Study Reviewed: Lenhard F et al. Therapist-guided, Internet-delivered cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: A randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2017;56(1):10–19. doi:10.1016/j.jaac.2016.09.515

Study Type: Randomized controlled trial

The prevalence of obsessive-compulsive disorder (OCD) in childhood and adolescence is 2% (Angst J et al, EurArch Psychiatry Clin Neurosci 2004;254:156–164). Cognitive behavioral therapy (CBT) is a very effective treatment for pediatric OCD. So why aren’t more parents taking advantage of it? It can be costly, and there aren’t enough therapists who are well trained in using CBT for adolescents with OCD. The question is, how can we deliver this proven treatment to the patients who need it? In this study, Lenhard and colleagues attempted to determine whether Internet-delivered CBT is ­effective.

This 12-week study took place in Stockholm, Sweden. In it, 67 patients with OCD, between 12 and 17 years of age, were randomly assigned to a therapist-guided Internet CBT group (ICBT, n = 33) or to a waitlist (n = 34). Participants were recruited through advertising or referral by primary care doctors or mental health specialists. Outcomes were measured at baseline, 12 weeks (the end of treatment), and 3 months post-treatment. The ICBT program, designed by trained CBT therapists for a previous study, consisted of 12 online chapters with text, films, and animations. Some chapters were primarily for the patients, whereas others were designed for parents. Therapists were available to parents via email and phone throughout the study, but there were no face-to-face therapy appointments ­scheduled.

Results
At the end of treatment, the ICBT group improved significantly more on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores compared with the waitlist group (p < .001); 9 ICBT subjects were responders, and 5 remitted. Interestingly, at the 3-month follow-up, there was even more improvement in the ICBT group, with 10 responders and 8 remitters. By contrast, no one in the waitlist group responded or remitted at any time point.

CCPR’s Take
This was a fairly small study, and it did not include an active control group, but nonetheless the results were impressive. At 3 months post-treatment, 18 of 33 adolescents responded or remitted. The authors point out that the response was not as robust as that seen in studies of adults using ICBT or in studies of face-to-face CBT in pediatric OCD populations. Still, clinicians spent only about 17 minutes weekly with each participant—far less than in face-to-face CBT—so cost was significantly reduced.

Practice Implications
Internet CBT is not the perfect solution: Patients must have access to the Internet and an ICBT program and have a parent who is motivated enough to participate. This is therapist-guided CBT, not just a self-help program. Still, despite its limitations, ICBT may offer a feasible way of getting treatment to individuals who otherwise might suffer the fate of those on the waitlist—that is, no relief.