Treatment-resistant obsessive-compulsive disorder (OCD) refers to OCD that persists after trials of at least two evidence-based treatments, typically cognitive behavioral therapy (CBT) incorporating exposure and response prevention and an adequate trial of a selective serotonin reuptake inhibitor (SSRI).
Despite following treatment guidelines, symptoms remain at a clinically significant level, causing distress and impairment in functioning. More intensive or alternative interventions may be required for these refractory cases.
Krebs, G., & Heyman, I. (2010). Treatment-resistant obsessive-compulsive disorder in young people: Assessment and treatment strategies. Child and Adolescent Mental Health, 15(1), 2–11. https://doi.org/10.1111/j.1475-3588.2009.00548.x
Key Points
- Specialist CBT treatment was associated with significant reductions in OCD symptoms among youth with severe, treatment-resistant OCD. Gains were maintained at 3-month follow-up.
- 58% met criteria for treatment response and 22% were in remission following specialist CBT.
- Medication optimization in conjunction with CBT tended to be associated with better outcomes, although differences were not statistically significant.
- Previous CBT was rated as inadequate in 95.5% of cases, most commonly due to insufficient focus on exposure techniques.
Rationale
Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) techniques and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for OCD.
Multiple randomized controlled trials have demonstrated the efficacy of these interventions, with 40-88% of pediatric OCD patients achieving remission with CBT and 25-44% showing symptom improvement with SSRIs (Barrett et al., 2004; POTS, 2004). Consequently, practice guidelines universally recommend CBT/ERP and SSRIs as the initial treatments for OCD (APA, 2007; NICE, 2005).
However, a subset of OCD patients fail to respond adequately to these first-line treatments even when properly administered at therapeutic doses and duration.
By definition, treatment response refers to at least a 35-40% decrease in Yale-Brown Obsessive Compulsive Scale (YBOCS/CYBOCS) scores, while remission signifies a score below 12-14 (Farris et al., 2013).
Individuals who remain symptomatic after evidence-based care delivered according to guidelines can be categorized as having treatment-resistant OCD.
Given the distress and functional impairment resulting from residual OCD symptoms, alternate interventions with higher efficacy are needed for these refractory patients. The pathophysiology underlying lack of response needs to be elucidated.
Treatment resistance likely involves complex interactions between biological vulnerabilities, genetic factors, and psychosocial variables. Elucidating these mechanisms can pave the way for novel personalized therapies.
It is unclear whether these patients have “technical” treatment failures, where treatment delivery was inadequate, or “serious” failures where patients are truly treatment refractory (Rachman, 1983)
Method
Naturalistic pre-post study design
Sample
Participants were youth with severe, treatment-refractory OCD who were referred to a national specialist clinic. All had inadequate response to both previous CBT and SSRI trials meeting referral criteria.
N = 43 consecutive referrals who completed outpatient CBT
Inclusion Criteria:
- Diagnosed with OCD using ICD-10 criteria
- Assessed by specialist multidisciplinary team
- History of at least one prior course of CBT for OCD
- Majority (39/43) had at least one past adequate trial of an SSRI
Demographics:
- Age: Mean 15.8 years (range 10-18 years)
- Gender: 22 males, 21 females
- Ethnicities: Mainly White British
Status at Baseline:
- 38/43 taking SSRIs currently
- Mean baseline CY-BOCS score: 32.7 → severe OCD
Measures
- Primary outcome: Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS), clinician-rated scale of OCD symptom severity (0-40 score)
- Secondary outcomes:
- Beck Depression Inventory for Youth (BDI-Y), self-report measure of depressive symptoms
- Children’s Global Assessment Scale (CGAS), clinician-rated measure of global functioning (1-100 score)
- Experience of Previous CBT Interview Schedule: Semi-structured interview to assess quality and adequacy of previous CBT among a subset of participants (n = 15)
Procedure
Following an intensive initial evaluation, participants received protocol-driven CBT with medication adjustments as needed. A subgroup provided insights into their previous CBT.
Initial Assessment:
- 3 hour assessment by specialist multidisciplinary team
- Interviewed child for OCD symptoms and comorbidities
- Interviewed parents for developmental history
CBT Treatment:
- Manualized protocol focused on psychoeducation, ERP, relapse prevention
- Mainly ERP carried out with therapist guidance and as homework
- Delivered in weekly 1-hour sessions over mean 18.3 hours
- Conducted by experts in childhood OCD and CBT protocols
- Supervision promoted protocol adherence
Medication Changes:
- Optimization in 21 participants via increased SSRI dose, additions, switches, etc.
Interview Sub-study:
- Previous CBT quality assessed in subset (n=15) via semi-structured interview
- Face-to-face or telephone interview conducted by psychologist
- Examined CBT format, content, ERP use
Analysis
- Linear regression to assess change in symptoms over time
- Compared outcomes between medication optimized vs. stable groups
Results
Overall, specialist CBT was associated with a 43% decrease in OCD severity, with 58% meeting criteria for treatment response. Secondary outcomes also improved.
Primary Outcome (CY-BOCS scores)
- Mean score decreased from 32.7 (severe OCD) at baseline to 18.6 at 3-month follow-up
- Represents significant 43% reduction in OCD symptoms (p < 0.001)
- Post-hoc tests: Significant reduction from pre- to post-treatment sustained at follow-up
Secondary Outcomes
- Children’s Global Assessment Scale (CGAS):
- Improved from 35.3 to 56.5 from pre- to post-treatment (p<0.001)
- Beck Depression Inventory for Youth (BDI-Y):
- Decreased from 66.7 to 58.2 from pre- to post-treatment (p=0.044)
Clinical Response
- Treatment response rate (≥35% CY-BOCS decrease): 58.1%
- Remission rate (CY-BOCS ≤12): 21.9%
Comparison by Medication Groups
- No significant differences in CY-BOCS change between optimized vs stable medication groups
- Numerical trends for better response (71% vs 45%) and remission (30% vs 14%) with optimization
Insight
- Specialist CBT was effective even in youth with prior treatment failure, suggesting many were “technical” rather than refractory failures
- Insufficient exposure therapy was the most common reason previous CBT was inadequate
- Need to disseminate proper CBT protocols and training among clinicians treating pediatric OCD
Strengths
- Use of treatment protocols and expert therapists
- Assessment of quality of prior CBT
Limitations
- Lack of control group
- Small sample for CBT quality analysis
- Assessments done by treating clinicians
Clinical Implications
- Among young people with OCD, failure to respond to treatment in routine clinical practice may often reflect the nature of the treatment received.
- Training clinicians in proper CBT techniques could increase treatment response rates. For example, The Progressive Cascading Model (PCM) is a competency-based approach for training novice therapists in exposure therapy techniques. It involves multiple tiers of experiential learning tailored to the trainee’s skill level.
- Low-intensity interventions like computerized CBT needed to increase access
- Meanwhile, optimizing pharmacotherapy, intensive CBT, residential treatment, deep brain stimulation, and other augmentations remain necessities for this subset.
- Further research is needed to establish effective methods for disseminating good quality CBT for OCD.
References
Primary reference
Krebs, G., & Heyman, I. (2010). Treatment-resistant obsessive-compulsive disorder in young people: Assessment and treatment strategies. Child and Adolescent Mental Health, 15(1), 2–11. https://doi.org/10.1111/j.1475-3588.2009.00548.x
Other references
Ginsburg, G. S., Kingery, J. N., Drake, K. L., & Grados, M. A. (2008). Predictors of treatment response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9), 868-878. https://doi.org/10.1097/CHI.0b013e3181799ebd
Pediatric OCD Treatment Study (POTS) Team (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder. JAMA, 292(16), 1969-1976. https://doi.org/10.1001/jama.292.16.1969
Rachman, S. (1983). Obstacles to the successful treatment of obsessions. In E. B. Foa & P. M. G. Emmelkamp (Eds.), Failures in behavior therapy (pp. 35–57). New York: Wiley and Sons.
Keep Learning
- What barriers exist that prevent clinicians from properly implementing exposure therapy? How can these be addressed?
- Would the results be generalizable to adults with treatment-refractory OCD?
- What modifications or additions to CBT protocols could improve outcomes among non-responders?
