From the Guidelines
The most effective treatment for Obsessive-Compulsive Disorder (OCD) is a combination of medication and psychotherapy, with Cognitive-Behavioral Therapy (CBT), particularly Exposure and Response Prevention (ERP), being the most effective psychotherapy approach. According to the most recent and highest quality study 1, CBT has larger effect sizes than pharmacological therapy for the treatment of OCD. The study found that CBT can be used as the initial treatment for OCD, particularly if this is the patient’s preferred treatment option, if there is access to trained clinicians, and in the absence of comorbid conditions that might require pharmacotherapy 1. Some key points to consider when treating OCD include:
- The integration of ERP with cognitive components can make ERP less aversive and enhance its effectiveness 1
- Individual and group CBT, delivered in-person or by internet-based protocols, are effective for the treatment of OCD 1
- The most robust predictor of good short-term and long-term outcome with CBT is patient adherence to between-session homework, such as carrying out ERP exercises in the home environment 1
- Computer and internet-based treatment is a promising way to overcome barriers to therapy, such as poor help-seeking behavior and inaccessible treatment 1
- Unguided computer-assisted self-help interventions without human contact may be effective in treating OCD, but more research is needed to fully understand their effectiveness and adherence 1. In terms of medication, first-line medications include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, escitalopram, or fluvoxamine, typically requiring higher doses than those used for depression and a longer treatment duration to see full benefits. For treatment-resistant cases, augmentation strategies might include adding antipsychotics like risperidone or aripiprazole, or considering clomipramine. Overall, treatment typically requires long-term management, with medication continuation for at least 1-2 years after symptom improvement to prevent relapse.
From the FDA Drug Label
Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of obsessions and compulsions in patients with obsessive-compulsive disorder (OCD), as defined in the DSM-III-R; i.e., the obsessions or compulsions cause marked distress, are time-consuming, or significantly interfere with social or occupational functioning. Obsessive-compulsive disorder is characterized by recurrent and persistent ideas, thoughts, impulses, or images (obsessions) that are ego-dystonic and/or repetitive, purposeful, and intentional behaviors (compulsions) that are recognized by the person as excessive or unreasonable. The efficacy of sertraline was established in 12-week trials with obsessive-compulsive outpatients having diagnoses of obsessive-compulsive disorder as defined according to DSM-III or DSM-III-R criteria
Sertraline is indicated for the treatment of OCD. The FDA has approved sertraline for the treatment of obsessions and compulsions in patients with OCD 2.
- Key characteristics of OCD include:
- Recurrent and persistent ideas, thoughts, impulses, or images (obsessions)
- Repetitive, purposeful, and intentional behaviors (compulsions)
- Marked distress, time-consuming, or significant interference with social or occupational functioning
- Sertraline efficacy was established in 12-week trials with obsessive-compulsive outpatients having diagnoses of obsessive-compulsive disorder as defined according to DSM-III or DSM-III-R criteria. Paroxetine is also indicated for the treatment of OCD. The FDA has approved paroxetine for the treatment of obsessions and compulsions in patients with OCD 3.
- Key characteristics of OCD include:
- Recurrent and persistent ideas, thoughts, impulses, or images (obsessions) that are ego-dystonic
- Repetitive, purposeful, and intentional behaviors (compulsions) that are recognized by the person as excessive or unreasonable
- Marked distress, time-consuming, or significant interference with social or occupational functioning
- Paroxetine efficacy was established in two 12-week trials with obsessive compulsive outpatients whose diagnoses corresponded most closely to the DSM-IIIR category of obsessive compulsive disorder.
From the Research
Treatment Options for OCD
- First-line treatments for OCD include serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) 4, 5, 6, 7, 8
- Combination treatment of CBT and SRIs may be beneficial for patients with severe depression, but not for all patients with OCD 4, 6
- Sequential administration of CBT after medications has been found useful in promoting remission in patients who partially responded to drugs and in promoting response in resistant patients 4, 5
Strategies for Treatment-Resistant OCD
- Addition of antipsychotics to SRIs is a effective strategy for treatment-resistant OCD 5
- CBT addition to medications is also an effective strategy for treatment-resistant OCD 5
- Switch to intravenous clomipramine (SRI) administration and switch to paroxetine (SSRI) or venlafaxine (SNRI) are promising strategies, but need further confirmation in double-blind studies 5
Optimizing First-Line Treatments
- NICE guidelines suggest low intensity psychological treatments, including ERP, as the first line treatment for OCD, and reserve combination treatment for adults with severe functional impairment or without an adequate response to SSRI alone or CBT alone 6
- US treatment guidelines suggest three first-line treatments for OCD: SSRI, CBT, and SSRI+CBT, and recommend combined treatment for patients with an unsatisfactory response to monotherapy or for patients with severe OCD 6