The University of Rhode Island Change Assessment as Predictor of Treatment Outcome and Dropout in Outpatients with Obsessive-Compulsive Disorder Treated with Exposure and Response Prevention
Authors: Stian Solem, Åsta S. Husby, Åshild T. Håland, Gunvor Launes, Bjarne Hansen, Patrick A. Vogel, Roger Hagen
Journal: Psychotherapy and Psychosomatics (2016)

Approximately 25-30% of patients suitable for exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) do not want to start treatment, drop out early or show limited compliance [1]. Lack of motivation can be an important reason given the active participation required both during and between treatment sessions. A common way of assessing treatment motivation has been with the University of Rhode Island Change Assessment (URICA), which is a self-report measure including 4 subscales [2]. People who score high on 'precontemplation' have no plan to quit their problem behavior in the near future. 'Contemplators' are considering change but have not yet started acting on their intentions. People in the 'action' phase have begun their change, while people in the 'maintenance' phase are trying to maintain an already acquired change. These subscales can be combined into a readiness-to-change index.There are four empirical studies into the role of motivation in treating OCD. Vogel et al. [3] found that readiness to change showed no relation to treatment outcome for 37 outpatients treated with cognitive-behavioral therapy. A similar study conducted by Pinto et al. [4] found a negative association between precontemplation and change in OCD symptoms using a sample of 32 outpatients receiving pharmacotherapy. In another outpatient study (n = 28), Maher et al. [5] found no significant relationship between readiness to change and cognitive-behavioral treatment outcome. One large-scale study has been conducted. Monaghan et al. [6] found no evidence for readiness to change as predictive of cognitive-behavioral treatment outcome in 424 OCD inpatients. However, people with high scores on precontemplation were discharged earlier. The generalizability of these studies is questionable as they either have small sample sizes or use inpatient treatment. Also, none of the studies have controlled for both OCD severity and comorbid depression in their analyses. Another relevant point is that descriptions of previous treatment attempts are unfortunately lacking in previous studies as well as in our study.In line with the literature reviewed, we hypothesized that high scores on precontemplation should predict premature dropout, and that the readiness-to-change index is not predictive of treatment outcome with ERP.We included 121 outpatients with a diagnosis of OCD in the present study. The mean age was 33.8 years (SD = 12.0). Only 25.9% of the sample worked full time. Some had part-time work (12.1%) or were students (20.7%), while the remaining subjects were unemployed. Data were aggregated from two different OCD clinics: one specializing in group treatment, whilst the other did individual treatment. Sixty-five patients were treated with group ERP, while the other 56 were treated individually with ERP. The main inclusion criterion was a primary diagnosis of OCD according to the DSM-IV. Exclusion criteria were meeting criteria for psychotic disorders, alcohol or drug addiction, mental retardation, autism and suicidal behaviors. Patients who had been on a stable dosage of selective serotonin reuptake inhibitors (SSRIs) for the last month could be included. Their doses were kept stable throughout the treatment. A total of 56 participants used SSRIs (missing data for 5 patients). Different comorbid disorders were present in the sample. The most common comorbid disorder was depression (n = 34). All participants gave written informed consent.People treated in a group met once a week for 2.5 h over a 12-week period. The behavioral group therapy was adapted from a manual developed by Krone et al. [7]. People treated individually received ERP based on a manual by Kozak and Foa [8]. Individual therapy consisted of 15 treatment sessions lasting 90 min. Pretreatment severity and treatment effects were similar to those of other studies on ERP for OCD, as Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores were reduced from 24.14 (4.03) to 12.80 (6.15) for completers and from 24.26 (4.14) to 13.60 (6.89) for the intent-to-treat sample.The 8 dropouts scored significantly lower than the 113 completers on the contemplation subscale, with t(119) = 2.98, p = 0.004, d = 1.05. There was no significant difference between the groups on any of the other URICA subscales.In order to determine predictors of treatment outcome (Y-BOCS after treatment) for treatment completers, we ran a multiple regression analysis entering pretreatment variables as independent variables. Y-BOCS, depression diagnosis and URICA subscales were entered into the equation, but the only significant predictor was Y-BOCS. Results from the regression are summarized in table 1.The participants using SSRIs scored significantly higher on the change index than drug-free participants [t(114) = 2.37, p = 0.02], suggesting that patients on SSRIs could be more motivated to change their problem behavior.The study suggests that the degree to which OCD patients contemplate changing their behavior could be predictive of dropout. Those who completed treatment had significantly higher scores on contemplation than dropouts. Similar findings have been observed in the treatment of patients with panic/agoraphobia and chronic pain patients [9,10]. Patients who take personal responsibility for changing their OCD behavior will in this sense have an increased chance of completing ERP. Both Monaghan et al. [6] and the present study suggest that the URICA is to some degree predictive of treatment completion or dropout, but different subscales emerged as significant. These two studies could support the use of motivational interventions for patients scoring high on precontemplation and low on contemplation before starting ERP in order to prevent premature dropout. Motivational interviewing could hold promise for improving adherence and outcomes in ERP for OCD [11], but more research is needed in order to establish its effect. Further, the results suggest, as hypothesized, that the URICA has no predictive value in estimating treatment outcome in OCD patients. This is compatible with previous research.A central limitation in this study was the open trial design with the lack of a control condition. Another limitation is that half the sample received ERP in groups while the other half received ERP individually. Also, the URICA was only administered before treatment. Treatment motivation may exhibit a fluctuating course, interacting with factors over time in ways that may ultimately affect treatment adherence, latency and outcome. Assessment of motivation for behavioral change in people with OCD can be complicated. Future studies should involve session-by-session assessment of motivation, and more research is needed in order to develop reliable and valid measures of treatment motivation in OCD.