There are those who fear their house is going to burn down unless they check and recheck the stove. And there are women who believe they are as depraved as serial killers because they think about harming their babies.

These are individuals with obsessive-compulsive disorder. And three different kinds of treatments may well help them, two psychiatrists who specialize in the disorder reported at APA’s annual meeting in San Francisco in May at the symposium "New Research and Novel Therapeutic Strategies for OCD." The symposium focused on what the presenters judge as the top three most-effective treatments for people with this disorder.

The selective serotonin-reuptake inhibitors (SSRIs), of course, are one of the trio, Brian Fallon, M.D., an associate professor of psychiatry at Columbia University and a researcher on obsessive-compulsive disorder, pointed out. For instance, studies have found that 20 mg, 40 mg, or 60 mg daily of fluoxetine are more effective than a placebo in treating people with the disorder. The same for a 50 mg or a 200 mg daily dose of sertraline. In these trials, the SSRIs reduced obsessive-compulsive symptoms between 20 percent and 28 percent.

Another member of the trio, Fallon continued, is the potent serotonin and norepinephrine reuptake blocker clomipramine. Multicenter trials have found that it can reduce obsessive-compulsive symptoms 36 percent to 46 percent. However, "there are no dose-finding studies for clomipramine that I know of," he added, "so that we really can’t say whether 150 mg is as good as 250 mg."

How do the SSRIs stack up against clomipramine in treating patients with obsessive-compulsive disorder? All double-blind trials that have compared clomipramine and the SSRIs have found them equally effective, Fallon said. Thus, "it is unlikely that clomipramine is more effective than the SSRIs," he concluded. Of course, he added, "that is not to say that there won’t be individual patients for whom one SSRI is better than another, or for whom clomipramine works when none of the SSRIs works. And it is reported that maybe 15 percent to 20 percent of patients will improve when you switch to another one of these standard agents."

Finally, the third member of the trio—yet one with which psychiatrists may not be familiar—is a kind of cognitive-behavior therapy called exposure and ritual prevention (EXRP) therapy. So reported H. Blair Simpson, M.D., Ph.D., of the Anxiety Disorders Clinic of the New York State Psychiatric Institute.

At the start of EXRP therapy, Simpson explained, the therapist spends time building an alliance with the patient, reviewing the treatment rationale, constructing a hierarchy of the patient’s feared situations or objects, then planning with the patient how and when to confront the feared situations or objects. The meat of the treatment is exposure sessions in which the therapist exposes the patient to situations or objects in progressive steps from those that generate moderate fear to high fear without the patient’s engaging in rituals (compulsions) for protection. While at home, the patient also practices confronting the feared situations or objects without ritualizing.

A number of studies have indicated that EXRP therapy counters obsessive-compulsive disorder, Simpson said. One was a large collaborative study in which she participated with colleagues not just from her clinic but also from the Center for the Treatment and the Study of Anxiety in Philadelphia.

In this 12-week study, 122 subjects who had had obsessive-compulsive disorder on average for 16 years were randomly assigned to one of four treatment arms. The first group received a fixed daily dose of clomipramine up to 200 mg daily, and if a subject did not respond to 200 mg, then it could be increased up to 250 mg. (The average daily dose for the group was 235 mg.) The second group received EXRP therapy five times a week for three weeks plus two home visits. The third group got clomipramine plus EXRP therapy. (The average daily clomipramine dose for the group was 194 mg.) The fourth group was given a placebo instead of medication and did not receive EXRP therapy.

All the subjects were assessed every four weeks over the 12-week study using a variety of rating scales. Both clomipramine alone and EXRP alone were significantly superior to placebo in reducing obsessive-compulsive symptoms, Simpson and her team found. What’s more, EXRP therapy was found to be superior to clomipramine in most analyses. However, EXRP therapy plus clomipramine, while superior to clomipramine alone, was not better than EXRP therapy alone.

These results thus suggest that EXRP therapy can help patients with obsessive-compulsive disorder, Simpson concluded. Still, it is no panacea, she admitted—for instance, it reduced symptoms 60 percent, but "60 percent isn’t 100 percent." Also, she pointed out, "you need skilled therapists to deliver the therapy in a correct manner, and skilled therapists are in short supply."

Nonetheless, "I would advocate that every OCD patient you see should be told about medication and EXRP therapy," Simpson declared. "That is standard care and correct care." ▪