Improving outcome of anxiety and obsessive-compulsive disorders
Authors:   , Remmerswaal Karin Cecilia Petronella 
Published: September 2023

For several decades, the treatment of anxiety disorders and obsessive-compulsive disorder (OCD) has consisted of cognitive behaviour therapy (CBT). Although this is an evidence-based treatment, many patients do not recover with it. The research presented in this thesis aimed to improve the outcome of anxiety disorders and OCD. The initial section focuses on identifying patients with a poor course, while the second part of this dissertation examines a number of novel treatments.

Predictors of course
Using data gathered in the context of the Nemesis-2 study in the Dutch general population, we explored predictors of long-term outcome in anxiety and depressive disorders to identify clues for influencing their course. With the cohort data of the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) study, we identified patient characteristics that contributed to a poor quality of life and relationship satisfaction. Furthermore, we investigated the relationship between severity of OCD and quality of life and how improving the severity of OCD influences quality of life of the participants in NOCDA. Last, we used NOCDA data to identify predictors of patients who would start with an intensive treatment – such as day-treatment or inpatient treatment – in the following two years.

Innovative treatments
We conducted several uncontrolled pilot studies and a meta-analysis to explore innovative treatments. The first innovation pertains to the involvement of family members in the treatment of OCD. Since it has been demonstrated that certain responses of family members have the effect of maintaining the OCD, treatments have been developed to improve family interaction on obsessive-compulsive symptoms. A second innovation is to change the planning of the sessions in such a way that sessions are concentrated. A brief, intensive schedule might be superior to a regular schedule because patients have less opportunity to avoid feared situations in between sessions. A third innovation is to target personality problems besides the anxiety disorder or OCD using schema therapy as personality problems are believed to account for treatment resistance in patients with anxiety disorders and OCD.

Summary of the main findings
Transdiagnostic risk factors that are present across disorders, such as neuroticism and childhood abuse, are important in predicting overall course of anxiety and depressive disorders in the general population while lifestyle and physical health indicators have little additional value in this prediction.
Paid employment and fewer comorbid anxiety and depressive symptoms contribute more to a better quality of life in patients with OCD than fewer obsessive-compulsive symptoms. Remission of OCD improves of quality of life. However, even in patients with a remitted OCD, the quality of life remains below the community level. Comorbid anxiety and depressive symptoms lower the quality of life in remitted patients.
Despair and limitations in daily life as a result of OCD are more important reasons for starting with an intensive treatment than having severe obsessive-compulsive symptoms per se.
The meta-analysis revealed that anxiety, obsessive-compulsive and comorbid depressive symptoms significantly reduce after brief, intensive CBT. Results did not significantly differ from those obtained after regular CBT except that the intensive format was better in reducing comorbid depressive symptoms and results were obtained faster due to its shorter lead time.
The uncontrolled pilot studies suggested that the family intervention, a brief, intensive scheduling of CBT sessions, and schema day-treatment are all feasible and effective in patients who did not respond to previous CBT, and are worth investigating further with a controlled design.

Conclusion
This thesis has argued that to improve mental health, we need to take a broader view on psychopathology, treatment and recovery which takes into account comorbid symptoms, the social environment, aetiological factors and quality of life besides the primary symptoms.