Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-26T16:52:15.412Z Has data issue: false hasContentIssue false
  • English
  • Français

Moderators and predictors of response to cognitive-behavioral therapy augmentation of pharmacotherapy in obsessive–compulsive disorder

Published online by Cambridge University Press:  26 April 2010

M. J. Maher ,
J. D. Huppert ,
H. Chen ,
N. Duan ,
E. B. Foa ,
M. R. Liebowitz  and
H. B. Simpson
M. J. Maher
Affiliation:
New York State Psychiatric Institute, New York, NY, USA
J. D. Huppert
Affiliation:
Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA Department of Psychology, The Hebrew University of Jerusalem, Jerusalem, Israel
H. Chen
Affiliation:
New York State Psychiatric Institute, New York, NY, USA Department of Psychiatry, Columbia University, New York, NY, USA
N. Duan
Affiliation:
New York State Psychiatric Institute, New York, NY, USA Department of Psychiatry, Columbia University, New York, NY, USA
E. B. Foa
Affiliation:
Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
M. R. Liebowitz
Affiliation:
New York State Psychiatric Institute, New York, NY, USA Department of Psychiatry, Columbia University, New York, NY, USA
H. B. Simpson*
Affiliation:
New York State Psychiatric Institute, New York, NY, USA Department of Psychiatry, Columbia University, New York, NY, USA
*
*Address for correspondence: H. B. Simpson, M.D., Ph.D., Associate Professor of Clinical Psychiatry, Columbia University, 1051 Riverside Drive, Unit 69, New York, NY 10032, USA. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive–compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment.

Method

Data were drawn from a large randomized controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification.

Results

Pretreatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pretreatment severity, significant predictors included greater co-morbidity, number of past SRI trials, and lower quality of life (QoL). Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the subgroup analysis of EX/RP alone (R2=55.2%).

Conclusions

This is the first randomized controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.

Keywords

CBTclinical trialsexposure therapyOCD
Type
Original Articles
Information
Psychological Medicine , Volume 40 , Issue 12 , December 2010 , pp. 2013 - 2023
Copyright
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Abramowitz, J, Foa, E (2000). Does comorbid major depressive disorder influence outcome of exposure and response prevention for OCD? Behavior Therapy 31, 795–800.CrossRefGoogle Scholar
Abramowitz, JS, Franklin, ME, Schwartz, SA, Furr, JM (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology 71, 1049–1057.CrossRefGoogle ScholarPubMed
AuBuchon, PG, Malatesta, VJ (1994). Obsessive compulsive patients with comorbid personality disorder: associated problems and response to a comprehensive behavior therapy. Journal of Clinical Psychiatry 55, 448–453.Google Scholar
Baxter, LR Jr., Schwartz, JM, Bergman, KS, Szuba, MP, Guze, BH, Mazziotta, JC, Alazraki, A, Selin, CE, Ferng, HK, Munford, P, Phelps, ME (1992). Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Archives of General Psychiatry 49, 681–689.CrossRefGoogle ScholarPubMed
Black, DW, Monahan, P, Gable, J, Blum, N, Clancy, G, Baker, P (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder. Journal of Clinical Psychiatry 59, 420–425.CrossRefGoogle ScholarPubMed
Blanco, C, Olfson, M, Stein, DJ, Simpson, HB, Gameroff, MJ, Narrow, WH (2006). Treatment of obsessive-compulsive disorder by U.S. psychiatrists. Journal of Clinical Psychiatry 67, 946–951.Google Scholar
Buchanan, AW, Meng, KS, Marks, IM (1996). What predicts improvement and compliance during the behavioral treatment of obsessive compulsive disorder? Anxiety 2, 22–27.3.0.CO;2-F>CrossRefGoogle ScholarPubMed
Burnham, KP, Anderson, DR (2002). Model Selection and Multimodel Inference: A Practical-Theoretic Approach. Springer-Verlag: New York.Google Scholar
Cottraux, J, Note, I, Yao, SN, Lafont, S, Note, B, Mollard, E, Bouvard, M, Sauteraud, A, Bourgeois, M, Dartigues, J-F (2001). A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder. Psychotherapy and Psychosomatics 70, 288–297.CrossRefGoogle ScholarPubMed
de Haan, E, van Oppen, P, van Balkom, AJ, Spinhoven, P, Hoogduin, KA, Van Dyck, R (1997). Prediction of outcome and early vs. late improvement in OCD patients treated with cognitive behaviour therapy and pharmacotherapy. Acta Psychiatrica Scandinavica 96, 354–361.CrossRefGoogle ScholarPubMed
Denys, D, Burger, H, van Megen, H, de Geus, F, Westenberg, H (2003). A score for predicting response to pharmacotherapy in obsessive-compulsive disorder. International Clinical Psychopharmacology 18, 315–322.Google Scholar
Endicott, J, Nee, J, Harrison, W, Blumenthal, R (1993). Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacology Bulletin 29, 321–326.Google Scholar
First, MB, Gibbon, M, Spitzer, R, Williams, J, Benjamin, L (1997). Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). American Psychiatric Press, Inc.: Washington, DC.Google Scholar
First, MB, Spitzer, RL, Gibbon, M, Williams, JB (1996). Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Edition (SCID-P), version 2. Biometrics Research Department, New York State Psychiatric Institute: New York, NY.Google Scholar
Foa, E, Abramowitz, J, Franklin, M, Kozak, MJ (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive-compulsive disorder. Behavior Therapy 30, 717–724.Google Scholar
Foa, EB, Grayson, JB, Steketee, GS, Doppelt, HG, Turner, RM, Latimer, PR (1983 a). Success and failure in the behavioral treatment of obsessive-compulsives. Journal of Consulting and Clinical Psychology 51, 287–297.CrossRefGoogle ScholarPubMed
Foa, EB, Liebowitz, MR, Kozak, MJ, Davies, S, Campeas, R, Franklin, ME, Huppert, JD, Kjernisted, K, Rowan, V, Schmidt, AB, Simpson, HB, Tu, X (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry 162, 151–161.CrossRefGoogle ScholarPubMed
Foa, EB, Steketee, G, Grayson, JB, Doppelt, HG (1983 b). Treatment of obsessive-compulsives: when do we fail? In Failures in Behavior Therapy (ed. Foa, E. B. and Emmelkamp, P. M. G.), pp. 10–34. John Wiley and Sons: New York.Google Scholar
Gershuny, BS, Baer, L, Jenike, MA, Minichiello, WE, Wilhelm, S (2002). Comorbid posttraumatic stress disorder: impact on treatment outcome for obsessive-compulsive disorder. American Journal of Psychiatry 159, 852–854.CrossRefGoogle ScholarPubMed
Goodman, WK, Price, LH, Rasmussen, SA, Mazure, C, Fleischmann, RL, Hill, CL, Heninger, GR, Charney, DS (1989). The Yale–Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Archives of General Psychiatry 46, 1006–1011.Google Scholar
Hamilton, M (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology 32, 50–55.CrossRefGoogle ScholarPubMed
Hamilton, M (1960). A Rating Scale for Depression. Journal of Neurology, Neurosurgery, and Psychiatry 23, 56–62.Google Scholar
Hohagen, F, Winkelmann, G, Rasche-Raeuchle, H, Hand, I, Koenig, A, Muenchau, N, Hiss, H, Geiger-Kabisch, C, Kaeppler, C, Schramm, P, Rey, E, Aldenhoff, J, Berger, M (1998). Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: results of a multicentre study. British Journal of Psychiatry 173, 71–78.CrossRefGoogle Scholar
Hoogduin, CA, Duivenvoorden, HJ (1988). A decision model in the treatment of obsessive-compulsive neuroses. British Journal of Psychiatry 152, 516–521.Google Scholar
Huppert, JD, Simpson, HB, Nissenson, K, Liebowitz, M, Foa, EB (2009). Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls. Depression and Anxiety 26, 39–45.CrossRefGoogle ScholarPubMed
Jacobson, D, Wu, A, Feinberg, J (2003). Health-related quality of life predicts survival, cytomegalovirus disease, and study retention in clinical trial participants with advanced HIV disease. Journal of Clinical Epidemiology 56, 874–879.Google Scholar
Keijsers, GP, Hoogduin, CA, Schaap, CP (1994). Predictors of treatment outcome in the behavioural treatment of obsessive-compulsive disorder. British Journal of Psychiatry 165, 781–786.Google Scholar
Lelliott, PT, Noshirvani, HF, Basoglu, M, Marks, IM, Monteiro, WO (1988). Obsessive-compulsive beliefs and treatment outcome. Psychological Medicine 18, 697–702.CrossRefGoogle ScholarPubMed
Little, R, Rubin, D (2002). Statistical Analysis with Missing Data. Wiley: New York.CrossRefGoogle Scholar
Mataix-Cols, D, Marks, IM, Greist, JH, Kobak, KA, Baer, L (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychotherapy and Psychosomatics 71, 255–262.CrossRefGoogle ScholarPubMed
SAS Institute (2007). Statistical Analysis System, Version 9.1. SAS Institute: Cary, NC.Google Scholar
Saxena, S, Maidment, KM, Vapnik, T, Golden, G, Rishwain, T, Rosen, RM, Tarlow, G, Bystritsky, A (2002). Obsessive-compulsive hoarding: symptom severity and response to multimodal treatment. Journal of Clinical Psychiatry 63, 21–27.CrossRefGoogle ScholarPubMed
Simpson, HB, Foa, EB, Liebowitz, MR, Roth Ledley, D, Huppert, JD, Cahill, SP, Vermes, D, Schmidt, AB, Hembree, EA, Franklin, M, Campeas, R, Hahn, C, Petkova, E (2008). A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. American Journal of Psychiatry 165, 621–630.CrossRefGoogle ScholarPubMed
Simpson, HB, Huppert, JD, Petkova, E, Foa, EB, Liebowitz, MR (2006). Response versus remission in obsessive-compulsive disorder. Journal of Clinical Psychiatry 67, 269–276.CrossRefGoogle ScholarPubMed
Steketee, G, Chambless, DL, Tran, GQ (2001). Effects of axis I and II comorbidity on behavior therapy outcome for obsessive-compulsive disorder and agoraphobia. Comprehensive Psychiatry 42, 76–86.Google Scholar
Steketee, G, Henninger, NJ, Pollard, C (2000). Predicting treatment outcomes for obsessive-compulsive disorder: effects of comorbidity. In Obsessive-Compulsive Disorder: Contemporary Issues in Treatment (ed. Goodman, W. K., Rudorfer, M. V. and Maser, J. D.), pp. 257–274. Lawrence Erlbaum: Mahwah, NJ.Google Scholar
Steketee, G, Shapiro, LJ (1995). Predicting behavioral treatment outcome for agoraphobia and obsessive compulsive disorder. Clinical Psychology Review 15, 317–346.CrossRefGoogle Scholar
Stewart, SE, Yen, C-H, Stack, DE, Jenike, MA (2006). Outcome predictors for severe obsessive-compulsive patients in intensive residential treatment. Journal of Psychiatric Research 40, 511–519.CrossRefGoogle ScholarPubMed
Storch, EA, Merlo, LJ, Larson, MJ, Geffken, GR, Lehmkuhl, HD, Jacob, ML, Murphy, TK, Goodman, WK (2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry 47, 583–592.CrossRefGoogle ScholarPubMed
Tenneij, NH, van Megen, HJ, Denys, DA, Westenberg, HG (2005). Behavior therapy augments response of patients with obsessive-compulsive disorder responding to drug treatment. Journal of Clinical Psychiatry 66, 1169–1175.CrossRefGoogle ScholarPubMed
Tolin, DF, Maltby, N, Diefenbach, GJ, Hannan, SE, Worhunsky, P (2004). Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial. Journal of Clinical Psychiatry 65, 922–931.CrossRefGoogle ScholarPubMed
Weissman, MM, Bothwell, S (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry 33, 1111–1115.CrossRefGoogle ScholarPubMed