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Anxiety
Obsessive–Compulsive Disorder—
Chronic, Impairing, Under-recognized, and Undertreated
a report by
Lorrin M Koran, MD
Professor Emeritus of Psychiatry, Department of Psychiatry and Behavior Sciences, Stanford University Medical Center
Obsessive–compulsive disorder (OCD) is a chronic disorder often comprehensive literature review that included all relevant randomized
associated with substantial distress, impaired functioning, and clinical trials and, when data from rigorously controlled trials were not
diminished quality of life.
1,2
Despite this, OCD is too often inadequately available, less well-controlled trials, cases series, and case reports. The
treated. One reason for this undertreatment is that OCD sufferers literature review utilized PubMed to identify related articles published
are often reluctant to seek care, or do not know that their symptoms are between 1966 and December 2004, and searched the Cochrane
treatable. For example, one study reported a delay of 10 years between databases for relevant meta-analyses. The workgroup experts also
symptom onset and seeking care.
3
Among a random sample of Baltimore integrated information from studies published during the Guideline’s
participants in the Epidemiological Catchment Area survey, only one of preparation. Despite this detailed review of evidence, the Guideline is not
15 individuals (7%) judged to need treatment for OCD was receiving it.
4
intended as a standard of care. Such standards must be developed for
A study of clinically recognized OCD in a large health maintenance individual patients, and should change with advances in knowledge and
organization found a prevalence rate of 0.084%, suggesting that only practice patterns.
8–28% of existing OCD cases were clinically recognized.
5
These studies
took place in the 1980s and 1990s, when OCD and its treatments had The Guideline consists of Part A (Treatment Recommendations), Part B
been less well publicized. A more recent British epidemiological study (Background Information and Review of Available Evidence), and Part C
reported that in the previous year only 27% of 114 subjects with OCD (Future Research Needs). Part A was published as a July 2007 supplement
had received treatment, mostly ineffective varieties.
6
A similar Canadian to the American Journal of Psychiatry. The entire guideline is available
study reported that only 37% of subjects with OCD had consulted a online at the APA web site (www.psychiatryonline.com) or at
doctor about their symptoms.
7
In both studies, those with comorbid http://www.psych.org/psych_pract/treatg/pg/OCDPracticeGuidelineFinal
conditions were significantly more likely to have sought treatment, which 05-04-07.pdf
suggested to the investigators that many had not revealed their OCD
symptoms to their treating clinicians. Treatment Recommendations of the American
Psychiatric Association’s Practice Guideline
The second reason for inadequate treatment, and perhaps the more The Guideline’s Treatment Recommendations section (Part A) includes:
easily remedied, is that physicians and psychologists do not apply in
clinical practice all that clinical research has revealed. For example, in a 1. executive summary of Part A;
study of OCD patients treated by a sample of US psychiatrists during the 2. formulation and implementation of a treatment plan (psychiatric
period 1997–1999, only 41% were receiving an adequate dose of a management, acute phase, discontinuation of active treatment);
serotonin re-uptake inhibitor (SRI), and fewer than 15% were receiving 3. specific clinical features influencing the treatment plan (psychiatric
any form of cognitive behavioral therapy (CBT).
8
A study of a cohort of features, demographic and psychosocial factors, treatment
OCD patients recruited from treatment centers a few years later implications of concurrent general medical disorders);
(2001–2004) reported better results: 78% of patients had been receiving 4. appendix (educational resources for patients and families); and
an adequate SRI dose for at least 12 weeks when studied, but only 24% 5. references.
had ever received an adequate trial of CBT.
9
Many patients still rated
themselves as minimally improved or less.
Lorrin M Koran, MD, is Director of the Obsessive–Compulsive
Disorder Clinic in the Department of Psychiatry and Behavior
The American Psychiatric Association’s Recent Practice Sciences, Stanford University Medical Center, where he also
Guideline for Obsessive–Compulsive Disorder
serves as Associate Professor and Professor of Psychiatry
(Clinical). In 1982, he was accorded the honor of Fellow of the
In July, 2007, the American Psychiatric Association (APA) published its
American Psychiatric Association (APA). Dr Koran received his MD
Practice Guideline for the Treatment of Patients with Obsessive– from Harvard Medical School in 1966. After completing his
Compulsive Disorder.
10
The Guideline was the result of more than two
residency at Stanford, he served as Assistant and Associate
Professor at the State University of New York at Stonybrook until
years of work by a group of experts and the integration of comments on
1977, when he returned to Stanford.
manuscript drafts from 11 professional organizations and 68 individuals,
E: lkoran@stanford.edu
as well as review and, ultimately, approval by the APA Assembly and
Board of Trustees. Development of the Guideline began with a
© TOUCH BRIEFINGS 2007
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