Public Release: 

New Guidelines To Set Standards For Best Treatment Of Obsessive-Compulsive Disorder

Duke University

DURHAM, N.C. -- A team of psychiatrists led by Duke University Medical Center has developed the first hands-on, practical reference guide to help clinicians treat real-world patients with obsessive-compulsive disorder, a condition that is often more complex and treatment-resistant than textbook cases indicate.

Obsessive-compulsive disorder (OCD) is a condition characterized by intrusive thoughts and repetitive behaviors such as hand-washing. It can be difficult to diagnose but once identified, responds well to treatment, doctors say.

The Expert Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder are published as a supplement to the May issue of the Journal of Clinical Psychiatry.

Researchers say the guidelines are intended to standardize the treatment of obsessive-compulsive disorder while at the same time helping practitioners more closely match their patients' diseases to the best and latest treatments. Currently, treatment decisions are based on somewhat arbitrary factors like results of small clinical trials, the cost of drugs, and anecdotal reports of what works and what doesn't.

"The OCD guidelines are very detailed and help answer questions that constantly arise in everyday practice but are not usually tracked in literature reviews," said Dr. John S. March, chief editor of the guidelines and director of the child and adolescent anxiety disorders program at Duke.

Typical treatments for OCD include cognitive-behavioral therapy (CBT) alone or CBT combined with one of several different medications, March said.

The new guidelines rank the effectiveness of all treatment options using newly collected data from 69 national and international OCD experts -- all psychiatrists or psychologists -- who completed a lengthy questionnaire. Their responses were statistically correlated to produce first-, second- and third-line treatment recommendations.

Such an approach is called the "consensus scholar" method -- what the researchers describe as a fresh review of all the available evidence in order to reduce the field's reliance on previously held views. The guidelines also reflect a composite of the existing research literature on OCD, albeit to a lesser degree.

The new guidelines are less theoretical and more user-friendly than existing ones, the researchers say. They employ charts, graphs and layman's terms to describe the preferred treatments so that patients and non-doctors can utilize them.

"A nice feature of these guidelines is that all of the survey results are illustrated in an easy-to-understand format that allows the clinician to compare his/her own treatment strategies with those favored by the experts," said Dr. Allen Frances, head of the Expert Consensus Guidelines Steering Committee and chairman of the department of psychiatry at Duke.

While less detailed clinical practice guidelines for OCD already exist, they are based on the opinions of a few academic experts and don't represent the vast experience of the entire field, March said.

The need to provide easy-to-use guidelines for treating OCD has been apparent for some time, according to James Broatch, executive director of the Obsessive-Compulsive (OC) Foundation and consultant to the OCD guidelines' development. "These guidelines now bridge the gap between state-of-the art research and expert opinion, providing easy access to key audiences, including managed care providers, policy makers and patients," Broatch said. "OCD is such a secretive disorder that most patients don't seek help. But when they do, tools like these guidelines are a valuable resource for health care providers, people with OCD, and their family members."

The 10 guidelines are extrapolated from a survey presenting 53 decision-making scenarios. Following are highlights of the guidelines:

  • Guideline #1: Selecting the Initial Treatment Strategy:
    The experts consider cognitive-behavioral therapy (CBT) to be the primary first-line treatment, especially in younger patients. As OCD becomes more severe in patients of any age, adding medication to CBT is also a first-line treatment. In very severe patients, it may make sense to start with medication before adding CBT.
  • Guidelines #2B: Level of Care for CBT
    The experts recommend beginning CBT sessions weekly, with homework assignments or therapist-assisted, out-of-office therapy. The experts believe that, for most patients, 13 to 20 sessions of CBT are adequate, although some patients require more sessions and some require fewer.
  • Guideline #3: Selecting a Specific Medication Strategy:
    There was agreement that serotonin reuptake inhibitors (SRIs) are the most effective medications for OCD. Experts recommend beginning with selective serotonin reuptake inhibitors (SSRIs) first. The experts recommend a trial of clomipramine, a tricyclic antidepressant, after two or three failed SSRI trials. (SRI refers to the five compounds clomipramine, fluoxetine, fluvoxamine, paroxetine and sertraline; SSRI refers to all but clomipramine).
  • Guideline #7: Minimizing Medication Side Effects
    Experts rated the side effects of the four SSRIs (fluoxetine, fluvoxamine, paroxetine and sertraline) as generally better tolerated than the one SRI, clomipramine.
  • Guideline # 10: Pharmacotherapy for OCD "Spectrum" Conditions
    For OCD "spectrum" conditions such as body dysmorphic disorder (disease of imagined ugliness) or bulemia (an eating disorder), pharmacotherapy with an SRI may be helpful.
The guidelines will be distributed nationally to 70,000 mental health care providers, policy makers, third-party payers, patients and their families. They will also be introduced at the American Psychiatric Association's annual meeting in San Diego on May 17. The guidelines include educational material -- developed in coordination with the OC Foundation -- to help patients and their families understand and manage the disorder.

"We will work closely with the Expert Consensus Guidelines editors to ensure that the guidelines' purpose and recommendations are clearly represented to our members," Broatch said.

Funding for development of the guidelines was provided by an unrestricted grant from Solvay Pharmaceuticals Inc. and Pharmacia & Upjohn Inc.

The Expert Consensus Guidelines for Treatment of Obsessive-Compulsive Disorder are the third set of guidelines to be published in the Expert Consensus Guidelines series. In November 1996, guidelines for the treatment of schizophrenia and bipolar disorder were published in the Journal of Clinical Psychiatry.


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