Psychological treatments compared with treatment as usual for obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is a chronic and disabling anxiety disorder characterised by recurrent obsessions, such as persistent thoughts, impulses or mental images, that promote anxiety, together with compulsions, such as repetitive behaviours or mental acts, that are performed in response to the obsessions. Currently the most commonly used therapies for OCD are pharmacological therapies, followed by psychotherapies, particularly cognitive behavioural approaches. We reviewed studies that compared psychological interventions to treatment as usual groups who either received no treatment, or were on a waiting list for treatment or received usual care. We found eight studies, which together suggested that cognitive and/or behavioural treatments were better than treatment as usual conditions at reducing clinical symptoms. Baseline OCD severity and depressive symptom level predicted the degree of response. However, the conclusions were based on a small number of randomised controlled trials with small sample sizes. There were no trials of other forms of psychological treatment such as psychodynamic therapy and client-centred therapy, and a lack of available evidence for the long-term effectiveness of psychological treatments.

Authors' conclusions: 

The findings of this review suggest that psychological treatments derived from cognitive behavioural models are an effective treatment for adult patients with obsessive compulsive disorder. Larger high quality randomised controlled trials involving longer follow up periods are needed, to further test cognitive behavioural treatments, and other psychological approaches, in comparison to each other and control conditions. Future trials should examine the predictors of response to each treatment, and also conduct cost-effectiveness evaluations.

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Background: 

Obsessive compulsive disorder (OCD) is a chronic anxiety disorder associated with significant morbidity, social impairment and lower quality of life. Psychological treatments are a frequently used approach for OCD.

Objectives: 

To perform a systematic review of randomised trials of psychological treatments for obsessive compulsive disorder in comparison with treatment as usual.

Search strategy: 

We conducted an electronic search of CCDANCTR-Studies (31/10/2006), and other databases. We searched reference lists, and contacted experts in the field.

Selection criteria: 

Published and unpublished randomised trials of psychological treatments versus treatment as usual for adults with a diagnosis of OCD

Data collection and analysis: 

Two review authors worked independently throughout the selection of trials and data extraction. Findings were compared and disagreements were discussed with a third review author. Full data extraction, using a standardised data extraction sheet, was performed on all studies included in the review. Results were synthesised using Review Manager software. For dichotomous data, odds ratios were calculated. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. Fixed and random effects models were used to pool the data. Reasons for heterogeneity in studies were explored and sensitivity analyses were performed by excluding trials of lower quality.

Main results: 

Eight studies (11 study comparisons) were identified, all of which compared cognitive and/or behavioural treatments versus treatment as usual control groups. Seven studies (ten comparisons) had usable data for meta-analyses. These studies demonstrated that patients receiving any variant of cognitive behavioural treatment exhibited significantly fewer symptoms post-treatment than those receiving treatment as usual (SMD -1.24, 95% CI -1.61 to -0.87, I² test for heterogeneity 33.4%). Different types of cognitive and/or behavioural treatments showed similar differences in effect when compared with treatment as usual. The overall treatment effect appeared to be influenced by differences in baseline severity.

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