The commentary assesses the B4DT trial’s contribution and limitations, patient selection and generalizability, and the treatment’s role and capacity within OCD care.
Approach:
Trial: Jelinek et al. randomized 119 adults with OCD to concentrated individual exposure and response prevention (B4DT) or unguided internet-based CBT (iCBT).
Commentary: The article discusses the trial’s contribution and limitations, patient selection and generalizability, and B4DT’s place in care and treatment capacity.
Key Findings:
B4DT was statistically superior to iCBT, with a large effect size (g = −1.6).
At 3 months, response rates were 61.4% with B4DT and 25% with iCBT; remission rates were 42.1% and 13.6%, respectively.
B4DT was rated more acceptable than iCBT, and only 3 of 60 participants were lost to 3-month follow-up.
Of 253 adults screened, 119 entered the trial; 53 did not meet inclusion criteria and 81 declined, with reasons for refusal unreported.
The authors note that the B4DT effects were smaller than those in earlier uncontrolled or waiting-list-controlled studies.
Interpretation:
The trial extends B4DT research by using an active iCBT comparator and an independent research group. The commentary notes that the self-guided ERP condition produced comparatively modest effects and calls for comparisons with an equivalent dose of active ERP delivered over a longer period, as well as studies in naturalistic settings with clinically diverse samples.
Limitations:
The self-guided iCBT condition produced comparatively modest effects, and the B4DT effects were smaller than those reported in earlier uncontrolled or waiting-list-controlled studies.
Reasons for declining participation were not reported, and the commentary questions how representative the screened and enrolled samples are of the broader OCD population.
The B4DT’s role in care and its accessibility at scale remain uncertain. The commentary estimates that the model could treat approximately 45–48 patients per therapist annually.
Conclusion:
The commentary calls for methodologically rigorous comparisons and broad international replication involving patients with differing levels of motivation and engagement.
