OCD and anxiety disorders: The Bergen 4-day Format. Gerd Kvale Bjarne Hansen

Transkript

1 OCD and anxiety disorders: The Bergen 4-day Format Gerd Kvale Bjarne Hansen

2 The Bergen OCD-clinic Evidence based treatment + quality ensurance + research= True Established in 2011 as an initiative from the UoB A genuine product of the combination of academia + health services Combine all we expect might work without letting infrastructure be a limitation Not compromise on quality - quality ensurance integrated Start with OCD aim for a clinic for anxiety disorders Always address dissemination (certification of teams, not individuals)

3 The Bergen OCD-clinic Specialist health care required to offer treatment to all severe OCD patients in the catchment area of No selection based on comorbidity (but do not start treatment if suicidal, psychotic, active bi-polar, active substance abuser) 4-day format now standard Quality ensurance integrated online since Sept 2015 Independent raters post treatment and follow up Re-referred if relapse

4 Treatment of OCD What is the state of art?

5 Treatment of OCD What is the state of art?

6 Background data 34 studies (25 CBT, 9 SRI) and 1990 participants Proportion of females: 45.9% (29-63%) Mean age of the samples: 12.5 years ( ) Mean age at onset of OCD: 8.5 years ( ) Previous treatment for OCD: 38.0% (7-100%) Using medication for OCD: 22.5% (0-100%) Any comorbid disorder: 54.3% (11 97%)

7 Treatment data: CBT Type of therapy: ERP (without CT): 8 conditions CT (without ERP): 2 ERP+CT: 15 Duration of treatment: 12.7 weeks (3-20) Number of therapy sessions: 12.5 (9-14) Total treatment time: 15.4 hours (10-23) Follow-up: 60% of studies (9.2 months)

8 Declining and dropping out It is often said that 25% decline to participate in RCTs and a further 25% drop out of therapy. Declining: 7.4% (0-53%) Mdn 4.3% Attrition CBT 12.7% ERP 17.8% SRI 23.5%* ERP+CT 9.9%* Placebo 24.7%* CT 5.5%*

9 Response and remission (%) Treatment Response Remission Post F-up Post F-up CBT 69.6 a a 66.3 SRI 48.9 b (60.0) 24.1 b Combo 66.1 a a (69.2) Placebo 29.3 c 14.7 b WLC 13.0 c 10.1 b Response: 35% reduction of Y-BOCS pre-treatment score. Remission: 12 points on Y-BOCS at post-treatment.

10 Clinical implications CBT and SRI lead to moderate effect sizes There is no additional gain in combining CBT and SRI. CBT has lower attrition than SRI and Combo CBT and Combo lead to higher response and remission than SRI SRI has higher response but not remission than placebo The improvements are maintained or furthered at follow-up The format (individual or family) does not significantly affect the outcome.

11 Treatment of moderate-severe OCD American Academy of Child and Adolescent Psychiatry (2012) recommends the combination of SSRI and CBT for youth with moderate to severe OCD. We found these results: Combo vs. CBT: g = 0.14 (NS) Response rate: Combo 66% vs. CBT 70% (NS) Remission rate: Combo 49% vs. CBT 53% (NS) Within-group ES: Combo 2.54 vs. CBT 2.43 (NS) CBT-ES increases but Combo-ES decreases with increased pre-treatment OCD severity

12 Ivarsson e al. (2015) meta-analysis A meta-analysis of SRIs in youth with OCD. On this issue they concluded: We find no support in the literature we reviewed that moderate to severe OCD should be treated with Combo from the start as recommended in the US AACAP parameter (p. 101). Based on their results and ours CBT should be recommended as the first-line treatment irrespective of comorbidity and pre-treatment severity.

13 Treatment of OCD What is the state of art? CBT and related treatments: Highly effective CBT=CT=ERP > medication Robust in several formats

14 Inpatient 9-12 weeks + weekly sessions 1-2 years 2/3 get clinically relevant change

15 CHANGE

16 CHANGE IF YOU ARE GOING TO CRACK THE CODE, YOU NEED TO GET ALL THE NUMBERS CORRECT Evidence based treatment Infrastructure Competent therapists Quality assurance BENCH MARKING

17 The Bergen OCD-clinic Evidence based treatment + quality ensurance + research= True Established in 2011 as an initiative from the UoB A genuine product of the combination of academia + health services Combine all we expect might work without letting infrastructure be a limitation Not compromise on quality - quality ensurance integrated Start with OCD aim for a clinic for anxiety disorders Always address dissemination (certification of teams, not individuals)

18 The Bergen OCD-clinic Specialist health care required to offer treatment to all severe OCD patients in the catchment area of No selection based on comorbidity (but do not start treatment if suicidal, psychotic, active bi-polar, active substance abuser) 4-day format now standard Quality ensurance integrated online since Sept 2015 Independent raters post treatment and follow up Re-referred if relapse

19 4-day format OCD Panic Social anxiety Adult Children Adult Children Adults Children Pilot Pilot Pilot Pilot Pilot Pilot Effectiveness study Effectiveness study Effectiveness study Effectiveness study Effectiveness study Effectiveness study Replication & Long term fu Replication & long term fu International RCT New sites & up-scale! New sites & up-scale International

20 Individual treatment in a group setting 1:1 ratio between patients and therapists FLEXIBLE Day 1(4 hrs): Teaching and deciding upon the most potent exposure tasks within the Day 2 (8 hrs): Individually tailored, therapist assisted ERP format! Day 3 (8 hrs): Individually tailored, therapist assisted ERP (2 hrs) Teaching for family/ friends Day 4 (4hrs): Wrapping up and preparing maintenance of the change

21 The 4-day format introduced as pre-treatment. and became INDIVDUAL TREATMENT IN A GROUP FORMAT

22 Individual treatment in a group setting 1:1 ratio between therapists and patients Less fragmented Therapist assisted and individually tailored help in the contexts that is needed More relevant settings -

23 The concentrated 4-day format: 600+ patients treated basically same results

24 4-day format Developed for the most severe anxiety disorders Basically no drop-out Better than «gold standard» Improves depression Get patients back to work 50% less resouces allocated to the actual treatment So far more than 500 treated with very good rsults

25 Are the patients satisfied? Quality of the treatment? The kind of treatment that you wanted? Satisfied your needs? Recommend to a friend? Amount of treatment? Helpful for your problems? All considered, how satisfied are you? Return to the clinic? Scores in %. Average score on CSQ was (2.49), range 19-32, median = 30.5 (possible range is 8 32).

26 Fischer % Wells RCI: Recovered =pre- to post-treatment or follow-up reduction in Y- BOCS of 10 points or more and had a Y-BOCS score of 14 points or below at posttreatment or follow-up.

27 Replication study Equally high levels 100 of treatment satisfaction Equal proportion 60 of patients reporting positive change in employment status Recovered Improved No change Pre Post Follow-up Y-BOCS Clinically significant change

28 Replication new site (Kristiansand) work in progress, do not cite David Mataix-Cols criteria: Improved= Min 35% change Recovered: Y-BOCS of 12 or lower Status i1 week Percent RCT currently running Unchanged (not 35% change) 6,3 % Improved (35% or more change) 93,7 % Recovered (35% change & Y-BOCS 12 75,0 % Status 3 months Percent Unchanged (not 35% change) 20,7 % Improved (35% or more change) 79,3 % Recovered (35% change & Y-BOCS 12 69,0 % Y-BOCS

29 Long term follow up (1-1.5 years) Bergen (work in progress, please do not cite) Independent rater 20% interrated - reliability (so far) 86% response rate at 1 year f.u. Mean Y-BOCS Response Remission

30 Long term follow up work in progress, please do not cite yrs 3-4 yrs Independent rater 20% interrated - reliability (so far) 86% response rate at 1 year f.u.

31 THE ULTIMATE TEST OF TE FORMAT.never done anything close

32 IN TWO WEEKS: 100 patients with severe OCD get treatment 50 therapists starts training OUS erased the waiting lists Unique network of therapists

33 Remarcable results.(work in progress, do not cite) 30,00 20,00 10,00 0,00 CHANGE RESPONSE REMISSION

34 OCD High demand from: 4-day format clincians clinics health authorities Panic Social anxiety Adult and Children most important Adult Children Adults Children Pilot Patients and relatives really want this format.. BECAUSE Pilot IT S Pilot WORKING Pilot Pilot Pilot Effectiveness study Effectiveness study Effectiveness study Effectiveness study Effectiveness study Effectiveness study Replication & Long term fu Replication & long term fu International RCT New sites & up-scale! New sites & up-scale International

35 Why not for children and adolescents?

36 CBT FOR PEDIATRIC OCD - Empirically supported in more than 30 RCTs - First line treatment (AACAP, 2012; NICE, 2005) - Effective in different formats

37 MOST COMMON FORMATS weeks Weekly sessions, mins Total duration approximately 15 hours Efficacy (Öst et al., 2016) Response: 70 % Remission: 53 % Within-group ES: g = 2.43

38 CONCENTRATED ANXIETY TREATMENT FOR ADOLESCENTS Specific phobia (Öst et al, 2001; Davis et al. 2012; Ollendick et al. 2015) Separation Anxiety Disorder (Santucci et al. 2009; 2013) Social Phobia (Donovan et al. 2015) Panic disorder and agoraphobia (Angelosante et al., 2009; Gallo et al. 2013)

39 INTENSIVE TREATMENT OF OCD Authors Intensity No of sessions Frequency Duration of sessions Storch et al. (2007, 2010) 3 weeks 14 Daily 90 mins Whiteside et al. (2010, 2014) 5 days 10 Twice daily 50 mins

40 cet FOR ADOLESCENTS The format Delivered to 2 3 adolescents simultanously Age Delivered at an outpatient clinic as part of standard health care Prolonged sessions 4 consecutive days: Day 1: Psychoeducation 3 hrs Day 2: Therapist-assisted ERP 6 hrs (continued ERP in the evening) Day 3: Therapist-assisted ERP 6 hrs (continued ERP in the evening) Day 4: Summary, plan three next weeks 3 hrs Parental involvement throughout treatment

41 cet FOR ADOLESCENTS Some core elements What we do Focus on emotional regulation - The patients fear normal and benign thoughts and emotions and trying to control these paradoxically maintain or increase the frequency and intensity of these. Treatment is all about breaking this vicious circle. Awareness training every time you notice you have a choice! Try to notice every time you get the urge to ritualize. Value the triggers of distress - they are opportunities for change! Approach and embrace them as if you were digging for gold! (Lean in > hold back) Go for the best! At any time, choose the task you expect to have the most potential for change Get out there! Exposure training in a variety of relevant settings. What we don t No focus on habituation No focus on disconfirmation of beliefs No hierarchy

42 SAMPLE CHARACTERISTICS (N = 22) Male n = 15 (68 %) Age M = 13.3 (SD = 1.6) (Range 11-17) Duration of OCD (months) M = 26.4 (SD = 19.2) Previous treatment n = 13 (59 %) Pre-treatment CY-BOCS M = 28.0 (SD = 4.06) Comorbidity n = 9 41 %

43 CY-BOCS

44 RESPONSE / REMISSION 100% 90% 80% 70% 60% 50% 91% 73% 77% 68% Response < 35 % reduction on CY-BOCS Remission 12 on CY-BOCS 40% 30% 20% 10% 0% Post 6-month follow up

45 SECONDARY MEASURES Anxiety Depression GAD-7 8 CDI Pre Post 6-month follow-up 0 Pre Post 6-month follow-up

46 FUNCTIONAL IMPAIRMENT COIS-R Pre Post 6-month follow-up COIS-R Parent-rated COIS-R Child-rated

47 CONCLUSIONS The format is acceptable for adolescents The results demonstrate substantial reductions in OCDsymptoms PROMISING! Treatment gains are maintained at 6-month follow-up

48 Change through distinct stages PREPARE Remove hindrances CHANGE Individually tailored and therapist assisted INTEGRATE Let change become part of normal life

49 The different stages 1. Prepare (2 appointments): Remove obstacles for change 2. Change (4 days): Individually tailored, therapist assisted individual treatment in a group setting 3. Integrate into daily living (3 weeks ): planned self-exposures with daily CW reports 4. Follow up: Independent rater 1 week and 3 months after treatment Invited to 1 follow-up session (individually) after 3 months. No exposure

50 Referral procedures Pre-screening Screening Contact with group leader

51 For whom? Standardized info What can you expect? What is offered? What is neccessary?

52 Kontakt med gruppeleder Etablere kontakt ha snakket sammen Svare på spørsmål Har pasienten forstått? Har pasienten tatt et valg? Ryddet tid? Forberedt seg? Fjerne hindre for endring Formidle positiv forventning

53 Forventningssjekk Gir det mening? Ville du anbefalt det? Kommer du til å gjør det? Vil det være nyttig?

54 Change through distinct stages PREPARE Remove hindrances CHANGE Individually tailored and therapist assisted INTEGRATE Let change become part of normal life

55 De fire dagene

56 The treatment: Same, but different hierarki habituation rationale focus on disconfirmation of dysfunctional beliefs

57 Characteristics Course in How to make the exposures work. Therapists as coachers. Covers repeated exposures across a substantial number of situations/ places Exposures in a number of differendt emotional states Anxiety and discomfort are the raw material for change chasing anxiety like gold Leaning into the anxiety/ exposures: Exposures without holding back

58 STADIENE Forberede Fjerne hindre for endring Endre: Skreddersydd og terapeutassistert Konsolidere : Integrere endringen i hverdagslivet

59 Tiden etter gruppe Tre uker med systematisk trening og on-line registrering Tre-måneders oppfølging på klinikken Online registrering av endring og telefonsamtale med «ekstern» etter 1 uke, 3 måneder, 6 måneder og 1 år

60 Trening og sertifisering Introduksjonskurs i 4-dagers formatet Diagnosespesifikt introduksjonskurs Direkte mester-svenn opplæring og veiledning i gruppe Vurdering av kompetanse

61 Monitorering av endring Integrert del av behandlingen Nettbasert Uavhengige bedømmere

62 Kliniske tilpasninger til barn og ungdom

63 Innsikt Har det betydning for utfall? Må pasienter vise god innsikt før behandling?

64 Er det en prediktor for endring? Motivasjon Krever behandlingen høy grad av motivasjon? Hvordan sikre tilstrekkelig motivasjon?

65 Relasjon til behandler Hvor godt må barn eller ungdom kjenne behandler før en starter med intensiv eksponeringsbehandling? Hvordan sikre tilstrekkelig god relasjon?

66 Inklusjon av pårørende Hvor mye bør pårørende inkluderes? Hvordan bør pårørende inkluderes?

67 Family accommodation All familieåtferd som midlertidig reduserer OCD-ubehag Fleire studiar har funne signifikant korrelasjon mellom family accommodation og OCD severity POTS I: høgt nivå av familietilpassing predikerte dårlegare behandlingsutfall (Garcia et al. 2010) Öst et al. (2016): grad av foreldreinvolvering eller format (individuell, familie eller gruppe) påverka ikkje effekt av CBT Merlo et al. (2009): Reduksjon i familietilpassing under behandling gav betre behandlingsutfall

68 Family accommodation scale 12 spørsmål, skåre Gje forsikringar 2. Sjå på når pas fullfører rituale 3. Ventar på barnet 4. Avholde seg frå å sei eller gjera ting 5. Hjelp til unngåelse. 6. Hjelp med tvangshandlingar 7. Delta i barnet sine tvangshandlingar 8. Hjelp med enkle oppg. el. beslutn. 9. Tolerere abnorm atferd 10. Endra personlege rutinar 11. Endra familierutinar 12. Overtek ansvarsoppgåver i familien

69 Family accommodation og 4-dagars formatet for ungdom FAS-intervju administrert til foreldre før behandling og ei veke etter behandling Utgangspunkt for foreldresesjon Dag 1 (etter psykoedukasjon)

70 Resultat (Work in progress. Do not cite)

71 Resultat (work in progress di not cite) Signifikant korrelasjon mellom CY-BOCS og FAS før behandling (r(39)=.36, p =.02.) Ingen signifikant korrelasjon mellom FAS pre og CY-BOCS post / FU Ingen signifikant korrelasjon mellom endring i FAS (pre-post) og CYBOCS post / FU

72 Resultat: Svært gode resultater og lite variasjon etter behandling (work in progress di not cite)

73 Kort oppsummert Signifikant sammenheng mellom cybocs og FAS før behandling Familietilpassing og OCD-symptom vesentlig redusert etter cet Grad av familietilpassing før behandling predikerer ikkje behandlingsutfall av cet Endring i familietilpassing predikerer ikkje behandlingsutfall av cet Kort fortalt: Det er (forståelig nok) mye FAS før, men det forsvinner som dugg for solen gjennom behandling og høyt nivå før, var ikke til hinder for et godt resultat

74 Hvordan få opplæring og bli sertifisert? Kontakt Se: