Defining and Addressing Gaps in Care for Obsessive-Compulsive Disorder in the United States

Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

Off-label higher doses of serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder: Safety and tolerability

OBJECTIVE

To examine the long-term safety and tolerability of off-label high-dose serotonin reuptake inhibitors (OLHD-SRIs) in the treatment of obsessive-compulsive disorder (OCD).

METHODS

A retrospective longitudinal study was performed on 105 randomly selected outpatients diagnosed with OCD and were treated with OLHD-SRIs for at least 6 months. Patients received sertraline >200 mg/day, escitalopram >20 mg/day, fluvoxamine >300 mg/day, and fluoxetine >60 mg/day, combined with exposure and response prevention therapy. Patients were divided into three dosing groups: sertraline equivalent dose (SED) ≤ 200 mg/day (n = 26, 24.7%), 201-400 mg/day (n = 51, 48.5%) and 401-650 mg/day (n = 28, 26.6%). Safety and tolerability were assessed with an electrocardiogram, blood biochemistry, complete blood count, and side-effects monitoring.

RESULTS

SED ranged from 100 to 650 mg/day and the mean duration of OLHD-SRI treatment was 20.8 months. The most common side-effects reported were sexual dysfunction (n = 36, 34%), weight gain (n = 28, 27%), sedation (n = 27, 26%), hyperhidrosis (n = 20, 19%), and tremor (n = 11, 10%). Abnormal ECG was documented in one patient, and another patient experienced a first-time seizure, whereas elevated liver enzymes were seen in 4.8% of the sample (n = 5). None of the patients had serotonin syndrome or drug-induced liver injury. Side-effects did not differ among the three dosing groups.

CONCLUSION

OLHD-SRIs appear to be safe and well tolerated in OCD patients in SED ≤ 650 mg/day doses and the side-effects did not differ between the three dosing groups.

Can an app increase health literacy and reduce the stigma associated with obsessive-compulsive disorder? A crossover randomized controlled trial

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling condition with a high delay in seeking treatment. esTOCma is an app developed to increase mental health literacy (MHL) about OCD, reduce stigma, and increase the intention to seek professional treatment. It is a serious game and participants are asked to fight against the "OCD stigma monster" by accomplishing 10 missions. The aim of this study is to evaluate the effectiveness of this app in a community sample.

METHODS

A randomized controlled trial with a crossover design was carried out. Participants were randomized to two groups: immediate use (iApp, n = 102) and delayed use (dApp, n = 106) of esTOCma. The iApp group started using the app at baseline until the game was over. The dApp group initiated at 10-days until the game finished. Participants were requested to complete a set of questionnaires at baseline and 10-day, 20-day and 3-month follow-ups.

RESULTS

The Time×Group interaction effect was significant for the primary outcome measures: there was an increase in MHL and intention to seek help, and a decrease in stigma and OC symptoms, with large effect sizes, only after using the app. Changes were maintained (or increased) at follow-up.

LIMITATIONS

The study did not include an active control group and some of the scales showed low internal consistency or a ceiling effect.

CONCLUSIONS

This study provides first evidence for the effectiveness of esTOCma as a promising intervention to fight stigma and reduce the treatment gap in OCD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04777292. Registered February 23, 2021, https://clinicaltrials.gov/ct2/show/NCT04777292.

Retrospective State Medicaid Claims Analysis of Children and Adults With Obsessive-Compulsive Disorder

OBJECTIVE

With a lifetime U.S. prevalence of 2.3%, obsessive-compulsive disorder (OCD) is a chronic condition often producing reduced quality of life and disability when left untreated. Little is known about the prevalence or treatment of diagnosed OCD in public behavioral health systems.

METHODS

Using a claims analysis of 2019 New York State Medicaid data (N=2,245,084 children; N=4,274,100 adults), the authors investigated the prevalence and characteristics of children and adults with OCD. The authors also examined whether these individuals received treatment with medication or psychotherapy.

RESULTS

The prevalence of OCD was 0.2% among children and 0.3% among adults. Fewer than half of children (40.0%) and adults (37.5%) received U.S. Food and Drug Administration-approved medications (with or without psychotherapy); another 19.4% of children and 11.0% of adults received 45- or 60-minute psychotherapy alone.

CONCLUSIONS

These data demonstrate the need for public behavioral health systems to increase their capacity to identify and treat OCD.

Efficacy of exposure and response prevention therapy in mixed reality for patients with obsessive-compulsive disorder: study protocol for a randomized controlled trial

Many patients with obsessive-compulsive disorder (OCD) do not receive cognitive behavioral therapy with exposure and response prevention (first line treatment for OCD), for example, due to patients' fear of the exposure and reservations of the therapists. Technology-supported exposure (e.g., exposure therapy with response prevention in mixed reality [MERP]) for patients with OCD may help to overcome this obstacle. Building upon findings of our pilot study objectives of this study are to evaluate the efficacy, expectations of treatment success, feasibility, and acceptance of MERP as well as to identify possible limitations. In total, 64 outpatients with contamination-related OCD will be recruited and randomized to one of two conditions: MERP (six sessions in six weeks) and self-guided exposure therapy (six exercises in six weeks). Participants will be assessed before (baseline), after the six-week intervention period (post), as well as three months after post assessment (follow-up) regarding symptomatology (Yale-Brown Obsessive Compulsive Scale; Y-BOCS), their subjective evaluation of MERP (acceptance) and sense of presence. The planned study is the first to investigate MERP in patients with OCD.

Treatment-resistant OCD: Pharmacotherapies in adults

Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.

Year of Zoom in a Year of Doom: Lessons Learned Delivering ERP Remotely During the COVID-19 Pandemic

In response to the COVID-19 pandemic and consequential shutdown measures, many mental health professionals started providing therapy to patients exclusively via telehealth. Our research center, which specializes in studying and treating obsessive-compulsive disorder (OCD), historically has provided in-person exposure and response prevention (ERP) to adults with OCD, but shifted to telehealth during the pandemic. Unlike in other modes of talk therapy, ERP's emphasis on therapist-supervised exposures presented unique opportunities and challenges to delivering treatment entirely via a virtual platform. This paper provides case examples to illustrate lessons we learned delivering ERP exclusively via telehealth in New York from March 2020 through June 2021 and offers recommendations for future study and practice. Though we observed a number of drawbacks to fully remote ERP, we also discovered advantages to delivering ERP this way, meriting additional research attention.

Obsessive-Compulsive Disorder Misdiagnosis among Mental Healthcare Providers in Latin America

Mental healthcare professionals often have limited awareness of different obsessive-compulsive disorder (OCD) symptom presentations, which may contribute to years between OCD symptom onset and treatment initiation. While research has identified high rates of OCD misdiagnosis among clinicians from the United States and Canada, research on OCD symptom awareness among healthcare providers in Latin American (LATAM) regions is limited. In this study, LATAM mental healthcare providers (N = 83) provided diagnostic impressions based on five OCD vignettes: three with symptoms centered on taboo thoughts (sexual, harming others, and religion/scrupulosity) and two about contamination or symmetry obsessions. Rates of incorrect (non-OCD) diagnoses were significantly higher for the taboo thoughts vignettes (sexual, 52.7%; harm/aggression, 42.0%; and religious, 34.7%) vs. contamination obsessions (11.0%) and symmetry obsessions (6.9%). The OCD vignette depicting sexual obsessions was often attributed to a paraphilic disorder (36.5%). Bachelor's level clinicians had significantly lower odds of accurately identifying all three vignettes related to taboo thoughts compared to respondents with a graduate degree. Accurate identification of the three taboo vignettes was also associated with first-line psychological treatment recommendations (i.e., cognitive-behavioral therapy) even when controlling for respondents' theoretical orientation. Exposure was rarely mentioned when clinicians were prompted to provide treatment recommendations for each vignette (8-9% of the time for symmetry and contamination vignettes, 5-7% for taboo though vignettes). Like clinicians in the United States and Canada, mental health professionals in LATAM may misidentify OCD symptom presentations, particularly sexual obsessions, highlighting a need for education and training.