OCD patients

cbrons

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    The patient is a 24 year old law student (on a medical leave of absence due to severe panic attacks and constant anxiety). Patient is also a severe hypochondriac, has been in the ER and off-campus urgent care centers ~30 times within the past 4 months worried about a serious heart condition (owing to his panic attacks). Patient has been hospitalized on psych for a few days but refused to take an SSRI, citing that he is afraid of the side effects. Will only use a minimal dose of clonazapam BID.

    Also a compulsive pulse and blood pressure checker.

    Any suggestions for how to get/pursuade this kid to take an SSRI? He has has a 2d echo, stress echo, full exam by an electrophysiologist, 24hr urinary metanephrine study to rule out a pheo, and yet still cannot let go of his compulsive need to monitor his heart. I feel really bad for this kid and he really wants help, he is just "afraid" of SSRIs.

    Anyone with similar stories or just suggestions on how you would treat this person pharmacologically?
     

    kugel

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      This sounds like it could completely ruin his life if he does not get it under control and really fast. I would consider one of the residential or intensive outpatient programs. I know UCLA used to have one. Get him reading right away. A law student is likely to believe things in text books, plus have him get started on BrainLock and my favorite Tormenting Thoughts and Secret Rituals.

      And it might be well worth it to get him involved with NAMI
       

      splik

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        The issue is not getting him on an SSRI (which in the long term appears to impede the prognosis of anxiety disorders) but getting him to engage in CBT. Why would you want to pharmacologically treat a condition where the best evidence was for behavioral intervention and not medication? IIRC for panic disorder CBT is superior to SSRIs or combination of SSRI + CBT. SSRIs can be useful in the short term, and the evidence is much better for SSRIs being useful for anxiety more than depression although of course they often increase anxiety in the first few weeks of treatment before receptor downregulation, and long term can interfere with therapeutic work by sending conflicting messages about the nature of anxiety to the patient or leading to dysfunctional beliefs which interfere with behavioral therapy. Clomipramine is another agent that is used 2nd line after SSRIs (although pharmacologically it is really a potent SSRI even though classified as a TCA and has the downsides of anticholinergic effects and toxicity in overdose through dose-dependent blockade of sodium channels)

        Benzos are excellent in the short term for acute severe anxiety but really worsen things after about 3 weeks and there is almost never a good reason to continue benzos for more than 4 weeks in this day and age. It is becoming clear that the anticonvulsants with anxiolytic properties (Gabapentin, pregabalin, tiagabine) have a massive abuse potential and likely dependence phenomenon and thus should be avoided in the most cases. I have found these most useful in severe anxiety in context of bipolar disorder where forwhatever reason progression relaxation, behavior therapy etc has not been possible and in preference to SSRIs.

        I agree that he might benefit from inpatient or intensive outpatient CBT.

        Not wanting to jump on to the bipolar bandwagon but patients with multiple anxiety disorders do frequently have an underlying bipolar diathesis and unleashing mania or more likely a mixed state is another argument against going in gung-ho with SSRIs before attempting exposure therapy.
         
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        nitemagi

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          The issue is not getting him on an SSRI (which in the long term appears to impede the prognosis of anxiety disorders) but getting him to engage in CBT. Why would you want to pharmacologically treat a condition where the best evidence was for behavioral intervention and not medication? IIRC for panic disorder CBT is superior to SSRIs or combination of SSRI + CBT. SSRIs can be useful in the short term, and the evidence is much better for SSRIs being useful for anxiety more than depression although of course they often increase anxiety in the first few weeks of treatment before receptor downregulation, and long term can interfere with therapeutic work by sending conflicting messages about the nature of anxiety to the patient or leading to dysfunctional beliefs which interfere with behavioral therapy. Clomipramine is another agent that is used 2nd line after SSRIs (although pharmacologically it is really a potent SSRI even though classified as a TCA and has the downsides of anticholinergic effects and toxicity in overdose through dose-dependent blockade of sodium channels)

          Benzos are excellent in the short term for acute severe anxiety but really worsen things after about 3 weeks and there is almost never a good reason to continue benzos for more than 4 weeks in this day and age. It is becoming clear that the anticonvulsants with anxiolytic properties (Gabapentin, pregabalin, tiagabine) have a massive abuse potential and likely dependence phenomenon and thus should be avoided in the most cases. I have found these most useful in severe anxiety in context of bipolar disorder where forwhatever reason progression relaxation, behavior therapy etc has not been possible and in preference to SSRIs.

          I agree that he might benefit from inpatient or intensive outpatient CBT.

          Not wanting to jump on to the bipolar bandwagon but patients with multiple anxiety disorders do frequently have an underlying bipolar diathesis and unleashing mania or more likely a mixed state is another argument against going in gung-ho with SSRIs before attempting exposure therapy.

          Wow, I disagree with almost everything you wrote! ;)

          I agree that CBT is a great treatment option, and if this patient is willing to engage in it that's terrific, but it's going to be difficult to engage him in any process. Reassurance isn't going to work and will only increase checking behavior.

          Splik can you provide evidence to your statement that SSRI's impede long term prognonsis of anxiety d/o's? And then you go on to recommend benzo's short term!?! Benzo's are the worst option for someone like this, as it just reinforces the anxiety avoidance pattern and would likely lead to withdrawal or escalation and worse problems. Akin to methadone treatment and taper, it's better to give something that slowly lowers the anxiety level (an ssri) than a benzo. Benzo's are only really appropriate in isolate panic disorder without comorbidities, and even then I'd argue it's a poor choice.

          We can agree that CBT is important, but my mode of approach is start out low dose on an SSRI, titrate up until sx's well controlled (by then you have a patient that's convinced you can help them), followed by behavioral interventions to teach them to manage anxiety and cognitive therapy to recognize their distortions and the aspect of somatosensory amplificatoin playing into things.

          OP, your pt. sounds moreso in the hypochondriasis range (which is really a trait) than classic OCD though they're in the same spectrum, with his checking behavior healthcare related (seeking reassurance or rechecking his BP). This is only a temporary fix. I've had a number of patients with this exact scenario, and the only success I've had is in getting them onto an SSRI first, because when someone is that anxious, it's very very tough to maintain the rapport and motivation to get them doing the CBT work they need to do. Not impossible, but very very tough.

          So how do you get someone to take a medication they're nervous about? You could try a motivational interviewing approach, and note that what he's doing now clearly isn't working. I've had reasonable success with the idea of giving a medication a 2-week trial (which I know the evidence doesn't support you'll hit maximum efficacy by that point, but it seems they have a small but real enough response to feel like things are improving).
           

          F0nzie

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            I haven't had much luck with CBT in all of my 3rd year of residency. This patient seems to hypothetically fit the 4 most common scenarios I have dealt with:

            1. They don't want to do the homework.
            2. They say they want to do the homework, then they don't do the homework.
            3. They say they're doing the homework, and they're secretly not doing the homework.
            4. They say they're doing the homework but they're only putting in 1/10th the effort required.
            *My personal favorite "my friends came into my house and stole my journal"*

            The problem I see with the above patient is that he was likely referred by another provider- which brings into question his level of motivation for this type of work. So you're back to the medical model where you're supposed to cure this guy and give him the antidote. If he does have OCD, SSRIs may help abate 30% of his symptoms. He needs psychoeducation and perhaps some relaxation training- prior to addressing cognitive distortions and developing a heirarchy of anxiety provoking situations. But even then, if he's not ready to do the homework, he's not ready to do the homework. Things I believe are key: good therapeutic relationship, good rapport, non-judgemental, non-coercive stance, lots of listening, empathy, time- without these fundamentals, the likelihood of successful treatment is very low. OCD and hypochondriasis are both very difficult to treat and our current medications only partially address some of these symptoms, which puts us in a position of having to address the core of these issues via psychotherapy. Our current data suggest CBT is effective for OCD which is true, however, by taking a complex multidimensional patient and assigning the pt "cookie cutter" psychotherapy or a "1 size fits all" approach may be ineffective practice when you're dealing with issues such as resistance, transference, or other underlying issues. If you want to the easy way out use the following algorithm: 1. patient refuses meds 2. patient refuses recommended therapy 3. close chart.
             

            zenman

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              I haven't had much luck with CBT in all of my 3rd year of residency. This patient seems to hypothetically fit the 4 most common scenarios I have dealt with:

              1. They don't want to do the homework.
              2. They say they want to do the homework, then they don't do the homework.
              3. They say they're doing the homework, and they're secretly not doing the homework.
              4. They say they're doing the homework but they're only putting in 1/10th the effort required.
              *My personal favorite "my friends came into my house and stole my journal"*

              CBT is a bunch of intellectual crap. Wish I could find the reference...
               

              cbrons

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                Wow, I disagree with almost everything you wrote! ;)

                I agree that CBT is a great treatment option, and if this patient is willing to engage in it that's terrific, but it's going to be difficult to engage him in any process. Reassurance isn't going to work and will only increase checking behavior.

                Splik can you provide evidence to your statement that SSRI's impede long term prognonsis of anxiety d/o's? And then you go on to recommend benzo's short term!?! Benzo's are the worst option for someone like this, as it just reinforces the anxiety avoidance pattern and would likely lead to withdrawal or escalation and worse problems. Akin to methadone treatment and taper, it's better to give something that slowly lowers the anxiety level (an ssri) than a benzo. Benzo's are only really appropriate in isolate panic disorder without comorbidities, and even then I'd argue it's a poor choice.

                We can agree that CBT is important, but my mode of approach is start out low dose on an SSRI, titrate up until sx's well controlled (by then you have a patient that's convinced you can help them), followed by behavioral interventions to teach them to manage anxiety and cognitive therapy to recognize their distortions and the aspect of somatosensory amplificatoin playing into things.

                OP, your pt. sounds moreso in the hypochondriasis range (which is really a trait) than classic OCD though they're in the same spectrum, with his checking behavior healthcare related (seeking reassurance or rechecking his BP). This is only a temporary fix. I've had a number of patients with this exact scenario, and the only success I've had is in getting them onto an SSRI first, because when someone is that anxious, it's very very tough to maintain the rapport and motivation to get them doing the CBT work they need to do. Not impossible, but very very tough.

                So how do you get someone to take a medication they're nervous about? You could try a motivational interviewing approach, and note that what he's doing now clearly isn't working. I've had reasonable success with the idea of giving a medication a 2-week trial (which I know the evidence doesn't support you'll hit maximum efficacy by that point, but it seems they have a small but real enough response to feel like things are improving).

                Thanks for your response.

                He has started seeing an psychologist who specializes in CBT. He has also said he would consider starting an SSRI, even though it is obvious he is still quite worried (mentioned that he worries about long QTc on his last EKG and we had to explain to him that the computer readout on an EKG needs to be hand calculated). Also, he insists on Lexapro because he feels is the "cleanest."
                 

                OldPsychDoc

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                  Thanks for your response.

                  He has started seeing an psychologist who specializes in CBT. He has also said he would consider starting an SSRI, even though it is obvious he is still quite worried (mentioned that he worries about long QTc on his last EKG and we had to explain to him that the computer readout on an EKG needs to be hand calculated). Also, he insists on Lexapro because he feels is the "cleanest."

                  Don't know if he reads textbooks, but he does apparently read drug ads. ;)
                   

                  whopper

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                    All the data I've read suggests that CBT helps but SSRIs have more benefit, but a combination of SSRIs and psychotherapy gives the best results. The use of the term "biochemical imbalance" has been overblown with mental illness, but OCD, out of the anxiety disorders, has much more evidence backing it is a physiological phenomenon vs. a personality/environmental one.

                    If the guy wants to refuse SSRIs, and you've given him a sincere session where you discuss the risks and benefits, and he refuses, so be it. Unless the guy does not have the capacity to decide you must honor his refusal. Perhaps he is wrong. Perhaps he is severely wrong, and may get kicked out of lawschool. The law is clear in this regard. He may eventually change his mind, but you cannot make him take the medication. It may be a mistake, but it's his to make unless he does not have capacity.

                    In cases like this, I do tell the patient what specifically he fears and I try to address them. I also tell the patient that if he does have side effects he can either lower the medication to a previous dosage or stop it (only if it's at a low dosage). The bottom line is per studies, most people have at least one side effect to an SSRI, but it's a minor one and one they are willing to deal with because the benefits outweigh the problem. I never promise the patient they will not experience side effects...because the bottom line is no one can even know unless the patient actually tries the medication, but I do inform them that the studies strongly suggest they will either not experience one or will but it will be minor.

                    In my current work (that will change in a week because I'm picking up a professor position), I have a dichotomy of two achetypes...several mentally ill in the forensic unit, and people not that bad in private practice. In the severel mentally ill (e.g. GAF < 30, and the person is dangerous off meds), I really do try to get them to take medications, but if they refuse, I will get a court-order, in private practice, if the person doesn't want to take meds, so be it. They pretty much always have the capacity to refuse. In this venue, I can only educate and make recommendations, ultimately the patient has the choice to make a decision, even if it's the wrong one. The ones that refuse often call me up a few weeks to monthslater and tell me they want to start after realizing they need to give it a try.
                     

                    nitemagi

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                      I'd ask what "OCD" obsessions and compulsions the pt. has, aside from health anxiety and compulsions to do checking behavior of blood pressure and seeking reassurance from physicians. This doesn't sound like classic OCD to me, but something in that anxiety spectrum, closer to hypochondriasis. I'd argue the treatment is the same, but the prognosis is better. Conceptually there's a similarity with OCD and the temporary reassurance reinforcing the process of seeking reassurance and the rebound of anxiety.

                      Here's an older paper on it--
                      http://www.ncbi.nlm.nih.gov/pubmed/3753387
                       

                      PETRAN

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                        All the data I've read suggests that CBT helps but SSRIs have more benefit, but a combination of SSRIs and psychotherapy gives the best results. The use of the term "biochemical imbalance" has been overblown with mental illness, but OCD, out of the anxiety disorders, has much more evidence backing it is a physiological phenomenon vs. a personality/environmental one.

                        If the guy wants to refuse SSRIs, and you've given him a sincere session where you discuss the risks and benefits, and he refuses, so be it. Unless the guy does not have the capacity to decide you must honor his refusal. Perhaps he is wrong. Perhaps he is severely wrong, and may get kicked out of lawschool. The law is clear in this regard. He may eventually change his mind, but you cannot make him take the medication. It may be a mistake, but it's his to make unless he does not have capacity.

                        In cases like this, I do tell the patient what specifically he fears and I try to address them. I also tell the patient that if he does have side effects he can either lower the medication to a previous dosage or stop it (only if it's at a low dosage). The bottom line is per studies, most people have at least one side effect to an SSRI, but it's a minor one and one they are willing to deal with because the benefits outweigh the problem. I never promise the patient they will not experience side effects...because the bottom line is no one can even know unless the patient actually tries the medication, but I do inform them that the studies strongly suggest they will either not experience one or will but it will be minor.

                        In my current work (that will change in a week because I'm picking up a professor position), I have a dichotomy of two achetypes...several mentally ill in the forensic unit, and people not that bad in private practice. In the severel mentally ill (e.g. GAF < 30, and the person is dangerous off meds), I really do try to get them to take medications, but if they refuse, I will get a court-order, in private practice, if the person doesn't want to take meds, so be it. They pretty much always have the capacity to refuse. In this venue, I can only educate and make recommendations, ultimately the patient has the choice to make a decision, even if it's the wrong one. The ones that refuse often call me up a few weeks to monthslater and tell me they want to start after realizing they need to give it a try.



                        I vehemently disagree here whopper. The only predisposition is for general neurotic traits and maybe sensory sensitivity but panic disorder and full-blown hypochondriasis need environmental interaction to appear (especially panic disorder, hypochondriasis is more like OC-type thing which could have a stronger neuro/basal-ganglia basis). There is no "chemical imbalance" for panic attacks (the pre-disposed overactive "locus-ceruleus" hypothesis is apparently dead) and i have met many chronic sufferers who couldn't get out of home for days (with hypochondriasis and social anxiety) and completely 100% got over it with systematic exposure (awful, awful but there is not other way) cognitive restructuring and support from family and friends.

                        I personally think that SSRIs just "blunt" the affective/stress overeaction which is nice but not the best thing to do in the long-term or for a life-time. You maybe need that in the beginning but in the long-term you need an experienced CBT therapist and exposure, period. There is always the danger that patient will get psychological dependence on the SSRIs for a life-time (e.g. for those with sexual side-effects). At some point the patient should get motivated to directly face his/her fears and overcome them. Obviously its not for everyone, but it is for the majority.
                         

                        whopper

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                          Hmm,

                          I'm not seeing what you disagree with. I read your points and don't disagree with them. I'm probably having a brain fart.

                          I was only writing in regard to OCD, not panic disorder or hypochondriasis. This person's problem might not even be OCD.

                          And I do agree with you on the need for psychotherapy.
                           
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                          nitemagi

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                            I don't think anyone is disagreeing that CBT is very important (except zenman). The dispute (at least part of it) is whether SSRI's have a place here. SSRI could just be blunting the stress overactivity, but qualitatively that seems moreso the case with benzo's than SSRI's. Furthermore, if the stress reaction is turned down that may interrupt the cycle of checking behavior, reduction of anxiety, and reinforcement, which then allows for more elective engagement of triggering anxiety and working with it psychotherapeutically.
                             

                            PETRAN

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                              I don't think anyone is disagreeing that CBT is very important (except zenman). The dispute (at least part of it) is whether SSRI's have a place here. SSRI could just be blunting the stress overactivity, but qualitatively that seems moreso the case with benzo's than SSRI's. Furthermore, if the stress reaction is turned down that may interrupt the cycle of checking behavior, reduction of anxiety, and reinforcement, which then allows for more elective engagement of triggering anxiety and working with it psychotherapeutically.



                              Yeah i agree with you. Thats what i think as well. Well, there is always the question of what SSRIs do, what i ment is that they don't induce some long-term synaptic plasticity (like e.g. exposure) but they "blunt", "regulate", "reduce", call it what you want (or what psychopharma theories call it), the final stress response. I agree that this is of benefit in the beginning.
                               

                              PETRAN

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                                Hmm,

                                I'm not seeing what you disagree with. I read your points and don't disagree with them. I'm probably having a brain fart.

                                I was only writing in regard to OCD, not panic disorder or hypochondriasis. This person's problem might not even be OCD.

                                And I do agree with you on the need for psychotherapy.


                                Oh ok, i thought that you were talking about all anxiety disorders in general my mistake. Yes OC-spectrum has a stronger neuro-basis (fronto-striatal circuits and stuff), i believe that in some cases you could get a lot of improvement with exposure and response prevention. Not doing it again and again would change the habit i think, but it is surely not for everyone.
                                 

                                whopper

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                                  Personally, my opinion with SSRIs is even if they produce significant improvement, if the case is something that is potentially "curable" such as depression or panic attacks, the person should shoot for psychotherapy.

                                  From the evidence with OCD, I do consider that something where a more physiological therapy needs to be done, though CBT definitely does help with OCD and I always recommend it with an SSRI. As for other anxiety disorders, I very much agree with you.

                                  Do SSRI's simply blunt a pathology? Perhaps. I guess it depends on how you see it. I don't disagree because I can see it going that way with several patients. If the person has issues that can be dealt with using psychotherapy that could dampen or even cure the mental illness, the use of an SSRI might prevent one from using that option. I have plenty of patients that once better on an SSRI simply go with that and ignore all else, against my recommendation. Like I said, if the patient has capacity, you can only educate and recommend. They have the power to choose even if that choice is wrong.

                                  But with depression and anxiety, SSRIs also reduce cortisol induced brain damage, excitation of the inflammatory pathways, etc. My personal opinion is so long as the SSRI is helping the person, the benefits outweight the cons, then keep continuing it, but also recommend psychotherapy becuase they may have some issue that might be ignored if they simply see the med as the solution.
                                   
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                                  nitemagi

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                                    Yeah i agree with you. Thats what i think as well. Well, there is always the question of what SSRIs do, what i ment is that they don't induce some long-term synaptic plasticity (like e.g. exposure) but they "blunt", "regulate", "reduce", call it what you want (or what psychopharma theories call it), the final stress response. I agree that this is of benefit in the beginning.

                                    Au Contraire ...;)

                                    http://www.ncbi.nlm.nih.gov/pubmed/22194582
                                    http://www.ncbi.nlm.nih.gov/pubmed/22054117
                                    http://www.ncbi.nlm.nih.gov/pubmed/21803060

                                    There's some interesting data - some is synergistic, others focusing on BDNF, both add to an interesting pool of data strongly suggesting SSRI's may improve neuroplasticity.
                                     

                                    cbrons

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                                      Okay, to offer some further clarification for this situation. The patient was diagnosed 5 years ago by another psychiatrist with OCD. Apparently he not only has a long history of hypochondriasis, but did grow up going through a series of phases with handwashing, separation anxiety from parents, etc.

                                      I think the best approach has been to get him to accept that his concerns/worries about taking an SSRI are merely another symptom of the problem (much like scary thoughts are a symptom of a panic attack, not a realistic appraisal of a given situation).

                                      Hard to really dealve much deeper into this but now that he is seeing a psychologist twice a week for CBT, it's still worth it to start him on a small dose of an SSRI? And why not Lexapro? if that is what he insists...
                                       

                                      Ollie123

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                                        Not my area, but Whopper - I'm somewhat curious where the notion that SSRI's alone were superior to CBT alone comes from. Though I am assuming that when people say CBT they are including ERP within that category (ERP is pretty much the "go to" psychotherapy for OCD). I've seen some suggestion that Clomipramine > SSRIs (though probably not enough to justify the side effects/risks) many suggestions of equivalence, some studies suggesting a superiority of therapy alone, but I'm not sure I've come across any substantive evidence that SSRIs alone are superior to CBT/ERP alone.
                                         

                                        nitemagi

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                                          Not my area, but Whopper - I'm somewhat curious where the notion that SSRI's alone were superior to CBT alone comes from. Though I am assuming that when people say CBT they are including ERP within that category (ERP is pretty much the "go to" psychotherapy for OCD). I've seen some suggestion that Clomipramine > SSRIs (though probably not enough to justify the side effects/risks) many suggestions of equivalence, some studies suggesting a superiority of therapy alone, but I'm not sure I've come across any substantive evidence that SSRIs alone are superior to CBT/ERP alone.

                                          No disrespect intended Ollie, but each of our respective fields gets biased presentations from biased mentors. I've seen a few too many psychology students that're dogmatic about the evils and inferiority of meds, based on half-truths. The pharm literature is just as riddled with misinformation, but many of us recognize it as such. The truth I believe is that there's literature to back up both viewpoints, which to me makes it a wash. We also need to specify superior for what and whom? MDD? OCD? Panic? I know you asked Whopper, but here's my quick lit review (pubmed search during downtime this evening)

                                          SSRI/TCA's good:
                                          http://www.ncbi.nlm.nih.gov/pubmed/11221150
                                          (obscure malaysian journal)

                                          http://www.ncbi.nlm.nih.gov/pubmed/11481130
                                          (combined best, drug better than CBT alone)

                                          http://www.ncbi.nlm.nih.gov/pubmed/12436805
                                          (For PMDD, medication better earlier, though CBT good longitudinally)

                                          http://www.ncbi.nlm.nih.gov/pubmed/15315995
                                          (JAMA - Adolescents with depression, SSRI>CBT, combo best)

                                          http://www.ncbi.nlm.nih.gov/pubmed/15507582
                                          (JAMA - pediatric OCD, CBT and sertraline fairly equiv, combo superior)

                                          http://www.ncbi.nlm.nih.gov/pubmed/16505130
                                          (Anxiety in older adults, many dropouts in both groups, SSRI>CBT)

                                          http://www.ncbi.nlm.nih.gov/pubmed/17003660
                                          (adolesc depression, combo not superior, CBT good, low dose SSRI)

                                          http://www.ncbi.nlm.nih.gov/pubmed/19616195
                                          (hypochondriasis, SSRI equivalent to CBT)

                                          http://www.ncbi.nlm.nih.gov/pubmed/19860993
                                          (Late life anxiety, SSRI>CBT)

                                          http://www.ncbi.nlm.nih.gov/pubmed/19958308
                                          (Late life panic d/o, SSRI=CBT)

                                          http://www.ncbi.nlm.nih.gov/pubmed/21608087
                                          (meta-analysis, CBT seemed a little better than meds for anxiety d/o's overall, but non-signficant finding)

                                          http://www.ncbi.nlm.nih.gov/pubmed/22252094
                                          (imipramine>CBT, though CBT arm may have been underpowered)

                                          Here's a nice review on moderators of how/when CBT works--
                                          http://www.ncbi.nlm.nih.gov/pubmed/20599132

                                          Yep, I had a slow day at the clinic...:D
                                           

                                          zenman

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                                          Gesundheit!
                                            I don't think anyone is disagreeing that CBT is very important (except zenman). The dispute (at least part of it) is whether SSRI's have a place here. SSRI could just be blunting the stress overactivity, but qualitatively that seems moreso the case with benzo's than SSRI's. Furthermore, if the stress reaction is turned down that may interrupt the cycle of checking behavior, reduction of anxiety, and reinforcement, which then allows for more elective engagement of triggering anxiety and working with it psychotherapeutically.

                                            The problem I have with CBT, in addition to those mentioned earlier is that intellectual knowledge means very little to some patients. They got to feel it in their hearts...get em out of their heads. I'm brain dead but maybe I'm clear. "Karate not here, karate not here, karate here."
                                             

                                            Ollie123

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                                              Sorry, I realize my post was a little unclear but I was referring specifically to OCD. I'm well aware of the biases in the literature and support of views on both sides for many of the issues that you posted (though to be fair...I've seen a few too many psychiatrists with blind faith in big pharma or who think handing out a pamphlet on deep breathing along with their 10 minute med checks means they are providing optimal care and no therapy referral is needed). I'm a scientist first and this discussion gets even more crazy when you look at the methodology of the studies and the inherent problems in equating them (e.g. its kind of hard to "blind" therapy). My research is actually geared more towards drug development than psychotherapy so believe me when I say I'm not on the "Meds are evil" bandwagon.

                                              However, it appears that not a one of the many studies you were nice enough to find supported superiority of SSRI's for the treatment of OCD! Maybe I misunderstood, but I thought Whopper was referring specifically to that having been shown specifically in populations with OCD. I only bring this up because from what I have seen, OCD is one of the few areas where everything I've seen suggests equivalence or superiority of therapy and I HAVEN'T seen anything to support the superiority of meds. If that literature is floating around out there somewhere I want to know about it.
                                               
                                              Last edited:

                                              nitemagi

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                                                However, it appears that not a one of the many studies you were nice enough to find supported superiority of SSRI's for the treatment of OCD! Maybe I misunderstood, but I thought Whopper was referring specifically to that having been shown specifically in populations with OCD. I only bring this up because from what I have seen, OCD is one of the few areas where I HAVEN'T seen a mixed pattern of findings, so if that literature is floating around out there somewhere I want to know about it.

                                                Ah, sorry for the confusion. As far as I know, there's almost zero data on head to head comparison of the two for OCD in particular. Almost all the research examines augmentation of non-responders to SSRI with CBT, and shows that that is effective.
                                                 

                                                Ollie123

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                                                  No worries. There is some out there and its growing (I have some colleagues doing a trial right now, which is why this is on my mind). One example comparing them directly (albeit with a respectable but not overwhelming sample size) is below, and showed superiority of ERP over clomipramine. Not an SSRI, but my read of the med literature is that if anything clomipramine likely has a slight edge in symptom reduction but is second line largely because of the side effects and potential lethality in folks at risk for suicide.

                                                  http://ajp.psychiatryonline.org/article.aspx?articleID=177285
                                                   

                                                  kugel

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                                                    I'm currently prepping for a Sunday D&D Temple of Elemental Evil session with a 3-D terrain.

                                                    so tape your glasses together, glue a scrawny soul patch onto your lower lip, and be sure to wear the t-shirt that you always wear with a saying that you think is so ironic that "most people just don't get it."
                                                    A) they've all seen that t-shirt the last few dozen times you wore it
                                                    B) they "got it" the first time. they just weren't impressed.

                                                    I say all this out of love......and experience.
                                                     

                                                    whopper

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                                                      I say all this out of love......and experience.

                                                      When I took my oral boards, I was having a discussion with a buddy who is a fellow gamer. We were both saying the hotel atmosphere was like a geek-con except everyone was wearing suits and no one was smelling bad.

                                                      I remember at Gencon, thinking to myself that some of these guys really need a makeover from Queer Eye from the Straight Guy but that show's over.
                                                       
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