Combining Serotonergic Medication with Cognitive-Behavior Therapy: Is it Necessary for all OCD Patients?

Literature reviews presented in earlier chapters of this book and elsewhere (eg, Franklin&Foa, 2002) have already explicated that cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) are both efficacious treatments for OCD; yet at the same time, response to either of these monotherapies is neither universal nor complete. One can readily hypothesize an advantage for combined treatment by CBT plus SRI over either monotherapy alone, and prevailing belief in the veracity of this view is already reflected in the field in a number of different ways. Commenting on clinical practice with anxiety disorders more broadly Balon (2004, p. 63) states, “A combination of proven pharmacotherapies and psychotherapies may be the most clinically prudent approach to the treatment of anxiety disorders.” Regarding OCD specifically, the OCD Expert Consensus Guidelines (March, Frances, Carpenter, & Kahn, 1997) recommended that for adults and adolescents with an initial Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989a, 1989b) score of 18 or higher, combined treatment should be considered the first-line option, along with SRI alone for adults (March et al., 1997). Some have advocated even more strongly for the relative advantages of combined treatment over monotherapies (eg, Greist, 1992; Greist & Baer, 2002). For example, on the Obsessive Compulsive Foundation's website there is a feature called “How to Select a Behavior Therapist (http://www.ocfoundation.org/ocf 0003.htm),” written by Dr Michael Jenike, who states that, “Over the last two decades, it has become increasingly clear that optimal treatment for most people with OCD involves the combination of medication plus the behavior therapy techniques of exposure and response prevention (EX/RP).” The purpose of this chapter is to consider whether initial treatment with CBT plus concomitant SRI should indeed be recommended for most OCD patients. In deliberating on this issue below, I have included discussion of practical, theoretical, and empirical factors, and conclude that the answer to this important question requires at least some qualification.