Psychological treatments versus treatment as usual for obsessive compulsive disorder

People with obsessive-compulsive disorder (OCD) are distracted by obsessive thoughts that cause intense anxiety.

In an attempt to relieve their distress, they repeat behaviors such as hand washing and become profoundly upset if they cannot perform these rituals.

OCD treatment often includes prescription medications such as Prozac (fluoxetine). However, a new review from Australian researchers, led by Ileana Gava of the Mandala Clinic in New South Wales, says that talk therapy can also help adults suffering from the condition.

The authors analyzed data from seven small studies of about 150 patients and concluded that “psychological treatments derived from cognitive behavioral models are an effective treatment for adult patients with obsessive-compulsive disorder.”

The review appears in the current issue of The Cochrane Library , a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Carol Mathews, M.D., associate professor of psychiatry at the University of California –San Francisco, said another key review finding is that many variants of such therapy work for OCD, “whether [they are] primarily cognitive, primarily behavioral, a combination of both, individual or group therapy, and with or without medications.”

Cognitive therapies for OCD aim to teach patients to distance themselves from their obsessive thoughts and to help them recognize that compulsive behaviors do not actually reduce the anxiety they feel.

The behavioral aspect of treatment involves exposing patients to situations that provoke obsessive thoughts and then having them stop themselves from enacting the corresponding compulsive behavior, in hopes of demonstrating that the anxiety is unwarranted.

Therapists explain the process to the patient, increasing and repeating exposures as the patient becomes more able to tolerate them and thus reduce their compulsive responses.

Many of the patients analyzed were also taking medication. Studies that included higher numbers of people using medication in both the waiting list and psychological therapy groups did slightly better with psychological therapy, although the results were not statistically significant.

“This is likely because the concomitant use of medication helps to minimize the anxiety, and make the individual more able to participate in the exposures. Medications are also known to help OCD symptoms even in the absence of therapy, so there could be a combined effect,” said Mathews, who was not involved with the study.

Although the result was not statistically significant, the review found a trend toward increased study dropout among those in the treatment groups. “A possible explanation might be that people on the waiting list are motivated to wait in order to pursue the active treatment,” the researchers say.

Mathews said that there is another possibility: “My clinical experience suggests that it is more likely to be due to increased anxiety related to participating in exposures, and not so much the motivation factor.”

However, group therapies had significantly lower dropout rates, but the same effectiveness as individual treatment. “Group therapy, with its characteristics such as … encouragement, reciprocal support, imitation and interpersonal learning [could] result in an increased motivation,” the authors write.

“This is a relatively weak finding, but still interesting,” Mathews said. “It suggests that group therapy, which is more cost-effective by far than individual therapy, may actually be the preferred form of therapy. If this is true, it would potentially help to make treatment more available to people with OCD, as it is less expensive, and requires fewer hours from trained personnel, so is easier to implement.”

OCD is the fourth most common psychiatric disorder, affecting up to 3 percent of the American population. The condition can be extremely debilitating, often making those who suffer from it unable to function because their obsessive thoughts and behaviors are so time-consuming.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

Gava I, et al. Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD) (Review). The Cochrane Database of Systematic Reviews 2007, Issue 2.