Unguided self-help psychological interventions for OCD refer to self-administered treatment protocols and materials such as books, audio, videos, or mobile applications that patients undergo independently to learn strategies to alleviate obsessive-compulsive disorder symptoms. They do not require guidance from a professional therapist.
Wang, Y., Amarnath, A., Miguel, C., Ciharova, M., Lin, J., Zhao, R., ... & Cuijpers, P. (2024). The effectiveness of unguided self-help psychological interventions for obsessive-compulsive disorder: A meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 152453.
Key Points
- Unguided self-help psychological interventions significantly reduced OCD symptom severity compared to control groups, with a moderate effect size (g = 0.42).
- Participants receiving unguided self-help interventions had a 2-fold higher probability of dropping out compared to control groups.
- Completer analyses showed a significant moderate effect size (g = -0.65) in reducing OCD symptoms, while intention-to-treat analyses did not.
- The majority of trials (92%) were rated as high risk of bias.
Rationale
Obsessive-compulsive disorder (OCD) is a common mental disorder affecting millions globally (American Psychiatric Association, 2013).
While evidence-based psychological treatments exist, many individuals face barriers accessing them, including cost, availability of therapists, and stigma (Goodwin et al., 2002; Marques et al., 2010).
Unguided self-help interventions that do not require therapist involvement may improve access, but evidence on effectiveness is limited (Pearcy et al., 2016).
This meta-analysis aimed to evaluate the effectiveness of unguided self-help psychological interventions for OCD compared to control groups.
Method
This meta-analysis followed PRISMA guidelines (Preferred Reporting Items for Systematic Review and Meta-Analysis Statement).
The authors searched major international and Chinese databases from inception to January 2023 for randomized controlled trials comparing unguided self-help psychological interventions to control groups for individuals diagnosed with OCD using semi-structured interviews.
The primary outcome was OCD symptom severity. Effect sizes were calculated using Hedges g, with values of 0.2, 0.5, and 0.8 indicating small, moderate, and large effects, respectively (Cohen, 2013).
Inclusion criteria
- Randomized controlled trials
- Comparing unguided self-help psychological interventions
- To control groups (no treatment/waitlist/care-as-usual/psychological placebo/pill placebo)
- For individuals diagnosed with primary OCD through valid semi-structured interviews
Exclusion criteria
- Trials designed as maintenance treatment or relapse prevention
- Studies involving human support related to the therapeutic content (although contact for data collection/technical support or automated messages was allowed)
The paper did not specify any restrictions based on treatment duration, number of sessions, sample size, language, gender, or age.
Data Extraction
The researchers extracted the following data:
- Study characteristics: Type of intervention, control group, publication year, region conducted, participant recruitment method
- Participant characteristics: Mean age, percentage women, psychiatric medication use, comorbidities
- Study dropout rates
- OCD symptom severity outcomes: Instrument, assessment timepoints, treatment length, sample analyzed, means/SDs, sample sizes
Risk of Bias Assessment
The revised Cochrane risk-of-bias tool (RoB 2) was used to assess study bias across 5 domains:
- Bias in randomization process
- Bias from deviations from intended interventions
- Bias from missing outcome data
- Bias in measurement of outcomes
- Bias in selection of reported results
Two independent researchers extracted all data and assessed risk of bias. Any disagreements were resolved through discussion. This process aimed to maximize reliability and validity of the meta-analysis results.
Sample
12 RCTS with 769 OCD patients (mean age 26-39 years, 42-77% female) were included. Eight trials were recruited from the community and four from clinical settings. Most trials were conducted in Europe.
Statistical Measures
Random effects meta-analysis was used. Heterogeneity was assessed with I2 values of 25%, 50%, and 75%, indicating low, moderate, and high heterogeneity. Relative risk (RR) quantified dropout rates.
Results
Characteristics of Included Studies
- 12 RCTs with 20 comparisons and 769 OCD patients were included
- Mean age ranged from 26-39 years
- 42-77% were women
- 8 trials recruited from community settings, 4 from clinical settings
- Most trials conducted in Europe
- Intervention types: Exposure and response prevention (ERP), cognitive therapy (CT), cognitive behavioral therapy (CBT), and third-wave CBT
- Controls: Waitlist, psychological placebo
- Main delivery format: Books/manuals
Effects of Unguided Self-Help Psychological Interventions
- Significant moderate effect size in reducing OCD symptoms (g=-0.42, 95% CI -0.69 to -0.14, p<0.001)
- Moderate heterogeneity (I2=59%)
- Sensitivity analyses supported the robustness of findings
- Only 1 trial had long-term follow-up data
Subgroup Analyses
- No significant differences based on intervention type, control type, or recruitment method
- Significant difference based on the handling of missing data: Completer analyses had significant moderate effect size (g=-0.65).
- Intention-to-treat analyses were non-significant.
Dropout
- Significantly higher dropout rates in intervention groups than controls (RR=2.08, 95% CI 1.53-2.81)
- Highest dropout among those receiving CBT interventions and recruited from the community
Insight
This rigorous meta-analysis provides initial evidence for the potential of unguided self-help interventions to reduce OCD severity. However, the effect varied a lot across the different studies included.
The findings support unguided self-help as an accessible first-step intervention for OCD, which could help reach more people globally.
However, the considerable dropout rates indicate that barriers persist in fully benefiting from self-help.
The significant difference in effect sizes between completer versus intention-to-treat analyses also highlights the need to find strategies to mitigate dropout and enhance adherence.
Strengths
- Rigorous inclusion criteria of RCTs diagnosing OCD using semi-structured interviews
- Inclusion of major Chinese databases providing a global perspective
- Extensive subgroup and sensitivity analyses to explore heterogeneity
- Investigation of dropout rates and potential reasons
Limitations
- Majority of trials had a high risk of bias
- Lack of long term follow-up assessments
- Small sample sizes
- No comparisons with other formats like guided self-help
Implications
Overall, unguided self-help shows promise for OCD, but addressing methodology limitations and treatment adherence issues is vital for strengthening the evidence base and expanding access globally.
The findings support integrating unguided self-help interventions into mental health systems globally to enhance access for OCD.
However, improving the methodological rigor of trials and finding strategies to address high dropout rates is vital to strengthening the evidence base and enhancing real-world effectiveness.
High dropout rates indicate substantial barriers limiting effectiveness in practice. Exploring factors influencing dropout and developing mitigation strategies should be prioritized.
Stepped care models gradually transitioning patients from unguided to guided self-help, and finally, intensive therapy may balance accessibility and adherence.
Knowledge sharing across countries are important for adapting interventions across diverse contexts.
References
Primary reference
Wang, Y., Amarnath, A., Miguel, C., Ciharova, M., Lin, J., Zhao, R., … & Cuijpers, P. (2024). The effectiveness of unguided self-help psychological interventions for obsessive-compulsive disorder: A meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 152453.
Other references
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Routledge.
Goodwin, R., Koenen, K. C., Hellman, F., Guardino, M., & Struening, E. (2002). Helpseeking and access to mental health treatment for obsessive-compulsive disorder. Acta Psychiatrica Scandinavica, 106(2), 143-149.
Marques, L., LeBlanc, N. J., Weingarden, H. M., Timpano, K. R., Jenike, M., & Wilhelm, S. (2010). Barriers to treatment and service utilization in an internet sample of individuals with obsessive–compulsive symptoms. Depression and anxiety, 27(5), 470-475.
Pearcy, C. P., Anderson, R. A., Egan, S. J., & Rees, C. S. (2016). A systematic review and meta-analysis of self-help therapeutic interventions for obsessive-compulsive disorder: Is therapeutic contact key to overall improvement?. Journal of Behavior Therapy and Experimental Psychiatry, 51, 74-83.
Keep Learning
Here are some suggested Socratic discussion questions for a college class:
- How might the high dropout rates have impacted the results and conclusions of the meta-analysis? What are some potential reasons participants may have dropped out?
- Do you think unguided self-help interventions can fully replace traditional therapist-led treatment for OCD? Why or why not? What might be some pros and cons?
- How could technology and innovation help address some of the limitations of unguided self-help interventions highlighted in this paper, like adherence and engagement? Can you think of any examples?
- What might be some ethical considerations in promoting unguided self-help interventions as widely accessible treatment options for mental health conditions like OCD? Who should determine what is an appropriate level of care?
- How could the role of culture, health literacy and digital literacy impact the effectiveness and uptake of unguided self-help interventions globally? What steps could researchers take to enhance cultural sensitivity?
