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Psychotherapy for OCD


not have comparable access to evidence-based psychotherapy as they do pharmacotherapy, as the number of therapists trained in CBT for OCD is fairly limited.62 Geographic, and relatedly financial factors, contribute additional barriers to accessing CBT. As such, the field has begun to examine ways in which treatment tailored to OCD can be more widely disseminated such as intensive therapy, manualized protocols, bibliotherapy, computer-guided therapy, and self- guided therapy.

Intensive treatment

Intensive CBT is appropriate for those who do not have access to qualified CBT therapists, children who may lack motivation to engage in treatment, and those with severe illness presentation.18,63,64 Sessions are conducted over 35 weeks (instead of 12 weeks), are held daily, may be longer (ie, 90 minutes or longer), or in some combination of these factors. A number of studies demonstrate the efficacy of this treatment modality for children and adults.14,38,65,66

Alternative delivery modalities

CBT is flexible in terms of the context in which it occurs. Its effects may be most robust if treatment occurs in the context in which the symptoms are triggered. Results from controlled trials, however, revealed no significant differences in out- comes when treatment was administered at home or in a more formal office environment.67 Storch et al68 are currently examining the efficacy of CBT administered via webcam in children and adolescents. Sessions follow the Pediatric OCD Treatment Study (POTS) model,22 in which sessions were held twice a week for 2 weeks, then weekly over the course of 10 weeks. Although there may be limitations in the types of exposures that can be conducted via webcam, a significant strength of this approach is that children can generalize the techniques typically used in an office to their home environ- ment more easily and naturally and that homebound patients can receive services. As well, many clinicians cannot make home visits despite their utility; this may be one manner of circumventing this issue. Additionally, Internet-based CBT can reduce geographic barriers to accessing evidence-based intervention.

Manualized treatments Manualized treatments offer another mechanism by which

to mitigate barriers to accessing treatment. Van Oppen et al.69 conducted a randomized controlled trial of CBT administered by a trained licensed clinician, a master’s level graduate student using manualized treatment, or a self-directed manualized treatment in adults. Under the self-guided treat- ment, participants followed the treatment protocol delineated by the manual, but were able to control the order and types of 41

exposures they conducted. All treatment arms consisted of 12 sessions, with the first 2 dedicated to constructing the fear hierarchy. Therapist-guided sessions were conducted in the environment in which they typically occur (eg, at home, public restrooms, etc.), focused on exposures, and were approxi- mately 90 minutes in length. Self-guided sessions were conducted in an outpatient clinic, did not entail an exposure, but instead focused on creating exposures for the individual to practice outside the session and lasted 30 minutes. On average, participants, irrespective of condition, experienced significant improvements in OCD symptom severity. Although there were no statistically significant differences in outcome, it appears that the therapist-guided treatments had a larger treatment effect than self-guided treatments. These results suggest that therapeutic techniques can be disseminated effectively to less experienced therapists, thereby enhancing treatment access.

Self-guided therapy

Bibliotherapy, the use of self-help manuals with minimal clinician contact.70 and computer-guided CBT,71,72 have demonstrated relative efficacy in the treatment of OCD. Tolin et al.73 compared the efficacy of self-guided therapy and clinician-guided therapy for the treatment of adults with OCD. Results support the enhanced benefit of clinician- guided treatment. Not surprisingly, although bibliotherapy or self-guided therapy are associated with modest reductions in OCD symptom severity, clinician-guided treatment remains the most effective and preferred mode of treatment for adults with OCD.

Considerations for children

The issue of limited CBT dissemination is particularly problematic for children with OCD, given the childhood onset for most affected individuals and that childhood is a developmentally critical period with marked consequences if gone astray. As well, despite the efficacy of SRI therapies, practice parameters suggest initiating treatment with CBT alone for mild and moderate cases, and CBT and SRI therapy concurrently for more severe cases.74 Off-label use of atypical antipsychotics is taking place with considerable frequency in the absence of efficacy data and with a relatively high risk profile for this medication class. Indeed, youth taking an atypical antipsychotic medication had an average weight increase of 8.5 kg over a 10-week period.75 necessitating that lower-risk alternatives should be considered prior to prescription of such medications in children.76

In a recent National Institutes of Health (NIH)-funded study

examining the additive effects of CBT to ongoing SRI treatment in children,77 three treatment arms were compared: CBT provided by highly trained psychologists in conjunction with SRI treatment; a less intensive version of CBT (con- ducted by the prescribing psychiatrist) that focused on encouraging CBT skills rather than guiding the individual through CBT in conjunction with SRI medication manage- ment; and continued SRI treatment alone. Although study

M&B 2011; 2:(1). July 2011

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