Addition of cognitive-behavioral therapy for nonresponders to medication for obsessive-compulsive disorder: a naturalistic study

Abstract

Objective: The best currently available treatments for obsessive-compulsive disorder (OCD) are serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT). It is generally recommended that patients who have been unsuccessfully treated with SRIs should receive supplementary CBT, although few studies have yet to investigate the proposal's validity. The purpose of the present study is to examine the effectiveness of CBT on a sample of nonselected, pharmacologically treatment-resistant OCD patients.

Method: Thirty-six OCD patients (based on DSM-IV criteria) who had not responded to at least 1 adequate SRI trial conducted in our outpatient clinic were treated from January 2000 through April 2004 with CBT, incorporating exposure and ritual prevention. The therapy was conducted in a naturalistic setting and manualized guidelines were adapted to each patient. Pharmacologic treatment underwent no changes during the trial period. Outcome measures included the Yale-Brown Obsessive Compulsive Scale, the Clinical Global Impressions-Severity of Illness scale, and the Global Assessment of Functioning scale. The primary outcome measure was a rating of "much improved" or "very much improved" on the Clinical Global Impressions-Improvement scale (CGI-I).

Results: Two patients (5%) refused CBT after 1 session, and 10 patients (28%) dropped out of the study. Three of the 24 remaining patients completed the trial at 6 months (T1) but did not follow through up to 12 months (T2). The 21 patients completing CBT showed statistically significant improvement (p < .0001) during follow-up on all outcome measures. At T2, 15 (42%) of 36 patients were rated as being "much improved" or "very much improved," as measured by the CGI-I. Symptom reduction was clinically modest but important, with nearly all patients presenting residual symptoms.

Conclusion: CBT could be usefully added to pharmacologic treatments for severe, real-world, medication-resistant OCD patients.