Outcomes for Patients with OCD
Abstract & Commentary
Synopsis: This prospective study examined the course of illness for patients with obsessive-compulsive disorder (OCD) over a two-year period.
Source: Eisen JL, et al. Patterns of remission and relapse in obsessive-compulsive disorder: A 2-year prospective study. J Clin Psychiatry 1999;60:346-351.
Obsessive compulsive disorder (ocd) affects approximately 4% of the population. Although selective serotonin reuptake inhibitors (SSRIs) are considered to be effective treatments, partial improvement is more common than remission, and a waxing and waning course is considered common. This is the first prospective study with measures evaluating improvement as well as clearly defined definitions of remission and relapse for patients with a primary disorder of OCD.
Consecutive patients were recruited from inpatient, outpatient, private practice, a mental health center, and by self-referral. Baseline evaluation included measures of OCD severity, comorbid diagnosis(es), and global assessment. Follow-up measures were identical and included a semistructured instrument to collect detailed data on treatment received. Patients had a mean age of 33 years and 55% were female. A total of 66/77 completed the study, with no statistical differences between the completers and noncompleters in terms of symptoms and global assessment. The mean global assessment rating was 55 (moderately ill). The mean duration of illness was 16 years prior to study entry and 78% of patients were in a full episode at baseline. Lifetime and current comorbid disorders were high, including depression (55% and 16%), social phobia (23% and 18%), specific phobias (21% and 16%), and generalized anxiety disorder (20% and 14%). Subjects had a 47% and 12% probability of reaching a partial or full remission, respectively. For subjects who achieved a partial remission, the probability of subsequent relapse was 48%. Most patients (77%) received an adequate 12-week SSRI trial, including 68% at doses appropriate for OCD (i.e., higher than for most patients with depression-see below). Patients were undertreated with behavior therapy, as only 12% received the recommended type and duration of therapy; it was unclear if this was due to problems with access or adherence, or both. Overall, despite adequate dosing, few patients achieve full remission and relapse is extremely common. Limitations of the study included the confounding effect of comorbid illnesses on outcome, a chronic population that may be different than patients with new-onset OCD, and a small sample size.
Comment by Donald M. Hilty, MD
OCD is the fourth most prevalent psychiatric disorder because despite a low incidence, patients suffer a particularly chronic course. Primary care and psychiatric physicians usually screen for OCD and monitor change with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a practical self-report scale that takes 10 minutes to complete. Unlike major depression and general anxiety disorder, in which antidepressant effects are typically evident in four weeks (or eight weeks in elderly patients), an adequate trial for OCD is considered 12 weeks. Doses of common antidepressants for OCD are: fluoxetine (Prozac) 20-80 mg/d, sertraline (Zoloft) 100-200 mg/d, paroxetine 40-60 mg/d, fluvoxamine (Luvox) 150-300 mg/d, and clomipramine (Anafranil) 150-250 mg/d.1
Cognitive Behavioral Therapy (CBT) is a first- or second line treatment for OCD2 and interestingly, research using positron emission tomography (PET) has demonstrated normalizing effects of both SSRIs and CBT in the orbitofrontal cortex.3
References
1. Goodman WK. Obsessive-compulsive disorder: Diagnosis and treatment. J Clin Psychiatry 1999;60z:27-32.
2. The Expert consensus panel for obsessive-compulsive disorder. J Clin Psychiatry 1997;58:2-72.
3. Schwartz JM. Neuroanatomical aspects of cognitive-behavioural therapy response in obsessive-compulsive disorder: An evolving perspective on brain and behaviour. Brit J Psychiatry 1998;35:38-44.
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