The road to improvement in obsessive-compulsive disorder
Authors: Albina R Torres
Journal: The Lancet Psychiatry (2016)

An important study by Petros Skapinakis and colleagues1Skapinakis P Caldwell DM Hollingworth W et al.Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis.Lancet Psychiatry. 2016; (published online June 15.)http://dx.doi.org/10.1016/S2215-0366(16)30069-4Google Scholar in The Lancet Psychiatry compares the efficacy of pharmacological and psychotherapeutic treatment strategies for adults with obsessive-compulsive disorder. The authors should be commended for having systematically reviewed just over 36 years of literature (1980–2016) and for using a new analytical approach—network meta-analysis—which allows for simultaneous comparison of several treatments in a single model and has been previously applied to other mental disorders.2Mayo-Wilson E Dias S Mavranezouli I et al.Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis.Lancet Psychiatry. 2014; 1: 368-376Summary Full Text Full Text PDF PubMed Scopus (331) Google Scholar The network meta-analysis1Skapinakis P Caldwell DM Hollingworth W et al.Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis.Lancet Psychiatry. 2016; (published online June 15.)http://dx.doi.org/10.1016/S2215-0366(16)30069-4Google Scholar included 54 randomised controlled trials (RCTs) and 6652 participants. This comprehensive, carefully done study1Skapinakis P Caldwell DM Hollingworth W et al.Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis.Lancet Psychiatry. 2016; (published online June 15.)http://dx.doi.org/10.1016/S2215-0366(16)30069-4Google Scholar is an example of how obtaining of evidence-based information to guide clinical practice is challenging, even in a well explored research area. Despite the large number of published RCTs, important clinical questions remain unanswered concerning obssessive-compulsive disorder treatment. As properly acknowledged by the authors, several gaps in knowledge remain to be addressed in future research. One of these gaps is that no potential differences in the efficacies of individual SSRIs or between SSRIs as a group and clomipramine could be shown; they seemed to be equally effective. The mean Yale-Brown Obsessive Compulsive Scale difference was −3·49 (95% credible interval −5·12 to −1·81) for SSRIs and −4·72 (−6·85 to −2·60) for clomipramine. The authors could not examine whether higher doses of the same drug are associated with greater treatment responses. Likewise, when studies that used waiting list control groups were excluded, the effects of recommended psychotherapies were similar in magnitude. The mean Yale-Brown Obsessive Compulsive Scale difference was −10·41 (95% credible interval −14·04 to −6·77) for behavioural therapy, −9·45 (−13·76 to −5·19) for cognitive therapy, and −7·98 (−11·02 to −4·93) for cognitive behavioural therapy. Therefore, the specific aspects of these approaches that are most effective are unclear. Another point is that although the effect of psychotherapeutic interventions was greater than that of medications, pure psychotherapeutic and pharmacological treatments could not be compared directly because most studies of psychotherapy included patients taking stable doses of antidepressants. Considering the short median duration of the RCTs included in the analysis (12 weeks [IQR 10–12]), medium-term and long-term responses to treatment are important aspects warranting further study. Obsessive-compulsive disorder is usually a long-lasting condition, and consistent clinical improvement might take much longer than 3 months to achieve. Almost all of the RCTs included in the analysis involved interventions recommended for obsessive-compulsive disorder in current guidelines (SSRIs, clomipramine, and behavioural and cognitive therapies). The effectiveness of other medications and forms of psychotherapy (eg, psychodynamic therapies) therefore remains largely unknown. Individual and group formats of behavioural or cognitive interventions were not compared. In trials that used both formats, data were extracted only for groups with the individual format. Nevertheless, some characteristics and therapeutic factors of group psychotherapy (eg, universality, instillation of hope, altruism, socialising, and interpersonal learning)3Yalom ID Leszcz M The theory and practice of group psychotherapy. Basic Books, New York2005Google Scholar might be particularly important for patients with obsessive-compulsive disorder who are usually ashamed of their symptoms and feel hopeless and socially isolated.4Weingarden H Renshaw KD Shame in the obsessive compulsive related disorders: a conceptual review.J Affect Disord. 2015; 171: 74-84Crossref PubMed Scopus (95) Google Scholar Obsessive-compulsive disorder is a mosaic of diverse phenomenological manifestations, and some symptom dimensions (eg, hoarding symptoms) seem to have a worse response to treatment than do other symptoms.5Bloch MH Bartley CA Zipperer L et al.Meta-analysis: hoarding symptoms associated with poor treatment outcome in obsessive-compulsive disorder.Mol Psychiatry. 2014; 19: 1025-1030Crossref PubMed Scopus (82) Google Scholar Thus, possible phenotypic differences in treatment response are a relevant yet underexplored clinical aspect. Even though comorbidities (except for schizophrenia and bipolar disorder) were allowed in most RCTs included in the analysis, the authors could assess only the effect of depression—the most common comorbidity in obsessive-compulsive disorder—because of an absence of information. Other disorders (including anxiety, somatoform, impulse control, trauma-related, substance use, and personality disorders) are very common among patients with obsessive-compulsive disorder and can affect adherence and response to treatment.6Pallanti S Grassi G Sarrecchia ED Catisani A Pellegrini M Obsessive-compulsive disorder comorbidity: clinical assessment and therapeutic implications.Front Psychiatry. 2011; 2: 70Crossref PubMed Scopus (86) Google Scholar Several other factors that can influence treatment response should be explored in future research, including the quality of the professional-patient therapeutic alliance;7Maher MJ Wang Y Zuckoff A et al.Predictors of patient adherence to cognitive-behavioral therapy for obsessive-compulsive disorder.Psychother Psychosom. 2012; 81: 124-126Crossref PubMed Scopus (44) Google Scholar level of insight,8Jacob ML Larson MJ Storch EA Insight in adults with obsessive-compulsive disorder.Compr Psychiatry. 2014; 55: 896-903Crossref PubMed Scopus (33) Google Scholar, 9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar which varies considerably between patients and within the same patient over time or according to symptom dimensions; and family accommodation to the symptoms.9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar, 10Lebowitz ER Panza KE Su J Bloch M Family accommodation in obsessive-compulsive disorder.Expert Rev Neurother. 2012; 12: 229-238Crossref PubMed Scopus (149) Google Scholar Family accommodation is a very common phenomenon in obsessive-compulsive disorder and has been associated with treatment refractoriness.9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar, 10Lebowitz ER Panza KE Su J Bloch M Family accommodation in obsessive-compulsive disorder.Expert Rev Neurother. 2012; 12: 229-238Crossref PubMed Scopus (149) Google Scholar Skapinakis and colleagues' network meta-analysis focused on adults with non-refractory obsessive-compulsive disorder; future studies are warranted for children and adolescents. For refractory patients, several alternative interventions have been investigated, mostly in the last decade, including pharmacological (eg, adjunctive antipsychotics, memantine, riluzole, ketamine, ondansetron, lamotrigine, topiramate, pregabalin, and gabapentin),9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar, 11Fineberg NA Reghunandanan S Simpson HB et al.Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults.Psychiatr Res. 2015; 227: 114-125Crossref PubMed Scopus (84) Google Scholar somatic (eg, deep-brain stimulation, transcranial magnetic stimulation, and limbic surgery),9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar, 11Fineberg NA Reghunandanan S Simpson HB et al.Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults.Psychiatr Res. 2015; 227: 114-125Crossref PubMed Scopus (84) Google Scholar psychological (eg, psychoeducation, family and motivational interventions, and intensive residential psychotherapy),9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar and mixed approaches (eg, d-cycloserine as an augmentation strategy of behavioural therapy).9Franz AP Paim M Araújo RM et al.Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?.Trends Psychiatry Psychother. 2013; 35: 24-35Crossref PubMed Scopus (12) Google Scholar Beyond symptom reduction, improvement in quality of life is a crucial treatment goal to be monitored, as well as factors associated with relapse after successful treatment. This secret, complex, chronic, and debilitating disorder requires increased identification and improved access to evidence-based treatments in the first place.12Torres AR Prince AJ Bebbington PE et al.Treatment seeking by individuals with obsessive-compulsive disorder from the British Psychiatric Morbidity Survey of 2000.Psychiatr Serv. 2007; 58: 977-982Crossref PubMed Scopus (55) Google Scholar Delayed help seeking4Weingarden H Renshaw KD Shame in the obsessive compulsive related disorders: a conceptual review.J Affect Disord. 2015; 171: 74-84Crossref PubMed Scopus (95) Google Scholar and an inadequate number of well trained health professionals are important problems to be addressed. For all of these reasons, “a long and winding road” still lies ahead before the distress of patients with obsessive-compulsive disorder and their families is really alleviated. I declare no competing interests. Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysisA range of interventions is effective in the management of obsessive-compulsive disorder, but considerable uncertainty and limitations exist regarding their relative efficacy. Taking all the evidence into account, the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder. Full-Text PDF Open Access