Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomised controlled non-inferiority trial
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38940.355602.80 (Published 26 October 2006) Cite this as: BMJ 2006;333:883
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I read with interest the trial by Lovell and others, and also the
rapid responses this paper has generated. Although I have not worked
within the OCD clinical area, I do have a particular interest in the
methodology of noninferiority (NI) trials. The first thing that struck me
was the large noninferiority margin - could a difference on 4.99 points on
the Yale Brown scale be deemed clinically irrelevent? Given the scale has
a maximum of 40, I find this hard to accept. No justification is given for
the choice of 5 points. Also, analysis was based on the ITT approach. In a
NI trial more information is required about the possibility of protocol
violation, with the likely need for a per-protocol analysis. Although
there may not have been a great deal of scope for protocol deviation in
this trial, this issue should be addressed.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
This is an interesting article and is cost effective treatment for the
National Health Service. There are big waiting lists for CBT and shortage
of trained therapists.
I am not sure whether one can call it a randomised controlled trial as
there were no control group in this particular study. Also reasons for
drop-out from the study was unclear. I wanted to know whether this may
lead to attrition bias.
Telephone treatments may be of use in other psychiatric disorders and this
study has thrown some light on this issue and makes professionals think
about future research on teletherapy in other mental disorders.
This may be useful in Indian rural settings but one needs to think about
the costs involved in arranging for video conferencing, telephone
installations in a typical village with lack of financial resources.
Competing interests:
None declared
Competing interests: No competing interests
It is heartening that CBT delivered by telephone (CBT-T) is found
comparable to that by face-to-face (CBT-F). However, we would like to
allude to the issue of ‘motivation’ in psychological therapies (including
CBT) that has not been discussed by the authors. We suspect that all
patients in the two groups probably had good motivation to undergo CBT for
their OCD leading to promising results for both arms of the study. This
assertion is based on the following indicators- marked distress or
severity of OCD, long duration of illness, less number of patients having
received any form of treatment (31%-53%), fewer patients receiving
psychological treatment (31%-39%) than pharmacological treatment (47%-
53%), and low attrition rates. Treatment-naïve patients show better
response to treatment (1), and the long waiting periods for psychology
input in the NHS (2,3) could have acted as an ‘incentive’ for all the
patients to adhere better to the CBT offered.
On similar lines, it may be argued that the patients who received CBT
-T were more motivated than those who received CBT-F as they had received
less exposure to either psychological or pharmacological treatments. Also,
it is not clear whether both groups had similar profile of OCD patients,
as certain sub-types tend to show poorer response to treatment (1). More
patients in the CBT-F group were on additional medications (61% vs 42%);
data supports that combination pharmacotherapy and psychotherapy works
best for patients with OCD (1,2) and hence, the CBT-T group may have
actually been less efficacious than CBT-F group.
It would have been useful if more information (especially on the
waiting times for this study, and access to specialist and the local
psychology services) had been presented on these variables as to how they
influenced motivation or acted as potential confounders to the results
obtained in the study.
The authors conclude by saying that they did not have a control (no
treatment) group. This could have been probably addressed by having the
patients who were on the wait-list for CBT for OCD to be taken as the
‘control’ arm during the same time frame (keeping in view-the long wait
periods of many months for patients to access psychological therapy in the
NHS).
Nevertheless, notwithstanding these caveats, CBT-T appears a
promising option to research further and consider for the cash-strapped
NHS (4) where patient choice (5) is assuming great importance. CBT-T
offers both ‘choice’ and ‘convenience’ for scheduling of time and day of
the sessions for both patient and therapist, saves on additional indirect
costs related to travel and time, and hence can be a viable option for
primary care to consider due to possibly lowered commissioning costs.
REFERENCES:
[1] Koran LM. Obsessive-compulsive and related disorders in adults: A
comprehensive clinical guide. Cambridge: Cambridge University Press, 1999.
[2] National Institute for Health and Clinical Excellence. Obsessive
compulsive disorder. Clinical Guidance 31. www.nice.org.uk/CG031 (last
accessed 12 November 2006).
[3] http://www.ocdaction.org.uk/ocdaction/index.asp?id=132 (last
accessed 12 November 2006).
[4] http://news.bbc.co.uk/1/hi/health/4815986.stm; (last accessed 12
November, 2006).
[5] www.nhs.uk; (last accessed 12, November 2006).
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
It is really encouraging to learn that Teletherapy can be so effective and
can save time and money but it raises a few questions in my mind ie what
about relapse?what about the incidence of relapse in people receiving
Teletherapy?I would be grateful if someone would mention what is the
relapse rate in people receiving teletherapy?Is it as effective in the
long term as Direct face to face Psychotherapy or is this just a short
term result?It can be helpful in determining if Teletherapy can replace
Face to Face Clinical Sessions all together
Competing interests:
None declared
Competing interests: No competing interests
If CBT offered by telephone is of similar effectiveness to face-to-
face contact there is no restriction on where the therapist can be based.
Indeed there is no reason why it could not be delivered by clinical
psychologists in India.
Competing interests:
None declared
Competing interests: No competing interests
Telephone administered and computerised cognitive behavioural therapies are gaining popularity because of the cost effectiveness and easy accessibility of these modes of treatment. This paper compares the effectiveness of telephone administered CBT with conventional therapy.
It is interesting to note that although the two groups were randomised, the methodology used is not explicit and noteworthy differences existed at the beginning of the trial – there were more male and married patients in the telephone CBT group. These factors may have acted as confounders to sway the result. Moreover 39% of the patients in the group allotted to the telephone Cognitive Behavioural therapy had received previous treatment as compared to 31% in the other group. The telephone CBT might have served as a booster to the previous psychological treatment.
The power calculation for this study was not done and the sample size is small and therefore the results might be a type II error failing to show the difference that might have existed.
The authors have implied that a 40% savings on the therapist’s time may be achieved by switching over to telephone CBT without compromising on the effectiveness. If this were to be the case, then a similar outcome can be expected from a face to face therapy spanning over 30 minutes with similar cost effectiveness. This study opens grounds for the need of a further research in this area.
Competing interests:
None declared
Competing interests: No competing interests
Lovell et al's findings certainly have promising prospects for
optimising CBT therapist time.I however would like to see the results of a
well designed economic analysis factoring in the additional but hidden
costs of this new delivery method.
I note the up to half hour telephone conversations eight times in the
treatmnet adding up to 4 hours of telephone conversation per patient.
There is also the additional cost of postage of literature between
therapists and patients.
I am no skeptic, but I would like to take a more universal look at
resource implications of this new method before making final
conclusions.Saving therapist time does not automatically equate to a cost
effective service.
An economic evaluation of telephone administered CBT in comparism
with the traditional face to face method is the only true umpire in this
case. Given the current dismal state of the NHS coffer, I would not be too
optimistic until I see the economic analysis figures.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR--This was an interesting study, CBT for OCD by telephone as
effective as face to face delivery, and there are many implications:
1.To see whether CBT by telephone and face to face contact gives similar results
in other psychiatric disorders in which CBT is the treatment of choice
2.With a big waiting list for CBT in many areas, CBT by telephone might be a useful way of
tackling that problem
3.Gives the opportunity to some therapists of working from home, out of
area, out of hours, etc
4.Gives the opportunity of treating patients who find it difficult to attend due to many
causes e.g, work, family, ill health, transport issues.
Dr.Al-Sheikhli
Competing interests:
None declared
Competing interests: No competing interests
I would say the above literature by Lovell et al ragarding telephone
administered cognitive behaviour therapy for treatment of obsessive
compulsive disorder has brought on mixed emotions. It once again
highlights on the usefulness of Telepsychiatry in delivering health care.
I am sure everyone is familiar with Telepsychiatry or atleast
Telemedicine ? Telepsychiatry is nothing but delivery of Psychiatry at a
distance. A common example is a Psychiatrist doing a mental state
examination of a patient, who didn't attend for his or her clinic
appointment,on the phone.This is an example of 'real
time'Telepsychiatry.Telepsychiatry can be particularly useful when the
patients have to travel from far off places and where public transport
system is not well organised. One example is India where majority of the
people live in rural areas but only 2% of the qualified Doctors practice
in the countryside.
I beleive Non verbal communication (NVC) is too important to be
ignored as pointed out by Michael C Smith, et al despite the fact that
this study shows telephone CBT as effective as face-to-face therapy.I
beleive NVC is important for formation of a therapeutic relationship.In a
telephone only medium, it could be argued that exchange of emotions could
be difficult or may be misinterpreted. However, Short et al, 1976 found
that telephone messages contained more verbal expression of agreement or
disagreement with other's opinion than those of the face-to-face
interactions. It conveys the message that human communication is highly
adaptive, and that non-verbal and verbal messages are interchangeable.
Since telephonic conversation would deliver fewer cues than face-to-
face conversation, would it amount to lower productivity ? Or is the other
way round, that is, more efficient since unnecessary cues can be
discarded!
Telephonic CBT might be able to increase compliance with therapy in
individuals who are not wanting to travel because of contamination fears.
Some patients with OCD take particularly long time to get ready and might
often turn up late for their appointments.In these cases, telephonic CBT
will save resources.However, professionals might not feel adequately
trained to deliver it on the phone and this might cause anxiety.There are
issues about confidentiality as well apart from language being
misinterpreted over the phone.On the positive side, telephonic CBT would
mean reduced need for patients to travel, patients treated in their own
less threatening home environment. Is is however important to stress how
much Psychiatrists in general rely on NVC e.g, Schizophrenia with negative
symptoms or depression secondary to OCD. Resistant patients might blame
telephonic CBT for non- response and lose future hope. Nevertheless,
Telephonic therapy does offer hope, particularly, Telepsychiatry.
REFERENCES
Lovell et all,Telephone administered cognitive behaviour therapy for
treatment of obsessive compulsive disorder: randomised controlled non-
inferiority trial;BMJ, doi:10.1136/bmj.38940.355602.80
Pilot studies of telemedicine for patients woth OCD; L Baer et al, Am
J Psychiatry 1995;152:1383-1385
Dwyer TF.Telepsychiaty:Psychiatric consultation by interactive
television. Am J Psychiatry. 1973Aug;130(8):865-9
Simon et al.BMj2000;320:550-554(26February)
Paul Mclaren.Advances in Psychiatric Treatment(2003) 9: 54-61
Competing interests:
None declared
Competing interests: No competing interests
CSQ-8
This article cites the CSQ-8 as being scored from 0 - 32. This is
incorrect. Each item in the scale generates a score in the range of 1-4.
It follows that the maxium score is 32 - as the authors quite rightly
claim. The minimum score however is 8; unless the scale is scored from 0
- 3 . . . in which case the maximum score would then be 24. Otherwise an
interesting paper.
Competing interests:
None declared
Competing interests: No competing interests