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Concentrated ERP delivered in a group setting: An effectiveness study
Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 319–324
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Concentrated ERP delivered in a group setting: An effectiveness study Audun Havnen a,b, Bjarne Hansen a,b, Lars-Göran Öst b,c,d, Gerd Kvale a,b,n a
Haukeland University Hospital, OCD-team, 5021 Bergen, Norway Department of Clinical Psychology, University of Bergen, Norway Department of Psychology, Stockholm University, Sweden d Department of Clinical Neuroscience, The Karolinska Institute, Stockholm, Sweden b c
art ic l e i nf o
a b s t r a c t
Article history: Received 6 June 2014 Received in revised form 10 August 2014 Accepted 21 August 2014 Available online 28 August 2014
The aims of the present study were to evaluate the acceptability and long term gains of a highly concentrated exposure and response prevention (ERP) for obsessive compulsive disorder (OCD). Treatment was individually tailored and delivered in a group format over four consecutive days in an outpatient OCD treatment unit, part of the ordinary specialist health care. A total of 35 patients accepted the offer of treatment; 23 of the patients were classified with “severe” to “extreme” OCD, and 74% of the sample had previously received treatment for their OCD (20% of these with ERP). The results showed that more than 90% of the patients expressed a high degree of satisfaction with the concentrated ERP. At six months follow-up 27 (77%) were classified as recovered and a significant improvement was seen in depressive symptoms as well. The majority of the sample also showed improvement with regard to employment status 12 months after treatment. The results indicate that this highly concentrated treatment may be a feasible format of delivering ERP. & 2014 Published by Elsevier Inc.
Keywords: OCD ERP 4-day intensive program Group format Long term follow up Patients' acceptance
1. Introduction Exposure and response prevention (ERP) combined with cognitive therapy is widely recognized as an effective and efficient treatment for obsessive–compulsive disorder (OCD) (Abramowitz, 1996; Cox, Swinson, Morrison, & Lee, 1993; Eddy, Dutra, Bradley, & Westen, 2004; National Collaborating Centre for Mental Health, 2006; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). It has been demonstrated to yield clinically significant results when delivered in a wide range of formats like individual, group, internet-based as well as by telematics and as selfhelp (Coles, Cook, & Blake, 2007; Himle et al., 2006; Jónsson & Hougaard, 2009; Mataix-Cols & Marks, 2006; Vogel et al., 2012). It has also been shown to be promising when delivered in a more concentrated form than weekly sessions (Abramowitz, Foa, & Franklin, 2003; Whiteside, Brown, & Abramowitz, 2008; Whiteside & Jacobsen, 2010). The treatment of another anxiety disorder, namely specific phobia, has in more than 30 randomized studies been shown to be successfully delivered in an even more concentrated format with substantial and lasting clinical changes following one prolonged session lasting maximum 3 h (Thompson, Ollendick, & Öst, 2012). For
n Corresponding author at: Haukeland University Hospital, OCD-team, 5021 Bergen, Norway. Tel.: þ47 55 95 63 80. E-mail address: [email protected] (G. Kvale).
http://dx.doi.org/10.1016/j.jocrd.2014.08.002 2211-3649/& 2014 Published by Elsevier Inc.
many patients, the one-session approach is highly attractive since they during a very short time may get rid of a severe problem affecting everyday life. From a cost-effectiveness perspective this concentrated form also has advantages, one of them being no dropout during treatment. Inspired both by features from the well documented approaches to the treatment of OCD as well as specific phobia, our research group has developed a highly concentrated mode of delivering ERP to OCD patients referred to an OCD-unit which is part of the ordinary specialist health care. In a recent pilot study the approach showed very promising results, even for patients with a number of previous treatment-failures (Havnen, Hansen, Haug, Prescott, & Kvale, 2013). During two consecutive treatment days, each lasting 8–10 h, five to six patients in each group received individually tailored and therapist assisted exposures. A comprehensive psycho-education was given to the group the day before the ERP was initiated, and immediately after the two days of ERP, the group of patients was instructed in strategies for maintaining the change and taught principles for how to be their own therapist. Three months later they met for a booster session (Havnen et al., 2013). In the current study, which is an extension of the pilot trial, we wanted to repeat the approach in a larger sample of patients, and to investigate both the patients' acceptability of this concentrated ERP treatment and its clinical effects.
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2. Method 2.1. Participants 2.1.1. Referral procedures and diagnostics The current study is part of a standard quality control performed at our outpatient OCD treatment unit, part of the ordinary specialist health care. Patients included in the study were first referred from their individual general practitioner to the local outpatient district psychiatric facility. If the OCD, or suspected OCD was considered severe enough to grant public health-care, patients were then referred to the OCD-team. Patients were offered treatment from the OCD-team if a principal DSM-IV-TR diagnosis of OCD was established (American Psychiatric Association, 2000) according to the administration of the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). Since the OCD-team is part of the secondary mental health services, all patients with OCD referred to the clinic have to be offered treatment, but treatment is not initiated if the patient is suicidal, psychotic or in active substance abuse. Also, ERP treatment in a group format is not offered if the patient is not Norwegian-speaking. A total of 37 individuals (26 females) between 20 and 60 years old (M ¼32.4, SD ¼ 10.0) who were consecutively referred to the OCD outpatient clinic were offered treatment. Two patients (females) did not want to participate in a group, and were offered individual treatment. Both were working with children and mainly had obsessions with sexual content, and the reason for declining was the fear of being recognized by other participants. The sample thus consisted of 35 individuals. 2.1.2. OCD duration/severity and previous treatment Mean Y-BOCS score pre-treatment was 26.14 (SD ¼4.33), with 12 patients (34%) classified with moderate OCD (Y-BOCS scores from16 to 23), M ¼21.00, SD ¼1.04, and 23 patients (66%) with severe/extreme OCD ( Y-BOCS from 24 to 40), M ¼ 28.83, SD ¼2.55 (Marques et al., 2010). Mean duration of OCD problems was 16.7 years (SD¼ 10.4) and 26 (74%) had previously received psychological treatment. Of these, 7 (27%) reported having received ERP, 3 (8.6%) cognitive therapy, and 16 (45.7%) had undergone other forms of therapy. Ten patients had received 1 therapy course, 6 patients had received 2 courses, 5 had 3 courses and 5 had 4 courses. The mean Y-BOCS pre-treatment scores for treatment naïve patients and patients with previous therapy trials did not differ significantly. 2.1.3. Comorbidity Fourteen patients had no comorbid diagnoses and 21 (60%) had comorbid disorders, which included generalized anxiety disorder (n¼ 7), panic disorder without agoraphobia (n¼ 6), hypochondriasis (n¼ 1), mild or moderate depression (n¼6), dysthymia (n ¼1), social phobia (n ¼1) and paranoid psychosis (n¼ 1). Patients with comorbidity did not differ from patients without comorbid disorders on pretreatment Y-BOCS scores (t(33)¼1.45, p¼ 0.16). 2.1.4. Pharmacological treatment Use of medication was registered at the initial interview. Twenty-one patients (60%) were currently receiving pharmacological treatment with SSRI. In addition one patient had prescribed antipsychotic medication; one had sleep medications prescribed (to be taken when needed); two had prescriptions for benzodiazepines (to be taken when needed) and one had prescribed an anxiolytic (to be taken when needed) other than benzodiazepine. Four patients had two different medications and one had three different medications. Patients with and without SSRI prescriptions did not differ on Y-BOCS scores (t(33)¼0.16, p ¼ 0.89) or BDI scores (t(33)¼ 0.17, p ¼0.89). Patients on SSRI were asked to keep medication doses unchanged four weeks prior to and during the four-day treatment period. The recommendation was however not followed by further assessment of medication use. Patients with prescribed sleep medication or anxiolytics were asked to discontinue these medications prior to and during treatment; adherence to these instructions was urged by the therapists throughout the treatment period. Patients were asked not to seek concurrent treatment during the treatment period. 2.1.5. Employment status Nine of the patients were on sick-leave 50% or more of the time prior to treatment, and another 18 patients stated (during the initial interview) that their work or studies were severely affected by the OCD. One of the patients was on disability pension, and one was at home caring for children. 2.2. Procedure Referred patients met for an initial interview session for clinician administered MINI and the registration of anamnestic information, and when the OCD-diagnosis was established they met for two additional assessment sessions. The severity of obsessive–compulsive symptoms was assessed with the Yale-Brown Obsessive– Compulsive Scale (Y-BOCS; Goodman et al., 1989a, 1989b). A detailed registration of the patients' obsessions and compulsions was collected and the patients received an introductory psycho-education, based on the Kozak and Foa (1997) manual,
offering an explanation of how obsessions were maintained by the use of rituals. Also, a presentation of the treatment rationale was offered. The patients' expectations of treatment outcome as well as their evaluation of the treatment credibility were assessed with an adapted version of the Borkovec and Nau (1972) Reaction to treatment scale, in which four aspects of expectancy and credibility were evaluated on a 0–100% scale, with higher values indicating more positive evaluations. If a patient reported an expectancy or credibility score below 70%, this was taken as an opportunity to clarify possible misunderstandings regarding the treatment. In total the sample had a mean score of 94.57 (SD ¼1.67). Prior to the first assessment session, patients were mailed a number of selfreport questionnaires (see below) to be completed before the first visit at the clinic. These questionnaires were also completed at the end of the treatment, as well as at three and six months after treatment (mailed and to be returned in pre-paid envelopes). In addition patients were telephoned 12 months after treatment to collect data concerning employment status to monitor any changes in rates of sick leave or whether the work related interference of obsessive–compulsive symptoms had changed. All patients were informed that data were routinely collected as part of standard quality control procedures at the clinic. The MINI interviews were conducted by a psychiatrist or a clinical psychologist trained in the administration of this structured clinical interview. Patients granted specialist health care had to be offered treatment within three months. As only three groups were initiated per semester at the OCD clinic, patients were offered individual treatment if group treatment was not available within the three months treatment deadline. The Y-BOCS interviews at pre-treatment were conducted by one of the psychologists or psychiatrists in the OCD-team. Y-BOCS at post-treatment as well as at three and six months follow-up were conducted by phone by an independent psychologist. The independent assessor was aware that the patients had received concentrated ERP treatment, but was otherwise not involved in the study. All Y-BOCS interviews were conducted by clinicians with special training in performing the interview.
2.3. Measures The Y-BOCS interview consists of 10 items covering the severity of both obsessions and compulsions, and is frequently used to assess treatment response. The Y-BOCS has good psychometric properties (Goodman et al., 1989a, 1989b). Beck Depression Inventory (Beck, Steer, & Brown, 1996) is a 21-item questionnaire that assesses depressive symptoms. Items are judged on a 0–3 scale, and higher total score indicates more severe symptom severity. The psychometric properties of BDI are well-established (Beck & Steer, 1984; Beck, Brown, Steer, Eidelson, & Riskind, 1987). Client Satisfaction Questionnaire 8 (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) is an 8-item questionnaire which measures patient satisfaction with health services. Each item is scored from 1 (very low satisfaction) to 4 (very high satisfaction), total score ranges from 8 to 32 with higher scores indicating higher degree of satisfaction. The CSQ-8 has sound psychometric properties (Larsen et al., 1979; Nguyen, Attkisson, & Stegner, 1983). All outcome measures were part of the standard quality control instruments of the health services offered at the outpatient OCD clinic at Haukeland University Hospital.
2.4. Therapists The individualized group treatment was always led by at least one out of four experienced psychologists in the team. Lead therapists were licensed clinical psychologists with extensive training and practice in cognitive behavioral therapy of anxiety disorders. Two of the lead therapists were authorized supervisors in cognitive behavioral therapy (CBT), the other two had more than 15 years of experience in delivering cognitive behavioral treatment. Co-therapists were licensed clinical psychologists or a psychiatrist, all with some basic training in ERP and CBT.
2.5. Treatment Treatment was delivered as part of the standard mental health care provided by the OCD team. The concentrated format was new to the health services; but since its total treatment hours did not exceed standard resources allocated to a 16 session individual treatment following the Kozak and Foa (1997) manual, but mainly represented an alternative approach to the distribution of therapist time, it was approved. It was conducted in groups of 5–6 participants with a 1:1 therapist– patient ratio, which would have been the same as if the treatment had been given individually. The treatment manual was adopted from the ERP principles described in the Kozak and Foa (1997) and Foa, Yadin, and Lichner (2012) manuals and had previously been described in more detail elsewhere (Havnen et al., 2013). A full manual with clinical examples is under preparation (Hansen, Havnen, Öst, & Kvale, 2014). Treatment was delivered over four consecutive days, with a booster session
A. Havnen et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 319–324 after three months. Relatives and friends were invited to a psycho-educative meeting in the afternoon, Day 3. Day 1: On day 1 the patients met for 3 h for a detailed psycho-education combined with deciding upon individually tailored exposure tasks. Rules for confidentiality between therapists and participants, and among participants were established. The group setting was introduced as especially useful for learning about the principles of OCD, since the patients would have different OCD-concerns, but at the same time could be helped by the same principles of treatment (ERP). They were also encouraged to be supportive and to help each other to be brave and to find the courage to engage fully in the most useful exposure tasks. During the psycho-education it was emphasized that in order to learn that anxiety and discomfort are misconceived by the brain as a sign of danger it is important to evoke anxiety without any rituals or anxiety-reducing behavior, and in this way let the brain gain new “experiences” about how anxiety is a poor indication of what is safe and what is dangerous. In line with this, anxiety and discomfort were explained as the “raw material of change”, and something to be chased and sought for like gold. They were also informed that they would not be told to do anything, but that the therapists would help identifying useful exposure tasks, which they in turn had to choose to perform. It was also underscored that each exposure task would consist of thousands of “micro-decisions” where they either could choose to “lean into the anxiety” or withdraw. When selecting exposure tasks, the ones with the expected largest potential for change were recommended. Expected largest potential for change was defined pragmatically by selecting the tasks that when performed, would exclude the necessity for training in a lot of different situations. It was furthermore underscored that none of the suggested exposures could be defined as guaranteed safe and none of them as dangerous. The mere task of exposure was presented as an opportunity to get encountered with specially designed uncertainty. If a patient e.g. was afraid of germs, exposure to toilets might be regarded as a task with “large potential for change” and given high priority. For a person afraid of harming someone, handling knifes in situations with loved ones might be considered a good task, as might lighting and turning out 30–40 candles in a variety of rooms, then blow them out in “bulks” instead of individually, and leave the house without checking might be considered a good exposure task for a patient with a checking problem. Day 2: The therapists and patients first met for a repetition of the principles and the tasks, lasting approximately 1 h. If two or three patients had similar exposure tasks, the exposures could start in a small group. The exposures were carried out in relevant settings, which in most cases were outside the clinic. Initial exposures were therapist-assisted, and typically the patient started with the exposure tasks with the “largest potential for change”, but in a gradual fashion. For a patient afraid of germs, the task would typically start with touching areas in the bathroom that the patient could manage with some effort, and then progress to the more difficult situations. When performing a certain task, the necessity to refrain from any strategy aimed at reducing anxiety was underscored, and the patients were told that it is better to start with performing one task with a “good technique” meaning that it should be done without any anxiety reduction strategies or rituals, and when the technique is learnt, progress to more challenging tasks instead of rushing ahead without paying attention to the anxiety reducing rituals. In order to help the patient to start he/ she was coached to identify subtle anxiety reducing strategies or compulsions, and was then encouraged to choose to fully engage in the exposure without them. An example of a subtle strategy to reduce anxiety could be calming self-assurances like “This is most likely not really dirty”, “I'm sure I won't get sick if I touch this” and replace it with self-talk underscoring the uncertainty “I cannot be certain that this is really safe”, etc. In addition to advice full response prevention, the patient was encouraged to spread the exposure to all thinkable situations. For a patient afraid of germs, this could be accomplished by making a water-based spray with traces of all the touched surfaces, and coach the patient to spray all rooms in the house, including cupboards. This spray was also to be used if the patient had washed the hands before eating, or if they had taken a shower in the morning on Day 3. During Day 2, each patient typically would practice exposure in all relevant situations including all relevant obsessions. The group had lunch together, and if practical, met at three or four in the afternoon to summarize. The exposure tasks did however have priority over group meetings. The patients were instructed to practice alone in the afternoon and evening, but with a detailed hour-by-hour plan. If needed, the therapist assisted at home and in the evening; this could e.g. be a “checker” performing exposure task like using electric kitchen items before bedtime. All patients were instructed to send an SMS to the therapist in the evening, evaluating their own performance during the day on a six-point scale. The patients were encouraged to give themselves a 6 if they had completed the exposure tasks in all the planned situations without any attempt to reduce anxiety, and without any rituals. They were also told to expect new “waves of anxiety” during the evening and/or night, and were told that their best way of handling it would be to find a situation to practice exposure (“lean into the anxiety”). Day 3: On day 3 patients and therapists met in the morning and summarized the progress and shared experiences before the exposure assignments were continued. Gradually during Day 3, the patients were given more responsibility for their own exposures. The groups and therapists met for lunch, and also for a meeting approximately at 4 p.m. if this was considered practical. In the afternoon of Day 3, relatives and friends were invited to a meeting together with the patients and therapists. During this, the psycho-education from Day 1 was basically repeated. Day 4: Patients and therapists met in the morning to summarize and to give each other feedback. Afterwards, the patients made a plan for continuing the
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exposure tasks for the coming three weeks. They also received psycho-education with the focus on relapse prevention. Booster session: 3 months after treatment patients were invited for a booster session. In the booster session the patients' experiences in the period following treatment were discussed. The principles for ERP were repeated and emphasis was put on how the patients' could best practice the therapy on their own. No exposure work was conducted in this session. 2.6. Statistics Statistical analyses were performed with SPSS version 22.0. Repeated measures ANOVA for Y-BOCS and BDI were conducted with Greenhouse–Geisser corrections. Effect sizes were calculated with Cohen's d, correcting for related means using the equation by Morris and DeShon (2002).
3. Results 3.1. Adherence and attrition One patient dropped out of treatment prematurely. The patient displayed a lack of motivation for adhering to the treatment principles of exposure and response prevention. This was addressed by the therapist and it was agreed that the patient terminated treatment prematurely and could reapply for treatment at a later stage if experiencing a higher degree of treatment motivation. The patient expressed satisfaction with this solution. A total of 34 patients completed treatment and were available for Y-BOCS interviews at post-treatment and 3 months follow-up. At 6 months follow-up 30 patients were available for Y-BOCS interviews, and 30 patients were available for collection of employment status at 12 months follow up. 3.2. Intention-to-treat analyses In order to allow participants with missing data to be included in the analyses, Full Information Maximum Likelihood procedure (FIML) was applied to impute missing data. This procedure provides unbiased estimates of the missing data and their standard errors based on the assumption that data are missing at random (MAR), and has been shown to perform better than alternative methods to estimate missing data (Enders, 2001a, 2001b). 3.3. Outcome measures Table 1 displays mean and standard deviations for Y-BOCS and BDI. The sample had a mean Y-BOCS score of 26.14 (SD¼4.33), which represents a pretreatment Y-BOCS score of slightly higher severity than in the 6 published randomized controlled trials directly comparing individual treatment (M¼24.02, SD¼2.44) and group treatment (M¼23.67, SD¼2.80; Öst, Havnen, Hansen, & Kvale, 2014), although these differences are non-significant. To Table 1 Means, standard deviations and effect sizes (Cohen's d) for Y-BOCS and BDI: intention to treat. Variable
M (SD)
ES
Pretreatment Posttreatment 3-month FU 6-month FU
26.14 9.00 10.63 10.26
(4.33) (4.76) (7.00) (5.67)
2.60 2.20 2.37
Pretreatment Posttreatment 3-month FU 6-month FU
18.56 10.04 9.76 8.84
(9.15) (6.56) (9.15) (7.31)
0.89 1.07 1.02
Y-BOCS
BDI
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examine Y-BOCS and BDI scores repeated measures ANOVA with Greenhouse–Geisser corrections was carried out. The results showed a significant change in Y-BOCS, F(2.82, 95.97¼ 102.00, p o0.0005). Subsequent dependent t-tests showed that the change from pre- (M¼26.14) to post-treatment (M¼9.00) was significant (t(34)¼15.34, po0.0005) whereas the change from post to 3-month (M¼10.63) or 6-month follow-up (M¼10.26) was not. A repeated measures ANCOVA with number of previous therapy trials as covariate showed that a number of previous treatment did not influence treatment outcome (p¼0.77). The analyses of BDI also showed a significant change, F(2.60,88.30¼ 15.89, po0.0005). Subsequent dependent t-tests showed a significant change from pre (M¼18.56) to post-treatment (M¼ 10.04); t(34)¼5.18, po0.0005), with no significant differences in BDI scores between posttreatment and 3- (M¼9.76) and 6-month follow-up (M¼ 8.84). OCD-severity was not related to outcome. Treatment naïve patients did not differ from patients with previous therapy trials in respect to outcome on any of the post-treatment measurements. The within-group effect-sizes for Y-BOCS and BDI are presented in Table 1. For both Y-BOCS and BDI large effect-sizes were found both from pretreatment to post-treatment and pretreatment to follow-up. 3.4. Clinical significant change To determine the number of patients who showed clinically significant change we applied the Jacobson and Truax (1991) criteria for clinical improvement, which states that in order to be defined as “recovered” a patient must a) show a reliable symptom reduction (the reliable change index) and b) be in the nondysfunctional range. Y-BOCS score was used to determine recovery status. We applied the Fisher and Wells (2005) criteria both for reliable change index and cut-off. To be defined as recovered in the present study a patient had to show a pre- to post-treatment or follow-up reduction in Y-BOCS of 10 points or more and had a Y-BOCS score of 14 points or below at post-treatment or follow-up. To be classified as improved patients had to obtain at least a 10 points reduction from pre- to post-treatment or follow-up and a post- or follow-up score above 14. Patients with a reduction less than 10 points were classified as unchanged, regardless of the final score being below the cut-off of 14 points. 77% of the sample was classified as recovered at post-treatment, 11% were improved and 11% showed no change. Of the latter two patients had a post Y-BOCS score at or below 14 but showed no reliable change. At follow-up 74% were identified as recovered, 14% as improved and 11% as unchanged. Three of the unchanged patients had a Y-BOCS score at or below 14 but no RCI. Table 2 shows the tracking of recovery rates at post-treatment and follow-up for the individual patient. Of the 27 patients who were recovered at post-treatment, 23 patients (85%) were still classified as recovered at 6-month follow-up, while 4 patients (15%) had deteriorated and were now classified as improved. Of the 4 patients who were improved at post-treatment, 2 had become recovered at 6-month follow-up,
1 remained improved whereas 1 had deteriorated to the category of no change. Of the 4 patients who were classified as unchanged at post-treatment, 2 had improved to a large extent and were at 6-month follow-up and 2 were still unchanged. Clinical significant change was also calculated for the subgroups moderate and severe/extreme OCD severity as assessed at pre-treatment. For the moderate subgroup (n ¼12), 67% were classified as recovered at post-treatment and 75% at follow-up. For the severe/extreme subgroup (n ¼23) 83% were recovered at post-treatment and 74% were recovered at 6-month follow-up 3.5. Employment status During a telephone interview 12 months after treatment patients were asked how the employment or study situation was affected by obsessive–compulsive symptoms now compared to before treatment. Of 9 patients who were on sick-leave 50% or more of the time prior to treatment, none were on sick-leave 12 months after treatment. Patients were also asked if they experienced a change in OCD-related interference during work (e.g. regarding interference by distressing obsessions or having to carry out compulsions). Of the 18 subjects who stated that the work or studies were affected prior to treatment, 15 stated that they had had a positive change. Two patients reported no change with regard to employment; one of them was on disability pension and the other was out of the job market. One patient did not want to comply and three patients were unavailable. 3.6. Treatment satisfaction A total of 31 patients completed CSQ-8 at post-treatment and results were analyzed as intention to treat using multiple imputations to account for missing data. Fully 69% described the quality of treatment as excellent and 66% stated they were highly satisfied with the extent of treatment. All patients stated that they would definitely return to the clinic in the future if they needed treatment. Details about treatment satisfaction are presented in Table 3. Overall, the results from CSQ-8 indicated that the majority of patients were highly satisfied with the concentrated treatment format.
4. Discussion The results from this study showed that the highlyconcentrated ERP treatment for OCD was well accepted by the participants. Only one patient terminated prematurely. Furthermore, the treatment produced substantial reduction in obsessive– compulsive symptoms as well as depressive symptoms, and changes were maintained at follow-up, even in patients with a number of previously unsuccessful treatments. Maybe the most
Table 3 Posttreatment scores on Client Satisfaction Questionnaire 8.
Table 2 Comparison of clinical improvement rates at post-treatment and 6-month followup. Posttreatment outcome
Recovered Improved No change Total
Follow-up Recovered
Improved
No change
Total
23 2 2 27
4 1 0 5
0 1 2 3
27 4 4 35
1. 2. 3. 4. 5. 6. 7. 8.
Question
Mean Absolute frequencies of satisfaction ratings score 1 2 3 4
Quality of service Kind of service Met needs Recommend to a friend Amount of help Deal with problems Overall satisfaction Come back
3.66 3.56 3.61 3.92 3.67 3.85 3.71 4.00
0 0 0 0 0 0 0 0
1 0 0 0 0 0 1 0
10 16 13 2 12 5 8 0
24 19 22 33 23 30 26 35
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important aspect of the concentrated treatment is the extent to which it was accepted by the participating patients, given that it was delivered over four consecutive days, with only two days of therapist assisted exposure. The results from CSQ-8 showed that the patients gave high ratings of different aspects of the treatment, suggesting that the treatment was accepted by the participants. In addition the statistical analyses showed that a large proportion of patients was classified as recovered both at post-treatment and at follow-up with results comparable to effectiveness studies of OCD (Öst, 2013). In general this study suggests that the four days concentrated ERP approach is a viable treatment format for patients suffering from OCD. The slightly higher mean Y-BOCS score at pretreatment compared to previous studies comparing individual and group treatment (Öst et al., 2014), the high recovery rate both in patients classified as having moderate and severe/extreme obsessive–compulsive symptom severity and the equal treatment outcome between treatment naïve patients and patients with previous therapy trials suggest that the therapy is also effective for severe cases of OCD. This is promising as it may be expected that a concentrated ERP approach would be too effortful for patients severely affected by OCD. Another expected finding is the concurrent reduction in obsessive–compulsive and depressive symptoms and that the drop in both symptom domains is maintained in the follow-up period. This can be interpreted as the depressive symptoms being secondary to the OCD and that the effective treatment of the primary disorder had a positive impact on comorbidity. In addition to the positive gains in symptom measures the positive changes in employment status must be noted, in particular the large number of patients no longer on sick-leave one year after treatment. Nine patients, who prior to treatment were on sick leave with various degrees of impaired working abilities, were back in fulltime work after the treatment. In addition 15 of 18 patients with impaired functioning in school or work had a decreased impairment after treatment. This is in correspondence with the majority of the sample expressing that the treatment had helped them deal more effectively with problems and that they were happy with the amount of help received. It is encouraging that the treatment led to substantial gains in terms of increased employment rates and this may suggest that in addition to producing decreases in obsessive–compulsive and depressive symptoms the treatment also had a positive impact on global functioning. The innovative approach of the concentrated treatment is the extended periods of therapist–patient contact, securing therapist assisted exposure work and response prevention, and the group setting that enhances group cohesion and positive peer influence, which has been suggested as important aspects of group treatment (Håland et al., 2010). The present treatment thus combines aspects both from individual and group treatment while keeping exposure and response prevention as the common denominator. The treatment format was new to the health service, but since the resources allocated to the treatment did not exceed standard care (Kozak & Foa, 1997), and the clinic had a group of therapists experienced with OCD-patients and ERP, it was approved. Since the approach is promising with regard to clinical results, one may argue that if the results are replicated in a larger-scale study, it has a good potential of dissemination, since the treatment is conducted across four consecutive days only. This means that a few available welltrained therapists can treat more patients during a certain time period and patients can travel to the experts and stay in a hotel during four nights to receive the treatment. Since the amount of therapy hours is not more than the common ERP according to the Kozak and Foa manual it should not be a reimbursement problem for insurance companies or state-funded health care. Clearly the study suffers from limitations. It might be a potential limitation that pre-treatment assessment was conducted
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face-to-face whereas post-treatment and follow-up Y-BOCS interviews were telephone administered, although it may also be argued that the telephone administration of Y-BOCS has received some empirical support (Baer, Brown-Beasley, Sorce, & Henriques, 1993) and that post-treatment evaluations carried out by an independent party enhances unbiased assessments. The most obvious limitations of the study are the lack of a control condition and the small sample size. The results must thus be interpreted cautiously and future research comparing the concentrated ERP to an established ERP format is warranted. In the wait of larger controlled trials this quality control study offers support that ERP can be successfully concentrated into a four-day treatment, delivered as individual treatment in a group setting, which further verifies the feasibility of ERP with successful outcomes in a variety of treatment formats.
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Nguyen, T. D., Attkisson, C. C., & Stegner, B. L. (1983). Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire. Evaluation and Program Planning, 6(3–4), 299–313. Öst, L. G. (2013). Behandling av angstlidelser med kognitiv atferdsterapi – gir det resultater i vanlig klinisk praksis?. In: G. Kvale, O. E. Havik, E. R. Heiervang, B. S. M. Haugland, & T. Tangen (Eds.), Hvordan sikre angstpasienter kunnskapsbasert behandling? (pp. 50–62). Oslo: Universitetsforlaget. Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. 2014. Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2013, Unpublished manuscript. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl. 20), S22–S33 (quiz 34–57). Task Force on Promotion and Dissemination of Psychological Procedures (1995). Training in and dissemination of empirically-validated psychological treatments: report and recommendations. The Clinical psychologist, 48(1), 3. Thompson, E. D., Ollendick, T. H., & Öst, L.-G. (2012). Intensive one-session treatment of specific phobiaNew York: Springer. Vogel, P. A., Launes, G., Moen, E. M., Solem, S., Hansen, B., Håland, Å.T., et al. (2012). Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: a case series. Journal of Anxiety Disorders 26(1), 158–164. Whiteside, S. P., Brown, A. M., & Abramowitz, J. S. (2008). Five-day intensive treatment for adolescent OCD: a case series. Journal of Anxiety Disorders, 22(3), 495–504. Whiteside, S. P., & Jacobsen, A. B. (2010). An uncontrolled examination of a 5-day intensive treatment for pediatric OCD. Behavior Therapy, 41(3), 414–422.
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Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Concentrated ERP delivered in a group setting: An effectiveness study Audun Havnen a,b, Bjarne Hansen a,b, Lars-Göran Öst b,c,d, Gerd Kvale a,b,n a
Haukeland University Hospital, OCD-team, 5021 Bergen, Norway Department of Clinical Psychology, University of Bergen, Norway Department of Psychology, Stockholm University, Sweden d Department of Clinical Neuroscience, The Karolinska Institute, Stockholm, Sweden b c
art ic l e i nf o
a b s t r a c t
Article history: Received 6 June 2014 Received in revised form 10 August 2014 Accepted 21 August 2014 Available online 28 August 2014
The aims of the present study were to evaluate the acceptability and long term gains of a highly concentrated exposure and response prevention (ERP) for obsessive compulsive disorder (OCD). Treatment was individually tailored and delivered in a group format over four consecutive days in an outpatient OCD treatment unit, part of the ordinary specialist health care. A total of 35 patients accepted the offer of treatment; 23 of the patients were classified with “severe” to “extreme” OCD, and 74% of the sample had previously received treatment for their OCD (20% of these with ERP). The results showed that more than 90% of the patients expressed a high degree of satisfaction with the concentrated ERP. At six months follow-up 27 (77%) were classified as recovered and a significant improvement was seen in depressive symptoms as well. The majority of the sample also showed improvement with regard to employment status 12 months after treatment. The results indicate that this highly concentrated treatment may be a feasible format of delivering ERP. & 2014 Published by Elsevier Inc.
Keywords: OCD ERP 4-day intensive program Group format Long term follow up Patients' acceptance
1. Introduction Exposure and response prevention (ERP) combined with cognitive therapy is widely recognized as an effective and efficient treatment for obsessive–compulsive disorder (OCD) (Abramowitz, 1996; Cox, Swinson, Morrison, & Lee, 1993; Eddy, Dutra, Bradley, & Westen, 2004; National Collaborating Centre for Mental Health, 2006; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). It has been demonstrated to yield clinically significant results when delivered in a wide range of formats like individual, group, internet-based as well as by telematics and as selfhelp (Coles, Cook, & Blake, 2007; Himle et al., 2006; Jónsson & Hougaard, 2009; Mataix-Cols & Marks, 2006; Vogel et al., 2012). It has also been shown to be promising when delivered in a more concentrated form than weekly sessions (Abramowitz, Foa, & Franklin, 2003; Whiteside, Brown, & Abramowitz, 2008; Whiteside & Jacobsen, 2010). The treatment of another anxiety disorder, namely specific phobia, has in more than 30 randomized studies been shown to be successfully delivered in an even more concentrated format with substantial and lasting clinical changes following one prolonged session lasting maximum 3 h (Thompson, Ollendick, & Öst, 2012). For
n Corresponding author at: Haukeland University Hospital, OCD-team, 5021 Bergen, Norway. Tel.: þ47 55 95 63 80. E-mail address: [email protected] (G. Kvale).
http://dx.doi.org/10.1016/j.jocrd.2014.08.002 2211-3649/& 2014 Published by Elsevier Inc.
many patients, the one-session approach is highly attractive since they during a very short time may get rid of a severe problem affecting everyday life. From a cost-effectiveness perspective this concentrated form also has advantages, one of them being no dropout during treatment. Inspired both by features from the well documented approaches to the treatment of OCD as well as specific phobia, our research group has developed a highly concentrated mode of delivering ERP to OCD patients referred to an OCD-unit which is part of the ordinary specialist health care. In a recent pilot study the approach showed very promising results, even for patients with a number of previous treatment-failures (Havnen, Hansen, Haug, Prescott, & Kvale, 2013). During two consecutive treatment days, each lasting 8–10 h, five to six patients in each group received individually tailored and therapist assisted exposures. A comprehensive psycho-education was given to the group the day before the ERP was initiated, and immediately after the two days of ERP, the group of patients was instructed in strategies for maintaining the change and taught principles for how to be their own therapist. Three months later they met for a booster session (Havnen et al., 2013). In the current study, which is an extension of the pilot trial, we wanted to repeat the approach in a larger sample of patients, and to investigate both the patients' acceptability of this concentrated ERP treatment and its clinical effects.
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2. Method 2.1. Participants 2.1.1. Referral procedures and diagnostics The current study is part of a standard quality control performed at our outpatient OCD treatment unit, part of the ordinary specialist health care. Patients included in the study were first referred from their individual general practitioner to the local outpatient district psychiatric facility. If the OCD, or suspected OCD was considered severe enough to grant public health-care, patients were then referred to the OCD-team. Patients were offered treatment from the OCD-team if a principal DSM-IV-TR diagnosis of OCD was established (American Psychiatric Association, 2000) according to the administration of the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). Since the OCD-team is part of the secondary mental health services, all patients with OCD referred to the clinic have to be offered treatment, but treatment is not initiated if the patient is suicidal, psychotic or in active substance abuse. Also, ERP treatment in a group format is not offered if the patient is not Norwegian-speaking. A total of 37 individuals (26 females) between 20 and 60 years old (M ¼32.4, SD ¼ 10.0) who were consecutively referred to the OCD outpatient clinic were offered treatment. Two patients (females) did not want to participate in a group, and were offered individual treatment. Both were working with children and mainly had obsessions with sexual content, and the reason for declining was the fear of being recognized by other participants. The sample thus consisted of 35 individuals. 2.1.2. OCD duration/severity and previous treatment Mean Y-BOCS score pre-treatment was 26.14 (SD ¼4.33), with 12 patients (34%) classified with moderate OCD (Y-BOCS scores from16 to 23), M ¼21.00, SD ¼1.04, and 23 patients (66%) with severe/extreme OCD ( Y-BOCS from 24 to 40), M ¼ 28.83, SD ¼2.55 (Marques et al., 2010). Mean duration of OCD problems was 16.7 years (SD¼ 10.4) and 26 (74%) had previously received psychological treatment. Of these, 7 (27%) reported having received ERP, 3 (8.6%) cognitive therapy, and 16 (45.7%) had undergone other forms of therapy. Ten patients had received 1 therapy course, 6 patients had received 2 courses, 5 had 3 courses and 5 had 4 courses. The mean Y-BOCS pre-treatment scores for treatment naïve patients and patients with previous therapy trials did not differ significantly. 2.1.3. Comorbidity Fourteen patients had no comorbid diagnoses and 21 (60%) had comorbid disorders, which included generalized anxiety disorder (n¼ 7), panic disorder without agoraphobia (n¼ 6), hypochondriasis (n¼ 1), mild or moderate depression (n¼6), dysthymia (n ¼1), social phobia (n ¼1) and paranoid psychosis (n¼ 1). Patients with comorbidity did not differ from patients without comorbid disorders on pretreatment Y-BOCS scores (t(33)¼1.45, p¼ 0.16). 2.1.4. Pharmacological treatment Use of medication was registered at the initial interview. Twenty-one patients (60%) were currently receiving pharmacological treatment with SSRI. In addition one patient had prescribed antipsychotic medication; one had sleep medications prescribed (to be taken when needed); two had prescriptions for benzodiazepines (to be taken when needed) and one had prescribed an anxiolytic (to be taken when needed) other than benzodiazepine. Four patients had two different medications and one had three different medications. Patients with and without SSRI prescriptions did not differ on Y-BOCS scores (t(33)¼0.16, p ¼ 0.89) or BDI scores (t(33)¼ 0.17, p ¼0.89). Patients on SSRI were asked to keep medication doses unchanged four weeks prior to and during the four-day treatment period. The recommendation was however not followed by further assessment of medication use. Patients with prescribed sleep medication or anxiolytics were asked to discontinue these medications prior to and during treatment; adherence to these instructions was urged by the therapists throughout the treatment period. Patients were asked not to seek concurrent treatment during the treatment period. 2.1.5. Employment status Nine of the patients were on sick-leave 50% or more of the time prior to treatment, and another 18 patients stated (during the initial interview) that their work or studies were severely affected by the OCD. One of the patients was on disability pension, and one was at home caring for children. 2.2. Procedure Referred patients met for an initial interview session for clinician administered MINI and the registration of anamnestic information, and when the OCD-diagnosis was established they met for two additional assessment sessions. The severity of obsessive–compulsive symptoms was assessed with the Yale-Brown Obsessive– Compulsive Scale (Y-BOCS; Goodman et al., 1989a, 1989b). A detailed registration of the patients' obsessions and compulsions was collected and the patients received an introductory psycho-education, based on the Kozak and Foa (1997) manual,
offering an explanation of how obsessions were maintained by the use of rituals. Also, a presentation of the treatment rationale was offered. The patients' expectations of treatment outcome as well as their evaluation of the treatment credibility were assessed with an adapted version of the Borkovec and Nau (1972) Reaction to treatment scale, in which four aspects of expectancy and credibility were evaluated on a 0–100% scale, with higher values indicating more positive evaluations. If a patient reported an expectancy or credibility score below 70%, this was taken as an opportunity to clarify possible misunderstandings regarding the treatment. In total the sample had a mean score of 94.57 (SD ¼1.67). Prior to the first assessment session, patients were mailed a number of selfreport questionnaires (see below) to be completed before the first visit at the clinic. These questionnaires were also completed at the end of the treatment, as well as at three and six months after treatment (mailed and to be returned in pre-paid envelopes). In addition patients were telephoned 12 months after treatment to collect data concerning employment status to monitor any changes in rates of sick leave or whether the work related interference of obsessive–compulsive symptoms had changed. All patients were informed that data were routinely collected as part of standard quality control procedures at the clinic. The MINI interviews were conducted by a psychiatrist or a clinical psychologist trained in the administration of this structured clinical interview. Patients granted specialist health care had to be offered treatment within three months. As only three groups were initiated per semester at the OCD clinic, patients were offered individual treatment if group treatment was not available within the three months treatment deadline. The Y-BOCS interviews at pre-treatment were conducted by one of the psychologists or psychiatrists in the OCD-team. Y-BOCS at post-treatment as well as at three and six months follow-up were conducted by phone by an independent psychologist. The independent assessor was aware that the patients had received concentrated ERP treatment, but was otherwise not involved in the study. All Y-BOCS interviews were conducted by clinicians with special training in performing the interview.
2.3. Measures The Y-BOCS interview consists of 10 items covering the severity of both obsessions and compulsions, and is frequently used to assess treatment response. The Y-BOCS has good psychometric properties (Goodman et al., 1989a, 1989b). Beck Depression Inventory (Beck, Steer, & Brown, 1996) is a 21-item questionnaire that assesses depressive symptoms. Items are judged on a 0–3 scale, and higher total score indicates more severe symptom severity. The psychometric properties of BDI are well-established (Beck & Steer, 1984; Beck, Brown, Steer, Eidelson, & Riskind, 1987). Client Satisfaction Questionnaire 8 (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) is an 8-item questionnaire which measures patient satisfaction with health services. Each item is scored from 1 (very low satisfaction) to 4 (very high satisfaction), total score ranges from 8 to 32 with higher scores indicating higher degree of satisfaction. The CSQ-8 has sound psychometric properties (Larsen et al., 1979; Nguyen, Attkisson, & Stegner, 1983). All outcome measures were part of the standard quality control instruments of the health services offered at the outpatient OCD clinic at Haukeland University Hospital.
2.4. Therapists The individualized group treatment was always led by at least one out of four experienced psychologists in the team. Lead therapists were licensed clinical psychologists with extensive training and practice in cognitive behavioral therapy of anxiety disorders. Two of the lead therapists were authorized supervisors in cognitive behavioral therapy (CBT), the other two had more than 15 years of experience in delivering cognitive behavioral treatment. Co-therapists were licensed clinical psychologists or a psychiatrist, all with some basic training in ERP and CBT.
2.5. Treatment Treatment was delivered as part of the standard mental health care provided by the OCD team. The concentrated format was new to the health services; but since its total treatment hours did not exceed standard resources allocated to a 16 session individual treatment following the Kozak and Foa (1997) manual, but mainly represented an alternative approach to the distribution of therapist time, it was approved. It was conducted in groups of 5–6 participants with a 1:1 therapist– patient ratio, which would have been the same as if the treatment had been given individually. The treatment manual was adopted from the ERP principles described in the Kozak and Foa (1997) and Foa, Yadin, and Lichner (2012) manuals and had previously been described in more detail elsewhere (Havnen et al., 2013). A full manual with clinical examples is under preparation (Hansen, Havnen, Öst, & Kvale, 2014). Treatment was delivered over four consecutive days, with a booster session
A. Havnen et al. / Journal of Obsessive-Compulsive and Related Disorders 3 (2014) 319–324 after three months. Relatives and friends were invited to a psycho-educative meeting in the afternoon, Day 3. Day 1: On day 1 the patients met for 3 h for a detailed psycho-education combined with deciding upon individually tailored exposure tasks. Rules for confidentiality between therapists and participants, and among participants were established. The group setting was introduced as especially useful for learning about the principles of OCD, since the patients would have different OCD-concerns, but at the same time could be helped by the same principles of treatment (ERP). They were also encouraged to be supportive and to help each other to be brave and to find the courage to engage fully in the most useful exposure tasks. During the psycho-education it was emphasized that in order to learn that anxiety and discomfort are misconceived by the brain as a sign of danger it is important to evoke anxiety without any rituals or anxiety-reducing behavior, and in this way let the brain gain new “experiences” about how anxiety is a poor indication of what is safe and what is dangerous. In line with this, anxiety and discomfort were explained as the “raw material of change”, and something to be chased and sought for like gold. They were also informed that they would not be told to do anything, but that the therapists would help identifying useful exposure tasks, which they in turn had to choose to perform. It was also underscored that each exposure task would consist of thousands of “micro-decisions” where they either could choose to “lean into the anxiety” or withdraw. When selecting exposure tasks, the ones with the expected largest potential for change were recommended. Expected largest potential for change was defined pragmatically by selecting the tasks that when performed, would exclude the necessity for training in a lot of different situations. It was furthermore underscored that none of the suggested exposures could be defined as guaranteed safe and none of them as dangerous. The mere task of exposure was presented as an opportunity to get encountered with specially designed uncertainty. If a patient e.g. was afraid of germs, exposure to toilets might be regarded as a task with “large potential for change” and given high priority. For a person afraid of harming someone, handling knifes in situations with loved ones might be considered a good task, as might lighting and turning out 30–40 candles in a variety of rooms, then blow them out in “bulks” instead of individually, and leave the house without checking might be considered a good exposure task for a patient with a checking problem. Day 2: The therapists and patients first met for a repetition of the principles and the tasks, lasting approximately 1 h. If two or three patients had similar exposure tasks, the exposures could start in a small group. The exposures were carried out in relevant settings, which in most cases were outside the clinic. Initial exposures were therapist-assisted, and typically the patient started with the exposure tasks with the “largest potential for change”, but in a gradual fashion. For a patient afraid of germs, the task would typically start with touching areas in the bathroom that the patient could manage with some effort, and then progress to the more difficult situations. When performing a certain task, the necessity to refrain from any strategy aimed at reducing anxiety was underscored, and the patients were told that it is better to start with performing one task with a “good technique” meaning that it should be done without any anxiety reduction strategies or rituals, and when the technique is learnt, progress to more challenging tasks instead of rushing ahead without paying attention to the anxiety reducing rituals. In order to help the patient to start he/ she was coached to identify subtle anxiety reducing strategies or compulsions, and was then encouraged to choose to fully engage in the exposure without them. An example of a subtle strategy to reduce anxiety could be calming self-assurances like “This is most likely not really dirty”, “I'm sure I won't get sick if I touch this” and replace it with self-talk underscoring the uncertainty “I cannot be certain that this is really safe”, etc. In addition to advice full response prevention, the patient was encouraged to spread the exposure to all thinkable situations. For a patient afraid of germs, this could be accomplished by making a water-based spray with traces of all the touched surfaces, and coach the patient to spray all rooms in the house, including cupboards. This spray was also to be used if the patient had washed the hands before eating, or if they had taken a shower in the morning on Day 3. During Day 2, each patient typically would practice exposure in all relevant situations including all relevant obsessions. The group had lunch together, and if practical, met at three or four in the afternoon to summarize. The exposure tasks did however have priority over group meetings. The patients were instructed to practice alone in the afternoon and evening, but with a detailed hour-by-hour plan. If needed, the therapist assisted at home and in the evening; this could e.g. be a “checker” performing exposure task like using electric kitchen items before bedtime. All patients were instructed to send an SMS to the therapist in the evening, evaluating their own performance during the day on a six-point scale. The patients were encouraged to give themselves a 6 if they had completed the exposure tasks in all the planned situations without any attempt to reduce anxiety, and without any rituals. They were also told to expect new “waves of anxiety” during the evening and/or night, and were told that their best way of handling it would be to find a situation to practice exposure (“lean into the anxiety”). Day 3: On day 3 patients and therapists met in the morning and summarized the progress and shared experiences before the exposure assignments were continued. Gradually during Day 3, the patients were given more responsibility for their own exposures. The groups and therapists met for lunch, and also for a meeting approximately at 4 p.m. if this was considered practical. In the afternoon of Day 3, relatives and friends were invited to a meeting together with the patients and therapists. During this, the psycho-education from Day 1 was basically repeated. Day 4: Patients and therapists met in the morning to summarize and to give each other feedback. Afterwards, the patients made a plan for continuing the
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exposure tasks for the coming three weeks. They also received psycho-education with the focus on relapse prevention. Booster session: 3 months after treatment patients were invited for a booster session. In the booster session the patients' experiences in the period following treatment were discussed. The principles for ERP were repeated and emphasis was put on how the patients' could best practice the therapy on their own. No exposure work was conducted in this session. 2.6. Statistics Statistical analyses were performed with SPSS version 22.0. Repeated measures ANOVA for Y-BOCS and BDI were conducted with Greenhouse–Geisser corrections. Effect sizes were calculated with Cohen's d, correcting for related means using the equation by Morris and DeShon (2002).
3. Results 3.1. Adherence and attrition One patient dropped out of treatment prematurely. The patient displayed a lack of motivation for adhering to the treatment principles of exposure and response prevention. This was addressed by the therapist and it was agreed that the patient terminated treatment prematurely and could reapply for treatment at a later stage if experiencing a higher degree of treatment motivation. The patient expressed satisfaction with this solution. A total of 34 patients completed treatment and were available for Y-BOCS interviews at post-treatment and 3 months follow-up. At 6 months follow-up 30 patients were available for Y-BOCS interviews, and 30 patients were available for collection of employment status at 12 months follow up. 3.2. Intention-to-treat analyses In order to allow participants with missing data to be included in the analyses, Full Information Maximum Likelihood procedure (FIML) was applied to impute missing data. This procedure provides unbiased estimates of the missing data and their standard errors based on the assumption that data are missing at random (MAR), and has been shown to perform better than alternative methods to estimate missing data (Enders, 2001a, 2001b). 3.3. Outcome measures Table 1 displays mean and standard deviations for Y-BOCS and BDI. The sample had a mean Y-BOCS score of 26.14 (SD¼4.33), which represents a pretreatment Y-BOCS score of slightly higher severity than in the 6 published randomized controlled trials directly comparing individual treatment (M¼24.02, SD¼2.44) and group treatment (M¼23.67, SD¼2.80; Öst, Havnen, Hansen, & Kvale, 2014), although these differences are non-significant. To Table 1 Means, standard deviations and effect sizes (Cohen's d) for Y-BOCS and BDI: intention to treat. Variable
M (SD)
ES
Pretreatment Posttreatment 3-month FU 6-month FU
26.14 9.00 10.63 10.26
(4.33) (4.76) (7.00) (5.67)
2.60 2.20 2.37
Pretreatment Posttreatment 3-month FU 6-month FU
18.56 10.04 9.76 8.84
(9.15) (6.56) (9.15) (7.31)
0.89 1.07 1.02
Y-BOCS
BDI
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examine Y-BOCS and BDI scores repeated measures ANOVA with Greenhouse–Geisser corrections was carried out. The results showed a significant change in Y-BOCS, F(2.82, 95.97¼ 102.00, p o0.0005). Subsequent dependent t-tests showed that the change from pre- (M¼26.14) to post-treatment (M¼9.00) was significant (t(34)¼15.34, po0.0005) whereas the change from post to 3-month (M¼10.63) or 6-month follow-up (M¼10.26) was not. A repeated measures ANCOVA with number of previous therapy trials as covariate showed that a number of previous treatment did not influence treatment outcome (p¼0.77). The analyses of BDI also showed a significant change, F(2.60,88.30¼ 15.89, po0.0005). Subsequent dependent t-tests showed a significant change from pre (M¼18.56) to post-treatment (M¼ 10.04); t(34)¼5.18, po0.0005), with no significant differences in BDI scores between posttreatment and 3- (M¼9.76) and 6-month follow-up (M¼ 8.84). OCD-severity was not related to outcome. Treatment naïve patients did not differ from patients with previous therapy trials in respect to outcome on any of the post-treatment measurements. The within-group effect-sizes for Y-BOCS and BDI are presented in Table 1. For both Y-BOCS and BDI large effect-sizes were found both from pretreatment to post-treatment and pretreatment to follow-up. 3.4. Clinical significant change To determine the number of patients who showed clinically significant change we applied the Jacobson and Truax (1991) criteria for clinical improvement, which states that in order to be defined as “recovered” a patient must a) show a reliable symptom reduction (the reliable change index) and b) be in the nondysfunctional range. Y-BOCS score was used to determine recovery status. We applied the Fisher and Wells (2005) criteria both for reliable change index and cut-off. To be defined as recovered in the present study a patient had to show a pre- to post-treatment or follow-up reduction in Y-BOCS of 10 points or more and had a Y-BOCS score of 14 points or below at post-treatment or follow-up. To be classified as improved patients had to obtain at least a 10 points reduction from pre- to post-treatment or follow-up and a post- or follow-up score above 14. Patients with a reduction less than 10 points were classified as unchanged, regardless of the final score being below the cut-off of 14 points. 77% of the sample was classified as recovered at post-treatment, 11% were improved and 11% showed no change. Of the latter two patients had a post Y-BOCS score at or below 14 but showed no reliable change. At follow-up 74% were identified as recovered, 14% as improved and 11% as unchanged. Three of the unchanged patients had a Y-BOCS score at or below 14 but no RCI. Table 2 shows the tracking of recovery rates at post-treatment and follow-up for the individual patient. Of the 27 patients who were recovered at post-treatment, 23 patients (85%) were still classified as recovered at 6-month follow-up, while 4 patients (15%) had deteriorated and were now classified as improved. Of the 4 patients who were improved at post-treatment, 2 had become recovered at 6-month follow-up,
1 remained improved whereas 1 had deteriorated to the category of no change. Of the 4 patients who were classified as unchanged at post-treatment, 2 had improved to a large extent and were at 6-month follow-up and 2 were still unchanged. Clinical significant change was also calculated for the subgroups moderate and severe/extreme OCD severity as assessed at pre-treatment. For the moderate subgroup (n ¼12), 67% were classified as recovered at post-treatment and 75% at follow-up. For the severe/extreme subgroup (n ¼23) 83% were recovered at post-treatment and 74% were recovered at 6-month follow-up 3.5. Employment status During a telephone interview 12 months after treatment patients were asked how the employment or study situation was affected by obsessive–compulsive symptoms now compared to before treatment. Of 9 patients who were on sick-leave 50% or more of the time prior to treatment, none were on sick-leave 12 months after treatment. Patients were also asked if they experienced a change in OCD-related interference during work (e.g. regarding interference by distressing obsessions or having to carry out compulsions). Of the 18 subjects who stated that the work or studies were affected prior to treatment, 15 stated that they had had a positive change. Two patients reported no change with regard to employment; one of them was on disability pension and the other was out of the job market. One patient did not want to comply and three patients were unavailable. 3.6. Treatment satisfaction A total of 31 patients completed CSQ-8 at post-treatment and results were analyzed as intention to treat using multiple imputations to account for missing data. Fully 69% described the quality of treatment as excellent and 66% stated they were highly satisfied with the extent of treatment. All patients stated that they would definitely return to the clinic in the future if they needed treatment. Details about treatment satisfaction are presented in Table 3. Overall, the results from CSQ-8 indicated that the majority of patients were highly satisfied with the concentrated treatment format.
4. Discussion The results from this study showed that the highlyconcentrated ERP treatment for OCD was well accepted by the participants. Only one patient terminated prematurely. Furthermore, the treatment produced substantial reduction in obsessive– compulsive symptoms as well as depressive symptoms, and changes were maintained at follow-up, even in patients with a number of previously unsuccessful treatments. Maybe the most
Table 3 Posttreatment scores on Client Satisfaction Questionnaire 8.
Table 2 Comparison of clinical improvement rates at post-treatment and 6-month followup. Posttreatment outcome
Recovered Improved No change Total
Follow-up Recovered
Improved
No change
Total
23 2 2 27
4 1 0 5
0 1 2 3
27 4 4 35
1. 2. 3. 4. 5. 6. 7. 8.
Question
Mean Absolute frequencies of satisfaction ratings score 1 2 3 4
Quality of service Kind of service Met needs Recommend to a friend Amount of help Deal with problems Overall satisfaction Come back
3.66 3.56 3.61 3.92 3.67 3.85 3.71 4.00
0 0 0 0 0 0 0 0
1 0 0 0 0 0 1 0
10 16 13 2 12 5 8 0
24 19 22 33 23 30 26 35
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important aspect of the concentrated treatment is the extent to which it was accepted by the participating patients, given that it was delivered over four consecutive days, with only two days of therapist assisted exposure. The results from CSQ-8 showed that the patients gave high ratings of different aspects of the treatment, suggesting that the treatment was accepted by the participants. In addition the statistical analyses showed that a large proportion of patients was classified as recovered both at post-treatment and at follow-up with results comparable to effectiveness studies of OCD (Öst, 2013). In general this study suggests that the four days concentrated ERP approach is a viable treatment format for patients suffering from OCD. The slightly higher mean Y-BOCS score at pretreatment compared to previous studies comparing individual and group treatment (Öst et al., 2014), the high recovery rate both in patients classified as having moderate and severe/extreme obsessive–compulsive symptom severity and the equal treatment outcome between treatment naïve patients and patients with previous therapy trials suggest that the therapy is also effective for severe cases of OCD. This is promising as it may be expected that a concentrated ERP approach would be too effortful for patients severely affected by OCD. Another expected finding is the concurrent reduction in obsessive–compulsive and depressive symptoms and that the drop in both symptom domains is maintained in the follow-up period. This can be interpreted as the depressive symptoms being secondary to the OCD and that the effective treatment of the primary disorder had a positive impact on comorbidity. In addition to the positive gains in symptom measures the positive changes in employment status must be noted, in particular the large number of patients no longer on sick-leave one year after treatment. Nine patients, who prior to treatment were on sick leave with various degrees of impaired working abilities, were back in fulltime work after the treatment. In addition 15 of 18 patients with impaired functioning in school or work had a decreased impairment after treatment. This is in correspondence with the majority of the sample expressing that the treatment had helped them deal more effectively with problems and that they were happy with the amount of help received. It is encouraging that the treatment led to substantial gains in terms of increased employment rates and this may suggest that in addition to producing decreases in obsessive–compulsive and depressive symptoms the treatment also had a positive impact on global functioning. The innovative approach of the concentrated treatment is the extended periods of therapist–patient contact, securing therapist assisted exposure work and response prevention, and the group setting that enhances group cohesion and positive peer influence, which has been suggested as important aspects of group treatment (Håland et al., 2010). The present treatment thus combines aspects both from individual and group treatment while keeping exposure and response prevention as the common denominator. The treatment format was new to the health service, but since the resources allocated to the treatment did not exceed standard care (Kozak & Foa, 1997), and the clinic had a group of therapists experienced with OCD-patients and ERP, it was approved. Since the approach is promising with regard to clinical results, one may argue that if the results are replicated in a larger-scale study, it has a good potential of dissemination, since the treatment is conducted across four consecutive days only. This means that a few available welltrained therapists can treat more patients during a certain time period and patients can travel to the experts and stay in a hotel during four nights to receive the treatment. Since the amount of therapy hours is not more than the common ERP according to the Kozak and Foa manual it should not be a reimbursement problem for insurance companies or state-funded health care. Clearly the study suffers from limitations. It might be a potential limitation that pre-treatment assessment was conducted
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face-to-face whereas post-treatment and follow-up Y-BOCS interviews were telephone administered, although it may also be argued that the telephone administration of Y-BOCS has received some empirical support (Baer, Brown-Beasley, Sorce, & Henriques, 1993) and that post-treatment evaluations carried out by an independent party enhances unbiased assessments. The most obvious limitations of the study are the lack of a control condition and the small sample size. The results must thus be interpreted cautiously and future research comparing the concentrated ERP to an established ERP format is warranted. In the wait of larger controlled trials this quality control study offers support that ERP can be successfully concentrated into a four-day treatment, delivered as individual treatment in a group setting, which further verifies the feasibility of ERP with successful outcomes in a variety of treatment formats.
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