The effectiveness of an algorithm of evidence-based treatments in patients with Obsessive-Compulsive Disorder

Phase 1:

Background:

The importance of the therapist’s education and experience for the successful behavior treatment of OCD has not been investigated. Data on the relative effectiveness of self-controlled versus therapist-controlled exposure in vivo with response prevention (ERP) have yielded conflicting results. The present study evaluated the effectiveness of different formats of ERP in a referred sample of Obsessive Compulsive Disorder (OCD) patients.


Method:

Of the 146 eligible outpatients with primary DSM-IV-defined OCD, 118 patients enrolled in this randomized controlled trial and were randomly assigned to 1) therapist-controlled ERP performed by experienced behavior therapists; 2) therapist-controlled ERP performed by master students of clinical psychology; 3) self-controlled ERP performed by experienced behavior therapists; and 4) self-controlled ERP performed by master students of clinical psychology. This trial was performed from January 1999 to January 2005.


Results:

The results clearly reveal that ERP can be effectively delivered in different ways. On the one hand patient-controlled ERP is as effective as therapist-controlled ERP and on the other hand ERP delivered by experienced behavior therapists is equally effective as ERP delivered by master student therapists in the treatment of OCD. There was no significant difference in clinical outcome between these different form of ERP at posttreatment.


Conclusions:
Our results suggest that master student-therapists may become effective in the deliverance of ERP with OCD patients . Our results suggest that less-experienced and no certified behavior therapist were as capable as the behavior therapists with long experience and specialty certification in treating OCD patients. However, all therapists were instructed to deliver a standardized treatment, and all were adequately trained and supervised. Furthermore, therapist-controlled ERP was not more effective than self-controlled ERP in patients with OCD.

1. Phase I:

Exposure in vivo with response prevention (ERP) performed by experienced behavior therapists is more effective than ERP performed by master clinical psychology students. Therapist-controlled ERP is more effective than self-controlled ERP. ERP performed by experienced behavior therapists leads to a lower drop-out rate than ERP performed by master clinical psychology students.


2. Phase II:

After 12-week treatment with exposure in vivo with response prevention, in non-responders, 12-week treatment with cognitive therapy is superior to 12-week treatment with fluvoxamine in patients with Obsessive Compulsive Disorder.

First Phase:

Pretest and posttest after 12-weeks. In case of non-response (defined as improvement of less than 35% measured with the Y-BOCS) admittance to phase 2

Second Phase:

Pretest and posttest after 12 weeks

Follow-up measures after 3 and 12 months

First Phase:
12-week exposure in vivo with response prevention (ERP). Participants were randomized to:

1. Therapist-controlled ERP performed by experienced behavior therapists;

2. Therapist-controlled ERP performed by clinical psychology students;

3. Self-controlled ERP performed by experienced behavior therapists;

4. Self-controlled ERP performed by clinical psychology students

Second Phase:

Non-responders of the first phase were randomised to 12 weeks treatment with:

1. Cognitive therapy;

2. Fluvoxamine.