New Guidelines to Set Standards for Best Treatment of Obsessive-Compulsive Disorder
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
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
"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
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
"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
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
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 bulimia
(an eating disorder), pharmacotherapy with an SRI may be
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,"
Funding for development of the guidelines was provided by an
unrestricted grant from Solvay Pharmaceuticals Inc. and
Pharmacia & Upjohn Inc.