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LetterLetters

Benefits of CBT for OCD in pregnancy

Brittney F. Dane and Eric A. Storch
Canadian Family Physician May 2014; 60 (5) 430-432;
Brittney F. Dane
Tampa, Fla
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Eric A. Storch
Tampa, Fla
PhD
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We read with great interest the article by Namouz-Haddad and Nulman,1 which discussed treatment options for obsessive-compulsive disorder (OCD) in pregnancy and puerperium. This issue is of critical importance given its prevalence, the level of impairment caused by OCD, and the need for clinicians to consider risks that occur when treating this population that would otherwise be absent in nongravid patients. We appreciate their informative and concise review of the literature and the authors’ resolve to present available treatment options. Within the article’s many strengths, there are 3 concerns that we would like to address.

First, the article lacks relative equipoise with cognitive-behavioural therapy (CBT) in relation to selective serotonin reuptake inhibitors (SSRIs). The authors supplied an excellent discussion of pharmacologic treatment; however, they provided only a 1-sentence rationale in favour of CBT for OCD. Indeed, CBT with exposure and response prevention has been shown to display more robust treatment outcomes than pharmacotherapy using serotonin reuptake inhibitors (SRIs)2,3 and has been recommended as the front-line treatment option for nongravid patients with OCD.4 Preliminary data support CBT for OCD in pregnancy and puerperium as monotherapy5 and in combination with an SRI.6 In addition to the aforementioned efficacy of treatment, CBT lacks the negative side effect profile discussed by Namouz-Haddad and Nulman that is associated with SSRIs.1

Second, patient considerations must be taken into account when prescribing a treatment plan.4 This is even more prudent when working with vulnerable populations such as pregnant and postpartum women. As discussed by Namouz-Haddad and Nulman,1 there is a lack of clinical agreement regarding the safety of exposing an infant to SSRIs through breast milk. Data suggest that CBT is a well regarded treatment approach relative to SSRI monotherapy among nongravid individuals with OCD.7 Given this, a behavioural approach that lacks these risks should always be considered in the initial treatment plan.

Third, although efficacious, treatment with SRIs rarely produces remission. In fact, using SRIs alone, only approximately 40% to 60% of individuals achieve a clinically meaningful treatment response.8 There are additional concerns to consider such as the substantial rates of relapse after medication is discontinued.9 This leaves the clinician at a loss for what to do next. There is clear support for providing CBT in an augmentation approach10,11; however, as discussed above, CBT alone should always be considered as an initial intervention given its efficacy, safety, and patient acceptability. Other approaches, such as antipsychotic augmentation, have concerning side effect profiles12 and have not consistently demonstrated superiority relative to placebo in methodologically rigorous controlled trials.10

We are grateful to Namouz-Haddad and Nulman1 for providing an excellent review of OCD in pregnancy and puerperium and treatment options for this population. Disseminating accurate and reliable treatment information to clinicians is of critical importance, as safe and effective treatment for this population is necessary for the well-being of both the mothers and newborns. In an effort to present well-rounded treatment suggestions, we suggest a more thorough and balanced explanation of CBT and the inherent benefits of this empirically supported behavioural treatment.

Footnotes

  • Competing interests

    None declared

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Namouz-Haddad S,
    2. Nulman I
    . Safety of treatment of obsessive compulsive disorder in pregnancy and puerperium. Can Fam Physician 2014;60:133-6.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Foa EB,
    2. Liebowitz MR,
    3. Kozak MJ,
    4. Davies S,
    5. Campeas R,
    6. Franklin ME,
    7. et al
    . Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry 2005;162(1):151-61.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Rosa-Alcázar AI,
    2. Sánchez-Meca J,
    3. Gómez-Conesa A,
    4. Marín-Martínez F
    . Psychological treatment of obsessive-compulsive disorder: a meta-analysis. Clin Psychol Rev 2008;28(8):1310-25. Epub 2008 Jul 4.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Koran LM,
    2. Hanna GL,
    3. Hollander E,
    4. Nestadt G,
    5. Simpson HB,
    6. American Psychiatric Association
    . Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry 2007;164(7 Suppl):5-53.
    OpenUrlPubMed
  5. 5.↵
    1. Christian LM,
    2. Storch EA
    . Cognitive behavioral treatment of postpartum onset. Obsessive compulsive disorder with aggressive obsessions. Clin Case Stud 2009;8(1):72-83.
    OpenUrl
  6. 6.↵
    1. Misri S,
    2. Reebye P,
    3. Corral M,
    4. Milis L
    . The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry 2004;65(9):1236-41.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Patel SR,
    2. Simpson HB
    . Patient preferences for obsessive-compulsive disorder treatment. J Clin Psychiatry 2010;71(11):1434-9.
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Kaplan A,
    2. Hollander E
    . A review of pharmacologic treatments for obsessive-compulsive disorder. Psychiatr Serv 2003;54(8):1111-8.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Abramowitz JS,
    2. Schwartz SA,
    3. Moore KM,
    4. Luenzmann KR
    . Obsessive-compulsive symptoms in pregnancy and the puerperium: a review of the literature. J Anxiety Disord 2003;17(4):461-78.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Simpson HB,
    2. Foa EB,
    3. Liebowitz MR,
    4. Huppert JD,
    5. Cahill S,
    6. Maher MJ,
    7. et al
    . Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry 2013;70(11):1190-9.doi:10.1001/jamapsychiatry.2013.1932
    OpenUrlCrossRefPubMed
  11. 11.↵
    1. Simpson HB,
    2. Foa EB,
    3. Liebowitz MR,
    4. Ledley DR,
    5. Huppert JD,
    6. Cahill S,
    7. et al
    . A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatry 2008;165(5):621-30. Epub 2008 Mar 3.doi:10.1176/appi.ajp.2007.07091440
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Gentile S
    . Infant safety with antipsychotic therapy in breast-feeding: a systematic review. J Clin Psychiatry 2008;69(4):666-73.
    OpenUrlCrossRefPubMed
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Canadian Family Physician: 60 (5)
Canadian Family Physician
Vol. 60, Issue 5
1 May 2014
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Benefits of CBT for OCD in pregnancy
Brittney F. Dane, Eric A. Storch
Canadian Family Physician May 2014, 60 (5) 430-432;

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Canadian Family Physician May 2014, 60 (5) 430-432;
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