Title:Combining Drug and Psychological Treatments for Obsessive- Compulsive Disorder: What is the Evidence, When and for Whom
VOLUME: 25 ISSUE: 41
Author(s): Umberto Albert*, Gabriele Di Salvo, Francesca Solia, Gianluca Rosso and Giuseppe Maina
Affiliation:Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin
Keywords:Obsessive-Compulsive Disorder, cognitive behavioral therapy, augmentation treatment, combination
treatments, serotonin reuptake inhibitors, treatment-resistant OCD, exposure and response prevention.
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.
