Study Plan

As a first post on this website, let me introduce the research that I will conduct as my PhD project. It probably won’t surprise you that the focus is on obsessive-compulsive disorder (OCD). In fact, the title of my study plan is ”Improving access and outcomes in the treatment of Obsessive-Compulsive Disorder”. There are four studies in total. I will present them one by one after giving you a brief background.

A minority of patients with OCD receive treatment, and even fewer receive an evidence-based treatment such as CBT.


Cognitive Behavioural Therapy (CBT) is a psychological treatment with empirical support as a treatment for OCD.12 Swedish and international guidelines recommend CBT as the first choice of treatment.3Even though the evidence for CBT is strong, too few patients with OCD receive adequate treatment. Here are some factors that contribute to the problem: - A shortage of trained CBT therapists - Direct and indirect costs associated with treatment - Geographical barriers - Patients do not know where to get help

This means that a minority of patients with OCD receive treatment, and even fewer receive an evidence-based treatment such as CBT.45

To bridge the gap between supply and demand for effective psychological treatments, researchers have adapted CBT treatments to deliver them over the internet. My supervisors Christian Rück and Erik Andersson have developed and tested internet-delivered CBT (ICBT) for OCD in several studies. They found that about 60% of patients had large reductions in their symptoms.67 ICBT is working and it is a way to increase the access to effective treatment for OCD.

Before implementing a new treatment in regular health care, we need to make sure that it is as good as the best available treatment. We are therefore doing a study to compare internet-delivered CBT and face-to-face CBT for adults with OCD. We will evaluate the treatments on how well they provide relief from symptoms, as well as how cost-effective they are. For example, if CBT can be delivered online with minimal input from a therapist, is is possible to help many individuals at a low cost.

We are also interested in learning more about who benefits from different types of CBT treatment. Even though the treatments are highly effective, they do not help everyone. What factors makes a patient more or less likely to benefit from treatment? The answer may lie in the characteristics of treatment, what the patient has experienced before and in the composition of their DNA.

Study I - Comparing internet-delivered CBT and individual face-to-face CBT for OCD in adults.

We are doing a study to evaluate the effectiveness of internet-delivered and individual face-to-face CBT for adults with OCD. We will follow participants for up to one year after treatment has ended. Recruitment is open and if you would like to receive treatment for OCD you can sign up here. Patients are randomised to receive one of three treatments:
- Face-to-face CBT: Weekly 90-minute sessions with a licensed psychologist. There are 16 sessions over 14 weeks of treatment.
- Therapist-guided internet CBT: Psychologists guide patients through 10 text-based modules over 14 weeks. The modules contain information about OCD, instructions related to CBT components, and worksheets to fill in after completing exercises. Communication with a licensed psychologist is possible through a built-in message system.
- Self-guided internet CBT: Patients gain access to all 10 modules at the beginning of treatment and progress through treatment without therapist contact. Treatment ends after 14 weeks.

First and foremost, we want to see whether the therapist-guided internet treatment is as good as the face-to-face treatment. We are also interested in the self-guided version, since it has the potential to be a very cost-effective treatment.

Study II - Cost-effectiveness of the treatments in study I

Before and after receiving treatment, participants answer a number of questions related to the burden of their OCD. Questions relate to their ability to work, their quality of life, and to what degree they experience anxiety and worry. We will combine these answers with data from the patient register, the prescription register (Läkemedelsregistret) and the database for health insurance (LISA). These databases provide additional information about the burden of OCD.

The ability of a treatment to decrease the burden of OCD will then be measured in relation to how costly it is to provide the treatment. Salaries of health-care workers, Hospitalisations, medical use, and sick leave all add to the costs.

By evaluating the cost-effectiveness of different forms of treatment, we get information about how to prioritise between them.

Study III - Predictors and moderators of treatment outcome in study I

Even though CBT helps many sufferers of OCD, it does not help everyone. To better understand why, we will look for individual differences and treatment features that may account for the differences in outcome. This will help us when deciding which person should receive what treatment. It can also reduce the amount of treatment failures, where a patient does not experience symptom relief despite investing time and energy in a treatment.

By making better decisions about interventions, we spend the time of patients and therapists in the most productive way.

Study IV - Genetic predictors of treatment outcome in study I

Another way to personalise treatment selection and avoiding treatment failure is to look for differences in the DNA of OCD patients. We will calculate a measure of genetic risk for OCD and test whether it accounts for some of the differences in treatment response between individuals. For example, we might find that individuals with a higher genetic burden have a poorer response to CBT overall, or certain forms of CBT.

Genetic differences are complex and this type of research requires DNA from many subjects. My colleagues are working on a large-scale project to collect DNA from 3000 patients with OCD in Sweden. I will discuss this research in more detail in a future post.

Closing words

I hope you have found this post interesting and fairly easy to follow. My aim is to write about exciting research in an accessible way. If this sounds like something for you, feel free to subscribe and receive an email when I post something new.

I welcome critique, feedback, and suggestions for future posts!


  1. Abramowitz JS. The psychological treatment of obsessive-compulsive disorder. Can. J. Psychiatry. 2006;51(7):407-416. ^
  2. Abramowitz JS, Whiteside SP, Deacon BJ. The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. Behav. Ther. 2006;36(1):55-63 ^
  3. Swedish guidelines and UK guidelines ^
  4. Goodwin R, Koenen KC, Hellman F, Guardino M, Struening E. Helpseeking and access to mental health treatment for obsessive-compulsive disorder. Acta Psychiatr. Scand. 2002;106(2):143-149 ^
  5. Ruscio, A. M., Stein, D. J., Chiu, W. T. & Kessler, R. C. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol. Psychiatry 15, 53–63 (2010). ^
  6. Andersson, E. et al. Internet-based cognitive behaviour therapy for obsessive–compulsive disorder: a randomized controlled trial. Psychol. Med. 42, 2193–2203 (2012). ^
  7. Andersson, E. et al. d -Cycloserine vs Placebo as Adjunct to Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder and Interaction With Antidepressants. JAMA Psychiatry (2015). doi:10.1001/jamapsychiatry.2015.0546 ^
Oskar Flygare
PhD Student in psychology