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Low intensity interventions do not have clinical treatment benefits

Researchers at the University of Manchester have concluded that low intensity interventions in the treatment of OCD (prior to CBT), as recommended by NICE, do not have any clinical treatment benefits. 

It’s already known that the NICE (National Institute of Health and Clinical Excellence) guidelines for the treatment of Obsessive-Compulsive Disorder (OCD) recommend CBT (including exposure and response prevention) for the treatment and management of OCD using a stepped care approach.

Low intensity psychological interventions are proposed at lower steps (including brief individual CBT using structured self-help materials, brief individual CBT by telephone and group CBT), moving up to more intensive psychological and pharmacological interventions at higher steps, which in reality is what OCD-UK believe the majority of patients presenting for OCD treatment should be offered. There is some preliminary evidence that self-managed therapy packages for OCD can be effective, but the NICE guidelines highlighted the need for research in to the use of low intensity therapy for the treatment of OCD.

The OCTET (Obsessive–Compulsive Treatment Efficacy Trial), led by Professor Karina Lovell at the University of Manchester, emerged from a research recommendation in NICE guidelines, which specified the need to evaluate CBT treatment intensity formats.

Attendees of our 2015 OCD-UK conference in York may remember Professor Lovell explained that the study aimed to see if using a self-help approach (either a book or a computer program), supported for a short time by a mental health practitioner, would be better than waiting for CBT.

The key objectives of the OCTET research was:

  • To determine the clinical effectiveness and cost-effectiveness of two low-intensity CBT interventions:
    • Supported computerised CBT (cCBT), using OCFighter, an internet-delivered OCD treatment package;
    • Guided self-help using a book for people experiencing OCD symptoms. The book was Overcoming OCD: a workbook (Lovell & Gega, 2011).

These treatments were supported by mental health professionals and took place over a 12-week period.  The study compared:

  • If after 3 months adults with OCD receiving either of the low intensity interventions showed improvement compared to adults with OCD on a routine waiting list for high-intensity;
  • If after 12 months adults with OCD receiving either of the low intensity interventions prior to high-intensity CBT showed more improvement than those adults with OCD who only received the high-intensity CBT.

OCTET team planned to review if their findings will determine whether these low intensity treatments could offer additional, and more accessible treatment options for people with OCD.

Research Method
The study was a multicentre randomised controlled trial which recruited 475 patients between February 2011 and May 2014 from IAPT (Improving Access to Psychological Therapies) services across 15 NHS Trusts in England. Two patients were excluded post randomisation therefore, data was analysed for 473 patients. Of the 473 people with OCD who took part, they were randomised:

  • one-third (158) were offered a self-help book with guided help,
  • one-third (157) were offered an OCD computer program with guided help,
  • one-third (158) stayed on a waiting list for CBT.

Both the guided self-help and cCBT interventions were delivered by psychological well-being practitioners (PWPs). Of the 93 PWPs allocated to the OCTET patients, most (87%) were female,  with a mean age of 34 years. More than half of the PWPs had received some training in OCD as part of their IAPT training, but this had largely focused on identification rather than treatment.

The OCTET PWPs were given three days additional training in both the guided self-help and supported cCBT interventions.

Supported cCBT:
157 participants in the OCTET research were given access to supported computerised CBT (cCBT). In addition to access to the cCBT program, participants received six 10-minute brief scheduled
telephone calls from a PWP.

The program used was the commercially available cCBT program called OCFighter. OCFighter consists of a nine-step CBT approach (focused on exposure and response prevention) to help people with OCD to design, carry out and monitor their treatment and progress. Participants randomised to OCFighter were given an access ID and password to log in to the system and advised to use the program at least six times over a 12-week period.  

Guided self-help
158 participants in the OCTET research received access to a guided self-help, consisting of a self-help book (focused on exposure and response prevention), ‘Overcoming OCD: a workbook’, written by the OCTET team. In addition to the book, participants received weekly guidance from a PWP for one initial session of 60 minutes (either face to face or by telephone, depending on patient preference) followed by up to 10 30-minute sessions over a 12-week period.

Conclusions:
In the short term (3 months), the OCTET team found no worthwhile improvements in symptoms in people using the self-help book or OCD computer program. They also found no differences in symptoms in the longer term (12 months), thus suggesting that low intensity interventions did not offer any additional clinical benefit.

They concluded that in the longer term, access to guided self-help and supported cCBT, prior to high-intensity CBT, did not lead to differences in outcomes compared with access to high intensity CBT alone.

However, interestingly access to lower intensity interventions led to significant reductions in the uptake of CBT; this did not seem to compromise patient outcomes at 12 months.

They also concluded that both the guided self-help book and the computer program were better value for money than CBT.

Patients told the OCTET team during qualitative interviews (which OCD-UK helped with) that they liked the guided self-help more than the computer program. Practitioners thought that the interventions could benefit patients and provide choice and flexibility.

Source: Clinical effectiveness, cost-effectiveness and acceptability of low-intensity interventions in the management of obsessive–compulsive disorder: the Obsessive–Compulsive Treatment Efficacy randomised controlled Trial (OCTET).  Lovell K, Bower P, Gellatly J, Byford S, Bee P, McMillan D, et al.

 

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