Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561

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Journal of Obsessive-Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

Internet-based cognitive behavioural therapy for treating symptoms of

obsessive compulsive disorder in routine care
John Luu a, Michael Millard a, Jill Newby b, c, Hila Haskelberg a, Megan J. Hobbs d, Alison E.
J. Mahoney a, *
a
Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital and University of New South Wales, Level 4 O’Brien Centre, 394-404 Victoria Street,
Darlinghurst, New South Wales, 2010, Australia
b
School of Psychology, University of New South Wales, Sydney, NSW, 2052, Australia
c
Black Dog Institute, Hospital Road, Prince of Wales Hospital, Randwick, NSW, 2031, Australia
d
New England Institute of Healthcare Research, University of New England, Armidale, NSW, 2351, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: A growing evidence base supports the efficacy of Internet-based cognitive behavior therapy (iCBT) for obsessive
Cognitive behavioural therapy compulsive disorder (OCD). However, very few studies have evaluated the effectiveness of iCBT for OCD in
Obsessive compulsive disorder routine care settings which service the bulk of a population’s health needs. This study evaluated the treatment
Internet
outcomes of 309 adults who enrolled in an online CBT course for their symptoms of OCD. Most patients (62.8%)
Routine care
enrolled in a self-help or unguided iCBT course, and the remainder were supported by a routine care, community
clinician. The entire iCBT course was completed by 39.3% of participants, with 61.2% completing the majority of
iCBT lessons. Higher baseline depression symptom severity predicted poorer adherence, while the presence of a
supervising clinician was associated with greater adherence. Medium effect size reductions in OCD symptom
severity (g ¼ 0.61), depression symptom severity (g ¼ 0.56), and psychological distress (g ¼ 0.69) were observed
from pre-to post-treatment. Pre-treatment OCD and depression symptom severity predicted post-treatment OCD
symptom severity. Current results support the use of iCBT for OCD in routine care settings, and as health care
resources are finite, iCBT for OCD may serve as a useful, low-intensity, and scalable addition to the existing
healthcare infrastructure.

1. Introduction
Obsessive compulsive disorder (OCD) is characterised by obsessions
(recurrent and intrusive thoughts, impulses or images) and/or compul­
sions (repetitive behaviours or rituals performed to alleviate distress)
(American Psychiatric Association, 2013). The disorder has an estimated
annual prevalence of 1.2% and lifetime prevalence of 2.3%; is associated
with psychiatric co-morbidities, impaired functioning and quality of life
(Ruscio, Stein, Chiu, & Kessler, 2010); and has a low spontaneous
remission rate (Mataix-Cols et al., 2002). Effective treatments are
needed to reduce this global burden of disease.
Cognitive behavioural therapy (CBT) is an established psychological
therapy for OCD (Ponniah, Magiati, & Hollon, 2013) with high
responder rates (e.g., 62–86%; Foa et al., 2005). Meta-analyses have
demonstrated its efficacy in individual (Hedges g ¼ 1.39; Olatunji,
Davis, Powers, & Smits, 2013), group (g ¼ 0.97; Schwartze, Barkowskia,
Burlingame, Strauss, & Rosendah, 2016) and intensive (g ¼ 1.23;
Jo
�nsson, Kristensen, & Arendt, 2015) formats, with evidence suggesting
effectiveness in routine care settings (e.g., Houghton, Saxon, Bradburn,
Ricketts, & Hardy, 2010). However, many individuals with OCD remain
untreated, and those who seek treatment delay doing so for many years.
The average length of time from disorder onset to receiving treatment is
11 years (Pinto, Mancebo, Eisen, Pagano, & Rasmussen, 2006). There
are several barriers to accessing traditional face-to-face CBT including
the financial costs, logistical difficulties of accessing a qualified thera­
pist, personal shame and fear of social stigma (Belloch, del Valle,
Morillo, Carrio, & Cabedo, 2009; Marques et al., 2010). Internet-based
cognitive behavioural therapy (iCBT) aims to address these barriers by
providing a remotely-accessible, scalable and cost-effective alternative
to face-to-face treatment (Andrews et al., 2018).

* Corresponding author.
E-mail addresses: John.luu@health.nsw.gov.au (J. Luu), michael.millard@svha.org.au (M. Millard), j.newby@unsw.edu.au (J. Newby), hila.haskelberg@svha.
org.au (H. Haskelberg), megan.hobbs@une.edu.au (M.J. Hobbs), alison.mahoney@svha.org.au (A.E.J. Mahoney).

https://doi.org/10.1016/j.jocrd.2020.100561
Received 2 May 2020; Received in revised form 7 July 2020; Accepted 9 July 2020
Available online 15 July 2020
2211-3649/© 2020 Elsevier Inc. All rights reserved.
J. Luu et al.
Andersson et al. (2012) conducted the first randomised controlled
trial (RCT) of iCBT for OCD compared to supportive therapy (n ¼ 101).
There was no face-to-face contact during the iCBT, but therapists aver­
aged 129 min with each participant for guidance with exposure and
response prevention (ERP) and homework feedback. Participants
receiving iCBT completed on average 7.28/10 modules and 60% expe­
rienced clinically significant improvement in OCD symptom severity,
compared to 6% receiving the online therapeutic support. There was a
large between-group effect size (d ¼ 1.12) in favour of the iCBT group.
Interestingly, greater pre-treatment OCD symptom severity predicted
higher post-treatment symptom severity but also greater change during
iCBT (Andersson et al., 2015).
Additional RCTs by Wootton, Dear, Johnston, Terides, and Titov
(2013) and Mahoney, Mackenzie, Williams, Smith, and Andrews (2014)
have also demonstrated large superior effect size reductions in OCD
symptom severity for iCBT compared to treatment as usual; and iCBT
was associated with adherence rates of 67% and 75%, respectively.
Subsequent studies have established that the benefits of iCBT are
enduring, with gains maintained up to two years post-treatment
(Andersson et al., 2014; Wootton, Dear, Johnston, Terides, & Titov,
2015). A recent RCT by Wootton, Karin, Titov, and Dear (2019) has
demonstrated that iCBT is an effective treatment for OCD even when
delivered self-guided (i.e., with no clinician support). This study found a
large between-group effect size (d ¼ 1.05) when compared to a waitlist
control group. Adherence of iCBT was 40%, with 27% of participants
meeting criteria for clinically significant change at post-treatment. Gains
were enduring; with 38% of participants meeting criteria for clinically
significant change at three-month follow up.
In addition to reductions in OCD symptom severity, iCBT for OCD has
been shown to improve psychological distress with Mahoney et al.
(2014) demonstrating large between-group effect size reductions (d ¼
1.12) when compared with waitlist control. Andersson et al. (2012)
demonstrated that iCBT also improved global functioning when
compared to online supportive therapy (Z ¼ 3.68–6.93), with gains
maintained at follow up. There is, however, mixed results on the effects
of iCBT on co-morbid depression, with the study by Mahoney et al.
(2014) showing large effect-size improvements (d ¼ 0.84); while
Andersson et al. (2012) was unable to demonstrate a significant differ­
ence in depression outcomes in the iCBT group relative to the control
group.
While results from iCBT OCD RCTs are promising, the evidence
supporting its use in routine clinical care has been more limited. When
iCBT for clinically significant depression and anxiety is considered in
general, there is considerable literature demonstrating its effectiveness
for generalised anxiety (Hobbs, Mahoney, & Andrews, 2017), panic
(Hedman et al., 2013; Mathiasen, Riper, Ehlers, Valentin, & Rosenberg,
2016; Nordgreen, Gjestad, Andersson, Carlbring, & Havik, 2018), social
anxiety (El Alaoui, Hedman, Ljotsson, & Linderfors, 2015), depression
(Hobbs, Joubert, Mahoney & Andrews, 2018); and comorbid anxiety
and depression (Morgan et al., 2017; Newby, Mewton, Williams, &
Andrews, 2014; Staples, Fogliati, Dear, Nielssen, & Titov, 2016; Staples
et al., 2019).
However, only one study to date (Titov et al., 2017) has evaluated
whether iCBT for OCD has utility beyond RCT conditions. This routine
care study examined the effectiveness of an iCBT program for OCD
delivered by the MindSpot Clinic which specialises in the provision of
online mental health services. The iCBT course comprised five online
lessons delivered over eight weeks. Lessons were augmented by an
average of 183 min of clinician support during treatment. Supervising
clinicians were qualified therapists working at the MindSpot Clinic. 69
patients enrolled in this iCBT program. Of the 51 (73.9%) who
completed treatment and the 28 (40.6%) who were followed up at 3
months, Titov et al. (2017) found significant improvements in OCD
symptom severity at post-treatment (d ¼ 0.9 [95% CI ¼ 0.6–1.3] with
average levels of OCD symptom severity reduced by 25.5%). These gains
were maintained at follow up (d ¼ 1.1 [95% CI ¼ 0.8–1.5]; average
2
Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561
reduction in symptom severity ¼ 27.5%). Treatment was also associated
with large effect size reductions in anxiety, depression and distress (ds ¼
0.9–1.2). Further studies examining the use of iCBT for OCD in routine
care settings are needed to replicate and extend these findings in settings
without extensive therapist supervision.
The vast majority of people with OCD seek and obtain treatment in
general medical settings and from community clinicians (e.g., psychol­
ogists and psychiatrists) (Ruscio et al., 2010). It is essential that further
studies examine the effectiveness of iCBT in routine care where pro­
grams are delivered by community-based clinicians who may only see
patients infrequently or for brief consultations (e.g., primary care phy­
sicians and psychologists), or where patients can elect to undertake a
self-guided or self-help iCBT program. In most countries, these settings
represent the most common, scalable, accessible and parsimonious av­
enues for patients with OCD to undertake treatment and receive ongoing
care following their program completion.
The current study evaluated the effectiveness of iCBT for OCD in
routine care. We investigated the effectiveness of an iCBT program for
patients who were supervised by community clinicians, as well as those
who elected to complete the program independently (i.e., self-guided or
self-help). Consistent with previous studies, we hypothesised that both
clinician-guided and self-guided iCBT would be associated with medium
to large effect size reductions in OCD symptom severity and co-morbid
depression, psychological distress and disability; and that pre-
treatment OCD symptom severity would predict post-treatment OCD
symptom severity. Also consistent with previous studies, we hypoth­
esised that the involvement of a prescribing clinician would be associ­
ated with higher adherence compared to those using the self-guided
program (e.g., Mohr, Cuijpers, & Lehman, 2011).
2. Methods
2.1. Sample
THISWAYUP is an online treatment service provided by St Vincent’s
Hospital (Sydney, Australia) and the University of New South Wales (see
thiswayupclinic.org.au). It is available as a paid service to Australian
residents over the age of 18 years either self-guided or guided by the
user’s clinician. Individuals residing outside Australia can only access
THISWAYUP courses if they are guided by their clinician (only Austra­
lian adults participated in the current evaluation). Over three years
(November 1, 2015 to October 31, 2018), 309 patients sought iCBT for
their OCD symptoms. Patients were mostly female (62.1%) and in their
early thirties on average (M(SD) ¼ 33.28(12.10) years, R ¼ 18–73).
Patients’ rurality was inferred from their postcode and the Australian
Statistical Geography Standards (Australian Bureau of Statistics, 2016).
Of the 231 participants who provided their postcode, 25.5% (n ¼ 59)
were living in regional or remote Australia.
Most patients (62.8%) enrolled in the self-guided/unsupervised
format of the program. Supervising clinicians were mostly psycholo­
gists (37.3%), psychiatrists (31.3%) and general practitioners (18.2%).
Professionals who prescribed iCBT retained clinical responsibility for
their patients for the duration of the treatment. Patients and their pre­
scribing clinicians were advised that patients were unlikely to benefit
from the iCBT program if they 1) were being treated with benzodiaze­
pines or atypical anti-psychotics; 2) had an alcohol or substance use
disorder; 3) had schizophrenia or bipolar affective disorder; or 4) were
actively suicidal. However, adhering to these recommendations was at
the discretion of the patient and clinician and were not exclusion
criteria.
This study was conducted as part of the routine Quality Assurance
activities of the THISWAYUP service and self-reported measures exam­
ined were required for the safe conduct of the program. Prior to enrol­
ment, participants provided electronic informed consent that their
pooled de-identified data would be collected, analysed and published for
quality assurance and research purposes. The study was approved by the
J. Luu et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561

Human Research Ethics Committee (HREC) of St Vincent’s Hospital 2.3. Measures

(Sydney, Australia) (2019/ETH00088).
The Dimensional Obsessive-Compulsive Scale (DOCS) assessed OCD
symptom severity in the past month using four symptom dimensions: (i)
2.2. Intervention concerns about contamination and germs; (ii) concerns about symmetry
and completeness; (iii) concerns about being responsible for harm and
The THISWAYUP OCD iCBT program comprises six online lessons injury; and (iv) unacceptable thoughts (Abramowitz et al., 2010). Each
that are completed over six to twelve weeks, the efficacy of which has dimension in measured using four items: assessing the patient’s distress,
been demonstrated (Mahoney et al., 2014). Patients access lessons avoidance, interference, time spent thinking about, and difficulty con­
sequentially, with patients only able to access subsequent lessons after trolling associated thoughts and behaviours. Participants completed the
completing each of the earlier lessons. DOCS prior to their first and fourth lessons, and on completion of the
During the program, patients follow an illustrated fictional patient final lesson.
with OCD who learns to use CBT skills to gain mastery over her symp­ The DOCS has an internal consistency of α ¼ 0.90–0.93 and a test-
toms and recover from OCD. Treatment lessons included psycho­ retest reliability of r ¼ 0.66 over 12 weeks (Abramowitz et al., 2010).
education; arousal reduction skills; cognitive restructuring; imaginal The measure is sensitive to change and evidence of construct validity
and graded exposure and response prevention; troubleshooting diffi­ (including convergent and divergent validity) has been provided
culties; and relapse prevention (Table 1). Following the completion of (Abramowitz et al., 2010; Wheaton, Abramowitz, Berman, Riemann, &
each lesson, participants were given a lesson summary with recom­ Hale, 2010). A DOCS total score of 18 distinguishes patients with OCD
mended homework exercises and therapy tasks that reinforce lesson from non-clinical groups (sensitivity and specificity ¼ 0.78, Abramowitz
content. The program also contained short ‘patient recovery’ stories et al., 2010), and was used as the clinical threshold for this study.
from patients who had previously completed a THISWAYUP course and Pre-treatment internal reliability in this study was α ¼ 0.90.
additional downloadable resources. The Patient Health Questionaire-9 (PHQ-9) is a nine-item self-reported
Supervising clinicians were encouraged to contact their patients after screening tool for probable Major Depressive Disorder (MDD) in the
the patient completed the first two lessons in order to provide support preceding two weeks (Kroenke, Spitzer, & Williams, 2001). Patients rate
and promote adherence. To track participant progress, the Kessler Psy­ their symptoms as “not at all”, “on several days”, “on more than half the
chological Distress Scale was administered prior to each lesson. Pre­ days” or “on nearly every day” with total scores�10 indicating probable
scribing clinicians were alerted by email if their patient’s distress MDD (Kroenke et al., 2001). Evidence of internal consistency (α ¼ 0.79)
became severe (K-10 � 30). and test-retest reliability (r ¼ 0.84 over 48 h) has been provided, as has
evidence of convergent, divergent, criterion validity and treatment
Table 1 sensitivity (Beard, Hsu, Rifkin, Busch, & Bjo €rgvinsson, 2016; Kroenke
THISWAYUP iCBT OCD program lesson content. et al., 2001). Participants of the study completed the PHQ-9 prior to the
first and fourth treatment lesson and on completion of the final treat­
Lesson Lesson Contents Homework Tasks Additional
Resources ment lesson (note that due to an administartive error, 30% of the sample
were not adminsitered the PHQ-9; these patients did not differ from
1 Psychoeducation about Identify core Boosting mood
OCD, CBT cognitive and and keeping
those who did complete the PHQ-9 in terms of demographic variables,
Controlled breathing behavioural active OCD symptom severity or psychological distress, all ps > .05). PHQ-9
exercises symptoms Good sleep guide baseline internal consistency was α ¼ 0.88 in this study.
In case of The Kessler Psychological Distress Scale (K-10) is a 10-item measure of
emergency
psychological distress experienced by patients in the preceding two
Information for
others weeks (Kessler et al., 2002). Patients reported how frequently they had
Motivation for experienced each item as either “none”, “a little”, “some”, “most” or
change “all” of the time. Total scores�20 indicate probable mental disorder(s)
Research about
(Andrews & Slade, 2001). Evidence of internal consistency (α ¼ 0.93),
intrusive thoughts
2 Psychoeducation about Identify cognitive Progressive
convergent and discriminant validity, and treatment sensitivity has been
cognitive therapy: the distortions muscle relaxation provided (Furukawa, Kessler, Slade, & Andrews, 2003; Slade, Grove, &
cognitive model, cognitive Cognitive Structured Burgess, 2011; Sunderland, Wong, Hilvert-Bruce, & Andrews, 2012).
distortions, meta-cognition, restructuring problem solving Current K-10 pre-treatment α was 0.89.
cognitive restructuring
The World Health Organization Disability Assessment Schedule (WHO­
Introduction to behavioural Behavioural Thought
experiments experiments challenging DAS 2.0) is a twelve item measure of general health-related disability
examples experienced over the past 30 days (Ustun, Kostanjsek, Chatterji, &
3 Exposure and response Construct graded Exposure Rehm, 2010). Evidence of internal consistency (α ¼ 0.98), test-retest
prevention (ERP) exposure hierarchy stepladder reliability (r ¼ 0.98 within 7 days), and construct validity (including
and begin ERP examples
Education about avoidance Shifting attention
treatment sensitivity) is extensive (Andrews, Kemp, Sunderland, von
and safety behaviours Korff, & Ustun, 2009; Ustun et al., 2010). Participants completed the
Graded ERP WHODAS 2.0 prior to the first lesson and on completion of the final
4 Imaginal exposure Continued graded Assertiveness and lesson (note 30% of the sample did not complete the WHODAS due to an
ERP healthy
adminstrative error: these patients did not differ from those who did in
Education about intrusive Imaginal exposure boundaries
experiences and avoidances terms of demographics, OCD symptoms or psychological distress, all ps
of these experiences > .05). Baseline internal consistency was α ¼ 0.86.
5 Troubleshooting difficulties Continued ERP Guide for
with cognitive therapy and supporting
2.4. Statistical analyses
graded ERP someone with
OCD
Continued Log of successes Participant Characteristics and Adherence: All analyses were per­
cognitive therapy formed in SPSS v 24.0. Independent samples t-tests and χ2 estimated
6 Relapse prevention Develop relapse Nil group differences regarding demographic data, probable pre-treatment
prevention plan
diagnoses, and program adherence. Those who completed all 6 lessons

3
J. Luu et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561

were classified as ‘completers’ and those who did not were classified as Table 2
‘non-completers’. Lesson-by-lesson completion rates for clinician-guided and self-guided
Treatment Effects: Linear mixed models were used to investigate re­ participants.
ductions in the outcome measures from pre-to post-treatment, using the Lesson completion iCBT for OCD clinician-guided iCBT for OCD self-guided
MIXED procedure with a random intercept for subject. These models n % n %
account for the unbalanced nature of data and yield more accurate es­
Lesson 1 115 100 194 100
timates of effect compared to completer analyses (Salim, Mackinnon,
Lesson 2 100 87.0 162 83.5
Christensen, & Griffiths, 2008). First, models were estimated using a Lesson 3 89 77.4 126 64.9
restricted maximum likelihood estimator and a variance components Lesson 4 82 71.3 107 55.2
covariance structure for the random effects. Second, the relative fit of Lesson 5 68 59.1 83 42.8
the residual covariance structure of the random effects was evaluated Lesson 6 54 47.0 67 34.5

using the Bayesian information criterion (Raferty, 1995), where we

found that an autoregressive covariance structure provided the closest
model fit for the residuals for all outcome measures. The fixed effects of Table 3
clinician assistance (supervised vs. unsupervised) and its interaction Correlates of adherence to iCBT for OCD.
with time were then added to each model. The fixed effect corre­ Pre-treatment total Completers Non- Completers vs. non-
sponding to the clinician assistance (supervised vs. unsupervised) by score completers completers
time interaction enabled us to examine whether there was a difference in Mean SD Mean SD Significance Test
improvements on the DOCS, K10, PHQ-9 and WHODAS variables in the
DOCS 30.1 14.8 29.9 13.0 t (307) ¼ - 0.19, p ¼
self-help vs. clinician-guided patients. Hedges’ g effect sizes were 0.85
calculated between pre- and post-treatment assessments based on the PHQ-9 9.54 6.52 12.4 6.61 t (214) ¼ 3.21, p <
pooled standard deviation and corrected for the correlation between 0.01
K-10 26.7 8.17 28.3 7.70 t (307) ¼ 1.65, p ¼
repeated measurements. Effect sizes of �0.49, 0.50–0.79, and �0.80
0.10
were considered to be small, medium and large, respectively. WHODAS 2.0 11.1 7.94 14.0 9.13 t (214) ¼ 2.39, p ¼
Clinically Significant Change: was evaluated in three ways among 0.02
treatment completers and the full (Intention-to-Treat, ITT) sample. Pre-treatment n % N % Significance Test
Participants whose post-treatment DOCS total scores <18 were classi­ probable diagnosis
fied as in remission. Participants who had a 50% pre-to-post treatment
OCD χ2(1) ¼ 1.17, p ¼
reduction in DOCS total scores were classified as in recovery. A reliable 0.17
change index was calculated where a change of 17 points or more on the Yes 93 37.7 154 62.3
DOCS total score between pre-and post-treatment assessments was No 28 45.2 34 54.8
considered to be a reliable change with 95% confidence (Jacobson & MDD χ2(1) ¼ 6.51, p <
0.01
Truax, 1991). Yes 42 35.3 77 64.7
Predictors of OCD Symptom Improvement: Among patients who No 51 52.6 46 47.4
completed treatment, a hierarchical linear regression was used to assess Demographics
whether (a) demographic variables (age, gender, rurality); (b) clinician Gender χ2(1) ¼ 0.19, p ¼
0.38
assistance (supervised vs. unsupervised); and (c) change in depression,
Female 77 40.1 115 59.9
distress and/or disability across treatment predicted post-treatment Male 44 37.6 73 62.4
OCD symptom severity (controlling for pre-treatment OCD symptom Location χ2(1) ¼ 3.69, p ¼
severity). The dependent variable was post-treatment DOCS score. Pre- 0.04
treatment DOCS score was entered at Step 1 with remaining variables Major City 63 36.6 109 63.4
Rural 30 50.8 29 49.2
entered at Step 2. Clinician assistance χ2(1) ¼ 4.68, p ¼
0.02
3. Results Clinician-guided 54 47.0 61 53
Self-guided 67 34.5 127 65.5
3.1. Patient characteristics Notes. DOCS ¼ Dimensional Obsessive-Compulsive Scale; PHQ-9 ¼ Patient
Health Questionnaire-9; K-10 ¼ Kessler Psychological Distress Scale; WHODAS
The current sample was characterised by high rates of probable 2.0 ¼ World Health Organization Disability Assessment Schedule 2.0.
disorder. At pre-treatment, 80% of patients reported OCD symptom
severity consistent with a diagnosis of OCD, 55.1% reported symptoms (47.0% vs. 34.5%; χ 2(1) ¼ 4.68, p ¼ 0.02). Compared to non-completers,
consistent with probable MDD, and 82.5% reported clinically significant completers were more likely to live in rural areas vs. major cities (50.8%
distress based on established thresholds. Of note, 10.6% of the sample vs. 36.6%; χ 2(1) ¼ 3.69, p¼ 0.04), be less depressed (PHQ-9 M(SD) ¼
reported experiencing severe comorbid depression with baseline PHQ-9 9.54(6.52) vs. M(SD) ¼ 12.4(6.61); t (214) ¼ 3.21, p < 0.01), and less
� 20. disabled (WHODAS 2.0 M(SD) ¼ 11.1(7.94) vs. M(SD) ¼ 14.0(9.13); t
(214) ¼ 2.39, p ¼ 0.02) at baseline. Age did not significantly vary across
3.2. Adherence completer status (completer M(SD) ¼ 34.5(12.4) vs. non-completer M
(SD) ¼ 32.5(11.8); t(307) ¼ -2.48, p ¼ 0.14). Gender, pre-treatment
The average number of completed lessons was 4.04 (SD ¼ 1.93); with OCD symptom severity, and baseline psychological distress were not
39.2% of participants completing all six lessons and 61.2% of patients associated with completer status.
completing four or more lessons (the stage at which all core CBT ele­
ments have been taught). Table 2 provided lesson-by-lesson completions
rates for participants who undertook iCBT clinician-guided versus un­ 3.3. Treatment effects
guided/self-help.
Correlates of adherence are shown in Table 3. Participants who were Table 4 shows the estimated marginal means and linear mixed model
clinician-guided were significantly more likely to complete all six les­ results for each outcome measure between pre- and post-treatment. Of
sons compared to those who completed the program independently the 121 participants who completed all six lessons, 99 (81.8%)

4
J. Luu et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561

Table 4
Reductions in symptom severity, distress and disability from pre-to post-iCBT for OCD in the total sample.
Measure N Pre-treatment EMM (SD) Post-treatment EMM (SD) Mean difference Df F r Hedges’ g (95% CI)

DOCS 309 30.0 (13.4) 20.4 (10.9) 9.58 2266 47.7* 0.61 0.61 (0.41–0.82)
PHQ-9 216 11.2 (6.32) 7.25 (5.68) 3.90 2260 29.1* 0.48 0.56 (0.35–0.77)
K-10 309 27.7 (7.91) 22.3 (5.87) 5.38 2353 83.9* 0.72 0.69 (0.48–0.90)
WHODAS 2.0 216 12.7 (8.49) 9.95 (7.21) 2.79 2209 17.6* 0.63 0.37 (0.16–0.58)

Notes. DOCS ¼ Dimensional Obsessive-Compulsive Scale; PHQ-9 ¼ Patient Health Questionnaire-9; K-10 ¼ Kessler Psychological Distress Scale; WHODAS 2.0 ¼ World
Health Organization Disability Assessment Schedule 2.0; r ¼ Pearson correlation between Lesson 1 and Lesson 6 scores for calculation of within-group effect sizes;
EMM ¼ estimated marginal mean, *p < 0.001.

completed the post-treatment DOCS and K-10, 96 (79.3%) completed
the post-treatment PHQ-9, and 95 (78.5%) completed the post-
treatment WHODAS 2.0. On average, participants experienced signifi­
cant (p < 0.001) effect size reductions on all outcome measures, with
medium reductions in OCD (g ¼ 0.61) and MDD (g ¼ 0.56) symptom
severity, and psychological distress (g ¼ 0.69), and small effect size re­
ductions in disability (g ¼ 0.37). The fixed effects of clinician assistance
(supervised vs. unsupervised) and the time by clinician assistance
interaction were not statistically significant in any model (DOCS clini­
cian assistance F(1, 359) ¼ 0.06, p ¼ 0.81, DOCS time*clinician assis­
tance F(2, 262) ¼ 1.03, p ¼ 0.36; PHQ-9 clinician assistance F(1, 226) ¼
0.17, p ¼ 0.69, PHQ9 time*clinician assistance F(2, 255) ¼ 0.57, p ¼
0.56; K10 clinician assistance F(1, 335) ¼ 0.18, p ¼ 0.67, K10 time*­
clinician assistance F(2, 348) ¼ 1.60, p ¼ 0.20; WHODAS clinician
assistance F(1, 230) ¼ 0.26, p ¼ 0.61, DOCS time*clinician assistance F
(1, 108) ¼ 1.41, p ¼ 0.24), indicating that clinician-guided and self-
guided participants did not differ in the degree of improvement across
iCBT on any outcome measure.
3.4. Clinically significant change
Of those who had a probable OCD diagnosis at pre-treatment, 37.3%
of treatment completers (15.4% ITT sample) were classified as in
remission, and 26.3% of treatment completers (11.0% ITT sample) were
classified as in recovery at post-treatment, with 20.2% of completers
(8.4% ITT sample) experiencing reliable improvement and only one
patient experiencing reliable deterioration in symptom severity post-
treatment.
3.5. Predictors of OCD symptom improvement
Pre-treatment OCD symptom severity significantly predicted post-
treatment OCD symptom severity at each step of the regression model
(Step 1 t ¼ 4.94; p < 0.001; Step 2 t ¼ 5.59; p < 0.001). Age, gender,
rurality and clinician assistance did not significantly predict post-
treatment OCD symptom severity, after controlling for pre-treatment
OCD symptom severity. At Step 2, reductions in PHQ-9 scores from
pre to post-treatment significantly predicted post-treatment DOCS
scores (t ¼ 2.45; p < 0.05), while changes in psychological distress and
disability scores did not (see Table 5). The bivariate partial correlation
showed that greater reductions in depression across treatment were
associated with lower post-treatment OCD symptoms (Part r ¼ -0.41, p
< 0.001 controlling for pre-treatment DOCS).
4. Discussion
The aim of this study was to explore the effectiveness of an iCBT
course for OCD when delivered in routine care. This is one of the few
studies to examine iCBT for OCD outside of an RCT setting and extends
previous work by investigating the utility of iCBT for OCD without
substantial clinical assistance to a large sample of patients.
Medium effect size reductions in OCD symptom severity (g ¼ 0.61)
were observed from pre-to post-treatment. Medium effect size re­
ductions were also observed for depression symptom severity (g ¼ 0.56)
and psychological distress (g ¼ 0.69), and small effect size reductions
were observed for disability (g ¼ 0.37) across treatment. In treatment
completers, 37% of patients who had reported symptom severity
consistent with a probable OCD diagnosis at pre-treatment were in
remission at post-treatment, 26% were considered to be in recovery, and
20% met the conservative criteria for clinically significant change.
However, these proportions were substantially less in the full (ITT)
sample (remission ¼ 15.4%; recovery ¼ 11.0%; clinically significant
change ¼ 8.4%).
Our results confirm the likely effectiveness of iCBT for some in­
dividuals experiencing OCD, however, the medium effect size reductions
observed in the primary outcome (g ¼ 0.61) and the modest program
adherence (clinician-guided ¼ 47%; self-guided ¼ 34.5%) obtained are
substantially lower than those observed in studies of face-to-face CBT (e.
g., Olatunji et al., 2013). Current treatment outcomes are also lower
than those reported in previous RCTs of guided-iCBT for OCD (Wootton
et al., 2013; Mahoney et al., 2014) and the open trial of guided-iCBT for
OCD by Diefenbach, Wootton, Bragdon, Moshier, and Tolin (2015),
which reported large within-group effect size reductions (1.20, 0.87, and
0.87, respectively) and adherence rates of 67%, 75%, and 71%,
respectively. It is possible that the iCBT programs in the Wootton et al.
and Diefenbach et al. trials were superior to the program evaluated in
the current study, however, it is also possible that treatment effects in
the aforementioned trials were bolstered by the therapist support and
guidance provided to particpants during the iCBT programs (e.g., in the
Diefenbach et al. trial, participants received nine sessions of face-to-face
or telephone-based therapist support averaging 13 min each). It is also
conceivable that RCT participants may be more motivated and

Table 5
Predicting post-treatment OCD symptom severity in treatment completers.
Criterion Predictors Δ R2 B SEB Beta t Part r

DOCS post-treatment score Step 1: DOCS pre-treatment score .26*** .42 .09 .51 4.94*** .51
Step 2: DOCS pre-treatment score .20** .48 .09 .57 5.59*** .52
Age .02 .09 .02 .18 .02
Gender -1.55 2.32 -.07 -.67 -.06
Rurality 1.87 2.12 .08 .85 .08
Clinician-guided vs. unguided -2.78 2.08 -.13 -1.34 -.12
Δ PHQ-9 Score - .57 .23 - .32 - 2.45* - .23
Δ K-10 Score - .30 .23 - .16 - 1.26 - .12
Δ WHODAS 2.0 Score .08 .21 - .05 .40 .04

Notes: Δ ¼ change; *p < 0.05, **p < 0.01, ***p < 0.001.

5
J. Luu et al.
help-seeking, and that the RCT process in itself may provide significant
incidental contact with researchers and clinicians, which may culminate
in additional therapeutic gains. Indeed, one RCT of self-guided iCBT for
social anxiety disorder found that a pre-treatment diagnostic interview
facilitated significant reductions on secondary outcome measures of
depression and general distress (d ¼ 0.15–0.42) (Boettcher, Berger, &
Renneberg, 2012). The current treatment outcomes are more consistent
to those observed in the RCT of self-guided OCD iCBT by Wootton et al.
(2019), which reported within-group effect size reductions on DOCS
total scores of 0.66 and adherence of 40%. Like the current evaluation,
the Wootton et al. RCT expressly avoided administering baseline struc­
tured diagnostic interviews and did not provide clinical guidance during
the iCBT program. Futher research is needed to replicate and extend
current findings because although it is highly scalable, very few studies
have evaluated self-guided iCBT for OCD.
The only other study evaluating iCBT for OCD in routine care settings
(Titov et al., 2017) reported a larger effect size reduction in OCD
symptom severity scores (d ¼ 0.9) than the current study as well as
greater program adherence of 73.9%. Again, this may relate to the
different clinical contexts and levels of therapeutic contact provided to
patients during their iCBT program. The patients in the Titov et al. study
were supported by qualified therapists working in a specialist iCBT
clinic, which augmented its iCBT program with an average of 37 support
emails (averaging 183 min of therapist contact). In contrast, the ma­
jority of participants in this study elected to complete the program un­
supervised and only received automated system emails to encourage
program engagement. The other patients in this study were supported by
their clinicians who were working in the community. Future research
may seek to investigate the level of therapeutic support required to
optimise adherence and treatment response. Nevertheless, our results
suggest that iCBT for OCD can be effective for some individuals with
OCD in routine care settings and it may serve as a useful, low-intensity,
and scalable addition to the existing healthcare infrastructure.
In the current study, the most significant predictor of post-treatment
OCD symptom severity was pre-treatment OCD symptom severity,
which is consistent with that observed in traditional face-to-face CBT
(Keeley, Merlo & Geffken, 2008). Despite the absence of a pre-treatment
OCD diagnostic assessment, participants in this study had similar
pre-treatment OCD symptom severity (DOCS M ¼ 30.1) as those
observed in RCTs by Mahoney et al. (2014; M ¼ 34.5) and Wootton et al.
(2019; M ¼ 28.1). Interestingly, greater reductions in depressive
symptomatology also significantly predicted lower post-treatment OCD
symptomatology. The majority of participants in this study had probable
co-morbid major depressive disorder at baseline, with 10.6% of all pa­
tients reported severe levels of depression. Furthermore, probable MDD
and higher disability at baseline were associated with a lower treatment
completion rates. Given the high rates of co-morbid depressive disorder
in the OCD treatment population, it may be useful for future studies to
explore whether concurrently treating co-morbid depression, either
through psychotherapy or pharmacotherapy, improves treatment
outcomes.
As hypothesised, participants who elected to have their iCBT course
supervised by their own clinician were more likely to complete the
program than those who elected to complete their course independently.
However, the presence of a guiding clinician was not associated with
greater reductions in OCD symptom severity at post-treatment (con­
trolling for pre-treatment severity). Our results appear consistent with
previous studies that have highlighted the importance of the therapeutic
relationship for treatment engagement; with strength of the working
alliance (Andersson et al., 2015) and attending concurrent therapist
sessions (Diefenbach et al., 2015) being associated with higher adher­
ence. Also of note was that participants living in regional, rural and
remote areas were more likely to complete treatment; and unlike in our
previous research (Mahoney et al., 2014), age did not correlate with
completion rates. Together, these findings suggest that iCBT can be a
beneficial treatment across the adult lifespan, and particularly useful for
6
Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561
populations where access to traditional face-to-face CBT may be very
limited due to geographical barriers.
Together with prior findings, our results raise the possibility that
iCBT (especially, self-guided iCBT) delivered in routine care settings
may be somewhat less effective for OCD than it is for other disorders (e.
g., Newby, et al., 2020; 2013). Like iCBT programs for other disorders,
therapist contact and support may be key to maximising adherence and
response rates, and this may be particular important for implementing
the essential ERP components of effective OCD treatment. Indeed, some
of the most efficacious face-to-face CBT protocols involve intensive
therapist-assisted ERP (e.g., Foa, et al., 2005 provided 2-h sessions, five
days/week for three weeks, in addition to 4 h of home visits followed by
eight weekly sessions). It is conceivable that additional disorder-specific
factors may influence treatment outcomes, however, future research is
required to clarify the relative effectiveness of iCBT across internalising
disorders, as well as its relative effectiveness compared to face-to-face
CBT for OCD. Given the current modest treatment outcomes, future
research may also explore the utility of augmenting iCBT for OCD in
routine care; for instance with pharmacological agents and psychosocial
interventions (Abramowitz, Blakey, Reuman, & Buchholz, 2018; Guzick,
Cooke, Gage, & McNamara, 2018), or with novel technologies such as
Apps for guiding ERP (Boisseau, Schwartzman, Lawton, & Mancebo,
2017).
Our findings should be considered in light of a number of limitations.
Firstly, we did not conduct structured diagnostic assessments for OCD
and all data were self-reported. Although this may enhance the
ecological validity of the study, it is uncertain whether the patients in
this study would meet diagnostic criteria for OCD, and therefore our
results cannot be generalised to such a population. Indeed, 20% of the
participants reported sub-threshold OCD symptom severity. However, it
is important to note that people with sub-threshold disorders experience
significant distress and impairment and often seek help for their mental
health symptoms, particularly in routine care settings (Druss et al.,
2007). For these patients, iCBT may represent one low-cost and acces­
sible entry to care. Secondly, we did not use a comparator condition or
exclude participation based on the presence of concurrent treatment (a
quarter of study participants were supervised by a psychologist or psy­
chiatrist who prescribed the OCD iCBT program). Although clinical su­
pervision did not significantly predict post-treatment symptom severity
in this study; it is possible that the observed improvements in OCD
symptom severity may be attributed to treatments outside of the iCBT
protocol, learning effects from past treatments, or spontaneous
improvement. Future routine care studies could compare iCBT to
standardised pharmacotherapy, psychotherapy, or a combination of
these treatments. Finally, there was no follow-up data collected which
limits conclusions regarding the long-term effects of iCBT in reducing
OCD symptoms in routine care settings. However, existing literature
suggests that treatment gains tend to be enduring both in the short term
(Titov et al., 2017; Wootton et al., 2019) and up to two years
post-treatment (Andersson et al., 2014; Wootton et al., 2015). These
results, if replicated in future routine care studies, appear promising for
further integrating iCBT into the health system.
5. Conclusions
In summary, the current study suggests that iCBT can be an effective
treatment for some individuals with symptoms of OCD when delivered
in routine care settings. The study demonstrated medium effect size
improvements in OCD symptomatology, depression symptomatology
and psychological distress in a large, consecutive sample of patients. The
majority of participants elected to complete the program self-guided,
however, the addition of a supervising clinician was associated with
greater treatment adherence. Further studies into predictors of treat­
ment response may reveal strategies in reducing non-responder rates
and guide the scaling of iCBT for OCD programs in the healthcare
system.
J. Luu et al. Journal of Obsessive-Compulsive and Related Disorders 26 (2020) 100561

Role of funding sources Guzick, A., Cooke, D., Gage, N., & McNamara, J. (2018). CBT-plus: A meta-analysis of
cognitive behavioral therapy augmentation strategies for obsessive-compulsive
disorder. Journal of Obsessive-Compulsive and Related Disorders, 19, 6–14.
This research did not receive any specific grant from funding Hedman, E., Ljotsson, B., Ruck, C., Bergstrom, J., Andersson, G., Kaldo, V., …
agencies in the public, commercial, or not-for-profit sectors. Lindefors, N. (2013). Effectiveness of internet-based cognitive behavior therapy for
panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica, 128(6),
457–467.
Contributors Hobbs, M., Jouert, A., Mahoney, A., & Andrews, G. (2018). Treating late-life depression:
Comparing the effects of internet-delivered cognitive behavior therapy across the
adult lifespan. Journal of Affective Disorders, 226, 58–65.
JL and AM analysed the data and wrote the first draft of the manu­
Hobbs, M., Mahoney, A., & Andrews, G. (2017). Integrating iCBT for generalized anxiety
script. MM, JM, HH and MH contributed to the design of the study and disorder into routine clinical care: Treatment effects across the adult lifespan.
supported data collection and collation. All authors contributed to and Journal of Anxiety Disorders, 51, 47–54.
Houghton, S., Saxon, D., Bradburn, M., Ricketts, T., & Hardy, G. (2010). The effectiveness
have approved the final manuscript.
of routinely delivered cognitive behavioural therapy for obsessive-compulsive
disorder: A benchmarking study. British Journal of Clinical Psychology, 49, 473–489.
Jacobson, N., & Truax, P. (1991). Clinical significance: A statistical approach to defining
Declaration of competing interest meaningful change in psychotherapy research. Journal of Consulting and Clinical
Psychology, 59(1), 12–19.
J�
onsson, H., Kristensen, M., & Arendt, M. (2015). Intensive cognitive behavioural
All authors declare that they have no conflicts of interest.
therapy for obsessive-compulsive disorder: A systematic review and meta-analyses.
Journal of Obsessive-Compulsive and Related Disorders, 6, 83–96.
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