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August 25, 2009

Best Practices for Treating Obsessive-Compulsive Disorder in Primary Care Setting

Laurie Barclay, MD
August 24, 2009 — Recommendations for diagnosing and treating obsessive-compulsive disorder (OCD) in the primary care setting are reviewed in the August 1 issue of American Family Physician.
"...OCD is a neuropsychiatric disorder characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety," write Jill N. Fenske, MD, and Thomas L. Schwenk, MD, from the University of Michigan Medical School in Ann Arbor.
"Symptoms are often accompanied by feelings of shame and secrecy because patients realize the thoughts and behaviors are excessive or unreasonable. This secrecy, along with a lack of recognition of OCD symptoms by health care professionals, often leads to a long delay in diagnosis and treatment. OCD has a reputation of being difficult to treat, but there are many effective treatments available."
Despite the considerable distress and disability accompanying OCD, it is often unrecognized and undertreated. Primary care physicians should be able to recognize various presentations of OCD as well as clues regarding the presence of obsessions or compulsions. Children with OCD and adults who are refractory to treatment should be referred to a specialist.
Various subtypes of OCD, and their typical presenting features, are as follows:
Early-onset OCD: This subtype typically manifests symptoms before puberty, with higher frequency of tics and other psychiatric comorbidities vs the other OCD subtypes. Compulsions, which are often severe and frequent, usually are evident before obsessions develop. Early-onset OCD is less responsive to first-line therapy than the other subtypes, and there is a strong familial predisposition, with incidence of 17% among first-degree relatives.
Hoarding OCD: Patients with this subtype usually have less insight vs other OCD subtypes and may be less responsive to psychological therapy. Symptoms are often more severe, with a greater degree of global impairment, and rates of psychiatric comorbidities are higher, especially for social phobia.
"Just right" OCD: In this subtype, the primary manifestation is a desire for circumstances or things to be "perfect," "certain," or "under control," resulting in a need to repeat certain actions to alleviate the uncomfortable feeling.
Primary obsessional OCD: This subtype occurs in one quarter of patients, with common themes including sex, violence, and religion. Although overt compulsions are absent, patients are not free from rituals, which may be mental, such as praying, counting, or reciting "good words." Although this subtype has been considered to be less responsive to treatment, patients do respond to medication and exposure and response prevention.
Scrupulosity OCD: This subtype, which is characterized by religious or moral obsessions, can be devastating for patients in whom faith or religious affiliation is important. The obsessions may involve blasphemous thoughts or focus on whether the patient has committed a sin, and the accompanying compulsions may include prayer, seeking reassurance from clergy, or excessive confession.
Tic-related OCD: This subtype overlaps significantly with early-onset OCD, and many patients meet criteria for Tourette's syndrome. Comorbid conditions often occur, such as, attention-deficit/hyperactivity disorder, body dysmorphic disorder, trichotillomania, social anxiety, and/or mood disorders. Hoarding and somatic obsessions typically occur. This subtype often requires combination treatment including a selective serotonin reuptake inhibitor (SSRI) and an atypical antipsychotic.

Important initial steps in facilitating recovery include correct diagnosis and educating the patient concerning the nature of OCD. Treatment is indicated when OCD symptoms cause impaired function or significant distress for the patient. Although treatment rarely cures the patient with OCD, significant symptomatic relief is achievable. Reasonable goals for treatment would be to spend less than 1 hour per day on obsessive-compulsive behaviors, causing minimal interference with daily activities.
First-line therapy should consist of cognitive behavioral therapy with exposure and response prevention, or pharmacotherapy with an SSRI, such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. Physicians should be aware that medication dosages required in OCD often exceed those needed for other indications, and there is also usually a longer duration of treatment needed before response becomes apparent.
For patients with OCD who are resistant to treatment, feasible options for therapy may include augmentation of an SSRI with an atypical antipsychotic. Because OCD is a chronic condition with a high rate of relapse, treatment should be discontinued only with caution. Patients with OCD should be carefully monitored to detect possible comorbid depression and suicidal ideation.

Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
Cognitive behavioral therapy including exposure and response prevention is an effective modality for OCD treatment (level of evidence, A).
Recommended first-line pharmacotherapy for OCD is SSRIs, which have been shown to be effective (level of evidence, A).
In some patients with treatment-resistant OCD, augmentation of SSRI therapy with atypical antipsychotic agents is effective (level of evidence, B).
Optimal duration for a trial of SSRI treatment is 8 to 12 weeks, with at least 4 to 6 weeks at the maximal tolerable dosage (level of evidence, C).
Before attempting discontinuation of SSRIs, patients should take these drugs for at least 1 to 2 years. To help prevent relapse when SSRIs are discontinued, the treating physician should consider exposure and response prevention "booster" sessions (level of evidence, C).
Patients with OCD should be monitored for psychiatric comorbidities and suicide risk (level of evidence, C).
"Patients with treatment-resistant OCD should be referred to a subspecialist," the study authors conclude. "There are a variety of treatment options for these patients, but the evidence for most therapies is based on small preliminary studies or expert opinion. Partial hospitalization and residential treatment facilities are options for patients with severe, treatment-resistant OCD."
The review authors have disclosed no relevant financial relationships.
Am Fam Physician. 2009;80:239-245. Abstract

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