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The Bergen 4-day concentrated exposure treatment (cET) for obsessive-compulsive disorder (OCD) has proven highly acceptable; with practically no drop-out and a 6 month remission rate of nearly 70%. The aim of the present study was to evaluate long term gains of the approach, and to compare the results to findings from our recent meta-analysis. Sixty-nine of 95 patients consecutively referred to an outpatient clinic in the specialist health care, were offered the Bergen 4-day treatment. Among the 65 who initiated treatment, 60.0% were classified with “severe” to “extreme” OCD. None of the patients dropped-out during treatment. Independent Yale-Brown Obsessive-Compulsive Scale interviews were conducted post-treatment, and at 3- and 12-month follow-up. Using the international consensus criteria, 83.1% responded to treatment at 12-month follow-up, and 67.7% of patients were classified as recovered. Significant changes were also seen in depression, as measured by Patient Health Questionnaire-9, and in generalized anxiety, as measured by Generalized Anxiety Disorder-7 scale. A total of 89% of the patients rated the treatment as very good and 100% would recommend the treatment to a friend. Compared to results in a recent meta-analysis, the Bergen 4-day treatment is favorable in respect to attrition, response and 12-month recovery. In sum the Bergen 4-day treatment is a feasible way to deliver treatment for OCD, and the effects are stable at 12-month follow-up. Implications for dissemination are discussed.
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ORIGINAL RESEARCH
published: 03 May 2018
doi: 10.3389/fpsyg.2018.00639
Frontiers in Psychology | www.frontiersin.org 1May 2018 | Volume 9 | Article 639
Edited by:
Changiz Mohiyeddini,
Northeastern University, United States
Reviewed by:
Dean McKay,
Fordham University, United States
Suzie Xu Wang,
Leeds Beckett University,
United Kingdom
*Correspondence:
Gerd Kvale
gerd.kvale@psykp.uib.no
Specialty section:
This article was submitted to
Clinical and Health Psychology,
a section of the journal
Frontiers in Psychology
Received: 06 November 2017
Accepted: 16 April 2018
Published: 03 May 2018
Citation:
Hansen B, Hagen K, Öst L-G,
Solem S and Kvale G (2018) The
Bergen 4-Day OCD Treatment
Delivered in a Group Setting:
12-Month Follow-Up.
Front. Psychol. 9:639.
doi: 10.3389/fpsyg.2018.00639
The Bergen 4-Day OCD Treatment
Delivered in a Group Setting:
12-Month Follow-Up
Bjarne Hansen1,2 , Kristen Hagen1,3, Lars-Göran Öst 1,4 , Stian Solem1,5 and Gerd Kvale 1*
1OCD-Team, Haukeland University Hospital, Bergen, Norway, 2Department of Clinical Psychology, University of Bergen,
Bergen, Norway, 3OCD-Team, Molde Hospital, Molde, Norway, 4Department of Psychology, Stockholm University,
Stockholm, Sweden, 5Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
The Bergen 4-day concentrated exposure treatment (cET) for obsessive-compulsive
disorder (OCD) has proven highly acceptable; with practically no drop-out and a 6
month remission rate of nearly 70%. The aim of the present study was to evaluate
long term gains of the approach, and to compare the results to findings from our recent
meta-analysis. Sixty-nine of 95 patients consecutively referred to an outpatient clinic in
the specialist health care, were offered the Bergen 4-day treatment. Among the 65 who
initiated treatment, 60.0% were classified with “severe” to “extreme” OCD. None of the
patients dropped-out during treatment. Independent Yale-Brown Obsessive-Compulsive
Scale interviews were conducted post-treatment, and at 3- and 12-month follow-up.
Using the international consensus criteria, 83.1% responded to treatment at 12-month
follow-up, and 67.7% of patients were classified as recovered. Significant changes
were also seen in depression, as measured by Patient Health Questionnaire-9, and in
generalized anxiety, as measured by Generalized Anxiety Disorder-7 scale. A total of
89% of the patients rated the treatment as very good and 100% would recommend the
treatment to a friend. Compared to results in a recent meta-analysis, the Bergen 4-day
treatment is favorable in respect to attrition, response and 12-month recovery. In sum the
Bergen 4-day treatment is a feasible way to deliver treatment for OCD, and the effects
are stable at 12-month follow-up. Implications for dissemination are discussed.
Keywords: OCD, ERP, concentrated exposure treatment, Bergen 4-day program, group format, long term
follow-up, patients’ acceptance
INTRODUCTION
Obsessive-compulsive disorder (OCD) has an estimated lifetime prevalence of approximately 2%
and the majority of patients are affected before their mid-twenties (Kessler et al., 2005). OCD has
been ranked by the WHO among the 10 most debilitating disorders (World Health Organization,
1999). Untreated the disorder tends to be chronic (Koran et al., 1996). This implies that each
patient who is not helped represents vast personal- and socioeconomic costs. The recommended
treatment of choice for OCD is cognitive behavioral therapy (CBT; National Collaborating Centre
for Mental Health, 2006), which refers to exposure and response prevention (ERP) with or without
the inclusion of cognitive therapy strategies. Despite documented effective, <50% of the OCD-
patients can expect long-term recovery after CBT-treatment (Abramowitz, 1998; Olatunji et al.,
2013; Öst et al., 2015).
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
We1have recently developed a new treatment format, the
Bergen 4-day treatment, for patients suffering from OCD,
where exposure treatment delivered during four consecutive
days. Compared to a recently published a meta-analysis of 37
controlled studies of cognitive behavior therapy (CBT) for OCD
in adults, all using Yale-Brown Obsessive Compulsive Scale (Y-
BOCS; Goodman et al., 1989a,b) as primary outcome measure
(Öst et al., 2015) the results from the 4-day treatment are good.
Before treatment the patients receiving the 4-day format were as
severely affected by OCD as the patients in the meta-analysis, but
after treatment the patients in the 4-day format had significantly
less OCD symptoms as compared to patients who had received
standard exposure and response prevention (ERP) (t=4.33, p
<0.0001). Pooled results from our previous studies show that
at post-treatment 86% of the patients have a clinically significant
response, and 6 months later 68% are in remission (Havnen et al.,
2013, 2017; Öst et al., 2015). The proportion of responders in
the meta-analysis was 67% at post-treatment, and 65% at 3- and
12-month follow-up, whereas proportion of remitters was 50, 45,
and 49%, respectively. Thus, it seems as cET might be as effective
as standard ERP (if not more effective) at post-treatment, and the
effects seem to be maintained at a short-term follow-up.
The dropout rate for cET was only 1.3% (Havnen et al., 2014,
2017). This is remarkably low as compared to the overall dropout
rate of 19.7% reported in a meta-analysis of Swift and Greenberg
(2012) covering 669 RCTs and almost 84,000 patients. In our
previous studies of the 4-day treatment the refusal rate was 2.5%.
Dropout rate for ERP has been found to be approximately 15%
across studies and similar to other treatments for OCD (Ong
et al., 2016).
The cET can be considered as “individual treatment in a
group setting, since it is delivered in a group of 3–6 patients
with the same number of therapists. The 1:1 ratio between
patients and therapists allows for individually tailored and
therapist assisted exposures in numerous OCD-relevant settings,
and simultaneously the format provides the patients with an
opportunity to observe and follow others going through parallel
processes. Since the concentrated exposure treatment (cET) is
delivered during 4 consecutive days, it is highly attractive to a
substantial number of patients, since they during a very short
time may get rid of a severe problem which highly impairs
everyday life. This is also reflected in the low declining rate
(2.5%) and low drop-out rate (1.3%) in the two Havnen et al.
(2014, 2017) studies. Also, the format yields an opportunity for
OCD-specialists within a given geographical area to join efforts
and work together with severe patients during clearly specified
time-slots.
One of the strengths of the 4-day format is that it has been
developed within an ordinary specialist health care in a clinic
responsible for delivering care to all OCD patients in a catchment
area of 440,000, which makes the ecological relevance high.
However, results from other brief interventions indicate that
even though they might yield good post-treatment results,
there could be some deterioration at short-term follow-up
1Gerd Kvale and Bjarne Hansen.
(Jónsson et al., 2015), which makes it highly important to evaluate
long-term effects in the Bergen 4-day format. The Bergen 4-day
treatment has received substantial interest2and the aim of the
present study was to evaluate the short- and long-term effects in
a new sample of OCD-patients. We also wanted to evaluate the
patients’ acceptance of the treatment as well as attrition, and to
compare the results from the 4-day treatment with the long term
results reported in a recent meta-analysis (Öst et al., 2015). Based
on the 6-month follow-up results in a previous studies (Havnen
et al., 2013, 2014, 2017), as well as the 12-month follow-up data
of standard ERP described above, we expected that the effects of
cET at post-treatment will be maintained at the 12-monthfollow-
up, also compared to the results from CBT as reflected in the
meta-analysis.
METHODS
Referrals
The data presented are part of a standard quality control
performed at the OCD treatment outpatient unit at Haukeland
University hospital, which is part of the ordinary specialist health
care. Patients are first referred from their general practitioner
to a local outpatient clinic, and if the patient is considered
to suffer from OCD with a severity that entitles them to care
in the specialist health care, the outpatient clinics refer the
patient to the OCD-team who does the full screening and
diagnostics of the patient. Because the OCD-team is part of the
secondary mental health services, all patients fulfilling a principal
DSM-IV diagnosis of OCD (American Psychiatric Association,
1994) according to the administration of the Mini International
Neuropsychiatric Interview (MINI; Sheehan et al., 1998) have
to be offered treatment. Treatment is, however, not initiated if
the patient is suicidal, psychotic or in active substance abuse.
Furthermore, treatment in a group format is not offered if the
patient does not speak Norwegian. Between September 2015
and July 2016, 95 of the patients referred to the clinic fulfilled
diagnostic criteria of OCD (for overview, see Figure 1). Ten
patients declined any treatment for the following reasons: the
OCD was ego-syntonic (3), fear for exposure exercises (3),
low severity when they met for screening (2), and lack of
motivation (2).
Of the 95 referrals during the specified time period,
nine patients were not offered treatment due to following
reasons: having a sub-clinical OCD (7), primarily suffering
from sensitivity to sound (1), and severe physical illness (1).
Six patients were offered individual exposure and response
prevention, due to the following reasons: intellectually challenged
(4), severe hearing problems (1), and treatment of a panic
disorder was prioritized (1), and this treatment was not
completed in the specified time period. Figure 1 presents a flow-
chart and includes the four sub-groups of patients (not offered
treatment; given individual treatment; declined any treatment;
offered 4-day treatment). In line with what is expected in the
specialist health care, patients with the lesser OCD-severity was
2At the moment more than 30 teams in Norway, Sweden and Iceland are trained
to deliver the Bergen 4-day treatment.
Frontiers in Psychology | www.frontiersin.org 2May 2018 | Volume 9 | Article 639
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
FIGURE 1 | Flow chart.
not offered treatment: There was a significant difference between
the groups on Y-BOCS pre-treatment, F(3) =15.21, p<0.001,
and post-hoc test using Tukey HSD showed that the significant
difference was between the patients not offered treatment (mean
Y-BOCS of 15.1, SD =5.7) and the other three groups. Thus,
the patients not offered treatment had lower Y-BOCS scores,
indicating less OCD-severity, than patients who were offered
treatment, refused treatment, or were given individual treatment
(p<0.001). There were no significant differences on Y-BOCS
between patients who were offered treatment and patients who
were given individual treatment or those who declined treatment.
No significant difference was found between the groups on GAD-
7 [F(3) =1.12, p=0.347], or PHQ-9, [F(3) =2.07, p=0.11].
Furthermore, there were no significant differences between
the groups with respect to number of comorbid disorders, F(3)
=1.43, p=0.238, age, F(3) =0.75, p=0.53, gender, χ2
(3) =2.85,
p=0.42, work status (working/studying vs. other), χ2
(3) =3.16,
p=0.37, or marital status, χ2
(3) =5.58, p=0.13.
Patients in the 4-Day Treatment
A total of 69 patients were thus offered, and accepted the
Bergen 4-day treatment. However, two of these moved to another
health region before the treatment started, and another two were
prohibited from starting due to physical health issues. Thus, 65
patients initiated treatment, and no patients dropped out after
starting treatment.
Age, Sex, Employment, Marital Status ,and Education
The patients had a mean age of 32.10 (SD =12.94) and 70.8%
were women. A total of 32% were working, 31% were studying,
whereas 37% received different social benefits. A total of 51.6%
were single. With respect to education: 19 had completed high
Frontiers in Psychology | www.frontiersin.org 3May 2018 | Volume 9 | Article 639
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
school, 32.3% had a college degree, while the remaining reported
other types of education.
OCD Severity
Mean pre-treatment Y-BOCS score was 25.83 (SD =4.65). A
total of 39.4% had a moderate OCD (Y-BOCS of 18–23), and
60.6% had severe OCD (Y-BOCS of 24-38). The mean Y-BOCS
pre-treatment scores for treatment naïve patients (M=28.33,
SD =7.65) and patients with previous therapy trials (M=26.11,
SD =4.14) did not differ significantly, t(42) =1.19, p=0.24.
Comorbidity
Patients had a range of 0 to 4 comorbid disorders.. A total
of 26 patients (40%) were diagnosed with OCD only, whereas
19 patients had one comorbid disorder, 14 had two, five had
three coexisting disorders, and one patient had four comorbid
disorders. 17 patients fulfilled the criteria of generalized anxiety
disorder (GAD), 17 of depression, 12 of panic disorder (PD),
eight had social anxiety disorder, and three patients fulfilled
the criteria of post-traumatic stress disorder (PTSD). Other
comorbid disorders included specific phobia, bulimia, anorexia,
health anxiety, and trichotillomania and ADHD as reported in
the referrals.
Pharmacological Treatment
Use of medication was registered at the initial interview. A
total of 46.2% (n=30) were using psychotropic medication.
More specifically, 41.5% used SRI/SSRI/SNRI, 7.7% used
benzodiazepines, 10.8% used anti-psychotics, and 4.6% used
Ritalin. Patients with and without psychotropics did not differ
on Y-BOCS scores [t(63) =0.14, p=0.89], PHQ-9 scores [t(64)
=0.19 p=0.85], or GAD-7 scores [t(64) =1.01, p=0.32] at pre-
treatment. Patients on SSRI were encouraged to keep medication
doses unchanged prior to and during the 4-day treatment period.
Patients with prescribed anxiolytics were asked to discontinue
these medications prior to and during treatment; adherence to
these instructions was urged by the therapists throughout the
treatment period. Patients were asked not to seek concurrent
treatment during the treatment period.
Procedure
Assessment
All patients were informed that quality control procedures were
an integrated part of the 4-day treatment, and all referred
patients were asked to complete a number of questionnaires
administrated online (for description, see below) prior to the first
visit at the clinic. For the patients who were offered the Bergen
4-day treatment these questionnaires were also completed post-
treatment (conducted 1 week after the 4 days of therapy), as well
as at 3-and 12-month follow-up.
The MINI interviews were conducted by a psychiatrist or
a clinical psychologist trained in the administration of this
structured clinical interview. The Y-BOCS interviews at pre-
treatment were conducted by one of the psychologists or
psychiatrists in the OCD-team. Y-BOCS at post-treatment, as
well as at 3- and 12-month follow-up, were conducted over
the phone by a specially trained independent psychologist. The
assessors were aware that the patients had received concentrated
ERP treatment, but were not involved in the treatment. At 12-
month follow up, 20% of the sample was randomly selected
to be re-interviewed within 1 week by another independent
psychologist. The inter-rater reliability, Intra Class Coefficient (3.
1) =0.95, was excellent. The independent assessors were aware
that the patients had received concentrated ERP treatment, but
were not involved in the treatment.
Referred patients met a clinician for an initial screening
session and if an OCD-diagnosis was indicated, they met for
one to two additional diagnostic sessions where anamnestic
information was obtained, a MINI and a Y-BOCS were
performed and the outline of the treatment presented.
Preparation for Treatment
In order to ensure standardized information regarding the
Bergen 4-day format, patients watched a video presenting the
outline of the treatment https://www.youtube.com/watch?v=
nqx8knpy3i4&feature=youtu.be After watching the video, the
patients’ expectations of treatment outcome as well as their
evaluation of the treatment credibility, was assessed with an
adapted version of the Borkovec and Nau (1972) Reaction
to treatment scale, in which four aspects of expectancy and
credibility were evaluated on a 0–100% scale, with higher values
indicating more positive evaluations. If a patient reported an
expectancy- or credibility score below 70%, this was taken as
an opportunity to clarify possible misunderstandings regarding
the treatment. When the patients were offered participation
in a group, and accepted this, they were informed in detail
about the 4-day treatment, and in order to ensure that this
was conducted in a standardized way, the patients watched
the following video: https://www.youtube.com/watch?v=1Fnxt0_
ljpY&feature=youtu.be. As preparation for the group the patients
were instructed to suggest relevant exposure tasks, and as
guidance they were told that the exposure tasks “that their OCD
would appreciate the least” often were the most relevant.
Treatment
Treatment was delivered as part of the standard mental health
care provided by the OCD team and it was conducted in groups
of 3–6 participants with a 1:1 therapist-patient ratio. This means
that each therapist was able to deliver full treatment for one
patient during less than a week. A full manual has been developed
and is currently being translated to Icelandic and to Swedish
(Kvale and Hansen, unpublished manuscript).
The first day (approximately 3 h) was allocated to
psychoeducation and, in the group setting, to prepare
individual exposure taks. The two middle days were dedicated
to individually tailored and therapist assisted exposure training
(8–10 h each day) in a wide range of OCD-relevant settings, and
the last day to summarize “lessons learnt” and preparing for the
next 3 weeks of self-administered exposure training. Relatives
and friends were invited to a psycho-educative meeting in the
afternoon of day 3.
The main feature of our 4-day intervention is to teach the
patients to approach whatever elicits the relevant anxiety or
discomfort, and to help them systematically learn how to LEan
Frontiers in Psychology | www.frontiersin.org 4May 2018 | Volume 9 | Article 639
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
into The anxiety” (LET- technique) instead of employing obvious
or subtle avoidance. This is done in numerous relevant situations
with a therapist as a coach. During two consecutive days the
therapists assist each patient to practice the LET-technique
consistently whenever anxiety or discomfort is elicited, and he
patient is encouraged to approach as many anxiety- or discomfort
eliciting situations, contexts, and thoughts as possible. To ensure
that therapist assisted exposure training to the most context-
relevant cues and situations are included, it is a prerequisite that
the patient live within a 1 h travel distance to the clinic. On
the last of the 4 days, strategies for maintaining the change and
principles for how to be their own therapist were focused. The
next 3 weeks, the patients were encouraged to report online every
day on how they were practicing the cET. The clinicians read the
reports, but there was no contact with the patients. On day 4 of
the treatment the patients were informed orally and in writing
how to contact the health care if an emergency situation should
occur.
Three months after treatment, patients were invited to an
individual session (0.5 h) where their experiences in the period
following treatment were discussed. The principles of cET were
repeated and emphasis was put on how the patients’ best could
practice the method on their own. No exposure work was
conducted in this session.
Therapists
All the 4-day treatment groups were led by experts on the format.
In order to qualify as a cET-expert, therapists must, in addition
to having extensive training and experience as an OCD-therapist,
have participated and received supervision in a minimum of
two cET groups and demonstrate competency in the exposure
procedure in accordance with a slightly modified version
of the OCD CORE competencies (Steketee, 1993) evaluated
independently by two cET experts. The group leader had always
participated in a minimum of 6 groups as a cET expert.
Measures
Yale-Brown Obsessive Compulsive Scale (Y-BOCS;Goodman et al.,
1989a,b) interview consists of 10 items covering the severity of
both obsessions and compulsions, and is frequently used to assess
OCD severity. The Y-BOCS has good psychometric properties
(Goodman et al., 1989a,b).
Patient Health Questionnaire-9 (PHQ-9;Kroenke et al.,
2010) is a self-administered screening instrument containing 9
questions each ranging from 0 to 3, yielding a maximum score of
27. According to Kroenke et al. (2010), a score of 10 or more is
indicative of a depressive disorder. The psychometric properties
of PHQ-9 are well-established (Titov et al., 2011; Feng et al.,
2016).
Generalized Anxiety Disorder Scale (GAD-7; Spitzer
et al., 2006) measures symptoms of generalized anxiety.
The psychometric properties are well-established (Kroenke et al.,
2010; Beard and Bjorgvinsson, 2014; Hinz et al., 2017; Rutter and
Brown, 2017).
Client Satisfaction Questionnaire 8 (CSQ-8; Nguyen et al.,
1983). The CSQ-8 is an 8-item questionnaire which measures
patient satisfaction with health services. Each item is scored
from 1 (very low satisfaction) to 4 (very high satisfaction), total
score ranges from 8 to 32. The CSQ-8 has sound psychometric
properties (Larsen et al., 1979; Nguyen et al., 1983).
Treatment Response
Severity of OCD was assessed at pre, post, 3- and 12-month
follow-up by specially trained raters. Treatment response was
calculated based on the international consensus criteria (Mataix-
Cols et al., 2016) which requires a 35% reduction of the
individual patient’s pre-treatment Y-BOCS score in order to be
classified as a clinically relevant response. A patient is classified
as remitted if the post-treatment Y-BOCS score is 12 points.
Recovery is defined by meeting the remission criterion at 12-
month follow-up.
We also used the Jacobson and Truax (1991) criteria for
clinically significant change. First, response is defined as reliable
change index (RCI) which requires that the individual patient’s
change from pre to post (follow-up) must be large enough to
be statistically reliable at the p-level of 0.05. In this sample the
RCI was 8 points. Second, recovery is defined as fulfilling RCI
and cutoff C; the mean between the patient sample and a normal
sample. For this analysis we used as normal mean the weighted
mean of the samples published by Dannon et al. (2006) and
Johansen and Dittrich (2013), and this resulted in a cutoff score
of 11.
Statistical Analyses
Statistical analyses were performed with SPSS version 24.0.
Repeated measures ANOVA for Y-BOCS, GAD-7, and PHQ-
9 were conducted with Greenhouse-Geisser corrections. Effect
sizes were calculated with Cohen’s d, defined as (Mpre-
Mpost)/SDpre as recommended by Morris and DeShon (2002).
There were no missing data for Y-BOCS or GAD-7 pre-
treatment. A total of 63 patients were available for Y-BOCS
evaluation post-treatment, 54 at 3-month and 59 at 12-month
follow up. Four patients had a missing GAD-7 score post-
treatment, and 19 at 3-month follow-up. One patient had a
missing PHQ-9 score pre-treatment and 19 at 3-month follow-
up. A total of 10 patients had missing values on CSQ-8 at post-
treatment. Missing data were replaced using the expectation-
maximization method of SPSS, version 24. The method was
chosen to allow for repeated measures ANOVA. Effect estimates
were also obtained by estimating both a random intercept
model and a random slope model, taking into account potential
clustering at treatment group level as well as at the individual
patient level. Likelihood ratio test was applied to compare these
two models, and the random intercept model was chosen since
there was no gain in allowing for random slopes. ICC was
calculated from this random intercept model.
RESULTS
Declining Treatment and Attrition
There were 10 patients (12.7%) who fulfilled inclusion criteria but
declined the offer of receiving the 4-day treatment (see Method
for description of reasons). All patients who started the treatment
also completed it so the attrition rate was 0%.
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Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
TABLE 1 | Means, standard deviations and effect sizes (Cohen’s d) for Y-BOCS,
GAD-7, and PHQ-9.
Y-BOCS M SD d
Pre 25.83 4.65
Post 10.24 5.13 3.35
3-month 10.45 5.86 3.31
12-month 10.64 7.00 3.27
GAD-7
Pre 11.51 5.15
Post 9.29 4.91 0.45
3-month 8.36 5.09 0.61
PHQ-9
Pre 11.54 5.93
Post 9.17 6.17 0.40
3-month 9.18 5.81 0.40
N=65 (treatment starters).
TABLE 2 | Random interception and random time slope linear mixed model.
b SEb95% CI
Constant 21.08 0.80 19.52, 22.64
Time 4.54 0.39 5.30, 3,77
OCD-Symptoms
Table 1 displays the results for Y-BOCS pre-treatment, post-
treatment, 3-month and 12-month follow up. Repeated measures
ANOVA (Wilks’ Lambda) found a significant effect of time, F(3,62)
=182.95, p<0.001, h2
p=0.90. There were no significant changes
in symptoms from post-treatment to follow-up assessment at
3- and 12-month (p=0.76 and p=0.82). Table 2 shows the
coefficient estimates from the chosen random intercept model.
This model also indicated a significant effect of time (p<0.001)
(see Table 2). The ICC from this model was 0.017 on group
level and 0.09 on the individual level, indicating that clustering
at treatment group level is small, while there are only moderate
correlations between measures within each patient.
Clinically Significant Change in
OCD-Symptoms
To determine the number of patients who showed clinically
significant change we applied the international consensus criteria
for clinical improvement. At post-treatment 93.8% of the patients
had responded and 76.9% were in remission. At 3-month follow
up, 81.5% responded, 72.3% were in remission, and at 12-month
follow-up 83.1% were classified as responders and 67.7% as
recovered. When using the asymptomatic criterion on Y-BOCS
(7), 19 patients (29.2%) at post-treatment and 25 (38.5%) at
12-month follow-up were considered asymptomatic.
Clinically significant change was also calculated in according
to the Jacobson and Truax (1991) criteria. At post-treatment
93.8% of the patients fulfilled RCI and 67.7% the cutoff for
TABLE 3 | Comparison of clinical improvement rates at post-treatment and
follow-up.
12-month follow-up
Recovered Responded Unchanged Total
POST-TREATMENT
Recovered 35 8 7 50
Responded 7 1 3 11
Unchanged 2 1 1 4
Total 44 10 11 65
clinically significant change. The corresponding proportion at
12-month follow-up was 86.2 and 64.6%, respectively.
Table 3 shows the clinical improvement at post-treatment
and 12-month follow-up for the individual patients, using the
international consensus criteria. Of the 50 patients who were in
remission at post-treatment, 35 patients (70%) were classified as
recovered at follow-up. Of the 11 patients who were classified as
responders at post-treatment, seven (64%) had become recovered
follow-up, one remained as a responder, whereas three had
deteriorated to the category of no change. Of the four patients
who were classified as unchanged at post-treatment, two were
recovered at follow-up, one had a treatment response, and one
remained unchanged.
Clinically significant change as defined by the international
consensus criteria was also calculated for the subgroups moderate
and severe/extreme OCD severity as assessed at pre-treatment.
For the moderate subgroup 80.8% were classified as remitted
at post-treatment, 73.1% at 3-month follow-up, and 76.9%
as recovered at 12-month follow-up. For the severe/extreme
subgroup; 74.4% were remitted at post-treatment, 71.8% at 3-
month follow up, and 61.5% were recovered at 12-month follow-
up. Treatment response for the two subgroups at 12-month
follow-up was not significantly different, χ2
(1) =0.19, p=0.28.
Depression and Generalized Anxiety
Table 1 displays the results at pre-treatment, post-treatment,
3- and 12-month follow-up for depressive symptoms and
generalized anxiety. Repeated measures ANOVA (Wilks
Lambda) showed a significant reduction in anxiety symptoms,
F(2,63) =15.43, p<0.001, ηp2=0.329. From post-treatment to
3-month follow-up there were no significant change (p=0.08)
but tendencies toward further improvement.
Repeated measures ANOVA for depressive symptoms
(Greenhouse-Geisser correction) found a significant effect of
time, F(1.82, 63) =13.90, p<0.001, η2
p=0.178. There were no
significant changes from post-treatment to 3-month follow-up
(p=0.993).
Treatment Satisfaction
Details about treatment satisfaction are presented in Table 3.
Fully 89.2% described the quality of treatment as excellent
and 87.7% stated that they were highly satisfied overall with
the treatment (see Table 4). Ninety-two percent stated that
they were satisfied with the amount of treatment. Ninety-eight
Frontiers in Psychology | www.frontiersin.org 6May 2018 | Volume 9 | Article 639
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
TABLE 4 | Post-treatment scores on client satisfaction questionnaire 8.
Scale Score
1 2 3 4
1. Quality of service 0 0 7 58
2. Kind of service 0 2 18 45
3. Met needs 0 3 33 29
4. Recommend to a friend 0 0 5 60
5. Amount of help 4 1 10 50
6. Deal with problems 0 0 9 56
7. Overall satisfaction 0 1 7 57
8. Come back 0 2 7 56
Mean CSQ score was 29.91 (2.33), range 19–32, mode =30, median =30.0 (possible
range is 8–32).
percent stated that they would return to the clinic in the
future if they needed treatment. Overall, the results from CSQ-
8 indicated that the majority of patients were highly satisfied
with the concentrated treatment format. There was no significant
difference on Y-BOCS post-treatment between patients that
completed the CSQ-8 and patients that did not, t(63) =1.76, p
=0.08.
Comparison With Our Previous Studies
We combined the Y-BOCS data from our previous studies
(Havnen et al., 2014, 2017;N=77) yielding the following means
(SD): pre-treatment 25.9 (4.33) and post-treatment 10.0 (4.26).
The present sample had at pre score of 25.8 (4.65) and post score
of 10.2 (5.13). The differences at pre (t=0.13) and at post (t
=0.25) were both non-significant. Thus, the present sample of
OCD-patients achieved as good a treatment effect as our previous
samples. A tentative comparison of the follow-up results, which
was done after 6 months in our previous studies (11.3 ±6.08)
and 12-month in the present study (10.6 ±7.00), also showed a
non-significant difference (t=0.64). Also, in the present study
the change between the post mean (10.2) and the follow-up mean
(10.6) was not significant.
Comparison With Other Studies on ERP for
OCD
In order to obtain a perspective of the outcome of the Bergen
4-day treatment (cET) we compared it to standard ERP from
randomized controlled trials as described in a recent meta-
analysis (Öst et al., 2015). Table 5 shows the outcome for Y-BOCS
and proportion achieving the criterion for response, remission,
and recovery (at follow-up). There was no significant difference at
pre-treatment but at post-treatment and at 12-month follow-up
cET had a significantly lower Y-BOCS mean than standard ERP.
Furthermore, the within-group effect size for the 4-day treatment
was higher than that for standard ERP (d=3.35 vs. 2.38) at
post-treatment as well as at follow-up assessment (d=3.27 vs.
2.46)3.
3Since the cET category only has one study the effect sizes cannot be statistically
compared.
TABLE 5 | Severity of anxiety and depression at pre-treatment, post-treatment
and 3-months follow-up.
GAD-7 PHQ-9
Severity Pre Post 3 m Pre Post 3 m
None 5 6 14 8 18 15
Mild 19 38 30 19 24 23
Moderate 21 10 12 21 11 17
Severe 20 11 9 17 12 10
Pre, Pre-treatment; Post, Post-treatment; 3 m, 3-months follow-up. Cut-offs used for both
GAD-7 and PHQ-9 were 0–4 (none), 5–9 (mild), 10–14 (moderate), 15 and above (severe).
Proportion of responders was significantly higher in cET than
in standard ERP both at post-treatment (93.8%) and at follow-
up (83.1%). More importantly, cET yielded a significantly higher
remission rate at post-treatment (76.9%) and a significantly
higher recovery rate at follow-up (67.7%) than standard ERP (see
Table 6).
DISCUSSION
We have previously shown in an effectiveness study and a
replication study that the Bergen 4-day treatment yields large
clinical change in adult patients with OCD and also is highly
accepted both as indicated with low refusal and exceptionally low
drop-out rates compared to a recently published meta-analysis
(Öst et al., 2015). The focus of the current study is to report
long-term effects. Based upon our previous findings we expected
comparable results in a new sample and that the effects of cET at
post-treatment will be on a par with our previous studies (Havnen
et al., 2014, 2017) and maintained at the 12-month follow-up.
As expected, both acute and long-term clinical effects were
maintained. The patients had the same pre-treatment OCD-
severity as the ERP-patients in our recent meta-analysis (Öst
et al., 2015), but at post-treatment and at 12-month follow-up the
patients receiving the 4-day treatment had improved significantly
more than patients treated with standard ERP. This was not
only seen in the effect sizes, but the proportions of patients
with clinically significant change and the proportion of patients
who were remitters. It is also noteworthy that the number of
patients with a Y-BOCS score of 7 or below, which is termed
asymptomatic, is remarkably high. In a Meta-analysis by Fisher
and Wells (2005) they found that 27% of the patients were
asymptomatic at post-treatment and that further improvement
does not occur during the follow-up period. In our study we
found an increase in the number of asymptomatic patients from
29.2% (n=19) at post-treatment to 38.5% (n=25) at 12-month
follow-up.
The low refusal rate, and exceptionally low attrition we found
in our previous studies, were replicated, with a drop-out of
0. Given that the current results are obtained in an ordinary
outpatient clinic which is required to deliver care to all OCD-
patients in the catchment area, these results are remarkable, since
Frontiers in Psychology | www.frontiersin.org 7May 2018 | Volume 9 | Article 639
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
TABLE 6 | Comparison between the Bergen 4-day treatment and standard ERP.
Bergen 4-day Standard ERP Statistic
Y-BOCS N M (SD) N M (SD) t-test (p=)
Pre 65 25.8 (4.65) 583 25.1 (4.88) 1.10 (0.271)
Post 65 10.2 (5.13) 552 13.5 (6.92) 3.72 (0.0002)
1 year f-up 65 10.6 (7.00) 105 13.1 (8.08) 2.06 (0.041)
INTERNATIONAL CONSENSUS CRITERIA
Response (35% reduction) Fisher 2-tailed
Post 65 93.8% 87 57.5% p<0.0001
1 year f-up 65 83.1% 23 52.2% p=0.0053
Remission/recovery (12 on Y-BOCS)
Post 65 76.9% 101 47.5% p=0.0002
1 year f-up 65 67.7% 104 44.2% p=0.0042
JACOBSON AND TRUAX (1991) CRITERIA
Response (Reliable Change Index; 8 points’ reduction) Fisher 2-tailed
Post 65 93.8% 87 57.5% p<0.0001
1 year f-up 65 86.2% 23 52.2% p=0.0026
REMISSION/RECOVERY (11 ON Y-BOCS)
Post 65 67.7% 101 47.5% p=0.0161
1 year f-up 65 64.6% 104 44.2% p=0.0115
Data for Standard ERP were taken from randomized controlled studies of ERP in the meta-analysis of Öst et al. (2015). N indicates the total number of participants across these
studies. Regarding the international consensus criteria response was calculated for ERP-studies using 35% reduction on Y-BOCS. Remission and recovery were calculated for those
ERP-studies using 12 on Y-BOCS (or lower) plus the response criterion.
the mean attrition rate in effectiveness studies (Öst et al., 2015)
is 15.1% (SD =12.5, range 0–41%). This result alone, suggest a
substantial cost-effectivenes with the 4-day treatment.
Furthermore, the patients are highly satisfied with the quality,
relevance and amount of treatment, and all of the patients
would recommend the 4-day treatment to a friend with similar
problems. This result is also in line with the day-to day experience
of demand for the 4-day treatment, both from patients as well as
relatives.
As in our previous studies, we also saw a significant effect
on depression and on generalized anxiety. However, these kinds
of comparisons of non-randomized groups should always be
regarded with caution but a tentative conclusion is that the
concentrated exposure treatment seems to be at least as effective
as standard ERP, if not more effective.
It might be speculated what makes the cET so effective, and
the combination of a number of features might be relevant:
Firstly, since the treatment is concentrated over four consecutive
days where the first is dedicated to preparing the patients
for the exposure training and the last one for summarizing
and preparing for how to integrate the change into normal
every-day living, the two middle days basically works as one
long treatment session separated by a night of sleep. Since
the treatment is delivered in groups of 3–6 patients with the
same number of therapists, this allows for individually tailored
and therapist assisted exposures in a wide range of relevant
setting. Simultaneously, the patients can take advantage of
being together with others going through basically the same
process of change. Also, the focus on “how-to-do” the exposures
without simultaneously applying subtle avoidance strategies, is an
important feature of the cET. Anxiety and discomfort is labeled
the raw material for change, and the task is to approach as many
potentially valuable situations as possible, and pay attention
to not holding back while doing the exposures, but rather do
something that is incompatible with the OCD. This might for
examples imply that the patient choose not merely to refrain from
rituals (e.g., washing) or from various reassurances (“is this safe
to do”) but to actively increase the uncertainty during a given
exposure task e.g., by reminding themselves that they cannot
be certain that they were not contaminated with something
harmful. This approach might facilitate robust change, since
the patients basically learn a new approach to regulate anxiety
and discomfort, meaning that recurrence of anxiety is just to
be regarded as a new opportunity to practice the “leaning in”
technique.
In sum, the 4-day treatment seems to be a highly feasible
approach to treating patients with OCD. The acceptance is high,
the drop-out is low and the clinical change obtained seems
to be superior to what is typically seen in standard ERP. The
patients want the treatment, and all of them would recommend
it to a friend with similar problems. Furthermore, the approach
represents a highly flexible and at the same time predictable
use of resources with a clearly defined start and completion of
the treatment. Since the 4-day approach is developed within
an ordinary outpatient clinic, the relevance of the approach is
undisputable. However, the results obtained from one clinic only,
and decline of quality and loss of effects might occur when a new
treatment approach is disseminated (Johnsen and Friborg, 2015).
There is a high demand for the Bergen 4-day treatment both
from patients, relatives as well as health care institutions, and
Frontiers in Psychology | www.frontiersin.org 8May 2018 | Volume 9 | Article 639
Hansen et al. 4-Day OCD Treatment 1-Year Follow-Up
when we now start to disseminate this new treatment, we have
decided upon an approach that aims at ensuring that the quality
is maintained. Basically this is done by a combination of efforts
that enables bench-marking between clinics. Firstly, the Bergen
4-day treatment is only to be offered by clinics who have agreed
to train and certify a minimum of three 4-day therapists, one of
which is certified as a group leader, and to deliver the treatment
in accordance with all parts of the manual and procedures. Since
the treatment is delivered during 4 consecutive days to groups of
3–6 patients with the same number of therapists, it provides an
excellent arena for hands on supervision where a junior therapist
can learn by observing and working side by side an experienced
therapist. Also, this means that the certified therapists directly
observe the trainees and ensure that they are following the
described and established procedures. Before a given therapist is
granted hands-on supervision and training, they have to attend
to a basic introductory course presenting the essentials of the
treatment. We have also developed brief courses for group leaders
and for administrative staff. When a new clinic sets up a 4-day
team, this is done in close collaboration with our clinic, and
certified therapists will participate in the groups the first times it
is delivered at a new site, and also evaluate and certify the group
leader when performing at the new site. Furthermore, detailed
quality assessment is an integrated part of the treatment, and
a new 4-day site is required to use the exact same procedure.
This enables bench-marking of results and if the results are not
within the expected range, the team will get more supervision,
evaluation and a new certification procedure. The agreements of
collaboration also ensure that a given clinic delivers a minimum
of six groups after it is certified, and also requires that it, as long
as it delivers the 4-day format, follows the described procedures.
All parts of this dissemination approach are done on a self-cost
basis.
ETHICS STATEMENT
This paper uses data collected as part of the standard assessment
procedure at the outpatient OCD-clinic in Helse Bergen, Norway.
The study was approved by the Data Protection OfficialAugust 5,
2012.
AUTHOR CONTRIBUTIONS
BH and GK contributed to the study design; BH, GK, and
KH contributed to the data collection. All authors contributed
to the statistical analysis, interpretation of the data, and
drafting of the manuscript. All authors approved the final
version.
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2018 Hansen, Hagen, Öst, Solem and Kvale. This is an open-access
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Frontiers in Psychology | www.frontiersin.org 10 May 2018 | Volume 9 | Article 639
... The B4DT is an concentrated treatment format delivered over four consecutive days to groups of 3-6 patients with an equal number of therapists. The treatment format integrates individualized therapist assisted exposure within a group setting [32]. This approach allows for tailored therapist exposure while utilizing the supportive dynamics of group therapy. ...
... are explored to facilitate this shift. An affirmative answer prompts reflection on whether it is reasonable to expect the body to alter its response patterns under such conditions [32]. ...
... However, the study included secondary self-reported outcome measures of depression and generalized anxiety which also showed large effect sizes, although considerably lower than the primary outcome measure. This could indicate that successful treatment of PD is associated with improvement in comorbid conditions and general functioning The large reduction in primary and secondary outcome measure is in line with previous studies on B4DT for OCD patients [32,[37][38][39], indicating that the treatment format also has a promising effect on longer-term outcomes. ...
Article
Full-text available
Introduction Bergen 4-Day treatment (B4DT) is a form of concentrated exposure-based cognitive behavioral therapy (CBT) in which patients receive treatment over four consecutive days. Previous studies have shown B4DT to be a promising treatment format for panic disorder (PD), although the long-term stability of treatment gains requires additional study. Aim The aim of the current study was to evaluate the longer-term effectiveness of B4DT for patients with panic disorder with or without agoraphobia. This study extends a previously published study by providing a long-term follow-up of the same cohort (n = 30), initially assessed at three months post-treatment. Method Thirty patients with panic disorder were consecutively included in a retrospect open trial. The primary outcome measure was the Panic Disorder Severity Scale. The secondary outcome measures were the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9. Outcomes were assessed at pretreatment, posttreatment, 3-month follow-up, and longer-term follow-up (with a mean time of 18 months). Results There was a significant reduction in panic disorder symptoms from pretreatment to longer-term follow-up (d = 5.03, 95% CI [18.55, 21.12] to [1.33, 3.87]). The Panic Disorder Severity Scale (PDSS) mean decreased from 19.83 (SD = 0.64, 95% CI [18.55, 21.12]) before treatment, to 4.37 (SD = 0.64, 95% CI [2.98, 5.76]) post-treatment, followed by further decreases at the 3-month follow-up to a mean of 2.84 (SD = 0.64, 95% CI [1.45, 4.22]), and at the longer-term follow-up to 2.60 (SD = 0.64, 95% CI [1.33, 3.87]). There was no significant difference in symptom severity between the 3-month and 18-month assessments, indicating a sustained improvement (p <.001). At the 18-month follow-up, 90% of the patients were classified as being in remission. There were also significant reductions in symptoms of depression (d = 1.44) and generalized anxiety (d = 1.62) that were maintained at the longer-term follow-up assessment. Conclusion The results from the current study indicated that the treatment effects of B4DT are stable over time and that the treatment format appears to be promising for PD. Confirming these preliminary results in rigorous study designs is needed. Trial registration The study was approved by the Regional Committee for Medical and Health Research Ethics of Northern Norway (REK Nord-2021/209619).
... We investigated whether the results for effectiveness of cERP could be (1) replicated at a German site over a follow-up period of three months and (2) extended by comparing cERP treatment results to treatment results of a historical inpatient control group. Based on previous uncontrolled studies (Davíðsdóttir et al., 2019;Hansen et al., 2018;Kvale et al., 2018;Launes et al., 2019), we hypothesized large within-group effect sizes for the decrease in OCD symptomatology (Y-BOCS, primary outcome) from baseline (T0 cERP ) to post-assessment (T1 cERP ) and from baseline (T0 cERP ) to three months follow-up assessment (T2 cERP ). Secondary outcome parameters were the changes in self-reported obsessivecompulsive symptoms, depression, self-esteem, quality of life, and experience avoidance/psychological flexibility as well as general level of functioning. ...
... We investigated whether the results for effectiveness of cERP could be (1) replicated at a German site over a follow-up period of three months and (2) extended by comparing cERP treatment results to treatment results of a historical inpatient control group. Based on previous uncontrolled studies (Davíðsdóttir et al., 2019;Hansen et al., 2018;Kvale et al., 2018;Launes et al., 2019), we hypothesized large within-group effect sizes for the decrease in OCD symptomatology (Y-BOCS, primary outcome) from baseline (T0 cERP ) to post-assessment (T1 cERP ) and from baseline (T0 cERP ) to three months follow-up assessment (T2 cERP ). Secondary outcome parameters were the changes in self-reported obsessivecompulsive symptoms, depression, self-esteem, quality of life, and experience avoidance/psychological flexibility as well as general level of functioning. ...
... We planned to compare the changes in OCD symptoms and treatment satisfaction from the concentrated treatment with those of a historical inpatient control group treated in the same hospital. Based on previous results (Hansen et al., 2018), we expected that the effects of cERP at post-treatment would be superior to the results of the historical inpatient controls. ...
... The Bergen 4-Day treatment (B4DT) is a form of concentrated CBT treatment that has demonstrated promising results in the treatment of obsessive-compulsive disorder (OCD) [12][13][14][15][16][17][18] and social anxiety disorder [19]. The B4DT demonstrated promising results for PD. ...
... We observed no significant difference in PD symptoms between the 3-month follow-up and the 12-month follow-up, and there were no significant changes in the secondary outcome measures for depression or generalized anxiety from the three-month follow-up to the twelvemonth follow-up. This is in line with previous findings of the B4DT for OCD [13,14,16,18], which indicate that the effects of intensive treatment are stable across time. ...
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Background The Bergen 4-Day Treatment (B4DT) is a concentrated cognitive behaviour therapy (CBT) approach that has shown promise in treating panic disorder (PD). However, the effectiveness of the B4DT, particularly regarding long-term outcomes in rural clinical settings, remains underexplored. Methods A total of 58 patients were included using a naturalistic open-label trial design. Patients were assessed at 12-month follow-up. Measures included the Panic Disorder Severity Scale (PDSS), the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 scale (GAD-7). Results The study revealed significant and lasting reductions in PD symptoms, with a high rate of remission maintained at 12-month follow-up (82.8%). Regarding the secondary outcomes, significant improvements in symptoms of depression and generalized anxiety were also shown. Conclusions The B4DT represents a promising treatment approach for PD, demonstrating stable long-term outcomes in rural settings. This finding supports the potential of concentrated CBT formats in achieving sustained symptom improvement in patients with PD, warranting further investigation and broader implementation. Trial registration The study was reviewed by the Regional Committee for Medical Research Ethics Northern Norway, REK North (REK Nord2021/273145).
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Purpose The purpose of this study was to explore experiences with an interdisciplinary micro-choice-based concentrated group intervention for people with type 2 diabetes. Methods A qualitative study with individual semistructured interviews were conducted with 14 adults (8 women, ages 45-74 years) with type 2 diabetes. Purposive sampling was used, and participants from 3 different intervention groups in the micro-choice-based concentrated group intervention were recruited. Thematic analysis was used for the data analysis. Results Three main themes were identified: (1) group intervention tailored to individual needs through friendly and skilled professionals, (2) valuable social interactions and an experience of fellowship, and (3) commitment to change through goal setting and conscious micro-choices. The participants described a readiness for change that was met by important knowledge from skilled professionals in the concentrated intervention. They reported that new knowledge, particularly about micro-choices and the focus on how insulin works in the body, led to change in their awareness and self-management. The concentrated group intervention was a preferred setting that contained a sense of community without compromising on meeting individual needs. Participants described internalized changes after the intervention and a willingness to adhere to changes necessary for their self-management. Conclusion Study findings showed that a micro-choice-based concentrated group intervention for people with type 2 diabetes can be a valuable approach contributing to improved patient activation and diabetes self-management. The findings underpin the importance of increased diabetes knowledge and support from an interprofessional team to bring about significant changes in everyday life.
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Obsessive-compulsive disorder (OCD) is often associated with great suffering for both the affected individual as well as their relatives. The treatment of choice for OCD is cognitive behavioural therapy (CBT) with exposure and response prevention. Exposurebased treatment is offered in a concentrated, high-frequency format over four consecutive days in the Bergen 4-Day Treatment (B4DT). This article presents the procedure and effectiveness of this concentrated exposure treatment.
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The COVID-19 pandemic has necessitated essential modifications to the administration of psychotherapy for patients with panic disorder (PD) through the increased use of videoconferencing. However, the effect of this change on treatment efficacy remains unclear. The current study is a long-term (1.5 years) investigation of the Bergen 4-day treatment (B4DT) for PD delivered as a combination of videoconferencing and face-to-face therapy. This study reported the long-term outcomes of B4DT for PD when delivered in a hybrid format. The B4DT includes multiple components delivered over four consecutive days. As the pandemic unfolded, B4DT was adapted to include different levels of in-person versus videoconference delivery, depending on COVID-19 infection rates and public health recommendations. Outcome measures included clinician-rated illness severity on the Panic Disorder Severity Scale (PDSS) and patient-rated symptoms of PD, agoraphobia, generalized anxiety, and depression. Follow-up treatment, work status, and current medications were assessed. We used multilevel models to estimate whether clinical improvement was maintained over time. Treatment effects achieved at three months were maintained at the 1.5-year follow-up. Patients who completed the PDSS scored M = 14.78 (SD = 3.37) before treatment, M = 5.88 (5.28) at the three-month follow-up (d = 2.01), and M = 5.44 (SD = 5.12) at the long-term follow-up (d = 2.15). The reduction in generalized anxiety and depression symptoms was maintained over time. The current study suggests that B4DT can be delivered successfully in a combination of face-to-face and videoconference therapy sessions. Moreover, long-term effects are maintained, even during the challenging circumstances of the pandemic.
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This study examined the psychometric properties of the Generalized Anxiety Disorder Scale-7 (GAD-7) in a sample of 536 outpatients presenting at a specialty clinic for anxiety and mood disorders. A confirmatory factor analysis (CFA) was used to test the unidimensionality of the GAD-7. This model did not fit the data well. The CFA solution was respecified correlating residuals among items assessing somatic symptoms. This respecified model fit the data well. A series of multiple-groups CFAs determined that the measurement properties of the GAD-7 were invariant between sexes. Scale reliability estimates of the GAD-7 were favorable for the full sample, and for males and females. Sensitivity and specificity could not be balanced at any cut-point. Findings attest to the value of this instrument as a dimensional indicator of GAD severity rather than a screening tool for the presence or absence of the disorder in outpatients with anxiety and mood disorders.
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- SUPPLEMENTARY RESOURCES ARE ATTACHED: Full Report and Quick Reference Guide - Marked inconsistencies exist in how terms such as treatment response, remission, recovery, and relapse are defined in clinical trials of Obsessive-Compulsive Disorder (OCD). This severely impairs the comparability of results across these trials and communication in the field. The aim of this study was to reach an international expert consensus on the conceptual and operational definitions of treatment response, remission, recovery, and relapse in clinical trials of OCD. First, second, last, and corresponding authors of international peer-reviewed papers on OCD published between 2007 and 2013 were invited to participate in a multi-stage Delphi survey. The responses obtained in Round 1 were analyzed and a summary returned to the participants. In Round 2, a new set of questions was designed to facilitate consensus on any remaining issues. For each definition, consensus was defined as ≥ 80% agreement. Consistent with the literature, the results of Round 1 illustrated that, while there was broad consensus regarding the conceptual definitions, lack of agreement was the norm regarding the operationalization of these constructs. At the end of Round 2, broad consensus (> 82% agreement) was achieved for all definitions except for the duration requirement for treatment response and remission. Based on the results, we propose consensus definitions for treatment response, remission, recovery, and relapse. Use of these definitions will improve the comparability across treatment studies and the communication between researchers, clinicians, and patients.
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Background: In a previous effectiveness study (Havnen et al., 2014), 35 obsessive compulsive disorder (OCD) patients underwent Concentrated Exposure Treatment (cET), which is a newly developed group treatment format delivered over four consecutive days. Aims: The primary aims of the present study were to evaluate the treatment results for a new sample of OCD patients receiving the cET treatment approach and to replicate the effectiveness study described in Havnen et al. (2014). Method: Forty-two OCD patients underwent cET treatment. Treatment was delivered by different therapists than in Havnen et al. (2014), except for two groups led by the developers of the treatment. Assessments of OCD symptom severity, treatment satisfaction, and occupational impairment were included. Results: The results showed a significant reduction in Yale-Brown Obsessive Compulsive Scale scores from pre-treatment to post-treatment, which was maintained at 6-month follow-up. At post-treatment, 74% of the sample was remitted; at 6-month follow-up, 60% were recovered. The sample showed a very high degree of overall treatment satisfaction. The results from the present study were statistically compared with those obtained in the previous study. The analyses showed that the study samples had comparable demographic data and equal application of treatment. The outcome of the present and original study did not differ significantly on primary and secondary outcome measures. Conclusions: This study shows that cET was successfully replicated in a new patient sample treated by different therapists than the original study. The results indicate that cET is well accepted by the patients, and the potential for dissemination is discussed.
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Background: The Generalized Anxiety Disorder Scales GAD-7 and GAD-2 are instruments for the assessment of anxiety. The aims of this study are to test psychometric properties of these questionnaires, to provide normative values, and to investigate associations with sociodemographic factors, quality of life, psychological variables, and behavioral factors. Methods: A German community sample (n=9721) with an age range of 18-80 years was surveyed using the GAD-7 and several other questionnaires. Results: Confirmatory factor analyses confirmed the unidimensionality and measurement invariance of the GAD-7 across age and gender. Females were more anxious than males (mean scores: M=4.07 vs. M=3.01; effect size: d=0.33). There was no linear age trend. A total of 5.9% fulfilled the cut-off criterion of 10 and above. Anxiety was correlated with low quality of life, fatigue, low habitual optimism, physical complaints, sleep problems, low life satisfaction, low social support, low education, unemployment, and low income. Cigarette smoking and alcohol consumption were also associated with heightened anxiety, especially in women. When comparing the GAD-7 (7 items) with the ultra-short GAD-2 (2 items), the GAD-7 instrument was superior to the GAD-2 regarding several psychometric criteria. Limitations: The response rate (33%) was low. Because of the cross-sectional character of the study, causal conclusions cannot be drawn. A further limitation is the lack of a gold standard for diagnosing anxiety. Conclusions: The GAD-7 can be recommended for use in clinical research and routine.
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Obsessive-compulsive disorder is ranked by the WHO as among the 10 most debilitating disorders and tends to be chronic without adequate treatment. The only psychological treatment that has been found effective is cognitive behavior therapy (CBT). This meta-analysis includes all RCTs (N=37) of CBT for OCD using the interview-based Yale-Brown Obsessive Compulsive Scale, published 1993 to 2014. The effect sizes for comparisons of CBT with waiting-list (1.31), and placebo conditions (1.33) were very large, whereas those for comparisons between individual and group treatment (0.17), and exposure and response prevention vs. cognitive therapy (0.07) were small and non-significant. CBT was significantly better than antidepressant medication (0.55), but the combination of CBT and medication was not significantly better than CBT plus placebo (0.25). The RCTs have a number of methodological problems and recommendations for improving the methodological rigor are discussed as well as clinical implications of the findings. Copyright © 2015 Elsevier Ltd. All rights reserved.