Optimal treatment for obsessive compulsive disorder: a randomized controlled feasibility study of the clinical-effectiveness and cost-effectiveness of cognitive-behavioural therapy, selective serotonin reuptake inhibitors and their combination in the management of obsessive compulsive disorder.

Naomi Fineberg ,Ayotunde Shodunke,Yana Varlakova,Ilenia Pampaloni,Sonia Shahper,Garry Barton,David S Baldwin,David Wellsted,Deela Monji-Patel,Karen Irvine,Tony Dyer,Virender Marwah,Sukhwinder Kaur,Ricky A Sachdev,Cliodhna O’Leary,Christopher Manson,Jemma Reid,Amy Dymond,Solange Wyatt,Jasmine Hanson,Davis Mpavaenda,Lynne M Drummond,Srinivas Gopi

doi:10.1097/yic.0000000000000237

Abstract

Established treatments for obsessive compulsive disorder (OCD) include cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication. Combined treatment may outperform monotherapy, but few studies have investigated this. A total of 49 community-based adults with OCD were randomly assigned to CBT, SSRI, or SSRI+CBT. Sertraline (50–200 mg/day) was given as the SSRI for 52 weeks. A 16-h-manualized individual CBT was delivered over 8 weeks with four follow-up sessions. Assessors were ‘blinded’ to treatment allocation. A preliminary health economic evaluation was conducted. At week 16, combined treatment (n=13) was associated with the largest improvement, sertraline (n=7) the next largest and CBT (n=9) the smallest on the observed case analysis. The effect size (Cohen’s d) comparing the improvement in Yale Brown Obsessive Compulsive Scale on CBT versus combined treatment was −0.39 and versus sertraline was −0.27. Between 16 and 52 weeks, the greatest clinical improvement was seen with sertraline, but participant discontinuation prevented reliable analysis. Compared with sertraline, the mean costs were higher for CBT and for combined treatment. The mean Quality Adjusted Life Year scores for sertraline were 0.1823 (95% confidence interval: 0.0447–0.3199) greater than for CBT and 0.1135 (95% confidence interval: ‑0.0290–0.2560), greater than for combined treatment. Combined treatment appeared the most clinically effective option, especially over CBT, but the advantages over SSRI monotherapy were not sustained beyond 16 weeks. SSRI monotherapy was the most cost-effective. A definitive study can and should be conducted.

Highlights

Obsessive compulsive disorder (OCD) is a common, disabling, relapsing psychiatric illness (Skoog and Skoog, 1999)
There is additional uncertainty relating to the quality of life (QOL) gain and cost-effectiveness associated with the different treatment options (National Institute for Health and Care Excellence, 2006; Skapinakis et al, 2016b)
Recruitment A total of 258 patients were assessed for eligibility, of whom 59 were excluded and 150 declined to participate (Fig. 1)

Summary

Introduction

Obsessive compulsive disorder (OCD) is a common, disabling, relapsing psychiatric illness (Skoog and Skoog, 1999). Combining pharmacotherapy with cognitive behaviour therapy (CBT) has been considered superior Optimal treatment for OCD Fineberg et al 335 medication as standard first-line treatments, with combined therapy (CBT + SSRI) reserved for patients with more severe or enduring illness. This staging is, largely based on clinical consensus (level IV evidence). There is additional uncertainty relating to the quality of life (QOL) gain and cost-effectiveness associated with the different treatment options (National Institute for Health and Care Excellence, 2006; Skapinakis et al, 2016b)

Results

Discussion

Conclusion