Combined behavioral and pharmacological treatment for obsessive-compulsivedisorders: Research findings and clinical practice

In obsessive-compulsive disorders (OCD), when are Behavior Therapy (BT) and Pharmacotherapy (PhT) to be applied simultaneously or sequentially? The an swer still largely depends on the expert's professional orientation. This p aper reviews the actual state of the art as published (including the latest meta-analyses) for BT and PhT separately, as well as for their combined ap plication. In most studies direct comparison, exposure treatment, one SRI, and several SSRIs do not differ significantly in pre-post outcome. Yet, som e studies do imply a better effectiveness of the only SRI investigated; nev ertheless, most authors do not regard this a clinical superiority because o f the more risky and unpleasant side effects compared to the SSRls. Long-te rm effectiveness has only been shown for BT, as no relevant long-term PhT s tudies have been published. Simultaneous use of BT and PhT has significantl y superior pre-post effects compared to BT alone in compulsions with high s econdary depression and in predominant obsessions. Whether this holds true at follow-up is currently under investigation. Several studies showed bette r numerical pre-post improvement of the combination, the clinical meaning o f which is judged differently in the publications. To sum up, BT alone clea rly comes out as first-choice treatment (also with regard to cost-effective ness) for the majority of OCD patients, even though in most countries it is the least applied. In spite of this apparently 'evidence-based' conclusion from reviewing the very recent literature, several problems remain: outcom es of meta-analyses have been far too much dependent on the varying methodo logy applied; reports about 'treatment responders' are still difficult to c ompare, as different operationalizations of 'response' have been used; the reported percentages of 'responders' do not necessarily indicate the percen tage of relevant improvement from a clinician's perspective or with regard to daily life functioning. Finally, almost all the studies reviewed were co nducted by Anglo-American or Dutch authors - and the treatments used in the se publications were very different in intensity and duration from those ap plied in outpatient and inpatient BT therapy in Germany. Implications for t reatment and research are discussed.