Combining Drug and Psychological Treatments for Obsessive- Compulsive Disorder: What is the Evidence, When and for Whom

Abstract

Background: Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). Since response is often inadequate, in recent years researchers investigated whether combining CBT and SRIs, either ab initio or sequentially, results in a greater reduction of obsessivecompulsive symptoms. Objective: The aims of the present paper are to assess if combination treatment seems adding benefits as compared to either monotherapy alone and if sequential strategies may be effective in converting partial or non responders to a first-line treatment into responders. Method: We reviewed available literature on pharmacological and CBT combination and sequential treatments for adult and pediatric OCD patients and then we conducted a separate analysis for studies concerning these two promising strategies. Search results included openlabel trials and randomized controlled trials (RCTs). Results: We identified ten controlled studies assessing the efficacy of combination treatments ab initio versus CBT alone and six evaluating combination strategies ab initio versus medications alone. Eleven studies, only two of which were RCTs, have been published on sequential treatments. The combination ab initio of CBT and SRIs has not been found to be clearly superior to either monotherapy alone in most studies conducted on this topic, except for patients with severe depression who might benefit more from the combination versus only CBT. A 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. Conclusion: OCD patients with comorbid major depression should receive medication firstly, eventually associated with CBT; for all remaining patients there is clear evidence from the literature of no additive benefits of combining ab initio CBT and medication. Therefore, the routine use of a combination approach in all adult patients affected by OCD is not supported by the literature. The available evidence supports the effectiveness of the sequential addition of CBT to SRIs.

Propensity to Sexual Response among Adults with Obsessive-Compulsive Disorder

“…We did not find a direct association between concurrent antidepressant treatment and both the propensity towards excitation and inhibition. These findings appear in contrast with the evidence showing that most of the antidepressants can influence the sexual response, particularly when prescribed at high dosages [26]. It should be noted however, that in our OCD group, only one-third of the patients on antidepressants were taking sertraline, which has been found to be one of the antidepressants associated with the highest incidence of sexual dysfunctions [26].…”

“…These findings appear in contrast with the evidence showing that most of the antidepressants can influence the sexual response, particularly when prescribed at high dosages [26]. It should be noted however, that in our OCD group, only one-third of the patients on antidepressants were taking sertraline, which has been found to be one of the antidepressants associated with the highest incidence of sexual dysfunctions [26]. This lack of difference may also be due to the fact that the SIS/SES specifically measures the psychological processes related to impaired sexual functioning such as the fear of failure during sexual performance instead of focusing on dysfunctions.…”

“…Given gender differences found in the literature [21], we expected that female gender was associated with a lower excitation and a higher inhibition. We also focused on the impact of a concurrent antidepressant treatment given its expected negative effects on propensity to sexual response [26, 27].…”

Efficacy of nicotine administration on obsessions and compulsions in OCD: a systematic review

“…As there is no evidence for the efficacy of other tricyclic antidepressants in OCD, the efficacy of clomipramine has been attributed to its effect on serotonin (5-HT) [ 79 ] and dopamine (DA) [ 15 ]. Unfortunately, about 40% of OCD patients do not achieve an acceptable remission of OC symptoms in response to SSRIs or clomipramine, among those who do respond, the response is often partial or incomplete [ 5 , 6 ]. Even when switching to another SSRI, the percentage of non-responders remains high, about 30% [ 55 ].…”

“…Even when switching to another SSRI, the percentage of non-responders remains high, about 30% [ 55 ]. Hence, augmentation with atypical antipsychotics is an established second-line drug treatment strategy, alternatives include combination with or switching to cognitive–behavioural therapy (CBT [ 5 , 6 ].…”