Internet-based cognitive behavioral therapy (iCBT) is a form of psychotherapy delivered via the internet, allowing patients to access treatment remotely. It applies principles of cognitive behavioral therapy (CBT), like identifying unhelpful thoughts and gradually facing fears, through online modules, assignments, and sometimes contact with a therapist via email or messaging.
Key Points
Rationale
Obsessive-compulsive disorder (OCD) is a disabling condition affecting 2-3% of the population, causing significant distress and impairment (Ruscio et al., 2010).
Cognitive behavioral therapy (CBT)with exposure and response prevention (ERP) is the gold standard psychological treatment, but barriers like accessibility and cost limit its reach (Andersson & Titov, 2014).
Internet-delivered CBT (iCBT) can increase access and be cost-effective, with demonstrated efficacy for OCD in previous studies (Dèttore et al., 2015; Pozza et al., 2016; Wootton, 2016).
However, prior meta-analyses are 5+ years old or lacked focus on iCBT specifically. This study provided an updated meta-analysis focused solely on iCBT for adult OCD patients to characterize its efficacy in ameliorating obsessive-compulsive symptoms.
Method
Thesystematic reviewandmeta-analysisfollowedPRISMA guidelinesfor meta-analyses. 15 studies (6 RCTs, 9 open trials) with 552 OCD patients receiving iCBT were included.
Treatments were 8-17 weeks long and could be therapist-guided or self-guided. TheYale-Brown Obsessive Compulsive Scale(YBOCS) was the primary outcome measure of OCD severity.
According to the paper, the inclusion criteria for the studies in the meta-analysis were:
Initially, the authors also established a control group as an inclusion criterion. However, due to the limited number of available studies, they opted to include studies without a comparison group as well.
Sample
552 OCD patients over 15 studies; 68% female; mean age range 29-41 years; mean baseline YBOCS range 20-25.8.
Statistical Analysis
Random effects meta-analysis models calculated pooled effect sizes and confidence intervals. Heterogeneity was assessed using I2 values. Moderator effects were analyzed using subgroup analyses and meta-regressions. Publication bias was evaluated through funnel plots, Egger’s tests, and trim-and-fill analysis.
Effect sizes(Cohen’s d converted to Hedge’s g) were calculated for pre-post (k = 15), pre-follow-up (k = 11), and between-group (iCBT vs. control condition; k = 6) comparisons. Moderator effects and publication bias were assessed.
Results
The meta-analysis found that internet-based CBT (iCBT) had a large effect (g = 1.14) in reducing OCD symptoms from pre- to post-treatment. This means iCBT was effective in decreasing OCD symptoms.
The gains from iCBT were also large (g = 1.16) when measured from pre-treatment to follow-up assessments, meaning the OCD symptom improvement was maintained over time after treatment.
However, there was significant variability (heterogeneity) in the results across the different studies analyzed. When two outlier studies with unusually low effect sizes were removed, this heterogeneity decreased considerably.
Insight
This meta-analysis demonstrates iCBT is an effective treatment approach for ameliorating OCD, with large improvements maintained over time.
Accessibility, cost-effectiveness, and other advantages make iCBT a promising avenue for OCD care.
Therapist guidance did not appear to affect efficacy significantly. However, dropout rates were lower with guidance, highlighting its potential value for adherence.
Strengths
Limitations
Implications
With demonstrated efficacy and advantages over face-to-face approaches, iCBT shows promise as a low-intensityfirst-line treatmentin a stepped care model, before progressing to traditional CBT if needed.
This could greatly expand OCD treatment access. More research should examine real-world feasibility and long-term outcomes. Predictors of dropout and adherence also warrant attention to optimize implementation.
References
Primary reference
Machado-Sousa, M., Moreira, P. S., Costa, A. D., Soriano-Mas, C., & Morgado, P. (2023). Efficacy of internet-based cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis.Clinical Psychology: Science and Practice, 30(2), 150–162.https://doi.org/10.1037/cps0000133
Other references
Andersson, G., & Titov, N. (2014). Advantages and limitations of Internet-based interventions for common mental disorders.World Psychiatry, 13(1), 4-11.https://doi.org/10.1002/wps.20083
Dèttore, D., Pozza, A., & Andersson, G. (2015). Efficacy of technology-delivered cognitive behavioural therapy for OCD versus control conditions, and in comparison with therapist-administered CBT: Meta-analysis of randomized controlled trials.Cognitive Behaviour Therapy, 44(3), 190-211.https://doi.org/10.1080/16506073.2015.1005660
Pozza, A., Andersson, G., & Dèttore, D. (2016). Therapist-guided internet-based cognitive-behavioural therapy for adult obsessive-compulsive disorder: A meta-analysis.European Psychiatry, 33(S1), s276-s277.https://doi.org/10.1016/j.eurpsy.2016.01.737
Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication.Molecular Psychiatry, 15(1), 53–63.https://doi.org/10.1038/mp.2008.94
Wootton, B. M. (2016). Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis.Clinical Psychology Review, 43, 103-113.https://doi.org/10.1016/j.cpr.2015.10.001
Keep Learning
Commentary
Adamis, A. M., & Olatunji, B. O. (2023). The promise and potential pitfalls of iCBT for obsessive–compulsive disorder.Clinical Psychology: Science and Practice, 30(2), 163–166.https://doi.org/10.1037/cps0000137
Promise: iCBT is Efficacious and Accessible
Potential Pitfalls: Methodology Matters
For Whom is iCBT Recommended?
Directions on Dissemination
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
