Cognitive behavior therapy in medication non-responders with obsessive-compulsive disorder: a prospective 1-year follow-up study

Evidence of efficacy of cognitive behavior therapy (CBT) in obsessive–compulsive disorder (OCD) non-responsive to multiple trials of serotonin reuptake inhibitors (SRI) is limited. We examined the efficacy of CBT in 31 adult patients with DSM-IV OCD who were non-responders to at least two SRI trials. They received 20–25 sessions of CBT over 3-month duration. The primary outcome measure was “response” to treatment [Clinical Global Impressions-Improvement score 1 or 2 and ≥35% reduction in Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) severity score]. Patients were assessed at baseline, post-treatment and at 3-, 6- and 12-month follow-up. Twenty-six (84%) patients completed treatment and number of responders at post-treatment, 3-, 6- and 12-month follow-up were 23 (74%), 20 (64%), 20 (64%) and 19 (61%) respectively. Quality of homework compliance and baseline Y-BOCS severity predicted remission (Y-BOCS < 16) to CBT. CBT is useful in OCD non-responsive to multiple trials of SRI.     

Clinical outcome in patients with obsessive-compulsive disorder after discontinuation of SRI treatment: results from a two–year follow–up

BACKGROUND: Combined treatment with serotonin-reuptake inhibitors (SRI) and cognitive-behavioral therapy (CBT) is a common therapy approach for obsessive-compulsive disorder (OCD). However, it is a matter of debate whether discontinuation of SRI after combined treatment leads to relapse. METHOD: Seventy-four consecutively admitted patients suffering from OCD were included in the study. Thirty-seven patients were treated with CBT alone, and 37 patients received combined CBT and SRI treatment. Of these latter patients, seventeen discontinued SRI treatment during the follow-up period (1 and 2 years after inpatient treatment). OCD symptom severity was determined by Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and mood was assessed by Hamilton Depression Rating Scale (HDRS). RESULTS: During the initial treatment, scores for Y-BOCS (p < 0.001), HDRS (p < 0.001) and the Global Assessment of Functioning Scale (GAF) (p < 0.001) improved significantly in all groups. Reassessment two years later revealed that a) OCD symptom severity and depression scores were similar between the groups and b) discontinuation of SRI did not prompt by a recurrence of symptoms. CONCLUSIONS: We interpret our results as suggesting that discontinuation of SRI treatment may be considered in formerly combined treated OCD patients after stable remission.     

A double-blind, randomized, placebo-controlled trial of quetiapine addition in patients with obsessive-compulsive disorder refractory to serotonin reuptake inhibitors

BACKGROUND: Although serotonin reuptake inhibitors (SRIs) are the most effective pharmacologic treatment currently available for patients with obsessive-compulsive disorder (OCD), 40% to 60% of patients do not respond to this treatment. This study was conducted to evaluate the efficacy and tolerability of quetiapine in addition to an SRI for treatment-refractory patients with OCD. METHOD: Forty patients (10 men/30 women, mean +/- SD age = 35.2 +/- 12.1 years; range, 18-60 years) with primary OCD according to DSM-IV criteria who were recruited between February 2001 and December 2002 were randomly assigned in an 8-week, double-blind, placebo-controlled trial to receive dosages titrated upward to 300 mg/day of quetiapine (N = 20) or placebo (N = 20) in addition to their SRI treatment. At entry, all patients were unresponsive to courses of treatment with at least 2 different SRIs at a maximum tolerated dose for 8 weeks. During the study, primary efficacy was assessed according to change from baseline on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). A responder was defined as having a final Clinical Global Impressions-Improvement scale rating of "very much improved" or "much improved" and a decrease of > or = 35% in Y-BOCS score. RESULTS: An intent-to-treat, last-observation-carried-forward analysis demonstrated a mean +/- SD decrease in Y-BOCS score of 9.0 +/- 7.0 (31%) in the quetiapine group and 1.8 +/- 3.4 (7%) in the placebo group (F=16.99, df=1,38; p <.001). Eight (40%) of 20 patients in the quetiapine group and 2 (10%) of 20 patients in the placebo group were responders (chi2=4.8, df=1, p=.028). The most common side effects in the quetiapine group were somnolence, dry mouth, weight gain, and dizziness. CONCLUSION: The results of this study show that quetiapine in addition to an SRI is beneficial for patients with OCD who do not respond to SRI treatment alone.     

Topiramate augmentation in treatment-resistant obsessive-compulsive disorder: a retrospective, open-label case series

Serotonin reuptake inhibitors (SRIs) are considered first-line treatments for obsessive-compulsive disorder (OCD). Many patients achieve some response but remain symptomatic despite an adequate SRI trial. Recent neuroimaging data found abnormally high glutamatergic concentrations in children with OCD. Following selective serotonin reuptake inhibitor (SSRI) treatment, a decrease in OCD symptom severity was associated with a decrease in caudate glutamatergic concentrations. We initiated an investigation of adjunctive topiramate (an anticonvulsant agent with glutamatergic properties) in the treatment of patients with OCD who were partially or nonresponsive to SRI treatment. Sixteen consecutive outpatients with OCD (mean age = 41.1 years; range = 21-58 years), who were partial or nonresponders to SRI monotherapy or SRI combination therapy (antipsychotic, other antidepressant, or benzodiazepines), and had topiramate added over a minimum of 14 weeks, were reviewed. Baseline and endpoint Clinical Global Impression-Severity (CGI-S) and CGI-Improvement (CGI-I) were evaluated retrospectively. Eleven of 16 patients were responders (68.8%) with a CGI-I score of much improved or very much improved. The mean dose of topiramate was 253.1 +/- 93.9 mg/day. The mean time to response was 9.2 +/- 4.5 weeks. CGI-S scores decreased significantly from initiation of topiramate until 26 weeks, from 6.1 +/- 0.9 to 4.5 +/- 1.3 (P < .001). This case series suggests some preliminary evidence that the addition of topiramate may be useful in treatment-resistant OCD.     

Olanzapine augmentation for treatment-resistant obsessive-compulsive disorder

BACKGROUND: Adding the atypical neuroleptic risperidone to a serotonin reuptake inhibitor (SRI) has benefited patients with treatment-refractory obsessive-compulsive disorder (OCD). Since olanzapine and risperidone have similar serotonergic and dopaminergic receptor binding profiles, we tested the hypothesis that olanzapine augmentation would be beneficial in treatment-unresponsive OCD. METHOD: For this 8-week trial, we recruited 10 adult OCD patients (DSM-IV criteria) unresponsive to fluoxetine (> or =60 mg/day) for > or =10 weeks, which was continued throughout the trial. Other psychotropic medications were discontinued. Subjects had OCD for > or =1 year, a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of > or =18, and no organic, psychotic, or other primary Axis I disorder. Two weeks after olanzapine, 2.5 mg/day, was added, and in the absence of responder status (Y-BOCS score decrease > or =25%) and limiting side effects, we increased the dose to 5 mg/day, and after 2 more weeks, to 10 mg/day for 4 weeks. RESULTS: The subjects had failed a mean of 3.3 SRI trials (range, 1-5) and had a mean +/- SD baseline Y-BOCS score of 29.0 +/- 4.9. Nine patients completed the trial. The subjects' mean +/- SD endpoint Y-BOCS score was 24.4 +/- 8.0 (a 16% decrease). The 3 responders' Y-BOCS scores dropped 68%, 30%, and 29%, but only 1 patient was rated "much improved." He maintained this improvement during a 6-month follow-up period taking olanzapine, 5 mg/day. Improvement in OCD was independent of improvement in mood symptoms. Six patients (60%) experienced significant weight gain. CONCLUSION: Olanzapine augmentation may benefit treatment-unresponsive OCD. Double-blind, placebo-controlled trials are warranted along with trials comparing risperidone and olanzapine augmentation.     

Paroxetine treatment of compulsive hoarding

OBJECTIVE: Compulsive hoarding, found in many patients with obsessive-compulsive disorder (OCD), has been associated with poor response to serotonin reuptake inhibitor (SRI) medications in some reports. However, no prior study has quantitatively measured response to standardized pharmacotherapy in compulsive hoarders. We sought to determine whether compulsive hoarders would respond as well as non-hoarding OCD patients to the SRI, paroxetine. METHODS: Seventy-nine patients with OCD (32 patients with the compulsive hoarding syndrome and 47 patients without prominent hoarding symptoms) were treated openly with paroxetine (mean dose 41.6+/-12.8 mg/day; mean duration 80.4+/-23.5 days) according to a standardized protocol, from 3/1993 to 7/2005. All subjects were free of psychotropic medication for at least four weeks prior to study entry. No psychotherapy or psychotropic medications except paroxetine were allowed during the study period. Subjects were assessed before and after treatment with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Scale (Ham-A), Global Assessment Scale (GAS), and Clinical Global Impression/Improvement (CGI) scale. RESULTS: Both compulsive hoarders and non-hoarding OCD patients improved significantly with treatment (p<0.001), with nearly identical changes in Y-BOCS, HDRS, Ham-A, and GAS scores. There were no significant differences between groups in the proportions of patients who completed or responded to treatment. Hoarding symptoms improved as much as other OCD symptoms. CONCLUSIONS: Compulsive hoarders responded as well to paroxetine treatment as non-hoarding OCD patients, suggesting that SRI medications are effective for compulsive hoarding. Controlled trials of SRI medications for compulsive hoarding are now warranted.     

Addition of cognitive-behaviour therapy for obsessive-compulsive disorder patients non-responding to fluoxetine

OBJECTIVE: Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behaviour therapy (CBT) have both proven to be effective in the treatment of obsessive compulsive disorder (OCD). It is generally recommended that adequate but unsuccessful SSRI treatment is supplemented with CBT, although only one empirical study was conducted to verify this recommendation. The present study examined the effects of supplemental CBT to continued fluoxetine treatment in OCD patients non-responding to fluoxetine alone. METHOD: After 12 weeks of fluoxetine, 14 of 56 out-patients had a reduction rate less than 25% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and were classified as non-responders. They subsequently received 12 sessions CBT additional to the continued fluoxetine treatment. RESULTS: The mean symptom reduction as rated by the Y-BOCS, for the patients who completed both treatment phases, was 8.5% in the first phase and 41% in the second phase. CONCLUSION: Supplemental CBT for OCD patients, after initial, unsuccessful fluoxetine treatment is shown to be effective.     

A double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder

BACKGROUND: The treatment guidelines for obsessive-compulsive disorder (OCD) propose to switch serotonin reuptake inhibitors (SRIs) in case of refractoriness. However, no controlled research has been published yet that prospectively examined the effects of changing SRIs. This article describes the first double-blind switch study of 2 SRIs in patients with OCD. METHOD: 150 patients with primary OCD, according to DSM-IV criteria, were randomly assigned in a 12-week, double-blind trial to receive dosages titrated upward to 300 mg/day of venlafaxine (N = 75) or 60 mg/day of paroxetine (N = 75). Primary efficacy was assessed by the change from baseline on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and nonresponse was defined as less than 25% reduction on the Y-BOCS. After a 4-week tapering phase, 43 nonresponders were switched to 12 additional weeks of the alternate antidepressant, of which 16 patients received venlafaxine and 27 received paroxetine. RESULTS: Eighteen of 43 patients benefited from a switch to the alternate SRI with a mean +/- SD decrease of at least 25% on the Y-BOCS. At the end of 12 weeks, responder rates were 56% for paroxetine (15/27) and 19% for venlafaxine (3/16). An intent-to-treat, last-observation-carried-forward analysis demonstrated a mean decrease on the Y-BOCS of 1.8 +/- 3.5 in the venlafaxine group and 6.5 +/- 7.1 in the paroxetine group. After 2 consecutive SRI trials, 109 of 150 patients (73%) achieved a Y-BOCS decrease of at least 25%. CONCLUSION: The results of the current study show that 42% of the nonresponders benefited from a crossover to the other SRI, and that paroxetine was more efficacious than venlafaxine in the treatment of nonresponders to a previous SRI trial. Switching SRIs in case of refractoriness may be considered a useful strategy for patients with OCD.     

Olanzapine augmentation of paroxetine-refractory obsessive-compulsive disorder

The aim of the present study was to investigate the effect of adjunctive olanzapine in patients with obsessive-compulsive disorder (OCD) refractory to paroxetine. Twenty-one patients unresponsive to treatment with paroxetine, administered for at least 12 weeks at the dose of 60 mg/day, participated to a 12-week open-label, add-on trial with olanzapine (10 mg/day). The psychopathological state was evaluated by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and by Clinical Global Impression (CGI). Three patients did not complete the 12-week adjunctive treatment with olanzapine. In the 18 completers, the mean Y-BOCS score decreased significantly from 27.1+/-4.0 at baseline to 20.1+/-3.9 at final evaluation (P<.001). Seven patients (38.9%) were rated as responders at final evaluation. Steady-state plasma concentrations of paroxetine were not modified during olanzapine coadministration. The drug combination was generally well tolerated and initial sedation and weight gain were the most frequent unwanted effects. Our findings confirm the results of previous studies and indicate that the addition of olanzapine to ongoing treatment with serotonin reuptake inhibitors (SRI) may be beneficial in some patients unresponsive to SRI monotherapy.     

Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy

BACKGROUND: The objective of this study was to examine the long-term course of obsessive-compulsive disorder (OCD) in patients treated with serotonin reuptake inhibitors (SRIs) and behavioral therapy and to identify predictors of clinical outcome. METHOD: Sixty outpatients meeting DSM-II-R or DSM-IV criteria for OCD were followed up for 1 to 5 years (mean = 2.5 years). All of them received prolonged pharmacologic therapy with an SRI. RESULTS: Thirty-seven patients (61.7%) completed an adequate behavioral treatment. At long-term assessment, 22 patients (36.7%) exhibited a global Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score greater than 16 or a final reduction in Y-BOCS global score of less than 35% and were considered nonresponders. Patients who completed behavioral therapy showed a significant decrease in Y-BOCS compulsions subscale score (p = .01), whereas no significant differences in either Y-BOCS global or obsessions subscale scores between those who did and those who did not undergo behavioral therapy were detected. Obsessions of sexual/religious content were the unique factor related to a poorer long-term outcome. CONCLUSION: A substantial number of OCD patients showed persistent disabling symptoms at the long-term follow-up in spite of combined pharmacologic and behavioral treatment. Major benefits from behavioral therapy appeared to be the improvement of ritualistic behaviors. Sexual/religious obsessions predicted poorer long-term outcome, whereas short-term response to SRI treatment failed to achieve predictive value in the long-term course of OCD.     

Double-blind treatment with oral morphine in treatment-resistant obsessive-compulsive disorder

BACKGROUND: Obsessive-compulsive disorder (OCD) often responds inadequately to serotonin reuptake inhibitors (SRIs). A case series reported substantial response to once-weekly oral morphine. We conducted a placebo-controlled, double-blind trial to investigate whether once-weekly oral morphine is effective in SRI-resistant OCD. METHOD: Subjects with DSM-IV-defined OCD for > or =3 years who had failed > or =2 adequate SRI trials and had a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of > or =20 were recruited. Current medications were continued. Subjects were randomly assigned to random-order, 2-week blocks of once-weekly morphine, lorazepam, and placebo. Week 2 dosage was increased, decreased, or maintained depending on response and side effects. RESULTS: We enrolled 23 subjects, who had failed 2 to 6 SRI trials. The median screening Y-BOCS score was 29. The median Y-BOCS score after morphine (highest dose) was 25 (median decrease = 13%). Seven subjects (30%) were responders (Y-BOCS decreases > or =25%). The median Y-BOCS score after lorazepam (highest dose) was 27 (median decrease = 6%). Four subjects (17%) responded to lorazepam; 1 was a morphine responder. The median Y-BOCS score after placebo (highest dose) was 27 (median decrease = 7%), and no subject responded. Responses differed significantly among the 3 conditions (Friedman 2-way analysis of variance, chir(2) = 13.92, df = 2, p = .01). Wilcoxon matched-pairs signed-rank tests (T = 56.5, p = .05) showed significance for morphine versus placebo but not lorazepam versus placebo. CONCLUSION: Our results support the hypothesis that once-weekly oral morphine can reduce symptoms in some treatment-resistant OCD patients. The mechanism of action is unknown. Further studies of mu-agonists and glutamate antagonists are warranted.     

Olanzapine augmentation of fluvoxamine-refractory obsessive-compulsive disorder (OCD): a 12-week open trial

A few studies have tried antipsychotic augmentation in obsessive-compulsive disorder (OCD) patients who are non-responders to selective serotonin reuptake inhibitors. The aim of this study was to investigate the efficacy and tolerability of olanzapine addition to fluvoxamine-refractory OCD patients and to assess if a comorbid chronic tic disorder or a concomitant schizotypal personality disorder was associated with response. Twenty-three OCD non-responders to a 6-month, open-label trial with fluvoxamine (300 mg/day) entered a 3-month open-label trial of augmentation with olanzapine (5 mg/day). OC symptom change was measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Clinical Global Impression (CGI) scale. Differences between responders and non-responders were assessed with regard to age, sex, duration of illness, baseline Y-BOCS score, and comorbidity with chronic tic disorders or schizotypal personality disorder. A significant decrease of mean Y-BOCS score between pre- and post-treatment (26. 8+/-3.0 vs. 18.9+/-5.9) was found at endpoint. Ten patients (43.5%) were rated as responders. The most common side effects were mild to moderate weight gain and sedation. In our sample, three patients (13. 04%) had a chronic motor tic disorder, and four (17.39%) had a codiagnosis of schizotypal personality disorder. Concomitant schizotypal personality disorder was the only factor significantly associated with response. It appears that augmentation of olanzapine in fluvoxamine-refractory OCD may be effective in a large number of patients, including those with comorbid schizotypal personality disorder.     

Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder

OBJECTIVE: The purpose of the study was to test the relative and combined efficacy of clomipramine and exposure and ritual prevention in the treatment of obsessive-compulsive disorder (OCD) in adults. Serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy by exposure and ritual prevention are both established treatments for OCD, yet their relative and combined efficacy have not been demonstrated conclusively. METHOD: A double-blind, randomized, placebo-controlled trial comparing exposure and ritual prevention, clomipramine, their combination (exposure and ritual prevention plus clomipramine), and pill placebo was conducted at one center expert in pharmacotherapy, another with expertise in exposure and ritual prevention, and a third with expertise in both modalities. Participants were adult outpatients (N=122 entrants) with OCD. Interventions included intensive exposure and ritual prevention for 4 weeks, followed by eight weekly maintenance sessions, and/or clomipramine administered for 12 weeks, with a maximum dose of 250 mg/day. The main outcome measures were the Yale-Brown Obsessive Compulsive Scale total score and response rates determined by the Clinical Global Impression improvement scale. RESULTS: At week 12, the effects of all active treatments were superior to placebo. The effect of exposure and ritual prevention did not differ from that of exposure and ritual prevention plus clomipramine, and both were superior to clomipramine only. Treated and completer response rates were, respectively, 62% and 86% for exposure and ritual prevention, 42% and 48% for clomipramine, 70% and 79% for exposure and ritual prevention plus clomipramine, and 8% and 10% for placebo. CONCLUSIONS: Clomipramine, exposure and ritual prevention, and their combination are all efficacious treatments for OCD. Intensive exposure and ritual prevention may be superior to clomipramine and, by implication, to monotherapy with the other SRIs.     

Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial

BACKGROUND: Cognitive-behavioral therapy (CBT) is generally recommended for obsessive-compulsive disorder (OCD) patients who have failed to respond to approved medications. However, few studies of the efficacy of CBT have selected patients who did not respond to medications. METHOD: We selected 20 adult OCD (DSM-IV criteria) patients with a history of inadequate response to adequate doses of multiple medications, as well as a high rate of comorbid disorders. After a 1-month wait-list period, patients received 15 sessions of outpatient CBT incorporating exposure and ritual prevention. RESULTS: OCD severity (as measured with the Yale-Brown Obsessive Compulsive Scale) decreased significantly (p <.05) after treatment, and gains appeared to have been maintained over a 6-month follow-up period. Analysis of clinical significance indicated that 53% (8/15) of treatment completers met this criterion at posttreatment and 40% (6/15) met the criterion at 6-month follow-up. The sample was characterized as having generally poor insight and putting low effort into CBT; these factors significantly (p <.05) predicted degree of improvement. CONCLUSION: CBT is a useful treatment for OCD patients who have failed to respond adequately to multiple serotonin reuptake inhibitor medications. However, these results were attenuated compared with previous trials. Patients with a long history of poor response to medication may have poor insight and/or not put sufficient effort into treatment; these factors are likely to diminish treatment outcome.     

Anterior cingulotomy for refractory obsessive-compulsive disorder

OBJECTIVE: This study was designed to prospectively investigate the efficacy and cognitive adverse effects of stereotactic bilateral anterior cingulotomy as a treatment for refractory obsessive-compulsive (OCD) patients for 12 months. METHOD: Patients were eligible if they had severe OCD and rigorous treatments had been unsuccessful. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Clinical Global Impression (CGI) and neuropsychological tests were used to assess the efficacy and cognitive changes of cingulotomy before and 12 months after operation. RESULTS: The mean improvement rate of the Y-BOCS scores achieved from baseline was 36.0%. Out of 14 patients six met responder criteria; 35% or higher improvement rate on Y-BOCS and CGI improvement of very much or much better at 12-month follow-up. There was no significant cognitive dysfunction after cingulotomy. CONCLUSION: Anterior cingulotomy shows few cognitive adverse effects, with about half of the OCD patients demonstrating significant symptomatic improvement.     

A retrospective review of clinical characteristics and treatment response in body dysmorphic disorder versus obsessive-compulsive disorder

BACKGROUND: Although body dysmorphic disorder (BDD) has many features in common with obsessive-compulsive disorder (OCD) and is frequently comorbid with OCD, few studies have directly compared the 2 disorders. Although BDD and OCD respond to similar medications and cognitive-behavioral therapy (CBT), their response to treatment has never been directly compared. METHOD: We studied 107 consecutive patients with DSM-III-R OCD (N = 96) or BDD (N = 11) treated openly for 6 weeks with intensive CBT, medication, and psychosocial rehabilitation, in a specialized partial hospitalization program for severely ill OCD patients. All patients were assessed, before and after treatment, with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for Anxiety (HAM-A), and Global Assessment Scale (GAS). Retrospectively, we compared the clinical characteristics, symptom severity, and response to treatment of BDD patients with those of OCD patients. RESULTS: BDD patients and OCD patients had similar sex ratio, age, treatment duration, prevalence of comorbid major depression, and pretreatment Y-BOCS and GAS scores. BDD patients had significantly higher pretreatment HAM-D and HAM-A scores. The proportions of patients treated with serotonin reuptake inhibitors and antipsychotics did not differ between groups. Both groups improved with treatment, with significant (p < .001) changes in Y-BOCS, HAM-D, HAM-A, and GAS scores. Change in Y-BOCS did not differ between groups, but changes in HAM-D and HAM-A were significantly greater in BDD patients than in OCD patients. CONCLUSION: While BDD may be associated with greater severity of depressive and anxiety symptoms than OCD, this study suggests that BDD may respond to intensive, multimodal treatment.     

Secondary outcomes from the pediatric obsessive compulsive disorder treatment study II

The Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II) investigated the benefit of serotonin reuptake inhibitor (SRI) augmentation with cognitive behavioral therapy (CBT). Primary outcomes focused on OCD symptom change and indicated benefit associated with a full course of CBT. Given that the majority of youth with OCD suffer from significant comorbid symptoms and impaired quality of life, the current study examined POTS II data for effects on secondary outcomes. Participants were 124 youth ages 7–17 years with a primary diagnosis of OCD who were partial responders to an adequate SRI trial. Participants were randomized to medication management, medication management plus instructions in cognitive behavioral therapy (CBT), or medication management plus full CBT. Acute effects on non-OCD anxiety, depression, inattention, hyperactivity, and quality of life were examined across treatment conditions. Improvement across treatment was observed for non-OCD anxiety, inattention, hyperactivity, and quality of life. Changes were generally significantly greater in the group receiving full CBT. Child-rated depression was not found to change. OCD-focused treatment lead to improvement in other areas of psychopathology and functioning. For youth who are partial responders to SRI monotherapy, augmentation with full CBT may yield the greatest benefit on these secondary outcomes.Clinical trials registrationTreatment of Pediatric OCD for SRI Partial Responders, Clinicaltrials.gov Identifier: NCT00074815, http://clinicaltrials.gov/show/NCT00074815.     

Development of the Treatment Adherence Survey-patient version (TAS-P) for OCD

This paper reports on the development and initial psychometric evaluation of the Treatment Adherence Survey-patient version (TAS-P), a brief instrument designed to assess patient adherence to Cognitive-Behavioral Therapy (CBT) and pharmacotherapy recommendations for OCD. Eighty individuals with Obsessive Compulsive Disorder (OCD) were administered the TAS-P as part of the intake interview of a prospective, observational study of the course of OCD. Results demonstrated excellent test-retest reliability. Responses on the TAS-P were also significantly correlated with scores on a self-report measure of general treatment adherence and with data collected from a chart-review, demonstrating concurrent validity. Treatment adherence was not explained by demographic variables. However, participants who reported nonadherence to CBT recommendations had more severe OCD symptoms at the time of intake than those who did not endorse CBT nonadherence (mean Y-BOCS = 23.27 +/- 7.5 versus 18.20 +/- 8.0, respectively). Results suggest that the TAS-P is a promising instrument for assessing reasons for nonadherence to recommendations for CBT and pharmacotherapy interventions.     

The effect of treatment on quality of life and functioning in OCD

BackgroundGiven that obsessive compulsive disorder (OCD) is associated with impaired quality of life (QoL) and functioning, it is important examine whether therapeutic recovery from OCD leads to improvements on these important secondary outcomes. Only a few studies have examined how measures of OCD symptom severity relate to QoL and functioning among patients receiving treatment for OCD.MethodsOCD severity was measured with the Obsessive–Compulsive Inventory-Revised (OCI-R), a self-report scale of OCD, and the Yale–Brown Obsessive Compulsive Scale (Y-BOCS), an interview measure of OCD. Participants were 100 adults with a primary diagnosis of OCD on serotonin reuptake inhibitors (SRIs) enrolled in a randomized clinical trial comparing SRI augmentation with either exposure and response prevention (EX/RP) therapy, risperidone, or pill placebo. At baseline, mid-treatment, and post-treatment, patients completed assessments for OCD symptoms and QoL/functioning measures. Multilevel modeling was used to assess changes in QoL/functioning over the course of treatment and to compare such changes across treatment conditions.ResultsImprovements in QoL/functioning were significantly greater among those receiving EX/RP compared to those receiving risperidone. Compared to pill placebo, EX/RP performed better on measures of functioning but not QoL. Greater improvement in individual OCI-R scores was associated with greater improvements in QoL/functioning, regardless of condition. In addition, Y-BOCS scores appeared to moderate improvements in QoL over the course of all treatment conditions, such that those with higher Y-BOCS scores showed the greatest improvements in QoL over time.ConclusionsImprovements in QoL/functioning were associated with reduction in OCD symptom severity. The implications on OCD treatment and clinical research are discussed.     

A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder

As many as half of obsessive-compulsive disorder (OCD) patients treated with an adequate trial of serotonin reuptake inhibitors (SRIs) fail to fully respond to treatment and continue to exhibit significant symptoms. Many studies have assessed the effectiveness of antipsychotic augmentation in SRI-refractory OCD. In this systematic review, we evaluate the efficacy of antipsychotic augmentation in treatment-refractory OCD. The electronic databases of PubMed, PsychINFO (1967-2005), Embase (1974-2000) and the Cochrane Central Register of Controlled Trials (CENTRAL, as of 2005, Issue 3) were searched for relevant double-blind trials using keywords 'antipsychotic agents' or 'neuroleptics' and 'obsessive-compulsive disorder'. Search results and analysis were limited to double-blind, randomized control trials involving the adult population. The proportion of subjects designated as treatment responders was defined by a greater than 35% reduction in Yale Brown Obsessive-Compulsive Scale (Y-BOCS) rating during the course of augmentation therapy. Nine studies involving 278 participants were included in the analysis. The meta-analysis of these studies demonstrated a significant absolute risk difference (ARD) in favor of antipsychotic augmentation of 0.22 (95% confidence interval (CI): 0.13, 0.31). The subgroup of OCD patients with comorbid tics have a particularly beneficial response to this intervention, ARD=0.43 (95% CI: 0.19, 0.68). There was also evidence suggesting OCD patients should be treated with at least 3 months of maximal-tolerated therapy of an SRI before initiating antipsychotic augmentation owing to the high rate of treatment response to continued SRI monotherapy (25.6%). Antipsychotic augmentation in SRI-refractory OCD is indicated in patients who have been treated for at least 3 months of maximal-tolerated therapy of an SRI. Unfortunately, only one-third of treatment-refractory OCD patients show a meaningful treatment response to antipsychotic augmentation. There is sufficient evidence in the published literature, demonstrating the efficacy of haloperidol and risperidone, and evidence regarding the efficacy of quetiapine and olanzapine is inconclusive. Patients with comorbid tics are likely to have a differential benefit to antipsychotic augmentation.