Treatment

In treating a patient with OCD the health professional must bear in mind that:

• the condition may run a chronic, fluctuating course and have long periods of remission
  
  
• depressive disorder often accompanies obsessional neurosis and treatment of the depressive state may lead to spontaneously resolution of obsessional symptoms
  
  
• the patient often believes that they are developing a more severe mental disorder; an important aim when initiating therapy is to explain that OCD does not progress in this way

Treatment may involve psychotherapy, drugs or other physical treatments. The treatment most often is a combination of serotonin reuptake inhibitors and behavioural therapy.

Review of the evidence suggests that benefiicial treatments in this condition are (1):

• behavioural therapy
• cognitive therapy
• serotonin reuptake inhibitors

NICE state (2):

• adults with OCD
  • in the initial treatment of adults with OCD, low intensity psychological treatments (including exposure and response prevention [ERP]) (up to 10 therapist hours per patient) should be offered if the patient's degree of functional impairment is mild and/or the patient expresses a preference for a low intensity approach. Low intensity treatments include:
    • brief individual cognitive behavioural therapy (CBT) (including ERP) using structured self-help materials
    • brief individual CBT (including ERP) by telephone
    • group CBT (including ERP) (note, the patient may be receiving more than 10 hours of therapy in this format)
  • adults with OCD with mild functional impairment who are unable to engage in low intensity CBT (including ERP), or for whom low intensity treatment has proved to be inadequate, should be offered the choice of either a course of a selective serotonin re-uptake inhibitor (SSRI) or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious
  • adults with OCD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious

Notes:

• OCD in pregnancy
  • if a woman is taking medication alone, stopping the drug and starting psychological therapy should be considered
  • if she is not taking medication, starting psychological therapy should be considered before drug treatment
  • if she is taking paroxetine, it should be stopped and switching to a safer antidepressant considered
• pregnant woman with OCD who is planning to breastfeed
  • use of a combination of clomipramine and citalopram should be avoided if possible.
• women who have a new episode of OCD while breastfeeding
  • the combination of clomipramine and citalopram should be avoided because of the high levels in breast milk

Reference:

1. Clin Evid Concise 2003;10:229-230.
2. NICE (2005).Obsessive-compulsive disorder
3. NICE (2007). Antenatal and postnatal mental health.