Cost-effectiveness of Internet-Delivered vs In-Person Cognitive Behavioral Therapy for Children and Adolescents With Obsessive-Compulsive Disorder.

Importance: Therapist-guided, internet-delivered cognitive behavioral therapy is an effective treatment option for children and adolescents with obsessive-compulsive disorder, but to our knowledge, its cost-effectiveness compared with traditional in-person treatment has not been established. Objective: To evaluate the cost-effectiveness of guided internet-delivered cognitive behavioral therapy implemented within a stepped-care model compared with in-person cognitive behavioral therapy for young people with obsessive-compulsive disorder. Design, Setting, and Participants: This economic evaluation of a randomized noninferiority trial conducted at 2 specialist obsessive-compulsive disorder clinics in Sweden enrolled 152 children and adolescents aged 8 to 17 years with obsessive-compulsive disorder, mainly through clinician referrals (110 [72%]). Recruitment began October 6, 2017, and ended May 24, 2019. Follow-up ended April 14, 2020. Interventions: Participants were randomly assigned to receive either guided internet-delivered cognitive behavioral therapy or in-person cognitive behavioral therapy during a 16-week period. At the 3-month follow-up, nonresponders in both groups were offered additional in-person cognitive behavior therapy sessions. Main Outcomes and Measures: Health outcomes were treatment response rates (primary outcome), remission rates, and quality-adjusted life-years. Cost data were collected before treatment, after treatment, at 3-month follow-up, and at 6-month follow-up (primary end point) and are presented in 2020 US dollars. The differences in incremental costs and health outcomes were compared between the groups and presented from the health care professional, health care sector, and societal perspectives. Results: A total of 152 participants (94 girls [62%]; mean [SD] age, 13.4 [2.5] years) were randomized; 151 (99%) completed the trial. At the 6-month follow-up, 50 of 74 participants (68%) in the stepped-care group and 52 of 77 participants (68%) in the in-person cognitive behavioral therapy group were classified as treatment responders (odds ratio, 1.00 [95% CI, 0.51-1.98]; P = .99). Health economic analyses showed that the stepped-care group used fewer therapist resources than the in-person cognitive behavioral therapy group, resulting in a mean cost savings of $2104 (95% CI, $1202-$3006) per participant for the full study period of 10 months, corresponding to a relative savings of 39%. The cost savings remained largely comparable when taking wider health care sector and societal perspectives. Conclusions and Relevance: This study suggests that, for young people with obsessive-compulsive disorder, a low-cost digital intervention followed by in-person treatment for nonresponders was cost-effective compared with in-person cognitive behavior therapy alone.

Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder.

PURPOSE: Current guidelines for first-line treatment of childhood OCD are cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP), and/or antidepressant (ADM) pharmacotherapy, specifically serotonin reuptake inhibitors (SRI). Given that first-line are relatively similar in terms of clinical effectiveness, the role of costs to provide such services may help influence treatment decisions. In the case of treatment refractory pediatric OCD, this cost-effectiveness analysis (CEA) aims to further evaluate two additional, higher intensity combination therapies, namely OCD-specific Intensive Outpatient (IOP) and Partial Hospitalization Programs (PHP), to determine the additional benefits, in terms of effectiveness, that may result, and the corresponding increase in costs for these higher-intensity courses of therapy. RESULTS: IOP was the most cost-effective strategy in terms of change in CY-BOCS, pre/post treatment, equal to 16.42 units, followed by PHP and CBT monotherapy augmented with ADM CBT-monotherapy augmented with additional CBT and ADM-only augmented with CBT followed closely with 15.56 and 14.75 unit improvements in CY-BOCS. IOP accomplished its superior cost-effectiveness with an Incremental Cost-Effectiveness Ratio (ICER), of $48,834, lower than either of the established willingness to Pay thresholds. CONCLUSIONS: Lack of access to high fidelity, high dose CBT paired with pharmacotherapy is an issue for OCD patients and families. Among youth who were treatment non-responsive, these results indicate the superiority of a high dosage CBT strategy, indicating the need to increase access to these treatments.

Optimal treatment for obsessive compulsive disorder: a randomized controlled feasibility study of the clinical-effectiveness and cost-effectiveness of cognitive-behavioural therapy, selective serotonin reuptake inhibitors and their combination in the management of obsessive compulsive disorder.

Established treatments for obsessive compulsive disorder (OCD) include cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication. Combined treatment may outperform monotherapy, but few studies have investigated this. A total of 49 community-based adults with OCD were randomly assigned to CBT, SSRI, or SSRI+CBT. Sertraline (50-200 mg/day) was given as the SSRI for 52 weeks. A 16-h-manualized individual CBT was delivered over 8 weeks with four follow-up sessions. Assessors were 'blinded' to treatment allocation. A preliminary health economic evaluation was conducted. At week 16, combined treatment (n=13) was associated with the largest improvement, sertraline (n=7) the next largest and CBT (n=9) the smallest on the observed case analysis. The effect size (Cohen's d) comparing the improvement in Yale Brown Obsessive Compulsive Scale on CBT versus combined treatment was -0.39 and versus sertraline was -0.27. Between 16 and 52 weeks, the greatest clinical improvement was seen with sertraline, but participant discontinuation prevented reliable analysis. Compared with sertraline, the mean costs were higher for CBT and for combined treatment. The mean Quality Adjusted Life Year scores for sertraline were 0.1823 (95% confidence interval: 0.0447-0.3199) greater than for CBT and 0.1135 (95% confidence interval: -0.0290-0.2560), greater than for combined treatment. Combined treatment appeared the most clinically effective option, especially over CBT, but the advantages over SSRI monotherapy were not sustained beyond 16 weeks. SSRI monotherapy was the most cost-effective. A definitive study can and should be conducted.

Treatment-Refractory Obsessive-Compulsive Disorder in Adults: A Cost-Effectiveness Analysis of Treatment Strategies.

OBJECTIVE: This study sought to assess the cost-effectiveness of 7 treatment strategies for treatment-refractory obsessive-compulsive disorder (OCD) in adults. METHODS: A model was developed to evaluate treatment alternatives for adults (18-64 years old) that consisted of 2 parts: a decision analytic model and a Markov model. The decision analytic model stratified 7 outpatient treatment strategies, and the Markov model accumulated benefits and costs across the life expectancy of a simulated cohort of individuals. The model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate net health benefits (NHBs), costs, and incremental cost-effectiveness ratio (ICER) for each treatment strategy. OCD was considered treatment refractory in adults with an OCD diagnosis who failed first-line therapies. Encounters took place from 2012 to 2015, and the analyses were performed from November 2016 to February 2017. RESULTS: Partial hospitalization with step-down to intensive outpatient treatment was the most cost-effective of the 7 strategies, with an estimated ICER of $7,983 and mean (SD) NHB of 10.96 (0.53) quality-adjusted life-years (QALYs) remaining. This result was 2.2 QALYs greater than that of the trial-based antidepressant and cognitive-behavioral therapy (ADM + CBT) strategy. Three additional ADM + CBT strategies were estimated not to be statistically significantly different from each other. These 4 ADM + CBT strategies outperformed both pharmacotherapy-only strategies. CONCLUSIONS: Treatment strategies that include higher-intensity CBT, with effectiveness outcomes that approached efficacy estimates, were superior to real-world CBT strategies. However, given the limited availability of high-quality CBT, especially through use of commercial insurance networks, specialized treatment programs offer greater effectiveness than real-world therapies in achieving wellness for this severe patient population.

The cost-effectiveness of deep brain stimulation for patients with treatment-resistant obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric disorder with a 2% to 3% lifetime prevalence; in addition, 10% of OCD patients are resistant to conventional therapy. Deep brain stimulation (DBS) has been an effective treatment for treatment resistant OCD patients (TROCD). We aimed to determine the cost-effectiveness of DBS for TROCD. METHODS: We used a Markov model to estimate the cost-effectiveness of DBS compared to conventional treatment for TROCD with a 10-year time horizon. Published data were used to estimate the rates of treatment response and complications. Costs were calculated from the perspective of the third-party payer. Data on quality of life were obtained from a literature review and a survey of OCD patients. We applied the model separately to Korea and the United Kingdom (UK) to enhance the validity. RESULTS: Base-case analysis showed an incremental cost-effectiveness ratio of US$37,865 per quality-adjusted life-year in Korea and US$34,462 per quality-adjusted life-year in the UK. According to the World Health Organization's criteria, DBS for TROCD was "cost-effective" in Korea (<3x GDP per capita) and "highly cost-effective" in the UK (

Parsing the phenotype of obsessive-compulsive tic disorder (OCTD): a multidisciplinary consensus.

Obsessive-Compulsive Disorder (OCD) and Tic Disorder (TD) are highly disabling and often comorbid conditions. Of note, the DSM-5 acknowledged a new 'tic-related' specifier for OCD, which might be referred to as Obsessive-Compulsive Tic Disorder (OCTD), raising new interest toward a better clinical characterisation of affected patients. Available literature indicates that early onset, male gender, sensory phenomena and obsessions of symmetry, aggressiveness, hoarding, exactness and sounds as well as comorbidity with Attention Deficit Hyperactivity Disorder (ADHD) may be of more frequent observation in patients with OCTD. In order to share expertise in the field from different perspectives, a multidisciplinary panel of Italian clinicians, specifically involved in the clinical care of OCD and TD patients, participated into a consensus initiative, aimed to produce a shared document. As a result, after having examined the most relevant literature, authors sought to critically identify and discuss main epidemiologic, socio-demographic and clinical features characterising OCTD patients, along with other specific aspects including Health-Related Quality-of-Life (HRQoL), economic consequences related with the condition and its management, as well as treatment-related issues, that need to be further investigated.

The cost and impact of compulsivity: A research perspective.

Compulsivity is the defining feature of various psychiatric disorders including Obsessive Compulsive Related Disorders (OCRDs), and other compulsive, impulsive, and addictive disorders. These disorders are disabling, chronic conditions with an early onset and high rates of comorbidity, misdiagnoses, and delay in treatment onset. Disorders of compulsivity are responsible for considerable socioeconomic burden to society. We review the costs and impacts of compulsivity. In order to facilitate earlier diagnosis and targeted treatments, we examine the overlapping mechanisms that underlie compulsivity. We reconceptualize psychiatric disorders based on core features of compulsivity, highlight challenges in harmonizing research in children and adults, describe newer research methodologies, and point to future directions that can impact the costs and impact of disorders of compulsivity.

Compulsive buying tendencies and personal finances.

In a community sample of 225 adults, scores on the Compulsive Buying Scale were associated with scores on the subscales of the Executive Personal Finance Scale (rs = -.35 to -.70) and the Money Attitudes Scale (positively with using money for impressing others, and negatively with saving and planning). The results suggested that common tendencies toward compulsive buying may not be pathological, but merely associated with attitudes toward money in general and financial management habits.

Obsessive Compulsive Treatment Efficacy Trial (OCTET) comparing the clinical and cost effectiveness of self-managed therapies: study protocol for a randomised controlled trial.

BACKGROUND: UK National Institute of Health and Clinical Excellence guidelines for obsessive compulsive disorder (OCD) specify recommendations for the treatment and management of OCD using a stepped care approach. Steps three to six of this model recommend treatment options for people with OCD that range from low-intensity guided self-help (GSH) to more intensive psychological and pharmacological interventions. Cognitive behavioural therapy (CBT), including exposure and response prevention, is the recommended psychological treatment. However, whilst there is some preliminary evidence that self-managed therapy packages for OCD can be effective, a more robust evidence base of their clinical and cost effectiveness and acceptability is required. METHODS/DESIGN: Our proposed study will test two different self-help treatments for OCD: 1) computerised CBT (cCBT) using OCFighter, an internet-delivered OCD treatment package; and 2) GSH using a book. Both treatments will be accompanied by email or telephone support from a mental health professional. We will evaluate the effectiveness, cost and patient and health professional acceptability of the treatments. DISCUSSION: This study will provide more robust evidence of efficacy, cost effectiveness and acceptability of self-help treatments for OCD. If cCBT and/or GSH prove effective, it will provide additional, more accessible treatment options for people with OCD. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN73535163. Date of registration: 5 April 2011.

Patients with obsessive-compulsive disorder vs depression have comparable health care costs: a retrospective claims analysis of Florida Medicaid enrollees.

BACKGROUND: The health care burden of obsessive-compulsive disorder (OCD) is relatively unknown. OBJECTIVE: To compare the health care burden of patients with OCD vs depression. METHODS: This retrospective claims analysis compared the 2-year median per-patient health care claims and costs for Florida Medicaid adult enrollees (1997 to 2006) newly diagnosed with "pure OCD" (P-OCD; OCD without comorbid major depression, bipolar disorder, psychosis, organic mental disorder, pervasive developmental disorder, nonpsychotic brain damage, developmental delay, or mental retardation) with matched patients newly diagnosed with "pure depression" (P-D; similar to P-OCD but excluding OCD instead of depression). RESULTS: Eighty-five newly diagnosed P-OCD patients were matched with 14,906 P-D patients. Although median per-patient total health care costs were comparable across groups, patients with P-D incurred significantly higher median outpatient medical costs ($1,928 vs $363, P = .003), while those with P-OCD incurred almost three-fold greater psychiatric costs ($2,028 vs $759, P < .0001). The latter was due primarily to significantly higher costs of psychotropic medications among those with P-OCD ($4,307 vs $2,317, P = .0006) rather than to psychiatric outpatient care. CONCLUSIONS: Patients with P-D and P-OCD carry a similar burden in overall health care costs. However, the burden of those with P-D was largely attributable to outpatient medical costs while that of those with P-OCD was due to higher costs of psychotropic medications.

Validación del inventario de obsesiones y compulsiones revisado (OCI-R) para su uso en población adolescente española / Validation of the Obsessive-Compulsive Inventory Revised (OCI-R) for Spanish adolescent population

Existe un creciente interés por los instrumentos diseñados para evaluar los síntomas obsesivo-compulsivos en niños y adolescentes. El “Inventario de Obsesiones y Compulsiones -Revisado” (OCI-R) se ha mostrado una prueba válida y útil en la evaluación de esta sintomatología transculturalmente tanto en contexto clínico como no clínico. El objetivo de este estudio fue examinar y ampliar las propiedades psicométricas y la estructura factorial del OCI-R en una muestra no clínica de 525 adolescentes (edad media= 15.82 años; DT= 1.77; rango=12-18). Los resultados confirmaron la estructura original de seis factores del OCI-R (Lavado, Obsesiones, Acumulación, Orden, Comprobación y Neutralización), así como también su consistencia interna, estabilidad temporal y validez convergente-discriminante. En resumen, el OCI-R es un instrumento breve y fiable que evalúa tanto una dimensión global del trastorno obsesivo-compulsivo como dimensiones sintomatológicas específicas en la adolescencia, lo cual coincide con la literatura previa. Su pertinencia en muestras clínicas de adolescentes requiere ser examinada en futuras investigaciones (AU)

There is a growing interest in instruments designed to assess obsessive-compulsive symptoms in children and adolescents. The Obsessive Compulsive Inventory-Revised (OCI-R) has demonstrated to be a valid and useful test in the evaluation of these symptoms cross-culturally in both clinical and nonclinical settings. The aim of this study was to examine and extend the psychometric properties and factor structure of the OCI-R in a non-clinical sample of 525 adolescents (mean age=15.82; SD=1.77; range=12-18). The results confirmed the original six-factor structure of the OCI-R (Washing, Obsessing, Hoarding, Ordering, Checking and Neutralizing), as well as the internal consistency, temporary stability, and concurrent-discriminant validity. To sum up, the OCI-R is a short and reliable instrument that measures global as well as domain-specific obsessive-compulsive symptomatology in adolescence, what is consistent with previous literature. Whether it will retain its psychometric properties in clinical samples of adolescents remains to be investigated (AU)

Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs.

BACKGROUND: Exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention. METHODS: Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in. RESULTS: The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes. CONCLUSIONS: These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.

Stepped care for obsessive-compulsive disorder: An open trial.

This study evaluated the effectiveness and treatment costs associated with a stepped care protocol of exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). In the current open trial, patients (N=14) began with self-directed EX/RP and minimal therapist guidance over the course of six weeks (Step 1). During this phase of treatment, no therapist-directed exposures were conducted. Those who did not respond optimally to Step 1 went on to Step 2, which consisted of 15 sessions of twice-weekly therapist-directed exposures. Results of this study show promise for stepped care utilizing EX/RP for some patients with OCD, with a response rate of 88% and a 60% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score among treatment completers. Significant improvements were found in Y-BOCS from pre to post-treatment for both Step 1 and Step 2 completers. Forty-five percent of participants (n=5) responded following completion of Step 1, resulting in reduced cost of treatment among these participants. All participants who responded to Step 1 maintained acute gains during the brief follow-up period. Limitations include a small sample size and high attrition rate.

Adequacy of pharmacotherapy among medicaid-enrolled patients newly diagnosed with obsessive-compulsive disorder.

OBJECTIVE: To determine the adequacy of pharmacotherapy received by patients with newly-diagnosed obsessive-compulsive disorder (OCD), based on current practice guidelines. METHODS: A 9 year (1997-2006) retrospective claims analysis of adults enrolled in Florida Medicaid for at least 3 continuous years was conducted to determine the percentage who received both a minimally effective duration (> 8 continuous weeks) and dose of first-line OCD pharmacotherapy during the year following their first ("index") OCD diagnosis. RESULTS: Among 2,960,421 adult (> 18 years of age) enrollees, 2,921 (0.1%) were diagnosed with OCD. Among the 2,825 OCD patients without comorbid Asperger syndrome or autism, 843 had newly-diagnosed OCD and at least 12 months of follow-up data after their index diagnosis. Among these 843 patients, 588 (69.7%) received first-line OCD pharmacotherapy but only 323 (38.3%) received a minimally effective pharmacotherapy trial in the year following their index diagnosis. CONCLUSIONS: Among clinically-diagnosed persons with OCD (<10% of those with the disorder), a minority of newly-diagnosed patients receive a minimally effective pharmacotherapy trial consistent with current standards of care. Reasons such as limited patient adherence and/or physician awareness of guidelines must be identified and redressed to ameliorate the patient, healthcare system, and economic burdens associated with OCD.

The economic and social burden of compulsive hoarding.

The aim of the present study was to determine the economic and social burden of compulsive hoarding in a large sample of individuals with self-identified hoarding, as well as a separate sample of family members of individuals who hoard. Self-identified hoarding participants (N=864, 94% female, 65% met research criteria for clinically relevant compulsive hoarding) and family informants (N=655, 58% described a relative who appeared to meet research criteria for compulsive hoarding), completed an internet survey. Questions were derived in part from those used in the National Comorbidity Survey (NCS), and when possible, hoarding participants were compared to NCS participants. Compulsive hoarding was associated with an average 7.0 work impairment days in the past month, equivalent to that reported by individuals with psychotic disorders and significantly greater than that reported by female NCS participants with all other anxiety, mood, and substance use disorders. Severity of hoarding predicted the degree of work impairment after controlling for age, sex, and non-psychiatric medical conditions. Hoarding participants were nearly three times as likely to be overweight or obese as were family members. Compared to female NCS participants, hoarding participants were significantly more likely to report a broad range of chronic and severe medical concerns and had a five-fold higher rate of mental health service utilization. Eight to 12% had been evicted or threatened with eviction due to hoarding, and 0.1-3.0% had a child or elder removed from the home. These results suggest that compulsive hoarding represents a profound public health burden in terms of occupational impairment, poor physical health, and social service involvement.

Family burden, quality of life and disability in obsessive compulsive disorder: an Indian perspective.

BACKGROUND: Obsessive compulsive disorder (OCD) is a psychiatric disorder that often tends to run a chronic course. The lifetime prevalence of OCD is around 1-3%, which is twice as prevalent as schizophrenia and bipolar disorder. AIM: To asses the family burden, quality of life (QoL) and disability in patients suffering from at least moderately ill OCD and then to compare them with schizophrenia patients of comparable severity. SETTINGS AND DESIGN: We recruited 70 consecutive subjects (OCD=35, schizophrenia=35) who met study criteria between March 2005 and March 2006 from the psychiatric services of the National Institute of Mental Health and Neuro Sciences, Bangalore, India. MATERIALS AND METHODS: The severity of illness was rated using the Clinical Global Impression-Severity (CGI-S). Instruments used in the current study were the Family Burden Schedule, the World Health Organization (WHO) QoL (Bref) and the WHO - Disability Assessment Schedule (DAS). STATISTICAL ANALYSIS: The Fisher's exact test/chi-square test was used to compare categorical variables and the independent sample t test was used to analyze continuous variables. Analysis of covariance (ANCOVA) was used to compare the groups after controlling for potential confounding variables. Pearson's correlation was used for correlation analysis. RESULTS: Overall family burden, financial burden and disruption of family routines were significantly higher in schizophrenia patients compared to OCD although the groups did not differ with respect to other domains of family burden. On the WHO QoL, OCD patients were comparable to schizophrenia patients with respect to the psychological and social domains. On the WHO - DAS, both the groups were similar in all the domains except getting around. CONCLUSION: Severe OCD is associated with significant disability, poor QoL and high family burden, often comparable to schizophrenia. Therefore, there is an urgent need to increase the sensitivity among healthcare professionals to recognize and treat OCD.