A large NIHR-funded review gathered evidence from trials to compare a wide range of medical and psychological treatments, delivered over a time period between 12 weeks and five years. The review used an approach called network meta-analysis to make new comparisons beyond what was directly researched in individual trials.
Medical and psychological treatments showed similar ability to reduce OCD symptoms. Some specific treatments seemed to have higher dropout rates. The review didn’t investigate why, but this may be because of negative experiences like drug side effects. For example, adults taking the drug clomipramine were more likely to drop out of the studies.
In practice, the stepped care approach as recommended in NICE guidance means psychological treatments tend to be offered first to people who have mild to moderate symptoms of OCD, while medication may be offered to those who have moderate to severe symptoms.
If one drug or approach doesn’t work, often another is suggested, or a combination of medical and psychological treatments.The review was unable to compare detailed characteristics of the exact treatments, such as amount of therapist contact offered with each treatment.
A large NIHR-funded trial of different intensities of psychological treatment looked at interim self-help for people who mostly had severe symptoms, while on a waiting list for CBT with a therapist. Those who used a workbook or computerised self-help materials with support, were less likely to go on to use more intensive CBT from a therapist, compared with those who did not receive supported self-help.
The research showed that psychological and drug treatments had similar cost effectiveness, and that self-help with low intensity support was more cost-effective than simply being on a waiting list for more intensive psychological treatment.
However, upfront cost and limited availability of more specialist therapists - which provide the most effective treatments - could restrict who is able to use them. Government investment in the Improving Access to Psychological Therapies programme has improved access to psychological treatments since 2008. Despite this investment, demand in some areas may mean that some people with OCD are unable to receive timely, effective help.
The evidence from the review shows that patient preferences may be the best guide to which treatment to choose, whether that is psychological treatment, drug treatment, both at different times, or both together. One of the mainstays of evidence based practice is CBT with exposure response prevention - a graded way to face fears and reduce anxiety. Some people find this daunting, but the treatment is very effective. Ashley Fulwood, CEO of OCD UK, emphasises that the therapist and person with OCD must work together to help achieve a successful outcome.
"What I’ve learned from other people and listening to OCD specialists, some therapists will set exposure exercises for patients at a level which is far too severe for the person at that time. The person ends up feeling that therapy won’t work. Whereas a specialist will make it a collaborative therapy - they will encourage the patient to set their own challenges. Or perhaps the therapist will set the challenge for them but work with them to achieve it. Therapy should always be collaborative."
Ashley Fulwood, CEO of OCD UK
Christine Molloy, a Psychological Wellbeing Practitioner from the University of Manchester, confirms this. She says:
"A person’s goals should decide how you’re going to proceed with the therapy. It’s important that the Exposure Response Prevention therapy is organised in such a way that is manageable for the patient so that they’re going to achieve success early on...I would say to people, if a step feels too difficult, you’ve not failed, what we need to do is break that step down so that it is more manageable. Some anxiety is to be expected with ERP; the aim is to stay with the anxiety until it subsides, with repeated exposure this will improve."
In practice, some people may find that it is difficult to get a timely referral to psychological treatment, or there may be waiting lists for specialist treatment.
After more evaluation, supported self-help (as studied in the OCTET trial) could give commissioners and referrers a cost-effective opportunity to help people, even while they are on a waiting list for specialist treatment.