A stepped care model for OCD

I recently read an article in BMC Psychiatry1 where researchers estimated that, in Sweden, 70 % of individuals with OCD are only seen in primary care. Only 30 % are referred to a specialized unit where there is a chance to receive evidence-based CBT-treatment! Primary care units (vårdcentraler) have limited resources and are unable to provide CBT-treatment to most sufferers of OCD.

If only there was a rigorously evaluated, easily scalable, CBT-treatment that was cost-effective enough to be a first-line treatment for OCD?

Internet-delivered cognitive behavioral therapy

In internet-delivered cognitive behavioral therapy (ICBT), patients log on to a secure website and work with self-help texts and homework assignments. An identified therapist provides support and answers questions through an in-build message system. The treatment content mirrors that of regular CBT for OCD, with an emphasis on exposure with response prevention.

My supervisors have developed and tested ICBT for OCD in one pilot study 2 and two randomized controlled trials34. The results show that ICBT is cost-effective5 and has similar efficacy compared to traditional face-to-face CBT. About two thirds of patients no longer meet diagnostic criteria for OCD after ICBT.

The results indicate that ICBT is a viable alternative and we are now directly comparing the effects and cost-effectiveness of ICBT and face-to-face CBT for OCD in a randomized controlled trial.

The role of ICBT in a stepped care model for OCD

The central idea of a stepped care model is that each patient should receive their optimal level of treatment. Patients should receive what is necessary for them to achieve desired improvements, while not wasting time and energy on unnecessary interventions.

In a stepped care model for OCD 6, patients would first get access to cost-effective interventions (such as ICBT), which would be stepped up to costly interventions (such as individual face-to-face CBT) if more help is needed. There may be indicators (e.g. severe symptoms, comorbid depression) that make patients bypass ICBT and go straight into face-to-face CBT treatment.

With a stepped-care model, the limited resources in mental health care would be used efficiently. More patients with OCD would receive an evidence-based treatment in a timely manner, and patients in need of more help would receive proper attention.


Most patients with OCD do not get access to proper psychological treatment. Internet-delivered CBT for OCD (ICBT) has been developed to increase access to effective treatment for patients with OCD. ICBT is likely to play a crucial role in a stepped care model for the treatment of OCD.


  1. Sundquist, J., Ohlsson, H., Sundquist, K., & Kendler, K. S. (2017). Common adult psychiatric disorders in Swedish primary care where most mental health patients are treated. BMC Psychiatry, 17(1), 235. https://doi.org/10.1186/s12888-017-1381-4 ^
  2. Andersson, E., Ljótsson, B., Hedman, E., Kaldo, V., Paxling, B., Andersson, G., … Rück, C. (2011). Internet-based cognitive behavior therapy for obsessive compulsive disorder: A pilot study. BMC Psychiatry, 11(1), 1–10. https://doi.org/10.1186/1471-244X-11-125 ^
  3. Andersson, E., Enander, J., Andrén, P., Hedman, E., Ljótsson, B., Hursti, T., … Rück, C. (2012). Internet-based cognitive behaviour therapy for obsessive–compulsive disorder: a randomized controlled trial. Psychological Medicine, 42(10), 2193–2203. https://doi.org/10.1017/S0033291712000244 ^
  4. Andersson, E., Hedman, E., Enander, J., Radu Djurfeldt, D., Ljótsson, B., Cervenka, S., … Rück, C. (2015). d -Cycloserine vs Placebo as Adjunct to Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder and Interaction With Antidepressants. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2015.0546 ^
  5. Andersson, E., Hedman, E., Ljótsson, B., Wikström, M., Elveling, E., Lindefors, N., … Rück, C. (2015). Cost-effectiveness of internet-based cognitive behavior therapy for obsessive-compulsive disorder: Results from a randomized controlled trial. Journal of Obsessive-Compulsive and Related Disorders, 4, 47–53. https://doi.org/10.1016/j.jocrd.2014.12.004 ^
  6. Tolin, D. F., Diefenbach, G. J., & Gilliam, C. M. (2011). Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: A preliminary study of efficacy and costs. Depression and Anxiety, 28(4), 314–323. https://doi.org/10.1002/da.20804 ^
Oskar Flygare
PhD Student in psychology