Obsessive - Compulsive Disorder - Chronic, Impairing, Under-recognized, and Undertreated
Obsessive - Compulsive Disorder - Chronic, Impairing, Under-recognized, and Undertreated
US Psychiatry 2007;1:7-9
Obsessive-compulsive disorder (OCD) is a chronic disorder often associated with substantial distress, impaired functioning, and diminished quality of life.1,2 Despite this, OCD is too often inadequately treated. One reason for this undertreatment is that OCD sufferers are often reluctant to seek care, or do not know that their symptoms are treatable. For example, one study reported a delay of 10 years between symptom onset and seeking care.3 Among a random sample of Baltimore participants in the Epidemiological Catchment Area survey, only one of 15 individuals (7%) judged to need treatment for OCD was receiving it.4
A study of clinically recognized OCD in a large health maintenance organization found a prevalence rate of 0.084%, suggesting that only 8-28% of existing OCD cases were clinically recognized.5 These studies took place in the 1980s and 1990s, when OCD and its treatments had been less well publicized. A more recent British epidemiological study reported that in the previous year only 27% of 114 subjects with OCD had received treatment, mostly ineffective varieties.6 A similar Canadian study reported that only 37% of subjects with OCD had consulted a doctor about their symptoms.7 In both studies, those with comorbid conditions were significantly more likely to have sought treatment, which suggested to the investigators that many had not revealed their OCD symptoms to their treating clinicians.
The second reason for inadequate treatment, and perhaps the more easily remedied, is that physicians and psychologists do not apply in linical practice all that clinical research has revealed. For example, in a study of OCD patients treated by a sample of US psychiatrists during the period 1997-1999, only 41% were receiving an adequate dose of a serotonin re-uptake inhibitor (SRI), and fewer than 15% were receiving any form of cognitive behavioral therapy (CBT).8 A study of a cohort of OCD patients recruited from treatment centers a few years later (2001-2004) reported better results: 78% of patients had been receiving an adequate SRI dose for at least 12 weeks when studied, but only 24% ad ever received an adequate trial of CBT.9 Many patients still rated themselves as minimally improved or less.
The American Psychiatric Association's Recent Practice
Guideline for Obsessive-Compulsive Disorder
In July, 2007, the American Psychiatric Association (APA) published its Practice Guideline for the Treatment of Patients with Obsessive- Compulsive Disorder.10 The Guideline was the result of more than two years of work by a group of experts and the integration of comments on manuscript drafts from 11 professional organizations and 68 individuals, as well as review and, ultimately, approval by the APA Assembly and Board of Trustees. Development of the Guideline began with a comprehensive literature review that included all relevant randomized clinical trials and, when data from rigorously controlled trials were not available, less well-controlled trials, cases series, and case reports. The literature review utilized PubMed to identify related articles published between 1966 and December 2004, and searched the Cochrane databases for relevant meta-analyses. The workgroup experts also integrated information from studies published during the Guideline's preparation. Despite this detailed review of evidence, the Guideline is not intended as a standard of care. Such standards must be developed for ndividual patients, and should change with advances in knowledge and practice patterns.
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- Koran LM, Obsessive-Compulsive and Related Disorders in Adults: A Comprehensive Clinical Guide, New York: Cambridge University Press, 1999;35-80.
- Koran LM, Quality of life in obsessive-compulsive disorder, Psychiatr Clin North Am, 2000;23:509-18.
- Marks I, Fears, Phobias and Rituals, Oxford: Oxford University Press, 1992.
- Nestadt G, Samuels JF, Romanoski AJ, et al., Obsessions and compulsions in the community, Acta Psychiatr Scand, 1994;89: 219-24.
- Fireman B, Koran LM, Leventhal JL, et al.,The prevalence of clinically recognized obsessive-compulsive disorder in a large health maintenance organization, Am J Psychiatry, 2001;158: 1904-10.
- Torres AR, Prince MJ, Bebbington PE, et al.,Treatment seeking by individuals with obsessive compulsive disorder from the British Psychiatric Morbidity Survey of 2000, Psychiatr Serv, 2007;58:977-82.
- Mayerovitch JI, du Fort GG, Kakuma R, et al.,Treatment seeking for obsessive-compulsive disorder: Role of obsessive- compulsive symptoms and comorbid psychiatric diagnoses, Compr Psychiatry, 2003;44:162-8.
- Blanco C, Olfson M, Stein DJ, et al.,Treatment of obsessive- compulsive disorder by U.S. psychiatrists, J Clin Psychiatry, 2006;67:946-51.
- Mancebo MC, Eisen JL, Pinto A, et al.,The Brown longitudinal obsessive compulsive study: treatments received and patient impression of improvement, J Clin Psychiatry, 2006;67: 1713-20.
- American Psychiatric Association, Practice guideline for the treatment of patients with obsessive-compulsive disorder, Am J Psychiatry, 2007;164(Suppl.):1-56.
