presented and discussed in relation to their importance for clinical practice, including key issues that remain in the treatment of OCD.

Additional file 1: Supplementary file 1: WHO trial registration data set.

Additional file 2: Supplementary material: SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.

Key Points Question Is internet-delivered cognitive behavioral therapy followed by face-to-face treatment for nonresponders a cost-effective alternative to in-person cognitive behavioral therapy alone for children and adolescents with obsessive-compulsive disorder? Findings In this economic evaluation of a randomized clinical trial including 152 children and adolescents with obsessive-compulsive disorder, internet-delivered cognitive behavioral therapy followed by face-to-face treatment for nonresponders was associated with reduced costs compared with traditional in-person cognitive behavioral therapy alone, without impairing effectiveness. Meaning This study suggests that a stepped-care model of cognitive behavioral therapy delivery may be cost-effective for young people 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., This economic evaluation assesses 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.