OCD Treatment: Symptom Reduction Versus Wellness and Recovery

Obsessive-compulsive disorder (OCD) affects 2% to 3% of the population and is a leading cause of disability worldwide.¹ This condition involves severe symptoms and serious impairment in multiple domains of functioning. Treatment research often focuses on reducing symptoms, yet a broader goal of clinical care is to promote wellness and recovery—concepts that include not only reduced symptoms but also improved functioning, quality of life, and subjective well-being. Therefore, as clinicians, when we evaluate our patients’ progress in treatment, we need to be able to differentiate between treatment response (ie, reduction in symptoms), symptom remission (ie, reduction of symptoms to a low level, below diagnostic criteria), and wellness (ie, symptom remission, restored functioning, and high quality of life).

Our recent study² evaluated data from 4 randomized, controlled OCD treatment trials to develop guidelines to help clinicians gauge patient progress in treatment. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is considered the “gold standard” measure to monitor OCD severity and is used in both research studies and clinical practice. Using the Y-BOCS, we established a metric to help clinicians determine that their patients’ symptoms truly are improving. Specifically, we found that a ≥ 35% reduction in scores on the Y-BOCS consistently identifies response to treatment. We also determined an absolute threshold score on the Y-BOCS (ie, a score of 12 or less) that reliably identifies patients who have attained a wellness state. That is, our analyses show that patients who achieve an OCD severity score below this benchmark not only have a low level of symptoms but also have high quality of life and are functioning well at work, at home, and in social situations. This score of ≤ 12 is a treatment target for providers to strive for to foster wellness rather than only symptom reduction.

What treatments help patients with OCD achieve this target? Serotonin reuptake inhibitors (SRIs) are the front-line pharmacotherapy for OCD, and, although many patients (over 50%) respond to this form of treatment,³ only around 25% achieve wellness from SRIs alone. Fortunately, SRIs can be successfully augmented by cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP). We have conducted 2 studies^4,5 that showed that adding EX/RP to SRI treatment significantly improves symptoms; 74% to 80% of our patients responded. Further, 33% to 40% of our patients achieved wellness, and many of these individuals maintained their treatment gains 6 months later.⁶

In summary, many patients taking SRIs for OCD will have clinically significant residual symptoms, but the addition of EX/RP can help some of these patients achieve wellness. Our patients then ask, “Do I still need to take my SRI to maintain my gains?”

To answer this important clinical question, we are actively recruiting individuals in New York City and in Philadelphia who continue to have significant and impairing OCD symptoms, despite SRI treatment, for an NIMH-funded research study led by Edna B. Foa, PhD, and me. Participants in our study are provided EX/RP treatment at no cost, with the aim of achieving wellness. Of the patients who reach this clinical benchmark, half will continue their medication and half will be slowly tapered off under medical supervision, and we will compare outcomes 6 months later. Our short-term goal is to determine who benefits most from the combination of SRIs and EX/RP. Our long-term goal is to provide clinicians with effective treatment strategies to help people with OCD live full and productive lives.

Please join our research team! Potential participants and interested clinicians can visit our study website at http://www.ocdtreatmentstudy.com/.

Financial disclosure:Dr Simpson is a consultant for Quintiles; has received grant/research support from NIMH, Transcept, and Janssen; and has received other financial support from UpToDate and Cambridge University Press.

Acknowledgment: Dr Simpson acknowledges the contributions of Michael G. Wheaton, PhD, to this blog entry.

References

1. Ruscio AM, Stein DJ, Chiu WT, et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15(1):53–63. PubMed

2. Farris SG, McLean CP, Van Meter, PE, et al. Treatment response, symptom remission, and wellness in obsessive-compulsive disorder. J Clin Psychiatry. 2013;74(7):685–690. Abstract

3. Simpson HB, Huppert JD, Petkova E, et al. Response versus remission in obsessive-compulsive disorder. J Clin Psychiatry. 2006;67(2):269–276. Abstract

4. Simpson HB, Foa EB, Liebowitz, MR, et al. A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatry. 2008;165(5):621–630. PubMed

5. Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized controlled trial [published online ahead of print September 11, 2013]. JAMA Psychiatry. PubMed

6. Foa EB, Simpson HB, Liebowitz MR, et al. Six-month follow-up of a randomized controlled trial augmenting serotonin reuptake inhibitor treatment with exposure and ritual prevention for obsessive-compulsive disorder. J Clin Psychiatry. 2013;74(5):464–469. Abstract