Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial

Sociodemographic representation in randomized controlled trials for anxiety-related disorders in the U.S.: A systematic review (1993-2023)

Cognitive behavioral therapies have been identified as evidence-based treatments for anxiety-related disorders. However, data supporting the effectiveness of these treatments have been largely collected from participants with majoritized identities, potentially limiting the extent to which they can be considered "evidence-based" for clients from minoritized groups. The current review examined sociodemographic representation and quality of sociodemographic reporting in randomized controlled trials for anxiety-related disorders in the U.S. between 1993 and 2023. We conducted a systematic literature review of U.S.-based randomized controlled trials of cognitive behavioral therapies for anxiety-related disorders, extracted data on sociodemographic variables, and rated quality of reporting. Data from 55 eligible studies (N = 4492) indicated that white and female identities were overrepresented relative to the U.S. population, with variables like disability status, sexual orientation, and religious identification consistently ignored. In addition, quality of reporting was generally poor (mean = 3.6 out of 10), with many studies failing to account for demographic variables in their analyses or description of study limitations. Publication year, sample size, and NIH funding status did not significantly predict gender representation (% women), ethnoracial representation (% white), or quality of reporting. These findings underscore the importance of critically evaluating to whom "evidence-based" treatments apply and increasing diversity of clinical samples, to ensure that evidence-based treatments are inclusive. Recommendations for future research, clinical implications, and limitations are discussed.

[Treatment-resistant obsessive-compulsive disorders]

BACKGROUND

Obsessive-compulsive disorders (OCD) are mainly treated with disorder-specific cognitive behavioral therapy using exposure and response management and/or selective serotonin reuptake inhibitors; however, a significant subgroup of patients does not sufficiently benefit from this approach.

OBJECTIVE

This article provides an overview of treatment-resistant OCD.

MATERIAL AND METHODS

In this narrative review the definition, causes, diagnostic and therapeutic approaches to treatment-resistant OCD are addressed.

RESULTS

Treatment resistance can be assumed in the absence of clinically relevant improvement under therapy, in the sense of a reduction of < 25% on the Yale-Brown obsessive-compulsive scale and a score of 4 (no change) on the clinical global impression-improvement scale. The number of unsuccessful treatment attempts required to establish treatment resistance is defined differently. Causative factors include misdiagnosis, a high severity, comorbid disorders, substance use, specific symptom constellations, organic causes, environmental factors, and aggravating factors in psychotherapy and pharmacotherapy. Suggestions for diagnostic and therapeutic approaches based on the German S3 guideline on OCD are presented.

CONCLUSION

For patients with treatment resistance to first-line therapy, useful diagnostic and therapeutic recommendations are available (psychotherapeutic, psychopharmacological and neurostimulation procedures).

The use of antipsychotics in obsessive compulsive disorder

Obsessive-compulsive disorder (OCD) is a chronic disease with a prevalence in the general population of around 2%-3%, generally accompanied by a severe impairment of functioning and quality of life. A consistent subgroup of patients may not achieve adequate symptom remission with first-line treatments (i.e., cognitive behavioral therapy, selective serotonin reuptake inhibitors [SSRIs]). The most validated option for treatment-resistant cases relies on the augmentative use of antipsychotics to SSRIs, preferably of the 'second generation'. Indeed, dopamine appears to be crucially involved in OCD neuropathology due to its implication in systems relating to goal-directed behaviour and maladaptive habits. Nevertheless, the mechanism of action of antipsychotics in OCD symptom improvement is still unclear. Risperidone, aripiprazole, and haloperidol seem to be the most useful medications, whereas 'first generation' antipsychotics may be indicated in case of comorbidity with tics and/or Tourette Syndrome. Antipsychotic augmentation may be also related to side-effects, particularly in the long term (e.g., alteration in metabolic profile, sedation, extrapyramidal symptoms). The present mini-review sought to provide the most updated evidence on augmentative antipsychotic use in treatment-resistant patients with OCD, providing a road map for clinicians in daily practice and shedding light on avenues for further research.

Personality traits as predictors for treatment response to sertraline among unmedicated obsessive-compulsive Disorder: A 12-weeks retrospective longitudinal study

The effectiveness of selective serotonin reuptake inhibitors (SSRIs) as a primary treatment for obsessive-compulsive disorder (OCD) remains uncertain. Even after undergoing standard SSRIs treatment, 40%-60% of individuals with OCD persistently endure symptoms. Recent studies proposed that personality traits may influence the diversity of OCD treatment results. Thus, in this retrospective study, we evaluated the Eysenck Personality Questionnaire (EPQ) scores of 51 untreated patients with OCD and 35 healthy controls. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was employed to assess OCD symptom severity at weeks 0, 2, 4, 8, and 12 of sertraline treatment. The primary outcome focused on the reduction rate of Y-BOCS scores (response: ≥25%; marked response: ≥50%). Our findings revealed that individuals with OCD demonstrated a significantly higher neuroticism score compared to healthy controls. Correlation analyses exposed a positive link between psychoticism and the duration of the disease. Moreover, family history strongly correlated with both obsessive thoughts and the total Y-BOCS score. Subsequent univariate Cox proportional analyses indicated that both low neuroticism and high extraversion traits could forecast the response to sertraline. Furthermore, only a high extraversion trait was linked to a marked response. Our results support the idea that personality traits may contribute to OCD vulnerability and predict sertraline treatment outcomes.

Comparison of internet-based and face-to-face cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review and network meta-analysis

Cognitive behavioral therapy (CBT) is widely recognized as an effective treatment for obsessive-compulsive disorder (OCD). However, few patients are able to receive CBT. Internet-based CBT (ICBT) may be able to overcome this problem. In this study, we aimed to compare the efficacy of CBT, therapist-guided ICBT (TG-ICBT), unguided ICBT (UG-ICBT), and none therapist-guided ICBT (NTG-ICBT) by a network meta-analysis. The primary outcome was the mean change in OCD severity measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The secondary outcomes included the severity of depressive symptoms, side effects, and cost-effectiveness. A total of 25 trials with 1642 participants were included. We found that the efficacy of CBT was superior to that of TG-ICBT. The mean improvement in Y-BOCS/CY-BOCS scores was higher in CBT group than in UG-ICBT group, but this difference was not statistically significant. The efficacy did not differ significantly between TG-ICBT and UG-ICBT. CBT, TG-ICBT, and UG-ICBT were all more effective than the psychological placebo, waiting list, and pill placebo. In terms of efficacy, CBT combined with drug therapy was better than CBT, TG-ICBT, and UG-ICBT. Sensitivity analyses supported these findings. Based on the current evidence, we recommend TG-ICBT when CBT is not available. However, it is undeniable that UG-ICBT also has the potential to be an effective alternative to CBT. More evidence is needed to support this possibility.

Comparing the effectiveness of CBT and low-frequency rTMS in reducing symptom severity and depression and improving working memory in adults with OCD: a clinical trial

OBJECTIVE

This study aims to compare the effectiveness of cognitive-behavioral therapy (CBT) and low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) in reducing symptom severity and depression and improving working memory in adults with obsessive-compulsive disorder (OCD).

METHODS

This is a randomized clinical trial conducted on 24 adults with OCD, randomly assigned into two groups of CBT (n = 12, received CBT with exposure and response prevention (ERP) individually at 20 sessions) and rTMS (n = 12, received LF (1-Hz) rTMS over the right dorsolateral prefrontal cortex (DLPFC) at 10 sessions). They completed the Yale-Brown Obsessive Compulsive Scale, the Hamilton Depression Rating Scale, and two N-Back tasks before, immediately, and 1 month after interventions.

RESULTS

Results showed a significant difference between the two methods in reducing the severity of OCD symptoms (p < 0.05) and depression (p = 0.002) immediately after interventions where the CBT with ERP was more effective, but no significant difference was found in terms of working memory (p > 0.05). No significant difference was found between groups in any study variables 1 month after interventions.

CONCLUSION

Individual CBT with ERP is superior to LF rTMS for reducing the severity of symptoms and depression in OCD patients. However, there is no difference between them in improving working memory.

Proton magnetic resonance spectroscopy-based evaluation of metabolic abnormalities in the right dorsolateral prefrontal cortex and caudate nucleus in treatment-naïve patients with obsessive-compulsive disorder

Background

Obsessive-compulsive disorder (OCD) is a common psychiatric disorder whose underlying pathophysiology is insufficiently understood. The pathophysiology of OCD may be related to abnormalities in the biochemistry of neurotransmitters.

Aim

The aim of the present study was to measure the absolute concentration of various metabolites in the right dorsolateral prefrontal cortex (DLPFC) and caudate nucleus (CN) in treatment-naive patients with OCD and compare it with healthy controls (HCs).

Methods

The present study investigated the metabolic profile of two brain regions, namely right DLPFC and CN, by using single voxel in-vivo proton magnetic resonance spectroscopy (1H MRS) in drug-naive patients with OCD (n = 17, mean age = 30.71 ± 10.104 years) and compared it with healthy controls (n = 13, mean age = 30.77 ± 5.449 years). The patients with OCD were recruited after appropriate psychometric assessments. The 1H-MRS experiments were performed using the 3 Tesla (3T) human MR scanner, and absolute concentrations of metabolites were estimated using the LC model.

Results

Significantly lower concentration of tNAA in the right DLPFC was observed in the patients with OCD compared to the controls, which may be indicative of neurodegeneration in this region. However, no significant differences were observed in the concentrations of the metabolites between the patients and controls in the CN region. The level of tNAA in DLPFC significantly correlated with the disability level (WHO-DAS) of the patients.

Conclusions

The present study demonstrates abnormalities in the metabolic profile of an important region, DLPFC of the CSTC circuit, which is suggestive of neurodegeneration in the region in OCD patients.

Changes in insight throughout the natural four-year course of obsessive-compulsive disorder and its association with OCD severity and quality of life

Objective

Patients with obsessive-compulsive disorder (OCD) and poor insight show higher symptom severity, lower quality of life (QoL), and a reduced treatment response compared to patients with good insight. Little is known about changes in insight. This study explored the course of insight and its association with OCD severity and QoL among 253 patients with OCD participating in the prospective naturalistic Netherlands Obsessive Compulsive Disorder Association (NOCDA) Study.

Results

In 70% of the participants with available insight data, the level of insight changed during the four-year course. Insight was most variable in participants with poor insight. Improvement of insight scores was statistically significantly associated with improvement of Y-BOCS scores (r = 0.19), but not with changes in QoL scores. Change in insight in the first 2 years was not statistically significantly predictive of OCD severity or QoL at four-year follow-up.

Conclusion

These findings suggest that patients' levels of insight may change during the natural four-year course of OCD and that improvement in the level of insight have a positive association with improvement in OCD severity.

Predictors of EX/RP alone versus EX/RP with medication for adults with OCD: does medication status moderate outcomes?

Exposure and response prevention (EX/RP) can be delivered as monotherapy or to augment serotonin reuptake inhibitors (SRIs). While both options are considered effective OCD treatments, responses are heterogenous. Substantial work has investigated EX/RP predictors to account for this variability in responses, with mixed findings. Little research has studied whether EX/RP predictors may differ in medicated versus non-medicated samples (i.e., medication status as a moderator). We pooled data from two clinical trials conducted concurrently in the same specialty OCD clinic. One enrolled patients who were on stable SRI doses (EX/RP as SRI augmentation, n=58) while the other enrolled non-medicated patients (EX/RP monotherapy, n=38). Both trials used the same manualized EX/RP protocol and blinded independent evaluators. LASSO regression derived predictors and moderators of outcome. Improvement did not significantly differ between the EX/RP alone group and the SRI+EX/RP group. In both groups, higher baseline OCD severity and worse quality of life predicted poorer outcome. OCPD traits moderated results: Patients with more severe OCPD traits had better outcomes from EX/RP monotherapy than those receiving EX/RP with SRIs. Patient adherence to EX/RP homework mediated the associations between the baseline variables and outcome. The effect of OCPD traits on outcome warrants future study to improve care.

Brazilian research consortium on obsessive-compulsive spectrum disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part II: Cognitive-Behavior Therapy treatment

OBJECTIVE

To summarize the evidence-based cognitive-behavioral therapy (CBT) treatment and propose clinical interventions for adult patients with obsessive-compulsive disorder (OCD).

METHODS

A systematic review of the literature on CBT interventions for the treatment of adult OCD, comprising behavior therapy and exposure and response prevention (ERP) was done. The objective of this study is to present updated clinical guidelines to clinicians, providing comprehensive details regarding the necessary procedures to be incorporated into the CBT protocol. We searched the literature published from 2013-2020 in five databases (PubMed, Cochrane, Embase, Psycinfo and Lilacs), considering: study design, primary outcome measures, type of publication and language. Selected articles were assessed for quality with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association (ACC/AHA).

RESULTS

We examined 44 new studies used to update the APA guidelines from 2013. High-quality evidence supports CBT including ERP techniques as the first-line CBT treatment for OCD. In addition, protocols for internet-delivered CBT have also demonstrated their efficacy for the treatment of adults with OCD.

CONCLUSION

CBT based on ERP is a widely used treatment according to high-quality scientific evidence to treat adults with OCD.

Clinical Recommendations for Augmentation Agents in Obsessive-Compulsive Disorder Partially Responsive to Serotonin Reuptake Inhibitors

BACKGROUND

Obsessive-compulsive disorder (OCD) affects 2% to 3% of adults worldwide. Although serotonin reuptake inhibitors (SRIs) reliably demonstrate efficacy for this condition, 40% to 60% of patients only achieve partial recovery. The purpose of this systematic review was to assess the efficacy of other agents that may be used as augmentation agents for patients who are partial responders to SRI monotherapy.

METHODS

Using PRISMA-P guidelines, PubMed and Embase were searched using the randomized controlled trial (RCT) filter and the key word "obsessive-compulsive disorder." To be considered for analysis, a potential augmentation agent needed to have at least 2 RCTs. This review specifically analyzes the effect of each augmentation agent on OCD symptoms as measured by the Yale-Brown Obsessive-Compulsive Scale.

RESULTS

The augmentation agents analyzed in this review are d-cycloserine (2 RCTs), memantine (4 RCTs), N-acetylcysteine (5 RCTs), lamotrigine (2 RCTs), topiramate (3 RCTs), riluzole (2 RCTs), ondansetron (2 RCTs), celecoxib (2 RCTs), aripiprazole (5 RCTs), risperidone (7 RCTs), quetiapine (9 RCTs), and olanzapine (3 RCTs).

IMPLICATIONS

The augmentation agents most supported by this review for OCD that is only a partial response to SRI monotherapy are lamotrigine, memantine, and aripiprazole. If an antipsychotic must be used and aripiprazole is not tolerated, risperidone may be considered as an alternative. Unlike the SRI class effect for OCD symptom reduction, augmentation agents demonstrate considerable intraclass variability.

'Excessive and Unreasonable': The Relation Between Clinical Insight and Clinical Correlates and Treatment Outcomes in Obsessive-Compulsive Disorder Across the Life Course

Individuals with mental disorders possess varying levels of clinical insight-the degree to which one understands that they are afflicted with a mental disorder and that their symptoms are manifestations of this psychopathology. Although clinical insight in OCD is thought to play an especially important role in determining various clinical characteristics and treatment outcomes, insight has not been sufficiently addressed developmentally, the importance of which this review will elucidate. Findings from this review suggest that clinical insight is typically associated with more complex cases and worse treatment outcomes across the life course, and also reveal nuances between pediatric and adult OCD cases with low insight. Implications of these findings, future research directions, and recommendations for the field are discussed.

Pharmacological augmentation of serotonin reuptake inhibitors in patients with obsessive-compulsive disorder: A network meta-analysis

OBJECTIVES

The augmentation of serotonin reuptake inhibitors (SRIs) can be achieved by add-on therapy with different pharmacological agents in obsessive-compulsive disorder (OCD) for a better clinical outcome. This network meta-analysis (NMA) was conducted to evaluate and compare the effects of available augmentation agents for SRIs in OCD.

METHOD

The data was extracted from 59 relevant clinical trials after a literature search on MEDLINE/PubMed, Scopus, Cochrane databases and clinical trial registries. PRISMA guidelines were followed in data extraction, analysis and reporting. Random effects Bayesian NMA was done to pool the effects across the interventions for the change in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scoring from baseline to the end of the study. Network graph was built, consistency model was run, node splitting analysis was performed, treatments were ranked as per SUCRA score and meta-regression was done for refractoriness to SRIs and duration of augmentation therapy as the predictor variables.

RESULTS

The drugs showing significant reduction in YBOCS scoring were pregabalin (MD:-8.1;95% CrI: -16, -0.43), memantine (MD:-6.2;95% CrI: -9.9, -2.3), lamotrigine (MD:-6;95% CrI: -12, -0.47), ondansetron (MD:-5.7;95% CrI: -11, -0.67), granisetron (MD:-5.6;95% CrI: -11, -0.44), aripiprazole (MD:-5.4;95% CrI:-9.1, -1.6), risperidone (MD:-3.3;95% CrI: -6.4, -0.20) and topiramate (MD:-5.3;95% CrI: -9.6, -0.97). The node-split analysis showed that direct and indirect pooled effect sizes for all comparisons were comparable. Meta-regression showed a statistically non-significant association between YBOCS score reduction with the duration of augmentation therapy, but significant with SRI-refractory status. Finally, the results were sorted based on certainty of evidence.

CONCLUSION

Memantine was found to be most effective augmentation agent for SRIs in OCD, followed by lamotrigine, ondansetron and granisetron with moderate certainty of evidence. The augmentation agents showed better symptom reduction in patients with SRI-refractory OCD in comparison to non-refractory OCD.

PROSPERO REGISTRATION

CRD42022360110.

Identifying trajectories of symptom change in adults with obsessive compulsive disorder receiving exposure and response prevention therapy

Exposure and response prevention (EX/RP) is a recommended psychotherapy for obsessive-compulsive disorder (OCD). Yet, not all patients benefit equally from EX/RP. Prior studies have examined EX/RP predictors by predicting endpoint symptoms and/or pre-post symptom change, rather than accounting for trajectories of symptom change across treatment. We pooled data from four NIMH-funded clinical trials, yielding a large sample (N = 334) of adults who received a standard course of manualized EX/RP. Independent evaluators rated OCD severity using the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Data were analyzed using growth mixture modeling (GMM) to detect subgroups of participants with similar trajectories of symptom change followed by multinomial logistic regression to identify baseline variables capable of predicting class membership. GMM revealed three distinct trajectory classes: 22.5% of the sample showed dramatic improvement (dramatic progress class), 52.1% showed moderate improvement (moderate progress class), and 25.4% showed little change (little to no progress class). Membership in the little to no progress class was predicted by baseline avoidance and transdiagnostic internalizing factor levels. These findings suggest that OCD symptom improvement with outpatient EX/RP occurs via distinct trajectories. These findings have implication regarding identifying treatment non-responders and personalizing treatment depending one's baseline characteristics in order to optimize treatment effectiveness.

The Pharmacological Treatment of Obsessive-Compulsive Disorder

Pharmacological treatment is a mainstay of the care of individuals with obsessive-compulsive disorder. Robust evidence supports the use of the selective serotonin reuptake inhibitors and the older tricyclic drug clomipramine. Other antidepressants are less effective (or have been insufficiently studied). When first-line treatment with these agents, and with appropriate psychotherapy, is ineffective, several augmentation strategies are available, though their evidentiary support is weaker. A substantial minority of patients have persistent symptoms despite optimal evidence-based treatment. Further work and more treatment options are needed.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by the presence of debilitating obsessions and compulsions. Cognitive and behavioral models of OCD provide a strong theoretic and empirical foundation for informing effective psychotherapeutic treatment. Cognitive-behavioral therapy (CBT) for OCD, which includes a deliberate emphasis on exposure and response/ritual prevention, has consistently demonstrated robust efficacy for the treatment of pediatric and adult OCD and is the front-line psychotherapeutic treatment for OCD. Two case vignettes describing CBT for OCD in practice as well as recommendations for clinicians are provided.

Therapies for obsessive-compulsive disorder: Current state of the art and perspectives for approaching treatment-resistant patients

Even though obsessive compulsive disorder (OCD) is one of the ten most disabling diseases according to the WHO, only 30-40% of patients suffering from OCD seek specialized treatment. The currently available psychotherapeutic and pharmacological approaches, when properly applied, prove ineffective in about 10% of cases. The use of neuromodulation techniques, especially Deep Brain Stimulation, is highly promising for these clinical pictures and knowledge in this domain is constantly evolving. The aim of this paper is to provide a summary of the current knowledge about OCD treatment, while also discussing the more recent proposals for defining resistance.

Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials

OBJECTIVES

Treatment-resistant obsessive-compulsive disorder is a chronic debilitating illness. We conducted a network meta-analysis [NMA] to compare the efficacy of all interventions in SRI-resistant OCD from published Randomised controlled trials [RCT].

METHODS

We performed an NMA of RCTs in SRI resistant OCD from all modalities of treatments; pharmacological, psychological, neuromodulation, neurosurgery including deep brain stimulation. The design-by-treatment interaction inconsistency model within the frequentist framework was adopted with a change in Yale-Brown Obsessive-Compulsive Scale score as the primary outcome. We conducted sensitivity analyses excluding studies examining neurosurgical interventions, deep brain stimulation, studies in the paediatric population, and studies from a single geographical region. We also conducted analyses of interventions categorised into treatment groups.

RESULTS

55 RCTs examining 19 treatments or placebo involving 2011 participants were included in the NMA. Ondansetron [Standardised mean difference -2.01 (95% CI: -3.19, -0.83)], deep TMS [- 1.95 (-3.25, -0.65)], therapist administered Cognitive Behavioural Therapy [CBT-TA] [-1.46 (-2.93, 0.01)] and aripiprazole [-1.36 (-2.56, -0.17)] were ranked as the best four treatments on using the Surface Under the Cumulative Ranking [SUCRA] percentage values (85.4%, 83.2%, 80.3%, 67.9% respectively). While all four interventions had large effect sizes, CBT[TA] narrowly missed statistical significance in our analysis. In sensitivity analyses, deep TMS was ranked as the best treatment strategy for SRI-resistant OCD. The small number of subjects in individual studies, higher confidence interval limits, and wider prediction interval for most agents warrant a cautious interpretation.

CONCLUSIONS

Considering the principal analysis and sensitivity analyses together, deep TMS, ondansetron, CBT[TA], and aripiprazole may be considered a first-line intervention for SRI-resistant OCD in adults.

OTHER

This work was not funded. The NMA has been registered with PROSPERO, [Registration number: CRD42020173589].

Is mirtazapine augmentation effective for patients with obsessive-compulsive disorder who failed to respond to sertraline monotherapy? A placebo-controlled, double-blind, clinical trial

Mirtazapine upsurges serotonergic activity by a mechanism different from reuptake inhibition. Our aim is to assess the efficacy of mirtazapine augmentation for patients with obsessive-compulsive disorder (OCD) who did not respond to sertraline monotherapy. Sixty-one patients suffering from OCD who were resistant to sertraline monotherapy were randomly allocated to receive mirtazapine (mean dosage = 39.56 mg/day) or placebo plus their current anti-OCD treatment (sertraline: average dose = 251.37 mg/day and 255.10 mg/day in the mirtazapine and placebo groups, respectively; P = 0.871). The primary outcome was OCD symptom severity as measured by Yale-Brown Obsessive-Compulsive Scale (YBOCS). Forty-five patients (22 in the mirtazapine group and 23 in the placebo group) completed the trial. Average YBOCS score decreased in the mirtazapine group from 27.14 ± 8.05 at baseline to 11.13 ± 4.27 at week 12. In the placebo group, average YBOCS score declined from 28.15 ± 3.27 at baseline to 18.94 ± 3.88 at week 12. Nine patients (40.90%) in the mirtazapine group and only one patient (4.34%) in the placebo group revealed at least a 35% decrease in YBOCS ( P < 0.000). We found that mirtazapine adds to the effect of sertraline in improving obsessive and compulsive symptoms in OCD patients.

The Therapeutic Effect of Electroconvulsive Therapy in Patients With Obsessive-compulsive Disorder: A Quasi-experimental Study

Introduction

Electroconvulsive therapy (ECT) is an effective treatment for some psychiatric disorders. It is postulated that ECT should primarily be considered for patients with treatment-resistant obsessive-compulsive disorder (OCD) in the context of major depression. Therefore, we aimed to evaluate the efficacy of ECT in OCD patients without comorbid psychiatric disorders.

Methods

This quasi-experimental study was conducted on 12 adult patients with severe OCD (Yale-Brown test score above 25) and no comorbid psychiatric disorders referred to a tertiary care hospital for psychiatric disorders. Treatment was administered three times a week for up to three to four weeks (a minimum of 8 sessions and a maximum of 12 sessions). We completed the Yale-Brown test for all patients before ECT, on the day after applying ECT, and two months after the final ECT session to evaluate the effect of therapy.

Results

Yale-Brown patients' Mean±SD significantly decreased after the ECT sessions from 28.08±2.50 to 17.17±3.78 (P=0.043). After treatment, the severity of OCD decreased in all patients and turned to mild and moderate levels in 4 patients (33.3%) and 8 (66.7%), respectively. After two months, the Mean±SD Yale-Brown score slightly increased to 18.08±1.62 (P=0.125), and the severity of OCD in all 12 patients (100%) became moderate. Nevertheless, in none of them, the Yale-Brown score increased and returned to the baseline value in this period. None of the patients developed significant side effects during or after ECT sessions.

Conclusion

ECT was a safe and effective therapeutic strategy for patients with treatment-resistant OCD with no comorbid psychiatric disorders. However, further randomized controlled trials are required to validate the efficacy of ECT for OCD treatment before implementing it in the routine clinical practice.

Serotonin reuptake inhibitor-cognitive behavioural therapy-second generation antipsychotic combination for severe treatment-resistant obsessive-compulsive disorder. A prospective observational study

INTRODUCTION

Six in ten patients with obsessive-compulsive disorder (OCD) do not respond to the first-line treatments with serotonin reuptake inhibitor (SRI) or cognitive behavioural therapy including exposure and response prevention (CBT/ERP), and several do not respond to second-line treatments, i.e., SRI-second generation antipsychotic (SGA) or SRI-CBT/ERP augmentation. Evidence on third-line treatments is inconsistent.

OBJECTIVE

We investigated the 1-year response to SRI-CBT/ERP-SGA combination in patients with severe treatment-resistant OCD, who failed to respond to SRI and to SRI-SGA or SRI-CBT/ERP augmentation.

METHODS

Twenty-eight patients were consecutively recruited and treated with SRI (drug(s) and doses previously administered), SGA (risperidone median dosage 1 mg/day in 14 cases, aripiprazole median dosage 3 mg/day in 14 cases) and CBT/ERP (median hours 32.5). Exclusion criteria: mental retardation and organic brain syndrome.

RESULTS

The mean Y-BOCS total score reduction at 12 months was 28.2%, 60.7% of patients improved, 46.4% partially responded, 32.1% responded, and 28.6% remitted. Patients previously resistant to SRI-SGA and SRI-CBT/ERP did not significantly differ in the rates of improvement, partial response, response and remission.

CONCLUSIONS

This study suggests that SRI-SGA-CBT/ERP combination could be useful for severe treatment-resistant OCD. Small sample size is a limitation.Key pointsUp to 6 in 10 patients with OCD do not respond to first line treatments (CBT/ERP or SRIs) and several to second-line treatments (SRI-SGA or SRI CBT/ERP augmentation).In our study, patients with OCD resistant to the first and the second line treatment improved (61%), partially responded (46%), responded (32%), or remitted (29%) combining SRI, SGA and CBT/ERP.In our patients the SRI-SGA-CBT/ERP augmentation improved working/school, social and family impairment.SRI-SGA-CBT/ERP augmentation is easier to use than other treatments for severe treatment-resistant OCD.

The efficacy of brief strategic therapy in treating obsessive-compulsive disorder: a case series

BACKGROUND AND AIM

International guidelines indicate pharmacological therapy and cognitive-behavioral therapy (CBT) as gold standard treatments for obsessive-compulsive disorder (OCD). However, up to 40% patients do not fully respond to CBT, thus manifesting persistent symptomatology. Empirical research reported brief strategic therapy (BST) as a potential treatment for OCD. The aim of the present study is to evaluate the efficacy of BST in treating OCD and to identify the clinical characteristics associated to response.

METHODS

BST protocol was administered to patients with OCD. During a 24-weeks observational phase, the following scales have been administered at the baseline and every 4 weeks: Yale Brown Obsessive-Compulsive scale (Y-BOCS), Clinical Global Impression, Global Assessment of Functioning, Quality of Life Index, Medical Outcomes Study Short Form 12-item, Clinical Outcomes in Routine Evaluation-Outcome Measure, Generalized Anxiety Disorder Scale, Patient Health Questionnaire - 9 and Somatic Symptom Scale-8.

RESULTS

eight patients completed the treatment and a subgroup of five patients obtained clinical remission, defined as Y-BOCS total score < 25. The repeated measures ANOVA performed showed a significant decreased of the Y-BOCS total scores (p<.001). Comparisons between the two subgroups (remitters vs. non-remitters) highlighted some potential baseline characteristics associated with remission: i.e., higher mean level of anxiety, quality of life, physical health, and lower mean level of somatic symptoms and lower prevalence of personality disorders comorbidity.

CONCLUSIONS

BST could be a useful therapeutic strategy in treating OCD patients. Further studies with larger samples and with long-term follow-up are needed to assess the post-treatment maintenance of clinical effects.

Adjunctive neuronavigated accelerated continuous theta-burst stimulation in obsessive-compulsive disorder: a randomized sham-controlled study

BACKGROUND

Approximately 40% of patients treated for obsessive-compulsive disorder (OCD) do not respond to standard and second-line augmentation treatments leading to the exploration of alternate biological treatments. Continuous theta burst stimulation (cTBS) is a form of repetitive transcranial magnetic stimulation inducing more rapid and longer-lasting effects on synaptic plasticity than the latter. To the best of our knowledge, only one recent study and a case report investigated the effect of cTBS at the supplementary motor area (SMA) in OCD.

OBJECTIVE

This study aimed to examine the effect of accelerated robotized neuronavigated cTBS over SMA in patients with OCD.

METHODS

A total of 32 patients with OCD were enrolled and randomized into active and sham cTBS groups. For active cTBS stimulation, an accelerated protocol was used. Bursts of three stimuli at 50 Hz, at 80% of MT, repeated at 5 Hz were used. Daily 2 sessions of 900 pulses each, for a total of 30 sessions over 3 wk (weekly 10 sessions), were given. Yale-Brown Obsessive-Compulsive Rating Scale (YBOCS), Clinical Global Impressions scale (CGI), Hamilton Depression Rating Scale (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A) were administered at baseline and at end of weeks 3 and 8.

RESULTS

A total of 26 patients completed the study. Active cTBS group showed significant group × time effect in YBOCS obsession (P < .001, η2 = 0.288), compulsion (P = .004, η2 = 0.207), YBOCS total (P < .001, η2 = 0.288), CGI-S (P = .010, η2 = 0.248), CGI-C (P = .010, η2 = 0.248), HAM-D (P = .014, η2 = 0.224) than sham cTBS group.

CONCLUSIONS

Findings from our study suggest that adjunctive accelerated cTBS significantly improves psychopathology, severity of illness, and depression among patients with OCD. Future studies with larger sample sizes will add to our knowledge.

[Treatment of obsessive-compulsive disorders: recommendations of the revised S3 guidelines on obsessive-compulsive disorders]

In 2022, the first revised version of the S3 guidelines on obsessive-compulsive disorder will be published under the auspices of the German Society for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). This article contains a summary of the most important recommendations for therapy in a condensed form. There were no major changes in the central basic therapy recommendations compared with the first version of the guidelines, as the evidence base has not fundamentally changed since then. Cognitive behavioral therapy (CBT) with exposure and response management is the most effective form of therapy for this clinical picture and therefore the therapy of first choice. Regarding pharmacotherapy, selective serotonin reuptake inhibitors are the first-line medications. They are indicated when CBT with exposure is not available or has not been effective, when CBT is rejected by the patient and in the patient's personal preference for medication, or to increase the readiness for CBT with exposure. New recommendations include, e.g., the use of Internet therapy, and recommendations for the use of CBT and exposure, e.g., also in group format, including video conferencing if appropriate as well as in intensive format.

Optimizing first line treatments for adults with OCD

OCD is characterized by obsessions (recurrent, intrusive, unwanted thoughts, images or impulses and compulsions (repetitive behaviors or mental acts that the individual feels compelled to perform), which can manifest together or separately (Fineberg et al., 2020). NICE guidelines suggest that low intensity psychological treatments (including ERP) is the first line treatment for OCD, and that a "stepped care" treatment approach for OCD reserves combination treatment for adults with OCD with severe functional impairment, and for adults without an adequate response to: 1) treatment with an SSRI alone (12 weeks duration) or 2) CBT (including ERP) alone (NICE, 2005). Existing US treatment guidelines (APA guidelines) suggest that there are three first-line treatments for OCD (SSRI, CBT, SSRI+CBT) and recommends combined treatment for patients with an unsatisfactory response to monotherapy or for patients with severe OCD. Although, systematic review and meta-analysis of studies published in 1993-2014 suggest that combination treatment was not significantly better than CBT plus placebo (Ost et al., 2015), based on data from a recent systematic and meta-analysis which searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group, the combination treatment approach is likely to be more effective than psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder (Skapinakis et al., 2016a). Based on data from Optimal treatment for OCD study conducted by Fineberg et al., (2018) combined treatment appeared to be the most effective especially when compared to CBT monotherapy, but SSRI monotherapy was found as the most cost effective. In this review we summarize available treatment recommendations.

Morbidity and mortality in obsessive-compulsive disorder: A narrative review

Current knowledge on the general somatic health of individuals with obsessive-compulsive disorder (OCD) is very limited. Here, we critically review the emerging literature on the topic. Rapidly accumulating evidence indicates an association between OCD and autoimmune diseases, which is not limited to streptococcus-related conditions. Similarly, an association with metabolic and circulatory system diseases has been reported, which is at least partially independent from psychiatric comorbidities and familial confounders. Preliminary results also suggest potential links with dementia, insomnia, respiratory diseases, gastrointestinal diseases, migraine, and chronic pain, but replication is warranted. The risk of death by suicide in OCD is now well established. OCD has also been associated to increased mortality due to natural causes, but more research on specific causes of death is needed. Clarification of the mechanisms behind the observed associations will be critical to inform the rational design of prevention efforts. In the meantime, while OCD symptom reduction remains a priority, clinicians should also focus on monitoring the general health and promoting healthy lifestyles of persons with OCD.

Maintenance of Wellness in Patients With Obsessive-Compulsive Disorder Who Discontinue Medication After Exposure/Response Prevention Augmentation: A Randomized Clinical Trial

IMPORTANCE

Serotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs.

OBJECTIVE

To assess whether patients with OCD who are taking SRIs and have attained wellness after EX/RP augmentation can discontinue their SRI with noninferior outcomes compared with those who continue their SRI therapy.

DESIGN, SETTING, AND PARTICIPANTS

A 24-week, double-blind, randomized clinical trial was performed from May 3, 2013, to June 25, 2018. The trial took place at US academic medical centers. Participants included 137 adults with a principal diagnosis of OCD (≥1 year) who were taking an SRI (≥12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score ≥18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score ≤14 points; 103 patients [75.2%]) were study eligible. Data were analyzed from June 29, 2019, to October 2, 2021.

INTERVENTION

Participants were randomly assigned either to receive taper to placebo (taper group) or to continue their SRI (continuation group) and monitored for 24 weeks.

MAIN OUTCOME AND MEASURES

The Y-BOCS score (range, 0-40 points) was the primary outcome; the Hamilton Depression Rating Scale (HDRS; range, 0-52 points) and the Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF; range, 0%-100%) scores were secondary outcomes. Outcomes were assessed at 8 time points by independent evaluators who were blinded to randomization. The taper regimen was hypothesized to be noninferior to continuation at 24 weeks using a 1-sided α value of .05.

RESULTS

A total of 101 patients (mean [SD] age, 31.0 [11.2] years; 55 women [54.5%]) participated in the trial: 51 patients (50.5%) in the taper group and 50 patients (49.5%) in the continuation group. At 24 weeks, patients in the taper group had noninferior results compared with patients in the continuation group (mean [SD] Y-BOCS score: taper group, 11.47 [6.56] points; continuation group: 11.51 [5.97] points; difference, -0.04 points; 1-sided 95% CI, -∞ to 2.09 points [below the noninferiority margin of 3.0 points]; mean [SD] HDRS score: taper group, 5.69 [3.84] points; continuation group, 4.61 [3.46] points; difference, 1.08 points; 1-sided 95% CI, -∞ to 2.28 points [below the noninferiority margin of 2.5 points]; mean [SD] Q-LES-Q-SF score: taper group, 68.01% [15.28%]; continuation group, 70.01% [15.59%]; difference, 2.00%; 1-sided 95% CI, -∞ to 6.83 [below the noninferiority margin of 7.75]). However, the taper group had higher rates of clinical worsening (23 of 51 [45%] vs 12 of 50 [24%]; P = .04).

CONCLUSIONS AND RELEVANCE

Results of this randomized clinical trial show that patients with OCD who achieve wellness after EX/RP therapy could, on average, discontinue their SRI with noninferior outcomes compared with those who continued their SRI. Those who tapered the SRI had higher clinical worsening rates. Future research should evaluate if SRI half-life alters these rates.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01686087.

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.

Neurobiological outcomes of cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review

INTRODUCTION

Obsessive-compulsive disorder (OCD) is characterized by recurrent distressing thoughts and repetitive behaviors, or mental rituals performed to reduce anxiety. Recent neurobiological techniques have been particularly convincing in suggesting that cortico-striatal-thalamic-cortico (CSTC) circuits, including orbitofrontal cortex (OFC) and striatum regions (caudate nucleus and putamen), are responsible for mediation of OCD symptoms. However, it is still unclear how these regions are affected by OCD treatments in adult patients. To address this yet open question, we conducted a systematic review of all studies examining neurobiological changes before and after first-line psychological OCD treatment, i.e., cognitive-behavioral therapy (CBT).

METHODS

Studies were included if they were conducted in adults with OCD and they assessed the neurobiological effects of CBT before and after treatment. Two databases were searched: PsycINFO and PubMed for the time frame up to May 2022.

RESULTS

We obtained 26 pre-post CBT treatment studies performed using different neurobiological techniques, namely functional magnetic resonance imaging (fMRI), Positron emission tomography (PET), regional cerebral blood flow (rCBF), 5-HT concentration, magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), Electroencephalography (EEG). Neurobiological data show the following after CBT intervention: (i) reduced activations in OFC across fMRI, EEG, and rCBF; (ii) decreased activity in striatum regions across fMRI, rCBF, PET, and MRI; (iii) increased activations in cerebellum (CER) across fMRI and MRI; (iv) enhanced neurochemical concentrations in MRS studies in OFC, anterior cingulate cortex (ACC) and striatum regions. Most of these neurobiological changes are also accompanied by an improvement in symptom severity as assessed by a reduction in the Y-BOCS scores.

CONCLUSION

Cognitive-behavioral therapy seems to be able to restructure, modify, and transform the neurobiological component of OCD, in addition to the clinical symptoms. Nevertheless, further studies are necessary to frame the OCD spectrum in a dimensional way.

The effectiveness of exposure and response prevention combined with pharmacotherapy for obsessive-compulsive disorder: A systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the effectiveness of exposure and response prevention (ERP) combined with medication on obsessive-compulsive disorder (OCD).

METHODS

PubMed, Web of Science, EBSCO, Cochrane, Embase, and Science Direct databases were searched to include randomized controlled trials of ERP combined with medication for OCD that met the criteria. The Yale Brown Obsessive Compulsive Scale was used as the primary outcome indicator, and Depression scales were used as secondary outcome indicators. An evaluation of bias risk was conducted to identify possible sources of bias based on methodological and clinical factors. Review Manager 5.3 and Stata 16.0 software was used to perform meta-analysis of the extracted data.

RESULTS

A total of 21 studies with 1113 patients were included. Meta-analysis showed that ERP combined with medication therapy was significantly better than medication therapy alone including selective serotonin reuptake inhibitors, clomipramine and risperidone (MD = -6.60, 95% CI: -8.35 to -4.84, P < 0.00001), but D-cycloserine (DCS) drugs do not enhance the effect of ERP intervention in patients with OCD (MD = 0.15, 95% CI: -0.87 to 1.17, P = 0.77). There is more significant maintenance by combined treatment method of medication plus ERP than medication treatment alone during the follow-up period (MD = -7.14, 95% CI: -9.17 to -5.10, P < 0.00001). DCS drugs did not enhance the effect of ERP intervention on depression in patients with OCD (SMD = -0.08, 95% CI: -0.31 to 0.15, P = 0.50). ERP combined with drug improved patients' depression levels significantly better than providing drug alone (SMD = -0.40, 95% CI: -0.68 to -0.11, P = 0.006).

CONCLUSION

Patients with OCD have significant improvement in symptoms of obsessive-compulsive disorder and depression when ERP is combined with medication, however, not enough to prove that DCS can enhance ERP effectiveness.

Pharmacological and Psychotherapeutic Interventions for Management of Obsessive-compulsive Disorder in Adults: A Systematic Review and Network Meta-analysis

Reprinted under Creative Commons CC-BY license.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Defining and Addressing Gaps in Care for Obsessive-Compulsive Disorder in the United States

OBJECTIVE

Obsessive-compulsive disorder (OCD) can be a chronic and disabling illness with a lifetime prevalence of 2%, twice that of schizophrenia. Although effective treatments exist, OCD often remains underdetected and undertreated.

METHODS

The authors performed a scoping review of the literature (of articles in PubMed and PsycINFO published from January 1, 2000, to February 1, 2020) to define gaps in OCD diagnosis and treatment among U.S. adults. Interventions at the patient, clinician, and health care system levels used to address these gaps are described, and promising approaches from around the world are highlighted.

RESULTS

Of 102 potential studies identified in the search, 27 (including five non-U.S. studies) were included. The studies revealed that lack of clinician and patient knowledge about OCD and misdiagnosis contributes to its underdetection. Suboptimal prescribing of selective serotonin reuptake inhibitor medications and limited use of exposure and response prevention, as a first-line psychotherapy, contribute to OCD undertreatment. Digital health technologies show promise in increasing OCD detection and delivery of evidence-based care and in ensuring continuity of care (including during the COVID-19 pandemic).

CONCLUSIONS

Given the significant rates of disability, morbidity, and mortality associated with OCD, addressing gaps in OCD care will reduce the U.S. burden of mental illness. Further research is needed to determine how the use of digital health technologies can increase the detection and management of OCD.

Transcranial direct current stimulation for treatment-resistant obsessive-compulsive disorder-A large case series

OBJECTIVE

The present study is a large case series evaluating the benefits of transcranial direct current stimulation (tDCS) in treatment-resistant obsessive compulsive disorder (OCD).

METHODS

We reviewed the charts of 32 patients with treatment-resistant OCD who received 10-20 sessions of anodal pre-SMA tDCS.

RESULTS

Overall, 9 (28 %) showed at least partial response to tDCS at the end of 10-20 sessions [responders = 8 (25 %), partial responders = 1 (3%)]. Two out of three partial responders at the end of 10 sessions had response at the end of 20 sessions.

CONCLUSIONS

tDCS may benefit a proportion of patients with treatment-resistant OCD.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.

Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration.

OBJECTIVE

To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo.

METHODS

A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies.

RESULTS

A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change ≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery.

CONCLUSION

LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.

Integrating Exposure and Response Prevention With a Mobile App to Treat Obsessive-Compulsive Disorder: Feasibility, Acceptability, and Preliminary Effects

Many individuals with obsessive-compulsive disorder (OCD) do not receive evidence-based care (specifically exposure and ritual prevention; EX/RP) due to barriers such as a lack of EX/RP-trained clinicians, geographic obstacles, and the cost and time associated with the treatment. Offering an integrated treatment model consisting of brief in-person therapy coupled with a mobile application (app) might be one way to increase access to and reduce the time burden (to clinicians and patients) of EX/RP. This pilot trial evaluated the feasibility, acceptability, and clinical effects of such a treatment program for adults with OCD. Thirty-three participants enrolled in the 8-week open trial. The integrated treatment program consisted of 3 to 5 in-person sessions followed by weekly phone calls supported by a mobile app (nOCD). Participants were evaluated by trained raters and completed self-report measures at baseline, midtreatment, posttreatment and 2-month follow-up; the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was the primary outcome. This integrated treatment program was feasible and acceptable to participants. Of the 33 study entrants, 14 (42%) responded to treatment (Y-BOCS decrease ≥35% with CGI- of 1 or 2), and 8 (24%) achieved minimal symptoms (i.e., Y-BOCS ≤12). At 2-month follow-up (n=20), 7/20 (35%) met criteria for treatment response, and 3/20 (15.0%) met criteria for treatment remission. Although preliminary, this model warrants further study as an efficacious and resource-efficient way to deliver EX/RP for some patients with OCD.

Pharmacotherapeutic Strategies and New Targets in OCD

Effective pharmacological and psychotherapeutic treatments are well established for obsessive-compulsive disorder (OCD). Serotonin reuptake inhibitors (SRIs) are first-line treatment and are of benefit to about half of patients. Augmentation of SRI treatment with low-dose neuroleptics is an evidence-based second-line strategy. Specialty psychotherapy is also used as both first-line and second-line treatment and can benefit many. However, a substantial number of patients do not respond to these treatments. New alternatives are urgently needed. This review summarizes evidence for these established pharmacotherapeutic strategies, and for others that have been investigated in refractory disease but are not supported by the same level of evidence. We focus on three neurotransmitter systems in the brain: serotonin, dopamine, and glutamate. We summarize evidence from genetic, neuroimaging, animal model, and other lines of investigation that probe these three systems in patients with OCD. We also review recent work on predictors of response to current treatments. While many studies suggest abnormalities that may provide insight into the pathophysiology of the disorder, most studies have been small, and non-replication of reported findings has been common. Nevertheless, the gradual accrual of evidence for neurotransmitter dysregulation may in time lead the way to new pharmacological strategies.

Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is an important cause of global health-related disability. In the last several decades, exposure and response prevention (EX/RP) has emerged as one of the most evidence-based treatments for adult and pediatric OCD. Recommended as a first-line treatment in practice guidelines for OCD, EX/RP, when expertly delivered, can be superior to serotonin reuptake inhibitor (SRI) medications alone and superior to adding antipsychotic medication to augment SRI treatment response. Despite a robust evidence base, EX/RP is not widely available. Moreover, although effective, only about half of patients who receive a standard course of EX/RP will achieve remission.This chapter will review innovations in delivering EX/RP, focusing on technology-based methods designed to increase access to EX/RP and translational neuroscience approaches to personalizing and optimizing EX/RP. Technology-based innovations to deliver EX/RP include video conferencing, internet-based treatment, and smartphone apps. Of these, internet-based, clinician-supported treatment has the most evidence base to date. Relevant to all technology-based innovations are the need for advances in the ethical, regulatory and financial aspects of understanding how access to EX/RP may be delivered to individuals of diverse socioeconomic backgrounds in accordance with professional standards and regulations and covered by healthcare.Advances in our understanding of the neural processes underlying learning and memory have led to new ways to combine EX/RP with medications, behavioral interventions, or neuromodulatory methods, with the goal of enhancing the functioning of brain circuits that subserve fear processing and cognitive control. Among the pharmacological approaches to enhancing EX/RP outcome, both ketamine and cannabinoids show promise in small open trials but are in need of further study. Studies to train cognitive control are at an early stage of development yet provide preliminary evidence that training neural processes may be a new path to personalize treatment. How best to combine EX/RP with different types of neuromodulation is being actively studied.Together these innovations in the delivery of EX/RP for OCD hold great promise for improving outcomes of care for individuals with OCD by increasing the availability and the individual treatment effects of this already effective treatment.

Long-term Outcomes of Intensive Inpatient Care for Severe, Resistant Obsessive-Compulsive Disorder: Résultats à long terme de soins intensifs à des patients hospitalisés pour un trouble obsessionnel-compulsif grave et résistant

OBJECTIVE

A substantial proportion of severely ill patients with obsessive-compulsive disorder (OCD) do not respond to serotonin reuptake inhibitors (SRIs) and are unable to practice cognitive behavioral therapy (CBT) on an out-patient basis. We report the short-term (at discharge) and long-term (up to 2 years) outcome of a multimodal inpatient treatment program that included therapist-assisted intensive CBT with adjunctive pharmacotherapy for severely ill OCD patients who are often resistant to SRIs and are either unresponsive or unable to practice outpatient CBT.

METHODS

A total of 420 patients, admitted between January 2012 and December 2017 were eligible for the analysis. They were evaluated using the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive Compulsive Scale (YBOCS), and the Clinical Global Impression (CGI) scale. All patients received 4 to 5 therapist-assisted CBT sessions per week along with standard pharmacotherapy. Naturalistic follow-up information at 3, 6, 12, and 24 months were recorded.

RESULTS

At baseline, patients were mostly severely ill (YBOCS = 29.9 ± 4.5) and nonresponsive to ≥2 SRIs (83%). Mean duration of inpatient stay was 42.7 ± 25.3 days. At discharge, there was a significant decline in the mean YBOCS score (29.9 ± 4.5 vs. 18.1 ± 7.7, P < .001, Cohen's d = 1.64); 211/420 (50%) were responders (≥35% YBOCS reduction and CGI-I≤2) and an additional 86/420 (21%) were partial responders (25% to 35% YBOCS reduction and CGI-I≤3). Using latent class growth modeling of the follow-up data, 4 distinct classes were identified, which include "remitters" (14.5%), "responders" (36.5%), "minimal responders" (34.7%), and "nonresponders" (14.6%). Shorter duration of illness, better insight, and lesser contamination/washing symptoms predicted better response in both short- and long-term follow-up.

CONCLUSION

Intensive, inpatient-based care for OCD may be an effective option for patients with severe OCD and should be considered routinely in those who do not respond with outpatient treatment.

A prospective study of intensive in-patient treatment for obsessive-compulsive disorder

Multimodal in-patient treatment incorporating intensive cognitive-behaviour therapy (CBT) and medication management is a promising alternative for obsessive-compulsive disorder (OCD) patients who do not respond to standard out-patient treatment. We prospectively examined the short-term outcome and predictors of outcome of intensive in-patient treatment in a largely pharmacotherapy-resistant OCD sample. Fifty eight consecutive patients, admitted for treatment of OCD were evaluated at admission, at discharge and 2 months post-discharge for psychiatric diagnosis, personality disorders, obsessive beliefs, insight into obsessions and severity of obsessive-compulsive, depressive and anxiety symptoms. All patients received comprehensive treatment consisting of a combination of pharmacotherapy and intensive CBT. The mean Y-BOCS score was 29.38(±5.72) at admission, which reduced to 16.62(±7.91) at discharge and 16.75(±8.85) at follow-up. Thirty five participants (60.3%) met the prespecified criteria for response and 19 (32.8%) for remission. There was a significant reduction in Y-BOCS scores at discharge [43.67 (23.81)%] and post-discharge follow-up [2.18 (29.32)%] as compared to baseline (p<0.01). Baseline Browns Assessment of Beleifs Scale score (insight) was the only variable that statistically differentiated responders and non-responders. In-patient treatment is an effective treatment for medication resistant, severe and chronic OCD. Poor insight is a potential predictor of non-response to in-patient treatment.

Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.

Cognitive-Behavioral Therapy Versus Transcranial Direct Current Stimulation for Augmenting Selective Serotonin Reuptake Inhibitors in Obsessive-Compulsive Disorder Patients

Introduction:

Obsessive-Compulsive Disorder (OCD) belongs to the categories of psychiatric disorders with the potential to turn into a chronic condition without receiving the necessary treatments. The main feature of OCD is the frequent or intense obsession and compulsion that might induce great pain and suffering in patients. Moreover, as one of the most prevalent abnormalities, depression usually follows OCD. The present study aimed to compare the effects of Exposure and Response Prevention (ERP) and Transcranial Direct Current Stimulation (tDCS) treatments adjunct to pharmacotherapy on decreasing the severity of obsession-depression symptoms and improving the quality of life in OCD patients.

Methods:

This was a quasi-experimental study with a pre-test, post-test design and a follow-up stage. The statistical population comprised all the patients diagnosed with OCD in Zanjan Province, Iran. Besides, 26 OCD patients referring to Shahid Beheshti Medical Center in Zanjan were selected using a purposive sampling method. Then, they were randomly assigned to two treatment groups. The study subjects completed the Yale Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory-II (BDI 2), and the Quality of Life Questionnaire at the pre-treatment, post-treatment, and follow-up stages (1 month and 2 months after the treatment). Analysis of Covariance (ANCOVA) and Reliable Change Index (RCI) methods were used to measure statistical and clinical significances, respectively. The collected data were analyzed using SPSS.

Results:

The obtained data suggested no significant difference between the ERP and tDCS groups concerning the symptoms of OCD and depression at the post-test stage (P>0.05). Conversely, in terms of life quality, there was a significant difference between the ERP and tDCS groups at the post-test phase (P<0.05).

Conclusion:

Although the present findings revealed no statistically significant difference between the ERP and tDCS groups (except for the quality of life variable), the pharmacotherapy-ERP combination proved to be more effective than pharmaco therapy-tDCS in treating OCD patients.