Stephen Ilardi

Stephen Ilardi Ph.D.

The Depression Cure


OCD Treatment: As Good As It Gets?

For OCD, medication not necessarily "as good as it gets."

Posted Jul 20, 2009

I got a call from a psychiatrist colleague of mine a while back. He was an old-school Freudian psychoanalyst who had his patients come in twice a week to lie on a couch, talk about their dreams, free-associate about childhood experiences, and so on. Although this type of treatment might be useful for some patients - especially those who wish to better understand and change troublesome personality patterns - it has not always been strongly supported by research.

As it turned out, the psychiatrist was calling to ask if I would take on one of his patients who suffered from obsessive-compulsive disorder (OCD) - a debilitating mental illness that afflicts about 2% of the population - wonderfully depicted by Jack Nicholson in the film, As Good As It Gets. The psychiatrist had already been treating this distraught young man for over 4 years, but his OCD symptoms actually worsened over that span of time. Since there's no good scientific evidence that Freudian psychoanalysis is an effective treatment for OCD, I wasn't terribly surprised.

Fortunately, during my grad school training at Duke, our instructors and supervisors emphasized the importance of asking, for each form of mental illness: which of the hundreds of possible treatments are most strongly supported by the research evidence?

For OCD, this is a no-brainer: a form of behavior therapy called exposure and response prevention (sometimes called exposure and ritual prevention) has outperformed other treatments (including meds) in the clear majority of relevant outcome trials.

To get some idea of the potency of behavior therapy for OCD, consider the results of the largest OCD comparative outcome study to date, sponsored by the National Institutes of Mental Health. The study pitted behavior therapy against a drug called Anafranil (clomiprimine), arguably the most effective OCD medication currently on the market. Here were the observed rates of favorable treatment response:

Behavior Therapy: 86%
Anafranil: 48%
Placebo: 10%

Notice that OCD is such a severe disorder that it has a minimal placebo response . . . it takes much more than placebo-induced positive expectancies to cure this particular illness. And even though Anafranil certainly outperformed the placebo in this study (48% to 10%), behavior therapy was considerably more effective (with a whopping 86% response rate). In fact, it wasn't even a close call.

There's a genuine tragedy, though, embedded in these numbers: many OCD patients will never even know that behavior therapy exists. While some will waste their time and money on ineffective forms of psychotherapy, most OCD patients will simply be told that they have a 'chemical imbalance', handed a prescription of Anafranil or a similar medication, and told in effect, "this is as good as it gets". 

Sadly, it's hard to get the word out about behavior therapy for OCD. Few mental health reporters understand the field well enough to do the story. Drug companies have multimillion dollar budgets to promote their products - for better and for worse - whereas psychotherapists skilled in behavior therapy for OCD are small in both numbers and financial resources. (To find such a therapist near you, try contacting the Center for Anxiety and Related Disorders.)

In case you're wondering . . . within 4 months of my taking on the aforementioned OCD patient and treating him with standard behavior therapy, his symptoms were in remission. I've seen it repeatedly over the course of my career, and I'm not a particularly gifted psychotherapist (clinical research is my main gig), nor is OCD my area of specialty.

So lately, whenever I see an antidepressant commercial, I find myself thinking, "If only someone had the money for a series of slick commercials about behavior therapy! We've got to find a way to tell the 6 million OCD sufferers that there's a potentially more efficacious treatment out there - one (alas) that many have never even heard of."