CPR-01473; No of Pages 11

Clinical Psychology Review xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Clinical Psychology Review

Remote cognitive–behavior therapy for obsessive–compulsive

symptoms: A meta-analysis
Bethany M. Wootton ⁎
Department of Medicine (Psychology), University of Tasmania, Locked Bag 30, Hobart, TAS 7001, Australia

H I G H L I G H T S

• This study synthesizes the findings on remote treatment for obsessive–compulsive symptoms using a meta-analytic approach.
• Eighteen controlled and uncontrolled studies were included in the meta-analysis.
• Remote treatment for OCD produces a large effect size.
• Remote treatment for OCD is significantly more effective than control.
• Outcomes from remote treatment do not differ from face-to-face treatment.

a r t i c l e i n f o a b s t r a c t

Article history: Obsessive–compulsive disorder (OCD) is a chronic mental health condition that results in a significant societal
Received 17 March 2015 burden. Remote treatments do not require the patient to attend traditional face-to-face treatment services and
Received in revised form 4 October 2015 can be used as a way to overcome barriers to accessing face-to-face treatment. The aim of the current study
Accepted 13 October 2015
was to synthesize the current literature on remote treatment for OCD using a meta-analytic approach. Relevant
Available online xxxx
articles were identified through an electronic database search and the references of previously completed re-
Keywords:
views on the topic of remote treatment for OCD were also reviewed. Eighteen studies (n = 823; mean age =
Obsessive–compulsive disorder 31.20 (SD = 10.36); 56.2% female) were included in the meta-analysis. Within-group findings indicate that re-
Remote-treatment mote treatment for OCD produces a decrease in symptoms of a large magnitude (g = 1.17; 95% CI: 0.91–1.43).
Meta-analysis Between-group findings indicate that remote treatment for OCD is more effective than control (g = 1.06; 95%
CI: 0.68–1.45) and outcomes are not meaningfully different from face-to-face treatment (g = −0.21; 95% CI:
−0.43–0.02). Those methodologies that are low intensity produce a decrease in symptoms of a large magnitude
(g = 1.36, 95% CI: 1.00–1.72), as do higher intensity treatments (g = 1.64, 95% CI: 1.33–1.95). These findings
have important implications for the development of stepped-care treatments, which may be able to be delivered
in a purely remote fashion.
© 2015 Elsevier Ltd. All rights reserved.

Contents

1. Measurement of obsessive–compulsive symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

2. Cognitive–behavioral treatment for obsessive–compulsive disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
3. Barriers to accessing evidence-based treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4. Remote treatment for obsessive–compulsive disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.1. High intensity remote treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.1.1. Videoconferencing administered CBT (vCBT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.1.2. Telephone administered CBT (tCBT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.2. Low intensity remote treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.2.1. Computerized CBT (cCBT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.2.2. Internet-administered CBT (iCBT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
4.2.3. Bibliotherapy administered CBT (bCBT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
5. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

⁎ Tel.: +61 3 6226 7124; fax: +61 3 6226 2883.

E-mail address: bethany.wootton@utas.edu.au.

http://dx.doi.org/10.1016/j.cpr.2015.10.001
0272-7358/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
2 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx

5.1. Search procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

5.2. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
5.3. Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.2. Within-group analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.2.1. Overall within-group effect size for remote treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.2.2. Low intensity vs. high intensity remote treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.2.3. Self-guided vs clinician-guided low intensity treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.3. Between-group analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.3.1. Remote treatment vs. control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
6.3.2. Remote treatment vs. face-to-face treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
7. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
7.1. Implications: stepped-care treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
7.2. Limitations and strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Role of funding sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

Obsessive–compulsive disorder (OCD) is a common psychologi-
cal condition that is characterized by the experience of obsessions
and compulsions (American Psychiatric Association, 2013). The
symptoms and clinical features of OCD have been documented for
hundreds of years (Burton, 1989) and the disorder is characterized
by significant symptom heterogeneity. Obsessive–compulsive disor-
der is a relatively common disorder, with a lifetime prevalence rate
of approximately 2–3% (Australian Bureau of Statistics, 2007;
Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Age of
onset appears to be bimodal, with a peak at mean ages of
12.8 years and 24.9 years (Anholt et al., 2014). In adult samples the
disorder is more commonly seen in females (3.6% lifetime preva-
lence rate) than males (1.8% lifetime prevalence rate) (Kessler
et al., 2012), however males appear to be over-represented in child-
hood presentations of OCD, with approximately one quarter having
an onset of symptoms prior to age 10, in contrast to females who
are more likely to develop symptoms during adolescence (Ruscio,
Stein, Chiu, & Kessler, 2010). Symptoms of OCD tend to wax and
wane in response to life stressors, but rarely remit spontaneously
without treatment (Pinto, Mancebo, Eisen, Pagano, & Rasmussen,
2006). The diagnosis of OCD is associated with considerable disabil-
ity in various domains of functioning and individuals with OCD are
significantly more impaired than community samples (Eisen et al.,
2006). The extent of impairment in functioning and quality of life
also appears positively correlated with the severity of symptoms
(Eisen et al., 2006).
1. Measurement of obsessive–compulsive symptoms
The Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) (Goodman
et al., 1989) is a 10-item measure of the severity of obsessive–compul-
sive symptoms regardless of symptom presentation and is the gold-
standard outcome measure in the OCD literature. The Y-BOCS is usually
completed as a clinician-administered measure, however a self-report
version of the scale is also available, and responses on the self-report
Y-BOCS correlate highly with those on the clinician-administered scale
(r = .76) (Steketee, Frost, & Bogart, 1996). The Y-BOCS demonstrates
good internal consistency in both clinician administered (range α =
.75–.87) (Anholt et al., 2010; Tolin et al., 2007) and self-report adminis-
tration (range α = .73–0.92) (Ólafsson, Snorrason, & Smári, 2010;
Wootton, Dear, Johnston, Terides, & Titov, 2014). Total scores on the
measure range from 0 to 40 and a cut score of 16 is generally used to de-
termine a clinical level of symptoms.
2. Cognitive–behavioral treatment for obsessive–compulsive disorder
Cognitive–behavioral models of OCD are largely based on the body
of research that demonstrates that intrusive thoughts are a universal
phenomenon which becomes problematic only when individuals mis-
interpret those intrusions as threatening (Rachman & de Silva, 1978).
These cognitive–behavioral models hypothesize that symptoms of
OCD are maintained by cognitive biases, engagement in compulsive be-
haviors, and avoidance of triggers (Rachman, 1997; Salkovskis, 1985,
1999). Best practice cognitive behavior therapy (CBT) addresses these
maintaining factors through a particular CBT technique, exposure and
response prevention (ERP). Specific cognitive interventions can some-
times be used in addition to ERP (Van Oppen et al., 1995). While the
exact mechanisms of this treatment are unknown it is hypothesized
that ERP for OCD is effective because of the resultant 1) cognitive change
(correction of faulty assumptions); 2) habituation to the conditioned
fear; or 3) increases in self-efficacy (Abramowitz, 2006).
In its contemporary administration ERP involves four components;
1) exposure in vivo, where the individual confronts feared stimuli in
real life; 2) exposure in imagination, where fears are confronted in
imagination; 3) response prevention, which involves instructing the in-
dividual to cease any overt or covert behaviors that they would normal-
ly do to eliminate their anxiety; and, 4) a processing component, which
Foa (2010) describes as reviewing with the client what they have learnt
from completing an exposure task. For example an individual with con-
tamination obsessions and cleaning/washing compulsions may be ex-
posed to touching progressively more ‘dirty’ objects in real life (in-
vivo exposure), may be instructed to imagine contracting a deadly dis-
ease (imaginal exposure), will be instructed to refrain from hand wash-
ing and other cleaning behaviors (response prevention), and may
discuss with the therapist after the exposure whether their fears
(i.e., of contracting a deadly disease) occurred (processing).
The initial literature on the efficacy of exposure based treatment for
OCD emerged in the late 1960s to early 1970s (Meyer, 1966; Rachman,
Hodgson, & Marks, 1971). Since this time traditional face-to-face expo-
sure based treatments have consistently demonstrated clinical efficacy
(Eddy, Dutra, Bradley, & Westen, 2004; Gava et al., 2007; Olatunji,
Davis, Powers, & Smits, 2013; Sánchez-Meca, Rosa-Alcázar,
Iniesta-Sepúlveda, & Rosa-Alcázar, 2014). For instance, a recent meta-
analysis of 16 randomized controlled trials (RCTs), spanning both child/
adolescent and adult samples, found a large effect size at post-treatment
(g = 1.39) (Olatunji et al., 2013). Similar results were also found in a re-
cent meta-analysis of pediatric OCD (Sánchez-Meca et al., 2014). While
CBT treatments for OCD can differ slightly depending on the emphasis

Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx
on ‘cognitive’ or ‘behavioral’ interventions, there does not appear to be
any differences in outcomes when primarily cognitive techniques are
used or when primarily behavioral techniques are used (Olatunji et al.,
2013; Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez,
2008), however to date the number of studies that emphasize cognitive
techniques is far fewer in number than those that emphasize behavioral
interventions (Olatunji et al., 2013). The literature also demonstrates
that CBT is effective regardless of baseline symptom severity, symptom
subtype, gender, number of sessions, or comorbidity profile (Olatunji
et al., 2013).
3. Barriers to accessing evidence-based treatment
Despite the availability of effective psychological treatments for OCD
many individuals do not access traditional face-to-face evidence-based
treatments. Results from epidemiological studies indicate that approxi-
mately 60% of individuals with OCD remain untreated (Kohn, Saxena,
Levav, & Saraceno, 2004). Other research indicates that when individ-
uals with OCD do access treatment they are often not provided with
an evidence-based treatment or do not receive a sufficient dose of ERP
(Stobie, Taylor, Quigley, Ewing, & Salkovskis, 2007). Additionally, indi-
viduals with OCD often wait more than a decade to access treatment
(Pinto et al., 2006). Multiple barriers exist to individuals seeking treat-
ment for OCD including the cost of treatment, geographical isolation,
lack of access to trained clinicians, and stigma (Baer & Minichiello,
2008; Belloch, Valle, Morillo, Carrió, & Cabedo, 2009; Goodwin,
Koenen, Hellman, Guardino, & Struening, 2002; Marques et al., 2010).
The consequence of these barriers is that a large proportion of people
with OCD experience burden that could be averted.
4. Remote treatment for obsessive–compulsive disorder
Remote treatments are those that can be delivered without the ther-
apist physically being in the same room as the client, and can thus im-
prove access to evidence-based care. Remote treatments differ along
multiple continua including whether they use technology to deliver re-
mote treatments in synchronous, or real time (high intensity remote in-
terventions) or whether they involve brief and often asynchronous
contact with a therapist (low intensity remote interventions). These in-
terventions are discussed in turn below.
4.1. High intensity remote treatments
High intensity remote treatments are those that use technology to
deliver a treatment that is analogous to traditional face-to-face treat-
ment. The skills provided (i.e., psycho-education and ERP), and length
of session (i.e., 60–90 min), are typically the same in high intensity re-
mote treatment as in a traditional face-to-face treatment, however,
the patient and therapist have their session using technology aids.
Using these technology aids the client and the therapist interact in
real-time. Typical technologies that are used in high intensity remote
treatments include traditional or internet-based videoconferencing, or
the telephone. The existing literature summarizing the use of these
high intensity technologies in the treatment of OCD symptoms are
outlined below.
4.1.1. Videoconferencing administered CBT (vCBT)
Videoconferencing delivered CBT involves the client and the thera-
pist interacting via a video-link, thus the client's non-verbal behavior
is able to be observed. The video-link may use traditional videoconfer-
encing software, or may use web-based software. Videoconferencing
delivered CBT has demonstrated equivalent outcomes to face-to-face
treatment for a variety of mental health conditions including depression
(Nelson, Barnard, & Cain, 2003), post-traumatic stress disorder (Frueh
et al., 2007), panic disorder (Bouchard et al., 2004) and a mixed sample
of individuals with mood and anxiety disorders (Stubbings, Rees,
Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
3
Roberts, & Kane, 2013). Videoconferencing administered CBT has also
been used successfully in the treatment of OCD. While there are current-
ly no direct comparisons of vCBT and face-to-face CBT in the treatment
of OCD there are two RCTs that have compared vCBT with a waitlist con-
trol and both have found large between-group effect sizes at post-
treatment (Storch et al., 2011; Vogel et al., 2014). Additional evidence
on the efficacy of vCBT for OCD comes from uncontrolled studies
(Goetter, Herbert, Forman, Yuen, & Thomas, 2014) and case series
(Comer et al., 2014; Himle et al., 2006).
4.1.2. Telephone administered CBT (tCBT)
Telephone administered CBT interventions involve the client and
therapist interacting over the telephone. This mode of treatment has
also been demonstrated to result in similar outcomes to standard face-
to-face treatments for a variety of conditions, including depression
(Mohr et al., 2012) and chronic pain (Carmody et al., 2013). Telephone
administered CBT has also been used quite extensively in the OCD liter-
ature. Studies comparing tCBT with face-to-face CBT have emerged in
both adolescent (Turner et al., 2014) and adult (Lovell et al., 2006) sam-
ples and demonstrate equivalent outcomes across methodologies. This
approach has also been demonstrated to be effective for OCD in a num-
ber of uncontrolled trials (Taylor et al., 2003; Turner, Heyman, Futh, &
Lovell, 2009) and case series (Lovell, Fullalove, Garvey, & Brooker,
2000).
These high intensity remote interventions are provided in a synchro-
nous (i.e., real time) fashion and generally involve the same amount of
therapist contact that would typically be seen in face-to-face treatment,
thus while not overly cost saving, they do reduce barriers such as geo-
graphical isolation and lack of access to a trained clinician. There is
now growing evidence to suggest that high intensity remote treatment
is just as effective as face-to-face treatment, however more controlled
trials are urgently needed.
4.2. Low intensity remote treatments
Low intensity remote treatments involve patients systematically
reading structured lessons, modules or information that present the
same information and skills typically taught in face-to-face treatment
(Titov, 2007). The most commonly administered low intensity remote
treatments include computerized, internet- and bibliotherapy adminis-
tered treatments. These low intensity interventions can be either
clinician-guided (i.e., some clinician contact is provided) or self-
guided (i.e., no clinician contact is provided), however it appears that
the provision of clinician support may result in improved outcomes
(Johansson & Andersson, 2012; Marrs, 1995; Spek et al., 2007). When
low intensity treatments are guided the interaction between the client
and therapist is asynchronous (i.e., not in real time). The existing litera-
ture summarizing the use of these low intensity technologies in the
treatment of OCD symptoms are outlined below.
4.2.1. Computerized CBT (cCBT)
Computerized treatments are those that consist of a treatment pro-
gram that is usually loaded on to a single computer or are administered
via a computerized device. Computerized treatments have been dem-
onstrated to be effective in the treatment of a number of disorders in-
cluding panic disorder and phobias (Marks, Kenwright, McDonough,
Whittaker, & Mataix-Cols, 2004) and anxiety and/or depression
(Proudfoot et al., 2003). The most commonly used computerized pro-
gram for the treatment of OCD is the Behavior Therapy (BT) Steps pro-
gram. Individuals access the computer generated program via a touch
tone telephone rather than a computer, and they advance through
each of the steps at their own pace (Greist et al., 2002). Several studies
have now demonstrated the efficacy of BT Steps in the treatment of OCD
(Bachofen et al., 1999; Greist et al., 2002; Greist et al., 1998; Kenwright,
Marks, Graham, Franses, & Mataix-Cols, 2005).
4 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx
4.2.2. Internet-administered CBT (iCBT)
Internet-delivered treatments are those that have materials that are
accessible via the internet and are thus generally more flexible than com-
puterized treatments. iCBT can be delivered as open access programs
(where anyone can access the program) or can be closed (where the pa-
tient logs in with a secure username and password) (G. Andersson,
Carlbring, Ljótsson, & Hedman, 2013). Open access programs tend to re-
sult in lower effect sizes than closed program (G. Andersson et al., 2013)
and the discussion that follows relates only to closed iCBT programs.
Results of a recent meta-analysis indicate that clinician-guided iCBT
is as effective as traditional face-to-face treatment for a variety of men-
tal health conditions (Andersson, Cuijpers, Carlbring, Riper, & Hedman,
2014). For OCD, a number of recent studies have emerged demonstrat-
ing the efficacy of iCBT for OCD, with large effect sizes seen across three
RCTs (Andersson et al., 2012; Mahoney, Mackenzie, Williams, Smith, &
Andrews, 2014; Wootton, Dear, Johnston, Terides, & Titov, 2013) and
5 open trials (E. Andersson et al., 2011; Lenhard et al., 2014; Wootton
et al., 2014; Wootton et al., 2011). Importantly, recent research suggests
that the effects of both clinician-guided and self-guided iCBT for OCD are
sustained beyond 12-months post-treatment (Andersson, Steneby
et al., 2014; Wootton, Dear, Johnston, Terides, & Titov, 2015).
4.2.3. Bibliotherapy administered CBT (bCBT)
Bibliotherapy is a remote treatment where the individual is provided
with a printed workbook to conduct his or her own treatment. Similar to
other remote treatments, bibliotherapy involves teaching the individual
the same skills and techniques taught in face-to-face treatment, howev-
er, material is presented in a paper workbook rather than online or via a
computer (Kavanagh, Connolly, White, Kelly, & Parr, 2010). There is
considerable evidence to suggest that such self-help treatments are use-
ful in decreasing symptoms of depression and anxiety, particularly
when the patient also receives remote support from a therapist
(Chung & Kwon, 2008; Cuijpers, Donker, Van Straten, Li, & Andersson,
2010; Marrs, 1995; Nordin, Carlbring, Cuijpers, & Andersson, 2010;
Scogin, Jamison, & Gochneaur, 1989). To date, one RCT has investigated
guided bCBT for OCD (Wootton et al., 2013) and another two RCTs have
also demonstrated the efficacy of unguided bCBT (Moritz, Jelinek,
Hauschildt, & Naber, 2010; Tolin et al., 2007), with moderate to large ef-
fect sizes seen. However, results are inconsistent with a more recent
RCT finding only small effects from unguided bCBT (Vogel et al.,
2014). Uncontrolled studies of bCBT for OCD demonstrate large effect
sizes (Gilliam, Diefenbach, Whiting, & Tolin, 2010; Tolin, Diefenbach,
Maltby, & Hannan, 2005), indicating that bCBT may be a promising re-
mote treatment approach for OCD.
These low intensity remote interventions are provided in an asyn-
chronous fashion and may be clinician-guided or self-guided. Due to
the reduced therapist time that is required, low intensity treatments
have the potential to provide considerable cost savings to healthcare
providers. These interventions are also important for those individuals
who avoid seeking treatment because of stigma or have a preference
to self-manage symptoms. While further research is needed, low inten-
sity treatments appear to be a promising treatment direction for indi-
viduals with OCD, however more controlled trials are needed.
While several excellent reviews of remote treatment for OCD are
currently available (Herbst et al., 2012; Lovell & Bee, 2011;
Mataix-Cols & Marks, 2006a, 2006b; Tumur, Kaltenthaler, Ferriter, Bev-
erley, & Parry, 2007), they are now largely outdated, as a large amount
of research in this area has been conducted in the last five years. Addi-
tionally, while previous meta-analyses have been conducted investigat-
ing remote treatments for other conditions (Bee et al., 2008) to date no
studies have quantitatively defined outcomes of remote treatment spe-
cifically for OCD by way of a meta-analysis. Therefore, the aim of the
current study is to extend the literature and synthesize the research
on efficacy of remote treatment for obsessive–compulsive symptoms
using a meta-analytic approach. While all studies included in this
meta-analysis were clinical samples, not all used a structured interview
Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
for diagnosis. For this reason the emphasis in this meta-analysis is on
‘obsessive–compulsive symptoms’, rather than ‘obsessive–compulsive
disorder’.
5. Method
5.1. Search procedure
Relevant articles were identified through electronic databases
(Scopus, Medline and PsycINFO) through to December 4th 2014. The
search terms used in the electronic database search included ‘obsessive
compulsive or OCD’ AND ‘internet or telephone or videoconferenc* or
bibliotherapy or computeri* or DVD or CD or distance or remote or
self-help’ AND ‘trial or RCT or randomi*ed’. The references of previously
completed reviews on the topic of remote treatment for OCD (Herbst
et al., 2012; Lovell & Bee, 2011; Mataix-Cols & Marks, 2006a, 2006b;
Tumur et al., 2007) were also reviewed.
5.2. Study selection
In order to be included, individual studies were required to: 1) be a
clinical trial with pooled data or a case series with calculable means
and standard deviations and an n ≥ five. Studies with a sample size less
than five were excluded as they were deemed to likely lead to unreliable
results when data was pooled. 2) The study must also have specifically
targeted OCD symptoms. 3) The study must include a remote treatment
(i.e., client located outside of the therapy office for bulk of treatment and
no more than 120 min of in-office face-to-face treatment). This
timeframe was chosen as a cut point because greater contact would im-
pact the ability to label the treatment ‘remote’. 4) Studies must have used
the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) (Goodman et al.,
1989) (either clinician administered or self-report) as an outcome mea-
sure with pre-treatment and post-treatment means and standard devia-
tions available. 5) Studies must use CBT that incorporated a component
of ERP in the remote treatment; 6) must be published in English and de-
scribe adequately the treatment methodology; and 7) must consist of
original data.
Due to the small number of studies in this area both uncontrolled tri-
als and RCTs were included as well as studies that investigated child/ad-
olescent and adult samples. The most conservative outcomes from each
study were used (intention to treat (ITT) data was used when possible
however completer data was used when ITT was unavailable). Studies
were divided into type of remote treatment (vCBT, tCBT, cCBT, iCBT
and bCBT) and were also divided into high and low intensity treatments
and self-guided and clinician-guided treatments.
5.3. Data analysis
Effect size data was analyzed using Comprehensive Meta-Analysis
Version 2.2 (Borenstein, Hedges, Higgins, & Rotherstein, 2011). All effect
sizes were calculated on the Y-BOCS (Goodman et al., 1989). Within-
group as well as between-group analyses were conducted using ran-
dom effects models. Within-group effect sizes were calculated for
X 1
X 2
Cohen's d using the following formula SDdiff where X1 is the pre-
treatment mean, X2 is the post-treatment mean and SDdiff is the SD of
the difference scores. The SDdiff was calculated with the following for-
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ffi
SD12 þSD22
2rSD1 SD2
mula pffiffiffiffiffiffiffiffiffiffiffi where SD1 is the pre-treatment standard de-
2ð1
rÞ
viation, SD2 is the post-treatment standard deviation and r is the
correlation between the pre-treatment and post-treatment scores
(Borenstein et al., 2011). However, because the correlations between
pre-treatment and post-treatment scores were not available a con-
servative estimate of r = .70 was used, consistent with previous
meta-analyses (Glombiewski et al., 2010; Winkler, Dörsing, Rief,
Shen, & Glombiewski, 2013). This score was then transformed to
 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx
Hedges's g by multiplying it by correction J based on the following
formula Jðdf Þ ¼ 1
4df3
1 (Borenstein et al., 2011). Consistent with pre-
vious meta-analyses (Glombiewski et al., 2010; Tolin, 2014; Winkler
et al., 2013) Hedges's g was interpreted in the following fashion: 0.2 a
small effect, 0.5 a medium effect, and 0.8 or greater a large effect. A pos-
itive g value indicates a decrease in symptoms of OCD and the larger the
value, the larger the effect. For within-group analyses an overall remote
treatment effect size was calculated as well as an effect size for each
type of remote treatment (vCBT, tCBT, cCBT, iCBT and bCBT). Compari-
sons were also made between low-intensity treatment and high-
intensity treatment and self-guided treatment and clinician-guided
treatment.
Between-group analyses were conducted between the remote treat-
ment group and waitlist/attention control conditions and between re-
mote treatment and face-to-face conditions. Consistent with the
recommendations of Higgins and Deeks (2008) for the between-
group comparisons the post-treatment scores of the remote treatment
were compared with the post-treatment scores of the control group (ei-
ther waitlist/attention control or face-to-face treatment) rather than
using change scores. For the between-group comparisons effect sizes
were first calculated for Cohen's d according to the following formula
X 1
X 2
SDpooled where X1 is the post-treatment score for the remote treatment con-
dition and X2 is the post-treatment score of the control condition. The
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
2 2
ðN 1
1ÞSD1 þðN2
1ÞSD2
SDpooled was calculated with the following formula N1 þN 2
2
where N1 is the sample size of the remote treatment group, N2 is the
sample size of the control group, SD1 is the standard deviation of the re-
mote treatment group and SD2 is the standard deviation of the control
group. Cohen's d was then converted to Hedges's g by multiplying it
with correction J (calculated as above). For the between-group compari-
sons a positive g value indicates a superiority of the remote treatment
compared with other treatments and a negative g value indicates
inferiority.
Homogeneity of effect sizes was evaluated using the I2 statistic. An I2
value of 25% is generally considered low heterogeneity among studies,
50% as moderate and 75% as high (Higgins, Thompson, Deeks, &
Altman, 2003). Where there was a moderate level of heterogeneity
(i.e., ≥50%) and sample size allowed for it, post-hoc moderator analyses
were conducted. Moderators included type of remote treatment
(i.e., iCBT, bCBT, cCBT, vCBT, or tCBT), intensity of treatment (i.e., low in-
tensity vs. high intensity), and level of therapist guidance in the treat-
ment (i.e., self-guided or clinician-guided). Sensitivity analyses were
also conducted to investigate the impact of each study on the combined
effect, using the ‘one-study removed’ method, which systematically
removes each study to determine the change in overall effect size. Pub-
lication bias was assessed using Duval and Tweedie's Trim and Fill
method (Duval & Tweedie, 2000), which ‘trims’ the most extreme
small positive studies from the analysis and ‘fills’ these studies with a
mirror image resulting in an unbiased estimate of the effect size
(Borenstein et al., 2011). Due to the preliminary nature of this study
an analysis of data quality was not performed.
6. Results
Fig. 1 outlines the study selection process. The search yielded 256 ar-
ticles. The abstracts were reviewed and 209 were excluded, resulting in
47 studies. These 47 studies were reviewed in full against the inclusion
and exclusion criteria and 29 were excluded, resulting in 18 included
studies in the meta-analysis. Study eligibility was determined by the au-
thor using a comprehensive coding sheet.
6.1. Study characteristics
In total 823 individuals (mean age 31.20 (SD = 10.36), 56.2% fe-
male) across 18 studies (with 23 remote treatment conditions) were
Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
5
included in the analysis. The mean Y-BOCS score at baseline was 23.41
(SD = 2.02) indicating moderate symptoms. There were 516 partici-
pants in the remote treatment conditions and 307 in the control condi-
tions. Control conditions included face-to-face treatment, attention
controls, relaxation training, and waitlist controls. Table 1 indicates all
studies included in the analysis and the type of remote treatment that
was provided. Half (50%) of the studies were RCTs and half (50%)
were uncontrolled studies.
6.2. Within-group analyses
6.2.1. Overall within-group effect size for remote treatment
Table 2 outlines the within-group effect sizes for each of the included
studies. The pooled within-group mean effect size was large across all
remote treatments from pre-treatment to post-treatment (k = 23;
g = 1.17; 95% CI: 0.91–1.43). A high level of heterogeneity across stud-
ies was indicated (I2 = 87.66). The Trim and Fill method indicated that
there was no publication bias (adjusted g = 1.03; 95% CI: 0.78–1.29).
Using the one study removed method effect sizes remained unchanged
(g = 1.17; 95% CI: 0.92–1.43).
Moderator analyses were conducted and the type of remote
treatment moderated outcome (Q4 = 28.70, p b .001). For each type
of remote treatment within-group pooled effect sizes were large from
pre-treatment to post-treatment for vCBT (k = 3; g = 1.68; 95% CI:
0.84–2.52; I2 = 69.02), tCBT (k = 3; g = 1.67; 95% CI: 1.41–1.93; I2 =
0.00), iCBT (k = 8; g = 1.40; 95% CI: 1.06–1.74; I2 = 78.49) and bCBT
(k = 3; g = 0.81; 95% CI: 0.06–1.56; I2 = 87.87). The effect size was
moderate for cCBT (k = 6; g = 0.61; 95% CI: 0.29–0.93; I2 = 80.52).
From pre-treatment to follow-up the pooled within-group effect
size remained large across all remote treatments (k = 15; g = 1.22;
95% CI: 0.95–1.48). There continued to be high levels of heterogeneity
however (I2 = 83.19). Again, the Trim and Fill method indicated no
publication bias (adjusted g = 1.09; 95% CI: 0.84–1.34). Using the one
study removed method effect sizes remained large (g = 1.06; 95% CI:
0.96–1.17).
Moderator analyses were conducted and the type of remote treat-
ment moderated outcome (Q4 = 50.84, p b .001). Pooled within-
group effect sizes remained large at follow-up for vCBT (k = 2; g =
1.57; 95% CI: 1.13–2.02; I2 = 0.00), tCBT (k = 3; g = 1.61; 95% CI:
1.36–1.87; I2 = 0.00), iCBT (k = 7; g = 1.21; 95% CI: 0.93–1.50; I2 =
69.40) and bCBT (k = 2; g = 0.80; 95% CI: 0.06–1.54; I2 = 85.33).
There was only one study of cCBT at follow-up and the effect size was
small (k = 1; g = 0.41; 95% CI: 0.16–0.66; I2 = 0.00).
6.2.2. Low intensity vs. high intensity remote treatment
Clinician-guided low intensity interventions (which utilize a much
lower level of clinician contact than standard CBT) were compared
with high intensity remote treatments (which utilize a similar amount
of clinician contact to standard CBT). Pre-treatment to post-treatment
pooled within-group effect sizes were large for the low intensity treat-
ments (k = 10; g = 1.36; 95% CI: 1.00–1.72), with high levels of hetero-
geneity (I2 = 82.59). High intensity treatments also resulted in a
decrease in symptoms of a large magnitude (k = 6; g = 1.64; 95% CI:
1.33–1.95), with low levels of heterogeneity (I2 = 40.60). A significant
difference between low intensity and high intensity treatments was
not seen (Q1 = 1.39, p = .24). The low intensity group demonstrated
a high level of heterogeneity, thus post-hoc moderator analyses were
conducted. The type of treatment moderated outcome (Q2 = 13.26,
p = .001; iCBT: k = 6; g = 1.60; 95% CI: 1.31–1.90; I2 = 54.08; bCBT:
k = 1; g = 1.65; 95% CI: 1.13–2.17, I2 = 0.00; cCBT: k = 3; g = 0.68;
95% CI: 0.25–1.11; I2 = 62.03). The results at follow-up were similar
with large pooled within-group effect sizes for low intensity treatment
(k = 6; g = 1.36; 95% CI: 1.14–1.57) with low levels of heterogeneity
(I2 = 25.91). High intensity treatments also demonstrated large
within-group effect sizes at follow-up (k = 5; g = 1.60; 95% CI: 1.38–
1.82), with low levels of heterogeneity (I2 = 0.00). At follow-up there
6 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx
Fig. 1. Study flow chart.
was no significant difference between the low intensity and high
intensity groups (Q1 = 2.48, p = .12).
6.2.3. Self-guided vs clinician-guided low intensity treatments
Low intensity remote treatments can be provided in either a self-
guided or clinician-guided fashion. Treatments were deemed as self-
guided when they did not utilize clinician contact during the treatment
and guided when some clinician contact was provided during the treat-
ment. Pre-treatment to post-treatment pooled within-group effect sizes
were large for the clinician-guided group (k = 10; g = 1.36; 95% CI:
1.00–1.72) with high levels of heterogeneity (I2 = 82.59). For the self-
guided group moderate effects were seen (k = 7; g = 0.58; 95% CI:
0.32–0.84) also with high levels of heterogeneity (I2 = 77.74). This
was a significant difference favoring the clinician-guided group (Q1 =
11.68, p b .001).
Both clinician-guided and self-guided treatments demonstrated
moderate levels of heterogeneity (I2 ≥ 50%) thus post-hoc moderator
analyses were conducted. For the guided treatment pre–post-treatment
effect size was moderated by type of treatment (Q2 = 13.26, p = .001),
with those using iCBT (k = 6; g = 1.60; 95% CI: 1.31–1.90; I2 = 54.08)
and bCBT (k = 1; g = 1.65; 95% CI: 1.13–2.17, I2 = 0.00) methodologies
outperforming those using cCBT (k = 3; g = 0.68; 95% CI: 0.25–1.11;
I2 = 62.03) methodologies. For the self-guided treatments pre–post-
treatment effect size was not moderated by type of treatment (Q2 =
3.49, p = .18; iCBT: k = 2; g = 0.82; 95% CI: 0.55–1.09; I2 = 12.67;
bCBT: k = 2; g = 0.44; 95% CI: 0.15–0.74; I2 = 0.00; cCBT: k = 3;
g = 0.54; 95% CI: 0.04–1.04; I2 = 89.91).
Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
From pre-treatment to follow-up the results were the same with
large pooled within group effect sizes for clinician-guided remote treat-
ments (k = 6; g = 1.36; 95% CI: 1.14–1.57) with low levels of heteroge-
neity (I2 = 25.91). The self-guided treatment effect size remained
moderate (k = 4; g = 0.58; 95% CI: 0.36–0.80) with low levels of het-
erogeneity (I2 = 43.70). Again, this was a significant difference favoring
the high intensity group (Q1 = 25.09, p b .001).
6.3. Between-group analyses
6.3.1. Remote treatment vs. control
A total of five studies (7 comparisons) compared a remote treatment
to a waitlist control or attentional control group in a randomized con-
trolled design. Between-group analyses indicated a large pooled effect
size at post-treatment (k = 7; g = 1.06; 95% CI: 0.68–1.45) favoring
the remote treatments (Q6 = 15.55, p = .02). Table 3 outlines the
between-group effect sizes at post-treatment for each of the included
studies. Heterogeneity was moderate (I2 = 61.42), suggesting differ-
ences in outcome across studies. The Trim and Fill procedure indicated
no evidence of publication bias (adjusted g = 0.94; 95% CI: 0.52–
1.37). The one study removed method also indicated no change to the
effect size (g = 1.06; 95% CI: 0.68–1.45). Two of the seven comparisons
(29%) were iCBT interventions, 1/7 (14%) were cCBT, 2/7 (29%) were
vCBT, and 2/7 (29%) were bCBT. Five of the seven comparisons (71%)
were low intensity treatments and 2/7 (29%) were high intensity
treatments. Two out of the seven (29%) comparisons were self-guided
and 5/7 (71%) were clinician guided. Post-hoc moderator analyses
 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx 7

Table 1
Characteristics of included studies.

Study Country Study Treatment n Amount of remote Mean baseline Mean age % Female Longest Population
type contact (min) Y-BOCS score (years) follow-up
period

E. Andersson et al. (2011) Sweden U iCBT 24 92.0 20.00 39.0 65.0 None Adult
iCBT 50 129.0 21.42 33.0 66.0 4-Month
Andersson et al. (2012) Sweden RCT Adult
Attention control 51 17.0 20.80 35.0 66.7 None
Bachofen et al. (1999) UK U cCBT 21 5.0 25.00 31.0 43.5 None Adult
Comer et al. (2014) USA U vCBT 5 Not reported 24.20 7.0 40.0 None Child
Greist et al. (1998) Multiple U cCBT 40 Not reported 23.6 34.9 47.5 ~22 weeks Adult
cCBT 55 Not reported 24.6 None
Adolescent
Greist et al. (2002) Multiple RCT Relaxation 66 Not reported 25.8 39.0 42.0 None
and adult
Face-to-face 55 660 25.2 None
cCBT (scheduled) 20 76 26.5 None
Kenwright et al. (2005) UK RCT 40.0 52.3 Not stated
cCBT (requested) 16 16 24.5 None
Lenhard et al. (2014) Sweden U iCBT 21 233.8 21.33 14.4 61.9 6-Month Adolescent
tCBT 36 360 25.9 33.4 56.0 6-Month Adolescent
Lovell et al. (2006) UK RCT
Face to face 36 600 25.5 30.4 61.0 6-Month and adult
Marks et al. (2003) UK U cCBT 9 Not reported 23.2 Not reported Not reported None Not stated
vCBT 16 ~840 21.27 11.00 37.0 3-Month Child and
Storch et al. (2011) USA RCT
Waitlist control 15 N/A 25.38 11.20 40.00 None adolescent
bCBT 20 Not reported 22.70 40.30 75.0 6-Month
Tolin et al. (2007) USA RCT Adult
Face to face 21 Not reported 23.95 34.10 52.4 6-Month
Turner et al. (2009) UK U tCBT 10 Not reported 27.00 Not reported 20.0 12-Month Adolescent
tCBT 36 Not reported 25.64 14.19 44.5 12-Month Child and
Turner et al. (2014) UK RCT
Face to face 36 Not reported 24.11 14.50 47.2 12-Month adolescent
vCBT 10 Varied 24.2 28.8 60.0 3-Month
Vogel et al. (2014) Norway RCT Waitlist control 10 N/A 23.4 40.7 70.0 None Not stated
bCBT 10 0 24.1 29.8 50.0 None
Wootton et al. (2011) Australia U iCBT 21 86.1 20.90 35.18 59.0 3-Month Adult
iCBT 15 86.63 23.53 39.93 93.3 3-Month
RCT bCBT 20 102.73 21.80 35.55 70.0 3-Month
Wootton et al. (2013) Australia Adult
Waitlist control 17 N/A 21.06 38.58 64.7 None
U iCBT 17 57.06 19.87 38.58 64.7 3-Month
U iCBT 16 0 21.81 32.62 87.5 3-Month Adult
Wootton et al. (2014) Australia
U iCBT 28 0 20.79 35.90 67.9 3-Month Adult

Note. RCT = randomized controlled trial and U = uncontrolled trial. tCBT = telephone administered CBT; bCBT = bibliotherapy administered CBT; vCBT = videoconferencing adminis-
tered CBT; cCBT = computerized CBT; iCBT = internet administered CBT.

were not conducted due to the small sample size. There were no
between-group comparisons available at follow-up.
6.3.2. Remote treatment vs. face-to-face treatment
Table 4 outlines the between-group effect sizes at post-treatment
and follow-up for each of these studies. A total of four studies compared
a remote CBT treatment to face-to-face CBT treatment at post-
treatment. Between-group analyses indicated a small pooled effect
size at post-treatment between the remote and face-to-face treatment
groups (k = 4; g = −0.21; 95% CI: −0.43–0.02). The Trim and Fill pro-
cedure indicated no evidence of publication bias (adjusted g = −0.20;
95% CI: −0.43–0.02). The one study removed method also indicated no
change to the effect size (g = −0.21; 95% CI: −0.43–0.02). There were
low levels of heterogeneity among the studies (I2 = 0.00). Similar re-
sults were also found at follow-up (k = 3; g = − 0.28; 95% CI:
−0.58–0.01; I2 = 0.00). The Trim and Fill procedure indicated no evi-
dence of publication bias (adjusted g = −0.28; 95% CI: − 0.57–0.00).
The one study removed method also indicated no change to the effect
size (g = −0.28; 95% CI: −0.58–0.00).
7. Discussion
The aim of this study was to extend the existing reviews of remote
treatment for OCD and to provide an evaluation of the efficacy of remote
treatment for OCD using a meta-analytic approach. Because of the small
amount of research conducted in this area to date both controlled and
uncontrolled studies were included the analysis. Overall, the results of
this meta-analysis indicate that remote treatment for OCD is an effica-
cious and promising treatment delivery with large within-group effect
sizes seen when all remote treatments are pooled together (g = 1.17).
This pooled effect size is within the same range as meta-analyses of
face-to-face treatment for OCD, where effect sizes of approximately
1.1 are generally seen (Eddy et al., 2004; Rosa-Alcázar et al., 2008).
When looking at the few studies (k = 4) that have compared a re-
mote treatment to standard best practice CBT face-to-face treatment
there do not appear to be any meaningful differences in outcome
(g = − 0.21; 95% CI: − 0.43–0.02), due to the small effect and confi-
dence interval crossing zero. While preliminary, this suggests that re-
mote treatment may be as effective as best practice face-to-face
treatment. However, it is important to note that across each of these
studies the effect size differences are in the favor of face-to-face treat-
ment and further research is required to elucidate the differences in out-
come between different types of remote treatment and face-to-face
treatment. Overall, this finding is consistent with a previous meta-
analysis of remote treatment for anxiety disorders that found a small
between-group effect size between remote treatment and face-to-face
treatment (d = − 0.11 (−0.60–0.38); Bee et al., 2008) favoring face-
to-face treatment. However, due to the small number of RCTs that
have been conducted to date that compare face-to-face and remote
treatment in the OCD literature this question requires further investiga-
tion in the future and these results should be considered preliminary.
This is particularly important since the included studies in the current
meta-analysis did not cover the full spectrum of remote treatments
for OCD. For instance, currently, no RCTs have been conducted to date
that compare iCBT or vCBT with face-to-face treatment and thus are im-
portant avenues for future research.
When investigated individually, almost all types of remote treat-
ment (vCBT, tCBT, iCBT and bCBT) for OCD resulted in large pooled effect
sizes at post-treatment (range: g = 0.81–1.68) and these results were
generally maintained at follow-up (range: g = 0.80–1.61). The excep-
tion was cCBT, which demonstrated moderate effect sizes at post-
treatment (g = 0.61) and small effect sizes at follow-up (g = 0.41). It

Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
8 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx

Table 2
Within-group effect sizes from pre-treatment to post-treatment and pre-treatment to follow-up.

Study Type of remote treatment Pre-treatment to Weight of Pre-treatment to Weight of included study
post-treatment included study follow-up

g 95% CI g 95% CI

E. Andersson et al. (2011) iCBT 1.47 1.01–1.92 4.50 – – –

E. Andersson et al. (2012) iCBT 1.47 1.16–1.78 4.88 1.30 1.01–1.59 7.64
Bachofen et al. (1999) cCBT 0.71 0.34–1.08 4.73 – – –
Comer et al. (2014) vCBT 1.21 0.32–2.10 3.18 – – –
Greist et al. (1998) cCBT 0.09 −0.15–0.33 5.03 0.41 0.16–0.66 7.84
Greist et al. (2002) cCBT 0.84 0.60–1.07 5.03 – – –
Kenwright et al. (2005) cCBT 0.33 −0.06–0.72 4.68 – – –
Kenwright et al. (2005) cCBT 0.73 0.35–1.11 4.70 – – –
Lenhard et al. (2014) iCBT 2.22 1.60–2.83 4.01 2.02 1.44–2.60 6.00
Lovell et al. (2006) tCBT 1.87 1.45–2.29 4.60 1.62 1.23–2.00 7.15
Marks et al. (2003) cCBT 1.18 0.52–1.84 3.88 – – –
Storch et al. (2011) vCBT 1.31 0.80–1.83 4.31 1.49 0.94–2.04 6.16
Tolin et al. (2007) bCBT 0.55 0.19–0.91 4.75 0.43 0.08–0.79 7.31
Turner et al. (2009) tCBT 1.67 0.93–2.41 3.62 1.57 0.85–2.28 5.20
Turner et al. (2014) tCBT 1.51 1.14–1.88 4.73 1.62 1.24–2.00 7.15
Vogel et al. (2014) vCBT 2.77 1.71–3.82 2.75 1.73 0.97–2.49 4.96
Vogel et al. (2014) bCBT 0.26 −0.23–0.75 4.40 – – –
Wootton et al. (2011) iCBT 1.59 1.10–2.09 4.37 1.24 0.80–1.68 6.82
Wootton et al. (2013) bCBT 1.65 1.13–2.17 4.30 1.19 0.74–1.63 6.81
Wootton et al. (2013) iCBT 2.15 1.44–2.87 3.71 1.17 0.66–1.68 6.42
Wootton et al. (2013) iCBT 1.10 0.60–1.59 4.38 1.49 0.92–2.06 6.05
Wootton et al. (2014) iCBT 0.64 0.23–1.06 4.61 0.73 0.30–1.15 6.91
Wootton et al. (2014) iCBT 0.93 0.61–1.24 4.87 0.82 0.51–1.13 7.57
Mean 1.17 0.92–1.43 1.22 0.95–1.48

Note. tCBT = telephone administered CBT; bCBT = bibliotherapy administered CBT; vCBT = videoconferencing administered CBT; cCBT = computerized CBT; iCBT = internet adminis-
tered CBT.

is not clear what might account for the lower effect size in cCBT treat-
ments. It is possible that the lower effect size reflects the intervention
(all used the same program) rather than the treatment modality. How-
ever this may also be an artifact of the small number of studies, and fur-
ther research is required.
Generally acceptable levels of heterogeneity were seen across each
type of treatment, and where heterogeneity was high post-hoc moder-
ator analyses indicated that those studies that were clinician-guided
(i.e., contained some amount of clinician contact) performed better
than those studies that were self-guided (i.e., contained no therapist
support). This finding is consistent with other studies that have found
that clinician-guided remote treatments are more effective than self-
guided treatments across various mental health conditions (Marrs,
1995; Spek et al., 2007). However recent research has indicated that
self-guided low intensity treatments can be enhanced with the use of
automated email reminders and prompts (Titov et al., 2013) and further
research is required to ascertain if self-guided treatments with prompts
and reminders are as effective as guided low intensity interventions.
Some authors argue that there may be a linear relationship between
the amount of therapist time spent with a patient and outcome in
remote treatments (Palmqvist, Carlbring, & Andersson, 2007). The re-
sults from this meta-analysis were generally consistent with this and in-
dicated that while both low intensity and high intensity treatments
result in a decrease in symptoms of a large magnitude at post-
treatment (g = 1.36 and g = 1.64 respectively) and follow-up (g =
1.36 and g = 1.60 respectively), the effect size in the high intensity
group are larger than the low intensity treatment, however this differ-
ence in effect size was not significant. The high intensity treatments
demonstrated low levels of heterogeneity suggesting that results are
generally robust across studies. Moderate levels of heterogeneity were
demonstrated in the low intensity treatment suggesting that results
are not uniform across studies. Moderator analyses indicated that type
of treatment may be important, however further research is required
to elucidate possible moderators of outcome in clinician-guided low in-
tensity treatment.
The comparisons of remote treatment to a control condition indicate
that remote treatments, regardless of what kind of methodology is de-
livered, is far more effective than no treatment. The current study
found an effect size of g = 1.06 at post-treatment between remote treat-
ments and control conditions. This finding is consistent with a previous

Table 3
Between-group effect sizes comparing remote CBT to no treatment, attentional control, or relaxation at post-treatment.

Study Type of remote treatment Type of control group Post-treatment Weight of included study

g 95% CI

Remote treatment vs. control

E. Andersson et al. (2012) iCBT Attention control 1.11 0.69–1.53 19.58
Greist et al. (2002) cCBT Relaxation 0.73 0.36–1.10 20.66
Storch et al. (2011) vCBT Waitlist control 0.76 0.05–1.48 13.66
Vogel et al. (2014) bCBT Waitlist control 0.13 −0.71–0.97 11.56
Vogel et al. (2014) vCBT Waitlist control 2.37 1.26–3.49 8.16
Wootton et al. (2013) bCBT Waitlist control 1.37 0.66–2.08 13.78
Wootton et al. (2013) iCBT Waitlist control 1.53 0.76–2.31 12.60
Mean – – 1.06 0.68–1.45 –

Note. tCBT = telephone administered CBT; bCBT = bibliotherapy administered CBT; vCBT = videoconferencing administered CBT; cCBT = computerized CBT; iCBT = internet adminis-
tered CBT. The attention control condition in E. Andersson et al. (2012) was also provided remotely and included non-directive supportive counseling. The format of the relaxation con-
dition in Greist et al. (2002) was not stated. The waitlist control conditions received no further contact until the post-treatment period.

Please cite this article as: Wootton, B.M., Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis, Clinical Psy-
chology Review (2015), http://dx.doi.org/10.1016/j.cpr.2015.10.001
 B.M. Wootton / Clinical Psychology Review xxx (2015) xxx–xxx 9

Table 4
Between-group effect sizes comparing remote CBT to face-to-face CBT.

Study Remote Face-to-face treatment Post-treatment Weight of included Follow-up Weight of

treatment study included study

Format Intensity Number of Total therapist g 95% CI g 95% CI

sessions contact

Greist et al. (2002) cCBT Low 11 11 h −0.21 −0.58–0.17 37.59 – – –

Lovell et al. (2006) tCBT High 10 10 h −0.08 −0.55–0.39 23.53 −0.11 −0.59–0.37 36.70
Tolin et al. (2007) bCBT Low 15 ns −0.47 −1.08–0.14 14.04 −0.46 −1.07–0.15 23.03
Turner et al. (2014) tCBT High 14 ns −0.17 −0.63–0.29 24.84 −0.34 −0.80–0.12 40.26
Mean −0.21 −0.43–0.02 −0.28 −0.58–0.00

Note. tCBT = telephone administered CBT; bCBT = bibliotherapy administered CBT; vCBT = videoconferencing administered CBT; cCBT = computerized CBT; iCBT = internet adminis-
tered CBT. ns = not stated.

meta-analysis that investigated remote treatments for anxiety more
generally, which also found a large between-group effect size between
remote treatment and control (d = 1.15 (0.81–1.49); Bee et al., 2008),
favoring the remote treatment condition. While the current results are
promising, the included studies did demonstrate moderate levels of het-
erogeneity and moderator analyses were not conducted due to the
small sample size. It is important for future research to focus on deter-
mining potential moderators such as treatment population (adult ver-
sus child/adolescent), type of remote treatment, severity of symptoms,
and type of symptoms once a greater number of RCTs emerge in this
field.
7.1. Implications: stepped-care treatments
Overall, remote treatment appears to be efficacious, with similar
outcomes to those seen in face-to-face treatment. It appears that the
amount of therapist contact may be a moderating factor and while
both low intensity and high intensity treatments resulted in a decrease
in symptoms of a large magnitude, the effect size in high intensity treat-
ments was larger. These finding have important implications for treat-
ment dissemination, and in particular, for the development of remote
stepped-care approaches in the treatment of OCD.
Stepped-care treatments provide the patient with the lowest inten-
sity (and most cost effective) option before moving up to more inten-
sive (and costly) treatments. Stepped-care treatments are commonly
recommended in the OCD literature (Lovell & Richards, 2000;
Mataix-Cols & Marks, 2006b; National Institute for Health and Clinical
Excellence, 2005), have been demonstrated to be effective in the treat-
ment of OCD (Gilliam et al., 2010; Tolin et al., 2005), and have been
shown to result in significantly reduced costs (Tolin, Diefenbach, &
Gilliam, 2011). However, a limitation of these traditional stepped-care
models is that they do not take into account geographical and other bar-
riers that impede an individual's ability to access traditional face-to-face
treatments (Baer & Minichiello, 2008; Belloch et al., 2009; Goodwin
et al., 2002; Marques et al., 2010). Thus, many individuals are not able
to ‘step up’ to the more intensive levels of care (such as face-to-face out-
patient or inpatient services) if they have not benefitted from a low in-
tensity treatment. According to the findings of this meta-analysis an
entirely remote stepped-care treatment may be possible where low in-
tensity remote treatments (such as iCBT or bCBT) are offered as a first
step in a stepped-care treatment for OCD, followed by higher intensity
remote treatments (such as vCBT or tCBT) if required. This will enable
individuals who are unable to access face-to-face treatment to obtain
highly effective treatment for their symptoms. An evaluation of such a
remote stepped-care design would be beneficial in future research
due to its important implications for service delivery.
and uncontrolled trials were included in analyses and as the field
emerges a greater emphasis should be placed on more internally valid
RCTs in order to evaluate the efficacy of remote treatments for OCD. Sec-
ondly, not all studies used a diagnostic assessment to ensure a diagnosis
of OCD prior to study entry. Thirdly, this study combined both child/ad-
olescent and adult samples and these groups may respond differentially
to remote treatments. Fourthly, a single author extracted the data and
future research may benefit from the utilization of a second coder,
with an additional assessment of inter-rater reliability. Finally, unpub-
lished data in this area may exist which may overturn the results of
this study and should be addressed in future studies in this area. Ad-
dressing these limitations in future meta-analyses is important as a
greater number of studies in this field emerge.
The major strength of this paper is that it is the first to quantify the
outcomes of remote treatments for OCD using a meta-analytic ap-
proach. In addition, the study compares various forms of remote treat-
ments (vCBT, tCBT, cCBT, iCBT, and bCBT), and also compares low
intensity and high intensity treatments, and guided and self-guided
treatments, rather than treating all remote treatment as equally effec-
tive. The results of this meta-analysis may help to explore further
novel methods of service delivery for OCD, in particular, remote stepped
care treatments for OCD.
Role of funding sources
This was an unfunded study and no funding sources have been
omitted.
Contributors
This is a single author manuscript and I confirm that there are no
other persons who satisfied the criteria for authorship that are not
listed. The author conducted literature searches, collected and analyzed
the data, and wrote the manuscript.
Conflict of interest
There are no known conflicts of interest associated with this publica-
tion and there has been no significant financial support for this work
that could have influenced its outcome.
Acknowledgments
None.
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