Obsessive-compulsive disorder among individuals of Hispanic and Latin American ancestry: Cultural considerations for assessment and psychotherapy.

Research specific to obsessive-compulsive disorder (OCD) among individuals of Hispanic and Latin American (H/L) ancestry is limited, as are culturally relevant assessment and treatment recommendations. This article discusses the implications of underrepresentation of H/L populations in OCD research and emphasizes the need to consider issues related to assessment, treatment, and structural barriers that hinder delivery of culturally appropriate first-line psychotherapy. Recommendations for assessment and treatment are provided to aid clinicians in distinguishing culturally normative thoughts and behaviors from OCD, as well as to inform the implementation of psychotherapeutic interventions with cultural humility. This manuscript offers recommendations for future research to tackle health equity concerns with respect to assessment and treatment and structural factors limiting access to culturally appropriate psychotherapy. Wide-scale efforts are needed to comprehensively understand how H/L cultures intersect with various OCD presentations and to further disseminate treatments to populations that have historically lacked access to mental health care.

Geospatial Distribution of Obsessive-Compulsive Disorder Specialists: Understanding Access as a Function of Distance, Insurance Status, and Neighborhood Socioeconomic Status.

Obsessive-compulsive disorder is an impairing psychiatric condition affecting 1-2% of adults and youth. Cognitive-behavioral therapy with exposure and response prevention (CBT) is an efficacious intervention but requires specialty training and access is often limited. While certain factors are associated with treatment access, one key barrier that has not been explored is the geographic availability of OCD treatment providers. Using integrated geographically-referenced data, we examined the geographic distribution of OCD CBT specialty providers across the state of Texas, with particular attention to the relationship to neighborhood socioeconomic disadvantage, insurance status, and rural versus urban status. We found that specialist providers are almost exclusively located inside the highly urbanized parts of the state, primarily in more affluent areas, and often only accept self-pay. The characteristics of the areas located the furthest away from specialty OCD care include a high proportion of persons identifying as Hispanic; a high proportion of non-English speakers, households with income below poverty; households with no vehicles; and persons with no health insurance. Average household income decreased as distances from specialist providers increased. Broadly, findings confirm that OCD CBT specialty providers are clustered in large socially advantaged areas and that economic disadvantage remains a significant barrier to care. As inadequate or inappropriate treatment of OCD is likely to result in sustained and impairing symptoms, this is of great concern.

Texas Youth Depression and Suicide Research Network (TX-YDSRN) research registry and learning healthcare network: Rationale, design, and baseline characteristics.

BACKGROUND: American youth are seriously impacted by depression and suicide. The Texas Youth Depression and Suicide Research Network (TX-YDSRN) Participant Registry Study was initiated in 2020 to develop predictive models for treatment outcomes in youth with depression and/or suicidality. This report presents the study rationale, design and baseline characteristics of the first 1000 participants. METHODS: TX-YDSRN consists of the Network Hub (coordinating center), 12 medical school "Nodes" (manage/implement study), each with 1-5 primary care, inpatient, and/or outpatient Sub-Sites (recruitment, data collection). Participants are 8-20-year-olds who receive treatment or screen positive for depression and/or suicidality. Baseline data include mood and suicidality symptoms, associated comorbidities, treatment history, services used, and social determinants of health. Subsequent assessments occur every two months for 24 months. RESULTS: Among 1000 participants, 68.7 % were 12-17 years, 24.6 % were ≥ 18 years, and 6.7 % were < 12. Overall, 36.8 % were non-Hispanic Caucasian, 73.4 % were female, and 79.9 % had a primary depressive disorder. Nearly half of the sample reported ≥1 suicide attempt, with rates similar in youth 12-17 years old (49.9 %) and those 18 years and older (45.5 %); 29.9 % of children <12 reported at least one suicide attempt. Depression and anxiety scores were in the moderate-severe range for all age groups (Patient Health Questionnaire for Adolescents [PHQ-A]: 12.9 ± 6.4; Generalized Anxiety Disorder [GAD-7]: 11.3 ± 5.9). LIMITATIONS: The sample includes youth who are receiving depression care at enrollment and may not be representative of non-diagnosed, non-treatment seeking youth. CONCLUSIONS: The TX-YDSRN is one of the largest prospective longitudinal cohort registries designed to develop predictive models for outcome trajectories based on disorder heterogeneity, social determinants of health, and treatment availability.

Economic Analyses of Obsessive-Compulsive Disorder Interventions: A Systematic Review.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition featuring patterns of obsessions, compulsions, and avoidant behaviors that are often time consuming and distressing to affected individuals. Cognitive-behavioral therapy (CBT) with exposure and response prevention and/or serotonin reuptake inhibitors are first-line treatments for OCD, though other therapeutic interventions may serve as economically practical modalities under various circumstances. Exploring and understanding the cost effectiveness of all indicated OCD interventions are important to inform therapeutic decisions and provide quality patient-centered care at a cost that is not burdensome to the patient and/or healthcare system. METHODS: A systematic literature review was performed and studies were extracted from PubMed, Embase, Ovid MEDLINE, and Cochrane. All cost-effectiveness studies that included economic analyses with respect to OCD treatment modalities and were written in English and published between January 2010 and July 2022 were eligible for inclusion in the present study. We report a narrative synthesis of the findings and quality appraisal of the selected references. RESULTS: Of the 707 references returned in the literature search, a total of 18 cost-effectiveness studies were included for review. Compared with treatment as usual, several studies reported clinical superiority and cost effectiveness of Internet-based CBT programs for adults and children with OCD at various willingness-to-pay thresholds and economic reference indicators, though cost effectiveness relative to in-person CBT with exposure and response prevention is unclear and estimates of efficacy are likely lower for Internet-based CBT. One study favored the cost utility of serotonin reuptake inhibitor monotherapy over CBT with exposure and response prevention although efficacy estimates of the former tend to be lower, and relative cost differences were low. Five studies evaluated the cost effectiveness of high-intensity neuroaugmentation, including deep brain stimulation and stereotactic radiosurgical capsulotomy, in the context of treatment-refractory OCD. CONCLUSIONS: Despite the relatively high prevalence of OCD worldwide, cost-effectiveness data for therapeutic modalities remain sparse. Because of the chronic nature of OCD, the cost of treatment accumulates and may lead to a significant financial burden over time, particularly when non-evidence-based interventions are used. However, several alternative therapeutic modalities hold promise for economic practicality without significant sacrifice in clinical efficacy. Future studies are necessary to directly compare the cost effectiveness of such therapeutic alternatives with the current standard of care, CBT with exposure and response prevention.

Cost-effectiveness analysis of radiosurgical capsulotomy versus treatment as usual for treatment-resistant obsessive-compulsive disorder.

OBJECTIVE: Stereotactic radiosurgical capsulotomy (SRS-C) is an effective neurosurgical option for patients with treatment-resistant obsessive-compulsive disorder (TROCD). Unlike other procedures such as deep brain stimulation and radiofrequency ablation, the cost-effectiveness of SRS-C for TROCD has not been investigated. The authors herein report the first cost-effectiveness analysis of SRS-C for TROCD. METHODS: Using a decision analytic model, the authors compared the cost-effectiveness of SRS-C to treatment as usual (TAU) for TROCD. Treatment response and complication rates were derived from a review of relevant clinical trials. Published algorithms were used to convert Yale-Brown Obsessive Compulsive Scale scores into utility scores reflecting improvements in quality of life. Costs were approached from the healthcare sector perspective and were drawn from Medicare reimbursement rates and available healthcare economics data. A Monte Carlo simulation and probabilistic sensitivity analysis were performed to estimate the incremental cost-effectiveness ratio. RESULTS: One hundred fifty-eight TROCD patients across 9 studies who had undergone SRS-C and had at least 36 months of follow-up were included in the model. Compared to TAU, SRS-C was more cost-effective, with an estimated incremental cost-effectiveness ratio of $28,960 per quality-adjusted life year (QALY) gained. Within the 3-year time horizon, net QALYs gained were greater in the SRS-C group than the TAU group by 0.27 (95% CI 0.2698-0.2702, p < 0.0001). At willingness-to-pay thresholds of $50,000 and $100,000 per QALY, the Monte Carlo simulation revealed that SRS-C was more cost-effective than TAU in 83% and 100% of iterations, respectively. CONCLUSIONS: Compared to TAU, SRS-C for TROCD is more cost-effective under a range of possible cost and effectiveness values.

A Qualitative Inquiry of Parents' Observations of Their Children's Mental Health Needs During the COVID-19 Pandemic.

Given that children and adolescents are at critical periods of development, they may be particularly vulnerable to the effects of the COVID-19 pandemic. Using a descriptive phenomenological approach, 71 parents' observations of their child's mental health difficulties were explored. Parents sought out treatment because their children were experiencing significant distress. Data used were transcribed from baseline questionnaires and therapy summaries. Data analysis revealed three themes: emotion regulation difficulties, hypervigilance, and despair. The search for strategies and tailored interventions to help mitigate the potential harmful and long-term mental health impacts of the pandemic should be at the forefront of research and clinical practice.

Obsessive compulsive disorder during the COVID-19 pandemic: A brief review of course, psychological assessment and treatment considerations.

Obsessive-compulsive disorder (OCD) is an impairing mental health condition defined by intense distress in the presence of unwanted, recurrent thoughts, images, or impulses which are accompanied by compulsions and avoidance performed to reduce distress. During the COVID-19 pandemic, OCD has continued to be an impairing mental health condition regardless of symptom dimensionality (e.g., contamination, harm, etc.) with varying reports of the overall clinical course. However, changes in the assessment, treatment, and diagnosis of OCD have occurred to personalize care and be aligned with public health guidelines. Exposure and response prevention and pharmacotherapy remain the treatment of choice, even though the setting in which treatment is conducted may have shifted. Telehealth in particular has been a 'game-changer' for clinicians and patients alike. Given the continued health risk posed by the pandemic, treatment personalization should still be made to ensure safety for both patients and providers while balancing efficacy and patient preferences.

Stepped Care Versus Standard Care for Children After Trauma: A Randomized Non-Inferiority Clinical Trial.

OBJECTIVE: Trauma-focused cognitive-behavioral therapy (TF-CBT) is an evidence-based therapist-led treatment for children after trauma. Parents often experience barriers to treatment engagement, including cost. Stepped care TF-CBT (SC-TF-CBT) was developed as an alternative delivery system. Step One is a parent-led therapist-assisted treatment. Step Two provides therapist-led TF-CBT for children who did not benefit from Step One and require more intensive treatment. This study compared SC-TF-CBT to standard TF-CBT in a community-based non-inferiority trial. METHOD: A total of 183 children (aged 4-12 years) experiencing posttraumatic stress symptoms (PTSS) and their caregivers were randomly assigned to SC-TF-CBT or standard TF-CBT within 6 community clinics. Assessments occurred at baseline, mid- and posttreatment, and 6 and 12 months. Primary outcomes included PTSS and impairment. Secondary outcomes included severity, diagnostic status, remission, and response. Treatment cost, acceptability, and satisfaction were measured. Difference and non-inferiority tests were applied. RESULTS: SC-TF-CBT participants changed at rates comparable to participants in TF-CBT for primary and secondary measures. SC-TF-CBT was non-inferior to TF-CBT for PTSS, impairment, and severity at all time points except for impairment at the 6-month assessment. Attrition did not differ between treatment arms (132 participants were completers). Baseline treatment acceptability was lower for SC-TF-CBT parents, although there was no difference in expected treatment improvements or treatment satisfaction at posttreatment. Based on regression estimates, total costs were 38.4% lower for SC-TF-CBT compared to TF-CBT, whereas recurring costs were 53.7% lower. CONCLUSION: Stepped Care TF-CBT provides an alternative way to deliver treatment for some children and parents, with reduced cost for providers and parents. CLINICAL TRIAL REGISTRATION INFORMATION: Stepped Care for Children after Trauma: Optimizing Treatment; https://clinicaltrials.gov; NCT02537678.

Cost-effectiveness analysis of deep transcranial magnetic stimulation relative to evidence-based strategies for treatment-refractory obsessive-compulsive disorder.

OBJECTIVE: This study examined the cost-effectiveness of deep transcranial magnetic stimulation (dTMS) for treatment refractory obsessive-compulsive disorder (OCD) relative to other established treatment options, including antidepressant medication (ADM), ADM + antipsychotic augmentation, real-world cognitive-behavioral therapy (ADM + CBT Effectiveness), clinical trial CBT (ADM + CBT), intensive outpatient program (IOP), partial hospitalization program (PHP), and PHP to IOP stepdown. METHODS: A decision analytic model was developed to evaluate the cost-effectiveness of dTMS relative to other established treatment alternatives for adults (18-64 years old) with refractory OCD. Building on Gregory et al. (2018), the model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate costs, and incremental cost-effectiveness ratio (ICER) for dTMS relative to each treatment strategy. Encounters took place from 2012 to 2015. Data for dTMS were taken from a recent multisite study. RESULTS: Although dTMS fit between ADM and ADM + CBT in overall costs, ADM + CBT had the lowest ICER and thus would be chosen before dTMS. dTMS was determined to be more cost effective relative to PHP/IOP stepdown, PHP, and IOP. CONCLUSION: dTMS is cost-effective, along the treatment continuum from outpatient medication management and CBT to more intensive, facilities-based approaches, and may be an incremental strategy to employ when higher intensity strategies are either not available, not financially feasible, or whilst on extended waits for admission to these higher levels of care.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model.

BACKGROUND: While multiple treatments for pediatric anxiety and obsessive compulsive disorder (OCD) are efficacious, little is known about their cost-effectiveness. In response, we sought to provide relevant information through systematic review and cost-effectiveness simulation. METHODS: We evaluated the cost-effectiveness of treatment for pediatric anxiety and OCD in two ways. First, we conducted a systematic review following PRISMA guidelines. Second, we evaluated cost-effectiveness for antidepressant medication, cognitive behavioral therapy, and their combination via a simulation that integrated information from the Truven MarketScan database and the NIMH National Database for Clinical Trials Related to Mental Illness. RESULTS: Both systematic review and simulation found antidepressant medication and cognitive behavioral therapy to be cost-effective for pediatric anxiety and OCD. Antidepressant medication was the least costly approach, and cognitive behavioral therapy provided additional cost-effectiveness, especially for OCD. LIMITATIONS: During systematic review, relatively few articles provided information about both costs and effectiveness. While there was a notable margin of error to support multiple interventions as cost-effective, limited prior research decreased precision of point estimates and comparisons between interventions. CONCLUSIONS: Both antidepressant medication and cognitive behavioral therapy were found to be cost-effective for pediatric anxiety and OCD. Results supported investment from third party payers, who serve as critical gatekeepers that can increase treatment dissemination. However, more precise information would better inform the exact amount of investment needed, especially with regard to selection decisions between active interventions. Cost-effectiveness research would benefit from systematic collection of data on treatment costs and quality of life in future clinical trials.

Assessment of improvement in anxiety severity for children with autism spectrum disorder: The matched correspondence analysis approach.

INTRODUCTION: Clinical trials typically involve random assignment to treatment conditions. However, random assignment does not guarantee a lack of systematic variation in the outcomes, and application of covariation methods for multiple dependent measures requires complicated assumptions that are often not met. METHODS: This study employed matched correspondence analysis (CA) for controlling systematic variation and handling multiple outcomes. One hundred nine children with autism spectrum disorder (ASD) were assessed for anxiety symptom severity across four studies, where participants were randomly assigned to either cognitive behavioral therapy (CBT) or treatment as usual or waitlist (TAU/WT). Matched CA is designed to optimally scale only the differences between baseline and posttreatment, rendering the systematic baseline carryover effects irrelevant. RESULTS: Differences in treatment efficacy were observed. CBT showed treatment efficacy on anxiety severity and anxiety-related impairment relative to TAU/WT, after the control of baseline carryover effects. CONCLUSION: This study provides a way to control systematic variation between groups at the outset of treatment trials and is expected to provide a novel pathway to more proper assessment of treatment efficacy for children with ASD and anxiety.

Long-term ecological assessment of intracranial electrophysiology synchronized to behavioral markers in obsessive-compulsive disorder.

Detection of neural signatures related to pathological behavioral states could enable adaptive deep brain stimulation (DBS), a potential strategy for improving efficacy of DBS for neurological and psychiatric disorders. This approach requires identifying neural biomarkers of relevant behavioral states, a task best performed in ecologically valid environments. Here, in human participants with obsessive-compulsive disorder (OCD) implanted with recording-capable DBS devices, we synchronized chronic ventral striatum local field potentials with relevant, disease-specific behaviors. We captured over 1,000 h of local field potentials in the clinic and at home during unstructured activity, as well as during DBS and exposure therapy. The wide range of symptom severity over which the data were captured allowed us to identify candidate neural biomarkers of OCD symptom intensity. This work demonstrates the feasibility and utility of capturing chronic intracranial electrophysiology during daily symptom fluctuations to enable neural biomarker identification, a prerequisite for future development of adaptive DBS for OCD and other psychiatric disorders.

Building brain capital.

Brains are indispensable drivers of human progress. Why not invest more heavily in them? We seek to place Brain Capital at the center of a new narrative to fuel economic and societal recovery and resilience.

Addressing the mental health needs of learners and nonlearners in an academic medical center during COVID-19.

The coronavirus disease (COVID-19) has impacted life for people throughout the world, especially for those in health care who experience unique stressors. To support the psychological needs of staff, faculty, and learners at a biomedical sciences university, faculty at Baylor College of Medicine created a mental health and wellness support program consisting of multiple behavioral health care pathways, including phone support, a self-guided mental health app, a coping skills group, and individual therapy services. The authors present this program as a model for academic institutions to support the well-being of faculty, staff, and learners.

Tailoring the Unified Protocol for Adolescents for a Stepped-Care Approach: Case Exemplars.

Emotional disorders, including anxiety, depressive, and obsessive-compulsive spectrum disorders are prevalent and impairing for youth. Dissemination efforts have been implemented to address these disorders in youth, but these are limited by cost and barriers to accessing mental health services. Stepped care is a method of treatment delivery meant to be cost-effective and less time intensive than administering a full treatment manual. Much, if not all of the research, assessing the efficacy of stepped care delivery has utilized disorder-specific treatment manuals. However, transdiagnostic stepped care approaches may prove more efficacious given that youth commonly present to treatment with more than one disorder and that such problems are not always comprehensively assessed at intake. This manuscript provides details regarding the implementation of a transdiagnostic stepped-care delivery (UPA-SC) using three case examples. Youth evidenced significant improvement in anxiety, depression, and quality of life. Future work to investigate the efficacy of UPA-SC in a larger, more heterogeneous sample of youth may be warranted.

Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder.

PURPOSE: Current guidelines for first-line treatment of childhood OCD are cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP), and/or antidepressant (ADM) pharmacotherapy, specifically serotonin reuptake inhibitors (SRI). Given that first-line are relatively similar in terms of clinical effectiveness, the role of costs to provide such services may help influence treatment decisions. In the case of treatment refractory pediatric OCD, this cost-effectiveness analysis (CEA) aims to further evaluate two additional, higher intensity combination therapies, namely OCD-specific Intensive Outpatient (IOP) and Partial Hospitalization Programs (PHP), to determine the additional benefits, in terms of effectiveness, that may result, and the corresponding increase in costs for these higher-intensity courses of therapy. RESULTS: IOP was the most cost-effective strategy in terms of change in CY-BOCS, pre/post treatment, equal to 16.42 units, followed by PHP and CBT monotherapy augmented with ADM CBT-monotherapy augmented with additional CBT and ADM-only augmented with CBT followed closely with 15.56 and 14.75 unit improvements in CY-BOCS. IOP accomplished its superior cost-effectiveness with an Incremental Cost-Effectiveness Ratio (ICER), of $48,834, lower than either of the established willingness to Pay thresholds. CONCLUSIONS: Lack of access to high fidelity, high dose CBT paired with pharmacotherapy is an issue for OCD patients and families. Among youth who were treatment non-responsive, these results indicate the superiority of a high dosage CBT strategy, indicating the need to increase access to these treatments.

Factors Associated With Length of Stay in Emergency Departments for Pediatric Patients With Psychiatric Problems.

OBJECTIVES: Length of stay (LOS) and boarding for pediatric psychiatric patients presenting in the emergency department (ED) have been understudied, despite evidence that children with psychiatric disorders experience longer LOS relative to those without. This investigation examined correlates of LOS and boarding among youth with psychiatric disorders presenting to the ED in a large, statewide database. METHODS: Using the 2010 to 2013 Florida ED discharge database, generalized linear mixed models were used to examine for associations between LOS and patient and hospital characteristics among pediatric patients (<18 years) who presented with a primary psychiatric diagnosis (N = 44,328). RESULTS: Patients had an overall mean ± SD ED LOS of 5.96 ± 8.64 hours. Depending on the definition used (ie, 12 or 6 hours), between 23% and 58% of transferred patients were boarded. Patient characteristics associated with a longer LOS included female sex, being 15 to 17 years old, Hispanic ethnicity, having Medicaid or VA/TriCare insurance, having impulse control problems, having mood or psychotic disorders, and exhibiting self-harm behaviors. Patient transfer, large hospital size, and rural designation were associated with longer LOS. Teaching hospital status and profit status were not significantly associated with LOS. CONCLUSIONS: These data suggest that LOS for pediatric psychiatry patients in the ED varies significantly by psychiatric presentation, patient disposition, and hospital factors. Such findings have implications for quality of care, patient safety, and health outcomes.

Treatment-Refractory Obsessive-Compulsive Disorder in Adults: A Cost-Effectiveness Analysis of Treatment Strategies.

OBJECTIVE: This study sought to assess the cost-effectiveness of 7 treatment strategies for treatment-refractory obsessive-compulsive disorder (OCD) in adults. METHODS: A model was developed to evaluate treatment alternatives for adults (18-64 years old) that consisted of 2 parts: a decision analytic model and a Markov model. The decision analytic model stratified 7 outpatient treatment strategies, and the Markov model accumulated benefits and costs across the life expectancy of a simulated cohort of individuals. The model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate net health benefits (NHBs), costs, and incremental cost-effectiveness ratio (ICER) for each treatment strategy. OCD was considered treatment refractory in adults with an OCD diagnosis who failed first-line therapies. Encounters took place from 2012 to 2015, and the analyses were performed from November 2016 to February 2017. RESULTS: Partial hospitalization with step-down to intensive outpatient treatment was the most cost-effective of the 7 strategies, with an estimated ICER of $7,983 and mean (SD) NHB of 10.96 (0.53) quality-adjusted life-years (QALYs) remaining. This result was 2.2 QALYs greater than that of the trial-based antidepressant and cognitive-behavioral therapy (ADM + CBT) strategy. Three additional ADM + CBT strategies were estimated not to be statistically significantly different from each other. These 4 ADM + CBT strategies outperformed both pharmacotherapy-only strategies. CONCLUSIONS: Treatment strategies that include higher-intensity CBT, with effectiveness outcomes that approached efficacy estimates, were superior to real-world CBT strategies. However, given the limited availability of high-quality CBT, especially through use of commercial insurance networks, specialized treatment programs offer greater effectiveness than real-world therapies in achieving wellness for this severe patient population.