by Christopher Pittenger, MD, PhD

This article was initially published in the Fall 2014 edition of the OCD Newsletter. 

The first-line treatments for OCD(1) are a specific type of cognitive behavioral therapy (CBT) and a type of antidepressant medication, called selective serotonin reuptake inhibitors (SSRIs).  As a practitioner, I am equally comfortable with recommending either (or both) of these treatments  — but the choice between them is a complex one. Some practitioners, and many patients and families, end up having very strong feelings on this issue.

Personal Obstacles to Choosing One or the Other

For some, thinking of OCD as a brain illness and not ‘all in my head’ means that it should be treated with a medication.  If a treatment based just on talking and behavioral exercises could be effective, it may seem to lessen the seriousness of the illness. For some, this may make OCD seem more like a personal failing or a form of weakness, rather than a disease.  I have talked to many patients who express this view in one way or another and are therefore not willing to consider psychotherapy for their symptoms.

Needless to say, I disagree with this view.   OCD (or any other mental disorder) can have biological(2), neurobiological(3), and genetic(4) components and still be effectively treated by cognitive-behavioral treatments.  We know that experience and behavior[v] have measurable effects(6) on brain structure and function(7).  Effective CBT can help overactive brain circuits in patients with depression(8) or OCD(9) return to “normal” levels.  Thus, feeling that OCD is primarily a brain disease with a biological cause in no way argues against CBT as a primary therapeutic strategy.

Meanwhile, some people are dead set against medication.  This may have to do with side effects or a general dislike of drugs.  Some patients I have spoken to believe that they should be able to overcome their symptoms through effort alone, and that relying on medication as a ‘crutch’ is in some way a sign of weakness.  Others have a more general sense that medications are ‘unnatural’.  In some cases, such a concern may get caught up with their OCD symptoms, with medication being seen as a form of contamination.  Such concerns are understandable, and can be very powerful.  My own view, however, is that anything that helps reduce symptoms and suffering can be a good thing.  Medication can help patients with OCD,(10) and in a great many cases, from my own experience and in the research, the benefits very clearly outweigh any side effects.(11)

CBT or Medication?

This is a more complicated question than you might think.  It has been most directly asked by a group of studies from Edna Foa and her colleagues at the University of Pennsylvania (and collaborators at other sites) directly comparing intensive, expert CBT and medication, in both adults and children.  In adults, the results are quite clear: medication is helpful, but patients receiving twice-weekly, expert CBT do better than those receiving medication alone.(12)  However, the evidence is not so clear in children.(13)  Furthermore, the comparisons done in the best research studies do not necessarily reflect what happens in the real world.  Typically psychotherapy in these studies is done by experts, under highly controlled conditions, at moderate to high intensity — ideal circumstances that are rarely achieved in clinical practice.  Psychotherapy outcomes can be quite different, even between expert sites. (14) The use of medications in these studies comparing medication to psychotherapy is quite rigid, with single medications and limited options for clinicians to change medications, optimize treatment, or attempt improve the outcomes.  This is not usually the case in the real world, where clinicians can change medications or dosages to better suit their patients’ needs, and therefore may have better outcomes.  Thus, while it is reasonably clear that the very best psychotherapy is superior to rigid pharmacotherapy, it is not clear how this comparison plays out in the real world outside of the strict and controlled research conditions.

Research is also somewhat murky regarding treatment that uses a combination of CBT and medication.  In the large trial of adults from the University of Pennsylvania group, combining medication with CBT provided no additional benefit to CBT alone(15); in the study in children, on the other hand, combining medication with CBT had the best outcomes compared to CBT alone or medication alone.(16)  Again, this is with fairly inflexible medication regimens and expert cognitive behavioral therapy, so it’s possible that the real-world benefits of medications are understated by these studies.

CBT & Medication

The one issue on which there is a lot of agreement in the research (and in my clinical experience) is the benefit of adding CBT when medications alone aren’t doing the job. Again, the best studies come from the University of Pennsylvania group (and their collaborators at Duke, Columbia, and elsewhere).  Both in adults(17) and in children,(18) when medication has led to only modest improvements (or none at all), the addition of expert CBT is of clear benefit.

My view is that, in the real world, looking across these and other studies and combining them with my own clinical experience and with that of colleagues, expert CBT and competently managed pharmacotherapy are about equally effective.  In my experience, both can be very helpful to 50-60% of patients, and of some moderate help to more than that.  I have found that about 25-30% of patients don’t receive much benefit from either.

Making the Decision

This brings us back to where I started — with the reality that the choice of CBT or medication, or their combination, is a highly individualized one.  Patient preference plays a huge role; there’s no point in pushing someone towards a treatment that they don’t believe in.  Medication side effects can prevent individual patients from ever having a good experience with an SSRI (or other medications).  An inability or unwillingness to tolerate the exposure component and anxiety that are the core part of CBT may limit an individual’s ability to benefit from it, even under otherwise ideal circumstances.

Speaking of ideal circumstances (and the lack thereof), the limited availability of skilled CBT therapists can be a major obstacle.  The reality is, medication is easier to administer correctly (it’s not that hard for a doctor to write a prescription, or for a patient to take a pill as directed) than CBT, which needs to be done properly by a well-trained practitioner to be as effective as possible. Past history can be a valuable guide — certainly, if a patient has had a good experience with CBT in the past, I would be more likely to refer them back to it, and if they’ve had a good response and few side effects with a particular medication, then that’s a good place to start.

The last thing I want to comment on is the problem of not knowing when to stop when a treatment isn’t helping. Most CBT treatments last from 8-16 weeks.  It’s clear that, in some cases, there is ongoing benefit for going longer than this — there’s nothing magic about an 8, 12, or 16-week trial; these are just the somewhat arbitrary time frames that have been picked for research studies.  But at some point, the benefits plateau and the individual stops improving.  Ideally, this is after a significant reduction in symptoms; but sometimes it becomes clear that a patient just isn’t getting better.  Continuing therapy beyond this point has drawbacks — it may be inconvenient, use up insurance and financial resources, and/or expose a patient to ongoing exposure-induced anxiety without any benefit.  A much bigger problem is overlooking the opportunity to consider something new  — a switch of therapist or technique; addition of medication; referral to an intensive program — before exhausting the patient’s resources and patience.

As a sidenote, I’m speaking above about treatment specifically aimed at symptom reduction. I don’t mean to diminish the benefit of ongoing supportive psychotherapy (i.e,. non-CBT therapy) in ill patients. This maintenance can be really valuable and help them manage their symptoms and their lives in important ways.

The risk of continuing an unhelpful treatment is greater with medications, because of the possibility of ongoing side effects, or of side effects that get worse with time.  For various reasons, it can be much more comfortable for a psychiatrist to start a medication than to stop one. Stopping medications in ill patients can be a very anxiety-provoking thing to do, for both doctor and patient — what if the medications are in fact helping, and we destabilize them by stopping the meds?  As a result, it can seem easier for a psychiatrist to add a new medication, instead of taking an ineffective medication away.

Sometimes additional medications do help; there is clear evidence that adding medications on top of standard SSRIs can help some patients.(19) Also called ‘augmentation therapy’, this strategy is a very active area of research.(20)

But, all too often, medications begin to pile up, with new ones being added, or doses raised, to manage crises or side effects. This can lead to astonishing numbers and mixes of medications with side effects that can become every bit as bad as the original symptoms.  Medications can help, but they can also harm, and they need to be managed with care.  It is hard, for both psychiatrists and patients, to admit that the available treatment options just aren’t working.  However, this is a fact that we must be willing to acknowledge.

Conclusion

At the end of the day, we are fortunate to have treatments for OCD that often work.  That wasn’t true 30 years ago.  But choosing among these treatments in individual cases is often more art than science, requiring the consideration of many factors more complex and personal than can be captured in any formal research study.  I dream of the day that I can use some objective test — a brain scan, a blood test, whatever — to identify the treatment that will work best for a new patient sitting in front of me, without guesswork or trial-and-error.  That day may come; it’s a focus of research in my Clinic, and at other centers.

For now, the best my patients and I can do is to work together to figure out which of the alternatives is the best fit for them. We know that many will improve, but also that some will not. It’s frustrating.  But it’s a start.

This entry was adapted from an article originally posted to the Yale OCD Research Clinic’s Director’s Blog (http://ocd.commons.yale.edu).

References:

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