Review of: Hollmann K et al, Front Psychiatry 2022;13:989550

Study Type: Randomized, single-blind, multiple-baseline controlled trial

Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) is an effective treatment for obsessive-compulsive disorder (OCD), but therapists with this specialty training are not always available. Internet-based therapy can expand access, but how well does it work? This study examined the efficacy of online CBT for children with mild to moderate OCD.

Sixty children ages 6–18 (average age 13.54) were recruited from a German outpatient OCD clinic. All had a primary OCD diagnosis with a score greater than 16 on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Children on stable psychotropic medication were included.

Participants underwent 14 weeks of live, online CBT, including ERP. They were split into two groups: Group 1 started immediate treatment, while Group 2 (control group) started after a 16-week delay. The primary outcomes were clinician-rated OCD symptoms (CY-BOCS) and Clinical Global Impressions (CGI), assessed at the outset and then at 16, 32, and 48 weeks post-treatment.

At 16 weeks, there was a very large and significant reduction in OCD symptoms in Group 1 compared to Group 2 (p<0.001, Cohen’s d=1.63). Seventy-nine percent of participants showed a positive response (35% reduction in CY-BOCS and improved CGI rating), and 64% achieved remission (CY-BOCS<12). Group 2 showed similar improvements, and both groups demonstrated sustained improvements post-treatment. Families generally preferred online CBT and rated it highly. Limitations included a large dropout rate, subject selection (lower generalizability), and openness to online therapy. Also, multiple-baseline studies inflate effect sizes.

Carlat Take

Results demonstrate the treatment’s effectiveness and are comparable to studies of face-to-face CBT for OCD, which found a large effect size (Cohen’s d=1.35) with 40% remission (Pediatric OCD Treatment Study Team, JAMA 2004;292(16):1969–1976). Still, this study theoretically supports expansion of OCD treatment to online formats for families that can comfortably navigate the technology. Replication studies should look at onset of efficacy and duration of effects.