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Patients under cognitive-behavioral or pharmacological treatment improved continuously in the long run, regardless of initial treatment modality or degree of early response, suggesting that OCD patients benefit from continuous treatment. Psychiatric comorbidity, especially depressive disorders, may impair the long-term outcome of OCD patients.

Few case series studies have addressed the issue of treatment response in patients with obsessive-compulsive disorder (OCD) and comorbid post-traumatic stress disorder (PTSD), and there are no prospective studies addressing response to conventional treatment in OCD patients with a history of trauma (HT). The present study aimed to investigate, prospectively, the impact of HT or PTSD on two systematic, first-line treatments for OCD. Two hundred and nineteen non-treatment-resistant OCD outpatients were treated with either group cognitive-behavioral therapy (GCBT n = 147) or monotherapy with a selective serotonin reuptake inhibitor (SSRI n = 72). Presence of HT and PTSD were assessed at intake, as part of a broader clinical and demographical baseline characterization of the sample. Severity and types of OCD symptoms were assessed with the Yale-Brown Obsessive-Compulsive Scale (YBOCS) and the Dimensional YBOCS (DYBOCS), respectively. Depression and anxiety symptoms were measured with the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). Both treatments had 12-week duration. Treatment response was considered as a categorical [35% or greater reduction in baseline YBOCS scores plus a Clinical Global Impression-Improvement rating of better (2) or much better (1)] and continuous variable (absolute number reduction in baseline YBOCS scores). Treatment response was compared between the OCD + HT group versus the OCD without HT group and between the OCD + PTSD group versus the OCD without PTSD group. Parametric and non-parametric tests were used when indicated. Data on HT and PTSD were available for 215 subjects. Thirty-eight subjects (17.67% of the whole sample) had a positive HT (OCD + HT group) and 22 subjects (57.89% of the OCD + HT group and 10.23% of the whole sample) met full DSM-IV criteria for PTSD. The OCD + HT and OCD without HT groups presented similar response to GCBT (60% of responders in the first group and 63% of responders in the second group, p = 1.00). Regarding SSRI treatment, the difference between the response of the OCD + HT (47.4%) and OCD without HT (22.2%) groups was marginally significant (p = 0.07). In addition, the OCD + PTSD group presented a greater treatment response than the OCD without PTSD group when treatment response was considered as a continuous variable (p = 0.01). The age when the first trauma occurred had no impact on treatment response. In terms of specific OCD symptom dimensions, as measured by the DYBOCS, OCD treatment fostered greater reductions for the OCD + PTSD group than for the OCD without PTSD group in the scores of contamination obsessions and cleaning compulsions, collecting and hoarding and miscellaneous obsessions and related compulsions (including illness concerns and mental rituals, among others). The OCD + PTSD group also presented a greater reduction in anxiety scores than the OCD without PTSD group (p = 0.003). The presence of HT or PTSD was not related to a poorer treatment response in this sample of non-treatment-resistant OCD patients. Unexpec...

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INTRODUCTION:In obsessive-compulsive disorder, early treatment discontinuation can hamper the effectiveness of first-line treatments.OBJECTIVE:This study aimed to investigate the clinical correlates of early treatment discontinuation among obsessive-compulsive disorder patients.METHODS:A group of patients who stopped taking selective serotonin reuptake inhibitors (SSRIs) or stopped participating in cognitive behavioral therapy before completion of the first twelve weeks (total n = 41; n = 16 for cognitive behavioral therapy and n = 25 for SSRIs) were compared with a paired sample of compliant patients (n = 41). Demographic and clinical characteristics were obtained at baseline using structured clinical interviews. Chi-square and Mann-Whitney tests were used when indicated. Variables presenting a p value <0.15 for the difference between groups were selected for inclusion in a logistic regression analysis that used an interaction model with treatment dropout as the response variable.RESULTS:Agoraphobia was only present in one (2.4%) patient who completed the twelve-week therapy, whereas it was present in six (15.0%) patients who dropped out (p = 0.044). Social phobia was present in eight (19.5%) patients who completed the twelve-week therapy and eighteen (45%) patients who dropped out (p = 0.014). Generalized anxiety disorder was present in eight (19.5%) patients who completed the twelve-week therapy and twenty (50%) dropouts (p = 0.004), and somatization disorder was not present in any of the patients who completed the twelve-week therapy; however, it was present in six (15%) dropouts (p = 0.010). According to the logistic regression model, treatment modality (p = 0.05), agoraphobia, the Brown Assessment of Beliefs Scale scores (p = 0.03) and the Beck Anxiety Inventory (p = 0.02) scores were significantly associated with the probability of treatment discontinuation irrespective of interactions with other variables.DISCUSSION AND CONCLUSION:Early treatment discontinuation is a common phenomenon in obsessive-compulsive disorder patients from our therapeutic setting. Psychiatric comorbidities were associated with discontinuation rates of specific treatments. Future studies might use this information to improve management for increased compliance and treatment effectiveness.

Letters to the Editor nonspecific factors were more important than the specific treatment factors because there were no differences at each level. However, nonspecific factors are present in both explanatory and pragmatic trials, and there is no evidence that they were more important than usual in STAR*D. Therefore, while we felt it necessary to acknowledge in our review that STAR*D could not answer the sorts of questions that explanatory trials can answer, we are not of the opinion that this means the study's value as a pragmatic trial is in any way diminished.Dr Gorman and Dr Abi-Jaoude suggest that it is difficult to interpret the 67% cumulative remission rate in STAR*D because of the length of the trial. However, one of the hallmarks of a well-designed pragmatic study is a longer trial length, 1 making STAR*D's length a strength. More importantly, the study quoted by Dr Gorman and Dr Abi-Jaoude followed a group of patients whose untreated depression had a median time to remission of 13 weeks. By comparison, patients in STAR*D entered the trial with a median current episode length of 7.8 months 2 indicating a higher degree of illness chronicity that would, in general, be unlikely to remit spontaneously on a short time scale.Pragmatic trials are valuable tools for determining the real-world impact of the treatments we offer. As such, they are often sought after by health system funders and government agencies. Explanatory trials also have their value; nonetheless, both of these types of trials must be judged on their quality rather than on the presence or absence of a placebo arm. Placebo-controlled trials help answer certain questions but are not the sole way to obtain valuable and meaningful data on treatment comparisons. Trial," 1 Dr Neil A Rector et al discussed the limited efficacy of cognitive-behavioural therapy (CBT) for obsessive-compulsive disorder (OCD) with a comorbid diagnosis of major depression. We share with the authors the experience of having evaluated the effectiveness of first-line treatments in a nonpure OCD population. Interestingly, we found similar results.Most of the clinical trials investigating treatments for OCD exclude patients with secondary psychiatric diagnoses. Although the methodology ensures a homogeneous sample, the results are limited regarding their generalization to a wider population, especially when the disorder occurs with a high level of psychiatric comorbidity-about 90% of OCD patients have a second psychiatric diagnosis during their lifetime. 2 We run a treatment service specialized in OCD as a primary diagnosis in which selective serotonin reuptake inhibitors (SSRIs) and group CBT are offered as first-line treatments. Our inclusion criteria are much broader than the ones from clinical trials with regulatory purposes but our treatment protocol is a structured one with sequential evaluations performed by blinded raters. Our sample has a comorbidity profile of up to 81% of patients having an additional psychiatric comorbidity. In a recent analysis of this sample, w...

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