Introduction
Obsessive-compulsive disorder (OCD), once thought to be a rare condition refractory to treatment, is now known to be surprisingly common. The lifetime prevalence in the US for adults is 2.6% [
1] with a 1-year prevalence of 1% [
2]. OCD is classified as a severe mental illness by the National Advisory Mental Health Council [
3,
4] and can be incapacitating, ranking 11th among all medical diseases for disability [
5]. Direct and indirect costs of OCD have been estimated to be $8.4 billion [
6]. Performing rituals may become a major life activity, severely interfering with one’s job, marriage, or other social relationships [
7-
9]. Comorbid depression is common, with increased levels of suicidal ideation and attempts [
10]. OCD has been reclassified in the
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition [
11] (DSM5) from an anxiety disorder to a new category of disorders, obsessive-compulsive and related disorders [
11]. This was based in part on data from studies on symptom phenomenology, treatment response, familialty, genetics, neurocircuitry, and cognitive functioning (see Stein et al. [
12] for a review). Brain imaging studies have found a unique pattern of neuronal activation not present in other anxiety disorders (i.e., baseline hyperactivity and hyper-response in the lateral orbitofrontal cortex, anterior cingulate cortex, and caudate). Unique deficits in cognitive functioning have also been found, involving difficulties with cognitive flexibility and response inhibition [
13,
14]. OCD is one of the first disorders to be reclassified based in part upon biomarker evidence, and thus in line with current trends in the classification of mental disorders as outlined by Research Diagnostic Criteria (RDoC) [
15].
Cognitive behavior therapy (CBT) with exposure and ritual prevention (E & RP) is recommended as a first-line treatment for OCD by clinical practice guidelines in both the US and abroad [
16-
18]. Several decades of research support both its
efficacy and
effectiveness [
19-
23]. It has effect sizes as large as pharmacological interventions [
24], with lower relapse rates [
25-
27]. CBT is considered an empirically supported treatment (EST), i.e., a treatment shown to be efficacious in controlled research with a defined population [
28]. There has been a growing emphasis on the need for ESTs from both legal, ethical, and economic perspectives [
29-
31], and professional and ethical guidelines now require therapists to integrate ESTs into their practice [
30,
31]. However, with this increased emphasis has come increased demand. As a result, the number of therapists trained in CBT falls far short of the demand [
32,
33]. The percentage of patients with OCD actually receiving CBT treatment ranges from 5% to 7% [
34,
35], in spite of the fact that persons with OCD have been found to prefer CBT (either alone or in combination with medication) over treatment with medication alone [
36]. Sixty percent of OCD patients receive no treatment at all, and the gap between onset of symptoms and effective treatment averages 17 years [
37].
New technologies may provide an opportunity to help solve this problem [
38]. A growing body of research has found that computerized self-administered CBT (CCBT) is highly effective, achieving clinical improvements similar to those obtained with therapist-administered CBT [
39-
42]. A recent meta-analysis of randomized, controlled trials of CCBT for anxiety or depressive disorders found a substantial effect size for CCBT (
g = 0.77, 95% confidence interval (CI) 0.59–0.95) [
41], with gains sustained up to 3 years after treatment [
43]. Studies of CCBT for OCD have found it to be an effective treatment [
44-
48], with effect sizes similar to those found with therapist-administered CBT [
44,
47,
49,
50]. Gains were maintained at 3- and 4-month follow-up. CCBT can be offered at a reduced cost, cited by patients in one study as the main barrier to seeking treatment [
51]. Patients can work at their own pace on their own schedule, and CCBT provides a treatment option for those who fail to seek treatment due to fears of social stigma [
52-
54]. A recent survey of OCD patients found that they considered CCBT an acceptable form of treatment, with the most common advantages reported being reduced time (67%), no need for travel (63%), reduced costs (60%), and privacy/anonymity (56%) [
55]. Only 10% reported preferring face-to-face treatment. Economic studies of CCBT for OCD have found it to be a cost-effective treatment compared to therapist-administered CBT [
56,
57].
As with any treatment, adherence is required for the treatment to exert its effect. Our previous work on CCBT for OCD found a clear dose–response relationship: patients who did more CBT homework sessions had greater decreases in symptoms [
46]. Studies have found that “computer-assisted” programs (CCBT with limited human contact) fare better than fully “computerized” (no human contact) programs, the former being associated with higher treatment adherence and lower dropout rates [
53]. Adding human ‘coaching’ to computer-administered CBT treatments has been found to enhance treatment compliance, patient satisfaction, and outcomes [
46,
53,
58,
59]. Human coaching appears to be effective in motivating patients to actually confront their fears using the exposure therapy techniques they learn in the self-help treatment programs and to complete their between session homework assignments. This ‘hybrid’ model of computerized self-help combined with human coaching has been endorsed and implemented by the United Kingdom National Health Service—the first governmental regulatory body to recommend web-based self-help CBT treatment [
60]. It utilizes a model with limited human contact with non-therapist coaches. However, the level of human support and whether coaching is done by a therapist or non-therapist have not been empirically examined [
53]. Using trained non-therapist ‘coaches’ may be a cost-effective means of improving outcomes. According to ‘stepped care’ models of treatment, matching the appropriate level of intervention, starting with the least restrictive and most effective, enhances treatment outcomes, controls healthcare costs, and helps allocate scarce mental health resources more effectively [
61-
64]. Recent studies of stepped care in OCD found equivalent treatment outcomes to standard clinical CBT but significantly lower treatment costs [
65-
67]. While CCBT fits nicely in the stepped care model, understanding the differences in treatment outcome associated with lay vs. therapist CCBT coaches will help inform the stepped care model. This goal of this study was to examine the impact of computerized self-help treatment for OCD alone and in combination with either a lay non-therapist coach or coaching provided by an experienced CBT therapist.
Discussion
In the current study, the addition of coaching did not significantly improve outcomes, using either a lay coach or a CBT therapist coach. This is divergent from other studies that have found coaching beneficial, or even necessary, for positive treatment outcomes [
53,
58,
59]. One possible reason is that while the BT Steps only group did not receive any coaching sessions, they did have an initial orientation call with the project manager. Recent studies have shown that even minimal human contact may be enough to encourage treatment compliance. In his review of the literature (‘What Makes Internet Therapy Work’) [
79], Andersson found that the most critical component seemed to be that it includes some form of minimal therapist support, be that email, phone call, or live sessions. Our data seem to bear that out. The pretreatment orientation session may have made it clear to the patient that there was a person behind the support [
79]. However a no-treatment control group would be necessary to confirm this hypothesis.
Another possible reason for the absence of benefit of coaching found in several earlier studies of CCBT programs was the difference in program media and components. There was a 20% greater reduction in YBOCS severity with this web version of BT Steps employing video components including exposure and response prevention vignettes compared with the original IVR version. While readily accessible via telephone, the IVR version also required correlated reading text from booklets. All text in the web version was embedded in the web program at appropriate spots, and the addition of videos and simple navigational tools was an additional difference from the original BT Steps.
Strengths of this study were inclusion of most subjects, excluding only those with significant comorbid depression, suicidal ideation, or severe OCD. The web is steadily more widely available as demonstrated by subject participation from 26 states and two ex-US countries (Canada and Singapore).
Limitations of the study include the sample being mainly college educated (66% with at least a 2-year degree, compared to a rate of 28.8% for all US citizens over 25 years old [
80]). While no significant difference was found in our sample between those with and without a college degree (mean YBOCS change of 6.6 vs. 6.5, respectively), only four subjects in our sample had only a high school diploma with no college experience at all. It is unknown if similar results would be found with this cohort. It is also unknown whether similar results would be found in patients with more severe OCD, patients with significant comorbid depression, or patients with limited insight or motivation.
Competing interests
KAK, JHG, and RG have a proprietary interest in the BT Steps computer program. DMJ and HLM declare they have no competing interests.
Authors’ contributions
KAK was the principal investigator and was responsible for developing the study design, conducting of diagnostic interviews, data analysis, and manuscript development. RG helped translate BT Steps from an IVR to a web-based version, coordinated the study, provided lay coaching, and provided input into the study design and manuscript. DMJ and HLM conducted coaching sessions and provided input into the study design. JHG was one of original authors of BT Steps and helped develop the study design, analysis plan, and manuscript. All authors read and approved the final manuscript.