OCD treatment guidelines recommend cognitive-behavioral therapy, SSRIs

The American Psychiatric Association released an update in 2013 to its guidelines for the treatment of patients with obsessive-compulsive disorder.

While the original guideline, which was drafted in 2007, is still “correct and current in its recommendations,” the American Psychiatric Association cited stronger evidence to support some treatments, and recommended additional treatments for OCD. Moreover, the 2013 update introduced two new patient self-report scales for self-observation and better understanding of symptoms and triggers.

Revision of scales

The updated guideline described the Florida Obsessive-Compulsive Inventory, which features a checklist of 20 symptoms and a five-point symptom severity scale. The APA also added to the updated guidelines the Obsessive-Compulsive Inventory-Revised (OCI-R), an 18-item self-report scale for identifying stress levels linked to six OCD symptom subtypes, including washing, checking, ordering, obsessing, hoarding and neutralizing.
Since the 2007 version, revisions have also been made to the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). This revision included broadening the rating scale for each questionnaire from five-point (0-4) to six-point (0-5), as well as the elimination of the “resistance to obsessions” item. The Symptom Checklist was also adjusted to clarify that some OCD symptoms do not originate from fear. Also in the update, the APA cited the Hoarding Rating Scale, which quantifies the severity of hoarding symptoms.

Treatment overview

As first-line treatment for OCD, the guidelines recommend cognitive behavioral therapy (CBT) in the form of exposure and response prevention (ERP), a serotonin re-uptake inhibitor (SSRI) or clomipramine. Selection of a specific therapy should be guided by the severity of symptoms, the existence and/or severity of psychiatric or medical comorbidities, the patient’s treatment and medication history, patient’s current medications and patient preferences. A 2008 study validated this recommendation, finding that SSRIs, clomipramine and CBT (either alone or with the aforementioned pharmaceutical agents) constituted first-line treatment for OCD. The 2007 guideline noted that combination therapy should be considered for patients who respond inadequately to monotherapy, for those with coexisting psychiatric conditions treatable with SSRIs, and for patients who prefer only short-term SSRI treatment. The update cited subsequent studies that support the validity of combined treatment.

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Dosage recommendations

The 2007 guidelines state that all SSRIs are effective in treating OCD, but noted that two of these agents, citalopram and escitalopram, are not FDA-approved for this purpose. The guidelines noted the optimal response may be achieved with an SSRI dose that is higher than the manufacturer’s recommended maximum dose. Specifically, for citalopram, the guideline advised a “usual target dose” of 40 mg to 60 mg per day, a “usual maximum dose” of 80 mg per day, and an “occasionally prescribed maximum dose” of 120 mg per day. However, the update encouraged clinicians to use caution when prescribing these high doses, citing a 2011 FDA Drug Safety Communication concerning the risk for clinically significant QT prolongation. Based on this cardiac risk, the FDA stated citalopram should “no longer be used in doses greater than 40 mg per day.” Additionally, this communication advised no more than 20 mg per day for patients older than 60 years of age.

The guideline update also discussed potential cardiac risks associated with the antipsychotic drug quetiapine in patients with concomitant conditions or who take medications that could increase QT intervals, or in “circumstances that may increase the risk of occurrence of torsade de pointes and/or sudden death.” The guideline clarified, however, that OCD patients are not at increased overall risk for cardiovascular side effects compared with other patients.

Psychotherapeutic approaches

The guideline recommended CBT in combination with ERP as the preferred psychotherapeutic modality in patients with OCD, and evidence published since the 2007 guideline was released continues to support this recommendation. The updated guideline noted that exposure in vivo to an OCD trigger combined with exposure in the patient’s imagination was more effective than real-life exposure alone. Studies have since been conducted that suggest possible utility for manual-driven stress management training (SMT), as well as acceptance and commitment therapy (ACT) and eye movement desensitization and reprocessing (EMDR).
Small studies have also suggested benefits from mindfulness meditation, tapping acupressure, and electro-acupuncture, but these studies were described in the guidelines as “methodologically weak.”

For more information:

Koran LM. Guideline Watch (March 2013): practice guideline for the treatment of patients with obsessive-compulsive disorder. Psychiatry Online. http://www.psychiatryonline.org. Accessed on Sept. 30, 2014.