APA’s 2007 practice guideline on obsessive-compulsive disorder (OCD) remains substantially correct and current in its recommendations, according to a new guideline “watch.”
More data are available regarding rates of response to some interventions, new rating scales have been developed, and preliminary studies suggest additional treatments or modes of delivery that deserve further study, according to the guideline watch.
The guideline watch was written by Lorrin Koran, M.D., and H. Blair Simpson, M.D., Ph.D., who were members of the APA work group that developed the 2007 guideline.
Guideline watches summarize significant developments in practice that have occurred since publication of an APA practice guideline. Watches may be written and reviewed by experts associated with the original guideline development and are approved for publication by APA’s Executive Committee on Practice Guidelines. Thus, watches represent the opinion of the authors and approval of the Executive Committee, but are not APA policy.
“We reviewed 236 articles selected from more than 900 possibly relevant ones selected by APA staff, and after review of those articles, we concluded that the guideline written in 2007 remains substantially correct and current,” Koran told Psychiatric News. “Some recommendations in the original guideline now have stronger evidence, and there are some new rating scales and new ways of delivering services.”
The guideline watch provides a review of issues in psychiatric management, acute-phase treatment, and discontinuation of active treatment.
Under psychiatric management, the guideline notes that two new self-report questionnaires for OCD are available. The Florida Obsessive-Compulsive Inventory includes a symptom checklist and a severity scale and has high internal consistency and high correlation with scores on the clinician-rated Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). The Obsessive-Compulsive Inventory–Revised (OCI-R), an 18-item, validated self-report scale for quantifying levels of distress associated with six OCD symptom subtypes, may be appropriate for both clinical and research purposes, according to the watch.
Although the original Y-BOCS remains a valid tool, the scale was recently revised; the Likert rating scale for each item has been expanded from five points (0–4) to six points (0–5), the Resistance to Obsessions item was deleted, and the Severity Scale item and scoring were revised to integrate avoidance behaviors.
Regarding treatment, there have been some intriguing new developments. Koran noted that encouraging behavior change now appears to be an important part of psychopharmacologic treatment, as opposed to just prescribing medicine. “Compulsions are done to either reduce anxiety or prevent some imagined bad thing from happening,” he said. “So people will compulsively check the stove because they believe the house might otherwise burn down. A recent study suggests that encouraging patients to resist doing their compulsions and thereby find out that their fears are irrational and that their anxiety and distress will go away of their own accord actually helps in conjunction with medication.”
Koran said the first-line treatments continue to be cognitive-behavioral therapy (CBT) or an SRI medication. And within CBT, the evidence continues to be strongest for exposure and response prevention (ERP) therapy.
Some augmentation therapies, such as adding ERP to medication or vice versa, now have stronger evidence, as does the addition of dextroamphetamine or topiramate to an SSRI. However, evidence for the efficacy of the addition of quetiapine or risperidone as adjunctive treatments now appears to be more mixed, and evidence for transcranial magnetic stimulation is equivocal.
Koran noted that recent literature indicates that comorbid PTSD does not lead to a poorer response to either ERP or medication. But comorbid social phobia was associated with worse outcome for either CBT or fluoxetine treatment. “This suggests that if a patient has social phobia, that condition has to be closely attended to in order to successfully treat the OCD,” Koran said.
The guideline watch concludes with a note about the future and the need for more research. “Clinicians can help in the discovery of the means to reduce suffering by searching for local, well-designed, and ethically approved studies and encouraging patients to look into such studies and participate,” the guideline watch states. “A helpful Web site is clinicaltrials.gov, a federally sponsored, searchable database designed to provide patients, family members, and the public with information about ongoing clinical trials.”
Koran said, “We still need more effective treatments, and we still need clinically useful predictors of response and indicators of which augmentation strategy would be effective for a particular patient. We also need longer-term studies of medication augmentation strategies, because almost all of them have been for only six or 12 weeks.”
He added, “OCD is clearly treatable, and patients should be encouraged to pursue sequential trials if the first treatment doesn’t work, because later treatments are quite likely to be beneficial.” ■